FOR SPIRITUAL PROVIDERS

PART 1: Please check the appropriate answer.

1. Highest educational attainment

Bachelor’s Degree

BS Degree with less than 24 MA units

BS Degree with more than 24 MA units

Masters Degree

Doctorate Degree

2. Length of experience in the Intensive Care Unit?

Less than 1 yr 1 yr 2 yrs 3 yrs 4 yrs 5 yrs & above

3. Attended training or seminar regarding spiritual care (if yes kindly answer the ff.)
Yes No

PART 2:
Direction: Please read the statements carefully and provide one response for each item.
Please indicate whether you practice or demonstrate the behavior when providing care to dying
patients in the ICU. Using a 4-point scale where 4 means Strongly Agree , 3 -Agree, 2 – Disagree
and 1 - Strongly Disagree, please check ( ✔ ) the appropriate box

Scale
SPIRITUAL ACTIVITIES
Strongly Agree Disagree Strongly
Agree Disagree

Activities of the Spiritual Care Providers for the Patient

1. I listen attentively to the patient.

2. I respond to patient initiated questions.

3. I create a safe environment to the patient

4. I stay with the patient and practice silence .

5. I hold patient’s hands to provide comfort.

6. I acknowledge and clarify patient’s concerns.

7. I say prayers with the patient.

8. I spend more time with the patient.

9. I provide measures to comfort and alleviate

the pain of the patient. .

10. I offer help to facilitate any kind of religious

practice requested by the patient.

Activities of the Spiritual Care Providers for Patient’s Family Members

11. I pay attention to the wellbeing of the patient’s

family members.
12. I communicate with the members to know how
they would like to be supported.

13. I encourage the patient’s family to pray.

14. I sing a religious song to the patient and family

15. I support family members who wish to

participate in caring for the patient.

16. I read inspirational messages to the family

members.

17. I inform the family members that there is a

chaplain available in the hospital.

18. I listen to the patient’s family's spiritual

concerns.

19. I respect and protect the family members’

privacy and confidentiality.

20. I give them space to express their emotions.

 FAMILY OF THE PATIENT

Part 1: Profile of the family

1. Marital Status
Single Married Widowed Separated
Others: _______

2. What is your religion? ______________

3. Relation to the patient? (check the box)

Spouse Child Parent Guardian Others: _______

Part 2: Satisfaction of family member on the spiritual providers

Direction: Put a check ✔ on a corresponding scale (1) Highly Dissatisfied (2) Dissatisfied (3) Satisfied
(4) Highly Satisfied.

Scale

Highly Dissatisfied Satisfied Highly

Dissatisfied (2) (4) Satisfie
(1) d
(5)

Illness Management

1. The environment or the surroundings is calm

and respectful.

2. The long-term care staff is direct and honest in

their explanations relating to your relative's
condition.
3. The care and treatment your relative receives
are consistent with his/her wishes.

4. Your relative received good care when you

were not able to be with him/her.

5. The spiritual care providers acknowledged the

options you discuss about comfort care
measures to your relative.

Spiritual Care Provider Offer

6. I was assisted with end of life perceptions and

planning.

7. There was a chaplain available in the hospital.

8. They provide a rosary, bible verse and a picture

of God.

9. Arrange for a chaplain to visit my relative.

10. The spiritual care provider maintained your

relative’s privacy and confidentiality.

Spiritual Concerns and Struggles

11. The health care provider allows me to express

my emotions.
12. I received an understanding on how to deal
with anticipatory grieving.

13. Ask me about religious practices and spiritual

beliefs.

14. Ask me about what gives life meaning.

15. Listen to me talk about spiritual concern and

strength.