Spiritual Assessment

Comparing and Discussing Two Spiritual Assessment Tools

by
Lori Hefner

Counseling Older Adults

Counseling 820
Dr. Gloria Gregg
April 3, 2008

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Introduction
Having worked as an interfaith chaplain at Kaiser Hospital in Walnut Creek and Vitas Hospice, I
have conducted numerous spiritual assessments and I thought this would be an ideal opportunity to
examine the literature and a wide array of published spiritual assessment tools. I seek to describe two
assessment tools, articulate the purpose and functioning of the instruments, and investigate clinical uses
and contraindications.

Background
For many people spirituality and religion are important dimensions of their existence and can be
powerful resources in helping them achieve well-being and deal with lifes challenges. Many clients
prefer to have their spiritual belief systems integrated into their therapeutic processes. A number of
studies have found a generally positive association between spirituality and religion and positive mental
health outcomes. Other studies have posited that elders grew up at during a time where religion and
spirituality were more a part of the fabric of life and in their aging years, they seek to reflect and
integrate those understandings with their life review. A 2001 Gallup poll showed that 58% of
respondents thought religion was very important. Of those same respondents 68% identified
themselves as a member of a particular religion (Nelson-Baker, Nakashima and Canda, 2007).

Description of the Instrument or Procedure

In reviewing the scholarly literature, I nearly had a hundred spiritual assessments to choose
from. Narrowing the list to two for the purposes of a four to five page paper was a challenge. I have
included my preferred spiritual assessment tools in Appendices A-E for my long term reference.
Additionally, I searched for a spiritual assessment tool that focused on an existential or secular humanist
tradition. The tools that I gravitate towards are secular humanistic in nature because according to my

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training as a chaplain the core mission is to be present with the person and his or her family, regardless
of faith, tradition or lineage, ethnicity, etc.. This is particularly important in the multiculturalism of the
San Francisco Bay Area. The tools I included are as neutral as I could find.
My first choice is Nelson-Becker, et al. Spiritual Assessment in Aging: A Framework for
Clinicians. (Appendix C) It contains questions that would be most useful in understanding eleven
domains of spiritual life. Those include: spiritual affiliation; spiritual belief; spiritual behavior; emotional
qualities of spirituality; values; spiritual experiences; spiritual history; therapeutic change factors; social
support; spiritual well-being; and extrinsic/intrinsic spiritual center. It is constructed from several
assessment tools written by distinguished researchers in the fields of aging, health, spirituality and wellbeing including Koenig (2002), Hodge (2001), Olson and Kane (2000). The framework includes 34
questions in the eleven domains. Interviewing an elder with these questions would assist in developing
a comprehensive understanding of the elders beliefs on a number of aspects of spirituality, including
negative reactions to spiritual and religious incidents.
Spiritual Assessment in Aging: A Framework for Clinicians
by Nelson-Becker

Strengths
Comprehensive.
Goes beyond religious constructions into
beliefs, personal definitions of the Divine.
Terms are straight forward. Not likely to
confound elders or lead to value laden
questions that would discourage or insult
the elder.
Culturally sensitive over a wide range of
aspects related to spiritual beliefs.
Designed for social work clinicians but
would work for a broad range of health
care professionals including physicians,
nurses, chaplains, etc.
Offers much to discuss about spiritual
orientation over many visits. This would
be ideal where circumstances would allow

Weaknesses
Time Consuming.
Would have to complete over several
visits.
May not be useful where death is
imminent.

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for 6-11 visits and the elder has the

interest, time and stamina to discuss.

My second choice of instruments is Anandarajahs and Hights, Spirtuality and Medical Practice:
Using the HOPE Questions as a Practical Tool for Spiritual Assessment. This was published in the
American Family Physician. Its key feature is that it is shorter than the Nelson-Baker instrument and
could be utilized where the elders time, physical or emotional strength is limited. (Appendix B)
Spirtuality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual
Assessment.
By Anandarajah and Hight

Strengths
Brief. Ideal for time limited situations.
Focuses on hope, love, peace, support,
and connection. Flexible enough to
include religion and spirituality.
Allows physicians a respectful and nonintrusive way to uncover how they could
further understand what is of value to the
elder including end- of-life preferences.
Sensitive over a wide range of aspects
related to multicultural beliefs. This tool,
if appropriately used, would elicit critical
ethnical issues that are likely to influence
health care choices. For example, a
Muslims need to not attach a continuous
chemotherapy portable pump to his body
because it would result in him being
impure in his faith tradition and not able
to say his daily prayers.
Designed for physicians and other health
care workers. Applicable to a wide range
of professionals.
Touches on but does not overwhelm an
elder about organized religion.
Encourages physicians to engage in
spiritual assessment discussions and
explicitly states that the physician wants to
be of assistance where possible.

Weaknesses
None detected.

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Area of Functioning to Which the Instrument is Directed

Gallo states, A systematic approach to spiritual assessment can be a key feature to
understanding the overall well-being of an older adult (2006, p. 261). A spiritual assessment is one
more window on the interiority of an elders reflection on life, values, meaning and purpose. A spiritual
assessment allows for another layer of the elders life story to be heard, acknowledged and shared. It
allows us to see another facet of his or her existence, social integration, participation in rituals or private
religion and how the elder fundamentally derives existential meaning. If there are death fears, pain,
anxiety, remorse, guilt, or severe unsolved conflicts, a spiritual assessment is a fiercely powerful
instrument to shed light on what is usually held as a very private part of a life. Extensive research has
also shown that spiritual assessments are linked with good health, positive mood states, well being,
social relationships and life satisfaction assessments.
Spiritual assessments are most valuable as dialogue tools. The resulting discussion is hoped to
further relationship building and comfort. It is not meant to encourage comparisons with an elders
cohort. There are no psychometric efforts employed to assure the tools validity. There is no right or
wrong answer. There is only wish to understand and honor the elder so she can live with courage,
emotional sustenance, determination, faith, and hope to face situations that seem beyond human
control (Ortiz and Langer, 2002, p.8).

Clinical Uses and Contraindications

I personally believe that the person best suited to administer a spiritual assessment is a Board
Certified Chaplain (BCC). Such certification denotes a 72-semester hour Masters of Divinity or its
equivalent, as established by the Association of Professional Chaplains. The certification also entails a
minimum of one year full-time (1,600 hours) of successful completion of Clinical Pastoral Education
(CPE) under a qualified and certified clinical pastoral supervisor. Special emphasis is placed on

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multiculturalism and respecting those who did not think of themselves as religious or spiritual. All
hospitals in the United States are required to be Joint Commission on Accrediting Health Organizations
(JCAHO) accredited. (Appendix F includes spiritual care as published by JCAHO.) Nursing homes are
more likely to have a religious official from the surrounding community who is a volunteer. Care
companions are not trained to give spiritual assessments. According to the rich literature in numerous
nursing journals, nurses appear to be sensitized to opportunities to assess spiritual resources and
spiritual distress. Geriatric, palliative care, oncology and hospice nurses are the most fluent in engaging
in spiritual assessments. Since 2001 the gerontological social work journals have encouraged their
professionals to become more comfortable with spiritual assessments (Galek, 2005; Hicks, 1999,
Hungelmann, 1996), Larson, 2003).
The person administering the spiritual assessment must be conversant with definitional
problems. The term and concepts around religion connotes normative behaviors, which includes some
people and excludes others. For some people it is empowering while for others it is disempowering.
The word spiritual on the other hand, refers to concepts that go beyond the structures of religion.
Being religious does not necessarily mean a person is also spiritual. A person may not be religious at
all, yet deeply spiritual and order his or her life around clearly identified sources of value and power
providing him or her an existentially meaningful interpretation for life (Ortiz and Langer, 2002, ,p. 9).
Clinebell advises, Use religious words and resources only after one has some awareness of
persons problems and their background, their feelings, and attitudes regarding religion *and spirituality+
(Clinebell, 1984, p. 122). This admonition allows for time for the person conducting the spiritual
assessment to look around the elder, see if any cultural, religious or spiritual figures or artifacts are
present. With open questions and active listening it allows the elder to introduce her personal
terminology about her sense of the Divine, holy, source, Allah, etc. Professional chaplains maintain that

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clients words should be substituted into the spiritual assessment tool selected. This way language can
comfort, reinforce and demonstrate respect for the elder and his or her belief systems.
It is also important to remember that a spiritual assessment is not an end in itself. It is the first
step in creating a Spiritual Care Plan. In gerontology we learn the acronym APIE which stands for
Assessment (A), Care Plan (P), Implement (I), and Evaluate (E). This is where the findings of the spiritual
assessment are analyzed, action plans are created and documented and then amended again based on
subsequent discussions. Such a care plan might include the spiritual interventions of:

Silent Witnessing
o

Be with the person

Provide a supportive presence

Avoid judgment

Liaison
o

Coordinate services and individuals requested by the individual. This may be specific
clergy, family, friends, or others with whom the individual has unfinished issues.

Ensure transportation to spiritual activities. This can be church services, Buddhist

sangha meditations, or a visit to a certain site.

Obtain requested spiritual related items. This is possibly a Koran or Bible, a rosary, a
cross, a Buddha statue or the symbol of Om. It can be a spiritual television show or a set
of tapes with sacred teachings along with a tape recorder and headset.

Work with others on the interdisciplinary team to assure the individual is not
interrupted during these spiritual engagements, if possible.

Active Listening
o

Engage in conversation about the spiritual matters of concern, if the individual desires.

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o

Be alert to the residents comfort and pain levelwatch for eye contact, body
movement, social isolation, questioning ones worth, and his or her sense of personal
resources in coping.

Does the individual want to engage in life-review? Is there a relationship, guilt or

aggression towards someone that needs to be discussed (Hicks, 1999, p.145)?

Contraindications
Among professional chaplains the clear professional requirement is to feel ones way into the
clients world and value system, and above all else, Do no harm. If the client is suffering from later
stage dementia, is in pain, or is in fragile psychological condition extreme care must be taken for the
benefit and comfort of the client. It is also important that the person administering spiritual
assessments is a competent multicultural broker. Clearly the strong cultural and professional
preference is to be skilled and knowledgeable enough to support that individual in their cultural systems
and not add additional hardship by expecting them to make the cultural, religious and spiritual
translations at a time of deep personal difficulty or during a health crisis.

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References
Clinebell, H., (1984). Basic types of pastoral care and counseling: Resources for the ministry of healing
and growth. Nashville, TN: Abingdon Press.
Galek, K., Flannelly, K.J., Vane, A., Galek, R.M. (2005) Assessing a patients spiritual needs: A
comprehensive instrument. Holistic Nursing Practitioner, 19(2), 62-69.
Gallo, J.J., Fulmer, T., Paveza, G.J., and Reichel, W. (2006). Handbook of geriatric assessment (4th ed.)
Boston, MA: Jones & Bartlett.
Hicks, T.J. (1999). Spirituality and the elderly: Nursing implications with nursing home residents.
Geriatric Nursing, 20(3), 144-146.
Hungelmann., J., Kenkel-Rossi, E., Klassen, L., and Stollenwerk, R. (1996). Focus on spiritual well-being:
Harmonious interconnectedness of mid-body-spirituse of the JAREL spiritual well-being scale.
Geriatric Nursing, 17(6), 262-266.
Ivey, A., Ivey, M., Myers, J. and Sweeney, T. (2005). Developmental counseling and therapy: Promoting
wellness over the lifespan. Boston, MA: Lahaska.
Larson, K. (2003). The importance of spiritual assessment: One clinicians journey. Geriatric Nursing,
24(6), 370-371.
Nelson-Becker, H., Nakashima, M., and Canda, E.R., (2007). Spiritual assessment in aging: A framework
for clinicians. Journal of Gerontological Social Work, 48(3/4), 331-347.
Olson, D.M. and Kane, R.A. (2000). Spiritual assessment. In R.L. Kane, and R.A. Kane (Eds), Assessing
older persons: Measures, meaning, and practical applications. New York: Oxford University
Press.
Ortiz, L.P., and Langer, N. (2002). Assessment of spirituality and religion in later life: Acknowledging
clients needs and personal resources. Journal of Gerontological Social Work, 37(2), 5-21.

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Appendices
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Appendix F

Spiritual Assessment Scale by Gallo

The HOPE Approach to Spiritual Assessment by G. Anandarajah and Hight
Spiritual Assessment in Aging: A Framework for Clinicians by NelsonBecker, et al.
Spiritual Assessment Protocol by Ortiz and Langer
Assessing a Patients Spiritual needs: A Comprehensive Instrument by
Galek
Select Statements from the Committee on Accrediting Medical Hospitals
(CAMH) and the Joint Commission on Accrediting Health Organizations
(JCAHO) on Spiritual Assessment and Accreditation

11
13
14
16
17
18

10

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11

Appendix A
Spiritual Assessment Scale
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.

Strongly
In the future, science will be able to
Agree
explain everything.
I can find meaning in times of hardship.
A person can be fulfilled without pursuing
an active spiritual life.
I am thankful for all that has happened to
me.
Spiritual activities have not helped me
become closer to other people.
Some experiences can be understood
through ones spiritual beliefs.
A spiritual force influences the events in
my life.
My life has a purpose.
Prayers do not really change what
happens.
Participating in spiritual activities helps
me forgive other people.
My spiritual beliefs continue to evolve.
I believe there is a power greater than
myself.
I probably will not re-examine my
spiritual beliefs.
My spiritual life fulfills me in ways that
material possessions do not.
Spiritual activities have not helped me
develop my identity.
Meditation does not help me feel more in
touch with my inner spirit.
I have a personal relationship with a
power greater than myself.
I have felt pressure to accept spiritual
beliefs that I do not agree with.
Spiritual activities help me draw closer to
a power greater than myself.
When I wrong someone, I make an effort
to apologize.
When I am ashamed of something I have
done, I tell someone about it.
I solve my problems without using

Agree

Neutral

Disagree

Strongly
Disagree

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spiritual resources.
23. I examine my actions to see whether they
reflect my values.
24. During the last week I prayed (check one)
10 or more times
7 times
4 times
1-3 times
0 times
25. During the last week I meditated (check one)
10 or more times
7 times
4 times
1-3 times
0 times
26. Last month I participated in spiritual activities with at least one other person (check one)
More than 15 times
11-15 times
6-10 times
1-5 times
0 times
As published in Gallo et.al. p. 266-267. Source: R. L., et al. The Spiritual Involvement and Beliefs
Scales, Development and Testing of a New Instrument, Volume 46, No.6 pp. 476-486. Dowden
Publishing Company, Inc. Reproduced with permission from The Journal of Family Practice.

12

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Appendix B
The HOPE Approach to Spiritual Assessment
H

Souces of hope, meaning, comfort, strength, peace, love and connection

We have been discussing your support systems. I was wondering what is there in your life that
give you internal support?
What are your sources of hope, strength, comfort and peace?
What do you hold on to during difficult times?
What sustains you and keeps you going?
For some people their religious or spiritual beliefs act as a source of comfort and strength in
dealing with lifes ups and downs. Is this true for you?
If the answer is Yes, go on to O and P questions.
If the answer is No, consider asking Was it ever? If the answer is Yes, ask What changed?

Organized religion
Do you consider yourself part of an organized religion?
How important is this to 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?

Personal spirituality/practices
Do you have personal spiritual beliefs that are independent of organized relirio? What are they?
Do you believe in God? [What is your sense of the divine?] What kind of relationship do you have
with God/Allah/Buddha/Nature (as appropriate)?
What aspects of your sprituality or spiritual practices do you find most helpful to you personally?
(e.g, prayer, meditation, reading scripture, attending religious services, listening to music, hiking,
communing with nature?

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 [professional nurse, doctor, social worker, chaplain, etc.] is there anything that I can 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?
Would it be helpful for you to speak to a clinical chaplain/community spiritual leader?
Are there any specific practices or restrictions I should know about in providing your medical
care? (e g, dietary restrictions, use of blood products, self-purity concerns)
If the patient Is dying How do your beliefs affect the kind of medical care you would like to be
provided over the next few days/weeks/months?

As published in G. Anandarajah and E. Hight (2001). Spirtuality and Medical Practice: Using the HOPE
Questions as a Practical Tool for Spiritual Assessment. American Family Physician, 63(1), 81-88.

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Appendix C
Spiritual Assessment in Aging: A Framework for Clinicians
Prefatory Questions
Is spirituality, religion, or faith important in your life?
What terms do you prefer? Please explain.
Affiliation
Do you belong to any spiritual group(s)?
What does membership in this group(s) signify to you?
Do you express your spirituality outside of participation in religoius or spiritual support grou?
Spiritual Beliefs
What religious or spiritual beliefs give you comfort or hope? Describe.
What religious or spiritual beliefs upset you? Describe.
Do you believe in God, A Transcendent Power, or Sacred Source of Meaning?
Describe your vision of who God or this Transcendent Power is?
Do you believe in an afterlife? What does this mean for you now?
Spiritual Behaviors
What religious or spiritual behaviors do you engage in?
How often do you engage in these religious or spiritual behaviors?
What about these behaviors do you find nourishing or underming?
Emotions
Have you recently experienced an emotion such as anger, sadness, guilt, or joy in the context of
religious or spiritual experience?
What significance if any did this have for you? Or if a client is describingh an experience, one
can ask, What feelings did you have in response? (To better clarify the meaning of the
experience for this person.)
Spiritual Experiences
Have you had any spiritiual experiences that communicate special meaninging to you? If so,
please describe.
Values
What are the guiding moral principles and values in your life?
How do these pricnicples guide the way you live life?
Spiritual History
Were you raised in a spiritual or religious tradition? Do you now practice in the tradition in
which you were raised? Describe early experience and parental involvement.
In what decades of your life were you involved in spiritual practices? Would you rate your
involvement as low, medium, or high for each? Were there any change points?
What events in your life were especially significant in shaping your spirituality?
Who encouraged your spiritual or religious practices?
Therapeutic Change
What might be an object or image that symbolizes/represents your spiritual strengths?
Could you tell me a story of how spirituality elped you cope with difficulties in the recent past?
How do you see this particular spiritual stregth as being able to help you in your current
problems?

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15

What spiritually-based strategies, rituals, or actions have helped you to cope with times of
difficulty or to experience healing or growth?
Social Support
When you have religious/spiritual concerns and problems, who do you talk to?
In the past, what types of supports have you received from these people that you have just
described?
If you belong to a religious or spiritual group, what types of support do you receive or provide to
them> To what extent are you satisfied? Explain.
Well-Being
How worthwhile do you find living your current life? Can you tell me more about it? How does
this relate to your spiritiuality?
How does your spirituality help you to find meaning in your life?
How strongly do you feel connected to God/Higher Power? Spirit?Universe?
Extrinsic/Intrinsic Spiritual Propensity
Do you find the teachings and values of your spiritual groups similar or different from your own?
Please explain.
How integrated are your spiritual practices with your dailylife apart from spiritual group
participation?
As published in H. Nelson-Becker, M. Nakashima, and E.R. Canda (2007). Spiritual assessment in aging: A
framework for clinicians. Gerontological Social Work, 48(3/4), 331-347.

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16

Appendix D

Spiritual Assessment Protocol

1. When talking with others, what common beliefs do you share with them that bring you a sense
of comfort and belonging?
2. Can you identify a spiritual force that brings you a sense of comfort and belonging? Explain.
3. Do you have family or friends that you depend upon to give you strength for living and energy to
overcome obstacles? Is so, what is it about this relationship that give you this strength or
energy?
4. Can you identify spiritual resources from which you gain strength and energy to overcome lifes
obstacles? Explain.
5. Do you have a belief system that helps give your life meaning or purpose? Can you give
examples of how this meaning or purpose is reinforced in your life?
6. Privately, what rituals or practices do you engage in that are renewing or comforting?

As published in Larry P.A. Ortiz and Nieli Langer, (2002). Assessment of spirituality and religion in later
life: Acknowledging Clients Needs and Personal Resources. Journal of Gerontological Social Work,
37(2)5-21.

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17

Appendix E
Assessing a Patients Spiritual needs: A Comprehensive Instrument

Published in Kathleen Galek, Kevin J. Flannelly, Adam Vane and Rose M. Galek, (2005). Assessing a
patients spiritual needs: A comprehensive instrument. Holistic Nursing Practitioner, 19(2): 62-69.

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Appendix F
Select Statements from the Committee on Accrediting Medical Hospitals (CAMH) and the Joint
Commission on Accrediting Health Organizations (JCAHO) on Spiritual Assessment and Accreditation
Standard RI.2.20
The hospital respects the rights of patients
Elements of Performance
2. Each patient has the right to have his or herspiritual and personal values, beliefs and preferences
respected.
3. The hospital accommodates the right to pastoral and other spiritual services
JCAHO Standard PC 2.20
The hospital defines in writing the data and information gathered through assessment and
reassessment.
JCAHO: The Source, February 2005, Vol 3, Issue 2
Per standards and elements of performance (EPs) found in the Provision of Care Treatment and
Services (PC) chapter in the accreditation manuals, the Joint Commission requires organizations to
include a spiritual assessment as part of overall assessment of a patient to determine how the patients
spiritual outlook can affect his or her care, treatment, and services.
The Source (continued)
Spiritual assessment should, at a minimum, determine the patients religious affiliation (if any), as well
as any beliefs or spiritual practices that are important to the patient.
Organizations should develop a basic policy regarding the content and scope of spiritual assessments
and outline who is qualified and competent to perform such assessment.
Physicians, therapists, nurses, and clinical pastoral staff should receive training on the value of spiritual
assessment and the tools that should be used to assess a patients spirituality.
As with any other kind of assessment, staff members who conduct a spiritual assessment should be
competent to do so.
Spirituality vs. Religion
While many people use the words spirituality and religion interchangeably, they are in fact very
different.
Spirituality can be defined as a complex and multidimensional part of the human experienceour inner
belief system. It helps individuals search for the meaning and purpose of life, and it helps them
experience hope, love, inner peace, comfort, and support.
Religion refers to a belief system to which an individual adheres. Religion involved particular rituals and
practicesthe externals of our belief system.

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19

Many people find spirituality through religion; however, some people find spirituality through
communing with nature, music, the arts, quest for scientific truth, or a set of values and principles.