Assessment of Spirituality and Religion
Framing the Issues and Importance to Providers
When to make a spiritual assessment, who should do it, who should be responsible for follow-up with referral or integration with care as appropriate, and who should monitor the impact of a spiritual intervention are all considerations based on the specifics of each patient. Providers express concern about time constraints, about not feeling comfortable approaching the subject, and about fear that they may overstep legal and ethical boundaries.
There are calls throughout the literature for spirituality and religion to be addressed more frequently in training and for a consistent approach to this topic to be developed and integrated into care.
An assessment does not involve a value judgment, but is merely a means to understand the role of spirituality and religion in everyday life of the patient and his or her family. Rather than seeing it as a barrier or as one more thing to be done, it can be viewed positively, as another potential source of support for the patient.
Discussion in the literature addresses the appropriate time to perform such an assessment, whether as part of an initial and annual office visit within the social history or only related to severe or life-threatening medical conditions; but there appears to be little consensus to date on this issue.
JCAHO, the Joint Commission on Accreditation and Healthcare, is the largest and oldest accrediting entity in the United States for health care. In 2001, JCAHO revised its standards and now mandates a spiritual assessment that is to be directed to the patient or his/her family. Health care institutions affected by this change include hospitals, home care organizations, long-term care facilities, and behavioral health settings that treat addiction (Hodge 2006). The Standard lists general content areas of discussion, but it does not mandate a specific instrument to be used. This initial assessment may be brief, but it is intended to serve a twofold purpose:
1. to identify the importance of spirituality and religion to the patient as it may affect care
2. to determine if follow-up with a more comprehensive assessment is needed.
Commonly seen instruments relate to end of life issues/death and dying, mental health, chronic illness, and acute incidents. Little is seen on spirituality and religion and preventive health or public health. Phrasing of questions is very important. Patients should be presented with non-leading, open-ended, non-judgmental inquiries that provide the opportunity for them to bring forward what is important to them. Spirituality and religion are not static and may be influenced by the course of the patient’s illness so this is a topic that may need to be revisited occasionally to see if any significant changes are taking place.
Assessment tools range from a simple list of 3-4 questions to the more detailed and complex. For example, Nelson-Becker et al. (2007) look at eleven domains of spirituality, each with its own set of a few questions.
Sites that provide a listing of assessments along with comments or reviews include:
T.I.M.E.: Toolkit of Instruments to Measure End-of-life Care, from the Center for Gerontology and Health Care Research at Brown University Medical School; and
FICA Spiritual History Tool from the Center to Improve Care of the Dying at George Washington University.
Other sites offering assessment tools include:
Anandarajah and Hight (2001) discuss the HOPE Instrument (sources of Hope, meaning, comfort, strength, peace, love, and connection; Organized religion; Personal spirituality/practices; and Effects on medical care and end-of-life issues). The authors see it as having the advantage of allowing for an “open-ended exploration of an individual’s general resources and concerns,” without immediately focusing on either of the words “spirituality” or “religion.” They have also developed a patient handout on spirituality and health that addresses the following questions: What is spirituality? How is spirituality related to health? How can I improve my spiritual health? and Why does my doctor need to know about my spiritual beliefs? How can that help?
The George Washington University Institute for Spirituality and Health in Washington, D.C. provides the FICA Spiritual History Tool (Faith and Belief, Importance, Community, and Address in care) for taking a spiritual history. This is accompanied by general recommendations for taking a spiritual history. This web site also provides a PowerPoint presentation on conducting a spiritual assessment.
Ambuel (2000) describes the SPIRIT Instrument (Spiritual Belief System, Personal Spirituality, Integration with a Spiritual Community, Ritualized Practices and Restrictions, Implications for Medical Care, and Terminal Events Planning.
The City of Hope Pain & Palliative Care Resource Center website offers numerous pain assessment tools on-line including one titled, “Pain, Suffering, and Spiritual Assessment."
Not all assessments are designed as static questionnaires. Hodge (2005b) proposes a “spiritual ecogram” which uses a diagrammatic method with time and space dimensions to assess spiritual strengths. Hodge (2005a) also proposes the use of a “spiritual lifemap” that goes beyond assessment and moves into planning interventions in clinical settings. McBride et al. (1998) describe a pictorial measurement modeled after the Dartmouth Medical School Primary Care Cooperative Charts (COOP).
Intrapersonal communication is “the most basic level of human communication… where we interact with ourselves in interpreting reality and creating messages for communication with others” (Kreps and Kunimoto 1994:140).
For both the provider and the patient, this level forms the foundation on which their interpersonal communication takes place, including the ability to hear and express the symbolic aspects of illness, such as spirituality and religion.
Research conducted by Hart et al (2003) demonstrates that while patients do not expect their physicians to be their primary spiritual advisors, physicians still need to be aware of and comfortable in addressing spiritual and religious matters.
If the provider is clear on his/her perspective, then being able to address the area of spirituality and religion and health and mental health is more comfortable and manageable. Carson (1989a) provides reflective activities throughout her book for providers.
The American Medical Student Association, in a section titled “Healing the Healer,” describes how to develop one’s own health plan including questions related to lifestyle, nutrition, family history, mind-body, and spirituality. The most common recommendation is that providers perform a self-assessment by using any assessment instrument that they would use with their patients.