Spirituality and the Patient- Provider Relationship Master’s Project Jennifer Dick Advisor- Michael Smith, Ph.D. Director, Council on Aging

Objectives: Describe why conducting a spiritual assessment is important Supply systematic methods Discuss barriers providers face Provide evidence and research of how spirituality affects patient and provider satisfaction

Introduction: Religion- more narrowly defined, behavior, cultural influences, identifying with a group of people Spirituality- innate drive to find purpose and meaning in life, many believe that it is the part of our nature that sets us apart from other creatures Organized religion provides a framework in which many people derive a sense of meaning and purpose

Main factor in determining patient satisfaction- provider’s caring about whole person, not just disease process Conducting a spiritual assessment validates a patient’s feelings and opens door for communication Important component of holistic healing Recommended by JCAHO

Increasing interest in spiritual growth 95% Americans believe in God 92% express particular denomination 99% pray, and ½ of those do so everyday % Americans interested in spiritual growth, % Last 50 years belief in God never dropped below 90% -Gallup Polls

According to JCAHO % of hospital patients believe in God >80% of inpatients had religious needs 94% of Americans believe spiritual health is just as important as physical health Require visits/access to chaplains, and assessments done on every patient obtaining at least patient’s denomination, beliefs and practices

Literature Review: Before 2000, 700 studies examined relationship between religion, well-being and mental health 500- significant positive relationship, including a number of well controlled, randomized clinical trials 60/93- less depression, faster recovery 5/5- better immune function 5/7-lower death rates from cancer 7/11- less heart disease or better cardiac outcomes 3/3- lower cholesterol 2 prospective studies with follow-ups at 23 and 31 years, found that 75% of religious people lived longer

203 adult inpatients, family medicine, urban Kentucky and N.C. 77% wanted physicians to consider spiritual needs 48% wanted physicians to pray with them 68% reported physicians never discussed any aspect of their spiritual needs with them Strength not in individual study, but in the number of studies with consistent data

Provider benefits- Find a way of maintaining their own personal meaningful world, a response to the basic human desire of finding meaning When there are differences in beliefs a healthy dialogue can enhance mutual respect and understanding Supporting a patient does not have to mean prescribing or recommending something

Assessment tools- Determine a patient’s spiritual needs and resources Evaluate impact of beliefs on medical decisions and outcomes Discover barriers to using spiritual resources Encourage healthy spiritual practices

Tools for Structuring Patient Encounters: Formal or informal Means of acquiring relevant information about patient’s spiritual values, religious beliefs, needs, and concerns Addresses views that may affect their health Identifies minister or spiritual counselor on whom to call

HOPE questionnaire Recommended by JCAHO Open-ended exploration of spiritual concerns and resources Natural follow-up to discussion of other support systems

H- sources of hope, strength, comfort, meaning, peace, love and connection O- role of organized religion for the patient P- personal spirituality and practices E- effects on medical care and end-of-life decisions Complete questionnaire at

Todd Maugans- mnemonic SPIRIT, published in Archives of Family Medicine to help students develop system S- spiritual belief system P- personal spirituality I- integration and involvement in spiritual community R- ritualized practice and restrictions I- implications for medical care T- terminal events planning (Advance Directives)

More structured tools- Spirituality Scale- developed from study that showed patients ranked spiritual assessment and care as a priority, and when these needs are unmet there is a negative correlation with health outcomes User-friendly format, reads at a 6 th -9 th grade level, can be completed in 10 minutes by most patient populations Can be self-administered to assess one’s own level of spirituality

Referral to chaplain- Most common resource used in hospital setting Valuable members of health care team Trained to assess patients of any or no faith Board Certified, graduate level theological education Knowledge of how medical procedures are viewed by various religious bodies Provide/arrange for certain rituals Read scripture, pray Offer communion, baptism, anointing and last rites

Hospice- Important resource for terminally ill Help patients redirect hope towards caring relationships and higher meaning Integrate pain relief, emotional and relational wellbeing, and broadly defined spiritual care

Clinical Applications: First, understand one’s own filters- spiritual beliefs, values and biases Remain patient centered and non- judgmental Strong personal foundation essential in developing therapeutic and trusting patient-provider relationship

Role of provider- Not to diagnose but to identify and refer when there is a problem Recognize when enhanced support might be helpful, or when religious beliefs might help or hinder patients

Discussion: A study in southern US, where religion is most prevalent, found that less than 10% of physicians regularly address spiritual issues with their patients

Most common cited reasons- Lack of time and training Concerns about projecting personal beliefs onto patients Uncertainty over managing issues raised, not knowing right person to refer to Unaware of why time and energy should be expended to address patient’s spiritual issues

Non-religious providers must not underestimate the importance of patient’s belief systems and religious ones must not use the time of vulnerability to impose their beliefs on the patient. A balance is found in respect for the patient.

For Further Investigation: Clinical trials on spiritual interventions and health outcomes Religious and spiritual needs of different patient populations Benefits and costs to patients and providers Impact of spiritual/religious instruction of student’s attitudes and behaviors on patient care

Neglect of research- Spirituality cannot/should not be studied scientifically Journal for the Scientific Study of Religion- over 40 published volumes Complex cognitive processes, emotional states, and inner workings of psychotherapy regular topics of scientific study

Easy to find flaws in single studies, but science proceeds through replication Should be most impressed with volume and consistency of evidence Evidence clearly suggestive of a link between religion and health, proves foremost that methodological research is warranted

Research validating specific tools- Hard to come by, specifically because of the open-ended constructs used by many of the tools However, it is the open-ended constructs that are so important in giving the patient an opportunity to express any religious or spiritual concerns

Medical Schools 72 US medical schools have courses to teach students to take spiritual assessments Some schools require it for students going into psychiatry, and is being considered a requirement for family medicine

“Spirituality in Medicine” University of Washington To strengthen students in commitment to relationship centered medicine with emphasis on caring for the suffering patient Encourages them to develop and maintain a program of physical, emotional, and spiritual self-care, including attention to purpose and meaning in their lives and work

Conclusion: Barriers can be dealt with and eliminated Lack of information- education Discomfort- training and experience Time management Treating medical diagnosis and diseases no longer acceptable Care for your patients

References: Anandarajah G, Hight, E. Spirituality and medical practice: Using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician 2001; 63(1): Astrow, A. Theological voices in medical ethics. N Engl J Med 1995; 332(22): Barnes L, Plotnikoff G, Fox K, Pendleton, S. Spirituality, religion, and pediatrics: Intersecting worlds of healing. Pediatrics 2000; 106(4): Bearon L, Koenig H. Religious cognitions and use of prayer in health and illness. The Gerontologist 1990; 103(2): Brody H. The healer’s power. New Haven: Yale University Press; Chatters, L. Religion and health: Public health research and practice. Annu Rev Public Health 2000; 21: Daaleman T. Religion, spirituality, and the practice of medicine. J Am Board Fam Pract 2004; 17: Delaney C. The spirituality scale, development and psychometric testing of a holistic instrument to assess the human spiritual dimension. Journal of Holistic Nursing 2005; 23(2): Galek K, Flannelly K, Vane A, Galek R. Assessing a patient’s spiritual needs, a comprehensive instrument. Holist Nurs Pract 2005; 19(2): Handzo G, Koenig H. Spiritual care: Whose job is it anyway? Southern Medical Association 2004; 97(12): Hinshaw D. Spiritual issues in surgical palliative care. Surg Clin N Am 2005; 85:

References: JCAHO, Koenig H. Medicine and religion. N Engl J Med 2000; 343: Koenig H. Religion, spirituality and medicine: Application to clinical practice. JAMA 2000; 284(13): Koenig H. Religion, spirituality and medicine: Research findings and implications for clinical practice. Southern Medical Association 2004; 97 (12): McCormick T. Spirituality and medicine. University of Washington Miller W R, Thoresen C E. Spirituality, religion and health: An emerging research field. Am Psychol 2003; 58(1): Peach H. Religion, spirituality and health: how should Australia’s medical professionalsresponds? MJA 2003; 178: Post S, Puchalski C, Larson D. Physicians and patient spirituality: Professional boundaries, competency, and ethics. Ann Intern Med 2000; 132: Powel L, Shahabi L, Thoresen C E. Religion and spirituality: Linkages to physical health. Am Psychol 2003; 58(1): Thoresen C E, Harris A. Spirituality and health: What’s the evidence and what’s needed? Ann Behav Med 2002; 24(1): 3-13.