Introduction

The spiritual assessment is a tool to evaluate a patient's spiritual beliefs, needs, and hopes in the clinical context. The spiritual assessment helps the healthcare team member address the whole person by building a therapeutic alliance with the patient, allowing the patient to express their reasons for medical decisions, and helping elicit the patient's goals in the medical context. The term "spirituality" includes organized religion, a broad range of views on one's place in the universe, and views on one's eschatology. Studies suggest that religiosity and spirituality have a positive effect on survival.[1] 

Other studies also suggest that religious or spiritual interventions decrease depression and anxiety, increase spiritual well-being, and can have benefits in the care of patients with PTSD.[2][3][4][5] Spiritual or religious intervention studies also suggest that such interventions promote health, well-being, and physical outcomes.[6] Finally, studies suggest a benefit in reducing pain and improving quality of life.[7]  With this in mind, medical providers must attempt to understand and address the spiritual aspects of the patient's care. 

Studies show that most patients are willing to discuss their spiritual beliefs with their healthcare providers. In one study conducted in the waiting room of 5 family medicine practices, 83% of patients were willing to discuss spiritual beliefs (63% depending on the situation and 20% always).[8] The same study showed that the willingness of patients to discuss their beliefs depended on the circumstance. The 3 most common situations when a spiritual discussion was welcome were when a patient was "very seriously ill with the possibility of dying," "suffering from an ongoing, long-term, serious illness," and "just diagnosed with a serious illness," suggesting that illness severity plays a significant role in willingness to discuss spiritual beliefs. The top 3 reasons patients desired a spiritual discussion were "so that the doctor can understand how your beliefs influence how you deal with being sick," "so that the doctor can understand you better," and "so that the doctor would understand how you make decisions," suggesting that patients wish to be understood by their provider. Another cross-sectional study of one hundred forty-one primary care patients comparing rural and urban patients showed that between 38.3 and 49.1% of patients desired a clinical assessment. This same study demonstrated that patients were rarely asked about their religious or spiritual beliefs.[9] 

Another study of 456 patients from 6 academic medical center clinics found that 33% of patients would like to be asked about their religious beliefs in a routine office visit, with the number increasing to 40% for patients who were hospitalized and 70% for patients who were dying.[10] A different study of physician spiritual and religious inquiry of one hundred sixty-two parents of children in the PICU setting found that 34% would like their physician to inquire about their spiritual/religious views. The number increased to 48% if the child was seriously ill.[11] 

Finally, another study of one hundred seventy-seven patients visiting a pulmonary clinic found that two-thirds of patients would welcome a question regarding spiritual or religious beliefs if they became gravely ill.[12] While the percentage of patients willing to discuss spiritual beliefs varies from a significant minority to a majority of patients across studies, studies consistently show the greater the severity of illness, the more likely a patient is willing to discuss their spirituality or would like to have their provider inquire about their spirituality.

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. 

Table

F – Faith, Belief, Meaning “Do you consider yourself spiritual?” or “Is spirituality something important to you?”

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.

Review Questions

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Disclosure: Nathan Henry declares no relevant financial relationships with ineligible companies.

Disclosure: Nathan Gilley declares no relevant financial relationships with ineligible companies.