Spirituality and Cultural Diversity
Reasons to address spirituality and religious heritage as part of cultural diversity:
• Religious beliefs are common. One survey of 150 outpatients demonstrated that over 90 percent believed in God, 85 percent used prayer, and 74 percent felt close to God. A survey of inpatients at two hospitals revealed that 98 percent believed in God and that 93 percent were very strong or somewhat strong in their beliefs. Seventy-three percent prayed daily or more often
• Impact on health-related decisions and behaviors. Sixty percent of Americans state that their religion is the most important influence in their daily lives.1 Patients undergoing inpatient or outpatient medical treatment express strong religious and spiritual orientations.2
• Spirituality is important to patients. Ninety-four percent of people admitted to the hospital agree that spiritual health is as important as physical health. Spiritual concerns are almost universal among hospitalized patients.3
• Recognized standard of care. The Joint Council for Accreditation of Healthcare Organizations (JCAHO) has recognized the influence of spirituality on hospitalized patients by requiring a hospital chaplain or access to pastoral services in the standards for accreditation of all hospitals since 1999. According to the JCAHO, a spiritual assessment should be performed on every patient, identifying, “at a minimum,” the patient’s denomination, beliefs, and spiritual practices.
• Better care for patients. Clinicians should be aware of the more common health beliefs of religious groups in their practice, so that they will be able to better counsel and care for their patients. Health beliefs vary according to culture, education, and experience. Religious beliefs can be very strong and can be the deciding factor in medical decisions like abortion or withdrawal of life support.
While individuals’ beliefs do not always coincide with the principles of a specific religious code, health professionals should be aware of the major moral and religious norms that guide the medical decision-making of many patients. Physicians should be especially mindful of potentially strong religion-based health beliefs when discussing life and death issues, contraception, abortion, and euthanasia.
How to address spiritual issues in patients:
• What is a spiritual history? Taking a spiritual history is the process of gathering relevant information from a patient about spiritual values, religious beliefs, spiritual needs and concerns, and whatever gives the patient’s life and illness meaning. It should also include questions about how their religious and spiritual views affect their health, whether they use religious coping, whether they have specific spiritual concerns at the time, and whether they have a minister or other spiritual counselor on whom to call.
• When should I take a spiritual history? Taking a spiritual history should be incorporated into the work-up of all hospital patients, new patients, seriously ill patients, or in those with stress, distress, substance abuse or issues related to spiritual or religious views.
• How do I take a spiritual history? Several clinicians have developed tools for taking a spiritual history that aid in the process and make the topics to cover easier to remember, including the FAITH tool,4 HOPE tool,5 and the FICA tool.6
At MUSC, we teach the HOPE method of taking a spiritual history because of its ease of use and the way it smoothly transitions from social support to spiritual topics.5 The HOPE questions, can be seen at on the web at http://www.aafp.org/afp/2001/0101/p81.html, or summarized below:
H addresses the person’s basic spiritual resources, such as sources of Hope, without immediately focusing on religion or spirituality. Using this method allows for meaningful dialogue with patients of diverse backgrounds, including those whose spirituality lies outside the boundaries of traditional religion or those who have been alienated in some way from their religion. It also allows those for whom religion, God or prayer is important to volunteer this information.
O focuses on the importance of Organized religion in patients' lives.
P focuses on the specific aspects of their personal spirituality and personal religious practices. If patients relate meaningful experiences at this point, then the interviewer can proceed with more specific questions regarding religion and personal spirituality. If not, then one can ask open-ended follow-up questions to open the door for patients to discuss important spiritual concerns they may have.
E focuses on the Effects of a patient's spiritual and religious beliefs on medical care and end-of-life issues. These questions help re-direct the discussion back onto clinical issues and medical-decision-making.
FICA tool 6
F—Faith, Belief, Meaning
I—Importance and Influence of religious and spiritual beliefs and practices to the individual
C—Community or Church connections
A—Address/Action in the context of medical care
FAITH tool 4
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 can I Help you with any spiritual concerns?
References, Bibliography, and More Information
1. Newport F, Agrawal S, Witters D. Religious Americans Enjoy Higher Wellbeing. 2010. Retrieved from www.gallup.com on September 7, 2011.
2. Fitchett G, Rasinski K, Cadge W, Curlin FA. Physicians’ Experience and Satisfaction With Chaplains: A National Survey. Arch Intern Med. 2009: 169:1808-1810. 3. King DE. Faith, Spirituality, and Medicine: Toward the Making of a Healing Practitioner. New York, Haworth Press, 2000.
4. King DE, Spirituality and Medicine, in Fundamentals of Clinical Practice; Eds Mengel, Holleman and Fields; Plenum, New York, 2002.
5. Anadarajah G, Hight E. Spirituality and Medical Practice: Using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician. 2001;63:81-88.
6. Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliative Med. 2000;3:129–137.