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Next steps for spiritual assessment in healthcare 

Next steps for spiritual assessment in healthcare
Next steps for spiritual assessment in healthcare

George Fitchett

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The past 25 years have seen remarkable developments in the relationship between religion, spirituality, and health. There is a growing body of research investigating the relationship between religion and health[1] and there is growing acceptance of the role of religion and spirituality in health, especially in palliative care.[2,3] During this period numerous models for spiritual assessment have also been developed. In light of this, I believe we no longer need to develop new models for spiritual assessment. Rather, we need to focus attention on a critical review of the existing models and the dissemination of best practices in spiritual assessment. The chapter has three sections: it begins with a review of some existing models for spiritual assessment, then describes the research about spiritual assessment and concludes with a description of issues that will need to be considered in a critical review of models for spiritual assessment. Readers should be aware that the perspective I bring to this chapter is that of a liberal Quaker chaplain and chaplain-educator who has worked in a large, urban, academic medical centre in the USA for over 30 years.

Some models for spiritual assessment

There is a lot of diversity in the things that people call spiritual assessment. In an effort to make sense of all the existing models for spiritual assessment, my colleagues and I described three levels of inquiry about spiritual life: spiritual screening, spiritual history-taking, and spiritual assessment [4; see Table 42.1).

Table 42.1 Three levels of inquiry about spirituality and religion

Level of Inquiry





Spiritual screening

Initial contact

Very brief


Fitchett and Risk (5)

Spiritual history-taking

Initial contact and periodic reassessment



Stoll (6)

FICA (7)

HOPE (8)

Spiritual assessment

Initial contact and on-going reassessment


Conceptual framework for interpretation

Pruyser (9)

7x7 (10)

Brun (11)

Spiritual screening

Like screening in other disciplines, spiritual screening is part of a two-tier approach to assessment.[12,13] It is designed to provide initial information about whether a patient is experiencing spiritual distress or a possible spiritual crisis and whether referral for a more in-depth spiritual assessment is indicated. A growing body of evidence describing the harmful effects of spiritual struggle, pain or distress points to the importance of being able to identify and refer patients who may be experiencing such pain.[1416] Good models of spiritual screening employ a few, simple questions that can be asked by any health professional. Figure 42.1 describes one approach to spiritual screening.[5] This protocol was tested in a sample of 173 medical rehabilitation patients in which 12 (7%) were identified as possibly being in the midst of spiritual struggle.[5] The chaplain's spiritual assessment confirmed spiritual struggle in 11 (92%) of these patients.

Figure 42.1 Religious Struggle Screening Protocol.

Figure 42.1
Religious Struggle Screening Protocol.

Republished with permission from Fitchett G and Risk J, Screening for Spiritual Struggle, The Journal of Pastoral Care and Counselling, Volume 63, Issue 1, Copyright © 2009 Journal of Pastoral Publications, Inc.

Other approaches to screening for acute spiritual distress include the distress thermometer[17] and the nursing diagnosis of spiritual distress.[18] Steinhauser and colleagues[19] have reported evidence for the validity of the question, ‘Are you at peace?’ Chaplains have also developed other screening models.[2022]

Spiritual history-taking

Spiritual history-taking is the process of interviewing a patient, asking them about their spiritual life, in order to develop a better understanding of their spiritual needs and resources. Compared to screening, spiritual history-taking employs a broader set of questions to capture salient information about spiritual needs and resources. These spiritual history questions are usually asked in the context of a comprehensive examination by a clinician such as a physician who is primarily responsible for providing direct care and referrals to specialists as indicated. The information obtained from the spiritual history permits the clinician to understand how spiritual concerns could either complement or complicate the patient's overall care. Box 42.1 shows the FICA model, a popular model for spiritual history-taking.[7] Other models for spiritual history-taking have been published.[8,2325]

Republished with permission from Puchalski and Romer, Taking a spiritual history allows clinicians to understand patients more fully, Journal of Palliative Medicine, Issue 3, Volume 1, pp. 129–37, 2000, Copyright © Christina M. Puchalski, MD.

Spiritual assessment

I reserve the term spiritual assessment to refer to an in-depth, on-going process of evaluating the spiritual needs and resources of persons to whom we provide care. In this view, models for spiritual assessment do not consist of a set of interview questions. They are interpretive frameworks that are applied based on listening to the patient's story as it unfolds in the clinical relationship. An early and influential model for spiritual assessment was developed by the psychologist Paul Pruyser.[9] In it, he identified seven aspects of a person's religious life, including awareness of the holy, beliefs about providence, and connections with others or their absence. Pruyser did not intend to propose a definitive model for spiritual assessment, although the strengths of his work and the absence of other resources led others to develop models based on his work [2628].

Another model for spiritual assessment is the 7 × 7 model, which my colleagues and I developed.[10] As can be seen in Table 42.2, the 7 × 7 model explicitly places spiritual assessment in the context of a holistic assessment. The model employs a multidimensional view of spirituality including spiritual beliefs, behaviour, emotions, relationships, and practices. My colleagues and I have published five case examples of spiritual assessment based on the 7 × 7 model.[4,10,29] Chaplain Arthur Lucas[30] described a model for spiritual assessment called the Discipline for Pastoral Care Giving. It focuses on the patient's concept of the holy, meaning, hope, and community. It places the work of spiritual assessment in the context of the clinical process and its cycle of assessment, care plan, intervention, and re-assessment. A case example of chaplain's care with a cancer patient that was informed by this model has been published.[31]

Table 42.2 The 7 × 7 model for spiritual assessment

Holistic assessment

Spiritual assessment

Medical dimension

Belief and meaning

Psychological dimension

Vocation and obligations

Family systems dimension

Experience and emotions

Psychosocial dimension

Doubt (courage) and growth

Ethnic, racial, or cultural dimension

Ritual and practice

Social issues dimension


Spiritual dimension

Authority and guidance

Used by permission from Academic Renewal Press, 5450 N. Dixie Highway, Lima, Ohio, 45807.

Research about spiritual assessment

There is limited research about spiritual assessment. This research includes validation studies of the nursing diagnosis spiritual distress. In one such study, 59 critical care nurses felt most of the defining characteristics for this diagnosis were major indicators of spiritual distress.[32] They also demonstrated an ability to distinguish the defining characteristics of spiritual distress from a diagnosis of ineffective individual coping. A similar study, using 26 board certified paediatric chaplains as raters, found the majority of the defining characteristics of the diagnosis of spiritual distress were not valid for use with children, especially those under age 13 years.[33] Other studies have found that many nurses report problems in conducting spiritual assessments, including lack of time and inadequate training.[34] Several studies have found that educational programmes increase nursing students’ awareness of the importance of spirituality and may increase their competence in providing spiritual assessment and spiritual care.[35]

Research nurses administered the FICA spiritual history-taking tool to 67 oncology clinic patients.[36] The investigators reported key themes in the patients’ responses to the FICA questions, but did not evaluate the clinical impact of its use. Like nurses, physicians have described lack of training and time as barriers to conducting spiritual assessment. One study found that 38% of oncologists and 48% of oncology nurses felt they were primarily responsible for addressing their patients’ spiritual distress, but significant majorities (97 and 90%, respectively) felt that chaplains were the ideal person for this work.[37] When they rated the most important three issues in a vignette of a patient with a poor prognosis very few of these doctors (12%) or nurses (9%) included spiritual distress.

Courses about spirituality are now common in US medical schools. In one course, first-year students received training on taking a spiritual history using the HOPE model.[38] Faculty raters reported that 65% of these students were able to recognize spiritual issues in an interview with a standardized patient and 57% of those students asked at least one further question about those issues. Another study trained four haematologists/oncologists to conduct a brief inquiry about their patient's spiritual concerns.[39] The physicians reported they were comfortable making the inquiry in 85% of the cases. The majority of the patients who received the inquiry (76%) felt it was useful and three weeks later they reported a better quality of life and more sense of interpersonal caring from their physicians than those who had received usual care.

The research about spiritual assessment among chaplains gives a mixed picture. Gleason reported levels of agreement between 66 and 89%, when he asked 21 clinical pastoral education students to use his ‘Four Worlds’ model to assess patients described in their verbatim reports.[40] A survey of 159 board certified US chaplains found that 79% had received training in spiritual assessment and they often noted their spiritual assessment in patient's charts.[41] Another study found Canadian chaplains had positive and negative views about spiritual assessment.[42] Most did not use any published models for spiritual assessment, but about one in three had developed their own model or used one developed in their chaplaincy department. A Canadian palliative care chaplain reported that consistent use of the HOPE model for spiritual history-taking[8] increased staff colleagues’ understanding and utilization of chaplaincy services.[43] According to a large survey of chaplains in England and Wales, 88% of hospices and 71% of hospitals had spiritual assessment protocols that recorded patients’ religious preferences, requests for religious care (e.g. visit from clergy, sacraments), and religion-based preferences for specific services [e.g. diet; 44]. In 90% of the hospices and hospitals nurses conducted these interviews.

Next steps

In the past 25 years, many models, especially models for spiritual history-taking and spiritual assessment, have been published. (The George Washington Institute for Spirituality and Health (GWish) website, and especially its Spirituality and Health Online Education and Resource Center (SOERCE), is a good resource. However, the current situation, where anyone can develop their own model for spiritual assessment,[42,45,46] has led to confusing variations in practice. In turn, this has inhibited the research needed to demonstrate the value of good spiritual assessment and spiritual care. In light of this, I would argue that the field does not need any new models at this time. Rather, what is needed is a critical review of the existing models. Some prior work has described criteria for evaluating models for spiritual assessment. For example, my colleagues and I developed criteria for evaluating models for spiritual assessment and used these criteria to examine a number of models.[10,47] These criteria included how spirituality was conceptualized in the model and whether the model included explicit attention to issues of norms and authority. Practical issues were also described such as amount of training required to understand and use the model, and the contexts in which the model would be useful. Others have also addressed the issue of criteria for evaluating and selecting the best approach for spiritual assessment for specific contexts.[46] Several critical reviews and overviews have also been published.[34,48,49]

Evaluations of spiritual assessment and spiritual care programs must reference norms or standards for these activities. An example of such a standard was developed by the Trent Hospice Audit Group in the UK. ‘The spiritual needs of patients and caregivers are integrated into the assessment and delivery of palliative care.’[12] The Group also suggested structure, process, and outcome criteria that can be used to audit whether healthcare teams are meeting this standard. An example of one of the process criteria is that the multidisciplinary team ‘uses consistent assessment processes to inform the planning of spiritual care interventions.’12, p. 211]

The critical review I am proposing should examine the strengths and weaknesses of existing models, and identify gaps in the published work and areas for future research. Most importantly, this critical review should lead to identification of best practices in spiritual assessment. Based on the existing literature I see five issues that need to be addressed in this critical review.

Defining spirituality

Clear definitions of spirituality and religion form an essential basis for developing and evaluating models for spiritual assessment.[13,50] A lot is at stake in the debate about definitions since some definitions describe spirituality as beneficial and religion as restrictive or harmful.[51,52] Many authors argue that spirituality is a universal feature of human life.[13,53] Some clinicians and investigators see existential issues of meaning as the most important spiritual issues faced by patients with serious illness[54] and recommend meaning-focused treatment offered by mental health professionals.[55] Still others argue against the idea of a universal spirituality and focus on the important role of the distinct beliefs and teachings of specific religious groups.[56,57] Some who hold this view believe that spiritual assessment and spiritual care can only be offered by religious authorities who share the patient's religious traditions.[49]

Normative issues in spiritual assessment

It is difficult to engage in spiritual assessment without eventually identifying some of the patient's spiritual or religious beliefs or behaviours as unhelpful, if not limited or immature. Many health professionals feel unqualified to make judgments about such a complex and personal aspect of a patient's life. Some chaplains are also uncomfortable with diagnostic labels and prefer models of spiritual assessment with descriptive summaries.[58] Hodge[59] suggests models for spiritual assessment that focus on clients’ strengths and resources.

However, there are models that are explicit about spiritual diagnoses. For example, the model developed by Denton, a pastoral counsellor, describes pathological struggles with guilt, betrayal, and defilement.[60] The model developed by Brun,[11] also a pastoral counsellor, describes ten issues in spiritual life (e.g. capacity for reverence, capacity for guilt/repentance/forgiveness, capacity to face death), each with healthy and pathological dimensions. In other models the focus is on spiritual distress,[18,61] spiritual pain,[62,63] or spiritual injury.[64] Several models conceptualize a continuum from spiritual suffering to spiritual wellness.[6568]

A related issue is describing mature or immature features of a patient's spirituality. The language of ‘growing in faith’ is familiar, even central, in many religious traditions. Explicit models of faith development add a new perspective to this idea of growing in faith. The well-known model of James Fowler[69] describes stages of faith development that include increasing complexity in the treatment of symbols and moral decision-making. Several early models for understanding differences in patients’ religious worldviews employed developmental perspectives that focused on patient's use of symbols.[40,70,71] Ivy described a model for spiritual assessment that focused on faith development.[72]

A few authors have addressed the issue of the authority that permits professionals to create normative models of spiritual life and to make assessments or diagnoses of whether another person's life conforms to those models.[9,10,49,73] Paul Pruyser believed the professionals’ job was to be a consultant to the patient's own spiritual self-assessment.[9] A critical review of models for spiritual assessment should address practitioners’ reluctance to evaluate another person's spiritual wellbeing or distress.

The quantification of spiritual assessment

While there are many published measures of religion and spirituality for use in research,[74,75] most models for spiritual assessment are descriptive or narrative. The psychologist Kenneth Pargament probably speaks for many clinicians when he writes that inviting clients to tell a story is the best way to learn about their spirituality and that fixed questions are ‘more likely to interfere with the unfolding of the client's tale than to promote it’ [76, p. 224]. Others would share Pargament's view.[58,59] One Canadian chaplain who participated in a survey about spiritual assessment commented, ‘My image of sitting in front of somebody with a piece of paper and writing answers down … is not a positive image.’[42]

A few models of spiritual assessment include quantification of the patient's spiritual needs and resources. An early example is the work of the US physician Elisabeth McSherry and her colleagues.[77] Building on McSherry's work, Gary Berg, a chaplain in the US Veterans Affairs health system developed the Computer Assessment Profile, which included a Spiritual Injury Scale.[64,78] With their numerical descriptions of a patient's spiritual needs and resources, the models developed by McSherry and Berg bring spiritual assessment closer to the quantitative language that is familiar to healthcare professionals. Despite the difficulty associated with developing quantitative descriptions of patient's spiritual needs and resources, such models make it possible to document on a routine basis, not just in limited investigations, whether spiritual care creates measurable improvement in spiritual needs or resources or other outcomes such as emotional wellbeing or quality of life.

The contexts for spiritual assessment

The great diversity in patients, for example, their age, illness, and religious background, makes spiritual assessment a challenge. In addition to models for general use that have been previously described, there are models for specific contexts including models for adults with psychiatric conditions[28,79] and for persons with intellectual disabilities.[80] Models for use in hospice and palliative care are available[2,12,81] as are models for spiritual assessment with older adults.[82,83] Several authors have described the spiritual needs of children,[84,85] and one model for screening for spiritual distress in children and adolescents has been published.[86] Faith-specific models have been proposed for Jewish patients.[87,88] Models have been developed by pastoral counsellors[11,60] and psychotherapists[76,89,90] to facilitate addressing the spiritual issues in their client's lives.

In the USA, the agency that sets standards for healthcare organizations, the Joint Commission, has a very modest requirement regarding spiritual assessment.[91] This leaves considerable room for tailoring the best approach to spiritual assessment for each context.[92] A critical review of the existing models for spiritual assessment will need to find the best mix of models for general and context-specific practice.

Spiritual assessment and professional authority

Many of those who write about spiritual assessment have approached the topic from within their professional discipline. For example, physicians have developed models for spiritual history-taking with acronyms such as HOPE,[8] SPIRIT,[25] and FICA.[7] Nurses write about the nursing process and the use of nursing diagnoses such as spiritual distress.[13] Social workers and chaplains have developed models for their colleagues.[58,65,93,94] This intradisciplinary focus should not be surprising since diagnostic models are ‘touchstones of professional identity.’[9] However, it is unfortunate that many writers about the topic appear to have limited familiarity with work by authors from other disciplines. There has been a lack of disciplinary cross-fertilization in much writing about spiritual assessment.

A final issue that will need to be considered in a critical review of the literature on spiritual assessment is the role of different professions in spiritual assessment. Some nurses[13,63] and physicians[23,95] describe spiritual assessment as part of their professional responsibility. Chaplains see spiritual assessment as ‘a fundamental process of chaplaincy practice.’[96] Others suggest that different members of the healthcare team should have different levels of involvement in spiritual assessment depending on their role in direct patient/family care and training in spiritual care. Using this perspective some professionals such as nurses and doctors may be seen as spiritual care generalists who can conduct spiritual screening and spiritual history-taking, while chaplains are seen as spiritual care specialists with the expertise for in-depth spiritual assessment.[2,12,97,98]


The past several decades have seen a growing acceptance of spirituality as a dimension of persons that is influenced by and influences their health. There is also growing recognition of the importance of spiritual care that focuses clinical attention on this dimension especially for patients with serious and life-limiting illness, or those with spiritual distress. The purpose of spiritual assessment is to help guide effective spiritual care. Clinicians can select from many models for spiritual assessment that have been published. A critical review of the existing models and further research about spiritual assessment are needed to help us identify and disseminate best practices.


I am grateful for the helpful comments of Mary Altenbaumer and Paul Derrickson on an earlier draft of this chapter.


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