Journal Review

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FACT, A Chaplain’s Tool for Assessing Spiritual Needs in an Acute Care Setting Mark LaRocca-Pitts BCC

Spiritual histories constitute a genre and are distinct from spiritual screens and spiritual assessments. Five spiritual history tools (CSI- MEMO, FICA, HOPE, FAITH and SPIRIT) are presented as examples of this genre. In comparison, FACT is not a spiritual history tool. Instead, FACT is a spiritual assessment tool designed for chaplaincy use in an acute care setting. Other health care clinicians interested in spiritual care may also find this tool helpful. A reviewer for the Australian Journal of Pastoral Care and Health (AJPCH) commented on a previous article by Mark LaRocca-Pitts as follows: “[T]itling FACT as a spiritual history tool seems unfortunate. FACT does not gather a history in the way a physician gathers a medical history. Rather, it provides information for an assessment, upon which an intervention might be planned.” In response, this article originally appeared in AJPCH (3:2, December 2009) under the title “In FACT, Chaplains Have a Spiritual Assessment Tool” and is reprinted with permission.

(Editor’s note: The discussion of how best to gather information in order to meet patients’ spiritual needs is ongoing. Comments or brief articles related to this topic, including how histories, screens and/or assessments are documented in the patient’s medical record, are invited. Submit via e-mail to [email protected].)

HEALTH CARE CHAPLAINCY CONTINUES TO DEVELOP as a clinical profession. Competencies for certification, professional codes of ethics and standards of practices are part of the professional chaplain’s landscape as evidenced by the Spiritual Care Collaborative.1 A new language for this new landscape is needed. Spiritual assessment is part of this new language and a professional chaplain needs to speak it.

Within this broad category called “spiritual assessment,” distinctions may be made, such as the differences among a spiritual “screen,” a spiritual “history,” and a spiritual “assessment.” This article will describe these differences including a discussion concerning the use of a spiritual history. Furthermore, the category called spiritual history now constitutes a genre. This article will delineate the chief characteristics of this genre and provide examples. Against this backdrop, we will evaluate whether FACT qualifies as a spiritual history.

Spiritual screens, histories and assessments A spiritual screen, a spiritual history and a spiritual assessment are distinct in form and function.2

Spiritual screen A spiritual screen is the shortest and generally uses one or two static questions aimed at determining the patient’s faith affiliation and whether the patient has special religious and/or cultural needs, such as diet, observances and/or restrictions, e.g., blood products. A spiritual screen obtains information that rarely changes in the course of a patient’s admission.

Mark LaRocca-Pitts PhD BCC serves as staff chaplain at

Crossroads Hospice of Atlanta, Tucker, GA. He is endorsed by the United Methodist Church.

[email protected]

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Generally, a clerk performs the spiritual screen during registration, though sometimes it forms part of a nursing admission form. Chaplaincy departments are constantly seeking the perfect one or two questions that will generate an appropriate chaplaincy referral.3

Spiritual history A spiritual history is more involved than a screen. Its questions engage the dynamics of the patient’s faith or spiritual experience identifying “specific ways in which a patient’s religious [or spiritual] life, both past and present, impact the patient’s medical care.”4

Not only are the questions dynamic, but also the answers in that they may change during the course of a patient’s hospitalization. A patient admitted with pneumonia may have sufficient spiritual resources to cope effectively, but if diagnostic procedures reveal the pneumonia is an opportunistic infection related to the patient’s until-then-unknown HIV+ status, then the patient may find that he/she has insufficient spiritual resources to cope effectively. Just as the medical history changes to reflect this, so may the spiritual history.

A spiritual history may need to be performed more than once during a single hospitalization and periodically during the progression of a disease. A physician, nurse or chaplain may take a spiritual history and place salient information in the medical chart.5

Furthermore, whereas a spiritual screen is limited in its form and function, i.e., one or two static questions asked at the time of admission, the spiritual history may be used in various settings and at various times. A spiritual history may be administered either as a formal checklist or as an informal one. When used as a formal checklist, it easily forms part of a larger, more in-depth assessment, such as a physician’s history and physical, a nurse’s admission assessment, or a professional chaplain’s spiritual assessment. A spiritual history functions like a social history, identifying a need that may result in a referral.

When used as an informal checklist, it serves as a tacit guide around which a clinician may organize a conversation in order to obtain clinically relevant information pertaining to a patient’s spiritual well-being. This latter use fits well within the ongoing relationship a clinician develops with a patient. If and when significant changes occur in the patient’s treatment process or if and when a patient initiates the topic of faith, the clinician may use that opportunity to reevaluate the patient’s spiritual well-being by using what appears to be casual conversation.

When taking a spiritual history, a few guidelines are recommended.

• A clinician should always show respect for the patients’ expressions of their faith or beliefs, even if the clinician’s differs radically. Imposing one’s faith on another is never the goal of a spiritual history.

• A spiritual history focuses less on what individuals believe and more on how their faith and/or beliefs function to help them cope positively with their illness crisis.

• The clinician does not conduct a spiritual history in order to “fix” anything. If something presents that makes the clinician uncomfortable or that is outside the clinician’s training, then the clinician places the appropriate referral for follow up.

• Many patients use their faith to help them cope, and when the clinician shows an interest in their individual spiritual paths, then the clinician provides a therapeutic intervention. Even when patients do not use faith or spirituality to help them cope, if the clinician respects this and is not judgmental, then the clinician again provides comfort.

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Spiritual assessment A spiritual assessment differs significantly from a screen and a history. A spiritual assessment is an in-depth look at the patient’s spiritual makeup with the goal of identifying potential areas of spiritual concern and determining an appropriate treatment plan.

In general, a spiritual assessment begins with the patients’ needs, hopes and resources in order to build a spiritual profile. Based on this profile, outcomes are determined that will contribute to their healing and well-being. This results in a spiritual care plan that includes appropriate interventions and a way to measure effectiveness.6

Often, along with a series of questions, a spiritual assessment may incorporate a complex algorithm in which various answers will result in different questions, e.g., If “yes,” then ask …. If “no,” then ask …. Due to the in-depth nature of a spiritual assessment and the training needed to use such a complex tool, the administration of a spiritual assessment should remain in the hands of a professional chaplain who has the appropriate training. Examples of spiritual assessment tools include The Discipline (Art Lucas), 7x7 (George Fitchett) and A-SNAP (Larry Austin).7

Chaplain-developed spiritual assessment tools, however, have two problems: their depth and complexity. As noted by Massey, Fitchett and Roberts, Paul Pruyser laid the foundation for spiritual assessment in his The Minister as Diagnostician (1976).8 Pruyser’s model, which was designed by a psychologist for the parish-based pastor, assumes both the time for in-depth uninterrupted pastoral conversations and the opportunity for repeated counseling sessions.

Chaplains providing spiritual care in an acute care setting do not have the luxury of both time and multiple follow-ups in the same way pastors do or as their colleagues in sub-acute, long term care, or hospice settings may have. Acute care chaplains need a spiritual assessment tool that fits the requirements of their setting: short and easy, versatile and focused.

The spiritual history genre A spiritual history arguably forms its own genre. A “genre” is defined as “a category of artistic, musical, or literary composition characterized by a particular style, form, or content.”9 Harold Koenig provides the groundwork for this genre study in Spirituality in Patient Care where he presents five criteria he considers critical for a spiritual history.10

1. It must be brief.

2. It must be easy to remember.

3. It must obtain appropriate information.

4. It must be patient-centered.

5. It must be validated as credible by experts.

When all five of these criteria are used together, the critic is able to adjudicate the strengths and weaknesses of various spiritual histories.11 However, when discussing spiritual histories as a distinct genre only the first three of these criteria are needed. When we modify these three criteria in light of published spiritual histories, we get the following requirements for this genre.

1. A spiritual history is brief: it contains a brief series of categories or topics with pertinent questions.

2. A spiritual history is easy to remember: a memorable acronym is used to recall the categories.

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3. A spiritual history obtains appropriate information: its questions address the patient’s spiritual resources, the patient’s use of them in his/her past and current situation and how these resources and uses impact the patient’s medical care.

We will look briefly at five examples of this genre and then compare these findings with FACT.12

CSI-MEMO (Koenig)13 CS Do your religious/spiritual beliefs provide Comfort, or are they a source of Stress?

I Do you have spiritual beliefs that may Influence your medical decisions?

MEM Are you a MEMber of a religious or spiritual community, and does it support you?

O Do you have any Other spiritual needs that you’d like someone to address?

FICA (Puchalski and Romer)14 F Faith, Belief, Meaning: “Do you consider yourself spiritual or religious?” or “Do you have

spiritual beliefs that help you cope with stress?”

I Importance or Influence of religious and spiritual beliefs and practices: “What importance does your faith or belief have in our life? Have your beliefs influenced how you take care of yourself in this illness? What role do your beliefs play in regaining your health?”

C Community connections: “Are you part of a spiritual or religious community? Is this of support to you and how? Is there a group of people you really love or who are important to you?”

A Address/Action in the context of medical care: “How would you like me, your health care provider, to address these issues in your health care?”

HOPE (Anandarajah and Hight)15 H Sources of hope, meaning, comfort, strength, peace, love and compassion: What is there in

your life that gives you internal support? What are the sources of hope, strength, comfort and peace? What do you hold on to during difficult times? What sustains you and keeps you going?

O Organized religion: Do you consider yourself as part of an organized religion? How important is that for you? What aspects of your religion are helpful and not so helpful to you? Are you part of a religious or spiritual community? Does it help you? How?

P Personal spirituality/practices: Do you have personal spiritual beliefs that are independent of organized religion? What are they? Do you believe in God? What kind of relationship do you have with God? What aspects of your spirituality or spiritual practices do you find most helpful to you personally?

E Effects on medical care and end-of-life issues: Has being sick (or your current situation) affected your ability to do the things that usually help you spiritually? (Or affected your relationship with God?) As a doctor, is there anything that I may do to help you access the resources that usually help you? Are you worried about any conflicts between your beliefs and your medical situation/care decisions? Are there any specific practices or restrictions I should know about in providing your medical care?

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FAITH (King)16 F Do you have a Faith or religion that is important to you?

A How do your beliefs Apply to your health?

I Are you Involved in a church or faith community?

T How do your spiritual views affect your views about Treatment?

H How may I Help you with any spiritual concerns?

SPIRIT (Abridged: Maugans; Ambuel and Weissman)17 S Spiritual belief system: Do you have a formal religious affiliation? Can you describe this?

Do you have a spiritual life that is important to you?

P Personal spirituality: Describe the beliefs and practices of your religion that you personally accept. Describe those beliefs and practices that you do not accept or follow. In what ways is your spirituality/religion meaningful for you?

I Integration with a spiritual community: Do you belong to any religious or spiritual groups or communities? How do you participate in these groups/communities? What importance does they have for you? What types of support and help does or could they provide for you in dealing with health issues?

R Ritualized practices and Restrictions: What specific practices do you carry out as part of your religious and spiritual life? What lifestyle activities or practices do your religion encourage, discourage or forbid? To what extent have you followed these guidelines?

I Implications for medical practice: Are there specific elements of medical care that your religion discourages or forbids? To what extent have you followed these guidelines? What aspects of your religion/spirituality would you like to keep in mind as I care for you?

T Terminal events planning: Are there particular aspects of medical care that you wish to forgo or have withheld because of your religion/spirituality? Are there religious or spiritual practices or rituals that you would like to have available in the hospital or at home? Are there religious or spiritual practices that you wish to plan for at the time of death, or following death? As we plan for your medical care near the end of life, in what ways will your religion and spirituality influence your decisions?

FACT (LaRocca-Pitts)18 F Faith (or Beliefs): What is your Faith or belief? Do you consider yourself a person of Faith

or a spiritual person? What things do you believe that give your life meaning and purpose?

A Active (or Available, Accessible, Applicable): Are you currently Active in your faith community? Are you part of a religious or spiritual community? Is support for your faith Available to you? Do you have Access to what you need to Apply your faith (or your beliefs)? Is there a person or a group whose presence and support you value at a time like this?

C Coping (or Comfort); Conflicts (or Concerns): How are you Coping with your medical situation? Is your faith (your beliefs) helping you Cope? How is your faith (your beliefs) providing Comfort in light of your diagnosis? Do any of your religious beliefs or spiritual practices Conflict with medical treatment? Are there any particular Concerns you have for us as your medical team?

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Up to this point, FACT fits well with the spiritual history genre: it is brief, it is using a memorable acronym and it is obtaining appropriate information. But with the next step, the T – Treatment plan, FACT moves beyond the content and purpose of the generic spiritual history and asks for a judgment. Instead of obtaining information only, as with a generic spiritual history, it asks the clinician to make an assessment upon which the clinician provides an intervention. Thus, describing FACT as a spiritual history was unfortunate.19 The question now focuses on the significance of this difference between FACT and the generic spiritual histories. Before addressing this question, we will finish describing the tool.

T Treatment plan: If patients are coping well, then either support and encourage or reassess at a later date as the situation changes. If patients are coping poorly, then

1. Depending on relationship and similarity in faith/beliefs, provide direct intervention, e.g., spiritual counseling, prayer, Sacred Scripture.

2. Encourage patients to address these concerns with their individual faith leaders.

3. Make a referral to the hospital chaplain for further assessment.

Explicitly addressing treatment provided an important and significant difference when FACT, a chaplain-developed tool, was compared to other physician-developed tools.20 It set this method apart as a strength and also differentiates it from spiritual histories in general. FACT falls exactly into the niche between the physician-developed spiritual history and the generally too in-depth and complex chaplain-developed spiritual assessment. In other words, FACT is a spiritual assessment tool that fits well the needs of an acute care chaplain: it is short and easy, versatile and focused.

For example, FACT may be used effectively in the span of a five- to ten-minute initial visit. In the context of a discipline-appropriate conversation, the chaplain may take a brief spiritual history, assess immediate spiritual needs and provide an appropriate intervention with the intended outcome of supporting the patient. An intervention may range from simply supporting and encouraging the patient to providing a prayer (treatment option 1) to conducting— time and length of stay permitting—a more in-depth assessment (treatment option 3) at that time or in a follow-up visit.

In addition, some health care clinicians believe praying with patients is within their scope of practice.21 Using FACT may prevent the clinician from crossing ethical and professional boundaries.22 If the clinician judges a direct and personal intervention is needed, such as praying with the patient, then the clinician may do so, but with extreme care.23

Choosing this option means the clinician has already administered a spiritual history and established the following:

1. The patient and the clinician share a similar faith.

2. The patient welcomes such an intervention.

3. The clinician is not imposing his/her beliefs onto the patient.24

With proper training, clinicians using FACT also will help identify patients who may benefit from treatment option 3 – referral to the chaplain.

Conclusion The spiritual history is a genre unique from that of a spiritual screen and a spiritual assessment. Technically, FACT does not qualify as a spiritual history tool: it is three parts spiritual history and one part spiritual assessment.25 In other words, it is a hybrid spiritual assessment tool that fits well with the needs of a professional chaplain in an acute care setting. It also works well with other

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health care clinicians who believe the scope of their practice includes addressing spiritual needs, such as providing spiritual encouragement or prayer and making referrals to chaplains.

1 The Spiritual Care Collaborative is comprised of five North American professional chaplaincy organizations: American Association of Professional Counselors, Association for Clinical Pastoral Education, Canadian Association of Pastoral Practice and Education, National Association of Catholic Chaplains and National Association of Jewish Chaplains. See www.spiritualcarecollaborative.org.

2 K. Massey, G. Fitchett, and P. Roberts, “Assessment and diagnosis in spiritual care,” in Spiritual Care in Nursing Practice, eds. K. L. Mauk and N. K. Shmidt (Philadelphia, PA: Lippincott, Williams and Wilkins, 2004), 209-42.

3 G. Fitchett and J. Risk, “Screening for spiritual struggle,” Journal of Pastoral Care and Counseling 63, no. 4 (2009): 1-12.

4 Massey, Fitchett and Roberts, “Assessment and diagnosis.”

5 Ibid.

6 L. VandeCreek and A. M. Lucas, Eds., The Discipline for Pastoral Care Giving: Foundations for Outcome Oriented Chaplaincy (New York: The Haworth Pastoral Press, 2001).

7 Ibid.; G. Fitchett, Assessing Spiritual Needs: A Guide for Caregivers (Lima, OH: Academic Renewal Press, 2002); L. Austin, “Spiritual assessment: A chaplain's perspective,” Explore: The Journal of Science and Healing 2, (2006): 540-42.

8 Massey, Fitchett and Roberts, “Assessment and diagnosis.” Paul Pruyser, The Minister as Diagnostician (Philadelphia, PA: The Westminster Press, 1976).

9 Webster’s New Collegiate Dictionary (Springfield, MA: G. & C. Merriam Company, 1977).

10 H. G. Koenig, Spirituality in Patient Care: Why, How, When and What (Philadelphia: Templeton Foundation Press, 2007).

11 M. LaRocca-Pitts, “FACT: Taking a spiritual history in a clinical setting,” Journal of Health Care Chaplaincy 15 (2008): 1- 12. (Published in 2009.)

12 M. LaRocca-Pitts, “The FACT spiritual history tool,” PlainViews, 5. www.plainviews.org/v5n7/lv.html; LaRocca-Pitts, “FACT: Taking a spiritual history.”

13 H. G. Koenig, “An 83-year-old woman with chronic illness and strong religious beliefs,” Journal of the American Medical Association 288 (2002): 487-93.

14 C. M. Puchalski and A. L. Romer, “Taking a spiritual history allows clinicians to understand patients more fully,” Journal of Palliative Medicine 3 (2000): 129-37.

15 G. Anandarajah and E. Hight, “Spirituality and medical practice: Using the HOPE questions as a practical tool for spiritual assessment,” American Family Practice 63 (2001): 81-88.

16 D. E. King, “Spirituality and medicine,” in eds. M. B. Mengel, W. L. Holleman and S. A. Fields, Fundamentals of Clinical Practice: A Text Book on the Patient, Doctor and Society (New York, NY: Plenum, 2002): 651-69.

17 T. A. Maugans, “The SPIRITual history,” Archives of Family Medicine 5 (1997): 11-16; B. Ambuel and D. E. Weissman, “Discussing spiritual issues and maintaining hope,” in eds., D. E. Weissman and B. Ambuel, Improving End-of-life Care: A Resource Guide for Physician Education, 2nd ed. (Milwaukee, WI: Medical College of Wisconsin, 1999).

18 LaRocca-Pitts, FACT spiritual history tool; LaRocca-Pitts, “FACT: Taking a spiritual history.”

19 LaRocca-Pitts, “FACT: Taking a spiritual history.”

20 Ibid.

21 Koenig, Spirituality in Patient Care.

22 S. G. Post, C. M. Puchalski and D. B. Larson, “Physicians and patient spirituality: Professional boundaries, competency and ethics,” Annals of Internal Medicine 132 (2000): 578-83.

23 R. P. Sloan, E. Bagiella, L. VandeCreek, M. Hover, C. Casalone, T. J. Hirsch, Y. Hasan and R. Kreger, “Should physicians prescribe religious activities?” New England Journal of Medicine 342 (2000): 1913-16.

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24 Koenig, Spirituality in Patient Care.

25 LaRocca-Pitts, “FACT spiritual history tool”; LaRocca-Pitts, “FACT: Taking a spiritual history.”

Additional reference Handzo, George and Harold G. Koenig. “Spiritual care: Whose job is it anyway?” Southern Medical Association 97 (2004): 1242-44.