Running head: SPIRITUAL ASSESSMENT AT SAN FRANCSICO GENERAL

Spiritual Assessment at San Francisco General Hospital

Andrea Idudhe
University of San Francisco

SPIRITUAL ASSESSMENT AT SAN FRANCSICO GENERAL

Spirituality Assessment at San Francisco General Hospital

In healthcare, there is much focus on physical, social, and mental dimensions of health.
So much focus that often, spiritual well-being, the fourth dimension of health, is often
overlooked. There have been numerous studies on the influence spirituality has on health.
However, spirituality is often used as a synonym for religion. Religion may include spirituality,
but spirituality does not necessarily include religion. Religion tends to focus on beliefs, ethics,
rituals and traditions. Spirituality is intangible and subjective, meaning different things to
different people (Wynne, 2013, p. 42). Spirituality is a commonly used word that is difficult to
describe. As a result, there is no definitive definition of spirituality that encompasses the
influence spirituality has on health outcomes (Reinert & Koenig, 2013).

Spirituality is an important element of nursing. Studies have shown, that patients would
like to have their spirituality addressed, as a part of their care (Puchalski, 2013). In an inpatient
care setting, nurses are the primary caretakers of patients. Nurses recognize that there is a
spiritual element to patient care, but they have difficulty assessing spirituality (Smyth & Allen,
2011). NANDA International (2012) created three nursing diagnosiss that specifically relate to
spirituality: at risk for spiritual distress, spiritual distress, and readiness for enhanced spiritual
well-being. The use of these nursing diagnoses is complicated without assessing spirituality.
Assessing spiritual needs may be difficult because there are many interpretations and the variety
of effects of spirituality (Naghi, Philip, Phan, Cleenewerck, & Schwarz, 2010). The San
Francisco General Hospital, inpatient acute care for the elderly (A.C.E.) with telemetry unit,
would benefit from a tool that assists with spirituality assessment.
With a spirituality assessment tool, clinicians would have a simple approach to spiritual
assessment. Being ill and/or facing death can be a scary experience. It is no surprise that patients

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often experience feelings of isolation, anxiety and depression, while hospitalized. Studies show,
In chronic illness such as heart failure, spirituality may serve as a coping mechanism to alleviate
the mental and physical stress from the condition and the possible end of life (Naghi, et al.).

System Setting
Unit 5d is a 34-bed, acute care for the elderly (A.C.E.) with telemetry in-patient ward.
This unit cares for adult and geriatric patients with cardiovascular and other illnesses. This
medical-surgical floor has one nursing manager and one clinical nurse specialist (CNS). There is
usually a 4:1 patient to nurse ratio. A majority of the nurse staff are middle class, Asian/Pacific
Islander females, between the ages of 22 and 40. On 5d unit, bachelors degrees in nursing are
more common the masters degrees.
The key stakeholders in this system are the: nurse manager, CNS, nurses, and patients.
The nursing manager approval would be integral to the implementation of a spirituality
assessment. One of nurse managers responsibilities is to keep the staff educated on new
procedures. Therefore, the nurse manager would be responsible for the spiritual assessment
training of the nursing staff. The clinical nurse specialist would be a source of guidance for the
nurses on the unit. The nurses are vital to the success of the spiritual assessment tool
implementation. Often, nurses would be using the tool to assess their patients. The patients are
the most important stakeholders. Nurses have to establish a rapport and trust with patients, so
the patients will feel comfortable sharing their feelings.
There are some barriers to the implementation of the spirituality assessment tool. On a
busy medical-surgical unit, nurses are often restricted by time limitations and numerous tasks to
perform. Lack of continuity of care, poor training, and uneasiness about conversation about

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spirituality are also barriers to giving spiritual care. Sometimes, nurses simply dont have
enough time to build a relationship with their patients. Therefore, it may be difficult for the
nurse to gain trust and confidence. Some nurses and patients are uncomfortable speaking about
spiritual matters. For a variety of reasons, patients may not be open to speaking with their nurse
or doctor about spirituality. Also, nurses must be able to be neutral, self-aware and accepting of
their patients personal beliefs.
To overcome these barriers, the nursing staff will be encouraged by the management to
take the time to complete the spiritual assessment. All of the staff member on the unit will
receive spiritual assessment training, prior to implementation of the assessment tool. The training
would be computer based and in-service training. The nurses will be asked to assess their own
spiritual beliefs. Once the staff members have assessed their beliefs and barriers for giving
spiritual care, it is expected that they will be able to move past their discomfort (Burkhardt &
Nagai-Jacobson, 2002). Charge nurses should be instructed to assign nurses according to the
patients spiritual needs, if they believe the patient will benefit.
Some elements of spirituality have positive influences on physical well-being. Research
suggests that while a patient prays their blood pressure, heart rate and respiratory rate decrease
(Benson, Beary, & Carol, 1974). On unit 5d, many of the patients have heart disease. Therefore,
prayer may be beneficial to the health of the patients on 5d. If the staff is uncomfortable praying
with the patient, a hospital chaplain will pray with them. Spirituality may also affect treatment
compliance. In chronic heart failure patients, spirituality may affect the likeliness of a patient to
adhere or comply with treatment, therapy and interventions (Naghi et al., 2010). When patients
are more receptive to their care plan it is much easier for clinicians to continue treatment.

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Clinical Nurse Leader (CNL) Role

Currently, the CNL role is not implemented on 5d. If there was a CNL, their primary role
would be to improve patient outcomes. CNLs must design, coordinate, and implement patient
care (Stavrianopoulos, 2012). Using evidenced based practice, the CNL will find a spiritual
assessment tool that best suits the patient population. There are numerous spiritual assessment
tools, which are commonly used in nursing practice. The CNL may choose to use the FICA
spirituality tool (see Appendix A). The FICA spirituality tool was created by Dr. Christina
Puchalski in 1996 and has been found to be a beneficial instrument for clinical assessment
(Borneman, Ferrell, & Puchalski, 2010). In addition to finding an appropriate assessment tool,
the CNL will coordinate and strategize with the nursing manager and CNS to plan the training of
the staff. Using failure mode analysis techniques, CNLs will determine the possible negative
effects of the change prior to implementation (Reid & Dennison, 2011). Also, The CNL will
evaluate the outcomes of the implementation by doing chart audits.
The CNL will be responsible for getting the staff and management on board with this
change. By showing the necessity of the change and getting as many people as possible
involved, the CNL will be able to gain support from the staff and management. The number
people that support the change will affect the likelihood of the change occurring (Harris &
Roussel, 2010). The necessity for change will be supported by evidence based practice.

Change Theory
The Lippitts change theory applies best to this implementation. The Ronald Lippitts
change theory is a seven phase process that includes four major parts: assessment, planning,
implementation and evaluation. The change theory phases are: diagnosing the problem, assess

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motivation/capacity for change, assess the change agents motivation and resources, select a
progressive change objective, chose the role of the change agent, maintain change and terminate
the helping relationship (Mitchell, 2013, p.33). Lippitts change theory puts a great deal of
emphasis on the change agent and the change agent becomes a part of a team (Harris & Roussel,
2010). CNLs are change agents and should be the change agent, on this unit.
Applying Lippitts change theory to implement the use of a spiritual assessment tool
requires an assessment of the unit. Assessing the unit characteristics, will aid in the diagnosis of
the problem. After diagnosing the problem, literature review should be done to look for evidence
to support the need for a spirituality assessment tool. After finding supportive evidence, the plan
to implement the use of the tool should be underway. Subsequently, the information from the
assessment will be used to finalize the implementation. There should be periodic staff meetings
to communicate the current status and any changes to the implementation. Keeping the staff
involved with the process will create buy-in. Then, the team members directly involved in the
implementation will be given tasks to perform and deadlines for completion. The role of the
change agent will then be defined by the change agent and the team. The evaluation of the use of
the spiritual assessment tool will be continuous. Patient responses will be evaluated and the
charts will be reviewed for assessment completion. Much of the success of the implementation
will rely on staff participation, especially nurses. The nurses must be motivated for the change.
If there is no motivation, there must be a capacity to change. The CNL, CNS, nurse manager are
typically change agents. Change agents should be able to influence people to change and they
must be motivated and have the resources needed for the change (Harris & Roussel, 2010).
There must be an objective for the progressive implementation of the spiritual assessment tool.
A step-by-step process is necessary, to achieve the implementation (Harris & Roussel, 2010).

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Maintaining the change of the use of the implementation will require follow-up. Once the
implementation is complete and stable, the change agent should gradually remove themselves
from the change process. At this point, spirituality assessment should be a part of the unit
culture.
Implementing the spiritual assessment tool will require a great amount of support from
nurses. The necessity for the spirituality assessment should be communicated with the staff.
Communication is an important part of a change process (Mitchell, 2010). The most imperative
information to explain to staff is why this intervention is important. Understanding the evidence
will motivate the staff to change. If the nurses are motivated the management will likely follow.
A step-by-step plan will be implemented by a team including the: CNL, CNS, nurse manager,
and nursing staff members. The CNL will perform periodic chart audits to if evaluate the use of
the spiritual assessment tool. Once the implementation is stable, the CNL will gradually be
removed from the process.

Action Plan
The action plan for this implementation is based on Lippitts change theory. The action plan
includes the actions and the roles of the key players. The action plan begins with assessing the
problem, making a plan, identifying resources, and communicating with those involved. The
implementation of the spiritual assessment plan is complete when the change becomes a part of
the unit culture (see Appendix B).

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Evaluation
Throughout the implementation process progress will be monitored by the team. It is
important to determine if the implementation is going according to plan. Once implementation is
complete, the goals and objectives will be evaluated to determine the success of the
implementation. According to Joint Commission (2005), the goal of implementing a spirituality
assessment tool is to assess the patients needs, hopes, resources, and possible outcomes
regarding spirituality and determine appropriate actions necessary to address those issues.
Nurses will be encouraged to write a note describing patient reactions and the outcomes of the
assessment in the patients chart. Collecting subjective responses from patient
comments/surveys and communicating with the nurses and other staff about their experiences,
will help to evaluate the outcome of this implementation. Any problems or concerns will be
noted and used during the evaluation process. Each modification made to the process will be
evaluated and the staff will be educated on the changes.

Conclusion
A spiritual assessment tool would be a great addition to the spiritual care regimen of the
A.C.E. unit at SFGH. Although there are some barriers to implementing this plan, such as time
and comfort with spirituality, the patient outcomes are expected to be exceptional. Getting the
participation of the nurses on the unit will rely on their level of motivation. The change agent
should be a person that can motivate and encourage involvement. The most important key
players are the patients. The responses of the patients should be taken in the highest regard. The
patient responses are an important part of the evaluation. The goal of implementing a spiritual
assessment tool is essentially to help nurses give spiritual care.

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References
AACN. (February 2007). White Paper on the Education and Role of the Clinical Nurse Leader.
Retrieved from http://www.nursing.vanderbilt.edu/msn/pdf/cm_AACN_CNL.pdf
Albers, G., Echteld, M.A., Henrica, C.W., De Vet, H.C., Onwuteaka-Philipsen, B.D., Van der
Linden, M.H., Deliens, L. (2010). Content and spiritual items of qualityoflife
instruments appropriate for use in palliative care: A review. J Pain Symptom Manage. 40:
290-300.
Benson, H., Beary, J. F., & Carol, M. P. (1974). The relaxation response. Psychiatry, 37(1), 37
46.
Borneman, T., Ferrell, B & Puchalski, C.M. (2010). Evaluation of the FICA Tool for Spiritual
Assessment. Journal of Pain and Symptom Management. 40(2), 163-173.
Burkhardt, M. A., & Nagai-Jacobson, M. G. (2002). Spirituality: Living our connectedness .
Albany , NY : Delmar.
Harris, J.L., & Roussel, L. (2010). Initiating and sustaining the clinical nurse leader role: A
practical guide. Sudbury, MA: Jones and Bartlett Publishers
Joint Commission. (2005). Asked and answered: Evaluating your spirituality assessment process.
Retrieved from http://www.professionalchaplains.org/files/resources/reading_room
/evaluating_your _spiritual_assessment_process.pdf

Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing
Management, 20(1), 32-37.
NANDA International. (2012). Nursing diagnoses: Definitions and classification 2012-2014.
Hoboken, NJ: John Wiley and Sons, Inc.
Puchalski,C.M. (2013). Integrating spirituality into patient care: An essential element of
personcentered care. Polish Archives of Internal Medicine. 123(9), 491-496.

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Reed, K.B., & Dennison, P. (2011). The clinical nurse leader (CNL): Point-of-care safety
technician. The Online Journal of Issues in Nursing. 16 (3)
Reinert, K.G., Koenig, H.G. (2013). Re-examining denitions of spirituality in nursing research.
Journal of Advanced Nursing 69(12), 26222634. Doi: 10.1111/jan.12152
Smyth, T., Allen, S. (2011). Nurses experience assessing the spirituality of terminally ill
patients in acute clinical practice. International Journal of Pallitative Nursing.17(7), 337343.
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Wynne, L. (2013). Spiritual care at the end of life. Nursing Standard. 28(2) 41-45.

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Appendix A

FICA spirituality tool

F- Faith, Belief and Meaning
Do you consider yourself spiritual or religious?
Do you have spiritual beliefs that help you cope with stress?
What gives your life meaning?
I- Importance and Influence
What importance does your faith or belief have in your life?
On a scale of 0 (not important) to 5 (very important), how would you rate the importance
of faith/belief in your life?
Have your beliefs influenced you in how you handle stress?
What roles do your beliefs play in your healthcare decision making?
C- Community
Are you a part of a spiritual or religious community?
Is this of support to you and how?
Is there a group of people you really love or who are important to you?
A- Address in care
How would you like your healthcare provider to use this information about your
spirituality as they care for you?
(Boreneman, Ferrell, & Puchalski, 2010)

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Appendix B
Assess

Diagnose the problem with the current spiritual assessment

Complete a literature review on the spirituality assessment tools in use
Provide a detailed plan for the implementation with a timeline
Communicate with the staff and change agent to assess motivation and/or resistance
Identify resources such as educators, chaplains and other spiritual leaders

Plan

Considering the assessment information finalize the implementation plan

Have periodic staff meetings to discuss the implementation
Assign responsibility and deadlines to team members
Define the role of the change agent

Implement

Train the staff on spirituality care and the use of the spirituality
assessment tool
Communicate the status of the implementation

Evaluate

Evaluate patient responses to the implementation

Review patient charts for completion of spiritual assessment
The change agent is removed from the implementation
process

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