HEART GUIDELINES
Enhancing Wellbeing Through Holistic Person-Centred Spiritual Care in Residential Aged Care
Dr Elizabeth Pringle / Meaningful Ageing Australia (Final Draft)
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PURPOSE
These Guidelines support residential aged care providers in enhancing wellbeing through holistic, person-centred spiritual care that recognises Australia's diverse spiritual and cultural needs and enables sustainable cultural change.
Spiritual care is a right, not a discretionary service. It is grounded in the Aged Care Act 2024 Statement of Rights, which enshrines the right to dignity, autonomy, identity, and spiritual care. The strengthened Aged Care Quality Standards require providers to deliver holistic care that attends to the physical, cognitive, psychological, social, and spiritual needs of each resident.
Spiritual care is not a subset of person-centred care. It is a distinct and irreducible dimension of holistic care that requires its own intentional attention, language, and organisational commitment.
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THE HEART MODEL
The HEART Model brings six interconnected Guidelines together in a single integrated framework. At its centre is the individual's enhanced wellbeing. This is surrounded by the six HEART Guidelines, enabled by a whole-of-organisation approach, grounded in integrated theoretical foundations, and situated within the wider policy and regulatory environment.
The six Guidelines are:
1. Knowing and Being Known
2. Meaning and Purpose
3. Connectedness and Belonging
4. Palliative Care and End-of-Life
5. Supporting Workforce Wellbeing
6. Diversity and Inclusion
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WHOLE-OF-ORGANISATION APPROACH
Implementation requires commitment at every level. These Guidelines cannot be delegated to a single role, a residential aged care home, or a corporate team. Success depends on commitment from governance and senior leadership through to all staff members.
Nine organisational enablers are required:
1. Leadership and governance — the single most critical enabler. Senior leaders must actively champion holistic, person-centred spiritual care, not merely endorse it. Governance structures must hold the organisation accountable for its delivery as a quality and safety matter.
2. Organisational culture — must affirm that relational, person-centred care is the core of the role, not an add-on.
3. Values-based recruitment — care workers selected for their relational orientation and values alignment, not just task competency.
4. Training and education — embedded in onboarding and ongoing professional development for all staff. Includes self-reflection on personal spirituality alongside building confidence in recognising and responding to diverse spiritual needs.
5. Adequate and consistent staffing — continuity of relationship between staff and individuals is not a luxury; it is an integral aspect of wellbeing.
6. Physical environment and design — sacred spaces, quiet rooms, access to outdoor environments, and culturally meaningful design elements all either support or undermine residents' spiritual wellbeing.
7. Technology — used well, can reduce social isolation, support connection to faith communities, and enable older people to maintain relationships and practices central to their sense of meaning and identity.
8. Co-design with individuals and supporters — not consultation. The ongoing, active involvement of residents and supporters in decisions about their own care.
9. Culturally safe practice — actively addressing barriers that prevent older people from having their physical, social, emotional, spiritual, and cultural needs recognised and met.
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GUIDELINE 1: KNOWING AND BEING KNOWN
Overview:
Addresses the fundamental human need for authentic relationships where individuals are recognised, valued, and understood as whole persons. Establishes the essential groundwork for all other Guidelines. Without genuinely knowing each individual, providers cannot effectively support Meaning and Purpose, foster authentic Connectedness and Belonging, deliver culturally appropriate Palliative Care, or build workforce capacity for compassionate care.
Theoretical grounding: Kitwood's understanding that personhood is relational; Swinton's insight that genuine presence begins with truly knowing the person.
Key strategies:
A. Workforce development and culture change — embed leadership responsibility, governance accountability, and workforce capability for spiritual care.
B. Organisation-wide person-centred care framework — validated frameworks integrated into governance systems.
C. Consistent staff assignment — promotes continuity, trust, and coordinated care. Reduces the conditions that prevent individuals from feeling genuinely known, seen, or safe.
D. Spiritual screening and assessment — formalise spiritual screening using validated tools; link care planning to meaning and transcendent connection; support referral pathways. ConnecTo is recommended as a spiritual screening tool.
E. Individual summary profiles and information systems — rich person-centred information documented and accessible with informed consent.
F. Life story work — deepens understanding of identity, culture, and meaning; informs care planning and activities; strengthens belonging.
For diverse populations: Understanding who a person is requires recognising that identity may be individual or inseparable from family, community, and cultural connections. Professional interpreter and translation services should be embedded as standard practice during admission assessments and care planning conversations.
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GUIDELINE 2: MEANING AND PURPOSE
Overview:
Addresses the fundamental human need to experience life as significant, purposeful, and worth living. Supports individuals to continue their search for ultimate meaning — whatever form that takes for them.
Theoretical grounding: MacKinlay's Spiritual Tasks and Processes of Ageing, recognising the search for ultimate meaning as the central developmental task of later life.
Key strategies:
A. Holistic spiritual screening and assessment — conduct spiritual screening using validated tools alongside psychosocial and clinical assessment to identify what gives each person meaning, purpose, connection, and hope.
B. Meaningful contribution and purpose — support autonomy and quality of life through purposeful engagement; align activities with abilities and preferences; integrate social prescribing and community connection.
C. Religious and spiritual practices — facilitate access to diverse religious, spiritual, and secular contemplative practices; support cultural safety, identity, and end-of-life spiritual care.
D. Spiritually meaningful activities — facilitate mindful meditation, spiritual reminiscence, music groups, creative reminiscence, cultural storytelling, communal celebrations, ancestral connection practices; offer sensory-based experiences and life review adapted for all cognitive levels.
E. Supportive and enriching environments — physical environments intentionally designed to support engagement in meaningful activities; prayer rooms, meditation areas, flexible communal spaces; access to nature and dedicated areas for creative pursuits.
For diverse populations: Opportunities for meaning and purpose must be adapted for all cognitive levels. Meaning-making must never assume individual expression — some people find meaning through collective cultural communities or intergenerational connections. Trauma-aware, healing-informed approaches are required for those with trauma histories.
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GUIDELINE 3: CONNECTEDNESS AND BELONGING
Overview:
Addresses loneliness in aged care and the fundamental human need for meaningful relationships, community, and a sense of belonging. Over 60% of aged care residents experience moderate loneliness and 35% severe loneliness. Loneliness leads to significantly higher mortality, chronic disease, clinical depression, and lower quality of life.
Theoretical grounding: Nolan's Senses Framework, particularly the senses of belonging, security, and significance.
Key strategies:
A. Intentionally prioritise relational connections — staff sensitively facilitate belonging through connections with supporters, peer-to-peer friendships in small groups, buddy systems, and recognition of emerging friendships.
B. Workforce development — mandatory training in spiritual care competencies, cultural competency, trauma-aware practice, and referral pathways.
C. Systematic assessment and intervention for loneliness — evidence-based screening during transition to aged care and ongoing; individualised intervention plans; organisational culture that systematically prioritises prevention of loneliness.
D. Connection to animals — facilitate access based on individual preferences; live animals are preferred; robotic pets must be introduced transparently with consent and ongoing assessment of individual responses.
E. Healing-informed strategies — support connection to Country for Aboriginal and Torres Strait Islander peoples; facilitate cultural ceremonies, storytelling, and creative arts; enable peer support connections; offer somatic and body-based therapies; support narrative therapy and life story work.
For diverse populations: Trust may take many months or years to build. Creating psychologically and culturally safe environments and allowing individuals to control the pace and depth of relationships is essential. Recognise and support both individual and collective expressions of connection and belonging.
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GUIDELINE 4: PALLIATIVE CARE AND END-OF-LIFE
Overview:
Recognises that dying is a profoundly spiritual experience and that the care provided in a person's final period of life must attend to their spiritual needs with the same intentionality and skill as their physical and clinical needs. Palliative care is appropriate at any stage of serious illness and can be provided alongside curative treatment.
Key strategies:
A. Advance Care Planning — systematic ACP using validated tools; policies that include exploration and documentation of the spiritual dimension, including preferences for end-of-life rituals, religious practices, and spiritual support; cultural safety and professional interpreters.
B. Access to palliative and end-of-life spiritual care resources — strengthen organisational systems and workforce capability; establish referral pathways and specialist involvement for complex spiritual needs.
C. Support for individuals choosing Voluntary Assisted Dying — holistic spiritual care alongside regulatory compliance; support meaning-making, values clarification, privacy, and relational continuity; address staff moral distress.
D. Spiritual accompaniment, rituals, and sacred spaces — ensures spiritual needs are embedded within end-of-life care plans; facilitates culturally appropriate rituals; creates sacred spaces with soft lighting, nature elements, and diverse religious and secular symbols; establishes rituals for death based on cultural and individual preferences (e.g. dignified departure, smoking ceremony, positioning of body, prayers, symbolic gestures); enables timely external referrals through a Spiritual Care Directory of diverse faith leaders and secular practitioners.
For diverse populations: The spiritual needs of individuals with dementia, those with trauma backgrounds, and people from diverse populations can be overlooked. Aboriginal and Torres Strait Islander peoples are at risk of cultural and spiritual harm when care does not recognise connections to Country or support culturally appropriate death rituals. LGBTIQ+ individuals with dementia face distinct barriers to person-centred end-of-life care.
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GUIDELINE 5: SUPPORTING WORKFORCE WELLBEING
Overview:
Addresses the inextricable link between staff wellbeing and the quality of relational and spiritual care that individuals receive. Staff who do not experience meaning and belonging in their own work cannot sustainably offer genuine presence and spiritual care to others.
Theoretical grounding: Nolan's principle that both care workers and individuals must experience a sense of belonging, purpose, and significance.
Key issues: High staff turnover and heavy workloads make it difficult to build the trusting, reciprocal relationships foundational to Knowing and Being Known. Burnout and compassion fatigue cause staff to withdraw from relational care. Moral distress compounds over time when staff know what care is needed but cannot provide it. Staff carrying unprocessed grief from providing care to dying individuals are at heightened risk of emotional shutdown.
Key strategies:
A. Establish workforce wellbeing programs — comprehensive programs addressing physical, emotional, and psychological health; recognise grief and loss as an occupational reality; provide a designated private retreat space for staff separate from the staff room.
B. Redesign work using SMART Work Design Model and P.A.R.R.T.H. methodology — ensure work is Stimulating, provides Mastery, offers Agency, is Relational, and has Tolerable demands; co-design work improvements with staff to reduce moral distress.
C. Peer support and reflective practice programs — structured Schwartz Rounds where all staff (clinical and non-clinical) reflect together on the emotional and ethical challenges of their work; mentoring programs, buddy systems, regular team debriefing; embedded in work time, not added to schedules.
D. Adequate staffing levels and reduce moral distress — implement appropriate staffing models that provide sufficient time for relational care; empower staff decision-making; remove organisational barriers.
E. Trauma-aware, healing-informed, and culturally responsive workplace practices — recognise vicarious trauma and compassion fatigue; cultural safety training for managers; support for culturally and linguistically diverse staff, LGBTQIA+ staff, staff with disability, and those with lived experience of trauma.
For diverse populations: Staff from culturally and linguistically diverse backgrounds may have different understandings of wellbeing, mental health, and help-seeking. Wellbeing initiatives should honour both collective and individual approaches to support.
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GUIDELINE 6: DIVERSITY AND INCLUSION
Overview:
Addresses the essential foundation that enables care to genuinely enhance wellbeing for every individual. Fundamentally shapes how all other Guidelines function. Cultural humility is an ongoing commitment to learning, listening, and adapting — not a destination.
Who has diverse needs: Aboriginal and Torres Strait Islander peoples; people from culturally and linguistically diverse backgrounds; LGBTQIA+ individuals; people living with dementia; people with disability or mental ill-health; people with trauma backgrounds including care leavers and Stolen Generations; people experiencing homelessness; veterans; people in rural, remote, or very remote areas; people from faith traditions; people with no religious affiliation.
Key strategies:
A. Embed cultural safety, diversity, and trauma-informed frameworks — across governance, policies, and leadership accountability; strengthen culturally safe partnerships and inclusive leadership.
B. Embed language access and communication support as standard practice — professional interpreter and translation services as routine practice, not a last resort; accessible communication for people with sensory or cognitive impairments.
C. Trauma-aware, healing-informed practice — recognise the impact of Adverse Childhood Experiences, historical trauma, discrimination, and marginalisation; build relational continuity and avoid re-traumatisation.
D. Elder abuse prevention and safeguarding systems — culturally responsive screening and reporting pathways; balance collectivist family involvement with individual safety.
E. Honour collectivist and individualist worldviews — integrate person-in-community approaches into assessment and care planning; balance autonomy with family and community decision-making structures.
F. Intersectional assessment and care planning — document intersecting identities, trauma history, and cultural identity; ensure systems support complex identity documentation.
G. Workforce capability and diversity-specific supports — build cultural safety, trauma-informed care, and intersectionality competencies; actively address discrimination and racism; create visible pathways for staff from diverse backgrounds to advance into leadership.
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KEY PRINCIPLES ACROSS ALL GUIDELINES
1. Spiritual care is the responsibility of all staff, not only specialists.
2. Spiritual care is not a subset of person-centred care. It requires its own attention, language, and commitment.
3. Spiritual care is a right under the Aged Care Act 2024.
4. Dying is a profoundly spiritual experience. Attend to spiritual needs at end of life with the same intentionality as physical needs.
5. Workforce wellbeing is inseparable from care quality.
6. Disconnection is not automatically bad. What matters is its meaning and impact for the individual.
7. For people from collectivist cultures, identity, decision-making, and spiritual practice are inherently relational. Person-centred language should be adapted accordingly.
8. Cultural humility is ongoing. Cultural understanding is never complete.
9. Safeguarding is a prerequisite for spiritual care. Without safety, it is impossible to know the person, support meaning and purpose, or foster authentic belonging.
10. Implementation requires co-design with individuals, supporters, and staff — not consultation.
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RELATIONSHIP BETWEEN THE GUIDELINES
Guideline 1 (Knowing and Being Known) is the foundation. Without it, all others are undermined.
Guideline 6 (Diversity and Inclusion) shapes how every other Guideline is delivered.
Guideline 5 (Workforce Wellbeing) enables every other Guideline — staff who are depleted cannot provide what they do not have.
Guidelines 2 and 3 (Meaning and Purpose; Connectedness and Belonging) are mutually reinforcing and depend on Guideline 1.
Guideline 4 (Palliative Care) draws on all preceding Guidelines with heightened urgency at end of life.
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CONNECTO — SPIRITUAL SCREENING TOOL
ConnecTo (Dr Julie Fletcher / Meaningful Ageing Australia, 2018) is the recommended spiritual screening tool. It is grounded in the language of connectedness and asks: "What's important to you?"
Five domains of connectedness:
- Self — connection to oneself; sense of identity, inner peace, self-compassion
- Others — connection to family, friends, community
- Nature — connection to the natural world, environment, seasons
- Creativity — connection through art, music, craft, expression
- Something Bigger — connection to transcendence, meaning, faith, religion, or a sense of purpose beyond the self
ConnecTo is a screening tool, not a full assessment. Where spiritual distress is identified, referral to a spiritual care specialist is required.
Three formats available: Visual Map, Likert Version, Spectrum Version.
ConnecTo can be used at: pre-admission, initial assessment, spiritual care planning, spiritual care referral, personal reflective practice, research, and at regular intervals in long-term care.
Proxy use: When an individual cannot complete ConnecTo for themselves (e.g. due to dementia or language), a proxy may assist. Include the person in the conversation wherever possible. Note the proxy's name on the form.
Key principle from ConnecTo: Disconnection from a domain does not automatically indicate a lack of spiritual wellbeing. What matters is discerning the impact of that disconnection on the particular person.
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SOURCE
HEART Guidelines: Dr Elizabeth Pringle / Meaningful Ageing Australia (Final Draft). CC BY-NC-ND 4.0.
ConnecTo: Dr Julie Fletcher / Meaningful Ageing Australia (2018 Revised Edition).
Further resources: www.meaningfulageing.org.au