AL

UMD,

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INThrelvestigators have demonstrated the negative and positive aspectsof faith. Studies concerning mental health,2 quality of life,3 sur-vival,4 ethical issues,5 and changes in biological markers6 havebeen associated to spirituality.

addAcintioidefavdislife

sesfaclacfesabo

awcusspideraddressed due to lack of confidence in effectiveness, and roleuncertainty.

To facilitate the addressing of spirituality in clinical practice,several authors have created instruments to obtain a spiritualhis 8,20,21 17,22

itunescomme

Phisbelpasheathafor

AHedusetproviding addiction services. The same framework, however, isused in all settings. At minimum, the brief assessment shouldinclude an exploration of three areas: (1) denomination or faith

1 Federal University of Juiz de Fora, Juiz de Fora, Brazil2 S3 Jo

# CRue-m

2ISS

REVIEW ARTICLEtradition, (2) significant spiritual beliefs, and (3) important spir-itual practices.

Anandarajah andHight20 suggested that a spiritual assessmentshould include determination of spiritual needs and resources,

o Paulo Medical Spiritist Association, So Paulo, Brazilo Evangelista Hospital, So Paulo, Brazil

orresponding Author. Address:a Dona Elisa 150, apto 153B, So Paulo 01155-030, Brazil.ail: g.lucchetti@yahoo.com.brIn addition, some authors suggest spiritual needs should beressed on the basis of a patient-centered approach to care.7-9

cording to Hebert, et al,10 patients see the role of spiritualitymedical encounters as closely tied to the interpersonal rela-nship and the psychosocial care provided by physicians. Ev-nce also shows that neglecting spiritual needs results in lessorable outcomes for patients such as reduced quality of life,satisfaction with care and increased costs at the end of.9,11-13

Nevertheless, health professionals experience difficulties as-sing this issue in clinical practice.14-16 Many obstacles may beed while the practitioner obtains a spiritual history, such ask of time or training, concern over activity beyond the pro-sionals area of expertise, discomfort with the subject, worriesut imposing religious beliefs on patients, lack of interest or013 Elsevier Inc. All rights reservedN 1550-8307/$36.00tory. According to Koenig, the purpose of the spir-al history is to learn about how patients cope with their ill-ses, the kinds of support systems available to them in themunity, and any strongly held beliefs that might influence

dical care.uchalski and colleagues7 believe the goals of the spiritualtory are (1) share and learn about the spiritual and religiousiefs, (2) assess spiritual distress or strength, (3) provide com-sionate care, (4) help the patient to find inner resources ofling and acceptance, (5) identify spiritual/religious beliefst affect the patients treatment, and (6) identify those in needreferral to a chaplain or spiritual care provider.ccording to the Joint Commission on Accreditation ofalthcareOrganizations (JCAHO),23 practitioners should con-ct an initial, brief spiritual assessment with clients in manytings, including hospitals and behavioral health organizationsTAKING SPIRITUAL HISTORY IN CLINICOF INSTR

Giancarlo Lucchetti, MD,1,2,3# Rodrigo M. Bassi, M

ckground: To facilitate the addressing of spirituality in clin-l practice, several authors have created instruments for obtain-a spiritual history. However, in only a few studies have au-rs compared these instruments. The aim of this study was topare the most commonly used instruments for taking a spir-

al history in a clinical setting.

thods: A systematic review of spiritual history assessments conducted in five stages: identification of instruments usedthe literature (databases searching); relevant articles from titleinitial abstract review; exclusion and Inclusion criteria; full

t retrieval and final analysis of each instrument.

sults: A total of 2,641 articles were retrieved and after thelysis, 25 instruments were included. The authors indepen-tly evaluated each instrument on 16 different aspects. Thetruments with the greatest scores in the final analysis were

TRODUCTIONere is currently a growing scientific interest in spiritual andigious influences on health outcomes.1 In several studies, in-PRACTICE: A SYSTEMATIC REVIEWENTS2 and Alessandra L. Granero Lucchetti, MD2,3

A, SPIRITual History, FAITH, HOPE, and the Royal Col-e of Psychiatrists. Concerning all 25 instruments, 20 of 25uire about the influence of spirituality on a persons life andaddress religious coping. Nevertheless, only four inquireut medical practices not allowed, six deal with terminalnts, nine havemnemonics to facilitate their use, and five wereidated.

nclusions: FICA, SPIRITual History, FAITH, HOPE, andyal College of Psychiatrists scored higher in our analysis. Theof each instrument must be individualized, according to thefessional reality, time available, patient profile, and settings.

y words: Spiritual assessment, spiritual history, spirituality,igiousness

plore 2013; 9:159-170. 2013 Elsevier Inc. All rights reserved.)

areness, and difficulty identifying patients who want to dis-s spiritual issues.16-18 Kristeller et al19 also point out thatritual distress experienced by cancer patients may be un-159EXPLORE May/June 2013, Vol. 9, No. 3http://dx.doi.org/10.1016/j.explore.2013.02.004

evaluation of the impact of beliefs on medical outcomes anddecisions, discovery of barriers to using spiritual resources andencPofleboinsnes

toatiinresorstrsetpromotor

MEDeFospisonabothearitio

DeWspishaissuwh

DeThRegusysrevmefiesioof

MEIntidewitexpinstorses

English, Spanish, and Portuguese, and articles were identified asrelevant from title and initial abstract review. Two researchers(Gexc

twomeclu(scothsta

tenforresofthoweme

sesinc

spimehisby

befulhoaddrelcomjou

the

1.

2.

3.

16ouragement of healthy spiritual practices. In addition,wer24 stated that an assessment tool should be easy to use,xible, adaptable, not time-consuming, and not yield a tick-x approach and, Larocca-Pitts25 believes that a successfultrument should include brevity, memorability, appropriate-s, patient-centeredness, and credibility.Within this context, there are many instruments availableobtain a spiritual history. Nevertheless, there is no system-c compilation of instruments to address spiritual historiesthe literature. We believe such a compilation would benefitearchers and clinical practitioners interested in reviewingusing existing instruments. The comparison between

engths and weaknesses of each instrument and the clinicalting that should be used would also help in this selectioncess. Therefore, the aim of this study was to compare thest commonly used instruments for taking a spiritual his-y in clinical settings.

THODSfinition of Spiritualityr the present study, we will use the following definition ofrituality provided by Koenig et al26: spirituality is the per-al quest for understanding answers to ultimate questionsut the life, about meaning and about the relationship withsacred or the transcendent which may (or may not) lead to orse from the development of religious rituals and the forma-n of the community.

finition of Spiritual Historye defined spiritual history according to Borneman et al27: Aritual history is a set of questions designed to invite patients tore their religious or spiritual beliefs to help identify spirituales. It is to be patient centered and guided by the extent toich the patient chooses to disclose his/her spiritual needs.

signis is a systematic review that follows the PRISMA28 (Preferredporting Items for Systematic Reviews and Meta-analyses)idelines adapted for the present review based on two recenttematic reviews on this field.29,30 Basically, this systematiciew was conducted in five stages: (1) identification of instru-nts used in the literature (database search); (2) articles identi-d as relevant from title and initial abstract review; (3) exclu-n and inclusion criteria; (4) full text retrieval; and (5) analysisselected instruments.Electronic databases were searched (all to March 30, 2012):DLINE (from 1966), PsycINFO (from 1966), institutionalernet sites, noninstitutional Internet sites, reference lists ofntified studies, and relevant review articles and books dealingh spirituality/religiosity and health. We used the Booleanression spiritual* AND (history OR assessment OR tool ORtrument) for PubMed/Medline and the terms spiritual his-y, spiritual instrument, spiritual tool, and spiritual as-sment for the other sources. The languages searched were0 EXPLORE May/June 2013, Vol. 9, No. 3.L., A.L.G.L.) independently screened the list of references tolude reports not assessing the issue in-hand.Articles were evaluated for exclusion and inclusion criteria byresearches (G.L., A.L.G.L.). Inclusion (Stage 3): Only instru-nts used for spiritual history assessment were included. Ex-sion (Stage 3): Spiritual Instruments for clinical researchales or score instruments), not assessing the issue in-hand, iner languages and/or response letters were excluded in thisge.Those remaining articles were retrieved full text. Another ex-sive revision of inclusion and exclusion criteria was per-med by all three researchers (G.L., A.L.G.L., R.M.B.). Theults of each authors analysis were tabulated and in the eventdiscordance, the article was separately discussed by the au-rs and decided upon by consensus. Selected instrumentsre conducted to the last stage (Analysis of selected instru-nts).Inclusion (Stage 4): Instruments used for spiritual history as-sment with proposed guidelines and proposed questions wereluded.Exclusion (Stage 4): Articles were excluded if they addressritual Instruments for clinical research (scales or score instru-nts), do not assess the issue in-hand, do not propose spiritualtories, describe instruments that has been already publishedothers and carry the same information in different journals.We determined that the ideal spiritual instrument should: (1)easy to remember, (2) not be time-consuming, (3) be respect-, (4) include both religious and spiritual aspects, (5) includew the patient uses their beliefs to cope with the disease, (6)ress terminal events andmedical practices not allowed due toigion, (7) assess negative aspects of the religion and religiousmunity support, (8) have been published in peer-reviewrnals, and (9) be based on scientific studies.The selected instruments were compared with each other forfollowing 16 attributes:

Memorability: It is sometimes difficult for health profession-als to remember all information required, which can preventthe use of some instruments. Currently, medicine is usingmnemonics in many situations, such as Advance CardiacLife Support (ie, ACLS)31 and pneumonia severity (ie,CURB-65),32 among others.We believe that the ideal instru-ment should contain easy mnemonics.Religious affiliation: although not a consensus among allexperts, religious affiliation is an important issue to address.This is especially true when considering that some religions,such as Jehovahs Witness, have specific traditions that caninfluence medical practices (eg, blood transfusion).33

Religious attendance: organizational extrinsic religiousnessseems to play an important role in some health outcomes,including mental2,33,34 and physical outcomes.1 However,its use in spiritual history taking is controversial.8 Some au-thors maintain that asking about religious attendance indi-cates, to some degree, social support,35 and therefore believeit should be included in a spiritual history.Taking Spiritual History in Clinical Practice

4. Influence of spirituality on life: This question can help tobetter understand the spiritual dimension of the person and

5.

6.

7.

8.

9.

10

11

12

13

14

15

sional cares about them and wishes to help the patientwith this complaint.

16

licatorCr

EquThevedec(Grieconpu

REAFig

DaA tfrotheanabasexcFroicathespo

incarticaissuinscartot

FIC20torSpMa(Ko(C(LaituspiquCotio

Tacould pave the way for a deeper conversation.Negative aspects of religion: this is a very important topicto be covered. Recent studies show that those with nega-tive religiousness have higher prevalence of depression,worst quality of life and even higher mortality.36 Healthprofessionals must be aware of the punitive side of reli-giousness and act, if necessary, refer patients to a special-ized professional.Spirituality meaning in life: the meaning of spirituality forthe patient helps to identify the importance of this dimen-sion and its cultural aspects. According to De Klerk37:Meaning in life entails a significance of beinga feeling,experience, or perception that ones existence is of signifi-cance. It relates to a sense of being committed to and fulfill-ing a higher purpose in lifeInfluence of spirituality on illness: this determines how thepatient links their disease with spiritual/religious beliefs. It isan important issue serving as an indicator of how the patientwill adhere to treatment and cope with the disease.Religious rituals/practices and their influence on treatment:Some rituals and practices could influence patients treat-ment and need further attention by the health professional.Religious coping: the way patients cope with their disease isan important question that should be addressed. The physi-cian should pay attention to the positive and negative as-pects of religious coping and identify these factors.33,34Mostinstruments addressed this issue.

. Religious support: It is important to show the support thepatient receives from the religious community. Sometimesthe religious community is responsible for transportation,shelter, and patient care, and the majority of the instru-ments assessed this aspect.

. Medical practices not allowed: awareness of which medicalpractices are not allowed by the patients as the result oftheir religious traditions (blood transfusions, oral contra-ceptives, hemodialysis) is important to respect the patientsreligion and to help with the treatment plan.

. Important spiritual experiences: if the patient wishes toreport his or her spiritual experiences, the health profes-sional should provide them with this opportunity. How-ever, considering the limited time available for medicalconsultations, omission of this item from an instrument isunderstandable.

. Dealing with terminal events: We believe this issue to bevery important for both patient and health professional.Religious aspects can influence their preferences of sup-portive care at the end of life38 and should thus beevaluated.

. Option to discuss religious issues: this aspect is importantbecause it shows the patient that their religious aspects areimportant to the health professional and provides the op-tion of discussing them during a consultation.

. Instrument option to refer to the religious leader orchaplain: the option to refer to a religious leader orchaplain can show the patient that the health profes-king Spiritual History in Clinical Practice. Validation: Validation studies are important to see the ev-idence of the instrument and whether the instrument issuitable for clinical contexts.

These topics were retrieved, and adapted, from previous pub-tions.20,24,25,39 Additionally, we decided to address the fac-s: Mean Time for application, Internet Site Available andedibility (Support literature).ach author was provided with all 25 instruments and subse-

ently determined which topics each instrument evaluated.e results of each authors analysis were tabulated and in thent of discordance, the item was discussed by the authors andided upon by consensus for the final analysis. The authors.L., R.M.B., and A.L.G.L.) have: (1) at least five years of expe-nce in addressing spiritual history, (2) participation inmedicalgresses on spirituality and its interface with health, and (3)blications in peer-reviewed medical journals.30,33,34,40-44

SULTSsummary of the stages of this systematic review is given inure 1.

ta Abstractionotal of 2,641 articles were retrieved (2,604 from PubMed, 34m PsycInfo, 2 from Internet sites, and 1 from books). Afterfirst stage, 2,506 were excluded for not assessing the topiclyzed. Therefore, 135 articles were judged relevant on theis of title and abstract. Articles were evaluated with the use oflusion and inclusion criteria, leaving 76 articles for next stage.m 59 articles excluded, 27 were spiritual instruments for clin-l research (scales or score instruments), 24 were not assessingissue in-hand, 3 were from other languages and 5 were re-nse letters.After the full text was retrieved, another extensive revision oflusion and exclusion criteria was performed, after which 51icles were excluded: 2 addressed spiritual Instruments for clin-l research (scales or score instruments), 4 did not assess thee in-hand, 35 did not propose spiritual histories, 7 describedtruments that has been already published by others, and 3ried the same information in different journals. Therefore, aal of 25 instruments were included in the final analysis.The 25 instruments for taking spiritual history selected were:A8 (Puchalski et al, 2000), HOPE20 (Anandarajah et al,

01), the SPIRITual History45 (Maugans, 1996), Spiritual his-y of the American College of Physicians46 (Lo et al, 1999),iritual Inventory of Kuhn47 (Kuhn, 1988), Spiritual History oftthews48 (Matthews, 1998), CSI-MEMO Spiritual History21

enig, 2002), Royal College of Psychiatrists assessment49

ulliford and Powell, 2006), FACTSpiritual history tool25

rroca-Pitts, 2002), the Spiritual Assessment Interview50 (Spir-al Competency Resource Center, 2009), Stolls guidelines forritual assessment51 (Stoll, 1979), Patient care/Spiritualityestions52 (Catterall et al, 1998), Brief Assessment Model thatnforms to the JCAHO Spiritual Assessment Recommenda-ns53 (Hodge, 2004), Spiritual Assessment questions161EXPLORE May/June 2013, Vol. 9, No. 3

JCmeAs(Ko20200et(H(Met aand

clutio2 s

Records identified through database

ESNOR

16AHO53 (Hodge, 2004), Five dimensional model for Assess-nt of Spirituality54 (Skalla et al, 2006), Spiritual Distresssessment Tool (SDAT)55 (Monod et al, 2010), ETHNICS56

bylarz et al 2002), Level 1 spiritual assessment57 (Hunt et al,03), Client Spiritual Assessment Tool (CSAT)58 (Hoffert et al7), Spiritual history assessment questions59 (Nelson-Beckeral, 2007), Qualitative questions for spiritual assessment60

odge, 2001), Questions to elicit the spiritual history61

cEvoy, 2000), 77 Model for Spiritual Assessment62 (Farranl, 1989), Spiritual assessment guide63 (Narayanasamy, 2004),FAITH64 (Neely et al 2006).

Table 1 shows where and how all tools were developed, in-ding the cultural and religious characteristics of the popula-n in which the instruments were developed and tested. Tablehows the authors consensus on each topic analyzed. Of the

searching (n = 2641)

Articles identified as relevant from title and initial abstract review (n=135)

Full text retrieved (n=76)

Instruments selected (n=25)

Figure 1. Flow diagra2 EXPLORE May/June 2013, Vol. 9, No. 3instruments assessed, 20 of 25 inquire about the influence ofrituality on a persons life; 17 address religious coping, and 17vide options to discuss religious issues. However, only 4 of 25uire about medical practices not allowed, 5 address terminalnts, 5 have been validated, and 9 have mnemonics to facili-e their use.he instruments with the highest scores in the final analysis

re FICA,8 which covered 13 of 16 of the topics analyzed;IRITual History45 and FAITH,64 which covered 12 of 16 and;PE20 and Royal College of Psychiatrists,49 which covered 11

16 aspects (Table 2).

mparison of InstrumentsA8 (Puchalski et al, 2000; Score: 13/16): This instruments developed by physicians and published in the Journal of

xcluded by type: (n=59)tudies evaluating quantitative scales (n=27)ot related to this issue (n=24)ther languages (n=3)esponse letters (n=5)

xcluded by type: (n=51)epetitive study (n=3)tudies not proposing spiritual histories (n=35)ot related to this issue (n=4)escribing instruments that has been already ublished by others (n=7)tudies evaluating quantitative scales (n=2)

Databases (n=22)

Sites (n=2)

Books (n=1)

data abstraction.25spiproinqevetat

TweSPHOof

CoFICwa

ERSNDpS

m forTaking Spiritual History in Clinical Practice

Palexphesionit

Table 1. Description of Instruments Selected by the Systematic Review

n ArePopulation Suggested Type of

Stos

SpiK

alliati

7a

SPISHPat

qSpi

AP

FICBELHOQu

sCS

hFACETHLev

aSpi

qBri

JSpi

gRoy

Pa

Fivas

CSSpi

qSpi

iFaiSD

CR,of l

a

Taliative Medicine. It was developed by the authors personaleriences with patients. The instrument can be used byalth professionals in all settings. It analyzes four dimen-ns (Faith or beliefs, Importance and Influence, Commu-y, and Address) and proposes 11 questions. Recently, Bor-

Instrument Name Author, Year Publicatio

lls guidelines forpiritual assessment51

Stoll, 1979 Nursing

ritual inventory ofuhn47

Kuhn, 1988 Psychiatry/pcare

7 model for spiritualssessment62

Farran et al, 1989 Chaplaincy

RITual history45 Maugans, 1996 Family medA48 Matthews, 1998 Primary carient care/spiritualityuestions52

Catterall et al, 1998 Palliative ca

ritual history of themerican College ofhysicians46

Lo et al, 1999 Palliative ca

A8 Puchalski et al, 2000 Primary carIEF61 McEvoy, 2000 Pediatrics

PE20 Anandarajah et al, 2001 Family medalitative questions forpiritual assessment60

Hodge, 2001 Social work

I-MEMO spiritualistory21

Koenig, 2002 Internal med

Tspiritual history tool25 Larroca-Pitts, 2002 ChaplaincyNICS56 Kobylarz et al. 2002 Geriatricsel 1 spiritualssessment57

Hunt et al, 2003 Nursing

ritual assessmentuestionsJCAHO53

Hoge, 2004 Social work

ef assessment model -CAHO53

Hodge, 2004 Social work

ritual assessmentuide63

Narayanasamy, 2004 Nursing

al College ofsychiatristsssessment49

Culliford et al, 2006 Mental heal

e dimensional model forssessment ofpirituality54

Skalla et al, 2006 Nursing

AT58 Hoffert et al. 2007 Nursingritual history assessmentuestions59

Nelson-Becker et al, 2007 Social work

ritual assessmentnterview50

Spiritual competency,2009

Mental heal

th64 Neely et al, 2009 Medical eduAT55 Monod et al, 2010 Geriatrics

case reports; CSAT, Client Spiritual Assessment Tool; EO, expert opinion; JCiterature; SDAT, Spiritual Distress Assessment Tool; SHA, spiritual history assValidation studies retrieved from articles included in this systematic analysis.king Spiritual History in Clinical Practiceman et al27 validated FICA and found that the instrumenta feasible tool for clinical assessment of spirituality. TheA proved easy to remember and to apply, and it was wellted for those physicians who want to address patientsrituality but do not have enough time for a consultation. It

a for Use Evidence Validation Studya

General EO, RL Not available

ve Medically ill EO, RL Not available

General EO, RL, CR Not available

General EO, RL, CR Not availableGeneral EO, RL Not availablePalliative care/general EO, RL Not available

Palliative care EO, RL, CR Not available

General EO, RL, CR, VS Borneman et al27

Pediatric EO, RL Not availableGeneral EO, RL Not availableGeneral EO, RL, VS Hodge et al65

General EO, RL, CR Not available

General EO, RL Not availableElderly EO, RL, CR Not availablePalliative care/general EO, RL, CR Not available

ral General EO, RL Not available

ral General EO, RL, VS Hodge et al66

General EO, RL, CR Not available

Mental health EO, RL Not available

Cancer patients EO, RL Not available

General EO, RL Hoffert et al58

Elderly EO, RL Not available

Mental health EO, RL Not available

n General EO, RL, CR Not availableElderly EO, RL, VS Monod et al55

oint Commission on Accreditation of Healthcare Organizations; RL, reviewnt questions (Nelson-Becker); VS, validation studies.neisFICsuispi

icineere

re

e

icine

icine

/gene

/gene

th

th

catio

AHO, Jessme163EXPLORE May/June 2013, Vol. 9, No. 3

cobe

SPstruchithesioallciawhitucommeBakeyevecanme

Table 2. Spiritual History Instruments and Their Analysis

Instruments Attributes FICA HOPE SPIR ACP CSI FACT RCP Stoll PCSQ JCAb FDM Kuhn

Mem

3-4

Me Re Re Ne Sp Infl Infl

i

Reat

Re Re Me Sp De Op

i

Opl

ValIntCreSco

(

CSAFAIcarAss

a

16vers the social aspect as well as treatment action, and it hasen validated by a recent study.

IRITual History45 (Maugans, 1996; Score: 12/16): This in-ment was first proposed by a physician and published in Ar-ves of Family Medicine. It was developed by a broad survey ofspirituality literature as well as personal experiences and discus-ns with professional colleagues and patients and can be used forkind of patients. Originally, the authors suggested that physi-ns administer it. The original article describes illustrative cases inich the instrument can be used. It analyzes six dimensions (Spir-al belief system, Personal Spirituality, Integration with spiritualmunity, Ritualized practices and Restritions, Implications for

dical care, and Terminal events) and proposes 22 questions.sed on our assessment, this instrument is very broad, evaluatingquestions such as medical practices not allowed and terminalnts. However, it takes a relatively long time to administer, whichhamper its use in certain settings and, until the present mo-

nt, there is no validation study.

an time for application,in

4-5 5-6 10-15 3-4

morability ligious affiliation ligious attendance gative aspects of religion irituality meaning uence of spirituality on life uence of Spirituality onllness

ligious rituals and practicesnd their influence onreatment

ligious Coping ligious Support dical practices not allowed iritual experiences aling with Terminal events tion to discuss religiousssues

tion to refer to religiouseader/chaplain

idation ernet Site Available a dibility (Support literature) a a a are of each instrumentOver 16)

13 11 12 6

T, Client Spiritual Assessment Tool; CSI, CSI MEMO; ETHN: E.T.H.N.I.C.S.; FDMTH; JCAb, Brief JCAHO; JCAt: Total JCAHO; Matt, Spiritual History of Matte/Spirituality questions; RCP, Royal College of Psychiatrists, SAI: Spiritual Asessment Tool; 77, 77 Model for Spiritual Assessment; SHA, Spiritual histAvailable.4 EXPLORE May/June 2013, Vol. 9, No. 3ITH64 (Neely et al, 2009; Score: 12/16): This instrumentwast proposedbyphysicians andpublished inTheClinical Teacher.as developed by a review of the literature and tested by medicaldents. The article provides illustrative cases and the instrumentbe used by physicians and medical students in all settings. Itlyzes five dimensions (Faith/Spiritual beliefs, Application, In-ence/Importance, Talk/Terminal events, and Help) and pro-ses 16 questions. Based onour assessment, this instrument is easyuse, very broad, evaluates some important questions such asminal events, and has a mnemonic to facilitate its use. However,FAITH questions have not been validated by research.

PE20(Anandarajah et al, 2001; Score: 11/16): Proposed byhysician and published in American Family Physician, it wasginally created for use by physicians and based on the litera-e. It analyzes four dimensions (Hope/meaning/comfort/ength, Organized religion, Personal spirituality and Practices,Effects on medical care and End-of-life issues). The HOPE

estions have not been validated by research. Our analysis

6-7 20-25 10-15 7-10 3-4 15-20 5-6

a a a a a a a a

10 11 6 2 9 7 4

imensional model for Assessment of Spirituality; Hodge, Hodge 2001; Hunt,McEv, Questions to elicit the spiritual history (McEvoy); PCSQ, Patient

ent Interview, SAG: Spiritual Assessment Guide, SDAT, Spiritual Distresssessment questions (Nelson-Becker); SPIR, SPIRITual history: Maugans.FAfirsIt wstucananaflupototerthe

HOa poriturStrandqu

a9

: five-dhews;sessmory asTaking Spiritual History in Clinical Practice

shothaallotioare

Roetvidpsydifsupshientofligchiforsitustu

S MScales Covering This

10 1

a

4

Tawed HOPE to be an instrument that is easy to remember andt addresses important questions such as medical practices notwed and personal spirituality. However, there is no valida-n study, and some important aspects, such as terminal events,not addressed.

yal College of Psychiatrists (RCP) Assessment49 (Cullifordal, 2006; Score: 11/16): Proposed by a psychiatrist and pro-ed by the RCP Web site, the instrument was developed bychiatrists for mental health professionals use. It analyzesferent dimensions such as meaning, major losses, coping, andport but does not have a mnemonic. It analyzes the relation-p between spirituality and religious aspects in the past, pres-, and future of the patients life. The tool also addresses sensemeaning/purpose, punitive/negative side of religion, and re-ious coping. However, this is an extremely extensive and psy-atric-centered instrument. This instrument appears valuablepsychiatrists and psychologists but is cumbersome to use inations such as primary care settings. There is no validationdy and no mnemonics.

AI Matt JCAt CSAT SDAT ETHN Hodge SAG

-12 3-4 8-10 15-20 25-30 7-8 15-20 20

a a a a a a4 8 5 9 5 10 6king Spiritual History in Clinical PracticeCTSpiritual History Tool25 (Larroca-Pitts, 2002; Score:/16): This instrument was published in the Journal of Healthre Chaplaincy. It is a chaplain-developed instrument that canused by trained healthcare practitioners. It analyzes four di-nsions (Faith and beliefs, Availability, Accessibility, Applica-ity, Coping or Comfort, and Treatment plan) and proposes 10estions. FACT is a straightforward instrument that is quickadminister, includes a treatment plan, and includes a questionut coping. However, no study has validated it, and someects, such as terminal events ormedical practices not allowed,not addressed.

I-MEMO Spiritual History21 (Koenig, 2002; Score: 9/16):blished in a case report in the Journal of the American Medicalsociation, its author explains each question by citing previousdies dealing with this issue. It was originally created for phy-ians and based on the literature. It analyzes five dimensionsomfort, Stress, Influence, MEMber of religious community,her spiritual needs). On our evaluation, the instrumentved easy to remember, easy to use, fast to apply, and ad-

cEv 77 SHA Hunt FAITH Area (of 25)

0-15 15 4-5 2-3 5-6 9 16 3 10 19 20 16

11

17 19 4 2 5 17

9

5 a a a a a 7 8 3 2 12 FA10Cabemebilqutoaboaspare

CSPuAsstusic(COtpro165EXPLORE May/June 2013, Vol. 9, No. 3

dressed important questions, such as coping (comfort), the neg-ative side of religion (stress), and the influence of spiritual beliefsonnonal

QuScoSoturdimCoimicaa recer

Brmmsocreqguiprefesspiofidaadmmesommi

Spi8/1Wospisiotioinmoticpre

SDsicstranaandstrmetolain

7ScoRe

settings. It analyzes seven dimensions (Holistic, Biological, Psy-chological, Family systems, Psycho-social, Ethnic/Racial/Cul-tura vreslain

Fiv(SkOnciaanatheBainsquwrotimcon

QuScoPedressyscomqurembeetin

Sp(LobynalIt plifeappthetaidu

StoScocangenDetioqufortolacres

Sp6/1Nu

16medical decisions. However, the CSI-MEMOquestions havet been validated by research, and some aspects, such as termi-events or medical practices not allowed, are not addressed.

alitative Questions for Spiritual Assessment60 (Hodge, 2001;re 10/16): Proposed by a social worker and published incial Work, it was developed by a survey of spirituality litera-e and can be used by health professionals. It analyzes sevenensions (Spiritual experiences, Affect, Behavior, Cognition,mmunion, Conscience, and Intuition) and proposes approx-ately 36 questions. There is a validation study inNative Amer-ns.65 It is a broad instrument validated by one study but takeslatively long time to administer, which can hamper its use intain settings.

ief Assessment Model JCAHO Spiritual Assessment Reco-endations53 (Hodge, 2004; Score: 9/16): Published by aial worker in the Social Work Journal, it reviews the JCAHOuirements for conducting a spiritual assessment and providesdelines for health professionals. It is a brief version of thevious instrument. The instrument can be used by health pro-sionals in all settings. It proposes four questions, includingritual needs/concerns, spiritual beliefs/practices, importancespirituality/religion, and religious attendance. There is a val-tion study in Native Americans.66 The instrument is quick toinister, validated, and in accordance with JCAHO recom-

ndations. However, it lacks mnemonics and fails to addresse questions, such as medical practices not allowed and ter-

nal events.

ritual Assessment QuestionsJCAHO53 (Hodge, 2004; Score:6): Proposed by a social worker and published in Socialrk. It reviews the JCAHO requirements for conducting aritual assessment and provides guidelines for health profes-nals. It proposes 15 questions, including religious denomina-n, spiritual beliefs, and spiritual practices. The instrument isaccordance with JCAHO recommendations but lacks mne-nics, fails to address some questions, such as medical prac-es not allowed and negative aspects of religion, and, until thesent moment, it has not been validated by research.

AT55 (Monod et al, 2010; Score: 9/16): Developed by phy-ians (geriatricians) and published in BMC Geriatrics, this in-ument can be used by chaplains in the geriatric setting. Itlyzes four dimensions (Meaning, Transcendence, Values,Psychosocial Identity) and proposes 17 questions. The in-

ument was validated by Monod et al.55 It is a validated instru-nt with a comprehensive analysis of the patient but takes 2030 minutes to interview the patient and is restricted for Chap-cy use.

7 Model for Spiritual Assessment62 (Farran et al, 1989;re: 8/16): Published by a Doctor of Ministry in Journal ofligion and Health, it was created for chaplaincy use in all6 EXPLORE May/June 2013, Vol. 9, No. 3al, and Social and Spiritual) and proposes 28 questions. Thisery complex spiritual assessment reviewing spiritual needs andources as a person but is quite extensive, restricted for chap-s, and there is no validation study.

e-Dimensional Model for Assessment of Spirituality54

alla et al, 2006; Score: 7/16): Published by nurses in thecology Nursing Forum, it was originally created for physi-ns and designed to be administered to patients with cancer. Itlyzes five dimensions (Moral Authority, Vocational, Es-tic, Social, and Transcendent) and proposes 25 questions.sed on our analysis, the Five-Dimensional Model is a valuabletrument in oncology settings. However, it evaluates someestions related to the meaning of life, principles of right orng, and moral struggles which, although important, takee and can render the instrument difficult to apply in routinesultations. In addition, there is no validation study.

estions to Elicit the Spiritual History61 (McEvoy, 2000;re: 7/16): Published by a pediatric nurse in the Journal ofiatric HealthCare, it was created for general practitioners andtricted for pediatric use. It analyzes six dimensions (Belieftems, Ethics or values, Lifestyle, Involvement in a spiritualmunity, Education, and Future events) and proposes 18

estions. It is a valuable instrument in pediatric settings, easy toember, and broad. However, the Belief questions have notn validated by research and it is restricted to pediatric set-gs.

iritual History of the American College of Physicians46

et al, 1999; Score: 6/16): This instrument was introduceda Palliative Care consensus published in the Annals of Inter-Medicine. It was originally created for palliative care patients.roposes four questions related to influence of spirituality in, religious coping, and support. This instrument is fast toly and easy to address. At the present moment, however,re is no validation study and, some important questions per-ning to palliative care, such as medical practices not allowede to religion and terminal events, are not included.

lls Guidelines for Spiritual Assessment51 (Stoll, 1979;re: 6/16): Proposed by nurses and published in the Ameri-Journal of Nursing, it was originally created for nurses foreral use. It analyzes four dimensions (Concept of God ority, Sources of hope and strength, Religious practices, Rela-nship between spiritual beliefs and health) and proposes nineestions. It addresses religious coping/support and its valuablea nursing spiritual history. However, Stools guidelines seembemore of a guide than a screening instrument, the guidelinesks mnemonics, and the questions have not been validated byearch.

iritual Assessment Guide63(Narayanasamy, 2004; Score:6): Proposed by a nurse and published in British Journal ofrsing. It was created by nurses for use in all settings. It ana-Taking Spiritual History in Clinical Practice

lyzes seven dimensions (Meaning and purpose, Sources ofstrength and hope, Love and relatedness, Self-esteem, Fear andanxheaa vliguseaddme

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HNICS56 (Kobylarz et al, 2002; Score: 5/16): Published byysicians in the Journal of the American Geriatrics Society, its originally created for geriatric health professionals and de-ned for elderly patients. It analyzes seven dimensions (Expla-ion, Treatment, Healers, Negotiate, Intervention, Collabo-e, and Spirituality seniors) and proposes 14 questions. Its auable instrument for geriatric settings, addresses religious sup-rt and option to discuss religious issues, and uses amnemonic.wever, it does not address some important aspects, such asminal events and medical practices not allowed and is notidated.

AT58 (Hoffert et al, 2007; Score 5/16): Published in Nurseucator, it was created by nurses for use in all settings andted by nurse students. It proposes eight questions related toationship with a Higher Power, religious support and prayer,ong others. The questions have been validated by research.58

ere is a validation study regarding this instrument, and itms to be a valuable nursing instrument for addressing spiri-lity. However, it does not address some important aspects,h as terminal events and medical practices not allowed. Untilently, the questions had not been validated by research.

e Spiritual Assessment Interview50 (Spiritual Competencysource Center, 2009; Score: 4/16): Proposed by a multidis-linary group and provided by a Web site, the instrument iseloped for use in all settings. It analyzes seven dimensionsligious backgrounds and beliefs, Spiritual meanings and val-, Prayer experiences, Faith and beliefs, Importance and Influ-e, Community, and Address) and proposes 22 questions. Itludes some aspects rarely included in other instruments, suchprayer. However, the instrument is not easy to remember, ist validated by research, and is based on an Internet site. To ourowledge, this instrument has no scientific peer-review publi-ion. It is basedmainly on religious and spiritual faiths and nottheir relationship with health aspects.

iritual Inventory of Kuhn47 (Kuhn, 1988; Score: 4/16): Pro-sed by a psychiatrist and published in Psychiatric Medicine, its originally created for use in palliative care. It proposes fiveestions addressing influence of faith in illness/life and beliefs.ere is no validation study. The inventory evaluates the influ-e of faith on life and illness but lacks a deep analysis of otherritual and religious aspects, is not easy to remember, and ist validated.king Spiritual History in Clinical Practiceling power of prayer. It was created for use in all settings. Itlyzes three dimensions (Importance, Influence, and Interac-n) and proposes three questions. The questions have not beenidated by research. Advantages: Easy to remember (mne-nic III). Disadvantages: this instrument is not validated andas the weakness of lacking a number of relevant questionsh as terminal events, negative aspects of religion and religiousing, among others.

iritual History Assessment Questions59 (Nelson-Becker et2007; Score: 3/16): Published in Journal of GerontologicalcialWork by social workers, it was created for use by cliniciansall settings. It proposes four questions for the spiritual history,t the article includes additional questions for spiritual experi-es, values, emotions, among others. For the present review wee considered only the Spiritual History section. It is a goodde for spiritual assessment in aging, showing some case vi-ettes. However, there is no validation study, it is difficult toember, and it does not address some important aspects, such

terminal events and medical practices not allowed.

tient Care/Spirituality Questions52 (Catterall et al, 1998;re: 2/16): Published in the International Journal of Pallia-e Nursing, it was created for use in palliative care. It embracesee dimensions (Outcome, Structure and Process) and pro-ses 15 questions. This instrument is designed for palliativedicine and contains questions relevant to palliative carems such as: Is there a place set aside for those who haveently died to be visited? However, some questions desig-ed for patients are more related to their treatment in hospitalsopposed to routine consultations. The questions have notn validated by research.

vel 1 Spiritual Assessment57 (Hunt et al, 2003; Score 2/16):posed by palliative care nurses and published in the Interna-nal Journal of Palliative Nursing, it was created for use inliative care and analyzes three levels of assessment (Level 1:ritual history; Level 2: Physical/Social/Psychological aspectsspiritual needs; and Level 3: Spiritual care specialist). For thesent review we considered the Level 1 (Spiritual history). Theessment addresses religious support and spirituality meaningt is not validated, lacks a mnemonic, and does not addresse important aspects, such as terminal events and medicalctices not allowed.

pics Covered by the Instrumentse most common topics covered by each instrument wereble 2) as follows: Memorability, that is, mnemonics to facil-te the instrument use (9 of 25), religious affiliation (16/25)igious attendance (3/25), influence of spirituality on life (20/), negative aspects of religion (10/25), spirituality meaning/25), influence of spirituality on illness (16/25), religious rit-s/practices and their influence on treatment (11/25), religious167EXPLORE May/June 2013, Vol. 9, No. 3

coping (17/25), religious support (19/25), medical practices notallowed (4/25), important spiritual experiences (2/25), address-ing(17and

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16terminal events (5/25), option to discuss religious issues/25), option to refer to the religious leader or chaplain (9/25),validated in clinical studies (5/25).

SCUSSIONalth professionals should be aware of every dimension ofir patients, including spiritual/religious aspects. Studies havewn that patients wish to be asked about their spiritual beliefspreferences.67,68 Furthermore, physicians feel they should

aware of a patients religious and spiritual beliefs.14 Spiritualtory taking, previously restricted to a chaplain or religiousder, is becoming a requirement in integrative care.Nonetheless, few doctors ask about spirituality and religious-s in medical consultations.69 In a bid to overcome this con-dictory barrier, scholars began proposing instruments for spir-al history, but comparisons of these instruments remainrce in the medical literature.e believe that health professionals should test all instru-

nts to select the most suitable. It is important to adapt eachtrument to suit different settings (ie hospital, outpatient, pal-ive care), time for application, and religious affiliation.he individual decision must be guided by several aspectsh as: (1) the ability of the practitioner to deal with this issueich includes training and religious/cultural backgroundsiner words, clinicians raised with religious backgrounds couldd easier to address this issue); (2) time for application: somesultations could take 15 minutes and some extensive in-ments would not be suitable; (3) religious affiliation: sometruments could not be suitable for oriental religious denom-tions and should be carefully chosen; (4) settings: some toolsy not be suitable for different settingsfor example, an instru-nt available for cancer patients should not be appropriate fortine consultations; (5) religious and spiritual aspects: theal instrument should address religious and spiritual beliefstheir implication for clinical practice and for the treatment;(6) Credibility: the appropriate instrument may be vali-

ed, with a good theoretical framework, evidence-based andted in a high number of persons by several trained practitio-s.evertheless, we should bear in mind that although such

truments are an easy method of addressing spiritual history,y are by no means the only approach. Some health profes-nals may use their own methods with the same or even betterults, and the instruments just may serve as a general guide.

plications for Further Researchere is a need to evaluate existing instruments to ascertain howective they are in clinical practice. Could the instruments beily learned by practitioners and feasible for use in clinicalctice?What additional benefits would these instruments pro-e for the traditional history assessment? Is it worthwhile? Atsent, few instruments have been validated and reliable forntification of spiritual needs. More studies evaluating theseects should be carried out.nother concern is the lack of studies evaluating the same

trument in different settings and religious backgrounds.8 EXPLORE May/June 2013, Vol. 9, No. 3ieties. Therefore, their uses in other cultural backgrounds aret totally understood. In our systematic review, we have notnd any tool specifically designed for Asian religious back-unds. In the future, researchers should focus on the evalua-n of these instruments in other settings.n addition, some would argue that these instruments are notquate to evaluate patients spirituality when a broader defi-ion of spirituality is used. In other words, are these instru-nts valid for secular humanists, agnostics, or even atheists?eed, some of these instruments include questions about theaning of life, connectedness, and purpose of life. Therefore,y can be administered even to those without a formal reli-us affiliation; see Puchalski, et al70 for a more detailed discus-n.Finally, would these instruments be appropriate for all settingshealth status? For instance, should they be used for palliativee as for family medicine? As reported in this systematic re-w, most instruments do not deal with terminal issues or med-l practices not allowed. Therefore, they may not be adequateaddressing end of life issues. More studies are needed topare these instruments in different types of patients.

itationse present study has some limitations that should be consid-d. First, since the search of instruments was based mainly onicles published in peer-review journals (22 articles), 2 fromernet sites, and 1 from books, some instruments were notluded in the final analysis. Second, only three reviewers ana-ed the instruments and reached decisions by consensus. Al-ugh these reviewers have experience in this field, their opin-s may not be representative of those of other experts. Third,e important spiritual/religious aspects were probably over-ked in this list of 16 topics. Forth, the differences in culturalreligious backgrounds should be considered for each tool.

r instance, some questions could not represent the religiousiefs of some religious denominations such as Jews, Hindus,Muslims. Fifth, it is difficult to say that an instrument is

ter than the other on the basis of scores or additional items.erefore, the instruments use should be particularized for eachation.

NCLUSIONSere are some good options available for spiritual assessmentt can be applied in clinical practice. FICA, SPIRITual His-y, FAITH, HOPE, and the Royal College of Psychiatriststrument scored higher in our analysis. The use of each instru-nt must be individualized, according to the professional re-y, time available, patient profile, and settings.

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170 EXPLORE May/June 2013, Vol. 9, No. 3 Taking Spiritual History in Clinical Practice

Taking Spiritual History in Clinical Practice: A Systematic Review of InstrumentsIntroductionMethodsDefinition of SpiritualityDefinition of Spiritual HistoryDesign

ResultsData AbstractionComparison of InstrumentsFICA8 (Puchalski et al, 2000; Score: 13/16)SPIRITual History45 (Maugans, 1996; Score: 12/16)FAITH64 (Neely et al, 2009; Score: 12/16)HOPE20(Anandarajah et al, 2001; Score: 11/16)Royal College of Psychiatrists (RCP) Assessment49 (Culliford et al, 2006; Score: 11/16)FACTSpiritual History Tool25 (Larroca-Pitts, 2002; Score: 10/16)CSI-MEMO Spiritual History21 (Koenig, 2002; Score: 9/16)Qualitative Questions for Spiritual Assessment60 (Hodge, 2001; Score 10/16)Brief Assessment Model JCAHO Spiritual Assessment Recommendations53 (Hodge, 2004; Score: 9/16)Spiritual Assessment QuestionsJCAHO53 (Hodge, 2004; Score: 8/16)SDAT55 (Monod et al, 2010; Score: 9/16)7 7 Model for Spiritual Assessment62 (Farran et al, 1989; Score: 8/16)Five-Dimensional Model for Assessment of Spirituality54 (Skalla et al, 2006; Score: 7/16)Questions to Elicit the Spiritual History61 (McEvoy, 2000; Score: 7/16)Spiritual History of the American College of Physicians46 (Lo et al, 1999; Score: 6/16)Stoll`s Guidelines for Spiritual Assessment51 (Stoll, 1979; Score: 6/16)Spiritual Assessment Guide63(Narayanasamy, 2004; Score: 6/16)ETHNICS56 (Kobylarz et al, 2002; Score: 5/16)CSAT58 (Hoffert et al, 2007; Score 5/16)The Spiritual Assessment Interview50 (Spiritual Competency Resource Center, 2009; Score: 4/16)Spiritual Inventory of Kuhn47 (Kuhn, 1988; Score: 4/16)Spiritual History of Matthews48 (Matthews, 1998; Score: 4/16)Spiritual History Assessment Questions59 (Nelson-Becker et al, 2007; Score: 3/16)Patient Care/Spirituality Questions52 (Catterall et al, 1998; Score: 2/16)Level 1 Spiritual Assessment57 (Hunt et al, 2003; Score 2/16)

Topics Covered by the Instruments

DiscussionImplications for Further ResearchLimitations

ConclusionsReferences