FOR SPIRITUAL PROVIDERS

PART 1: Demographic Profile

1. What is your highest educational attainment?

______________________

2. How long is your length of experience in the Intensive Care Unit?

______________________

3. Do you receive training regarding spiritual care? (if yes kindly answer the ff.)
Yes No

PART 2: ACTIVITIES OF SPIRITUAL CARE PROVIDER:

Direction: Put a check ✔ on a corresponding scale (1) Strongly Disagree (2) Disagree (3) Agree (4)
Strongly Disagree.

Scale

Strongly Disagree Agree Strongly Agree

Disagree (2) (3) (4)
(1)

Spiritual Care Activities for Patient

1. I give spiritual
care and
treatment in
accordance with
the dying
patient's
preferences.

2. I encouraged
talking to and
touching the
dying patient.
3. I make sure that
the environment
or surroundings
in which the
dying patient
receives care
are calm and
respectful.

4. I acknowledge
the dying
patient’s values.

5. I respect the
dying patient's
religious
beliefs.

6. I facilitated
spiritual or
religious rituals,
rites, or
practices for the
dying patient

7. I assist the
dying patient
with end-of-life
perceptions and
planning.

8. I give the dying

patient a visit to
perform a
prayer
ceremony.

9. I always offer
 prayers for the
dying patient.

10. I offer help (if

needed) to the
dying patient
with their
religious
practices.

Spiritual Care Activities for Patient’s Family

11. I pay attention

to the wellbeing
of families and
those important
to the dying
patient.

12. I always check

with the dying
patient’s family
and those
important to
them about how
they would best
like to be
supported.

13. I assured the

patient's family
that the dying
patient would
be kept
comfortable.

14. I respect the

dying patient's
 and family’s
wishes for end-
of-life care.

15. I support family

members or
important others
who wish to
participate in
caring for the
dying patient.

16. I offer
information and
explanations to
the dying
patient’s family
and those
important to
them.

17. I inform the

dying patient’s
family and
those important
to them that
there is a
chaplain
available in the
hospital.

18. I ensure that

dying patient’s
families and
those important
to them have
easy access to
information
about available
chaplaincy
and/or spiritual
 care.

19. I use simple,

appropriate, and
straight-forward
language in my
explanations of
issues relating
to the dying
patient's
condition.

20. I gave the dying

patient’s family
and those
important to
them space to
express their
emotions.

Spiritual Care Activities for both Patient and Family

21. I am able to
identify and
engage
community
resources that
support dying
patients and
their families
spiritually.

22. I assess the

spiritual and
religious needs
of the dying
patient and
family members
on a regular
 basis.

23. I carefully
address (if
possible) the
dying patient's
and his or her
family's
spiritual and
religious needs.

24. I respect and

protect the
dying patient's
and family's
privacy and
confidentiality.

25. I encourage the

dying patient
and his/her
family to pray.

26. I advise the

dying patient
and his or her
family to read
the Bible.

27. I give the dying

patient and
family a rosary,
a Bible verse, or
a picture of
God.

28. I find out from

the dying
 patient, their
family, and
those important
to them the
details of any
cultural or
religious-
specific
requirements,
including what
constitutes
respectful
treatment of the
body after
death.

29. I offer
information
about getting
access to other
sources of help
and support.

30. I always listen

to the dying
patient’s and
family’s
spiritual
concerns.
 FAMILY OF THE PATIENT

Part 1: Profile of the family

Sociodemographic Profile:

1. Marital Status
Single Married Widowed Seperated 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 Satisfied

Dissatisfied (2) 1(4) (5)
(1)

Illness Management

1. Your relative is
given care and
treatment in
accordance with
his or her
preferences.

2. The
environment or
the
 surroundings in
which your
relative receives
care is calm and
respectful.

3. The health care

provider
facilitated
spiritual/
religious rituals,
rites or
practices.

4. The health care

team is able to
identify and
engage
community
resources that
support patients/
family
spiritually.

5. The long-term
care staff is
direct and
honest in their
explanations of
issues relating
to your
relative's
condition.

6. The care and

treatment of
your relative
receives
consistent with
his or her
wishes
7. The chaplain
and provider
(IBHC) then
work as a team
in determining
next steps for
the patient

8. Your relative
received good
care when you
were not able to
be with him/her.

9. The physical
symptoms of
your relatives
are adequately
assessed and
controlled.

10. You discuss

options with the
nursing staff
about initiating
palliative care
or comfort care
measures of
your relative.

Spiritual Care Provider Offer

11. I was assisted

with end of life
perceptions and
planning.

12. There was a

 chaplain
available in the
hospital.

13. They provide a

rosary, bible
verse and a
picture of God.

14. Arrange for a

chaplain to visit
my relative

15. The healthcare

staff of your
privacy and
confidentiality
as it maintained

Spiritual Concerns and Struggles

16. It lessened the

burden that I
felt when my
relative was
gone.

17. The health care

provider allows
me to express
my emotions.

18. I received
supportive
counseling to
identify
 personal sources
of strength,
meaning and
hope.

19. I received an
understanding
on how to deal
with
anticipatory
grieving.

20. Ask me about

religious
practices and
spiritual beliefs

21. Ask me about

what gives life
meaning

22. Listen to me
talk about
spiritual
concern and
strength

23. Help me to have

a quiet time and
space

23. Tell me about

any nearby
spiritual
resources I can
use.
23. The emotional
problems your
relative has are
adequately
assessed and
controlled.

24. You discuss

options with the
long term care
nurse about the
use of life
sustaining
technologies
(e.g. CPR or
cardiopulmonar
y resuscitation,
breathing
machines,
dialysis)

25. You have trust

and confidence
in the
physician(s)
caring for your
relative.