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Abstract
Since the onset of the pandemic and murder of George Floyd, the realities of social determinants of health, the need for health justice and antiracism have been featured more prominently in our daily work in healthcare. There is increasing evidence that we must focus our efforts on retaining all within healthcare and in particular those from marginalised groups to ensure our ability to: care for our increasingly diverse patient populations, address health inequities and improve the health of our patients and communities. Thus, if we truly want to recruit and retain a diverse healthcare workforce that reflects our diverse patient population, we need to create a culture of respect and inclusion and a place where each individual can thrive. The biopsychosocial-spiritual framework is one model that we can use. In 2013, in Geneva, a global consensus developed a set of standards and recommended strategies to provide whole person care and spiritual care across the health continuum, not only for palliative care. Integrating health justice into the biopsychosocial-spiritual model to promote well-being, we believe we will create a culture of respect and inclusion for each healthcare worker to thrive and define/renew their meaning and purpose in medicine in hopes to retain and recruit a diverse healthy workforce to provide high-quality whole person care for our diverse patient population, especially those from historically marginalised groups, and create sustainable strategies to promote health justice.
- care redesign
- clinical leadership
- patient-centred care
- multi-professional
- Social Justice
Data availability statement
No data are available.
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In teaching the biopsychosocial-spiritual model to trainees, faculty and other healthcare workers, a common question has arisen—how do and why should we apply the biopsychosocial-spiritual model1 to our patients and ourselves? Since the onset of the pandemic and murder of George Floyd, the realities of social determinants of health, the need for health justice and antiracism have been featured more prominently in our daily work in healthcare. Globally, in healthcare, a field that is already strained by staffing shortages, there was an increase in the turnover of healthcare workers during the pandemic due to fear of COVID-19 exposure, psychological response to stress, sociodemographic characteristics, organisational support and adverse working conditions.2 This study noted over 125 000 healthcare workers, a 4-fold difference in turnover rates between physicians and health aides and assistants occurred. Also, rates for those identifying as Black and Hispanics were slow to recover.3 Others have noted that in the UK, retention of ethnic minority staff is essential to solving the English National Health Service workforce crisis.4 There is increasing evidence that we must focus our efforts on retaining all within healthcare and in particular those from marginalised groups to ensure our ability to: care for our increasingly diverse patient populations, address health inequities and improve the health of our patients and communities.5 The data denote that some with marginalised identities within healthcare experience harassment that leads to them wanting to leave.6 7
Thus, if we truly want to recruit and retain a diverse healthcare workforce that reflects our diverse patient population, we need to create a culture of respect and inclusion and a place where each individual can thrive to promote their well-being and lead efforts to promote health justice (box 1). The biopsychosocial-spiritual framework is one model that we can use, as patients and healthcare workers have common factors of being human with unique experiences, backgrounds and beliefs. Dialoguing to understand and respect an individual’s spirituality, prior experiences and backgrounds, and responding with care is about honouring the diversity of perspectives, providing equitable attentiveness, and ensuring the inclusion and well-being of all. With this approach, we believe we will create a culture of respect and inclusion for each healthcare worker to thrive and define/renew their meaning and purpose in medicine in hopes to retain and recruit a diverse healthy workforce to provide high-quality whole person care for our diverse patient population and create sustainable interventions to promote health justice.
Defining inclusion, well-being, and health justice
Inclusion: ‘Refers to how our defining identities are accepted in the circles that we navigate. It refers to the extent to which individuals feel they can be authentic selves and can fully participate in all aspects of their lives. In total, inclusion is a set of behaviours (culture) that encourages employees to feel valued for their unique qualities and experience a sense of belonging’.28
Well-being: Well-being is a state of positive feelings and meeting full potential in the world.29
Health justice: ‘Health justice requires that all persons have the same chance to be free from hazards that jeopardise health, fully participate in society and access opportunity. Health justice means dismantling the effects of racism and working towards sustainable policies and innovations that will last through generations…It is about meeting the needs to bring equity and fairness to the forefront, where people can live to their fullest potential’.16
The biopsychosocial-spiritual model consensus guidelines were developed initially in palliative care.8 In 2013, in Geneva, a global consensus, building on a prior consensus conference in the USA for guidelines in palliative care, developed a set of standards and recommended strategies to provide whole person care and spiritual care across the health continuum, not only for palliative care. The George Washington University’s Institute for Spirituality and Health, in collaboration with Caritas Internationalis and funded by the Fetzer Institute, held the International Consensus Conference on Improving Spiritual Dimension of Whole Person Care: The Transformational Role of Compassion, Love, and Forgiveness in Healthcare. Participants included 41 international leaders, including physicians, nurses, psychologists, social workers, theologians, spiritual care professionals, donors, researchers, and policy-makers.9 Protected demographics, that is, race, ethnicity, sexual orientation, sexual identification, disability, were not included in the report. However, participants were invited based on experience in spiritual care, clinical care from diverse professions and represented 13 countries with diverse cultural, religious backgrounds as well as genders. In developing the definition of spirituality, which is now used as an accepted global definition, the discussion included perspectives from the cultural groups that attended and attention to marginalised groups such as the native Australians. It is important that the entire definition of the biopsychosocial-spiritual framework be similarly conceptualised to include the possible experiences of historically marginalised groups (figure 1).
Integrating health justice into the biopsychosocial-spiritual model. The biopsychosocial-spiritual model can be expanded to include social determinants of health, structural racism, trauma and more that patients and healthcare workers, especially individuals from communities of colour, lower socioeconomic status and/or other historically marginalised groups, may face. Multifaceted interventions can be created at individual, institutional, national and global levels to promote health justice and well-being for all. Adapted from ISPEC programme.9
In the biological domain, access to healthcare, equitable access to particular medicines10 and timely diagnostic testing and procedures due to prior authorisation requirements would be included and lead to health justice by providing access to equitable and affordable quality care for all.8 As part of the psychological approach, mistrust, the lack of trustworthiness of healthcare workers and thus the implications on a patient’s personal experience should be addressed. The patients’ historical experiences with healthcare due to race, culture, gender, sex, age, socioeconomic status, homelessness, chronic medical conditions (ie, hepatitis C) and/or behavioural health conditions with the healthcare system and other institutions should be reviewed.11–14
Determining a patient’s access to internet and smart devices,15 social and legal roots resulting in poor health16 and various forms of trauma can be included within the social domain. As we care for patients, we must understand that trauma can occur in multiple areas—at home, schools or in the community, at centres of worship, healthcare and/or shopping markets and by individuals the individuals may know or not.17 Trauma may result in a loss of trust and security in the world, which may impact the individual’s sense of self and relationship with others.18 The relationship between trauma and spirituality can have both positive or negative impacts; thus, understanding the relationship and concepts of trauma and spirituality are important to provide effective treatment regimen.18
In the spiritual domain, the community can include a religious organisation, but also family, senior center, fraternity, social collective and/or another group the patients feel that are important to them and provide a sense of inclusion. Groups and/or communities can also cause distress when they exclude individuals based on their perceived ‘difference’ and/or if they are dogmatic in nature. For example, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual+ individuals may have more positive psychological health in faith affirming communities compared with non-affirming faith communities19 20 or more negative psychological outcomes with exclusive faith communities.21 Individuals or groups in power using religious doctrine to implement policies on human rights and health can have negative consequences on marginalised individuals, especially those with lower socioeconomic status.
In regard to spirituality, we must understand its broad definition as developed in the aforementioned consensus conference. ‘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’.1 Spirituality may include religion but is not defined only by religion which is why the definition of spirituality is framed on how persons seek ultimate meaning, purpose and connectedness and how people experience relationship in many different ways.
How and why to incorporate biopsychosocial-spiritual model with health justice lens for all patients?
Historically marginalised communities have been impacted more than others from the COVID-19 pandemic, climate change, natural disasters and/or racial tensions in terms of death, economic hardships, discrimination and/or other repeated trauma. The medical community can use the expanded model to promote whole person care, which employs ‘a multidimensional, integrated approach rather than a biomedical reductionist model’22 for our diverse patient population, especially groups who have been historically marginalised now and during ongoing crisis.
To assess for spiritual health, use of a validated spiritual history tool, such as the FICA tool,23 allows exploration of a patient’s spiritual health, while listening for spiritual strengths and identifying spiritual distress. Spirituality is necessary to explore as it can provide information on patient’s beliefs, values and resources, including how people cope, can help build trust between clinician and patient, demonstrate respect and/or address spiritual distress if diagnosed (box 2).8 Often when treating complex patients with multimorbidity, social determinants of health and/or who have faced discrimination, if the clinician only focuses on the biological or psychological, the clinician may not be able to engage in patient-centred care and improve health outcomes.24 For example, if a patient with complex medical conditions is also depressed, the patient may not improve if the clinician does not address the depression simultaneously.25 Similarly, if a patient who is suffering from spiritual distress, is not appropriately diagnosed, or not addressed, the patient may not follow through with medical recommendations as they may have lost hope, meaning, purpose and/or connection.
Spiritual distress can be diagnosed if an individual is experiencing one of these. If diagnosed, a plan can be made to address this problem.8
Spiritual distress can be diagnosed if the patient is experiencing:
Existential, lack of meaning/purpose,
Abandonment by God or others,
Anger at God or others,
Concerns about relationship with deity,
Conflicted or challenged belief systems,
Despair or hopelessness,
Grief or loss,
Guilt or shame,
Reconciliation or isolation,
And/or religious specific, religious/spiritual struggle.
How and why to incorporate the biopsychosocial-spiritual model with a health justice lens for trainees and healthcare workers?
Healthcare clinicians, educators and leaders can learn to apply the biopsychosocial-spiritual model with a health justice lens of patient care to medical trainees and healthcare workers. Aspects of the model can be applied across the continuum of the professional journey as trainees and healthcare workers are individuals coming from diverse backgrounds, experiences and beliefs. Interventions at the individual and institutional level can be developed for trainee well-being, which include creating protected time for observation of spiritual practices as well as the ability to engage in clinical experiences that resonate with one’s passion and values. These could be activities such advocacy, community engagement, or peer mentorship,26 which may renew one’s meaning and purpose in medicine or sense of belonging in a community. The biopsychosocial-spiritual model can also be applied to healthcare workers.
Examples of biological interventions could include providing protected time to make primary care and preventative health appointments and to encourage the use of all paid time off. For psychological interventions, we can create safe environments in healthcare that places value in seeking behavioural and mental health and ensure that those who provide that care are diverse in their approach and backgrounds. For social interventions, interventions should be created based on seeing the healthcare worker from the lens of a human, who may have had various experiences and possibly trauma based on their race, socioeconomic, sexual orientation, gender, age and/or training in medicine. Recognising and mitigating the impacts of past discrimination and trauma in one’s approach to the workforce will be key. Also, creating trauma-responsiveness plans when traumatic situations arise at work are essential. For spiritual interventions, schedules could be created for healthcare workers to enhance their participation in spiritual practices, which may be faith based, secular such as meditation practices or the ability to gather in community with others or explore nature. Opportunities for healthcare workers to pursue their passions in medicine and not solely as volunteer or ‘going above and beyond’ could be developed. An example would be for the healthcare worker to spend once a month with a programme or organisation that they are passionate about, which are included in the work expectations and do not require the use of leave. These passions may be in direct clinical care in working in asylum clinic, advocacy for improved policies, community engagement, education of trainees, faculty, or patients, and/or leadership enhancements, which could include professional development or mentorship. Lastly, leaders need to be aware that trainees and healthcare workers can also suffer from spiritual distress. Thus, measures should be taken to ensure the appropriate evaluation and treatment are provided.
As interventions at individual, institutional, national, and global levels are developed, it is essential that senior leadership model and celebrate the importance of these interventions and provide appropriate resources to create a paradigm shift. These include reimaging the workday and creating an environment of team-based care, where all team members’ ideas are valued, and will be a necessary ingredient for success to improve their physical, mental, emotional, and spiritual health. In some healthcare systems, many institutions may focus on productivity, efficiencies of the whole and/or revenue. This paradigm shift seems to be in conflict with the institutions’ or systems’ priorities as in, for example, valuing healthcare worker experience or meaning/purpose in medicine over productivity. In creating this paradigm shift from an ideal state to reality, there will be tension and challenges.27 As strategies are developed, there may be more expenses and resources initially up front. Power dynamics may be strained. However, over time, with the unified goal of improving well-being of patients and healthcare workers, attrition, cost and waste will be reduced potentially leading to recruitment and most importantly retention of a healthy diverse workforce to care for all patients and revenue generation that can sustain an equitable, high-quality healthcare system.
Using this framework for diverse groups of trainees and healthcare workers can provide educators, administrators and/or leaders with possible areas to explore to create interventions that include the entirety of one’s humanity to help each individual to flourish. If we were to further incorporate this framework in healthcare, we may create environments where all those engaged in patient care will feel valued, a sense of belonging and connection, possibly find renewed meaning and purpose in healthcare, and thus joy in being a part of medicine. Hopefully, this may improve recruitment and most importantly retention in all sectors of healthcare so we can provide high-quality care for our diverse patient population and create sustainable solutions for health justice.
Next steps to navigate this new era and move forward
The biopsychosocial-spiritual model is essential for providing whole person care to a diverse patient population,1 especially those who are most marginalised by society when using a health justice lens. In addition, this model can be used as a holistic framework for diverse group of trainees and healthcare workers by recognising each as human with difference experiences, backgrounds, and beliefs and creating holistic interventions to recruit and most importantly retain a healthy diverse health workforce with renewed meaning and purpose in medicine and creating an environment of respect and belonging to improve the well-being of our patients, the communities and the healthcare workers who care for them.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
References
Footnotes
Twitter @LuTorresDeasMD
Contributors LT-D conceived of the presented idea. LT-D, MLL and CMP all contributed to final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests MLL: Associate Editor of Academic Medicine, paid by the AAMC. CMP: Associate Editor of Journal of Pain and Symptom Management. Not paid; Senior Section Editor, Bioethics, Spirituality, Humanities PC-FACS. Not paid.
Provenance and peer review Not commissioned; externally peer reviewed.