Keywords

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7.1 Contributions

Looking back, the search for a culturally sensitive and effective way to enhance the spiritual well-Being of Chinese older adults has been both a challenging and joyful journey. The original idea came from a group of frontline social workers, passionate about supporting the elderly, who were puzzled by the findings of a research study saying that their proposed palliative care intervention was not effective in enhancing spiritual well-Being. My curiosity was immediately sparked, and I volunteered three hypotheses: First, the power of the intervention study had been limited by its design; second, the intervention itself had not had enough impact (limited effect size); and third, the measurement and intervention did not match one other (or, in other words, the outcome measures used for spiritual well-Being did not match the outcomes intended by the intervention). My community partner (Tung Wah Group of Hospitals) commented that this third hypothesis was worth further exploration for two reasons. Firstly, spiritual well-Being is not part of the public discourse in the Chinese context, regardless of the academic research position. Secondly, spiritual well-Being was an essential element of the whole-person caring philosophy adopted by the agency offering the intervention. After a few meetings, the research team and social workers agreed to pursue our common goal and support was obtained for the studies reported in this book.

The most challenging aspect of this work, at least initially, was finding a way to conceptualize spiritual well-Being in the Chinese context. There are linguistic obstacles to selecting an appropriate Chinese word that is capable of communicating to lay people while still being academically meaningful. The team confronted the theoretical tension between a Western tradition that has tended to integrate religiosity with spirituality and a Chinese tradition that stresses the unity of humans with the environment. Questions were also posed by frontline social workers about the meaning of spiritual well-Being and whether it is feasible for them to implement professional interventions. Having completed the work, it is moving now to recall how these challenges were openly shared within the research and community partner teams, and the tremendous trust developed between us that led to constructive and creative solutions being found. As a team, we always reminded ourselves that we were not aiming to develop the “right” conceptualization of spiritual well-Being. Instead, we sought to arrive at a culturally sensitive and contextually appropriate notion that would guide an effective intervention and enable holistic care to be better actualized in the Chinese context. Based on such a humble passion, we are proud to be able to conclude that we have achieved our goals in at least four ways.

Firstly, we have conceptualized spiritual well-Being as a dynamic process in which individuals generate transcendent forces through harmonious relationships with self, family, others, and the environment. This conceptualization contributes to the expansion of the literature on spiritual well-Being by putting forward culturally and contextually relevant perspectives. Chinese culture is in a general sense nonreligious, so our conceptualization purposefully excluded the element of religious beliefs, practices, and rituals. Chinese social context is most often considered relational, with a strong emphasis placed on the relationship between human beings and their surroundings (social and physical) in terms of social cognition, self-constructs, interpersonal relationships, organizational behavior, and even governance. Hence, our conceptualization here has focused on the relational aspect by crystallizing relationships into four key domains: self, family, friends and others, and the environment. These layers have helped to generate meaningful intervention strategies in the latter stages of our project. While this is not necessarily a comprehensive articulation of the concept, we have introduced a new slant on an area largely neglected in the literature.

Secondly, we have developed a reliable and valid measurement tool—the Spirituality Scale for Chinese Elders (SSCE)—for use in research and practice. The SSCE comprises 44 items assessing seven domains: spiritual well-Being (the affective aspect of the sense of meaning), meaning of life (the cognitive aspect), transcendence, relationship with self, relationship with family, relationship with friends and others, and relationship with the environment. Responses are captured using a 5-point Likert scale. The SSCE is the first validated tool to have been purposefully developed from qualitative studies conducted in a Chinese context. It is also the first instrument designed to include both the cognitive and affective aspects of spiritual well-Being. We also contributed to designing a visual version of the tool tailored toward older adults with low levels of literacy (who form the majority in many Chinese populations) to facilitate the assessment procedure. Our study showed that older adults with an education of secondary school or above can self-administer the SSCE and complete it in around 25 min. Otherwise, it can be administered during a face-to-face interview by a trained assessor, which takes around the same amount of time. From an academic point of view, the SSCE can be used to assess spiritual well-Being in any study looking at the topic as a unique and specific area of interest. For example, it was recently used to assess the spiritual well-Being of community-dwelling childless older adults in Shanghai. From a practice perspective, the SSCE can also be used as a screening tool to identify populations at risk in terms of spiritual well-Being, and to evaluate the effectiveness of interventions, particularly those aiming to enhance spirituality, among older adults.

Thirdly, we have developed a process model of spiritual well-Being that highlights the mechanisms of enhancement. The spiritual process model (SPM) demonstrates that relationship harmony generates a positive life energy that facilitates individuals to achieve transcendence, which in turn will lead to improvements in the affective and cognitive aspects of the meaning of life. The SPM provides a general road map of how spiritual well-Being among older Chinese adults can be enhanced through developing harmonious relationships between individuals and their social and natural surroundings. Based on these five relationships, the SPM provides general principles for developing intervention strategies. Firstly, it suggests that individuals can benefit from multiple sources of harmonious relationships, so limiting these to one or two sources could have unintended negative consequences. Secondly, the five elements of relationship harmony could overlap to some extent with religious relationships. For example, relationships with family and friends could include religious networks, the relationship with oneself could accommodate religious rituals and practices, and the relationship with the environment could include concepts such as supernatural power. As noted earlier, we purposefully excluded narratives about God from the ambit of this study. Thirdly, transcendence, a sense of going beyond the boundaries of time, plays a significant role in the process of achieving a sense of meaning. Therefore, effective interventions should consider how to incorporate a framework of time (past, present, and future). We found the SPM very useful in guiding our development of the Spiritual Enhancement Group for Chinese Elders (SEGCE).

Fourthly, guided by the SPM, we proposed a three tiers intervention strategy. Among older adults who suffered from low spiritual well-Being, an professional led intervention is suggested. By integrating the values of existential therapy, self-transcendence theory, relationship therapy, and group process theory, we developed an effective group intervention for enhancing spiritual well-Being among Chinese older adults, both living in the community and those in long-term residential care. Existential therapy and self-transcendence theory provided a relevant reference point to develop the values and principles of this intervention, while relationship therapy formed a central focus for generating intervention strategies which aimed to encourage and enhance harmonious relationships within the five domains. Group process theory was used as a framework to arrange the sequence of themes to be introduced in the intervention. After piloting, the SEGCE has been developed into a short-term, professionally led group intervention comprising eight weekly interventions of approximately 1.5 h each, accompanied by a written manual. Two postcompletion booster sessions were also recommended to consolidate change and address any barriers. Based on a quasi-experimental study as reported in Chap. 6, the SEGCE was found to be effective in enhancing the spiritual well-Being of participants compared to the results of a control group. We also identified potential barriers to the intervention, namely being older, being in poor health, and dealing with significant life events. These insights encouraged us to think about alternative applications that would focus more on early intervention and prevention. A self-help manual was developed, which contains similar content to the SEGCE but streamlined and simplified for self-help use.

7.2 Looking Ahead

At the time of writing, in reflecting on and summarizing these four key achievements, as a researcher I have to admit that our views are limited by our own backgrounds, values, and cultures. We have tried our very best to learn from multiple sources, including relevant literature, the expertise of medicine and nursing specialists, therapists, and the experiences of the older adults and their family caregivers. Yet, our perceptions may still be flawed by bias and the lack of comprehensiveness. However, we are proud of the positive feedback we have received from older adults and their family caregivers, as well as our practice partners who delivered the interventions. Their responses have been very encouraging.

There is also promise for the future, as reflected in the four research and practical activities in which we have been involved. Firstly, Joint hands by the Sau Po Centre on Aging of the University of Hong Kong and the Tung Wah Group of Hospitals, we have launched a two-level certificate course on spiritual well-Being. Upon end of 2014, more than 200 people have received the SSCE training and over 50 professionals have completed training in the SEGCE. Secondly, a volunteer-assisted self-help intervention has been piloted in four community elderly centers. This was designed specifically to respond to the obstacles we identified for the frail elderly, those living alone, and those with limited education to benefit from self-help groups. A quasi-experimental validation study is currently in progress. Thirdly, some frontline social workers are now trying to use the SEGCE in their work with family caregivers, with a pilot group showing positive outcomes. Fourthly, a mobile application has been developed based on the self-help manual. Soon, those competent in the use of such technology (of any age) can conduct a self-assessment using this application, practice the recommended activities basing on the assessment, and review their progress. This move is expected to contribute to our understanding of how older adults might use such a techonology-assistant intervention and how best practice can be developed as a result.

As I write these final words, it is early morning, and I can observe our relationship with the universe through my office window. We are all connected as human beings, and through connections, we achieve the meaning and purpose of our lives. This book is the first I have written in my second language. Sometimes, I have found it really challenging to find the right words to express my thoughts. However, I have never felt lost and always feel that words are floating from my mind to the paper. Everything included in this book is based on experiences that I have had with my team members. Limited my experiences may be, they are real.