Professional Documents
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BSc, PhD, Cert Ed, Dip Theol. Min, RN, RNT, FRSA, FEANS, FHEA
Senior Lecturer, Faculty of Health and Social Care, University of Hull, Cottingham, UK
Correspondence
Peter Draper
Faculty of Health and Social Care
University of Hull
HU6 7RX
UK
E-mail: p.r.draper@hull.ac.uk
DRAPER P.
Aims To describe the current state of the art in relation to spiritual assessment,
focusing on quantitative, qualitative and generic approaches; to explore the
professional implications of spiritual assessment; and to make practical
recommendations to managers seeking to promote spiritual assessment in their
places of work.
Method The paper integrates aspects of a recent systematic review of quantitative
approaches to measuring spirituality and a recent meta-synthesis of qualitative
research into client perspectives of spiritual needs in health and the principles of
generic assessment, before drawing on the wider literature to discuss a number of
professional implications and making recommendations to nurse managers.
Implications for nursing management The issues to emerge from this paper are
(1) that spiritual assessment is an increasingly important issue for nursing
practice, (2) that the range of reliable and valid quantitative instruments for use
in clinical practice is limited, (3) that there is overlap in the domains and
categories of spirituality identified by quantitative and qualitative researchers, and
(4) that nurse managers seeking to introduce spiritual assessment will do so in the
context of a professional debate about the relevance of spirituality to
contemporary practice.
Keywords: integrative literature review, spirituality, spiritual assessment
Accepted for publication: 27 July 2012
Introduction
This paper explores the implications for nursing management of the spiritual assessment of patients and
clients. The paper draws on the literature of spiritual
assessment in clinical practice, and the literature of
spiritual assessment in research, seeking to integrate
the most important aspects of each and to explore
their significance for nursing management.
In recent years, scholars from fields as diverse as
medicine, nursing, social work, sociology, psychology
and theology have investigated the relationships
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Spiritual assessment
P. Draper
Table 1
The FICA model of spiritual assessment (Puchalski & Romer 2000,
Puchalski 2006)
F
2000, Puchalski 2006), Spiritual belief system, Personal belief system, Integration with a spiritual community, Ritualized practices and restrictions if any,
Implications for medical care, Terminal events planning (SPIRIT) (Maugans 1996) and sources of Hope,
Organized religion: level of identification or participation, Personal spirituality and Practices, Effect on
medical care and end-of-life issues (HOPE) (Anandarajah & Hight 2001). The FICA model is presented
in Table 1 as a single illustration of the generic
approach.
Generic methods of spiritual assessment are based
on an approach to spirituality stripped of any connections with specifically religious or other traditional
frameworks of meaning. They assume that spiritual
care is for people of all faiths and none (Swinton
2010). The strength of the generic approach is that it
does not require detailed understanding of particular
religious or other spiritual traditions, and has the
capacity to identify both needs and resources for
coping that might otherwise go unnoticed by carers.
However, generic approaches also have their limitations. Paradoxically, the lack of an explicit definition
of spirituality can lead to a situation in which
the carers implicit understanding of spirituality is
imposed on patients, leading to inappropriate assumptions being made about patients values and preferences. A further weakness of generic approaches
to spiritual assessment is that, with exceptions
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Spiritual assessment
Table 2
Instruments including items measuring a current spiritual state and specific domains investigated by these items (Adapted from Monod et al.
2011)
Instrument name
Number of items
specifically
investigating
a current
spiritual state
General spirituality
The Daily Spiritual Experience Scale (Underwood &
Teresi 2002)
Spirituality Assessment Scale (Howden 1992)
2 of 16
4 of 28
4 of 38
6 of 12
assessment (see Table 2 for details). Only three instruments (Brady et al. 1999, Daaleman et al. 2002, Hermann 2006) had at least three items focusing on
current spiritual state, and of these, one (Hermann
2006) had undergone a less rigorous evaluation process. Thus, two instruments, the FACIT-Sp, and the
Spirituality Index of Wellbeing, emerged as the bestvalidated instruments for the assessment of a patients
current spiritual state. The FACIT-Sp (Brady et al.
1999, Peterman et al. 2002) measures spiritual wellbeing in people with cancer. The Cronbachs alpha coefficient for the FACIT-Sp is 0.87 and the scale is
moderately correlated with other measures of spirituality and religion (Peterman et al. 2002). The Spirituality Index of Well-being (Daaleman & Frey 2004) is
a general purpose instrument for use in health-related
quality of life studies. It has a Cronbachs alpha coeffi 2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2012, 20, 970980
Specific domains
investigated
2 of 24
6 of 28
1 of 20
Connectedness/universality
Peacefulness, sense of harmony, identity, purpose/
meaning, life satisfaction
Punishment
2 of 23
6 of 98
1 of 8
Self-esteem, meaning
Happiness, self-esteem, connectedness, well-being
Fulfillment
7 of 12
8 of 20
5 of 32
5 of 21
17 of 17
10 of 42
P. Draper
Hodge & Horvath suggest that these findings underscore the importance of spiritual assessment in health
care settings. They recommend that in clinical
practice, an initial brief assessment should be made to
assess the relevance of spirituality to client care, and
that a more comprehensive spiritual assessment can
then be conducted if spirituality emerges as an important factor for a specific client.
Table 3
Strengths and limitations of assessment methods
Strengths
Generic
Limitations
Generally not well
validated
Not underpinned by
specific models of
spirituality
May lead to
assumptions being
made about patients
spiritual needs
Very few available for
clinical use
Limited generalizability
beyond original patient
group
Intensive and timeconsuming assessment
process
Dependent on skilled
assessors
Spiritual assessment
Table 4
Integrating qualitative and qualitative domains
Categories of spiritual
need (Hodge & Horvath 2011)
Meaning, purpose and hope
Spiritual practices
Religious obligations
Interpersonal connection
Spiritual domains
(Monod et al. 2011)
Hope
Outlook
Purpose and meaning
Loving God
Punishment
Sense of harmony
Universality
Inspiration
Spiritual activities
Religion
Sense of harmony
Community
Giving and receiving love
None
Fulfilment
Happiness
Identity
Life satisfaction
Self esteem
Wellbeing
Sense of wholeness
Peacefulness
Spiritual wellbeing
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P. Draper
Spirituality has to do with respecting the inherent value and dignity of all persons, regardless
of their health status. It is the part of humans
that seeks healing, particularly in the midst of
suffering. Spiritual care models are based on an
intrinsic aspect that calls for compassionate presence to patients as well as an extrinsic component where health-care professionals address
spiritual issues with patients and their loved
ones.
(Puchalski 2007)
I have referred to the differences of opinion between
the critics of spirituality and its advocates as a debate,
but there often seems little prospect that either side
will persuade the other to change its mind. Kuhn
(1970) argues that competing paradigms are often
seen as incommensurable: their advocates perceive the
world through different lenses and use different
concepts to describe what they see. Ultimately, for the
sake of consistency, one simply has to choose one paradigm and reject the other. Thus, Paley presents it as
a logical conclusion that the provision of scientific
health care within secular health services automatically excludes and disenfranchises other ways of
thinking about health.
Walter (2002) outlines an alternative approach to
conceptualizing multiple perspectives in health. He
accepts that there are spiritual, religious and secular
discourses in the literature but does not regard them
as logically or mutually exclusive. As Jordan (Jordan
1997) suggests, in many situations, equally legitimate
parallel knowledge systems exist and people move
easily between them, using them sequentially or in
parallel fashion for particular purposes. If we take this
point of view there is no reason why a commitment to
evidence-based practice cannot sit comfortably alongside the values of spiritually based health care.
The normal purpose of nursing assessment is to
establish a baseline, monitor progress or identify if
there is a deviation from expected norms. Modern
nurses who understand their practice in terms of the
nursing process are therefore likely to assume that,
whether spiritual assessment is conducted quantitatively (Monod et al. 2011) or qualitatively (Hodge &
Horvath 2011), the point of assessment is to identify
patients needs and to represent them in numbers (in
the case of quantitative approaches) or words (for
qualitative ones).
The concept of spiritual need is, however, a
contested one, and the question can legitimately be
asked as to whether the numbers or words generated
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P. Draper
Conclusion
This paper has reviewed the most recent literature on
quantitative, qualitative and generic approaches to
spiritual assessment in order to describe and evaluate
the state of the art revealed by the most recent
reviews of high-quality research; it has also explored
the professional implications of this literature for
nurse managers who wish to consider the introduction
of spiritual assessment in their places of work.
The paper recommends that spiritual assessment
should begin with one of the generic models such as
FICA (Puchalski & Romer 2000, Borneman et al.
2010) as these are relatively simple to use and do not
require detailed training. A range of qualitative and
quantitative approaches is then available if more
978
Acknowledgements
Thanks to Jane Wray and Jo Aspland for commenting
on an earlier draft of this paper. This paper was
unfunded but received institutional support from the
University of Hull.
Source of funding
This study was unfunded.
Ethical approval
Ethical approval was not required.
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