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Journal of Nursing Management, 2012, 20, 970980

An integrative review of spiritual assessment: implications for

nursing management

BSc, PhD, Cert Ed, Dip Theol. Min, RN, RNT, FRSA, FEANS, FHEA

Senior Lecturer, Faculty of Health and Social Care, University of Hull, Cottingham, UK

Peter Draper
Faculty of Health and Social Care
University of Hull

(2012) Journal of Nursing Management 20, 970980

An integrative review of spiritual assessment: implications for nursing


Aims To describe the current state of the art in relation to spiritual assessment,
focusing on quantitative, qualitative and generic approaches; to explore the
professional implications of spiritual assessment; and to make practical
recommendations to managers seeking to promote spiritual assessment in their
places of work.
Method The paper integrates aspects of a recent systematic review of quantitative
approaches to measuring spirituality and a recent meta-synthesis of qualitative
research into client perspectives of spiritual needs in health and the principles of
generic assessment, before drawing on the wider literature to discuss a number of
professional implications and making recommendations to nurse managers.
Implications for nursing management The issues to emerge from this paper are
(1) that spiritual assessment is an increasingly important issue for nursing
practice, (2) that the range of reliable and valid quantitative instruments for use
in clinical practice is limited, (3) that there is overlap in the domains and
categories of spirituality identified by quantitative and qualitative researchers, and
(4) that nurse managers seeking to introduce spiritual assessment will do so in the
context of a professional debate about the relevance of spirituality to
contemporary practice.
Keywords: integrative literature review, spirituality, spiritual assessment
Accepted for publication: 27 July 2012

This paper explores the implications for nursing management of the spiritual assessment of patients and
clients. The paper draws on the literature of spiritual
assessment in clinical practice, and the literature of
spiritual assessment in research, seeking to integrate
the most important aspects of each and to explore
their significance for nursing management.
In recent years, scholars from fields as diverse as
medicine, nursing, social work, sociology, psychology
and theology have investigated the relationships

between spirituality and health. Nurse scholars have

been particularly active in the field of spirituality
research, and recent studies have explored the attitudes, characteristics and practices of nurses and other
health professionals in relation to the provision of
spiritual care (Belcher & Griffiths 2005, Baldacchino
2006, Hubbell et al. 2006, Lundmark 2006, Yang
2006, Chung et al. 2007, Bush & Bruni 2008, Nagai
2008, Wong et al. 2008, Bailey et al. 2009, Seccareccia
& Brown 2009, Tanyi et al. 2009, Chism & Magnan
2009, Chan 2010, Noble & Jones 2010, Wehmer et al.
2010, Kale 2011, Smyth & Allen 2011). Nurses have
DOI: 10.1111/jonm.12005
2012 Blackwell Publishing Ltd

Spiritual assessment

also examined spirituality from the perspective of

patients and carers in diverse clinical settings, including
acute areas, but perhaps with an emphasis on older
people, oncology and palliative care (Daaleman et al.
2008, Edwards et al. 2010). Recommendations have
been made concerning the place of spirituality in the
curriculum (Taylor et al. 2009) and the experiences of
student nurses have been discussed (van Leeuwen et al.
2008). The contemporary literature is international in
scope, with contributors from Hong Kong (Luk et al.
2007, Mok et al. 2010), Singapore (Chan 2010),
Taiwan (Shih et al. 2009), Thailand (Lundberg &
Kerdonfag 2010), Uganda (Kale 2011), the UK (Elliott
2011) and the USA (Alcorn et al. 2010), and there is a
clear trend to recognizing the distinctive spiritualities
of those who do not share a Judaeo-Christian heritage
or explicitly reject religious frameworks (Smith-Stoner
2007, Yakushko 2011). The importance of spirituality
as an aspect of health care is also reflected in significant
number of policy documents produced by the World
Health Organization (2003), the Department of Health
(2001), National Institute For Health And Clinical
Excellence (2004) and other such bodies (Johnson
As the literature on spirituality grows, the importance of spiritual assessment has increasingly been discussed (Pesut & Sawatzky 2006). A wide range of
tools and methods for spiritual assessment is available
and managers who are interested in spiritual assessment will wish to know which approach to support.
This decision is likely to be made on the basis of the
evidence from research, but will also be influenced by
practical issues, including patient needs and the roles
and skills sets of staff. Of course it could be argued
that there is no role for spiritual assessment, or indeed
any aspect of spiritual care, in contemporary health
care. Paley (2009) claimed that spirituality represents
a defunct and discredited world view based on
religion and that the only interventions available in a
secular health service should be those with a scientific
pedigree; even those who are broadly sympathetic to
spirituality in health care will recognize the potential
for ethical conflict in this area. Spiritual perspectives
are often deeply rooted in culture and may represent
profoundly held beliefs. At the very least, this creates
the potential for friction and misunderstanding. Thus,
managers exploring spiritual assessment will wish to
consider the professional implications of spiritual
assessment and their relevance to its practice.
The foregoing discussion has identified a number of
issues that give rise to the questions this paper seeks
to address:
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2012, 20, 970980

What is the current state of the art in relation to

spiritual assessment?
What are the professional implications of spiritual
What recommendations can be made to managers
seeking to promote spiritual assessment?

Spiritual assessment: the state of the art

Four approaches to spiritual assessment are described
in the helping professions: generic, quantitative, qualitative and domain-based (Holloway & Moss 2010,
Holloway et al. 2011). This paper explores the first
three of these in some detail, incorporating domainbased approaches in the discussion of the strengths and
weaknesses of the others. Generic spiritual assessment
takes place in the routine encounter with the individual.
The generic approach is open-ended and its purpose is
to recognize and acknowledge any spiritually based
issues the person may have and to identify any
resources on which they might draw. This is not a
detailed assessment of the persons spiritual state and
does not directly lead to clinical interventions. Quantitative approaches to spiritual assessment attach numbers to different aspects of spirituality. These are often
derived from psychometric research and may be embedded within scales measuring other constructs such as
the quality of life. The third approach represents qualitative, biographical or narrative approaches to spiritual
assessment, tending to focus on the unique spiritual
journey of the individual. The fourth approach is to
understand the persons spirituality within a series of
overlapping domains, such as physical, emotional, family and community; as noted above, this approach will
be incorporated in the wider evaluation of spiritual
assessment methods. Thus, the framework outlined by
Holloway and Moss (2010), and Holloway et al.
(2011) offers a useful structure within which to consider the state of the art in spiritual assessment.

Spiritual assessment generic approaches

Generic approaches to spiritual assessment are
perhaps the most widely used in clinical nursing practice, being the approach typically taken to the initial
assessment of a patient or clients spiritual needs.
McSherry and Ross (2010) discussed a wide range of
generic instruments for spiritual assessment and
outlined how they might be evaluated in practice.
These include Faith and Belief, Importance, Community, Address in Care (FICA) (Puchalski & Romer

P. Draper

Table 1
The FICA model of spiritual assessment (Puchalski & Romer 2000,
Puchalski 2006)

Faith and belief Does the patient consider himself or herself

to be spiritual or religious? Or: does the
patient have spiritual beliefs that help him or
her cope with stress? If the patient answers
No, ask: What gives your life meaning?
(ask about meaning even if the patient
answers Yes)
What importance does this faith or belief
have in the patients life? Have these beliefs
influenced how the patient takes care of
himself or herself during the illness? What
role do these beliefs play in the patients
health? Do these beliefs affect any of the
patients health-care decisions?
Is the patient part of a spiritual or religious
community? Is this of support to the patient?
How? Is there a group of people the patient
really loves or who are important to the
Address in
How would the patient like the healthcare
care or action
provider to address these issues in his or
her healthcare? Or: What action or steps
does the patient need to take in his or her
spiritual journey?

2000, Puchalski 2006), Spiritual belief system, Personal belief system, Integration with a spiritual community, Ritualized practices and restrictions if any,
Implications for medical care, Terminal events planning (SPIRIT) (Maugans 1996) and sources of Hope,
Organized religion: level of identification or participation, Personal spirituality and Practices, Effect on
medical care and end-of-life issues (HOPE) (Anandarajah & Hight 2001). The FICA model is presented
in Table 1 as a single illustration of the generic
Generic methods of spiritual assessment are based
on an approach to spirituality stripped of any connections with specifically religious or other traditional
frameworks of meaning. They assume that spiritual
care is for people of all faiths and none (Swinton
2010). The strength of the generic approach is that it
does not require detailed understanding of particular
religious or other spiritual traditions, and has the
capacity to identify both needs and resources for
coping that might otherwise go unnoticed by carers.
However, generic approaches also have their limitations. Paradoxically, the lack of an explicit definition
of spirituality can lead to a situation in which
the carers implicit understanding of spirituality is
imposed on patients, leading to inappropriate assumptions being made about patients values and preferences. A further weakness of generic approaches
to spiritual assessment is that, with exceptions

(Borneman et al. 2010), they tend lack validation

through formal testing. This does not mean that they
should not be used but it is important that practitioners should be prepared to evaluate their usefulness in
practice. McSherry and Ross (2010) suggest that
this can be done by considering whether generic
instruments are safe, adaptable, easy to administer,
non-intrusive and inclusive.

Spiritual assessment quantitative

This section describes a range of quantitative
approaches to spiritual assessment. The instruments
discussed in this section have been developed primarily
for research, but an important subset of quantitative
instruments has the potential to be used in clinical
practice and these are also discussed.
Monod et al. (2011) published the most recent
systematic review of instruments measuring spirituality
in clinical research. Monods search strategy identified
research published before January 2011, which used a
spiritual assessment instrument to investigate the association between spirituality and health (physical or
mental), health-related quality of life or any other
clinical outcome. For the purposes of this paper, a
further search was undertaken for new spirituality
scales published between January 2011 and January
2012. A total of 125 papers were identified assessing
spirituality and measuring its association with health
outcomes within this period. However, when the
abstracts were reviewed, none reported the use of a
new scale. Thus the work of Monod et al. (2011) still
represents the state of the art.
Monod et al.s (2011) review identified 35 instruments used to measure spirituality in clinical research.
The instruments were scored on the basis of the content
(construct definition, instrument development), internal
structure (factor analysis), reliability and validity (internal consistency and test-retest) of the instrument, and
were then classified as to whether they addressed
general spirituality, spiritual wellbeing, spiritual needs
or spiritual coping. The spirituality domains identified
in Monods review are listed in the right hand column
of Table 2. Items within the instruments were also
classified as to whether they captured cognitive,
behavioural or affective expressions of spirituality.
The team then evaluated these instruments in terms
of their clinical potential, identifying a subset of 16
instruments that measured a current spiritual state
and, as such, had the potential to determine the need
for spiritual intervention as part of a clinical
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2012, 20, 970980

Spiritual assessment

Table 2
Instruments including items measuring a current spiritual state and specific domains investigated by these items (Adapted from Monod et al.

Instrument name

Number of items
a current
spiritual state

General spirituality
The Daily Spiritual Experience Scale (Underwood &
Teresi 2002)
Spirituality Assessment Scale (Howden 1992)

2 of 16

Peacefulness, loving God

4 of 28

Sense of harmony, peacefulness, self-esteem,

fulfilment, purpose/meaning
Peacefulness, loving God, punishment

The Brief Multidimensional Measure of Religiousness/

Spirituality (John 1999, Wasner et al. 2005)
The Spiritual Transcendence Scale (Piedmont 1999)
The Spiritual Health Inventory (Veach & Chappel 1992,
Korinek & Arredondo 2004)
The Royal Free Interview for Religious and Spiritual
Beliefs (King et al. 1995, 2001)
The Spirituality Scale (Delaney 2005)
The Expressions of Spirituality Inventory (Macdonald 2000)
The Spirituality Transcendence Scale (Seidlitz et al. 2002)
Spiritual Wellbeing
The Functional Assessment of Chronic Illness Therapy
Spiritual Well-being Scale (Brady et al. 1999, Peterman
et al. 2002)
The Spiritual Wellbeing Scale (Ellison 1983)
WHOQOL SRPB (spirituality, religion and personal
beliefs; a cross-cultural study of spirituality, religion, and
personal beliefs as components of quality of life)
(WHOQOL SRPB Group 2006)
Jarel Spiritual Wellbeing Scale (Hungelmann et al. 1989)

4 of 38

The Spirituality Index of Wellbeing (Daaleman et al. 2002,

Daaleman & Frey 2004)
Spiritual Coping/Spiritual Needs
Spiritual Needs Inventory (Hermann 2006)

6 of 12

The Spiritual Interests Related to Illness Tool (spirit)

(Taylor 2006)

assessment (see Table 2 for details). Only three instruments (Brady et al. 1999, Daaleman et al. 2002, Hermann 2006) had at least three items focusing on
current spiritual state, and of these, one (Hermann
2006) had undergone a less rigorous evaluation process. Thus, two instruments, the FACIT-Sp, and the
Spirituality Index of Wellbeing, emerged as the bestvalidated instruments for the assessment of a patients
current spiritual state. The FACIT-Sp (Brady et al.
1999, Peterman et al. 2002) measures spiritual wellbeing in people with cancer. The Cronbachs alpha coefficient for the FACIT-Sp is 0.87 and the scale is
moderately correlated with other measures of spirituality and religion (Peterman et al. 2002). The Spirituality Index of Well-being (Daaleman & Frey 2004) is
a general purpose instrument for use in health-related
quality of life studies. It has a Cronbachs alpha coeffi 2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2012, 20, 970980

Specific domains

2 of 24
6 of 28
1 of 20

Peacefulness, sense of harmony, identity, purpose/
meaning, life satisfaction

2 of 23
6 of 98
1 of 8

Self-esteem, meaning
Happiness, self-esteem, connectedness, well-being

7 of 12

Purpose/meaning, peacefulness, sense of harmony

8 of 20
5 of 32

Identity, purpose/meaning, life satisfaction, wellbeing

Purpose/meaning, hope, peacefulness, sense of

5 of 21

Spiritual wellbeing, purpose/meaning, life satisfaction,

sense of harmony
Purpose/meaning, identity, self-esteem

17 of 17
10 of 42

Outlook, inspiration, spiritual activities, religion,

Meaning/purpose in life, relationship with God,
receiving/giving love, hope

cient of 0.91 indicating significant correlations with

other scales measuring wellbeing or spirituality (Daaleman & Frey 2004). The authors of this instrument
acknowledge that the study population consisted of
primary care patients in the Midwest of the USA who
were predominantly white and recognize it is uncertain as to whether the study can be generalized to
wider populations.
Monod et al.s (2011) review shows a very small
number (2 from 35) of instruments with significant
potential for clinical assessment of patients current
spirituality to be currently available. The FACIT-Sp is
for use in oncology populations, whereas the Spirituality Index of Wellbeing is more generally applicable.
It can therefore be argued that there is a need for
good quality instruments to be developed to assist in
the clinical assessment of spirituality.

P. Draper

Spiritual assessment qualitative

A further body of literature describes qualitative
approaches to spiritual assessment. In comparison with
the quantitative literature, this work is less exclusive in
its focus on research and the approaches described are
more readily adaptable for use in the clinical setting.
Hodge and Horvath (2011) published a review of
qualitative approaches to clinical assessment. Their
work consists of a meta-synthesis of qualitative
research examining the types of spiritual needs clients
commonly experience in health-care settings and
includes qualitative investigations exploring understandings of clients spiritual needs published in
English in peer-reviewed journals. Most of the 11
studies reviewed were conducted in the USA, but
work from Finland and Taiwan is also represented.
Studies investigating clients needs towards the end of
life were specifically excluded on the grounds that the
spiritual needs of such individuals may differ substantially from those of other clients. The research
subjects clinical contexts were diverse, including heart
transplant recipients and psychiatric inpatients. Their
formal spiritual affiliations were also varied, including
people with membership of well-established religious
traditions and those expressing no spiritual allegiance.
Having reviewed 11 studies that met their inclusion
criteria, Hodge and Horvath (2011) identified six
over-arching categories of spiritual needs:

meaning, purpose and hope

relationship with God (or the transcendent)
spiritual practices
religious obligations
interpersonal connection
professional staff interactions

Hodge & Horvath suggest that these findings underscore the importance of spiritual assessment in health
care settings. They recommend that in clinical
practice, an initial brief assessment should be made to
assess the relevance of spirituality to client care, and
that a more comprehensive spiritual assessment can
then be conducted if spirituality emerges as an important factor for a specific client.

Spiritual assessment domains of

The most commonly used approaches to spiritual
assessment take either a generic, quantitative or qualitative approach, and their respective strengths and

Table 3
Strengths and limitations of assessment methods

Quick and easy to use in

clinical situations
Do not require in-depth
understanding of
specific spiritual
Leads to rapid
identification of spiritual
problems and
Quantitative Rigorously tested
Address specific and
known spiritual domains
Enable comparisons to
be made over time
High degree of
specificity to
clients own spiritual
journey and narrative
May follow initial, generic

Generally not well
Not underpinned by
specific models of
May lead to
assumptions being
made about patients
spiritual needs
Very few available for
clinical use
Limited generalizability
beyond original patient
Intensive and timeconsuming assessment
Dependent on skilled

limitations, as identified in the foregoing discussion,

are summarized in Table 3. It is interesting to note
that although Monod et al. (2011) and Hodge and
Horvath (2011)adopt differing methodological standpoints, there is considerable overlap in the spiritual
domains they each identify in their respective bodies
of literature. This is illustrated by Table 4 where
Hodge and Horvaths (2011) categories of spiritual
need are taken as a framework, and into which the
various domains investigated in the 16 scales identified
by Monod et al. (2011) as measuring a current spiritual state are then fitted. There is clearly a considerable degree of overlap between the two approaches,
but there are also important differences. First, it is
notable that none of the specific domains drawn from
instruments measuring a current spiritual state address
Hodge and Horvaths (2011) category professional
staff interactions. Hodge and Horvath (2011) discovered that many clients singled out relationships with
health-care providers as an aspect of care in which
spiritual needs were expressed. Clients mentioned the
need for friendly facial expressions, word, and body
language and interactions that communicated dignity
and respect (Hodge & Horvath 2011). It is likely that
Monod et al.s (2011) list of domains excluded interactions with staff because their focus was the measurement of clients current spiritual state. The
quality of interactions with staff could perhaps more
accurately be described as an antecedent of a clients
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Journal of Nursing Management, 2012, 20, 970980

Spiritual assessment

Table 4
Integrating qualitative and qualitative domains
Categories of spiritual
need (Hodge & Horvath 2011)
Meaning, purpose and hope

Relationship with God

(or the transcendent)

Spiritual practices
Religious obligations
Interpersonal connection

Professional staff interactions

Domains not fitting Hodge &
Horvaths categories

Spiritual domains
(Monod et al. 2011)
Purpose and meaning
Loving God
Sense of harmony
Spiritual activities
Sense of harmony
Giving and receiving love
Life satisfaction
Self esteem
Sense of wholeness
Spiritual wellbeing

current spiritual state than one of its characteristics.

Nevertheless, it is important to note that clients may
consider the quality of staff interactions to be spiritually significant, especially insofar as they display
respect and promote dignity.
Second, it is also noted that Hodge and Horvaths
(2011) categories are not receptive to a cluster of
domains, including happiness, life satisfaction, selfesteem and wellbeing. This is unsurprising because the
focus of Hodge and Horvath (2011) is spiritual need,
whereas these domains are linked by a common
emphasis on a persons overall appraisal of their life
a common feature of quality of life scales (Draper &
Thompson 2001). The significance of this in the context of a discussion of spiritual assessment is that it
demonstrates the relationship between spirituality and
quality of life and shows that formal scales may capture important information about a clients spiritual
state that might otherwise be missed.
The fact that there is considerable overlap between
the findings of qualitative and quantitative investigation
demonstrates a degree of consensus about the nature of
spirituality and the key domains for assessment. If practitioners and managers have a working understanding
of the concept of spiritual need then it is more likely
that they will be able to assess clients needs appropriately and ensure that suitable provision is made.
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2012, 20, 970980

Professional implications of spiritual

This section of the paper explores the professional
implications of spiritual assessment, focusing specifically
on the concept of spiritual need, the role of nurses in
giving spiritual care and the medicalization of spirituality. We begin, however, by addressing the most important debate to arise when spiritually based care is
proposed the elephant in the room: Is spirituality relevant to the practice of healthcare in a modern, secular
health service?
John Paley (2008, 2009), is one of the most trenchant critics of spirituality in health. Paley regards
spirituality as a contemporary manifestation of religious worldviews that have lost credibility and are
increasingly irrelevant in the modern, secular world.
He writes:
In those parts of the world where secular
rational values are clearly established, it is
unnecessary for nurses to provide something
called spiritual care, and there should be no
expectation on the part of government, educators, managers, or health-care policy makers
that they should do so. In fact unnecessary is
far too non-committal a term. It is, rather, a
requirement of the great separation of civil
order and religion, in both its institutional and
spiritual forms, that the health service, as a public space, should remain thoroughly secular.
(Paley 2009)
Elsewhere, Paley (2008) accepts that it is legitimate
for health professionals to study and intervene in the
existential concerns that are often addressed in
models of spirituality, but contends that this is best
achieved under a naturalistic model by scientific disciplines such as clinical psychology, neuropsychology
and pharmacology.
A significant body of opinion disagrees with Paley.
Swinton and Pattison (2010) argue that spirituality
has a legitimate place as part of a critical discourse
within health care, where its function is to point to
absences and inadequacies in care. They also claim
that spirituality provides a vocabulary for those people
whose experience of health and illness has led them to
an existential crisis. Elsewhere, Puchalski (2007)
claims that spirituality is an essential part of the
humanity of all people and that it forms the basis of
the altruistic care to which health-care professionals
are committed:


P. Draper

Spirituality has to do with respecting the inherent value and dignity of all persons, regardless
of their health status. It is the part of humans
that seeks healing, particularly in the midst of
suffering. Spiritual care models are based on an
intrinsic aspect that calls for compassionate presence to patients as well as an extrinsic component where health-care professionals address
spiritual issues with patients and their loved
(Puchalski 2007)
I have referred to the differences of opinion between
the critics of spirituality and its advocates as a debate,
but there often seems little prospect that either side
will persuade the other to change its mind. Kuhn
(1970) argues that competing paradigms are often
seen as incommensurable: their advocates perceive the
world through different lenses and use different
concepts to describe what they see. Ultimately, for the
sake of consistency, one simply has to choose one paradigm and reject the other. Thus, Paley presents it as
a logical conclusion that the provision of scientific
health care within secular health services automatically excludes and disenfranchises other ways of
thinking about health.
Walter (2002) outlines an alternative approach to
conceptualizing multiple perspectives in health. He
accepts that there are spiritual, religious and secular
discourses in the literature but does not regard them
as logically or mutually exclusive. As Jordan (Jordan
1997) suggests, in many situations, equally legitimate
parallel knowledge systems exist and people move
easily between them, using them sequentially or in
parallel fashion for particular purposes. If we take this
point of view there is no reason why a commitment to
evidence-based practice cannot sit comfortably alongside the values of spiritually based health care.
The normal purpose of nursing assessment is to
establish a baseline, monitor progress or identify if
there is a deviation from expected norms. Modern
nurses who understand their practice in terms of the
nursing process are therefore likely to assume that,
whether spiritual assessment is conducted quantitatively (Monod et al. 2011) or qualitatively (Hodge &
Horvath 2011), the point of assessment is to identify
patients needs and to represent them in numbers (in
the case of quantitative approaches) or words (for
qualitative ones).
The concept of spiritual need is, however, a
contested one, and the question can legitimately be
asked as to whether the numbers or words generated

through spiritual assessment represent or describe

facts about the clients spiritual situation, or whether
the categories of spiritual need identified through the
assessment process are produced by the measurement
process itself? Paley (2008) takes the latter view,
noting that the growth of the spirituality literature has
coincided with the emergence of new categories of
spiritual need and links this to an attempt by the nursing profession to carve out new territory for itself.
Other authors (Narayanasamy 2010) argue that the
assessment of spiritual needs is an essential aspect of a
holistic care and that categories of spiritual need
represent a legitimate means of conceptualizing of a
persons situation.
The identification of spiritual need also raises the
question as to the nurses role in the provision of
spiritual care. Once again, it may be useful to explore
this question from the perspectives provided by alternative discourses. As we have seen, Paley (2008) takes
a secularist position, arguing that there should be no
expectation for nurses working in a secular health
service to offer spiritual care. The increased availability
of qualitative and quantitative instruments for spiritual
assessment, and the identification of spiritual need,
indicates the emergence of an alternative discourse that,
for the sake of the argument, could be called evidencebased spirituality. This discourse represents the view
that, if changes in patients spiritual state can be measured, it will be possible to demonstrate the benefits of
spiritual care through research, as with any other
clinical intervention. The role of the nurse under the
evidence-based spirituality model would be to assess
patient needs and, using validated interventions, to
deliver whatever care is appropriate to the patients
needs. The recent growth of interest in quantitative
approaches to spiritual assessment suggests that this
approach is currently influential, and there are, perhaps, two reasons why this should be so: the proper
dominance of the evidence-based approach to health
care and, linked to this, a desire by the advocates of
spiritual approaches to health care to meet the secularist agenda on its own terms by demonstrating that
the benefits of spirituality can be quantified.
Although the evidence-based approach to spirituality
reflects the priority that is rightly given to empirically
verifiable patient benefit, the exclusive adoption of this
approach may also lead to a narrow focus on spirituality as therapeutic intervention to the exclusion of
other discourses. This is particularly relevant in those
areas of health care where the focus is less on cure
and more on supporting vulnerable people (Walter
2002). Walter (1997) fears that the routine use of
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Journal of Nursing Management, 2012, 20, 970980

Spiritual assessment

scales and instruments for spiritual assessment will

make assessment a routine procedure and spiritual
care a bureaucratic process. This would be to the
detriment of models of spiritual care based on deep
human relationships, which emphasize the importance
of accompanying people as they seek meaning in their
situation rather than simplistic problem solving
approaches. For example, Walter (2002) supports a
model of palliative and bereavement care in which,
rather than offering treatment, the carer accompanies
the dying or bereaved person on their journey. It
should be noted that it is not my intention to argue
that what might be called spiritual interventions
ought to be exempted from the rigours of scientific
testing a strong ethical case can be made for preferring clinical interventions for which there is evidence
of benefit and avoiding those where there is none.
Rather, I argue against the exclusive conceptualization
of spirituality as an intervention on the grounds that
the biomedical model does not represent the only
legitimate response to illness. The literature, art,
teaching, rituals and habits of the great spiritual and
religious traditions provide structures of meaning
within which individuals can locate themselves as they
live and die, and I resist the richness and complexity
of these traditions being reduced to a medical subcategory of spirituality within an all-embracing superphenomenon of health, which, having been weighed
and measured, can be improved by suitable interventions under the continuing supervision of the medical
gaze. Part of the strength of the spirituality discourse
is that in the ongoing discussion about health and the
human experience of illness, it represents a voice that
is not conditioned by the priorities and vocabulary of

Discussion and implications for nursing

The final section of the paper draws on the foregoing
material to make a series of six observations that may
be relevant to managers considering the implications
of spiritual assessment for their place of work.
First, spirituality as a clinical construct in healthcare settings is a contested field. Although some
consider spirituality to be conceptually distinct from
religion (McSherry 2006) others maintain that it is
not (Paley 2009) and it is likely, therefore, that some
members of staff will be uncomfortable with the inclusion of terms or practices associated with spirituality
because of a perceived association with religion. Some
may argue, as Paley does, that spirituality has no place
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2012, 20, 970980

in a secular health service, while others may suggest

that nurses should engage with any issue even spirituality that emerges as important for patients and
clients. Nurses without a religious affiliation may be
anxious because of a perception that they are being
asked to support practices that they do not fully
understand, and nurses who have a religious faith may
be worried that they are being asked to bring their
faith to work. It may be helpful for nurses manager
to clarify these issues with staff, establishing mutually
agreed ground rules so that staff feel safe, before discussing the routine spiritual assessment of patients or
clients needs.
Second, I suggest it may be useful for staff to explore
the meaning(s) of spirituality together. A starting point
might be to consider the domains of spirituality presented in Table 4, as they represent a degree of consensus about the content of spiritual practice and the
range of issues to which it refers. Staff may have different views about the relative importance of each issue,
viewing some as highly contentious, some as an essential aspect of good practice and others as difficult to
understand. It may also be helpful to discuss the likely
importance of each domain to patients and clients in
each specific clinical setting, and it is good practice to
draw on the insights of patients and clients themselves,
and their carers. Those employed in or using services
where the work is relatively routine and predictable
may offer different responses from those in areas
where clients often face life-changing or life-threatening questions and staff are called on to support them.
Third, if spiritual assessment is planned, it may be
appropriate to begin with a simple approach based on
a mnemonic. Several such approaches are described in
the literature, for example FICA (Table 1). If an initial
assessment raises significant issues, then a more
detailed assessment can be made. It is also helpful to
remember that spiritual needs may be reflected in
behavioural, cognitive and affective responses, prompting appropriate intervention or onward referral to
appropriate others.
Fourth, following the initial assessment it may be
deemed appropriate to undertake a more structured
assessment of spiritual need. The literature contains
numerous examples of qualitative and quantitative
approaches. It is advisable to select an approach that
reflects the purpose of the assessment. As we have
seen, a small number of reliable and valid scales are
available which will produce a series of scores that
can be compared over time. Alternatively, open-ended
qualitative approaches may be deemed more useful
and acceptable as means of enabling clients to explore

P. Draper

their own spirituality. Whichever approach is taken, it

should be remembered that all spiritual assessment
tools are developed in specific cultural contexts, and
no assumption should be made that they are neutral.
It is important to be sensitive to the diversity of
spiritual and cultural values of individual patients and
Fifth, spiritual assessment has implications for the
subsequent provision of care and the allocation of
resources. Having undertaken a spiritual assessment, a
nurse may simply need to note the patients religious
affiliation, taking appropriate account in the provision
of resources. In other cases, onward referral to a
religious or other professional may be needed. Sometimes, spiritual assessment may bring to the surface
complex problems requiring a sophisticated response.
Nurses should only engage with such issues if they are
competent to do so. As with all competencies, nurses
are required to practice within their professional
The sixth and final point to be addressed relates to
the view that spirituality reflects an ethical position
offering a critical stance towards absences and shortcomings of health care. Opponents would argue that
it is possible to voice these concerns without recourse
to the vocabulary and concepts of spirituality or religion, and this is undoubtedly true; however, I would
argue that it is possible to come to the same conclusion from different starting points and some find that
spirituality offers a humanizing perspective on healthcare practice. As Hodge and Horvath (2011) argue,
clients desire interactions that communicate dignity
and respect, and this is an essential characteristic of
professional care whether or not one accepts the validity of spirituality in health care.

This paper has reviewed the most recent literature on
quantitative, qualitative and generic approaches to
spiritual assessment in order to describe and evaluate
the state of the art revealed by the most recent
reviews of high-quality research; it has also explored
the professional implications of this literature for
nurse managers who wish to consider the introduction
of spiritual assessment in their places of work.
The paper recommends that spiritual assessment
should begin with one of the generic models such as
FICA (Puchalski & Romer 2000, Borneman et al.
2010) as these are relatively simple to use and do not
require detailed training. A range of qualitative and
quantitative approaches is then available if more

detailed assessment is required. Surprisingly, however,

only a very limited number of quantitative instruments
are available to measure the current spiritual state of
patients or clients. This paper also compared and
contrasted qualitative and quantitative approaches to
assessment, noting a significant degree of overlap in
the domains addressed by each.
This paper acknowledges that spiritual assessment is
contentious, noting the concerns of Paley (2008, 2009)
and others, but has pointed out potential consequences
of an exclusively evidence-based approach to health
care, arguing in favour of deploying overlapping or
complimentary discourses in theorizing about nursing
practice in relation to spirituality. I have outlined a
number of practical issues that nurse managers may
wish to address when developing spiritual assessment
in their workplaces.

Thanks to Jane Wray and Jo Aspland for commenting
on an earlier draft of this paper. This paper was
unfunded but received institutional support from the
University of Hull.

Source of funding
This study was unfunded.

Ethical approval
Ethical approval was not required.

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