Abstract
Spiritual assessments are used in conjunction with physical assessment in planning patient care. Utilizing
a valid and reliable tool for spiritual assessment is vital in obtaining the information necessary to create a
holistic care plan. Understanding and knowledge of patient and staff in the use of various spiritual
assessments is essential in building trust and rapport so understanding the necessity to elicit the vital
information and its influence patient outcomes. Knowing when to use the assessment tools, how to use to
use it and what to do with the information is the role of healthcare providers. The examination of two
spiritual assessment tools increases one’s awareness of the skill needed in assessing spirituality. This
report will highlight the HOPE and FICA assessment tools and incorporate the importance of its findings
at the bedside.
Spiritual Assessment Tool
Healthcare’s goal is to provide quality care for patient’s physical, emotional and spiritual
needs. Spirituality is complex and reflective of the individual’s internal resources which affect
one’s ability to view health. This perspective influences a patient’s recovery (Puchalski, 2001).
According to Anandarajah & Hight (2001), spirituality is more than religious and non-religious
perspective. Some may find spirituality through music, art, nature (Puchalski, 2001).
Identification of patient’s spiritual needs through spiritual assessment is vital for optimal
recovery.
The Joint Commission on Accreditation (JACHO) revised its standards in 2001,
mandating initial spiritual assessments as a requirement for all patients in hospitals, long-term
care facilities, home care and mental health settings that treat addiction (JACHO, 2005). The
Joint Commission (2005) does not dictate a specific tool but suggest its content include
identification of spirituality’s importance as it may affect care. This mandate is influential in
integrating spiritual assessment in patient care.
A recent study by Monod, Brennan, Rochat, Martin, Rochat, & Büla (2011) revealed that
78% of advanced cancer patients relied on religion to help them cope with their illness,
prolonged treatments and end of life decisions. In addition, an overwhelming 77 % of patients
believe physicians should consider their spiritual needs. Yet, only 10-20 % reports that
caregivers actually discuss spirituality or religion with them (Medical University of South
Carolina, 2011).
This paper will present two spiritual assessment tools. It will provide an analysis of the
tools’ validity and reliability. In addition, the paper will provide an explanation on spiritual
assessment’s purpose, its influence and its impact on health care and patient outcomes.
Spiritual Assessment Tool Description
Spiritual assessment can help identify spiritual needs of individuals. It can gain insight
into an individual spirituality and evaluate how an individual’s spiritual practice can affect the
way the patient is cared for. The assessment should be conducted as a form of conversation
allowing key things to emerge and address on an on-going basis (Laudet, Morgen & White,
2006).
The HOPE Assessment Tool
Spiritual assessment tool is instrumental in incorporating an individual’s spirituality into
healthcare practices. Spiritual assessments can be measured in many ways. One of the tools used
in assessing patient’s spiritual belief is the HOPE questionnaire. HOPE concepts are as follows:
H stands for sources of an individual’s hope, comfort, meaning, strength, love or connection and
finding peace; O- role of organized religion in one’s life; P- for personal spirituality and
practices; E- effects of spirituality on medical care including end of life issues (Anandarajah &
Hight, 2001).
According to Anandarajah & Hight (2001), HOPE assessment is conducted as part of a
conversation by first establishing an empathetic connection with a patient with statements such
as it must be difficult for you to be sick. It includes the questions to include the following: How
are you holding up? Follow –up questions would follow the patient’s lead to include sample
questions such as would there be anything you would hope for even if you were not going to get
better or are there resources you draw strength from? Positive response to the H question,
questioning should proceed to the O with the following: Do you consider yourself religious or
how important is this to you and how does it help you? P questions can include Do you believe
in God, have spiritual beliefs and practices? E questions will follow positive responses to the first
three questions and will assess what the above may have on medical and end of life decisions.
Utilizing statements such as Are you worried about how your beliefs conflicts with your medical
situation or is there anyone with whom to need to say sorry or express your feelings to?
Following this guideline can reveal the way an individual perceives treatment.
According to Anandarajah & Hight (2001), HOPE is an instrument utilizing a series of
questions to assess the role of spirituality in a person’s life for the main purpose of minimizing
spiritual distress. The process involves asking four open-ended questions inquiring about a one’s
source of hope, strength, peace and comfort; what particular religion are they involved in; what
personal spiritual belief and practices including if that relation is with God; and how the one’s
spiritual belief affect their medical care. Lastly, through the responses, spiritual interventions
appropriate to address issues will be formulated to maintain religious belief, practices and
cultural preferences (Walsh, 2010).
Validity and Reliability
The HOPE Assessment Tool was developed at the Department of Family Medicine at
Brown University by Gowri Anandarajah and Ellen Hight. The advantages of the HOPE tool are
that it is brief yet encompasses all the critical areas to be assessed, allowing the caregiver
information in a non-threatening way. The HOPE tool is efficient, recognized, easy to remember
and proven effective (Walsh, 2010). Its questions were developed as a teaching tool to
incorporate spiritual assessments in medical interview for medical students and residents.
Validated by research, HOPE questions’ strength is its approach of using open-ended questions
to explore an individual’s spiritual resources and concerns (Medical University of South
Carolina, 2011). It provides an opportunity for the patient to tell his/her story and allows open
discussion of support system and what is important to the patient (unlike physical exam which
reveals what is important to the caregiver). Because it does not focus on the word spirituality or
religion, it minimizes discussion barriers based on language (Anandarajah & Hight, 2001). Use
of this tool in many medical programs adds to the validity and reliability of its purpose (Yates,
Chalmer, St James, Follansbee, & McKegney, 1981).
FICA Assessment Tool
Created by Dr. Cristina Puchalski in 1996 (in collaboration with Drs. Sumalsky, Teno &
Matthews), the FICA Spiritual History Tool provides an efficient integration of spirituality to a
standard medical assessment. According to Puchalski (1996), the questionnaires were created to
reflect what healthcare would need to know about a patient’s spiritual belief in the clinical
setting (Puchalski, 1996). Its basis are: F- the presence of faith, meaning or belief; I- importance
of spirituality on an individual’s life and the belief/value system on the patient’s ability to make
health care decisions; C-spiritual community; and A- addressing needs with interventions.
FICA Tool is conducted by first determining faith (F) with questions such as Do you
consider yourself spiritual (attitude and beliefs related to God, forces of life or nature) or
religious (beliefs, values, rituals) or Do you have beliefs that help you cope or give life meaning?
Importance and Influence (I) questions can include what importance does faith have in your life,
have your beliefs influence how you handle stress, what role does your belief play in healthcare
decisions? (Borneman, Ferrell, Puchalski, 2010). Meanwhile community (C) questions can
include are you part of a spiritual or religious community, who can you rely on and how do they
support you? The questioning ends with addressing information shared in the patient’s plan of
care. Questions by asking how can health caregiver’s best support one’s spirituality and what
information can be shared (Puchalski, 1996).
FICA tool utilizes open ended questions, allowing for descriptive data. FICA
respondents rated faith or spirituality as important or very important in helping patients to cope
and control stress. It further revealed the importance of support from family and friends
(Borneman, Ferrell, Puchalski, 2010). FICA tool identifies aspects of life that provides the
greatest spiritual support. FICA’s framework suggests that inquiry of beliefs opens the door to
further conversation about other issues the patient’s may be experiencing (Puchalski, 1996).
FICA can draw spiritual belief information on decisions related to health care. The tool help
elicit important clinical information such as ability to cope which may affect patient outcomes.
Validity and Reliability
Evaluations of the FICA tool reveal that the spiritual information gathered helps create
clinical plans but many felt its assessment went beyond just healthcare system and extends to the
community (Borneman et al., 2010). Interest in spirituality is seen as an aspect of respectful
patient care during illness, enhancing patient-caregiver relationship rather than just impacting the
plan (Monod, et al., 2011). Findings lend support to the importance of spiritual care as an aspect
of quality patient care and use of the FICA tool as a valuable instrument for clinical assessment
(Büssing, Balzat & Heusser, 2010). Responses to the FICA questions reveal the depth and
breadth of spirituality. The tool opens door for more conversation. Studies support importance
of care and tool valuable instrument for clinical assessment (Borneman et al., 2010). Responses
to the FICA reveal depth and breadth of spirituality including identification of intervention. The
FICA tool is the simplest tool for quick assimilation. Studies suggest the tool is feasible in
clinical assessment and enhances patient outcomes seen in many setting: mental health (Walsh,
2010), oncology (Cohen, Mount, Strobel, & Bui, 1995), palliative care as well as crisis
intervention (Yates et al., 1981). The tool has been published in many publications and
referenced by many studies with positive results for obtaining spiritual information for clinical
intervention (Highfield, 2000).
How the Spiritual Assessment Would Be Used in a Health Assessment
Research indicates a close connection between spiritual needs and physical needs, thus,
integrating spiritual assessment into patient care has become an integral part of holistic care
(Medical University of South Carolina, 2011). In order to assess spirituality, it is important for
the clinician to have some self-awareness of their own spirituality, care for their own spiritual
needs, establish good patient relationships and know the appropriate time to discuss the topic
(Highfield, 2000). Though spiritual assessments have no clear answers or solutions, its impact
has been proven to clearly affect the way a patient faces suffering and illness (Highfield, 2000).
Following an assessment, the best therapeutic intervention is presence, acceptance, compassion
and understanding (Walsh, 2010).
According to spirituality studies by Puchalski (2001), many patients believe spirituality
plays an important role in one’s life. Studies also suggest a correlation between patient’s
spirituality and health outcomes (Cohen et al., 1995). Patients agree that healthcare providers
should consider their spirituality into health care practice influencing pain control and outlook on
disease (Yates et al., 1981).
Spirituality assessment can be utilized with health assessments to create a treatment plan
that considers the patient’s holistic needs. It can be incorporated into preventative care by
helping identify and mobilize one’s own internal resources such as using prayer, meditation,
yoga, walks or music to bring strength and meaning to events happening around the patient
(Walsh, 2010). The inclusion of spirituality as an adjuvant care is an advantage of these
assessments. In addition to standard medical treatments, spiritual based measures can affect how
one deals with clinical situations (Yates et al., 1981). The patient can turn to music before
surgery for relaxation or say a prayer before taking medication to deal with fears. Understanding
an individual’s spiritual needs allows for the ability to modify treatment or decisions (Walsh,
2010) such as decisions on stopping or continuing treatments or chemotherapy, referrals of
distressed individual to a chaplain or religious minister of the right religion, using relaxation for
patients in pain (Highfield, 2000).
Conclusion
More than 80 percent of Americans perceive religion as important. Issues of belief can
affect the health care encounter (Borneman et al., 2010). Spiritual assessment tools such as the
FICA, the HOPE questions can be used as a compliment to health care interventions. Spiritual
assessments, as the first step, show convincing evidence in its beneficial role in the practice of
medicine. If spiritual assessments are done in a compassionate, culturally sensitive way, it can
provide relief to our distressed patients and accomplish the healthcare goal of holistic care for
those we care for.
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