Assessing Spiritual Wellness
UMA Conference, May 16, 2017
George Fitchett, DMin, PhD, BCC
Rush University Medical Center
[email protected]
Three Levels of Clinical Inquiry about S/R
Level of Inquiry
Examples
SPIRITUAL SCREENING
Context - Initial contact
Length - Very brief
Mode – Questions
Clinician - Any trained clinician
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Rush Religious/Spiritual Struggle Screening Protocol
(Fitchett and Risk, 2009)
“Are you at peace?” (Steinhauser et al., 2006)
“Do you have any spiritual pain?” (Mako et al., 2006)
Spiritual Injury Scale (SIS, Berg, 1994, 1999)
SPIRITUAL HISTORY- TAKING
Context - Initial contact
Length - Brief
Mode – Questions
Clinician- Primary care provider
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FICA (Puchalski and Romer, 2000)
HOPE (Anandarajah and Hight, 2001)
SPIRIT (Maugans, 1996)
SPIR (Frick et al., 2005)
SPIRITUAL ASSESSMENT
Context - Initial contact and ongoing reassessment
Length - Extensive
Mode – Conceptual framework for
interpretation and development of
care plan
Clinician- Board certified chaplain or
other with equivalent training
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Pruyser (1976)
7x7 (Fitchett, 1993)
Discipline for Spiritual Caregiving (Lucas, 2001)
Spiritual Pain (Millspaugh, 2005a, 2005b)
MD Anderson Model (Hui et al., 2011)
Spiritual AIM (Shields et al., 2014)
Spiritual Distress Assessment Tool (SDAT, Monod et al.,
2010)
Limitations of Current Practice in Spiritual Assessment
Current Practice
One-size fits all
Narrative
Revised Practice Rationale
Multiple
Recent research about R/S needs in specific
condition specific clinical populations supports condition-specific
assessments
assessment
Communication with colleagues is thwarted by
narrative models whose assessments are too long
and use chaplain jargon
Quantifiable
Identify degrees of R/S distress and R/S resources
in order to inform care plan
Describe change in R/S distress or other sx in
response to chaplain spiritual care
Acceptable to patients
Inefficient
Useful
Acceptable to chaplains: helpful guide to spiritual
care; consistent with identity and education
Provides information valued by other clinicians
Local
Universal
The same model is used by all chaplains working
with patients with this condition
SDAT: Needs, Interview Questions & Scoring
PATIENT INTERVIEW
SPIRITUAL NEEDS MODEL
MEANING
NEED FOR LIFE BALANCE
TRANSCENDENCE
NEED FOR CONNECTION
VALUES
NEED FOR VALUES
ACKNOWLEDGEMENT
NEED TO MAINTAIN CONTROL
PSYCHO-SOCIAL IDENTITY
NEED TO MAINTAIN IDENTITY
Monod et al., 2010
Set of questions for patient interview
Are you having difficulties coping with what is happening to you
now (hospitalisation, illness)?
Is your religion / spirituality / faith challenged by what is
happening to you now?
Does what is happening to you now change or disturb the way
you live or express your faith / spirituality / religion?
Do you think that the health professionals caring for you know
you well enough?
Scoring
Score = 0
No evidence of unmet
need for life balance
Score = 1
Some evidence of
unmet need for life
balance
Do you feel that you are participating in the decisions made
about your care?
Score = 2
Substantial evidence of
unmet need for life
balance
Do you have any worries or difficulties regarding your family or
other persons close to you?
Do you feel lonely?
Could you tell me about the image you have of yourself in your
current situation (illness, hospitalisation)?
Score = 3
Evidence of severe
unmet need for life
balance
Spiritual Distress in Older Medical Rehab Patients
65% some
distress
27% some
distress in all 5
dimensions
22% severe
distress in at
least one
dimension
60% of severe
unmet needs
were for Life
Balance
From Monod et al., 2012; n=203 geriatric patients in medical rehabilitation,
Switzerland
Measuring
Spiritual
Needs
Galek K, Flannelly KJ,
Vane A, Galek RM.
Assessing a patient's
spiritual needs: a
comprehensive
instrument. Holist Nurs
Pract. 2005 MarApr;19(2):62-9.
Assessing
spiritual needs in
agencies serving
older adults
Stranahan S. A spiritual
screening tool for older
adults. Journal of Religion
and Health. 2008
Dec;47(4):491-503.
Assessing spiritual needs in agencies
serving youth
How often do you think that…(responses Never to Always)
1. A Good God watches over me.
2. I have to live with God’s Punishment.
3. I feel God’s Love in my life.
4. My Shame makes me feel dirty.
5. My Hope tells me it’s got to get better.
6. Being Cut Off from my family is hard.
7. My Church is a safe place.
8. My Loneliness makes life hard.
9. My Friendships help me.
10.Being Cut Off from God is hard.
11.My Parent’s Presence helps me.
12.My religion tells me my sickness is my Fault.
13.Stuff in my room reminds me that people love me.
14.I can feel God’s Anger in my life.
15.I Love who I am.
16.Betrayal is part of my life story.
Grossoehme DH. Development of a spiritual screening tool for children and adolescents.
Journal of Pastoral Care and Counseling. 2008 Spring-Summer;62(1-2):71-85.
Importance of R/S to Patients with
Schizophrenia
Total
Switzerland Quebec
(n=276)
(n=92)
(n=121)
Importance of Religion (0=not at all, 10=essential)
No Carolina
(n=63)
In your day to day life
7.0 (3.2)
6.7 (3.5)
6.5 (3.2)
8.3 (2.1)
To give meaning to
your life
6.0 (4.1)
6.0 (4.3)
4.9 (4.1)
8.1 (2.6)
5.7 (3.6)
7.4 (8.7)
5.5 (3.7)
7.7 (2.6)
84%
16%
92%
8%
To cope with your
5.7 (3.7)
4.5 (4.0)
illness
To gain comfort
5.7 (3.8)
4.7 (4.0)
Global Evaluation of Religion (interviewer rated)
Positive
87%
80%
Negative
13%
13%
Mohr S et al. Spirituality and religion in outpatients with schizophrenia: a multi-site
comparative study of Switzerland, Canada, and the United States. Int J Psychiatry Med.
2012;44(1):29-52.
Next steps for evaluating spiritual care
service outcomes for UMA agencies
• No current best practices to be implemented by UMA agencies
• Developing best practices – a 5 year research project
• UMA leadership works with agency spiritual care providers
and others to get a grant
• Aim of project is to identify and disseminate best practices
for evaluating spiritual care service outcomes
• Participants: spiritual care researchers, spiritual care providers, and
researchers in gerontology, youth services, and community mental
health
• A 5 year project, estimated cost of $100,000/year, will change these
fields for UMA agencies and others
EMPOWERING CHAPLAINCY RELEVANCE:
EMBRACING FOUR KEY PRINCIPLES
An Endorser’s Perspective
FOUR PRINCIPLES FOR SUCCESS

Identify Need & Align Resources and Vision
Then create outcome goal by completing this
statement in fulfilling the Need: “When (your area)
accomplishes what we are setting out to
accomplish, we want and expect to see…
 This is the Change you expect to impact

Create Objectives and Programs to meet the Goal
 Establish Measures that communicate outcome
attainment

Quantitative
 Qualitative


Communicate
STRATEGY FOR SUCCESS
Identify Need
Measurement
Indicators
SPIRITUAL CARE:
WHAT IT MEANS,
WHY IT MATTERS
IN HEALTH CARE
REV. BRIAN P. HUGHES, BCC
• Board-certified chaplain with Association of Professional Chaplains (APC) since 2003
• Involved in leadership with APC, chairing this year’s APC National Conference in Houston
next month
• Will be presenting the 5th annual Best Chaplaincy Papers webinar on Thursday, May 18
• Work with HealthCare Chaplaincy Network
• Chaplaincy advocate, author, consultant, and researcher
• Previous research includes authoring the Handbook for Spiritual Care to those with PTSD
and Traumatic Brain Injury for the US Navy and Department of Defense, the Spiritual Care
advocacy paper I will be presenting this afternoon, and the hot-off-the-press Spiritual Care
and Nursing paper
• Worked clinically in inpatient setting, specifically with critical care and palliative care
• Presented research and workshops at numerous conferences on Self-Care for
Caregivers, Spiritual Care for End of Life, Communication in Healthcare, Spiritual Care
for Staff, among other topics
WHAT IS SPIRITUAL CARE?
Health care shifting to whole-person patient-centered care
• This includes assessment of culture, ethnicity, religion, spirituality, and relational aspects of
patients & families
• Palliative care & hospice have been leaders in this paradigm shift within health care
• Patient- and family-centered care requires the entire team to be able to consider spirituality
in deciding how to best optimize the overall well being and quality of life of the patient and
family
Spirituality & religion have always been central to many Americans
• 23% identify as “nones” – atheist, agnostic, or no religious affiliation
• 89% believe in God
• 37% consider themselves to be “spiritual but not religious”
• 87% call spirituality important to their lives
• 51%-77% consider religion important
WHAT IS SPIRITUAL CARE?
Key Definitions:
• Spirituality: a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning,
purpose and transcendence, and experience relationship to self, family, others, community, society, nature,
and the significant or sacred. Spirituality is expressed through beliefs, values, traditions and practices.
• Religion: “a subset of spirituality, encompassing a system of beliefs and practices observed by a
community, supported by rituals that acknowledge, worship, communicate with, or approach the Sacred,
the Divine, God (in Western cultures), or Ultimate Truth, Reality, or nirvana (in Eastern cultures).”
• Health Care: the field concerned with the maintenance or restoration of health of the body or mind.
• Palliative Care: an approach that improves the quality of life of patients and their families facing the
problems associated with life-threatening illness, through the prevention and relief of suffering by means
of early identification and impeccable assessment and treatment of pain and other problems, physical,
psychosocial and spiritual.
• Spiritual Distress: the impaired ability to experience and integrate meaning and purpose in life through
connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself.
WHAT IS SPIRITUAL CARE?
• The Joint Commission requires that all patients be assessed in order to ascertain
religious affiliation and any spiritual practices or beliefs that have the potential to impact
their care
• Yet only 54% to 63% of hospitals fulfill these requirements by employing chaplains
• Institute on Medicine (now the National Academy of Medicine) report states
that frequent assessment of a patient’s spiritual well-being and attention to a patient’s
spiritual and religious needs should be among the core components of quality end-of-life
care across all settings and providers
• American Board of Internal Medicine, in offering palliative medicine board
certification, places psychosocial and spiritual needs second only to medical management
within their allotment of content for their board exam
• The American Medical Association adopted a new policy that recognizes the
importance of spirituality and its potential impact on patients’ health
WHAT IS SPIRITUAL CARE?
• Research shows patients and families turn to their spiritual beliefs in order to cope with a
wide variety of diseases and experiences of hospitalization.
• Research shows patients from across the spectrum of health concerns turning to their
spiritual beliefs:
Geriatrics
HIV/AIDS
Cancer
Trauma
Cardiac hospitalizations
Rheumatoid arthritis
Mental Illness
Sickle cell disease
End of life
Chronic illness
Chronic pain
SPIRITUAL WELL-BEING
• Patients and families prioritize spirituality in the health care setting
• Studies consistently demonstrate that there is a positive relationship between spirituality and
health & well-being
• Spirituality is studied on a spectrum of well-being (also called spiritual pain), from spiritual wellbeing on the healthy end through spiritual concerns and spiritual distress/struggle to spiritual
despair at the unhealthy end
• 28% of cancer inpatients, 40.8% of cancer patients undergoing chemotherapy, and 65% of older
inpatients have been measured to be experiencing spiritual distress
• 72% of patients said they received little to no spiritual support from the medical team
SPIRITUAL WELL-BEING
• Higher level of spiritual distress has been shown to have higher resting heart rate, as well as increase:
Likelihood of pain
Incidence of depression
Risk for suicidality
Clinically-impactful anxiety
• Spiritual struggles are associated with greater psychological distress and diminished levels of wellbeing.
• A study by the Dana-Farber Cancer Institute found that patients who did not receive adequate spiritual
support are less likely to receive a week or more in hospice, and are more likely to die receiving aggressive
care in the intensive care unit
• One study of 3,585 hospitals found that providing chaplaincy services is related to lower rates of deaths in the
hospital and higher rates of hospice enrollment
• In several studies, spiritual care has been demonstrated to have a positive impact on pain severity
• Spirituality is often used as a coping strategy, with prayer, meditation and mindfulness among the many spiritual
resources patients use to help cope with the intensity of the pain they experience.
SPIRITUAL CARE AND PATIENT SATISFACTION
• A recent study of over 9,000 patients found that chaplaincy visits increase the patient’s willingness to
recommend the hospital, as measured by both Press Ganey and HCAHPS
• Press Ganey’s research shows that patients who have a chaplain visit are more likely to indicate positive
responses to questions regarding whether the “staff addressed my emotional needs” and “staff addressed
my spiritual needs”
• Press Ganey’s research among more than 2 million patients worldwide also found that the single most
unmet need as it relates to the overall patient satisfaction with the care they received in a hospital is that
the “staff addressed my emotional and spiritual needs”
• Patients who have been unable to have their spiritual needs adequately addressed are more likely to have
lower levels of satisfaction with and perception of quality of care
• The Joint Commission concludes that the “emotional and spiritual experience of hospitalization
remains a prime opportunity for Quality Improvement”
• Addressing spiritual concerns not only positively impacts overall patient satisfaction, but also serves to
increase trust in the medical team
• When patients’ spiritual needs go unmet, patients’ rating of both their satisfaction with their care as well
as the quality of their care received are significantly lower.
SPIRITUAL CARE GENERALISTS AND SPECIALISTS
• All health care providers should provide some spiritual care, but most are not adequately trained,
nor do not feel they have the time or comfort level to do so
• Patients and families do express a strong preference for basic spiritual care from their physicians,
nurses, social workers – including listening, communicating and expressing compassion
• High percentage of patients wish their health care providers would ask about or discuss
spirituality and/or religion
• Spiritual Care Generalist: any health care provider (nurse, physician, social worker) who
addresses spirituality/religion with patients and families through empathic listening, communicating
compassion, and seeking to connect on a human level. Spiritual Care Generalists would also
perform a Spiritual Care Screen and a Spiritual Care History, making referrals to the Spiritual Care
Specialists when appropriate
• Spiritual Care Specialist: most often a board certified chaplain who provides in-depth, complex
spiritual care, including a formal Spiritual Assessment and plan
ROLE OF BOARD CERTIFIED CHAPLAINS
Board certified chaplains (BCCs) are uniquely trained as the spiritual care specialists within health care
Board certified chaplains have:
- Completed a Master’s degree
- Substantial clinical training
(most commonly a three-year Master of Divinity)
CPE)
(most commonly Clinical Pastoral Education –
- Gone through thorough rigorous review process
clinical knowledge
- Or, more recently, passed a standardized
(formal interview with board certified chaplains &
through written
test and a demonstration of clinical competence
written submissions of competency essays)
encounter)
work or a standardized patient exam (simulated patient
- Often ordained by their own faith community
- Often endorsed by their faith community for service in health care
Two international interdisciplinary expert consensus panels recently published two important evidence-based
documents:
• The Quality Indicators document summarizes the research on the “indicators of quality spiritual care in health care,
the metrics that indicate quality care is present, and suggested evidence-based tools to measure that quality.”
• The Scope of Practice document provides a synthesis of the research “to articulate the scope of practice that
chaplains need to effectively and reliably produce quality spiritual care ... [and] to establish what chaplains need to be
doing to meet those indicators and provide evidence-based quality care.”
ROLE OF BOARD CERTIFIED CHAPLAINS
• BCCs have common Standards of Practice and Code of Professional Ethics
• BCCs provide spiritual care to patients of all faith traditions and none
• BCCs seek to connect the patient, family, or staff person to their own spiritual frame of
reference, not superimpose or proselytize any specific religious or spiritual tradition
• BCCs assess patients, families and staff for spiritual and emotional needs through a
formal Spiritual Assessment with every patient or family visit
• BCCs provide in-depth and specialized patient-centered spiritual care interventions that
are sensitive to the unique spiritual, emotional, religious and cultural needs of the person
being served
• BCCs identify and contribute toward a specific positive outcome
• BCCs clearly communicate their assessment, intervention, plan, and outcome to other
health care professionals through charting
BOTTOM-LINE IMPACT OF SPIRITUAL CARE
• BCCs provide spiritual and emotional support to health care providers as well, influencing their
organization’s bottom line through fostering resilience & well-being, and having a potential positive impact
on compassion fatigue, burnout, employee engagement, retention
• 45.8% of MDs – and 76% of MDs-in-training - exhibit one or more symptom of burnout
• Studies show that between 33% - 86% of RNs show significant signs of compassion fatigue & burnout
• According to one study, patients who receive less than adequate spiritual support results in higher cost of
care, estimated at $2,114 per patient (in 2010 dollars), $4,257 for minority patients, and $3,913 for “high
religious copers”
• Palliative care, for whom spiritual support is central, contribute to a cost savings of $1,696 (in 2008
dollars) in direct cost per admission, and $4,098 per admission for patients who die in the hospital
• Another showed congestive heart failure patients who experience spiritual struggle also have poorer
physical function and increased hospitalizations
• Another revealed that religious struggle is a predictor of mortality in ill elderly patients
• “Negative religious coping” – related to spiritual distress – shown to be associated with increased
incidence of depression, distress, mental health, pain, and fatigue in stem cell transplant patients
CONCLUSION
• For the vast majority of patients, a hospitalization is an unwelcome interruption into their
daily lives, potentially creating stress and spiritual distress, which can negatively impact the
course of their recovery
• Health care providers, doctors, nurses, and social workers, are spiritual care generalists, and
should incorporate spiritual care into their routine clinical practice through taking spiritual
screens and histories
• Board certified chaplains are the spiritual care specialists, and bring a wealth of depth,
breadth and expertise in assisting people in making meaning, addressing their spiritual
distress, and walking with them through their medical journey