George Fitchett, a trailblazing researcher in chaplaincy and spiritual care, recently delivered a webinar titled "New Approaches to Spiritual Assessment" for the Duke University Center for Spirituality, Theology, and Health. As Professor Emeritus at Rush University Medical Center, George has been a driving force in advancing spiritual care through evidence-based practices. I have had the honor of knowing George for over a decade, and he is truly one of my chaplaincy heroes—a role model whose work I deeply admire and strive to emulate. Moreover, I’ve had the privilege of working closely with him as my dissertation mentor for my Ph.D. in Health Sciences at Rush University. Over the years, we’ve collaborated weekly on my dissertation, an experience that has profoundly shaped my academic and professional growth. In his presentation, George highlighted a significant development in chaplaincy: the creation of quantifiable, condition-specific spiritual assessment models. These innovative tools aim to enhance patient care, improve interdisciplinary communication, and elevate healthcare outcomes.
In this article, I explore the themes, methodologies, and broader implications of George’s groundbreaking work, offering a detailed summary, key takeaways, and critical questions for reflection from this webinar.
Overview of Spiritual Assessment: Three Levels of Clinical Inquiry
George began by outlining the three levels of inquiry used to integrate spirituality into healthcare settings. These levels help distinguish between different approaches, ensuring that patients receive appropriate care tailored to their needs.
Spiritual Screening
A basic, often yes-or-no approach that seeks to identify whether a patient has spiritual concerns that might affect their care. Common questions include, "Are you at peace?" or "Do you have spiritual needs we can support?" Screening is typically performed by healthcare professionals other than chaplains and serves as a preliminary step to identify patients requiring further attention.
Spiritual History-Taking
Conducted primarily by physicians or primary care providers, this step involves a more detailed exploration of the patient’s spiritual background and needs. Models like Dr. Christina Puchalski’s FICA tool or other history-taking frameworks are often used to gain insight into how a patient’s spiritual beliefs may impact their health and treatment.
Spiritual Assessment
The most intensive level, spiritual assessment is conducted by trained, board-certified chaplains. This process involves a detailed examination of a patient’s spiritual concerns, resources, and struggles, forming the basis for creating spiritual care plans and evaluating their effectiveness over time. (For more information about the history of spiritual assessment, see Wendy Cadge and Julia Bandini's article below.)
George’s work focuses on advancing the third level, moving beyond narrative-based approaches to embrace quantifiable and condition-specific models.
Limitations of Current Spiritual Assessment Models
While traditional models have been foundational to chaplaincy, George identified several limitations that hinder their effectiveness:
One-Size-Fits-All Frameworks
Most existing spiritual assessment models are designed for universal application across all clinical settings. While this approach provides consistency, it often fails to account for the unique spiritual needs associated with specific patient populations, such as palliative care patients, oncology patients, or older adults in long-term care.
Narrative-Based Approaches
Narrative models rely on qualitative descriptions of spiritual concerns, which can lead to inconsistencies in communication with interdisciplinary teams. These approaches often lack the precision needed for evaluating spiritual care outcomes and may not adequately convey the severity of spiritual distress.
Lack of Standardization Across Institutions
Many spiritual care departments develop their own assessment tools locally, creating a fragmented system where healthcare professionals must adapt to different models depending on the institution. This variability complicates efforts to integrate spiritual care into broader healthcare practices.
George argued for a paradigm shift: the adoption of evidence-based, condition-specific, and quantifiable models that address these limitations and enhance spiritual care delivery.
Introduction to New Spiritual Assessment Models
George introduced three innovative models, each designed to meet the specific spiritual needs of different patient populations. These models build on the foundation laid by the Spiritual Distress Assessment Tool (SDAT), developed in Switzerland.
SDAT (Spiritual Distress Assessment Tool)
Developed by Swiss researchers, the SDAT was designed for older adults in geriatric medical rehabilitation. This tool identifies five core spiritual needs, such as life balance, connection to others, and acknowledgment of values. Unique to this model is its quantifiable scoring system, which allows chaplains to rate the intensity of unmet spiritual needs on a scale from 0 to 15. George highlighted the SDAT’s demonstrated validity and reliability, noting that it served as an inspiration for his team’s work.
PC-7 (Palliative Care Seven)
Tailored for patients receiving palliative care, the PC-7 identifies seven spiritual concerns commonly experienced by this population:
Meaning in the face of suffering.
The need for legacy and generativity.
Relationships with family and loved ones.
Fears about dying.
Treatment decision-making.
Religious or spiritual struggles.
Other unique, patient-specific concerns.
The PC-7 model uses a scoring system similar to the SDAT, with scores from 0 to 3 for each theme. A total score of 2 or 3 in any category indicates significant unmet spiritual concerns that require a chaplain’s attention.
ONC-5 (Oncology Five)
The ONC-5, designed for outpatient oncology settings, includes themes similar to the PC-7 but emphasizes concerns specific to cancer patients, such as guilt, the alignment of values with medical decisions, and navigating relationships during treatment. The model has been tested in multiple research settings, demonstrating strong validity and reliability.
GERO (Geriatric Spiritual Assessment)
Still under development, the GERO model focuses on the spiritual needs of older adults in residential care. Themes include meaning, identity, connection, and religious or spiritual needs. George noted that his team is refining this model through case discussions and plans to publish their findings in the near future.
Research Evidence Supporting the Models
George presented evidence for the validity and reliability of the PC-7 and ONC-5 models. Highlights include:
Quantifiable Scoring
Both models use a standardized scoring system that facilitates clear communication with healthcare teams and enables chaplains to track changes in spiritual distress over time.
Positive Patient Feedback
Patients reported feeling heard and supported during assessments, with many noting that the process helped them reflect on spiritual concerns they had not previously considered.
Inter-Rater Reliability
Studies showed consistent scoring among chaplains, demonstrating the models' reliability in clinical practice.
Applications and Benefits
These models offer several key advantages for healthcare chaplaincy:
Enhanced Communication
Quantifiable data allows chaplains to clearly convey the severity of spiritual distress to interdisciplinary teams, fostering better collaboration.
Informed Care Planning
By identifying specific areas of spiritual concern, chaplains can develop targeted care plans that address patients' unique needs.
Population-Level Insights
Aggregated data from these models can reveal patterns of spiritual distress within patient populations, helping healthcare institutions allocate resources more effectively.
Key Takeaways
Quantifiable Models Represent a Paradigm Shift
These tools enable chaplains to move beyond qualitative narratives, offering measurable insights into spiritual distress.
Condition-Specific Models Address Unique Needs
Tailoring assessments to specific patient populations ensures that spiritual care is relevant and effective.
Research Validates the Models’ Effectiveness
Initial studies demonstrate strong evidence for the validity, reliability, and clinical utility of these tools, though more research is needed.
Outstanding Questions
Inclusivity and Diversity
How can these models be adapted to ensure validity across diverse racial, cultural, and religious groups?
Electronic Health Record (EHR) Integration
What are the steps for integrating these tools into electronic health record (EHR) systems like Epic, and how can this improve care coordination?
Balancing Standardization and Flexibility
As condition-specific models proliferate, how can chaplaincy maintain consistency while allowing for individualized care?
Looking Ahead
George emphasized the need for further research to refine these models and validate their use across diverse populations. He invited chaplains and researchers to collaborate on future studies and announced plans for training sessions to help healthcare professionals implement these tools.
Conclusion
George’s work on spiritual assessment models represents a step forward for spiritual care in healthcare. By adopting quantifiable, condition-specific models, chaplains can enhance their ability to assess and address patients’ spiritual needs while contributing to the broader healthcare team’s understanding of spiritual care. These advancements hold promise for improving patient outcomes, fostering interdisciplinary collaboration, and elevating the field of chaplaincy.
