Improving Outcomes for ICU Family Members: The Role of Spiritual Care.

Having a family member hospitalized in the intensive care unit (ICU) can be a stressful experience for family members, encompassing both psychological and spiritual distress. With over 5 million ICU admissions annually in the United States, it is imperative to enhance the experiences and coping mechanisms of ICU family members. In particularly challenging situations, some family members even face psychological effects known as post-intensive care syndrome-family, which includes anxiety, depression, and posttraumatic stress. The distress may be worsened when patients and families experience poor communication or medical care, which has been shown to be more common among minoritized populations including Black and Hispanic patients and families. Family members' emotional and spiritual distress also has an effect on the medical decisions they make for the patient. While research has delved into the impact of spiritual care for ICU family members, further investigation is still needed to determine the most effective approaches for delivering such care. This narrative review will describe a conceptual model aimed at guiding future research in this endeavor. The model proposes that chaplains provide emotional, spiritual, and information support to ICU family members. This affects both their ICU experience, decision making, and outcomes for the patient and family. This process is also affected by characteristics of the family such as race, ethnicity, and economic status. This model helps identify gaps in research, including the need for randomized trials of spiritual care that identify mechanisms underlying outcomes and demonstrate impact of spiritual care, and consider race, ethnicity, and other characteristics.

Understanding non-pharmacological palliative care for people with serious COPD: the individual and organizational perspective.

TOPIC IMPORTANCE: This narrative review emphasizes the growing interest in palliative care for people with serious lung diseases, such as COPD. It reflects upon recent publications from the American Thoracic Society (ATS), the World Health Organization (WHO) and European Respiratory Society (ERS) with a focus on non-pharmacological palliative care for people with COPD, from both the healthcare professional and the organizational perspective. REVIEW FINDINGS: The concept of palliative care has changed over time and is now seen as applicable throughout the whole disease trajectory according to need, in conjunction with any disease-modifying therapies. Palliative care should pay attention to the needs of the person with COPD as well as the informal caregiver. Timely integration of palliative care with disease-modifying treatment requires assessment of needs at the individual level as well as organizational changes. High-quality communication, including advance care planning is a cornerstone of palliative care. SUMMARY: Therefore, services should be based on the understanding that palliative care is not just specific standardized actions and treatments, but a holistic approach that includes compassionate communication and treatment and care addressing the patient, informal and formal caregivers. Living with and dying from COPD is much more than objective measurements. It is the sum of relationships with others and the experience of living in the best possible harmony with one's own values and hopes despite having a serious illness.

The Spiritual Well-Being Scale in the Polish Catholic Setting: Construct, Structure, and Relationships with Psychological Well-Being.

The population of Poland could be of particular interest to researchers studying religion and spirituality. Catholicism has played a significant role in shaping the country's culture, history, and tradition and is considered a national religion. More recently, however, the processes of moving away from regular participation in religious services and loosening ties with the institution of the Catholic Church are marked (Polish Public Opinion Research Center, CBOS). The Polish Catholic setting may modify the associations between psychological variables that have been studied in their relationships with spirituality, which have been investigated in religious contexts differing from a Polish Catholic one. Given this context, we examined the internal structure of spiritual well-being in the sample of present-day Polish Catholics (Study 1) and how spiritual well-being is related to mental health (Study 2). The internal structure of the Spiritual Well-Being Scale was replicated in the Polish sample, but only positively worded items loaded on the Religious and Existential Well-Being subscales. Spiritual well-being was positively related to positive mood, satisfaction with life, and psychological well-being; it was negatively associated with negative mood, depression, and anxiety, thus remaining significantly related to psychological well-being among Polish Catholics.

Predictive role of spiritual health, resilience, and mental well-being in treatment adherence among hemodialysis patients.

BACKGROUND: End-stage renal disease (ESRD) causes numerous physical and psychological problems in patients, so that they must adhere to their treatment regimen to recover their disease, alleviate these problems, and increase their lifespan. The present study aimed to determine the predictive role of spiritual health, resilience, and mental well-being in treatment adherence among hemodialysis patients. METHODS: This correlational cross-sectional study investigated some variables related to treatment adherence in 184 patients undergoing hemodialysis referred to two dialysis centers in Kerman, southeastern Iran. A census method was used to select the participants and data were collected using socio-demographic characteristics questionnaire, Adherence to Treatment Questionnaire (ATQ), Conner-Davidson Resilience Scale, Reef Psychological well-being Questionnaire, and Spiritual Well-Being Scale (SWBS). RESULTS: The overall treatment adherence score was 155.42 ± 27.98 and we found a positive significant correlation between spiritual health, resilience, psychological well-being, and treatment adherence (p < 0.001). The mean scores of resilience, spiritual health and psychological well-being were 70.59 ± 17.02, 90.09 ± 12.01, and 77.88 ± 11.72, respectively. Spiritual health, psychological well-being, resilience, gender and marital status predicted 54% of the variance of treatment adherence, with psychological well-being being the best predictor (p < 0.001). CONCLUSIONS: Spiritual health, psychological well-being, and resilience are factors that influence treatment adherence of the patients undergoing hemodialysis, with psychological well-being having the greatest contribution to improving patient's treatment adherence. Interventions effective in improving psychological well-being, spiritual health and resilience can improve treatment adherence of patients undergoing hemodialysis. Healthcare workers must pay more attention to the factors affecting treatment adherence of patients undergoing hemodialysis.

Intersections of Compassion, Science, and Spiritual Care in Global Health for Public Health Benefits.

Across the globe, spiritual care is offered by individuals, healthcare chaplains, and humanitarian, social and related spiritual groups on account of zeal, voluntary and paid services. Sometimes, services are provided without understanding the connectivity of compassion, spiritual care, and scientific protocols. There are instances where health professionals and managers disagree with spiritual caregivers or reject spiritual services because of poor service deliveries in conflict with healthcare protocols. Against this background, this article focuses on how spiritual care services can be provided scientifically to improve service delivery. It presents leading questions to link the scientific and compassionate approach to spiritual care. These include-What is science? What is compassion? What is spiritual care? What makes compassion and spiritual care scientific? Are there tenets of compassion in religions? How are compassion, science and spiritual care linked? What are the implications of the intersections for public health and safety? Hopefully, the provided answers may improve the service delivery performance of spiritual caregivers and their collaboration with healthcare professionals, social workers, and related groups.

Exploring the influence of spiritual leadership, leader - member exchange, and traditionality orientation on employee voice behavior.

This research builds on the idea that the exchange of resources between leaders and followers can influence the behavior of employees. Specifically, the study investigates how leaders can develop strong leader-member exchange (LMX) with their followers, and how this exchange can lead to increased employee voice behavior. The study analyzed data collected from 365 individual employees working in Chinese organization. The findings indicate that LMX acts as a mediator between spiritual leadership and employee voice behavior. The strength of this mediation, however, depends on the followers' level of traditionality orientation. Notably, the findings indicate that the effect is significant only among individuals who exhibit low traditionality. Theoretical contributions and implications for practice are discussed in later sections.

The impacts of cancer treatment on lifestyle habits and mental health in Vietnamese women: an exploratory qualitative study.

AIMS: This qualitative study explores the experiences of women after cancer treatment in terms of habit changes and mental health impact. METHOD: The study involved 10 women who had undergone cancer treatment, recruited from three major hospitals in Hanoi, Vietnam. Data were collected through semi-structured interviews, which were transcribed and analyzed using thematic analysis. RESULTS: The findings of the study shed light on the various factors influencing lifestyle behavior and mental health changes among women after cancer treatment. Ten participants, aged 39 to 64 years, shared experiences including dietary changes, sleep disruptions, and reliance on non-scientific sources for health decisions. Initially shocked by their diagnosis, many transitioned to acceptance, adopting a "giving-in" attitude. Cultural beliefs, word-of-mouth sharing, and social support networks played significant roles in shaping post-treatment lifestyle changes, coping mechanisms, information-seeking behaviors, and mental health. CONCLUSION: The study highlights the need for accessible and scientifically verified information for women after cancer treatment to make informed decisions about their health. It emphasizes the importance of addressing traditional beliefs and promoting evidence-based practices. Moreover, the study underscores the importance of social support and relationships in coping with the challenges of post-cancer experiences.

Adventure and mental health: an ecological perspective.

In this paper, we explore the concept of outdoor adventure in the context of mental health, proposing an ecological perspective to redefine adventure beyond its traditional associations with risk and physical challenge. We critically examine current frameworks and definitions of adventure, which often emphasise specific activities and natural environments yet overlook the individual's experience and potential mental health benefits. From an ecological perspective, we emphasise the dynamic interplay between the individual, the activity, and the environment. This approach, grounded in ecological psychology, considers the multi-dimensional nature of adventure, including social, psychological, physical, and spiritual aspects. The paper challenges the traditional risk-focused view of adventure, advocating for a broader definition that includes diverse experiences and interactions, as well as the transformative potential of adventure in various environments, including urban settings. We highlight the changing demographics and motivations of adventure participants, moving away from the stereotypical young male risk-seeker, to more diverse and inclusive participant profiles. We argue that adventure facilitates the realisation of fundamental human affordances, often untapped in daily life, thereby enhancing mental health and wellbeing. This ecological perspective opens new avenues for understanding the role of adventure in mental health and wellbeing, offering a more comprehensive and inclusive approach to adventure activities as therapeutic interventions. This redefined understanding of adventure emphasises its potential as a powerful tool for enhancing human wellbeing, harmonising the relationship between people, tasks, and the environment, and offering profound implications for mental health contexts.

Positive Social Mentalities and Quality of Spiritual Living in Old Age: Roles of Social Participation and Life Meaning.

Quality of spiritual living (QSL) in old age is closely related to the health and well-being of older adults. It is necessary to explore the psychosocial factors and mechanisms that affect the QSL of older adults. The researchers investigated 512 older Chinese people using the positive social mentalities scale, social participation scale, sense of life meaning scale, and spiritual living self-assessment questionnaire. (1) Positive social mentalities (PSMs), social participation (SP), and life meaning (LM) had significant positive correlations with QSL of older adults; (2) SP and LM had serial mediating effects between PSMs and QSL. PSMs influenced QSL through the serial mediating effects of SP and LM. It revealed the critical psychosocial factors and the mechanism affecting QSL in old age, which can provide scientific reference for implementing an active aging strategy.

How emotional contagion shapes spiritual care competence: Insights from a cross-sectional study on intensive care nurses.

BACKGROUND: Intensive care units (ICUs) are environments where nurses are open to emotional interactions because of complex structures and dynamic relationships. Nurses' susceptibility to emotional contagion and their spiritual care competence may affect the quality of care by influencing their ability to manage and respond to the emotional dynamics present in these environments. AIM: This study aimed to determine the level of emotional contagion and spiritual care competence in intensive care nurses. STUDY DESIGN: This study is a descriptive cross-sectional study conducted with 199 nurses working in the ICUs of a training and research hospital in Turkey. The data were collected between December 2021 and June 2022 using the Emotional Contagion Scale (ECS) and the Spiritual Care Competence Scale (SCCS). RESULTS: The mean score of the nurses was 50.29 ± 15.36 on the ECS and 90.29 ± 29.53 on the SCCS. A statistically significant difference was found between the ECS and SCCS and gender, marital status, weekly working hours and some approaches about spiritual care (p < .05). It was determined that there was a statistically significant positive correlation between the total scales and sub-dimensions of the ECS and SCCS (p < .05). In this study, it was found that intensive care nurses' susceptibility to emotional contagion was high, and that their spiritual care competence was at a moderate level. The results show that gender, marital status, weekly working hours, type of ICU and some approaches about spiritual care are crucial factors in nurses' emotional contagion and spiritual care competence. In addition, as the intensive care nurses' susceptibility to emotional contagion increased, their spiritual care competence also increased. CONCLUSIONS: The results of this study will guide the planning of interventions to protect intensive care nurses from the negative effects of emotional contagion and increase their spiritual care competence. RELEVANCE TO CLINICAL PRACTICE: It is necessary to protect intensive care nurses from the negative effects of emotional contagion and to increase their competences in spiritual care.

Forgiveness and Religiosity Among Nurses: A Correlational Descriptive Study.

The purpose of the study was to explore how nurses' religious beliefs affect their ability to forgive themselves and others. Design: A descriptive correlational mixed methods approach was employed. Methods: The data were collected using an online survey via Qualtrics using three validated tools Enright Forgiveness Inventory - 30 (to measure forgiveness of others), Enright Self-Forgiveness Inventory (to measure forgiveness of self), and Duke University Religious Index (to measure religiosity). Findings: As hypothesized, there was a meaningful relationship between forgiveness of others and intrinsic religiosity. Nurses with intrinsic religiosity or internal beliefs of a higher being showed a higher level of forgiveness toward their offender. The nurse forgiving the offender chose to replace negative, hurtful feelings with positive emotions such as compassion and love. Conclusion: Stressed nurses become distracted, may miss effective job performance, and patient care may suffer. Emotional and spiritual health and better patient outcomes can be attributed to the nurse forgiving others and the self. Nurses must be self-aware to develop forgiveness strategies for their well-being and provide effective care. Faculty should teach "person-centered" care and educate students to forgive others and themselves for effective patient care.

Interpersonal and individual effects of an app-based Christian and Islamic heart meditation intervention in healthy adults: protocol of a stratified randomised controlled trial.

BACKGROUND: The academic development and widespread adoption of meditation practices for well-being and therapy have predominantly focused on secularised adaptations of Buddhist and Hindu techniques. This study aims to expand the field by investigating Christian and Islamic meditation that emphasize the spiritual significance of the heart through elements of visualisation and recitation. It compares the effects of spiritual heart-centred meditation with mindfulness meditation and a waitlist control, focusing on dimensions of social functioning, psychophysiology, cognition, and mental health. METHOD: This study employs a stratified 3-arm randomised controlled method with mixed-method repeated measures across three assessment time points: before intervention (T1), after an 8-week intervention (T2), and at a 3-month follow up (T3). The three conditions include spiritual meditation (either Christian or Islamic), mindfulness meditation (Mindfulness-Based Stress Reduction - MBSR), and a waitlist. Participants will be stratified into Christian and Muslim samples and randomly allocated to the spiritual meditation, MBSR, or waitlist control conditions. Importantly, participants assigned to the spiritual meditation condition will be matched to the spiritual meditation program corresponding to their religion. The intervention will be administered through a mobile phone app with daily 20-minute guided meditation sessions for eight weeks. Primary outcomes pertain to the domain of interpersonal functioning, focusing on prosociality, forgiveness, empathy, and perspective taking. Secondary outcomes include physiology: pain tolerance, pain intensity, stress reactivity assessed via heart rate (HR) and heart rate variability (HRV), psychophysiological reactivity associated with a forgiveness task as measured through HR and HRV, attention (alerting, orienting, and executive attention networks), and mental health (stress, depression, anxiety, subjective well-being, positive and negative affect). DISCUSSION: This trial aims to test the effects of an app-based Christian and Islamic meditation, compared to secular mindfulness and a waitlist, using a randomised controlled trial. If the results yield positive outcomes, this study will support the efficacy of these contemplations, offering practitioners a way to enhance their well-being within their religious framework. TRIAL REGISTRATION: ClinicalTrials.gov, NCT06136676. Registered on 18 November 2023. https://clinicaltrials.gov/study/NCT06136676 .

The Effects of Spiritual Care with and Without Aromatherapy on the Sleep Quality of Prisoners Referred to the Emergency Department of the Prison Clinic in Iran: A Randomized Clinical Trial.

Rest and sleep are health fundamentals and essential phases of human life rhythms. Sleep disturbances can negatively affect an individual's physical and mental balance. Due to the psychological pressure resulting from problems, prisoners experience more sleep disturbances than other people. Therefore, this study aimed to compare the effects of spiritual care with and without aromatherapy on the sleep quality of prisoners in the emergency department of the central prison clinic in Sanandaj County. A single-blind clinical trial was conducted on 90 male prisoners of the emergency department of the central prison clinic in Sanandaj, Kurdistan-Iran, and they were randomly assigned to three groups: spiritual care (intervention 1), spiritual care with aromatherapy (intervention 2), and control group. Spiritual care and aromatherapy, along with spiritual care interventions, were performed using lavender essence for one month. Data collection was performed using a demographic checklist and the pittsburgh sleep quality index before and after the interventions. The collected data were analyzed using descriptive and analytical statistical methods in SPSS.26. The mean age of the prisoners was 34.99 ± 7.011 years, 75.6% had a diploma or lower education level, and 46.7% had been imprisoned for more than one year. At baseline, the mean sleep quality score was 9.33 ± 3.55 in intervention group 1, 9.53 ± 4.06 in intervention group 2, and 10.50 ± 3.59 in the control group, with no significant difference between the groups (p = 0.413). After the interventions, the mean sleep quality score was 8.40 ± 2.94 in intervention group 1, 7.86 ± 4.90 in intervention group 2, and 11.23 ± 3.81 in the control group, showing a significant difference between the groups (p = 0.002). According to findings, aromatherapy, along with spiritual care, significantly improved the sleep quality of prisoners (p = 0.003), but spiritual care alone was not effective (p = 0.137). Aromatherapy-based spiritual care improved the sleep quality of prisoners; hence, considering the congruency of spirituality with pleasant scents symbolizing cleanliness and aligning with human nature and religious recommendations, the combination of these two interventions can be used to enhance the sleep quality of prisoners.

Fire Kasina advanced meditation produces experiences comparable to psychedelic and near-death experiences: A pilot study.

Psychedelic-assisted therapy studies suggest that the induction of "mystical experiences" combined with psycho-therapy is a possible intervention for psychiatric illness. Advanced meditation may induce powerful experiences comparable to psychedelics. We investigated effects of an intensive meditation practice called Fire Kasina. Six individuals completed a retreat, and participated in an interview in which they described their experiences. They also completed the Revised Mystical Experience Questionnaire (MEQ), Hood Mystical Experience Scale (HME), and Cole's Spiritual Transformation Scale. Mean MEQ scores were 85 %, similar to prior observations of high-dose psilocybin and were stronger than moderate-dose psilocybin (t(5) = 4.41, p = 0.007, d = 1.80; W(5) = 21, p = 0.031). Mean HME scores were 93 %, exceeding levels reported for NDEs (mean 74 %) and high-dose psilocybin (mean 77 %). In qualitative analysis, experiences were described as the most intense of the individual's life, while subsequent transformational effects included substantial shifts in worldview.

Determining the Spiritual Care and Comfort Needs of Patients Having Undergone Open-Heart Surgery: Cross-Sectional Descriptive Study in Turkey.

This study was aimed at determining the spiritual care and comfort needs of patients having undergone open-heart surgery. This cross-sectional descriptive study was conducted with 147 patients in the Cardiovascular Surgery Intensive Care Unit of a training and research hospital in Izmir, a province in western Turkey, between May 1, 2022 and November 1, 2022. The comfort level of the patients who had undergone open-heart surgery was moderate, and the levels of their spiritual care needs were high. A statistically significant relationship was found between the patients' Perianesthesia Comfort Scale total score and the Spiritual Care Needs Inventory (p < 0.05). We concluded that the patients' comfort levels decreased as their spiritual care needs increased. We recommend authors to conduct studies in the future which should include different sample groups and compare the data obtained before and after the surgery.

Investigation of Hope and Spiritual Well-Being Levels among Relatives of Intensive Care Patients in Turkey.

This study was conducted to determine the levels of hope and spiritual well-being among relatives of intensive care patients. The data were collected using the Patient Descriptive Information Form, Trait Hope Scale, and Spiritual Well-Being Scale. The mean total scores on the Trait Hope Scale and the Spiritual Well-Being Scale were 48.24 ± 8.37 and 104.99 ± 8.06, respectively. The mean scores on the Trait Hope Scale differed significantly according to the employment status, income status, and the reaction of the patient's relatives during the visit (p < 0.05). A significant difference was found between the mean scores of patient relatives on the Spiritual Well-Being Scale according to the level of education, income, and the intensive care unit where the patient was hospitalized (p < 0.05). A significant positive correlation was found between the Trait Hope Scale and the Spiritual Well-Being Scale (p < 0.05). This study found that patient relatives had good hope and spiritual well-being levels, and spiritual well-being increased the level of hope among patient relatives.

The Enhancing of Nurses' and Midwives' Competence in Providing Spiritual Care through Innovative Education and Compassionate Care using the Spiritual Care Competency Self-Assessment Tool: Turkish Version.

Spiritual care is an important part of holistic care and is at the center of nursing/midwifery care. Nurses/midwives are expected to graduate by receiving adequate training in spiritual care and gaining spiritual care competence during their student days. It is important to evaluate the spiritual care competencies of nursing/midwifery students and to correct the deficiencies, if any. Therefore, a self-assessment tool is needed to increase awareness and knowledge and improve skills and attitudes in the field of spirituality and pastoral care. One of these tools is EPICC (Enhancing Nurses' and Midwives' Competence in Providing Spiritual Care through Innovative Education and Compassionate Care). This EPICC Spiritual Care Education Standard describes the spiritual care competencies expected from undergraduate nursing and midwifery students. For every competence, the learning outcomes are described in aspects of knowledge, skills, and attitudes. This research was conducted with a methodological design to ensure that the Turkish version of the EPICC Spiritual Care Competency Self-Assessment Tool can be used as a reliable and valid measurement tool in nursing research in Turkey. Methodological and cross-sectional research design was used in the research method. The research was carried out with 300 nursing and midwifery students in Turkey. Data were collected using the personal information form and the EPICC Spiritual Care Competency Self-Assessment Tool. The results of exploratory factor analysis and confirmatory factor analysis confirmed the four-factor structure of the scale. Cronbach's α, item-total correlation, test-retest analysis, and equivalent form analysis showed high reliability. EPICC Spiritual Care Competency Self-Assessment Tool For Student Nurses And Midwives: Turkish Validity And Reliability Study consists of 24 items on a five-point Likert-type scale. The Turkish version of the EPICC Spiritual Care Competency Self-Assessment Tool is a valid and reliable tool for assessing the Spiritual Care Competencies of nursing and midwifery students. Evaluating the Spiritual Care Competencies of nursing and midwifery students is an important issue, it is now possible in Turkey with this scale given its validity and reliability.

Chaplains' reports of integration in community health initiatives: a qualitative study.

Health care and religious organizations have a long history with one another. Chaplains' investments in the health and wellbeing of their local communities have extended beyond the hospital walls for longer than many chaplains may recognize. However, the published evidence suggests these efforts have been limited. Given the history of health care evolution in the United States, the small evidence of cases highlighting chaplains' leadership within community health initiatives, and the pressure for health systems to address the social determinants of health, we sought to explore chaplains' integration in community health and wellness initiatives. This paper presents the results of a qualitative analysis of interviews with chaplains working to promote community health and wellness (n = 10). The identified themes highlight factors at the individual chaplain level, such as how chaplains got involved, characteristics of the chaplains' contexts, and the impact of chaplains' involvement.

Expanding Access through Representation and Inclusion in the Spiritual Care Workforce: An Exploratory Qualitative Examination of Insights from Somali Muslim Chaplains and their Educators in the USA.

Diversifying the chaplain workforce in hospital spiritual care departments and Clinical Pastoral Education (CPE) programs is essential for meeting the needs of a religiously diverse population in the USA. We interviewed seven total participants, including two Somali Muslim chaplain students and their Muslim and Christian chaplain educators in one CPE program. Participants described their personal journeys and motivations for pursuing careers in healthcare chaplaincy, their impact on hospitalized patients, and the role of expanding perspectives for those with little prior exposure to Somali Muslim faith leaders. Representation and linguistic diversity were viewed as positive attributes despite challenges of racial and religious discrimination. Recommendations include adjusting educational requirements for entry into the field to consider professional equivalencies; engaging community chaplains; and collaborating with local communities. These findings have important implications on creating pathways for spiritual care providers from underrepresented faith traditions to meet local community needs.

Spiritual assessment in palliative care: multicentre study.

OBJECTIVES: This study aims to provide an in-depth exploration of everyday spiritual concerns of patients with advanced cancer seeking palliative care in Bangladesh, and assess their spiritual well-being (SWB). METHODS: This study was conducted among 163 patients with advanced cancer from three tertiary care hospitals in Bangladesh. It was divided into two parts: a quantitative segment that assessed the SWB of the participants using the EORTC QLQ SWB32, and a qualitative segment that explored their spiritual history. RESULT: Spirituality was commonly interpreted and understood synonymously with religion by all participants, and their sense of life's meaning centred on their families and friends. The lack of support from religious organisations led to feelings of isolation and disconnection from spiritual communities. Highest scores in SWB were observed in Relationships with God and Someone/Something Greater Scales. The lowest score was observed for Existential fulfilment. Patients expressed a desire for their palliative care team to address their spiritual concerns, regardless of their training in this area. CONCLUSION: Spirituality is a deeply personal aspect of the human experience. Understanding and respecting these beliefs can empower palliative care professionals to deliver culturally sensitive care to their patients, irrespective of their level of training.