Spiritual Assessment in Clinical Care - Part 1: The Basics
by Walt Larimore, MD
Today's Christian Doctor - Spring 2015
About 25 years ago, while sharing an early morning cup of coffee with my dear friend and practice partner, family physician John Hartman, MD, he asked, “Walt, how come we don’t bring our faith to work with us more often?”
It was a question the Lord used to convict me of the fact that although my personal relationship with God was the primary and most important relationship in my life, more often than not I tended to leave Him at the door when entering the hospital or medical office.
Over several years, John and I prayed about and explored ways in which we might incorporate a number of spiritual interventions into our practice. The fruit we experienced eventually led to my working with William C. Peel, ThM, and CMDA to develop the Saline Solution in the mid-1990s and, more recently, Grace Prescriptions. Feedback from tens of thousands of attendees from these conferences and small group curricula from around the world indicate that these interventions have revolutionized their witness for Christ and their satisfaction with practice. In the first part of this two-part article, we’re going to explore the basics of spiritual assessment in clinical care.
Are spiritual assessments important?
The value of religiousness and/or spirituality (R/S) to patients and health professionals is underscored by lay polls, medical research, undergraduate curricula, recommendations of professional organizations, government regulations and clinical practice guidelines.
The most recent data from Gallup indicate 86 percent of adults in the United States believe in God and 78 percent consider religion either very important (56 percent) or important (22 percent).1 An informal survey of physicians revealed that 99 percent believe religious beliefs can heal and 75 percent believe others’ prayers can promote healing.2 Studies demonstrate that up to 94 percent of hospitalized patients believe spiritual health is as important as physical health,3 40 percent of patients use faith to cope with illness4 and 25 percent of patients use prayer for healing each year.5
According to Duke University psychiatrist Harold Koenig, MD, “Nearly 90% of medical schools (and many nursing schools) in the U.S. include something about R/S in their curricula and this is also true to a lesser extent in the UK and Brazil. Thus, spirituality and health is increasingly being addressed in medical and nursing training programs as part of quality patient care.”6
Numerous health professional organizations call for greater sensitivity and training concerning the management of religious and spiritual issues in the assessment and treatment of patients.7 For example, the Joint Commission, whose certification is a requirement for organizations receiving government payment (i.e., Medicare and Medicaid), now requires a spiritual assessment for patients cared for in hospitals or nursing homes or by a home health agency.8,9
Health professionals who don’t take a spiritual history are often surprised to learn how frequently spirituality affects their patient encounters and how open their patients are to their inquiry. For example, one recent review found that “studies have shown that (up to) 90% of patients (depending on the setting) want physicians to address their spiritual needs” and emphasizes that “the ability to identify and address patient spiritual needs has become an important clinical competency.”10
Another review concluded, “The majority of patients would not be offended by gentle, open inquiry about their spiritual beliefs by physicians. Many patients want their spiritual needs addressed by their physician directly or by referral to a pastoral professional.”11
Why aren’t more health professionals doing spiritual assessments?
Nevertheless, most ambulatory and hospitalized patients report that no health professional has ever discussed spiritual or religious beliefs with them,12,13 even though 85 to 90 percent of physicians felt they should be aware of patient spiritual orientation.14,15 In fact, our most recent national data (now about 10 years old) reveals that only 9 percent of patients have ever had a health professional inquire about their R/S beliefs.16
So why do health professionals ignore this “important clinical competency” of quality patient care? When asked to identify barriers to the spiritual assessment, family physicians in Missouri pointed to a lack of time (71 percent), lack of experience taking spiritual histories (59 percent) and difficulty identifying patients who wanted to discuss spiritual issues (56 percent).17
I have seen the same concerns expressed time and time again. In fact, Saline Solution and Grace Prescriptions were designed specifically to address these apprehensions.
Yet, one review on spiritual assessment concluded:
Assessing and integrating patient spirituality into the health care encounter can build trust and rapport, broadening the physician-patient relationship and increasing its effectiveness. Practical outcomes may include improved adherence to physician-recommended lifestyle changes or compliance with therapeutic recommendations. Additionally, the assessment may help patients recognize spiritual or emotional challenges that are affecting their physical and mental health. Addressing spiritual issues may let them tap into an effective source of healing or coping.18
From the perspective of the health professional, a spiritual assessment, included routinely in the patient’s social history, provides “yet another way to understand and support patients in their experience of health and illness.”19
How do I do a spiritual assessment?
Before you get started, I must share this caution from Stephen Post, PhD: “Professional problems can occur when well-meaning healthcare professionals ‘faith-push’ a patient opposed to discussing religion.” However, on the other side of the coin, “rather than ignoring faith completely with all patients, most of whom want to discuss it, we can explore which of our patients are interested and who are not.”20
Simply put, a spiritual assessment can help us do this with each patient we see. We can potentially gain the following from a spiritual assessment:
- The patient’s religious background,
- The role that religious or spiritual beliefs or practices play in coping with illness (or causing distress),
- Beliefs that may influence or conflict with decisions about medical care,
- The patient’s level of participation in a spiritual community and whether the community is supportive, and
- Any spiritual needs that might be present.21
Several fairly-easy-to-use mnemonics have been designed to help health professionals, such as the “GOD” spiritual assessment I developed for CMDA’s Saline Solution:
- G = God:
- May I ask your faith background? Do you have a spiritual or faith preference? Is God, spirituality, religion or spiritual faith important to you now, or has it been in the past?
- O = Others:
- Do you now meet with others in religious or spiritual community, or have you in the past? If so, how often? How do you integrate with your faith community?
- D = Do:
- What can I do to assist you in incorporating your spiritual or religious faith into your medical care? Or, is there anything I can do to encourage your faith? May I pray with or for you?
However, this and other spiritual assessment tools fail to inquire about a critical item involving spiritual health: any religious struggles the patient may be having. A robust literature shows religious struggles can predict mortality, as there is an inverse association between faith and morbidity and mortality of various types.22 In Part 2 of this article, I’ll review that literature with you and show you a new tool I’m using in my practice to address this factor.
Sir William Osler, one of the founding professors of Johns Hopkins Hospital and frequently described as the “Father of Modern Medicine,” 23 wrote, “Nothing in life is more wonderful than faith…the one great moving force which we can neither weigh in the balance nor test in the crucible—mysterious, indefinable, known only by its effects, faith pours out an unfailing stream of energy while abating neither jot nor tittle of its potence.”24
You can experience that driving force of faith when you apply these principles of spiritual assessment in your practice of healthcare, thereby allowing you to minister to your patients in ways you never imagined possible, while also increasing personal and professional satisfaction. One doctor recently shared with me, “Ministering in my practice has allowed God to bear fruit in and through me in new and wonderful ways. I can’t wait to see what He’s going to do in and through me each day. My practice and I have been
Are you ready to be transformed? Visit www.cmda.org/graceprescriptions to start learning how to share your faith in your practice. For an expanded version of this article and a complete list of citations, please visit www.cmda.org/spiritualassessment. Look for Part 2 of Dr. Larimore’s article in the fall 2015 edition of Today’s Christian Doctor.
1 Gallup, Inc. Religion. http://www.gallup.com/poll/1690/Religion.aspx?version=print. Accessed November 21, 2014.
2 Larimore WL. Providing Basic Spiritual Care for Patients: Should It Be the Exclusive Domain of Pastoral Professionals? Am Fam
Physician. 2001(Jan 1);63(1):36-41.
3 King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract. 1994;39(4):349–352.
4 Koenig HG. Religious attitudes and practices of hospitalized medically ill older adults. Int J Geriatr Psychiatry. 1998;13(4):213–224.
5 Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of
use. N Engl J Med. 1993;328(4):246–252.
6 Koenig, HG. Religion, Spirituality, and Health: The Research and Clinical Implications. ISRN Psychiatry. 2012;Article ID 278730.
7 Puchalski, CM. Taking a Spiritual History: FICA. Spirituality and Medicine Connection. 1999:3:1.
8 Koenig, HG. Spirituality in Patient Care. Why, How, When, and What. 2nd Ed. Templeton Press. West Conshohocken, PA. 2007:188–227.
9 Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. The Joint Commission. Oakbrook Terrace, IL. 2010. (This document mentions spirituality throughout, but see especially pp. 15, 21-22, 27, and 85. See: http://bit.ly/1vx3NXA and http://bit.ly/1r668Cj. Accessed November 21, 2014).
10 Katz PS. Patients and prayer amid medical practice. ACP Internist 2012(Oct).
11 McLean, CD, Susi, B, Phifer, N, et al. Patient Preference for Physician Discussion and Practice of Spirituality. Results From a Multicenter Patient Survey. J Gen Int Med. 2003(Jan);18(1):38–43.
12 King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract. 1994;39(4):349–352.
13 Maugans TA, Wadland WC. Religion and family medicine: a survey of physicians and patients. J Fam Pract. 1991;32(2):210–213.
14 Monroe MH, Bynum D, Susi B, et al. Primary care physician preferences regarding spiritual behavior in medical practice. Arch Intern Med. 2003;163(22):2751–2756.
15 Luckhaupt SE, Yi MS, Mueller CV, et al. Beliefs of primary care residents regarding spirituality and religion in clinical encounters with patients: a study at a midwestern U.S. teaching institution. Acad Med. 2005;80(6):560–570.
16 McCord G, Gilchrist VJ, Grossman SD, et al. Discussing spirituality with patients: a rational and ethical approach. Ann Fam Med. 2004(Jul/Aug);2(4):356-361.
17 Ellis MR, Vinson DC, Ewigman B. Addressing spiritual concerns of patients: family physicians’ attitudes and practices. J Fam Pract.1999;48(2):105–109.
18 Saguil, A, Phelps, K. The Spiritual Assessment. Am Fam Phys. 2012(Sep 15);86(6):546-550.
19 Saguil. Ibid.
20 Post SG. Ethical Aspects of Religion in Healthcare. Mind/Body Medicine: J Clin Behav Med. 1996;2(1):44-48.
21 Koenig, HG. Religion, Spirituality, and Health: The Research and Clinical Implications. ISRN Psychiatry. 2012. http://bit.ly/1wnA4iP. Accessed December 13, 2014.
22 Pargament, K, Koenig, HG, Tarakeshwar, N, et al. Religious struggle as a predictor of mortality among medically ill elderly patients: a two-year longitudinal study. Arch Int Med. 2001(Aug);161(15):1881-1885.
23 William Osler. Wikipedia. 2014. http://bit.ly/1wsfixo. Accessed December 13, 2014.
24 Osler W. The faith that heals. BMJ. 1910;2:1470–1472.