Physician barriers
GPs often feel uncertain about initiating spiritual discussions. They have a fear of alienating or causing discomfort in their patients.26,29 The following comment reflects some of the dissonance that exists for many GPs. They generally feel that addressing spirituality is important, but are uncertain about how to do so appropriately:
‘The barrier would be myself, because I'm a little hesitant on approaching some issues [spirituality], especially for someone who's here for ankle twisting. But it's my own personal belief not to try to infringe on other people's personal beliefs and judge them, but just try and find out about them.’31
GPs not only feel discomfort about initiating spiritual discussions, but they also struggle with the language describing such existential and spiritual suffering.31 They feel reticence about approaching the subject directly, because of fears that patients will refuse to discuss it or consider their raising spiritual questions inappropriate.26,29 They also fear that patients will misinterpret discussion of spirituality as pushing religion.26,27,29
One GP strongly opposed the initiation of spiritual discussions, out of concern about role definition and invasion of patients' privacy. This physician felt that spiritual matters were ‘no more in the physician's domain than questions regarding patients' finances or their most evil thoughts’.26 In other studies, some GPs also felt that it would be inappropriate to raise such intimate issues.29,32
GPs reporting infrequent spiritual assessment expressed the view that spiritual issues have lower priority than other medical concerns.26 Almost all GPs noted that physicians and patients whose views about the importance of spirituality differ experience such barriers.27 Another barrier reported by GPs is the belief that spiritual discussions will not influence patients' illnesses or lives.26
An important barrier perceived by GPs is their own spirituality. Lack of spiritual awareness or inclination on the part of physicians may be a barrier to addressing spiritual issues. Many GPs identified the theme of physicians' own ‘spiritual place’ or ‘centre’ as among the most influential factors determining whether they addressed spirituality in clinical care:26,31
‘[The barrier] is physicians' own belief system. That either it's inappropriate for them to talk about it or it's not a “medical” problem so they shouldn't be addressing it. There are people who just don't think it's really what they should be doing. They should be talking about diabetes and hypertension and taking care of those things, and letting the priest or the family or whoever talk about these other things. Those physicians I find are usually people who are not very spiritually in-tune themselves. Therefore they don't think it's important to other people.’31
Almost all GPs commented that different belief systems may create barriers to spiritual discussions. They noted that physicians and patients whose views about the importance of spirituality differ, or who differ in their belief in a higher power or God, experience such barriers.26,27,31,32 Olson and colleagues observed that the few GPs who did not report that they assessed patients' spirituality in clinical care all similarly related that they themselves were not religious or spiritual:31
I'm not very religious. However, I think I'm a very spiritual person. One of the hardest questions I've had to answer, a patient asked me if I was a Christian. If I told her the truth, that I am not, would she still be as open and interactive ?I told her the truth and that if she felt like Christianity was an important part of her life I would understand.’31
However, in another study by Kelly and colleagues, in response to probes regarding exploration of spiritual issues, reference to the practitioner's own particular religious or spiritual beliefs did not emerge.30
Patient barriers
In response to the question ‘What factors constrain discussion of spiritual needs?’ a theme emerged about patients being the ‘wrong sort of person’.28 Some GPs described patients in significant spiritual need as ‘unreachable’, ‘vulnerable’, ‘difficult to get in touch with’ patients, who often displayed a strong facade of coping, covering a refusal to accept their mortality:32
‘I certainly do see these as part of my role and am keen to do more. But it's not possible with everyone. Some people are very open to it and others are like a brick wall. You can't make people talk to you about death and dying. The same with relatives too. Sometimes you can involve them and sometimes you can't.’28
Contextual barriers
A lot of GPs feel uncomfortable with discussions of spirituality with patients because of lack of formal training and appropriate strategies. They feel they lack the skill to ‘do spiritual care’.26,29,32
Time was mentioned almost unanimously as a limiting factor.26,28,29,31,32 Some of the GPs admitted though that time was not a major problem compared with the perceived importance of spiritual care to the providers' practice.29
But, yes, I mean, I think it is part of our job, you know, we try and … well most of us try and practise [a] fairly holistic type of approach (laughing) and it's difficult, it's frustrating when we can't spend time with people but you have to realise that, you know, you're a limited resource and, you know, if we spend three-quarters of an hour with one patient, you're spending 5minutes with the other three (laughing).’28
The setting can also be a barrier, for example, an examination room, where the patient does not feel at ease.26 Finally, some organisational factors were also identified as barriers, such as lack of discussion of the role of spirituality among care providers,29 and lack of continuity of managed care.26
