Benchmark - Patient's Spiritual Needs: Case Analysis

The International Journal of Health, Wellness, and Society Volume 11, Issue 1, 2021, https://healthandsociety.com © Common Ground Research Networks, Cheryl Green, All Rights Reserved. Permissions: cgscholar.com/cg_support ISSN: 2156-8960 (Print), ISSN: 2156-9053 (Online) https://doi.org/10.18848/2156-8960/CGP/v11i01/189-197 (Article)

Assessing Spiritual Health through the Use of Spiritual Health Assessment Tools:

Indications for End-of-Life Care Cheryl Green,1 Southern Connecticut State University, USA

Abstract: Nurses deliver patient-centered care daily to end-of-life patients and provide emotional support for family members and significant others. Compassionate care that embraces the alleviation of suffering, the recognition of values and self-determination, and non-judgmentally provides support to the dying, is the distinctive feature of end-of- life care provided by nursing professionals. Therefore, like physical and mental health assessments that are provided by nursing professionals, spiritual health assessments must also be provided. Spiritual health encompasses an assessment of one’s experience of spiritual distress. Spiritual distress is the disturbance within values and belief systems that would otherwise be a source of hope and peace for the affected person(s). A spiritual health assessment, implemented during end-of-life care, can determine whether spiritual distress is absent or present. Upon the determination of the necessity of patients’ spiritual needs, interventions can be facilitated by the nurse and collaborating healthcare team members to address the patient’s spiritual needs(s), hence ensuring that patients can die peacefully.

Keywords: Spiritual Health Assessment, Patients, Nurses, End-of-Life, Care

Introduction

ursing is a profession of caritas that is profoundly spiritual. In the care of patients, the licensed professional nurse recognizes that death is a normal occurrence that co-exists within the natural order of the continuum of life (ANA 2019). The physiological and

psychological needs of patients are met with vulnerability to sickness and cellular deterioration. Healthcare institutions are required by organizations such as the Joint Commission and the American Nurses Association to provide care and offer services that meet the spiritual needs of patients. Nurses play an important role in addressing the spiritual needs of patients. Spiritual health is defined by this author as the process of assessment for the absence or presence of patients’ experiencing spiritual distress (disturbances within value and belief systems that would otherwise be a source of peace and hope to the affected person(s)).

Hypothetical Scenario

The following scenario is a hypothetical patient case. This hypothetical patient case is not based on an actual person, family, or event. The purpose of this hypothetical patient case is to provide understanding of the provision of end-of-life care delivery and how a spiritual health assessment tool may bring clarity to patients’ end-of-life spiritual health needs.

Clinical Application Scenario

A nurse is providing end-of-life care to a patient diagnosed with Stage 4 pancreatic cancer. The patient confides in the nurse that while undergoing chemotherapy, he found out that his wife of thirty years was having an affair. The patient shares, “I am having difficulty forgiving my

1 Corresponding Author: Cheryl Green, 501 Crescent Street, Jennings Hall, Southern Connecticut State University Department of Nursing, New Haven, Connecticut, 06515, USA. email: [email protected]

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wife.” The nurse asks the patient would he like to discuss the situation with a therapist or social worker. The patient becomes tearful and refuses to disclose any further information.

The nurse’s inquiry for behavioral health services, while well-intended for this dying patient, was not appropriate for this particular situation. Forgiveness is a spiritual issue. Given the brevity of life for this patient dying of cancer, the provision of comfort and compassionate care is the goal, and one that can be immediately addressed through a spiritual health assessment.

Nursing Assessment

Conducting physical and mental health assessments are both diagnostic and assessment areas that nurses engage within while admitting patients for healthcare services in inpatient and outpatient settings. Spiritual health assessments are of equal importance for patients. The Joint Commission (TJC 2021), as well as the American Nurses Association (ANA 2001, 2003, 2004), recognizes the value of spiritual care for patients seeking health care and/or experiencing a healthcare crisis.

The ANA standards for nursing practice assist the professional nurse in making decisions that are morally congruent with maintaining the dignity and well-being of patients who are the recipients of health care from nurses. Within codes of ethics and standards, healthcare associations and disciplines acknowledge the necessity of spiritual care for patients (Sessanna, et al. 2011; Zehtab and Adib-Hajbaghery 2014).

Identifying the Problem

Currently, there are no standardized clinical instruments that are universally used to assess the spiritual needs of patients admitted to healthcare institutions. Standardization of instrumentation that is used to assess patients experiencing spiritual health concerns may identify immediate referral needs for counseling, mental health, or chaplaincy services. When nurses are trained to use spiritual health instrumentation that can assess patients’ spiritual healthcare needs, patients can receive spiritual support in a timely manner and holistic care is delivered. Spiritual health assessment provided within the context of end-of-life care can assist these patients in the midst of the continuum of life to die with respect and self-determination.

Institutional Review Board and Conflict of Interest

Institutional review board (IRB) approval for this evidenced-based practice (EBP) project was obtained from Southern Connecticut State University and Gaylord Specialty Healthcare during the fall of 2016. The project was implemented on the grounds of Gaylord Specialty Healthcare during the spring of 2017. No conflicts of interests were identified.

Purpose of the Study

The purpose of this study was to examine the effectiveness of two spiritual health assessment tools in helping to identify the spiritual needs of patients and increase awareness of nursing professionals as to the importance of initiating referrals to chaplaincy when patients’ spiritual health needs are identified. Two spiritual health assessment tools were developed by this project implementer with the consultation of Rabbi Jeffery Silberman of the Bridgeport Hospital, an affiliate of the Yale-New Haven Health System. Spiritual Health Assessment Tool 1 used language that was non-spiritually based—such as feel, judged, and worry—while Spiritual Health Assessment Tool 2 used language that was spiritually-based, such as God, Heaven, and sin.

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Design

This study used a quantitative and qualitative approach in the gathering of data from both nurses and their patients, verbally and in writing, using two different spiritual health assessment tools. The first spiritual health assessment tool (Spiritual Health Assessment Tool 1) consisted of language that was non-spiritually-based. The second spiritual health assessment tool (Spiritual Health Assessment 2) consisted of spiritually-based language. A group of nurses and patients were provided the two different spiritual health assessment tools that each consisted of five items.

Nurses were provided a PowerPoint presentation with a patient case scenario about a patient diagnosed with melanoma. Within the patient case scenario, the patient diagnosed with melanoma verbalized fear of dying from cancer because his biological father had died as a result of melanoma metastatic disease. Participating patients were interviewed and provided information about the Joint Commission and the American Nurses Associations’ stance on the inclusion of spiritual health assessments when admitting patients to healthcare institutions.

Patients, unlike the nurses, were not shown a PowerPoint presentation, nor were they provided a case scenario. Patient interviews focused on education about spiritual health being a part of the healthcare admission process in healthcare facilities within the United States (a Joint Commission requirement for accredited facilities). The role of nurses in providing information about the availability of chaplain visitation or the contacting of patients’ clergy (i.e., a priest, a rabbi, or imam), as well as information on their religious, faith, or belief systems that could impact their delivery of health care (i.e., dietary choices, scheduled times of prayer and meditation, and recipient of blood products), was discussed. Thirty nurses and twelve patients volunteered to participate.

Literature Review

Spiritual care has traditionally been associated with nursing care of terminally ill (palliative care, hospice care) patients. However, spiritual care can be experienced by nurses in a variety of clinical settings (Giske and Cone 2015). Giske and Cone (2015) conducted a study from 2008 to 2014 using a grounded theory approach to provide eight focus groups for twenty-two nurses to explore the nurses’ perceptions of how patients’ spiritual needs can be met. The twenty-two nurses who participated in the study identified their primary concern as being to “assist the patient to alleviation.” According to Giske and Cone (2015), the nurses addressed their patients’ spiritual needs by “discerning the healing path,” which consisted of three stages: (1) tuning in on spirituality, (2) uncovering deep concerns, and (3) facilitating the healing process.

Vermandere et al. (2015) examined the ars moriendi texts, which are medieval in origin and provide instructions for a peaceful death experience. For example, the texts address five temptations that the dying must contend with as they transition from life to death. These five temptations included: an inability to cope with suffering and pain, the hanging on of temporal affairs, the loss of confidence in salvation, pride, and loss of faith. The ars moriendi texts were used to conduct a study using a parallel, convergent, mixed-methods approach in the evaluation of the Ars Moriendi Model (AMM) for Spiritual Assessment.

Quantitative and qualitative data were gathered by Vermandere et al. (2015) using a survey that was issued to nurses and physicians who were instructed to evaluate the AMM as a spiritual assessment tool and provide feedback as to whether it was a beneficial tool for patients receiving person-centered end-of-life care. Five physicians and nineteen nurses participated within the qualitative phase of the study, and four family physicians and seventeen nurses participated in the quantitative phase. Results were that the AMM Model was in fact conducive to use as a spiritual assessment tool and effective for end-of-life care (Vermandere et al. 2015).

Spanish- and English-speaking Hispanic/Latinos were interviewed in English or Spanish regarding the use of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-

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Being-Expanded (FACIT-SP-Ex) instrument, a 23-item measure of spiritual well-being. The number of Hispanics/Latinos participating within this study conducted by Brintz et al. (2017) was 5,163. The FACIT-SP-Ex instrument measured the spiritual well-being themes of faith, meaning, and peace. Findings indicated that this instrument demonstrated validity in the measurement of spiritual well-being for patients of Latino and Hispanic descent.

The comfort level of nurses in providing spiritual assessment to patients in their care was examined by Cone and Giske (Cone and Giske 2017). In a study conducted from 2014, 172 nurses were administered a 21-item survey. Participants indicated in open-ended questions that spirituality was a private matter. Nurses who had experience in discussing spiritual issues with patients shared that they felt comfortable addressing patients’ spiritual needs. Cone and Giske (2017) found that nurses who had prior preparation and experience with spiritual issues were better able to address the spiritual needs of their patients.

Nurses are more likely to witness issues of unforgiveness in their care of patients, particularly at the end of life. Ferrell et al. (2014), applying qualitative analysis, studied the narratives of 339 nurses from the United States, Belize, India, Romania, and the Philippines. Findings of Ferrell et al. (2014) were that nurses who are educated on the concept of forgiveness were better prepared to address their patients’ concerns with this issue before death occurred.

Methodology

Both quantitative and qualitative data, written and verbal, were used to evaluate the results of two separate groups of participants for this EBP project; patients and the nurses providing care to the patients on a Medical/Palliative Care Unit located in New England at the Gaylord Specialty Healthcare. Two spiritual health assessment tools were provided to the patients (n = 12) and nurses (n = 30). The first assessment tool was a 5-item questionnaire (Spiritual Health Assessment Tool 1) that did not use language suggestive of one having a faith or religious affiliation. The second assessment tool was also a 5-item questionnaire (Spiritual Health Assessment Tool 2) that used faith-based and traditionally spiritual language to describe one’s spiritual health. The two different instruments were used to determine preference of language for both nurses and patients when completing spiritual assessment tools. These spiritual assessment tools were developed by the author with consultation provided by Rabbi Jeffrey M. Silberman, DMin, DD, Director of Spiritual Care and Education at Bridgeport Hospital in Bridgeport, Connecticut. No funding was provided for this project.

Thirty nurses and twelve patients volunteered to participate in the review, feedback, and completion of the two spiritual health assessment tools upon the signing of a consent form. This EBP project was conducted over the course of three months; late May, June, July, and August of 2017. The nurses and patients self-identified as Baptist, Catholic, Sikh, Atheist, and Agnostic.

The thirty registered nurses who volunteered to participate in the EBP project were provided a brief training on the subject of spiritual health assessment. A PowerPoint discussing a case scenario of a patient diagnosed with melanoma (skin cancer) with a familial history of a parental (biological father) death from advanced stage melanoma was presented to the nursing staff. The patient in the case scenario was identified as experiencing spiritual distress concerns as he questioned the longevity of his life and prognosis. The nurses were then provided education on the American Nurses Association’s (ANA) and The Joint Commission’s (TJC) stance that spiritual assessments should be included in the care of patients. The nurses (n = 30) then were provided option one (Tool 1) and two (Tool 2) of the spiritual health assessments to complete.

Twelve patients who were inpatient on the Medical/Palliative Care Unit volunteered to participate in the EBP project. The patients were provided a verbal explanation for the purpose

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of the project which included how the ANA and TJC support the use of spiritual assessment in the healthcare setting; which presents itself during the admission process as nursing staff inquire about patients’ religious and faith preferences. Patients were also informed that nurses may notify them (patients) of the availability of chaplaincy services during the process of their admission to a hospital unit. Patients (n = 12) were then provided option one and two of the spiritual health assessments to complete for the purposes of determining their preferred instrument.

Examples of statements included in the two options of the spiritual health assessments provided to the nurses and patients were:

 Option one (Spiritual Health Assessment Tool 1, language is not suggestive of a faith or religion, nor belief in monotheistic God): “I believe that a higher power can help me cope with my illness and other life problems and I need to talk to someone about how I feel, that will not judge me or worry about what I say.”

 Option two (Spiritual Health Assessment Tool 2, language is suggestive of a faith or religious belief and a belief in a monotheistic God): “I believe that my faith can help me cope with my illness and other life problems and I talk to God about how I feel, that way I will not feel judged or worry about what I say.”

Results

For each of the two 5-item spiritual health assessments, Likert-type measurements were used to obtain data that included the selections of never, sometimes, occasionally, always, and definitely. For spiritual assessment Tool 1 all p-values were greater than 0.05 (Tables 1, 2, 3, 4), and no significant differences were noted between the group of twelve patients or the thirty nurses. However, for spiritual health Tool 2, patients’ and nurses’ answers differed for statements 1 (p = 0.031) and 4 (p = 0.050).

Patients’ scores for statements 1 and 4 were higher than the nurses’ scores. The patients (n = 12) mean score for statement 1 was 3.83 with a standard deviation of 1.115 and the nurses’ (n = 30) mean score was 2.77 with a standard deviation of 1.455. Statement 1 was “I talk to God about how I feel, that way I will not feel judged or worry about what I say.” Patients’ mean score for statement 4 was 3.33 with a standard deviation of 1.497 and nurses’ mean score was 2.34 and 1.344. Statement 4 was “I wonder will I be forgiven of my sins.”

In review of the participants (patients and nurses) data for the total scores for spiritual health assessment Tool 1 and spiritual health assessment Tool 2, nurses’ scores were higher on Tool 1 (18.07) in comparison to Tool 2 (14.43). A significant difference was noted with a p value of p = 0.000. The patients’ total scores for Tool 1 were 18.56 and Tool 2 17.22 with minimal differences noted in the p value, which was p = 0.134. Six patients preferred Tool 1 and six preferred Tool 2 with an insignificant p value of p = 1.00. Twenty-one out of the thirty nurses participating in the EBP project preferred Tool 1, while seven nurses preferred Tool 2, with a significant p value of p = 0.0008.

Limitations of the Study

The clinical unit, a Medical/Palliative care unit, had patients that were on medical-related precautions and/or too fatigued secondary to illness to participate in the study. In respect of these patients’ additional needs for rest and healing, they were omitted from study participation. Hence, of the twenty-six patients who were eligible to participate, twelve were selected.

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Discussion

Of the twelve patients who participated in the study, six preferred Tool 1 (language not suggestive of a faith or religious affiliation) and six preferred Tool 2 (language used was associated with traditionally faith and religious beliefs). In review of the qualitative data obtained from patients that participated within this EBP project, patients who identified themselves as atheist and agnostic at the time of their admission to inpatient hospital care shared that they would have appreciated it if the nurse who completed the admission or another nurse (e.g., primary care nurse assigned to provide care) revisited them during their diagnostic and treatment phases of care. Interestingly, patients who identified themselves as agnostic or atheist reported that after receiving a poor prognosis or a change in their treatment regimen secondary to a worsening condition, they found themselves alone in their hospital room questioning the brevity of their own existence and the existence of a God or after-life. Changes in patients’ condition and prognoses led to their experiencing spiritual distress. The patients shared that they felt uncomfortable seeking additional spiritual support because they were unaware that they could seek spiritual support after having already identified themselves as not being persons associated with a religion, faith, or belief system.

Conclusion

The spiritual health assessment of patients completed by nurses is necessary for patients’ overall health care. The mental and physical health of patients is only a component of their identity. Nurses, by virtue of being a part of a caritas profession, know that as the physical body withers and the mind deteriorates, patients still require care of their emotional and spiritual health. Hence, the spiritual health assessment of patients in the care of nurses must be prioritized.

By providing standardized spiritual health assessment tools that can meet patients at their level of spiritual health need, be they believers in God at the time of their illnesses or atheist, nurses can ensure that patients’ spiritual health needs are addressed. Nurses, when identifying that patients are in spiritual distress through the completion of a spiritual health assessment tool, can facilitate appropriate referrals for chaplaincy support, counseling, and/or mental health services. Support for patients can also be met through the connection of communities of faith in patients’ own cultures of community (a shared set of values and beliefs, folklore).

Reliability statistics for spiritual health assessments Tool 1 and Tool 2 were used to measure the consistency of the five items in each spiritual health assessment tool. The total scores for reliability were calculated by statistician Richard Feinn, PhD, of the Quinnipiac Medical School in Hamden, Connecticut. Results were a Cronbach alpha score of 0.633 for Tool 1 and a Cronbach alpha score for Tool 2 of 0.083. These scores support the reliability of the use of Tool 1 and Tool 2 within inpatient clinical environments.

Indications for Nursing Practice

While there are multiple spiritual assessment tools available, there has not yet been a standardized spiritual health assessment tool proposed that can be used nationally or internationally in healthcare settings. Current spiritual health assessment tools tend to be lengthy (i.e., over ten to twenty items) and not conducive to the rapid assessments required in clinical settings to expedite the patient admission processes by nurses. The two spiritual health assessment tools used in this study consisted of five items and were developed specifically to address the spiritual needs of all patients; the believer in a higher power, the agnostic, and the atheist.

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Nurses, as the first-line of contact for patients in many healthcare settings, are the ideal profession to ensure that patients have spiritual assessments completed upon admission to healthcare facilities. When patients’ spiritual, emotional, and physical health needs are met, patients can gradually begin to discuss their end-of-life journey with family, significant others, healthcare providers, and chaplains (their own clergy or faith leader). Dying patients who have been provided the opportunity for spiritual support through spiritual health assessments completed by nurses may have their spiritual needs met.

Comparison between Nurses and Patients for Each Item of Tools

Tool 1

Table 1: Tool 1 Test Statistics Statistical

Assumptions Statements

I need to talk to someone about how I feel, that will not judge me or worry what I say

I believe that a higher power can help me cope with my illness and other life problems

I wonder if there is an after-life

Everyone makes mistakes and is deserving of forgiveness

Peace is having a clear conscious and feeling unconditionally loved

Mann- Whitney U 160.00 123.00 143.000 129.500 136.500

Wilcoxon W 226.000 588.000 608.000 594.500 601.500 Z 1.152 -1.291 -.662 -1.153 -.981 Asymp. Sig. (2 tailed) .879 .197 .508 .249 .327

Exact Sig. (2*(1-tailed Sig.)

.896 .226 .532 .301 .407

Source: Green

Table 2: Tool 1 Report- Nurses and Patients Group Statements

I need to talk to someone about how I feel, that will not judge me or worry what I say

I believe that a higher power can help me cope with my illness and other life problems

I wonder if there is an after-life

Everyone makes mistakes and is deserving of forgiveness

Peace is having a clear conscious and feeling unconditionally loved

Nurse Mean 3.50 3.40 2.70 4.17 4.30 Std Deviation 1.280 1.522 1.264 1.053 1.088 Patient Mean 3.36 4.09 3.09 4.45 4.73 Std Deviation 1.567 1.221 1.640 1.036 .467

Source: Green

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Comparison between Nurses and Patients for Each Item of Tools

Tool 2

Table 3: Tool 2 Test Statistics Statistical

Assumptions Statements

I talk to God about how I feel, that way I will not feel judged or worry about what I say

I believe that my faith can help me cope with my illness and other life problems

I wonder whether there is a heaven or hell in the after-life

I wonder will I be forgiven of my sins

I want peace in my life and hope I can achieve this through my belief in God and faith

Mann-Whitney U

104.000 130.000 164.000 107.500 141.000

Wilcoxon W 569.000 595.000 599.000 542.000 576.000 Z -2.163 -1.454 -.294 -1.957 -.578 Asymp. Sig (2- tailed)

.031 .146 .769 .050 .563

Exact Sig. (2*(1-tailed Sig.)

.034 .170 .788 .056 .591

Source: Green

Table 4: Tool 2 Report- Nurses and Patients Group Statements

I talk to God about how I feel, that way I will not feel judged or worry about what I say

I believe that my faith can help me cope with my illness and other life problems

I wonder Whether there is a heaven or hell in the after-life

I wonder will I be forgiven of my sins

I want peace in my life and hope I can achieve this through my belief in God and faith

Nurse Mean 2.77 3.50 2.52 2.34 3.38 Std. Deviation 1.455 1.456 1.326 1.344 1.568 Patient Mean 3.83 4.25 2.67 3.33 3.82 Std. Deviation 1.115 .965 1.435 1.497 .982

Source: Green

Acknowledgement

Thank you to the nurses and patients on the Medical/Palliative Care Unit at Gaylord Specialty Healthcare, Jean Shutak, Nurse Manger for the unit, the Gaylord Specialty Healthcare and Southern Connecticut State University IRB teams and Gaylord Specialty Healthcare Administrators for their support of this study.

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ABOUT THE AUTHOR

Dr. Cheryl Green: Associate Professor of Nursing, Department of Nursing, Southern Connecticut State University, New Haven, Connecticut, USA

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