position paper n n

Teaching Spirituality in the Physical Therapy Classroom and Clinic

Darina M. Sargeant, PT, PhD

Background and Purpose. This paper addresses physical therapists that face patients who are experiencing health challenges requiring the ability to cope with life-altering circumstances. One tool that physical therapists can use to help patients cope is to address a patients spiritual or religious beliefs. The purpose of this paper is to clarify the role of the spiritual domainwhich includes the patients spiritual and/or religious beliefs in physical therapy practice; advocate for the inclusion of the spiritual domain in physical therapist curricula; and identify educational goals, content, and strategies used in teaching spirituality/spiritual domain in either postgraduate or professional doctor of physical therapy curricula. Position and Rationale. Content on the role of spirituality in physical therapy practice should be included in physical therapy curricula because of its relevance as a tool to reorganize life experiences, a coping mechanism and component of pain control, and as an aspect of wellness and cultural competence. The inclusion of the spiritual domain in the physical therapy plan of care reflects 2 core values of the profession: compassion/caring and professional duty. However, only a limited number of physical therapists receive formal training in the spiritual domain. Physical therapist students can improve their level of comfort with the spiritual domain through exposure to the concepts, discussion, and reflection regarding their own beliefs. Conclusion and Recommendations. Educational goals, content, educational theories, and teaching strategies provided in this paper may help the physical therapy educator provide meaningful learning experiences in the spiritual domain.
Darina Sargeant is an associate professor in the Program in Physical Therapy, Doisy College of Health Sciences, Saint Louis University, 3437 Caroline Street, Saint Louis, MO 63104 (sargeant@slu.edu). Received October 23, 2007, and accepted December 29, 2008.

Opportunities to engage in active-learning activities, including reflection on the spiritual domain in physical therapy practice, may result in increased level of comfort for students and improved outcomes for patients. Key Words: Spirituality, Spiritual domain, Physical therapy, Education, Core values.

BACKGROUND AND PURPOSE Physical therapists must practice in a culturally competent manner, which includes attention to the spiritual domain, that is, the patients/clients religious and/or spiritual beliefs. In the Blueprint for Teaching Cultural Competence in Physical Therapy Education1, found on the Commission on Accreditation for Physical Therapy Educations (CAPTE) Web site, culture is defined as the integrated patterns of human behavior that include thoughts, communications, actions, beliefs, customs, as well as institutions of racial, ethnic, religious or social groups.(p4) Religion is defined as rules, rites, and rituals (ie, the exoteric or external manifestation of beliefs) and may or may not be associated with spirituality depending on individual preference.2 Spirituality is defined in many ways.3-5 For some individuals, spirituality is the esoteric or internal manifestation of religion, which is referred to later in this paper as religious spirituality. For others, it is totally separate from religion and is secular in nature; referred to later as secular spirituality. For the purpose of this paper, Scandurras6 definition is used: Spirituality is the fundamental life process through which wellness is experienced. It involves a connectedness to oneself, others, nature, and to a larger meaning or purpose.(p104) Patients/clients have varying levels of religious conviction and, for some; religion may have negative rather than positive connotations. For these patients/clients, spirituality may be a reasonable alternative to religious institutions as a coping strategy. Harold Koenig,7 a leader in the field of spirituality in patient care states Because religious or spiritual beliefs are important to many patients in
Journal of Physical Therapy Education

rehabilitation settings, and these beliefs are often used to cope with disability and create meaning for illness, this is an area related to the patients psychological and social functioning that therapists cannot ignore.(p160) As future health care practitioners, physical therapist students must not only be culturally competent but must develop skills to assist patients experiencing health challenges, which requires the ability to cope with life-altering circumstances.8 Physical therapists awareness of religious symbols, metaphors, and the need for transcendence in a frightening circumstance may enhance the patients/clients level of trust and assist in promoting patient/client relaxation during routine procedures.8-10 Physical therapists may give support to their patients/clients by offering health care in a compassionate manner that respects the religious and spiritual beliefs of the patient/client.11 Increasingly, physical therapists use their knowledge to help promote wellness in various populations.12 The pursuit of wellness has grown on university campuses, in the general population, and the government sector.13-15 William Hettler,16 director of Health Services at the University of Wisconsin-Stevens Point and co-founder of the National Wellness Institute, defined wellness as an active process through which people become aware of, and make choices toward a more successful existence.(p13) Hettler, in his Hexagon Model of Wellness identified 6 dimensions in wellness: social, occupational, spiritual, physical, intellectual, and emotional. Spirituality, as part of this wellness model, is grounded in the developmental theories of Maslow, Jung, Erikson, Frankl, Kohlberg, and Fowler.17,18 To some degree, each of these theorists speaks to the development of the human to his/her highest potential. While the primary focus for the physical therapist is the physical dimension of wellness, physical therapist students can apply their knowledge of spirituality as a coping mechanism, motivational strategy, or tool to find meaning in life; not only with patients who experience life-altering events but also those patients/clients interested in obtaining and maintaining wellness.
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Although Shepard and Jensen,19 in The Handbook for Physical Therapists, indicate the spiritual domain should be part of physical therapy education, the literature on the inclusion of spirituality in physical therapy curricula is limited.19,20 Academic and clinical faculty may experience discomfort with including the spiritual domain in physical therapists education due to concerns with scope of practice, overstepping boundaries, the separation of church and state, and unfamiliarity with either the content and/or appropriate teaching strategies.21 Therefore, the purpose of this paper is to (1) clarify the role of spirituality and the spiritual domain in patient/client care, (2) define spiritual domain, spirituality, and religion, (3) advocate for inclusion of the spiritual domain in physical therapy curricula, and (4) identify educational goals, content, educational theories, and teaching strategies for the spiritual domain. POSITION AND RATIONALE Implications of Spirituality/Spiritual Domain in Patient/Client Care The literature on the role of spirituality in patient/client care is expansive in the areas of medicine, nursing, and occupational therapy.22-30 However, while articles addressing the impact of a patients/clients spirituality and religious beliefs on physical therapy outcomes are limited, other manuscripts associate use of the spiritual domain in physical therapy to positive outcomes.11(p93) For example, Pressman and colleagues31 demonstrated a relationship between adherence to religious beliefs/depression and the distance patients with hip fractures were able to ambulate. They concluded that religious practice is associated with less depression and greater levels of independence.31 Mackey and Sparling32 suggested that physical therapists (in their study, specifically those working with elderly women in hospice for cancer) who consider the spiritual aspect of care along with the physical can assist the patient in finding meaning and peace. Additionally, they indicated that physical therapists could support their patients by listening to them and incorporating their values into physical therapy goals and interventions.32 In a study on spiritual beliefs after traumatic disability, McColl and colleagues8 reported that spirituality positively affected restructuring of beliefs and awareness of self, purpose of life, trust, interdependence with others, and greater understanding of other marginalized groups. As stated previously, consideration of a patients/clients spiritual and religious needs is a component of a persons cultural identity as well as a facet of patient-centered care. Mad30

dox33 reported that 82% of Americans believe in the healing power of personal prayer. Concerns over lack of patient-centered care and increased need for training in the area of cultural competence are noted in the Institute of Medicines Crossing the Quality Chasm: A New Health System for the 21st Century,34 and The Joint Commission has advocated the inclusion of spiritual and religious needs in health care, although the physical therapists role is not defined.35 The Spiritual Domain and the Core Values In August 2003, the American Physical Therapy Associations (APTA) Board of Directors adopted the document, Professionalism in Physical Therapy: Core Values36. In 2007, APTAs House of Delegates endorsed the adoption of the Core Values. The document, which defines 7 core values, impacts physical therapy practice, research, and education. Two of the core values, compassion/ caring and professional duty, particularly call educators to include the spiritual domain in physical therapy curricula. According to the document, compassion compels the physical therapist to understand the patients/clients perspective and advocate for the patients/ clients needs while understanding the sociocultural, psychological, and economic influences in the individuals life and ultimately leads to an ethic of care. Physical therapists can demonstrate stronger adherence to their professional duty, defined as the commitment to meeting ones obligations to provide effective physical therapy services,36(p6) by including the spiritual domain in their plan of care. Attention to the whole person is a beneficent act and, as such, reflects our professional duty to facilitate the patients/ clients optimal return to function, health, and wellness. Connecting with patients/clients on a spiritual level allows health professionals to develop trusting relationships and may enhance treatment outcomes.11(p93),37 The literature indicates that to be comfortable addressing spiritual needs, health care professionals must be able to recognize and be comfortable with their own feelings about the spiritual domain.19,38 Physical therapists must be able to recognize their own biases, recognize the impact of these biases on the patient/client, and identify resources for their patients/clients as the need arises. A limited number of physical therapists have received formal training regarding spirituality in practice. Janice Pitts20 sampled 101 physical therapy programs to determine faculty perceptions regarding the inclusion of spirituality in their curricula. Pitts20 determined that only 49% of the respondents
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include content on spirituality even though 56% of respondents felt it should be included in physical therapy curricula.(p157) According to the respondents in the Pitts20 study, 74.9% included topics on how personal spirituality affected patients/clients health; 72.4% included how spirituality affected disease and disability; 70.5% included content on mind, body, and spirit connection; and 67.5% addressed spirituality as a fundamental component of being a human.(p160) Several articles have been written on attitudes of students in medicine, counseling, social work, and nursing regarding spiritual and religious beliefs and how to best teach these topics38-42 whereas physical therapy is just beginning to explore the area.43 In the Handbook of Teaching for Physical Therapists, Shepard and Jensen19 state that the level of comfort in the spiritual domain among physical therapists is variable and that the degree of comfort with a patients spirituality and/or comfort teaching about spirituality is related to the physical therapists own comfort with spirituality.(p58) Puchalski and Larson44 found that medical students experienced an increased comfort level discussing spiritual and religious needs with their patients after attending a course on spirituality. While familiarity with the cognitive components of spirituality is necessary, it is the opportunity to reflect on the meaning of the content in the students life that is most important to enhanced comfort with the spiritual domain.45 Prior to discussing educational goals and content, the physical therapy educator needs to visit the possible concern that teaching about the spiritual or religious needs of patients is contrary to the separation of church and state. According to Chickering13: The question of whether educators should be engaged with college students in matters of spirituality is often raised by those who are concerned that such activities may violate church-state boundaries or are simply too personal and subjective. These concerns appear to be diminishing in higher education for a number of reasons: (1) students are now expressing greater interest and concern about spirituality and are actively pushing institutions to give greater support and attention to this area, (2) there is growing acceptance among college educations and administrators in making a distinction between spirituality and religion and acknowledging that an active engagement of spirituality does not necessarily involve the promotion of religion or violation of churchstate boundaries, (3) the society at
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large is more willing to treat faith and spirituality as important considerations in education and student development, and (4) spiritual search and fulfillment are topics of widespread interest in the popular culture.(p155) The churchstate boundary is not infringed upon as long as the physical therapy educator is diligent in sharing information based on evidence, clearly identifies patient narratives, presents opposing views of the topics, and is vigilant to the danger of misunderstanding student response and/or imposing personal values when assigning grades. Chickering13 observes that in a country with religious pluralism, students need to be familiar with the beliefs of people from diverse cultures, including religious and spiritual experiences. According to Chickering,13 there is no constitutional law averse to teaching about religion/spirituality in state or federally funded institutions, but each institution does have the right to approve course content.(p100) If in doubt about the acceptance at a specific institution, the physical therapy educator should speak with those in authority at his/her institution. Effectively Implementing a Course on Spirituality Educational goals of courses on spirituality. Greenstreet,46 a nurse educator, believes faculty members are responsible for increasing a students awareness of the spiritual needs of patients. Based on the literature and the experience of the author of this paper, the following goals for classes or a course on spirituality should be addressed by physical therapy educators: To increase students awareness of patients/clients spiritual and/or religious needs To assist the student in recognizing the importance of spirituality and religion in becoming a culturally competent practitioner To provide the student with the opportunity to explore definitions of spirituality and religion To assist the student in recognizing his/ her personal biases and beliefs To provide the student with the opportunity to explore the pros and cons of including the patients/clients religious/ spiritual needs in the physical therapy plan of care To clearly delineate physical therapy scope of practice and referral to appropriate services Content. The role of spirituality or spiritual domain in physical therapy practice should
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be included in physical therapy curricula because of its relevance as a tool to reorganize life experiences, a coping mechanism, a component of pain control, an aspect of wellness and cultural competence, and as a component of the Core Values of compassion/caring and professional duty. Content can include characteristics of spirituality and religion as well as components of spiritual distress as outlined in Greenstreets46 article on teaching spirituality to nursing students. Knowledge of spiritual distress can assist the student to interpret the signs a patient/client may manifest during treatment sessions. Knowledge of the biopsychosocial model of health47,48 provides a foundation for discussion on holistic or person-centered care. According to Drench and colleagues,49 the holistic approach to patient care not only incorporates mind, body, and spirit connections but also recognizes support from family, society, and the cultural framework of the patient. Depending on the length of the course or the number of hours devoted to the topic of spiritual and religious needs, content on the psychology of faith and spiritual development can be included. Previous knowledge of ethical principles is useful during classroom and small-group discussions. Students can share knowledge of world religions, which can be useful in understanding religious pluralism when working with a diverse population. Content that addresses effective communication skills is necessary to ensure that misunderstanding does not occur when discussing sensitive topics with the patient. Therefore, the student needs to learn active-listening, observation and questioning skills.46 Of particular importance when developing student interviewing skills in the spiritual domain is providing the student with the tools to assess the patients/clients level of interest in spirituality or religion. Assessment tools such as the FICA,50 HOPE,51 or SPIRITual History2 help the student determine when and how to incorporate a spiritual history into the patient interview in an efficient and effective manner. Koenig7 believes that physical and occupational therapists should assess the spiritual needs of the patients using a spiritual assessment tool and refer to other professionals as necessary. The students success in incorporating spiritual care into physical therapy interventions may be enhanced if they are aware of the possible personal and organizational barriers to recognizing and acting on a patients/ clients spiritual or religious needs. These barriers may include: Preference for the biomedical model, which focuses on finding a cure rather
Journal of Physical Therapy Education

than promotion of healing49 over the biopyschosocial model in approach Comfort with a practice in which the patient is the objective-of-care versus the subject-of-care37 Concern over productivity issues Concern that spiritual and religious needs are beyond the physical therapists scope of practice Discomfort with the idea of discussing a patients/clients spiritual or religious beliefs Students may be able to overcome these barriers if they have knowledge of the literature and organizational policies (eg, mission statements) that may or may not support the inclusion of spiritual and religious needs in patient interaction; they are able to recognize their beliefs and biases, and they are trained how and when to refer patients/clients with spiritual or religious needs to the appropriate source. Physical therapy educators must teach the students to exercise extreme caution when incorporating spirituality into patient/client care. Students need to understand that, as physical therapists, we can never force personal values on patients/clients. Knowledge of the negative, as well as positive, effects of religion and spirituality on a person is crucial. Each of our patients/clients comes to us with a variety of life experiences; some with positive religious and spiritual experiences and others with negative experiences. Religious beliefs have also been associated with negative consequences such as increased obesity, guilt, personal biases, and refusal of medical interventions.22 Care must be taken to assist the student in recognizing when religious or spiritual beliefs may be inhibitory to patient/client progress or emotional wellbeing. Appropriate referrals must be made to provide the level of care needed by patients/ clients on an individual basis. Students must have opportunities to practice clinical decision-making using the biopsychosocial model of health.52 Physical therapists must develop skills that allow them to listen and act without judgment even when the patients/clients verbalize values and beliefs different from the physical therapists values or beliefs. The physical therapy educator can choose strategies based on research that will enhance learning in all domains. Teaching and Evaluation Strategies Research. Research on brain-based learning indicates that learning is enhanced through making meaning of the experience using active engagement.53-56 PET (positron emission tomography) scans indicate increased activity
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in areas of the brain and increased dendritic growth when the student is actively engaged in the learning process. The more engaged the student, the more dendritic interconnections are formed.57 The more the educator incorporates active participation, the more the students brain is stimulated. Additionally, the classroom atmosphere must be one of trust where students and faculty speak freely and with respect for the beliefs of others. Willis57 reports when the brain is overstimulated by stress, learning is diminished because information cannot pass from the sensory memory into long-term storage.(p58) When creating an atmosphere of trust and acceptance while teaching spirituality, the educator must look at all the options and, more importantly, accept the other persons belief system as valuable.3 As educators, we must be as respectful of the beliefs of the students as we would be with our patients/clients beliefs. Bush45 explains that we must engage students through reflection and self-exploration, but we cannot expect this to happen without encouragement and without an atmosphere of trust in the classroom. As educators, creating an atmosphere of trust means that we must be authentic and vulnerable in our interaction with students while appropriately sharing our experiences as practitioners.13,54,56-59 The physical therapy educator must provide the student numerous opportunities for the student to reflect on the content, as well as their biases and beliefs, so that they are not inclined to proselytize their patients. Educators must offer opportunities for the students to share experiences and be watchful for students in distress.45 Like our patients, students bring a variety of experiences to the classroom, both positive and negative, and these memories could elicit feelings of vulnerability or disagreement with the concepts being explored. If students appear to be in distress as result of the content, the educator can meet with them privately or refer them to a counselor or campus minister as appropriate and needed.46 The student must feel safe in offering views that may appear in conflict with the concepts being explored. Andragogy and Brain-Based Learning Theories. The teaching strategies presented in this paper are taken from the literature on andragogy (ie, adult learning theory), which includes brain-based learning and activelearning techniques.13,19,54,56-58,60-62 Although andragogy is closely associated with teaching spirituality, the strategies utilized are not exclusive to education of adults. The adult learner uses past experiences to make connections to new concepts and organizes the material in meaningful ways allowing learn32

Table 1. Strategies for Teaching Spirituality in the Classroom and Clinic

Classroom
Case studies Journal of student experience/beliefs Brainstorming in class Role play Concept/mind map Literature search Web sites Spiritual autobiography Lecture On-line discussions Think-pair-share Group activities

Clinic
Real patient situations Journal of student experience/beliefs One-on-one discussion Shadow pastoral-care professional Concept/mind map Literature search Web sites Spiritual autobiography Modeling by physical therapist On-line discussions

ing to occur. However, educators addressed the value of learning through experience before the theories associated with andragogy were proposed.54,58,60 Leaders in the field of andragogy have indicated that transformative learning, often associated with andragogy, utilizes reflection on an experience that promotes meaningful learning, resulting in the learner being changed as a result of the experience.58 Active-learning strategies, such as reflection, narrative, and student-determined learning outcomeseach associated with andragogycan facilitate meaningful learning in the spiritual domain. Chickering13 suggests that reflection is necessary to convert experience into knowledge that can be used regardless of the context.(p143) Strategies. There are a variety of strategies available to teach students about the spiritual and religious needs of the patient. Lecture is certainly a tool that allows the educator to share information in an efficient manner. However, in order to facilitate retention and recall, lecture supplemented by active-learning techniques that engage the student is most useful. There are several active-learning methods that can be utilized. For example, mind/thinking/concept maps allow learners to organize key events in life or key concepts that have impacted their understanding of spirituality.19,56,61,63,64 A spiritual autobiography/narrative, journals, 5-minute writing exercises, and reaction papers all use learners past experiences and make meaning for the learning experience (Table 1). Tisdell54 advocates the use of a spiritual narrative to assist the student in making meaning of new material, thus enhancing retention and recall of the concepts. A spiritual narrative activity asks the students to think about their life experiences and consider how those experiences shape their view of the world. The student would then read articles or other
Journal of Physical Therapy Education

students narratives and reflect on how their views may be different had they had the experiences about which they read. The opportunity then exists for the student to leave the experience with an enlarged understanding of why and how people make decisions that may be different from their own. In order to increase their level of comfort with the spiritual domain, students require the opportunity to reflect on their personal beliefs about religion and spirituality. Ingersoll41 suggests that students should reflect on their spiritual traditions throughout their lifespan, a task that may be extremely challenging for many students. Journaling is a method that could assist the student to understand past experiences in light of new information. Journaling helps refine thinking, either through directed questions or freethinking techniques.56 Journals and spiritual autobiographies are more private in nature, are usually not shared with classmates, and allow the student to process their thoughts at their own speed.45 The resulting learning experiences can be transformative. Shepard and Jensen19 indicate that active-learning can be perceived as risky because it involves new skills for both the student and the educator; however, research indicates that learning is enhanced by using active-learning techniques. Discussion of beliefs can be challenging in a large-class format; therefore, educators may want to use techniques that will minimize student and educator discomfort. Examples of useful active-learning strategies are brainstorming, think-pair-share, and a variety of small-group activities. In a large group, brainstorming can be used to help students identify characteristics of spirituality and religion without attaching value judgments.65 The educator establishes the ground rule that the purpose of brainstorming is idea generation and not an analysis of values, thus
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Table 2. Group Activities to Enhance Knowledge of the Spiritual Domain

Classroom
Identify characteristics of spirituality and religion

Clinic
Present an in-service on how to incorporate spirituality into daily care and increase patient/client satisfaction with the clinic Present an in-service on how to implement spirituality in a clinic with a highproductivity requirement Present the differences/similarities between secular and religious spirituality and how to appropriately incorporate each depending on the mission of the institution

Present a group project on how to implement spirituality in a clinic with a high-productivity requirement Present the differences/similarities between secular and religious spirituality and how to appropriately incorporate each depending on the mission of the institution Brainstorm on positives and negatives of discussing spirituality or religion with patients/clients Prepare a debate of pros and cons of incorporating spirituality into patient/ client care

diminishing student and faculty discomfort. The think-pair-share technique can be useful in giving the student time to think about a concept without feeling that an immediate response is expected. One student is paired with another and after considering the question independently, the 2 students discuss their thoughts. Finally, their thoughts can be shared with the class. The use of the think-pair-share method can be especially helpful with the more reticent student. Think-pair-share provides a mini-break during lecture, decreases anxiety, and promotes improved retention of material.57,62,65 Finally, the use of small groups can facilitate the sharing of beliefs in a less intimidating format. Each small group is responsible for sharing their outcomes with the entire class, but the perceived protection of the group may allow a deeper discussion to occur. Tisdell54 believes that small-group work allows the learner to experience the communal component of spirituality and work for social justice and greater equity in the world, concepts that support the Core Values. Case studies are one example of a small-group activity that can reduce student stress and encourage collaboration, thus enhancing retention and recall of content.57 The students give their rationale for the choices they make when determining if, when, and/or how the patients/clients spiritual or religious needs are included as part of physical therapy interventions. Case studies that recognize the patient/client as a contributor to the physical therapy plan of care are useful in reinforcing the World Health Organizations International Classification of Function model as the students practice clinical reasoning skills.52 Other examples of small-group activities for both
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the classroom and the clinic can be found in Table 2. Role playing can be incorporated into the learning module allowing the students to experience human interaction and practice communication skills, conflict management, and interpretation of meaning.19,56,66 Examples of role-playing scenarios include: physical therapists with opposing views of incorporating spirituality or religious beliefs into patient care (with the students acting as patient and therapist), patient/client and pastoral-care professional, physical therapist and family member, and physical therapist who oversteps boundaries and pushes his or her beliefs onto the patient/client. The educator gives the students a script to follow and all students write a reflection on their personal reactions to the topic and/or other thoughts they would like to explore related to the topic. The use of debate can be effective in providing the students the opportunity to consider the pros and cons of a stance, such as whether a physical therapist should talk to his or her patients/clients about the their spiritual or religious needs.19,67 Students prepare their point of view and present it to their classmates. The classmates are expected to participate since they must decide which point of view resonates with them in a reflection paper or small-group discussion. The value of active-learning techniques (eg, the mind/concept map, journal, spiritual narrative, spiritual autobiography, or a variety of small-group activities) is that each requires the students to reflect on their beliefs or growth throughout their lives and provides the student with opportunities to utilize verbal or visual representation of concepts, thus strengthening their learning.58
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Whether content on spirituality is designated as part of a distance-learning course or is housed in a traditional classroom format, online discussion formats can be useful in promoting discussion of sensitive issues or challenging concepts. The educator posts a question and each student gives a response. The educator can also request that students respond to questions related to readings or comments by classmates. According to Conrad and Donaldson,68 the use of asynchronous activities can support more in-depth reflection. Students have the time to reflect and develop their responses at their own pace. Their responses are independent of the response rate of their classmates. Even the most introverted of students tends to respond when using the discussion-board format because it allows them to feel comfortable about their responses before posting it for the entire group to read. Another online technique that is effective in increasing the students knowledge base is to have each student read an article related to spirituality/religion and disability/ physical therapy. The student then posts an annotated bibliography summarizing the key concepts in the article and poses a question to be answered by one or more classmates.58 In keeping with the theory of andragogy and brain-based learning, this technique allows students to identify an area of personal interest and share this information with classmates. Students can be responsible for facilitating the discussions generated. The educator may desire to assign points on how well learners developed their responses or may choose to assign points based on the number of times learners accessed the discussion board. In either case, the use of a rubric outlining the assignment of points is helpful in assisting the student in organizing his or her learning experience.57 In the clinic, one of the most effective teaching strategies the clinical educator can use is modeling of spiritual care by members of the health care team.58 The clinical educator cues the student to observe how the patients/clients spiritual and/or religious needs are addressed by health care and pastoral care professionals. For example, the student watches the clinician incorporate questions aimed at spiritual care of the patient during the subjective interview. The student may also observe the physical therapist utilize active listening skills to support the patients spiritual needs or as a tool to recognize that the patient may be experiencing spiritual distress. Accordingly, the physical therapist may ask the patient if the patient would like someone from pastoral care to visit. Observation of spiritual care by the physical thera33

pist, pastoral-care professional or health-care providers can provide the student with the opportunity to reflect on how to maximize the spiritual domain as a coping mechanism and is supported by the work of Bandura58 on observational learning. The clinical educator can further encourage growth in spiritual care by participating in one-on-one discussions with the student about how patients/clients may use their beliefs in either a positive or negative manner to cope with the situation at hand. Puchalski and Larson44 suggest that such a discussion can provide the student the opportunity to practice ways to respond to present and future situations. CONCLUSION AND RECOMMENDATIONS Knowledge of the spiritual domain is a necessary component of patient-centered care, wellness, cultural competence, and building trusting relationships. Spirituality is recognized by The Joint Commission as critical to comprehensive care.35 Attention to spirituality and the spiritual domain can provide the patient/client with strategies to cope with life-altering events and assist in the patients/ clients restructuring of life following injury. The physical therapists level of comfort with the spiritual domain informs his or her ability to address the patients spiritual and/or religious needs in the plan of care. In order to prepare students to function in a culturally diverse health care system, physical therapy educators should include spirituality in physical therapy curricula, whether postgraduate or professional. Physical therapist students need the opportunity to gain knowledge in the spiritual domain, explore their biases and beliefs, and practice techniques for the inclusion of the spiritual domain in patient care. The purpose of including content on spirituality as a course or as a unit across one or more courses is to provide students with the knowledge and skills to assess and address the spiritual needs of their patients/clients. The exposure each student has to the spiritual domain will be dictated by the time allotted in the programs curriculum. Some programs will only be able to devote 2-3 contact hours on the topic, while others will be able to do more, perhaps an entire course. Class hours are less important than the opportunity for the students to reflect on their beliefs and explore the evidence that the spiritual domain is an important component of health, wellness, and recovery. At the very least, students can understand the differences and similarities between spirituality and religion. Students must first
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explore their own spiritual and religious beliefs and those of their fellow classmates so that they can approach the spiritual and religious needs of the patient/client without imposing their beliefs into the situation. Next, they develop the skills to recognize the spiritual needs of the patient/client through observation of patients/clients and their surroundings. By listening and asking respectful questions about the spiritual and religious beliefs of patients, the students can establish a trusting relationship with their patients. Finally, students demonstrate APTAs Core Values of compassion/caring and professional duty by incorporating the beliefs of the patient into patient goals and interventions, making referrals to other services, recognizing the limits of physical therapy scope of practice, and providing physical therapy management. Despite all of the literature regarding the value of embracing spirituality in health care available from other professions, little research on the topic has been done in physical therapy. Formal research on the value of spirituality or the spiritual domain in physical therapy curricula and assessment of teaching strategies and outcomes needs to be conducted. REFERENCES
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