Spiritual Assessment

Function

Many spiritual assessment tools have been developed by various patient care team members, including the chaplaincy, nurses, social workers, and physicians. Spiritual assessments vary in scope and style and can be as simple as the intake questionnaire about religious preference to the detailed spiritual history obtained by a chaplain. Given the breadth of spiritual beliefs and practices, many assessments adopt a conversational approach with open-ended questions to allow patients to express their spiritual beliefs most fully. For patients who do not identify with organized religion, the provider can ask open-ended questions such as, "What gives meaning to your life?" or how the patient views their place in the universe. A skillful patient care provider will tailor the spiritual assessment to the patient, situation, and environment. 

The ©FICA Spiritual History Tool questionnaire exemplifies a prototypical spiritual assessment. It was developed by Dr. Christina Puchalski [13] and is now maintained by the George Washington Institute for Spirituality and Health (GWISH).  It uses a conversational approach to touch on the domains of Faith/belief/meaning, Importance and influence, Community, and Address/action in care (or how the patient would like the healthcare team member to address the spiritual aspects of their care).  The FICA tool provides suggested conversational prompts and is reproduced with permission below. 

Issues of Concern

The healthcare team members should know that not all patients desire a discussion about their spiritual beliefs. In the study conducted in the waiting room of 5 family medicine practices discussed above, 17% of patients never wanted to discuss spiritual beliefs with their physician.[8] The healthcare team members should always approach the concept of a spiritual assessment in a respectful, non-judgemental way. If the patient indicates discomfort or a desire not to converse about spiritual beliefs, the healthcare team members should respect the patient’s desire. While healthcare team members' spiritual beliefs may inform their care, they should be mindful of their belief systems and how their beliefs influence the conversation with the patient.

The spiritual assessment is a tool used to understand the patient and should not be used to impress the beliefs of the healthcare team member on the patient. The healthcare team member should also respect beliefs with which they are not familiar and be open to learning the specifics of how those beliefs may affect their patient's decision. Research and genuine questions that give insight into the cultural and religious context of the patient are encouraged. Findings pertinent to the current or potential future medical care of the patient should documented accordingly.

Clinical Significance

A successfully performed spiritual assessment can have several positive effects on patient care. First, in allowing the patient to express their spiritual beliefs combined with careful listening, the healthcare team member attempts to strengthen the therapeutic alliance with the patient. The spiritual assessment also allows the patient to help the provider understand the context in which the patient makes their healthcare decisions. The healthcare team member can help the patient marshall the spiritual resources with the information gathered from the spiritual assessment. Examples of a patient's spiritual resources could include involving a patient's minister/imam/rabbi/priest/life coach, encouraging spiritual practices such as prayer/reflection/meditation/yoga, or other practices not traditionally seen as religious or spiritual such as a painting/poetry/exercise. The spiritual assessment can also be used to understand the hopes and to help address the patient's fears. By understanding the hopes and fears of the patient, the healthcare team member can help the patient develop goals of care. Also, by understanding the hopes and fears of the patient, the healthcare team member can diagnose and then attempt to address spiritual distress.

Enhancing Healthcare Team Outcomes

Information gathered in a spiritual assessment can be used to inform care by all healthcare team members and should be made available to all team members. Examples of how the spiritual assessment could enhance healthcare team outcomes by individual healthcare team members are included below.  

• Clinic office staff: Avoiding scheduling office visits on Holy days and scheduling office encounters with religious accommodations when available
• Social work: Connecting patients with ministries or resources specific to their beliefs and/or spirituality
• Chaplaincy: Understanding when a patient might desire a spiritual intervention or care and what an appropriate intervention might entail for a particular patient
• Physicians/APPs: Understanding the reasons a patient makes medical decisions (such as refusing a transfusion) or choices regarding end-of-life care

Evidence-Based Approach

A systematic review by Luchetti et al. of twenty-five instruments of spiritual assessment from various fields evaluated each assessment scored on 16 aspects such as memorability, religious affiliation, religious attendance, influence on spiritual life, and others.[14] According to the study, the 5 highest scoring assessments were the ©FICA Spiritual History Tool, SPIRITual History, Faith, HOPE tools, and the Royal College of Psychiatrists tool. Given that the review used an internally developed scoring method, expert opinion should be considered. In general, spiritual assessment tools suffer from a lack of validation studies. In Luchetti's study, only 5 out of twenty-five assessment tools were validated by a study, and of the 5 assessments that scored highest, only the ©FICA Spiritual HistoryTool was validated. Another article comparing the ©FICA Spiritual History Tool, SPIRITual History, Faith, and HOPE tools in the palliative care setting decided that the HOPE tool most comprehensively addressed spiritual themes important in healthcare literature.[15] Again this article used an internally developed rating method. The HOPE questions were designed to help medical students, residents, and practicing physicians incorporate spiritual assessment into the medical interview.[16] Like many assessment tools, the HOPE questions suffer from a lack of validation studies. 

The ©FICA Spiritual History Tool assessment discussed above was evaluated in a study of patients with solid tumors recruited from ambulatory clinics.[17] After completing the open-ended ©FICA Spiritual HistoryTool, patients were asked to rate their subjective measure of the importance of spirituality. On a scale of 0-10 with seventy-six patients, the mean spirituality score was rated at 8.4. This was correlated to the Spiritual Well-Being subscale of the Quality of Life Instrument (cancer patient/cancer survivor version) and several other items of the QOL tool, including pain, control, anxiety, depression, and isolation, collected in a parent study.[18][19] There was a positive correlation between the ©FICA Spiritual History Tool quantitative score and many of the QOL items, with the 3 strongest correlations being: purpose, activities, and religion.[17] Ultimately, the study suggested that the ©FICA Spiritual History Tool tool could be useful for clinical assessment. Another study used a thematic analysis of twenty-three Flemish GPs’ semi-structured interviews using the ©FICA Spiritual History Tool in palliative care.[20] The study concluded that the ©FICA Spiritual History Tool could be useful for clinical assessment of spirituality.