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Spiritual Assessment 1 Comparing and Discussing Two Spiritual Assessment Tools by Lori Hefner Counseling Older Adults Counseling 820 Dr. Gloria Gregg April 3, 2008
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Page 1: SpiritualAssessmentTools2 by Gallo

Spiritual Assessment 1

Comparing and Discussing Two Spiritual Assessment Tools

by

Lori Hefner

Counseling Older Adults Counseling 820

Dr. Gloria Gregg April 3, 2008

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Spiritual Assessment 2

Introduction

Having worked as an interfaith chaplain at Kaiser Hospital in Walnut Creek and Vitas Hospice, I

have conducted numerous spiritual assessments and I thought this would be an ideal opportunity to

examine the literature and a wide array of published spiritual assessment tools. I seek to describe two

assessment tools, articulate the purpose and functioning of the instruments, and investigate clinical uses

and contraindications.

Background

For many people spirituality and religion are important dimensions of their existence and can be

powerful resources in helping them achieve well-being and deal with life’s challenges. Many clients

prefer to have their spiritual belief systems integrated into their therapeutic processes. A number of

studies have found a generally positive association between spirituality and religion and positive mental

health outcomes. Other studies have posited that elders grew up at during a time where religion and

spirituality were more a part of the fabric of life and in their aging years, they seek to reflect and

integrate those understandings with their life review. A 2001 Gallup poll showed that 58% of

respondents thought religion was very important. Of those same respondents 68% identified

themselves as a member of a particular religion (Nelson-Baker, Nakashima and Canda, 2007).

Description of the Instrument or Procedure

In reviewing the scholarly literature, I nearly had a hundred spiritual assessments to choose

from. Narrowing the list to two for the purposes of a four to five page paper was a challenge. I have

included my preferred spiritual assessment tools in Appendices A-E for my long term reference.

Additionally, I searched for a spiritual assessment tool that focused on an existential or secular humanist

tradition. The tools that I gravitate towards are secular humanistic in nature because according to my

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training as a chaplain the core mission is to be present with the person and his or her family, regardless

of faith, tradition or lineage, ethnicity, etc.. This is particularly important in the multiculturalism of the

San Francisco Bay Area. The tools I included are as neutral as I could find.

My first choice is Nelson-Becker, et al. “Spiritual Assessment in Aging: A Framework for

Clinicians.” (Appendix C) It contains questions that would be most useful in understanding eleven

domains of spiritual life. Those include: spiritual affiliation; spiritual belief; spiritual behavior; emotional

qualities of spirituality; values; spiritual experiences; spiritual history; therapeutic change factors; social

support; spiritual well-being; and extrinsic/intrinsic spiritual center. It is constructed from several

assessment tools written by distinguished researchers in the fields of aging, health, spirituality and well-

being including Koenig (2002), Hodge (2001), Olson and Kane (2000). The framework includes 34

questions in the eleven domains. Interviewing an elder with these questions would assist in developing

a comprehensive understanding of the elder’s beliefs on a number of aspects of spirituality, including

negative reactions to spiritual and religious incidents.

“Spiritual Assessment in Aging: A Framework for Clinicians”

by Nelson-Becker

Strengths Weaknesses

Comprehensive. Time Consuming.

Goes beyond religious constructions into beliefs, personal definitions of the Divine.

Would have to complete over several visits.

Terms are straight forward. Not likely to confound elders or lead to value laden questions that would discourage or insult the elder.

May not be useful where death is imminent.

Culturally sensitive over a wide range of aspects related to spiritual beliefs.

Designed for social work clinicians but would work for a broad range of health care professionals including physicians, nurses, chaplains, etc.

Offers much to discuss about spiritual orientation over many visits. This would be ideal where circumstances would allow

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for 6-11 visits and the elder has the interest, time and stamina to discuss.

My second choice of instruments is Anandarajah’s and Hight’s, “Spirtuality and Medical Practice:

Using the HOPE Questions as a Practical Tool for Spiritual Assessment.” This was published in the

American Family Physician. Its key feature is that it is shorter than the Nelson-Baker instrument and

could be utilized where the elder’s time, physical or emotional strength is limited. (Appendix B)

“Spirtuality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual

Assessment.”

By Anandarajah and Hight

Strengths Weaknesses

Brief. Ideal for time limited situations. None detected.

Focuses on hope, love, peace, support, and connection. Flexible enough to include religion and spirituality.

Allows physicians a respectful and non-intrusive way to uncover how they could further understand what is of value to the elder including end- of-life preferences.

Sensitive over a wide range of aspects related to multicultural beliefs. This tool, if appropriately used, would elicit critical ethnical issues that are likely to influence health care choices. For example, a Muslim’s need to not attach a continuous chemotherapy portable pump to his body because it would result in him being “impure” in his faith tradition and not able to say his daily prayers.

Designed for physicians and other health care workers. Applicable to a wide range of professionals.

Touches on but does not overwhelm an elder about organized religion.

Encourages physicians to engage in spiritual assessment discussions and explicitly states that the physician wants to be of assistance where possible.

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Area of Functioning to Which the Instrument is Directed Gallo states, “A systematic approach to spiritual assessment can be a key feature to

understanding the overall well-being of an older adult” (2006, p. 261). A spiritual assessment is one

more window on the interiority of an elder’s reflection on life, values, meaning and purpose. A spiritual

assessment allows for another layer of the elder’s life story to be heard, acknowledged and shared. It

allows us to see another facet of his or her existence, social integration, participation in rituals or private

religion and how the elder fundamentally derives existential meaning. If there are death fears, pain,

anxiety, remorse, guilt, or severe unsolved conflicts, a spiritual assessment is a fiercely powerful

instrument to shed light on what is usually held as a very private part of a life. Extensive research has

also shown that spiritual assessments are linked with good health, positive mood states, well being,

social relationships and life satisfaction assessments.

Spiritual assessments are most valuable as “dialogue tools”. The resulting discussion is hoped to

further relationship building and comfort. It is not meant to encourage comparisons with an elder’s

cohort. There are no psychometric efforts employed to assure the tool’s validity. There is no right or

wrong answer. There is only wish to understand and honor the elder so she can live with “courage,

emotional sustenance, determination, faith, and hope to face situations that seem beyond human

control” (Ortiz and Langer, 2002, p.8).

Clinical Uses and Contraindications I personally believe that the person best suited to administer a spiritual assessment is a Board

Certified Chaplain (BCC). Such certification denotes a 72-semester hour Masters of Divinity or its

equivalent, as established by the Association of Professional Chaplains. The certification also entails a

minimum of one year full-time (1,600 hours) of successful completion of Clinical Pastoral Education

(CPE) under a qualified and certified clinical pastoral supervisor. Special emphasis is placed on

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multiculturalism and respecting those who did not think of themselves as religious or spiritual. All

hospitals in the United States are required to be Joint Commission on Accrediting Health Organizations

(JCAHO) accredited. (Appendix F includes spiritual care as published by JCAHO.) Nursing homes are

more likely to have a religious official from the surrounding community who is a volunteer. Care

companions are not trained to give spiritual assessments. According to the rich literature in numerous

nursing journals, nurses appear to be sensitized to opportunities to assess spiritual resources and

spiritual distress. Geriatric, palliative care, oncology and hospice nurses are the most fluent in engaging

in spiritual assessments. Since 2001 the gerontological social work journals have encouraged their

professionals to become more comfortable with spiritual assessments (Galek, 2005; Hicks, 1999,

Hungelmann, 1996), Larson, 2003).

The person administering the spiritual assessment must be conversant with definitional

problems. The term and concepts around religion connotes normative behaviors, which includes some

people and excludes others. For some people it is empowering while for others it is disempowering.

The word spiritual on the other hand, refers to concepts that go beyond the structures of religion.

“Being religious does not necessarily mean a person is also spiritual. A person may not be religious at

all, yet deeply spiritual and order his or her life around clearly identified sources of value and power

providing him or her an existentially meaningful interpretation for life” (Ortiz and Langer, 2002, ,p. 9).

Clinebell advises, “Use religious words and resources only after one has some awareness of

persons’ problems and their background, their feelings, and attitudes regarding religion *and spirituality+

(Clinebell, 1984, p. 122). This admonition allows for time for the person conducting the spiritual

assessment to look around the elder, see if any cultural, religious or spiritual figures or artifacts are

present. With open questions and active listening it allows the elder to introduce her personal

terminology about her sense of the Divine, holy, source, Allah, etc. Professional chaplains maintain that

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clients’ words should be substituted into the spiritual assessment tool selected. This way language can

comfort, reinforce and demonstrate respect for the elder and his or her belief systems.

It is also important to remember that a spiritual assessment is not an end in itself. It is the first

step in creating a Spiritual Care Plan. In gerontology we learn the acronym “APIE” which stands for

Assessment (A), Care Plan (P), Implement (I), and Evaluate (E). This is where the findings of the spiritual

assessment are analyzed, action plans are created and documented and then amended again based on

subsequent discussions. Such a care plan might include the spiritual interventions of:

Silent Witnessing

o Be with the person

o Provide a supportive presence

o Avoid judgment

Liaison

o Coordinate services and individuals requested by the individual. This may be specific

clergy, family, friends, or others with whom the individual has unfinished issues.

o Ensure transportation to spiritual activities. This can be church services, Buddhist

sangha meditations, or a visit to a certain site.

o Obtain requested spiritual related items. This is possibly a Koran or Bible, a rosary, a

cross, a Buddha statue or the symbol of Om. It can be a spiritual television show or a set

of tapes with sacred teachings along with a tape recorder and headset.

o Work with others on the interdisciplinary team to assure the individual is not

interrupted during these spiritual engagements, if possible.

Active Listening

o Engage in conversation about the spiritual matters of concern, if the individual desires.

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o Be alert to the resident’s comfort and pain level—watch for eye contact, body

movement, social isolation, questioning one’s worth, and his or her sense of personal

resources in coping.

o Does the individual want to engage in life-review? Is there a relationship, guilt or

aggression towards someone that needs to be discussed (Hicks, 1999, p.145)?

Contraindications

Among professional chaplains the clear professional requirement is to feel one’s way into the

client’s world and value system, and above all else, “Do no harm.” If the client is suffering from later

stage dementia, is in pain, or is in fragile psychological condition extreme care must be taken for the

benefit and comfort of the client. It is also important that the person administering spiritual

assessments is a competent multicultural broker. Clearly the strong cultural and professional

preference is to be skilled and knowledgeable enough to support that individual in their cultural systems

and not add additional hardship by expecting them to make the cultural, religious and spiritual

translations at a time of deep personal difficulty or during a health crisis.

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References

Clinebell, H., (1984). Basic types of pastoral care and counseling: Resources for the ministry of healing

and growth. Nashville, TN: Abingdon Press.

Galek, K., Flannelly, K.J., Vane, A., Galek, R.M. (2005) Assessing a patient’s spiritual needs: A

comprehensive instrument. Holistic Nursing Practitioner, 19(2), 62-69.

Gallo, J.J., Fulmer, T., Paveza, G.J., and Reichel, W. (2006). Handbook of geriatric assessment (4th ed.)

Boston, MA: Jones & Bartlett.

Hicks, T.J. (1999). Spirituality and the elderly: Nursing implications with nursing home residents.

Geriatric Nursing, 20(3), 144-146.

Hungelmann., J., Kenkel-Rossi, E., Klassen, L., and Stollenwerk, R. (1996). Focus on spiritual well-being:

Harmonious interconnectedness of mid-body-spirit—use of the JAREL spiritual well-being scale.

Geriatric Nursing, 17(6), 262-266.

Ivey, A., Ivey, M., Myers, J. and Sweeney, T. (2005). Developmental counseling and therapy: Promoting

wellness over the lifespan. Boston, MA: Lahaska.

Larson, K. (2003). The importance of spiritual assessment: One clinician’s journey. Geriatric Nursing,

24(6), 370-371.

Nelson-Becker, H., Nakashima, M., and Canda, E.R., (2007). Spiritual assessment in aging: A framework

for clinicians. Journal of Gerontological Social Work, 48(3/4), 331-347.

Olson, D.M. and Kane, R.A. (2000). Spiritual assessment. In R.L. Kane, and R.A. Kane (Eds), Assessing

older persons: Measures, meaning, and practical applications. New York: Oxford University

Press.

Ortiz, L.P., and Langer, N. (2002). Assessment of spirituality and religion in later life: Acknowledging

clients’ needs and personal resources. Journal of Gerontological Social Work, 37(2), 5-21.

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Appendices Appendix A Spiritual Assessment Scale by Gallo 11 Appendix B The HOPE Approach to Spiritual Assessment by G. Anandarajah and Hight 13 Appendix C Spiritual Assessment in Aging: A Framework for Clinicians by Nelson-

Becker, et al. 14

Appendix D Spiritual Assessment Protocol by Ortiz and Langer 16 Appendix E Assessing a Patient’s Spiritual needs: A Comprehensive Instrument by

Galek 17

Appendix F Select Statements from the Committee on Accrediting Medical Hospitals (CAMH) and the Joint Commission on Accrediting Health Organizations (JCAHO) on Spiritual Assessment and Accreditation

18

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Appendix A

Spiritual Assessment Scale

1. In the future, science will be able to explain everything.

Strongly Agree

Agree Neutral Disagree Strongly Disagree

2. I can find meaning in times of hardship.

3. A person can be fulfilled without pursuing an active spiritual life.

4. I am thankful for all that has happened to me.

5. Spiritual activities have not helped me become closer to other people.

6. Some experiences can be understood through one’s spiritual beliefs.

7. A spiritual force influences the events in my life.

8. My life has a purpose.

9. Prayers do not really change what happens.

10. Participating in spiritual activities helps me forgive other people.

11. My spiritual beliefs continue to evolve.

12. I believe there is a power greater than myself.

13. I probably will not re-examine my spiritual beliefs.

14. My spiritual life fulfills me in ways that material possessions do not.

15. Spiritual activities have not helped me develop my identity.

16. Meditation does not help me feel more in touch with my inner spirit.

17. I have a personal relationship with a power greater than myself.

18. I have felt pressure to accept spiritual beliefs that I do not agree with.

19. Spiritual activities help me draw closer to a power greater than myself.

20. When I wrong someone, I make an effort to apologize.

21. When I am ashamed of something I have done, I tell someone about it.

22. I solve my problems without using

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spiritual resources.

23. I examine my actions to see whether they reflect my values.

24. During the last week I prayed (check one) 10 or more times 7 times 4 times 1-3 times 0 times

25. During the last week I meditated (check one) 10 or more times 7 times 4 times 1-3 times 0 times 26. Last month I participated in spiritual activities with at least one other person (check one)

More than 15 times 11-15 times 6-10 times 1-5 times 0 times As published in Gallo et.al. p. 266-267. Source: R. L., et al. The Spiritual Involvement and Beliefs Scales, Development and Testing of a New Instrument, Volume 46, No.6 pp. 476-486. Dowden Publishing Company, Inc. Reproduced with permission from The Journal of Family Practice.

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Appendix B

The HOPE Approach to Spiritual Assessment

H Souces of hope, meaning, comfort, strength, peace, love and connection

We have been discussing your support systems. I was wondering what is there in your life that give you internal support?

What are your sources of hope, strength, comfort and peace?

What do you hold on to during difficult times?

What sustains you and keeps you going?

For some people their religious or spiritual beliefs act as a source of comfort and strength in dealing with lifes’ ups and downs. Is this true for you?

If the answer is “Yes,” go on to O and P questions.

If the answer is “No,” consider asking “Was it ever? If the answer is “Yes,” ask “What changed?

O Organized religion

Do you consider yourself part of an organized religion?

How important is this to you?

What aspects of your religion are helpful and not so helpful to you?

Are you part of a religious or spiritual community? Does it help you? How?

P Personal spirituality/practices

Do you have personal spiritual beliefs that are independent of organized relirio? What are they?

Do you believe in God? [What is your sense of the divine?] What kind of relationship do you have with God/Allah/Buddha/Nature (as appropriate)?

What aspects of your sprituality or spiritual practices do you find most helpful to you personally? (e.g, prayer, meditation, reading scripture, attending religious services, listening to music, hiking, communing with nature?

E Effects on medical care and end-of-life issues

Has being sick (or your current situation) affected your ability to do the things that usually help you spiritually. (Or affected your relationship with God?)

As a [professional nurse, doctor, social worker, chaplain, etc.] is there anything that I can do to help you access the resources that usually help you?

Are you worried about any conflicts between your beliefs and your medical situation/care/decisions?

Would it be helpful for you to speak to a clinical chaplain/community spiritual leader?

Are there any specific practices or restrictions I should know about in providing your medical care? (e g, dietary restrictions, use of blood products, self-purity concerns)

If the patient Is dying How do your beliefs affect the kind of medical care you would like to be provided over the next few days/weeks/months?

As published in G. Anandarajah and E. Hight (2001). Spirtuality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment. American Family Physician, 63(1), 81-88.

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Appendix C

Spiritual Assessment in Aging: A Framework for Clinicians

Prefatory Questions

Is spirituality, religion, or faith important in your life?

What terms do you prefer? Please explain. Affiliation

Do you belong to any spiritual group(s)?

What does membership in this group(s) signify to you?

Do you express your spirituality outside of participation in religoius or spiritual support grou? Spiritual Beliefs

What religious or spiritual beliefs give you comfort or hope? Describe.

What religious or spiritual beliefs upset you? Describe.

Do you believe in God, A Transcendent Power, or Sacred Source of Meaning?

Describe your vision of who God or this Transcendent Power is?

Do you believe in an afterlife? What does this mean for you now? Spiritual Behaviors

What religious or spiritual behaviors do you engage in?

How often do you engage in these religious or spiritual behaviors?

What about these behaviors do you find nourishing or underming? Emotions

Have you recently experienced an emotion such as anger, sadness, guilt, or joy in the context of religious or spiritual experience?

What significance if any did this have for you? Or if a client is describingh an experience, one can ask, What feelings did you have in response? (To better clarify the meaning of the experience for this person.)

Spiritual Experiences

Have you had any spiritiual experiences that communicate special meaninging to you? If so, please describe.

Values

What are the guiding moral principles and values in your life?

How do these pricnicples guide the way you live life? Spiritual History

Were you raised in a spiritual or religious tradition? Do you now practice in the tradition in which you were raised? Describe early experience and parental involvement.

In what decades of your life were you involved in spiritual practices? Would you rate your involvement as low, medium, or high for each? Were there any change points?

What events in your life were especially significant in shaping your spirituality?

Who encouraged your spiritual or religious practices? Therapeutic Change

What might be an object or image that symbolizes/represents your spiritual strengths?

Could you tell me a story of how spirituality elped you cope with difficulties in the recent past?

How do you see this particular spiritual stregth as being able to help you in your current problems?

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What spiritually-based strategies, rituals, or actions have helped you to cope with times of difficulty or to experience healing or growth?

Social Support

When you have religious/spiritual concerns and problems, who do you talk to?

In the past, what types of supports have you received from these people that you have just described?

If you belong to a religious or spiritual group, what types of support do you receive or provide to them> To what extent are you satisfied? Explain.

Well-Being

How worthwhile do you find living your current life? Can you tell me more about it? How does this relate to your spiritiuality?

How does your spirituality help you to find meaning in your life?

How strongly do you feel connected to God/Higher Power? Spirit?Universe? Extrinsic/Intrinsic Spiritual Propensity

Do you find the teachings and values of your spiritual groups similar or different from your own? Please explain.

How integrated are your spiritual practices with your dailylife apart from spiritual group participation?

As published in H. Nelson-Becker, M. Nakashima, and E.R. Canda (2007). Spiritual assessment in aging: A framework for clinicians. Gerontological Social Work, 48(3/4), 331-347.

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Appendix D

Spiritual Assessment Protocol

1. When talking with others, what common beliefs do you share with them that bring you a sense

of comfort and belonging?

2. Can you identify a spiritual force that brings you a sense of comfort and belonging? Explain.

3. Do you have family or friends that you depend upon to give you strength for living and energy to

overcome obstacles? Is so, what is it about this relationship that give you this strength or

energy?

4. Can you identify spiritual resources from which you gain strength and energy to overcome life’s

obstacles? Explain.

5. Do you have a belief system that helps give your life meaning or purpose? Can you give

examples of how this meaning or purpose is reinforced in your life?

6. Privately, what rituals or practices do you engage in that are renewing or comforting?

As published in Larry P.A. Ortiz and Nieli Langer, (2002). Assessment of spirituality and religion in later life: Acknowledging Clients’ Needs and Personal Resources. Journal of Gerontological Social Work, 37(2)5-21.

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Appendix E

Assessing a Patient’s Spiritual needs: A Comprehensive Instrument

Published in Kathleen Galek, Kevin J. Flannelly, Adam Vane and Rose M. Galek, (2005). Assessing a patient’s spiritual needs: A comprehensive instrument. Holistic Nursing Practitioner, 19(2): 62-69.

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Appendix F

Select Statements from the Committee on Accrediting Medical Hospitals (CAMH) and the Joint

Commission on Accrediting Health Organizations (JCAHO) on Spiritual Assessment and Accreditation Standard RI.2.20 The hospital respects the rights of patients Elements of Performance 2. Each patient has the right to have his or her…spiritual and personal values, beliefs and preferences respected. 3. The hospital accommodates the right to pastoral and other spiritual services JCAHO Standard PC 2.20 The hospital defines in writing the data and information gathered through assessment and reassessment. JCAHO: The Source, February 2005, Vol 3, Issue 2 Per standards and elements of performance (EPs) found in the ‘Provision of Care Treatment and Services’ (PC) chapter in the accreditation manuals, the Joint Commission requires organizations to include a spiritual assessment as part of overall assessment of a patient to determine how the patient’s spiritual outlook can affect his or her care, treatment, and services. The Source (continued) Spiritual assessment should, at a minimum, determine the patient’s religious affiliation (if any), as well as any beliefs or spiritual practices that are important to the patient. Organizations should develop a basic policy regarding the content and scope of spiritual assessments and outline who is qualified and competent to perform such assessment. Physicians, therapists, nurses, and clinical pastoral staff should receive training on the value of spiritual assessment and the tools that should be used to assess a patient’s spirituality. As with any other kind of assessment, staff members who conduct a spiritual assessment should be competent to do so. Spirituality vs. Religion While many people use the words spirituality and religion interchangeably, they are in fact very different. Spirituality can be defined as a complex and multidimensional part of the human experience—our inner belief system. It helps individuals search for the meaning and purpose of life, and it helps them experience hope, love, inner peace, comfort, and support. Religion refers to a belief system to which an individual adheres. Religion involved particular rituals and practices—the externals of our belief system.

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Many people find spirituality through religion; however, some people find spirituality through communing with nature, music, the arts, quest for scientific truth, or a set of values and principles.


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