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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 52  |  Issue : 4  |  Page : 144-150

Exploring spirituality and its use as a domain of practice among Indian occupational therapists: A qualitative study


1 Department of Orthopaedic Surgery, Goa Medical College, Bambolim, Goa, India
2 Jaipur Occupational Therapy College, Maharaj Vinayak Global University, Jaipur, Rajasthan, India

Date of Submission31-Aug-2020
Date of Acceptance15-Jan-2021
Date of Web Publication22-Apr-2021

Correspondence Address:
Pooja Vivek Vajaratkar
Department of Orthopaedic Surgery, Goa Medical College, Bambolim - 403 202, Goa
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijoth.ijoth_32_20

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  Abstract 

Background: Most occupational therapy (OT) practitioners recognize that it is important to integrate client's personal beliefs, values, and spirituality into OT practice. However, ambiguity and diverse practice notions have an impact on the use of spirituality in day-to-day life. Thus, the purpose of the study is to bridge this gap by exploring spirituality as a domain of practice in OT among Indian OTs. Objectives: The objectives of this study were to explore and understand spirituality and its use as a domain of practice among Indian OTs. Study Design: A qualitative narrative study design was chosen for this research. Methods: Fifteen participants (n = 15) who are expert in the field of OT with major inclusion criteria of minimal 10 years' experience were recruited for this study using nonprobability convenient and snowball sampling method. The study was conducted with OTs working in private and public sectors in India. In-depth semi-structured interviews were conducted with senior OTs to explore their knowledge and understanding of spirituality as a domain of OT practice from an Indian perspective. Results: Three major themes emerged from this study were as follows: (1) understanding of spirituality, (2) differences in understanding the meaning of spirituality, and (3) importance of the use of spirituality as a domain of practice in OT. Conclusion: Overall, this study is a first step in understanding the complexity of spiritual considerations in day-to-day practice in Indian context. This study found that there is limited understanding of spirituality among Indian OTs. Lack of clarity in this area found difficult for the Indian OTs to differentiate spirituality from religion. This study also gave insight into how OTs use spirituality as a domain of practice in India. Based on this study, we suggest that there is an upmost need to develop guidelines on practicing spirituality in OT practice by generating further discussion and evidence on this subject.

Keywords: Domain of Practice, India, Occupational Therapy, Religion, Spirituality


How to cite this article:
Vajaratkar PV, Dwivedi AK. Exploring spirituality and its use as a domain of practice among Indian occupational therapists: A qualitative study. Indian J Occup Ther 2020;52:144-50

How to cite this URL:
Vajaratkar PV, Dwivedi AK. Exploring spirituality and its use as a domain of practice among Indian occupational therapists: A qualitative study. Indian J Occup Ther [serial online] 2020 [cited 2021 Nov 27];52:144-50. Available from: http://www.ijotonweb.org/text.asp?2020/52/4/144/314218


  Introduction Top
Occupational therapies (OTs) have shown considerable interest in spirituality as a domain of practice. Spirituality and OT are associated with the holistic, person-centered approach to care, in order to restore a sense of well-being and recognize individual coping strategies.[1]

However, ambiguity and diverse practice notions have an impact on the use of spirituality in day-to-day life.[1],[2] Another challenge was spirituality that has not been given much importance due to the lack of a clear definition of spirituality and the unclear relationship between religion and spirituality.[3],[4]

The recent study[5] indicated that there is limited research in the area of spirituality in OT groups and educational programs in a South African context and other Western contexts. Likewise, there is a scarcity of research on OTs' perspectives on understanding and concerning spirituality in OT practice in India.

Thus, the purpose of the study is to bridge this gap by exploring spirituality as a domain of practice in OT among Indian OTs.

Knowledge of spirituality among Indian OTs could help identify their understanding and how we could incorporate it as a domain of practice. In addition, a more contextual understanding of spirituality would add to the growing research on spirituality.


  Methods Top


Setting

All the participants selected for this study were from different regions of India, working in private and public organizations. A qualitative narrative study design was chosen for this research. Ethical clearance was obtained from the Institutional Ethics Committee at Goa Medical College, Goa, on July 9, 2020. Participants were provided with comprehensive information about the study, and informed written consent was obtained from all participants prior to conducting the research.

Fifteen OTs from private and public sectors (n = 15) with minimal 10 years of experience and currently practicing in India were recruited in the study. In qualitative study, the sample size is not determined by the number or participants, but by data saturation, or when the repetition of salient points is achieved.[6]

In-depth semi-structured interviews were conducted with senior OTs to explore their knowledge and understanding of spirituality as a domain of OT practice from an Indian perspective. The interview questionnaire (Annexure 1) was developed based on a review of literature considering three themes, namely understanding of spirituality, differences in understanding the meaning of spirituality, and use of spirituality as a domain of practice in OT.[4],[7] Each interview was conducted telephonically on a one-to-one basis and in a single sitting lasting for 35–60 min with additional 8 follow-up via telephone as needed.

The analytic process is shown in [Figure 1]. The interviews were transcribed by the author. Before undertaking the analysis, the audiotapes and transcripts were compared for accuracy by both authors. Meaningless or redundant utterances were eliminated to aid in the clarification of analysis and readability. The interview themes were developed iteratively using the thematic analysis process,[4] starting with the set of research questions by the authors. Data were organized and coded manually using an Excel sheet. Codes from the data were identified and defined in an iterative manner. First, two interviews were coded by both authors to generate a preliminary coding system until a consensus coding system evolved. This coding system was then tested by a third independent researcher to achieve reliability by carrying out blinded double coding of two interviews.
Figure 1: The Analytical Process

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The analysis aimed at describing therapists' understanding of spirituality, their understanding of spirituality about religion in the Indian context, and finally, the knowledge of OTs on spirituality as a domain of practice in OT. This resulted in a refinement of the coding framework. The remaining transcripts were coded using this framework.

Concept of Spirituality

Spirituality is defined as the search for meaning and purpose in life, which may or may not be related to a belief in God or some form of a higher power. For those with no conception of supernatural belief, spirituality may relate to the notion of a motivating force, which involves an integration of the dimensions of mind, body, and spirit. These personal beliefs or faith also shapes an individual's perspective on the world and is expressed in the way that he or she lives life. Therefore, spirituality is expressed through connectedness to God, a higher being, and/or by one's relationships with self, others, or nature.[2]


  Results Top


Demographic Characteristics of Participants

A total of 15 OTs, who were experts in the field of OT (mean age in the years ± standard deviation: 44 ± 9.88) were participated in this study. [Table 1] summarizes the other demographic characteristics of the participants.
Table 1: Demographic Characteristics of Participants

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This paper describes occupational therapists' understanding of spirituality, their understanding of spirituality about religion, and finally, their knowledge of spirituality as a domain of practice in OT in the Indian context. Three key themes [Table 2] emerged from the data analysis are (1) understanding of spirituality, (2) differentiating spirituality from religion, and (3) spirituality as a domain of practice in OT as follows.
Table 2: Themes Emerged from Data Analysis

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Understanding of Spirituality

As reported by all the participants, spirituality has been understood considering either secular as well as theological or religious concepts.

Spirituality is guiding source, higher self, sense of power which is a higher power beyond our power which can affect the outcome of our effort and I also believe in that destiny is affected by guiding source.”

Many participants used religious terminology, which provided them with the clearest way to explain their ideas in depth. Most of the participants noted that they felt that each individual's spirituality was unique and did not necessarily include religious content.

“I consider the religion of the person. I respect the religious practices of the person.…. for me ritual may not really mean anything, however, I would understand and act accordingly.”

Interestingly one therapist considered functional aspects or skills required to follow religious or spiritual acts are more important.

He found that “Praying for a man in a certain way by kneeling is an important step for that person unless that is meaningful for that person. That becomes part of my therapy programs.”

Differentiating Spirituality from Religion

Spirituality and religion are increasingly recognized as influencing people's health and rehabilitation. In OT, spirituality is recognized as important in influencing occupational performance, yet “methods of integrating this performance component into daily practice remain elusive.”

I believe it is different than Religion as we know, religion is something which is more like practice followed by the community or a group of people…and spirituality is more individual, it's up to you. What makes you feel connected with some superpower or a higher power?”

One therapist informed that he is not sure about his beliefs on spirituality or religion.

“I have never given so much thought to spirituality or whatever, but yes, you are yourself and you also have to realize that, like there is something I believe in, I don't know if it's spiritual (or religion).”

However, some of the therapists who were secular while defining spirituality may result in a clear differentiation between religiosity and spirituality. These therapists consider the patients' spiritual needs enacted through developing effective therapeutic relationships; was not necessarily linked to meeting religious needs.

“I use Meditation, yoga, relaxation techniques which can be helpful in mental health conditions. I consider the hobbies of the patient wherein they forget themselves and feel peaceful. According to me, process is important than end-product in practicing spirituality.”

“If self-development or self-realization or actualization is also a form of spirituality, then yes, but it is also has a science behind it.”

Spirituality as a Domain of Practice in Occupational Therapy

When we asked therapists whether they use spirituality as a domain of practice, they responded that either they brought it up directly or indirectly, while few therapists informed that they were never brought up spirituality in their practice due to various reasons. Other therapists reported that they brought spirituality up directly or indirectly by permitting the clients by raising spiritual issues, creating an environment that was conducive to spiritual discussions.

Few therapists reported that how they are assessing spirituality domains into their practice and related challenges.

At present, we are not using any formal assessment tool and also not aware of any assessment tool, which assesses the spirituality aspect of the person. We use COPM (Canadian Occupational Therapy Performance Measure) which has some components on spirituality. She also said that what she uses is more of a quality of life assessment.”

While some spoke about the importance of meditation, time for reflection, daily personal rituals, the therapeutic use of self, playfulness as a medium of intervention in their routine OT practice.

“We use meditation, yoga, relaxation techniques which are helpful in mental health conditions. We need to consider the hobbies of patients wherein they forget themselves and feel peaceful.”

“I also consider therapeutic use of self which is a part of spirituality but that is also in a covert and minimal amount.”

“At our center, we do counselling wherein we sit with parents and talk to them. We are also introducing practices such as playfulness, mindfulness, and reflective practices.”

Several participants expressed their views that therapists need to be sensitive to beliefs and values different from their own, as the following examples illustrate.

“Sometimes if patients don't believe in themselves, there are times when people don't find that life is meaningful and they feel they are of no help to anyone and that might be their spiritual calling, so we tend to along with their value system and their thought, and try to incorporate where we see that this may help the person.”

Interestingly, it was also found that one occupational therapist does not consider spirituality as a domain of practice in OT.

“I would say that spirituality is not within our domain because we should know on which path we want to take the people. Especially in the case of spirituality a “guru” (master) who can do this….generally in order to achieve spirituality, you should have a master. So it's definitely out of focus (as a domain of practice).”

However, most of them agreed that practitioners should try to incorporate activities into their programs that allow clients to express spiritual needs and concerns. This finding seemed consistent and considered incorporating spirituality into the professional scope of OT practice. Perhaps, it was on a more formal level that the respondents wished that they could devote more attention to issues of spirituality in treatment programs.

We also found that few therapists never brought up spirituality due to various reasons as follows:

  1. OTs do not know how to talk about it, do not have language for it other than religious language, and are not comfortable with that
  2. OTs do not know enough about other faiths besides their own to feel comfortable talking to people about their spirituality
  3. OTs feel that spirituality is too personal to talk to clients about
  4. OTs feel that the therapy milieu is not appropriate for discussions of this kind
  5. OTs feel that their therapeutic relationships are not of sufficiently long duration to build the trust necessary for these discussions.


One therapist cautiously reported that “Yes, definitely that is needed but I didn't make any effort to use spirituality in my practice. We don't provide direct intervention for spirituality. So that should not be a domain of practice.”

“I would think it would depend on each patient because this (Spirituality) is very personal. So, unless you have built a therapeutic relationship with the patient, you can't go on to the level of Spirituality.”

Few of the respondents were confused, undecided, or disagreed that spirituality holds a viable position in the scope of OT practice, even though majority agreed that spirituality was an important part of their daily job responsibilities.

One therapist interestingly shared that little is known about spiritual practices among practicing therapists and need to include in academic programs.

“Occupational therapist has to guide patient in spirituality and if we (therapists) do not know what it is, then how can we guide them? We have to include “spirituality” at the undergraduate level itself as a part of the curriculum and we have to conduct professional development programs.”


  Discussion Top
This study aimed to explore Indian OTs' understanding of spirituality, their understanding spirituality and religion, and finally, their knowledge on spirituality as a domain of practice. The major finding of this study was that there is limited understanding of Spirituality among Indian OTs with that understanding lacking clarity. Despite a range of definitions of spirituality offered for health-care practice, there are concerns about understanding a concept so individual and deeply personal which is influenced by an individual's beliefs, culture, and worldview. These findings are supported by the previous studies on spirituality as experienced by OTs in practice.[1],[8],[9] This study found that essentially spirituality was defined as one's beliefs about the world and one's place in it and how these beliefs are reflected in their conscious actions and life. Especially important among these beliefs and actions were those regarding the interconnectedness of persons to themselves, to one another, and God or some other intangible force beyond the self. Participants appeared to feel that this reflection and activity determined how individuals viewed their experiences and how they chose to act. They also seemed to believe that spirituality provided individuals with a feeling of well-being, a sense of purpose and meaning, development of their unique selves, greater connection with others, or increased closeness to God or some other organizing force in the universe.[2],[3],[10],[11],[12]

While none of the participants seemed to be completely at ease offering an understanding of spirituality, together their ideas formed some understanding about spirituality as a domain of practice. As per all the participants, spirituality has been defined; considering both secular as well as theological concepts. [4,13] The complexity of the concept, although included many attributes associated with spirituality, has been criticized for its lack of operational utility for practitioners who are already struggling with such a nebulous concept.[2],[3],[14],[15],[16]

This brought the second finding which depicts that the majority of therapists found difficulty in differentiating spirituality from religion. This is aligned with previous study findings which reported that definitions commonly depict the tensions between a religious or sacred expression of spirituality and the concerns for an inclusive expression of spirituality which encompasses a belief in God or other force sometimes expressed as the “ultimate” or higher being.[2],[3],[7],[17]

The third major finding of the study was how therapists use spirituality as a domain of practice in OT in India. We found that some therapists brought it up directly. Other therapists reported that they brought spirituality up indirectly by permitting clients to raise spiritual issues, creating an environment that was conducive to spiritual discussions. Furthermore, there are circumstances when no one discusses spirituality.[2],[4],[5],[7],[16],[17] Little is known about spiritual practices that sustain and inform among OT practice. Some interviewees reported drawing on their religious faith to orient, ground, and give meaning to their work. While some of them spoke about meditation, time for reflection, daily personal rituals, the therapeutic use of self, playfulness, mindfulness, yoga, reiki, pursuing hobbies and being peaceful as a medium of intervention in the OT practice.[2],[3],[8],[17],[19],[20]

Reasons for this finding may be indicated by the respondent's opinions about the appropriateness of initiating discussion of spirituality in therapy. The majority of respondents seemed willing to initiate discussion on spirituality carefully and limitedly when they are setting related treatment goals. That is, to most of the respondents, discussion on spirituality would be initiated only when the client explicitly brought it up. With regard to assessments and intervention, few of the respondents were unsure about devoting or did not wish to devote any more attention in terms of formal evaluation and treatment to issues of spirituality.

A limitation of the current study is that the findings may not give in-depth information to OT practice in India as a group of participating occupational therapists may not be representative of the general population. This indicates a need for further research to be conducted with more OTs or by conducting focus-group discussions to enhance the body of knowledge related to spirituality. However, it is noted that the findings are consistent with studies from the Western context and studies conducted by non-OT professionals in India.[17],[18],[19] Thus, even though the sample represented a relatively “informed” group of therapists, the findings of this study indicated the likely large gaps in practicing spirituality as a domain of practice in India.

The current interest in how and whether spirituality should be considered within OT highlights the need for an understanding of how therapists are presently incorporating spirituality into practice. This study is a first step in understanding the complexity of spiritual considerations in day-to-day practice. Furthermore, it is the upmost need to develop guidelines on practicing spirituality in OT practice by generating further discussion and evidence on this subject.

Many respondents in the present study wished to devote more attention to the spiritual function of practice, and the majority agreed that current academic training is not enough to prepare them to deal with clients' spiritual needs. Therefore, it is prudent to include topics on the understanding of spirituality and its clinical implications in OT practice in current OT curricula to help practitioners be more prepared to address and respond to clients' spiritual needs.[20],[21],[22]


  Conclusion Top
Overall, this study is a first step in understanding the complexity of spiritual considerations in day-to-day practice in Indian context. This study found that there is limited understanding of spirituality among Indian OTs. Lack of clarity in this area found difficult for the Indian OTs to differentiate spirituality from religion. This study also gave insight into how OTs use spirituality as a domain of practice in India. Based on this study, we suggest that there is an upmost need to develop guidelines on practicing spirituality in OT practice by generating further discussion and evidence on this subject.

Acknowledgment

The authors expresses their heartfelt thanks to participants for their kind co-operation and participation, which helped in making this study a success. The authors also express their deep sense of gratitude to Prof. (Dr.) S.M. Bandekar, Dean, Medical Superintendent and H.O.D, Orthopaedics Department, Goa Medical College, Goa, for providing the necessary infrastructure and resources to accomplish the work in this honorable institute.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

Annexure 1: Semi-Structured In-Depth Interview Guide

  1. Demographic Information about Participants
    1. Date
    2. Name of the therapist
    3. Age
    4. Gender
    5. Address
    6. Workplace
  2. Questions
    1. Tell me something about yourself
    2. Since when are you working in the field of occupational therapy?
    3. Areas in which you deal with (orthopedic, neurology, pediatrics, psychiatry, plastic surgery, or any other?)
    4. What are the most important underlying beliefs or values which guide your life? (E.g., optimism, patience, respect, right choices, sacrifice, tolerance, unity, vision, integrity, gratitude, forgiveness, devotion, effort, courtesy, caring, belief in others, appreciation)
    5. What is your understanding about Spirituality and Religion?
    6. What is your understanding of the word “Spirituality”? (E.g., belief that divine is within us, personal belief/value system, person's inherent goodness, authenticity, joyful living, present oriented: Heaven is a state of mind, human relationship)
    7. Do you use spirituality as a domain of practice? (If “Yes,” How?)… (If “No,” Why?)
    8. Do you believe it is an important domain to be practiced? If “Yes,” How?)… (If “No,” Why?)
    9. What method do you use to evaluate/assess/know about the spiritualty aspect of a person?
    10. Which do you think is the most appropriate method to evaluate/assess/know about the spiritualty aspect of a person?
    11. Now coming to intervention, which method you use to intervene spiritual aspect of a person? Why do you think this method is most useful?
    12. Which medical conditions you prefer to use spirituality as a domain of practice in Occupational Therapy?
    13. Why do you think in certain medical conditions practicing spirituality is feasible while not feasible in certain conditions?
    14. Do you think practicing spirituality as a domain of occupational therapy practice is feasible in the Indian context or outside India and why?
    15. Do you have any suggestions to incorporate spirituality in practice and how will it help?


 
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