Clinical Simulation in Nursing (2017) 13, 314-320

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Religious and Spiritual Assessment:

A Standardized Patient Curriculum Intervention
Cindy A. Schmidt, PhDa,*, Melissa A. Patterson, MDb, Adam M. Ellis, MDc,
Henka L. Nauta, BTE, CHSEd
a
Schmidt, C. A. Assistant Professor, American University of the Caribbean School of Medicine, Cupecoy, Dutch Lowlands, St
Maarten
b
Patterson, M.A. Family Medicine Resident, St. John Hospital and Medical Center, Detroit, MI, USA
c
Ellis, A.M. Anesthesiology Resident, Indiana University School of Medicine, Indianapolis, IN, USA
d
Nauta, H.L. Standardized Patient Program Director, American University of the Caribbean School of Medicine, Cupecoy,
Dutch Lowlands, St Maarten

KEYWORDS Abstract
standardized patient; Background: Most patients want to discuss religious and spiritual needs with their physicians, but
medical student; only 3% of the physicians ask.
religious and spiritual Method: Medical students (n ¼ 110) participated in a sensitizing experience with standardized pa-
assessment; tients (SPs) who presented with religious and spiritual concerns.
sensitizing experience; Results: Thirteen students misperceived their simulation experience, believing they had discussed
simulation; their SP’s religious and spiritual needs, whereas their SPs stated they had not. At 4-month follow-
teaching OSCE; up, religious assessment improved; however, retention was lower at 12-month follow-up.
self-monitoring; Conclusions: This curriculum is effective for large groups; however, the change in behavior was short
misperception of term. Subsequent intervention may improve retention.
simulation;
curriculum; Cite this article:
simulated patient Schmidt, C. A., Patterson, M. A., Ellis, A. M., & Nauta, H. L. (2017, July). Religious and spiritual assess-
ment: A standardized patient curriculum intervention. Clinical Simulation in Nursing, 13(7), 314-320.
http://dx.doi.org/10.1016/j.ecns.2017.05.007.
Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.

Introduction

Ninety-four percent of patients who have religious and

The authors have no conflicts of interest to report. This research did not
receive any specific grant from the funding agencies in the public, commer-
cial, or not-for-profit sectors. The university’s institutional review board
approved the study as exempt from human subjects review due to the use
of routine evaluation data for study #2015-005 on November 12, 2015.
* Corresponding author: CSchmidt@aucmed.edu (C. A. Schmidt).
spiritual beliefs want to talk with their health care providers
about it (Ehman, Ott, Short, Ciampa, & Hansen-Flaschen,
1999). Moreover, nearly half of patients who do not hold
religious and spiritual beliefs still want to discuss it
(Ehman et al., 1999). There may be a duty to follow the
ethical principle of beneficence to discuss religious and

1876-1399/$ - see front matter Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2017.05.007
Religious and Spiritual Assessment 315

spiritual needs, considering their influence on health out- reflective writing. Does this curriculum intervention
comes and also that some patients avoid formal medical improve the assessment of religious and spiritual needs?
care because of the dissonance between medicine and their
faith (Post, Puchalski, & Larson, 2000).
A discrepancy exists between what patients want and the Method
care they receive. Seventy-
eight percent of loved ones Needs Analysis
Key Points of intensive care unit pa-
 Most patients want to tients (i.e., their surrogate Beginning in the first semester, medical students learned to
discuss their religious decision makers) rated reli- use an interview tool called FICA that discusses the
and spiritual needs gious needs as important; patient’s Faith, the Importance of their faith, the sense of
with their physicians, yet, only 3% of their health Community, and how to Address their faith within their
but only 3% of physi- care providers attempted to medical care (Borneman, Ferrell, & Puchalski, 2010;
cians ask. understand the religious Puchalski & Romer, 2000) (see Table 1). FICA use
 Medical students (n needs of their patients, and degraded per semester, however, dropping from an average
¼ 110) participated a mere 16% of their goals- of 90% when they initially learned FICA, down to an
in a sensitizing expe- of-care discussions included average of 62.5% by the time the students embarked on
rience with a stan- religious needs (Ernecoff, their clerkships in their third year (see Table 2). Therefore,
dardized patient (SP) Curlin, Buddadhumaruk, & we introduced this curriculum intervention.
who presented with White, 2015).
religious and spiritual Although most U.S. med- Participants
concerns. ical schools deliver curricula
 Nearly 12% of students in religion and spirituality, A total of 110 second-semester medical students
misperceived their increasing from 13% in participated.
simulation experience, 1994 to 75% in 2011, the
believing they had dis- literature suggests that a gap Curriculum
cussed their SP’s reli- still remains between what is
gious and spiritual taught and praxis (Puchalski, One week prior to this new curriculum, students reviewed
needs, whereas their Blatt, Kogan, & Butler, FICA during a lecture (Borneman et al., 2010; Puchalski &
SP stated they had not. 2014; Puchalski & Larson, Romer, 2000). For this curriculum, students participated in
2000). Addressing this gap, a workshop entitled Advanced Social History (10 students
Chibnall and Duckro (2000) per session, 11 sessions of the workshop). One consistent
found that exposing medical students to patients with reli- faculty member provided an orientation reviewing the so-
gious needs increased their comfort with this aspect of cial history and describing the logistics for the three phases
care. Ledford, Seehusen, Canzona, and Cafferty (2014) of the workshop (i.e., SP interview, individual reflection,
designed an intervention using the objective structured clin- and group reflection). This faculty member explained that
ical examination (OSCE) as a teaching tool. Twenty-eight individual reflections were both anonymous and voluntary,
medical heterogeneous learners (i.e., students, residents, inviting students to maximize their learning experience by
and attending physicians) completed a teaching OSCE engaging in the reflections and to voluntarily provide their
with a standardized patient (SP), designed to be a sensitizing information for the purpose of educational evaluation. Stu-
experience (i.e., when learners do not know beforehand what dents received instructions to refrain from providing any
to expect, making the learning more memorable). The identifying information on their papers and to either submit
learners then engaged in reflective writing, 1:1 reflections their reflection papers into a cardboard box, to submit a
with faculty, and follow-up group reflections. After blank reflection paper into the cardboard box, or to retain
completing the curriculum, learners advanced their stage of it for themselves. No faculty members observed students
change in terms of their readiness to discuss patients’ reli- while they were writing or while they submitted/retained
gious and spiritual needs (Ledford et al., 2014). their reflection papers.
The Ledford et al. (2014) curriculum would be difficult Students began the workshop by individually interview-
to implement with large groups of learners, however, ing an SP whose case was designed to provide a sensitizing
because of the demand on faculty for 1:1 reflections and experience (Ledford et al., 2014). The orienting faculty
on using one SP for the entire group. This study explored member instructed students to take a social history and
an educational intervention modifying Ledford et al.’s listen for elements worth exploring in greater depth. This
(2014) curriculum for a larger homogeneous group of orientation provided a brief review of the elements of a so-
learners by using more SPs and by changing the 1:1 reflec- cial history, including FICA but not emphasizing it above
tion with faculty to small group reflection and individual the other elements of the social history. After concluding

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Religious and Spiritual Assessment
Table 1 FICA Spiritual History Tool* With Done/Not Done
Checklist for SPs
F Faith and ‘‘Do you consider yourself spiritual or
Belief religious?’’ or ‘‘Is spirituality
something important to you’’ or ‘‘Do
you have spiritual beliefs that help
you cope with stress/difficult times?’’
if the patient responds ‘‘no,’’ the
health care provider might ask,
‘‘What gives your life meaning?’’
I Importance ‘‘What importance does your spirituality
have in our life? Has your spirituality
influenced how you take care of
yourself, your health? Does your
spirituality influence you in your
healthcare decision making?’’
C Community ‘‘Are you part of a spiritual
community?’’ Communities such as
churches, temples, and mosques or a
group of like-minded friends, family,
or yoga can serve as strong support
systems for some patients. ‘‘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 ‘‘How would you like me, your
healthcare provider, to address these
issues in your healthcare?’’
Please complete this form and provide to faculty at the
completion of this workshop. Please do not write student’s
name or provide any information about student on this form.
1. Did Student complete ‘‘F’’ of the FICA? Yes No
2. Did Student complete ‘‘I’’ of the FICA? Yes No
3. Did Student complete ‘‘C’’ of the FICA? Yes No
4. Did Student complete ‘‘A’’ of the FICA? Yes No
5. Did Student inquire about religion/
spirituality in another way? If so, how?
(What did the student ask you, if you can
recall?)
Note. SP, standardized patient.
* Borneman et al. (2010) and Puchalski & Romer (2000).
their SP interview, students completed individual written
reflections. Then, students gathered for small group reflec-
tions led by a second faculty member where students
learned about sensitizing educational experiences. Follow-
up occurred three times (i.e., 2 weeks, 4 months, and
12 months) when students completed end-of-semester inter-
view checkoffs. SPs completed checklist ratings for the
elements assessed, including FICA.
SP Training
For the interview, ten SPs were trained on a standard
delivery of the prompt that they ‘‘felt deserted’’ to ensure
students would receive the same verbal and nonverbal
stimulus. SPs used a done/not done checklist on the four
pp 314-320  Clinical Simulation in Nursing  Volume 13  Issue 7
316
components of FICA, where SPs could indicate whether the
four specific parts of the spiritual assessment were elicited
(see Table 1). Specific interrater training established a
mutual understanding of done versus not done. Also, SPs
could write a response if their student interviewer had
inquired about their religious and spiritual needs through
any other type of questioning than FICA.
The case history for the OSCE was a 47-year-old female
who presents to the office with a cough. The initial history
of present illness, medical history, and family history of the
patient was presented as doorway information before the
students were sent in for the specific task of eliciting the
social history. Within two minutes of the interview, regard-
less of the topic of conversation, the patient stated she ‘‘felt
deserted.’’ Students’ initial responses to this prompt were
documented; the case history would provide a religious
concern if the prompt was followed up by the student,
resulting in the acquirement of one of the FICA compo-
nents. The case history for the SPs contained clear
instructions regarding when to share information and
when to be more reticent.
Measures
Individual Reflection Questions
Students responded to reflection questions after interview-
ing their SPs (see Table 3). Every student completed some
of the reflection questions, and most students completed
most or all the questions. Each individual reflection paper
had a randomized number written on it, and this matched
the same randomized number written on the SPs’ question-
naires. No master list was created that could potentially
result in matching students with their randomized numbers.
Group Reflection Questions
In small groups of 10, a faculty member led reflections on
whether students discussed their SPs’ religious and spiritual
concerns, their (dis)comfort with this discussion, possible
impact of their own religion and/or spirituality with their
(dis)comfort, medical and social issues with the case, and
what they wished they had done differently in their patient
interviews. The faculty member reviewed FICA and led a
discussion about the discrepancy found in the literature
between patients’ desire for discussing religious and
spiritual concerns and common physician practices. The
faculty member reported that all students engaged in their
small group reflections.
Done/Not Done SP Checklist
For done/not done SP checklist, see Table 1.
Qualitative Analysis
We individually conducted a qualitative analysis of the SPs’
evaluations identifying a subset of students who did not
assess religious and spiritual needs. This process identified
17 students of 110 (15.5%), and we agreed unanimously on
Religious and Spiritual Assessment 317

Table 2 Needs Analysis by Cohort: Percentages of Students Who Assessed Religious and Spiritual Needs
Intervention Cohort: Learned FICA in First Semester and Received the New Curriculum in Second Semester
First semester Summer 2015 95% (2-week follow-up from learning FICA)
Second semester Fall 2015 95% (2-week follow-up from this intervention curriculum)
Third semester Spring 2016 88% (4-month follow-up from this intervention curriculum)
Fifth semester Fall 2016 63.6% (12-month follow-up from this intervention curriculum)
Comparison Cohort A: Learned FICA in First Semester
First semester Spring 2015 96% (2-week follow-up from learning FICA)
Second semester Summer 2015 82% (4-month follow-up from learning FICA)
Third semester Fall 2015 68% (8-month follow-up from learning FICA)
Fifth semester Summer 2016 59% (12-month follow-up from learning FICA)
Comparison Cohort B: Learned FICA in Second Semester
Second semester Fall 2014 91% (2-week follow-up from learning FICA)
Third semester Spring 2015 65% (4-month follow-up from learning FICA)
Fifth semester Fall 2015 66% (12-month follow-up from learning FICA)
Comparison Cohort C: Learned FICA in Second Semester
Second semester Summer 2014 88% (2-week follow-up from learning FICA)
Third semester Fall 2014 71% (4-month follow-up from learning FICA)
Fifth semester Summer 2015 65% (12-month follow-up from learning FICA)
Comparison Cohort D: Learned FICA in Second Semester
Second semester Spring 2014 85% (2-week follow-up from learning FICA)
Third semester Summer 2014 68% (4-month follow-up from learning FICA)
Fifth semester Spring 2015 60% (12-month follow-up from learning FICA)

this subset of 17 students. Next, we individually conducted
a content analysis of the 17 students’ reflection questions
along with the information provided by their SPs to identify
reasons why the students omitted this portion of the social
history. Two key reflection questions provided the most
useful information: (a) how does your own personal be-
liefs/religion/spirituality impact your ability to talk with
your patient about his or her religion/spirituality and (b)
if you did not address religion/spirituality in any way
with your SP, why not.
Based on responses to these questions, we identified
primary and secondary reasons to describe each student’s
omission. For 7 of the 17 students, we agreed based on their
Table 3 Reflection Questions for First-Year Medical Students
After Conducting a Social History With SPs
1. How do your own personal beliefs/religion/spirituality
impact your ability to talk with your patient about his
or her religion/spirituality?
2. If you did not address religion/spirituality in any way with
your SP, why not?
3. How would you describe your religion/spirituality?
4. Why do you think you felt comfortable/uncomfortable/
neutral with conducting a religious/spiritual assessment?
5. If your religion matched that of the SP, how did that
impact your level of comfort with doing the FICA or in
another way addressing religious concerns?
6. If your religion did not match that of the SP, how did that
impact your level of comfort with doing the FICA or in
another way addressing religious concerns?
Note. SP, standardized patient.
initial reviews that students indicated they had forgotten
(e.g., ‘‘I forgot’’), were uncomfortable (e.g., ‘‘religion is a
sensitive topic for some people’’), were not sure of the task
(e.g., ‘‘was not sure if addressing the hopeless concern was
a part of the workshop so I stopped probing’’), or believed
they had assessed religious and spiritual needs (e.g., ‘‘I did,
she brought it up’’). For 6 of the 17 students, 2 of us agreed
on the reason, and for 3 of the 17 students, we disagreed
with each other. Then, we used consensus decision making
until achieving unanimous agreement on the reason we
believe the students had not assessed religious and spiritual
needs of their SPs. In agreement, we identified 13 students
who believed they had sufficiently addressed their SP’s
religious and spiritual needs, 3 students who were uncom-
fortable discussion religious and spiritual needs, and 1
student who forgot. Six students seemed to have a second-
ary reason: three students who thought they had sufficiently
addressed their SP’s religious and spiritual needs also
seemed uncomfortable with religious and spiritual distress
or with discussing religion, and three other students seemed
to have a poor interviewing technique as their secondary
reason for not assessing religious and spiritual needs.
Results
All 110 students completed the one-on-one SP social history
assessments. A few students omitted some individual
reflection questions, but most students completed all the
questions. All students turned in their anonymous individual
reflections to the drop box. All students participated in the
group reflection.

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Religious and Spiritual Assessment
Follow-Up Checklist of Using FICA
During the sensitizing experience, 84.5% (n ¼ 93) of
students assessed religious and spiritual needs, either by
using FICA or by asking through more improvised
questions. During their check-off exams two weeks after
completing the curriculum, 95% (n ¼ 104) of students used
FICA to assess religious and spiritual needs, which is
similar to previous cohorts’ end-of-semester check-off rates
of using FICA (90%, averaged across four previous
cohorts). At the four-month end-of-semester checkoffs,
rates of using FICA for this intervention cohort was 88%
(n ¼ 97) compared with an average of 71.5% for the four
cohorts prior to the curriculum intervention. Therefore, the
intervention cohort experienced a decrease in use of FICA
of 7%, whereas the comparison cohorts experienced an
average decrease of 18.5% (see Table 4). However, at the
12-month end-of-semester checkoffs, rates of using FICA
were 63.6%, which is similar to the rate of using FICA
prior to this new curriculum (average 62.5%).
Qualitative Analysis
Most of the 17 students who did not assess religious and
spiritual needs (n ¼ 13, 76.5%) thought they had actually
assessed the religious and spiritual needs of their SPs. Other
students omitted this assessment because they felt uncom-
fortable discussing religion (n ¼ 2, 11.8%), they felt
uncomfortable with spiritual distress (n ¼ 1, 5.9%), or
they forgot (n ¼ 1, 5.9%). They were distributed throughout
the small groups in the workshop (i.e., seven students from
the early morning small groups, four students in the middle
morning small groups, and six students in the last small
groups).
Reflections from the 13 students who misperceived (i.e.,
believing they had actually assessed their SP’s religious and
spiritual needs when their SPs indicated they had not) were
further explored to identify how they conveyed their belief
that they had conducted this assessment. Eight of the 13
students did not respond to the reflection question ‘‘If you
did not address religion/spirituality in any way with your
Table 4 Rates of Using FICA at Two-Week, Four-Month and Twelve-Month Follow-Ups
2-Week
Cohort Follow-Up
Intervention cohort 95%
Comparison cohort A 96%
Comparison cohort B 91%
Comparison cohort C 88%
Comparison cohort D 85%
Average for comparison cohorts 90%
Comparison cohorts are the recent, previous classes of students.
318
Standardized Patient, why not?’’ but responded to the other
reflection questions. Four of these eight students drew a line
in lieu of a response, three students wrote ‘‘N/A,’’ and one
student omitted the question. Reviewing their responses to
all the reflection questions indicated the students believed
they had discussed religious and spiritual needs with their
patients. Among the five students who provided responses
to this question, three students outright stated that the topic
‘‘was addressed’’ with their SPs. The other two students
indicated their belief in having conducted this assessment
by stating they were able to understand the role of religion
in their SP’s life and by being able to relate to her because
of their own religious background.
Discussion
These modifications to the Ledford et al. (2014) curriculum
make this curriculum design feasible to use with larger homo-
geneous groups of students. Results indicate this intervention
using SP simulation yielded less decrease in skill retention
for conducting an assessment of religious and spiritual needs
(7% in the intervention cohort vs. 18.5% average among the
comparison cohorts). This success seems to be due to the
combination of presenting an urgent religious concern within
the SP interview in the context of a sensitizing experience.
This may fill the identified gap between what patients want
as opposed to the care they typically receive.
The improvement did not ‘‘stick’’ by the 12-month
follow-up (Brown, Roediger & McDaniel, 2014). Aquel
and Ahmad (2014) had a similar finding, with a decrease
in retention of skills occurring at 3 months. Another study
found that at the one-year follow-up, learners performed the
same, regardless of whether the intervention was a simula-
tion experience or a more traditional teaching method (Lo
et al., 2011). The results of this study mirror those of Lo
et al. (2011) and Aquel and Ahmad (2014), with decreased
retention of skills by the 12-month follow-up, independent
of the teaching method.
The qualitative analysis found 14.5% (n ¼ 17) of
students believed they had assessed religious and
Decrease in Using FICA from
4-Month 12-Month Two-Week to Four-Month
Follow-Up Follow-Up Follow-Up (Percentage Difference)
88% 63.6% 7%
82% 59% 14%
65% 66% 26%
71% 65% 17%
68% 60% 17%
71.5% 62.5% 18.5%
pp 314-320  Clinical Simulation in Nursing  Volume 13  Issue 7
Religious and Spiritual Assessment
spiritual needs, when their SPs stated they had not.
Among the 17, there were 13 students (11.8%) who
misperceived the clinical interview. That is, 13 students
believed that they had, in fact, evaluated religious and
spiritual needs in their SPs, when their SPs reported that
these students had not.
How could 13 students report they completed an
evaluation when their SPs reported it had not occurred? It
could be that they did not have a working understanding of
what constitutes an assessment of religious and spiritual
needs. Perhaps, some students thought that the fact that
their SPs mentioned something about religion (i.e., that
they felt deserted by God) seemed sufficient to mentally
‘‘check off’’ having completed that item from the social
history. Students may not know how deep to go with certain
topics because at this point in their education, they do not
always know how to use the information. This study
highlights a situation where students believed that a
patient’s brief reference to religion constituted their having
assessed their patient’s religious and spiritual needs. This
lack of depth is likely an indication of their inexperience
with practicing medicine, but it also mirrors research
findings on experienced physicians having poor communi-
cation skills and increased medical errors (Berner &
Graber, 2008; Levinson, Roter, Mullooly, Dull, &
Frankel, 1997; Stewart, 1995).
Another possible explanation, first-year medical students
may be experiencing high levels of anxiety during an SP
encounter, which could reduce accurate self-monitoring
skills, particularly in males (Colbert-Getz, Fleishman, Jung,
& Shilkofsky, 2013). Good self-monitoring skills are neces-
sary for conducting a thorough evaluation.
Limitations and Recommendations
Ensuring that successive groups of students did not know
the nature of the sensitizing experience was a challenge. We
asked students to maintain SP confidentiality, and the data
suggest that some students from all sessions omitted the
FICA (suggesting they had not been informed by previous
students about the case). Relying on the goodwill of
students to maintain this type of workshop confidentiality
may not always work, however, which could mean that
some students might not benefit from the sensitizing
experience aspect of the curriculum.
Additionally, summarized reflective questions are not
amenable to quantitative evaluation. Future research could
use validated questionnaires, for the students and also for
the SPs.
Future studies could conduct focus groups with those
students who omitted the assessment of religious and
spiritual needs. Saying that they forgot may have been
more of a defense mechanism than actual forgetting, and
having a group discussion with others might provide an
opportunity to explain their reasons. To improve the
pp 314-320  Clinical Simulation in Nursing  Volume 13  Issue 7
319
‘‘stickiness’’ of learning and using FICA, a future study
could provide a ‘‘booster’’ simulation experience or an
additional group reflection (Brown et al., 2014). Alterna-
tively, experiencing this curriculum later in their education,
such as during their clerkship, residency, or fellowship years,
may prevent the aforementioned misperceptions about
whether they had completed a religious and spiritual
assessment.
Finally, this curriculum intervention appears to be
promising for use with any health care students and
providers to improve their assessment of religious and
spiritual needs. Future studies will help define the optimal
timing for delivery and establish effectiveness within
various disciplines.
Acknowledgments
We would like to thank the simulation staff and all the
standardized patients at the Clinical Skills Simulation
Center. Mark Quirk, EdD, and Teresa Boese, DNP, pro-
vided substantive reviews.
References
Aquel, A. A., & Ahmad, M. M. (2014). High fidelity simulation effects on
CPR knowledge, skills, acquisition, and retention in nursing students.
Worldviews on Evidence-Based Nursing, 11(6), 394-400.
Berner, E. S., & Graber, M. L. (2008). Overconfidence as a cause of diagnostic
error in medicine. The American Journal of Medicine, 121(5A), 2-23.
Borneman, T., Ferrell, B., & Puchalski, C. M. (2010). Evaluation of the
FICA tool for spiritual assessment. Journal of Pain and Symptom Man-
agement, 40(2), 163-173.
Brown, P. C., Roediger, H. L., III, & McDaniel, M. A. (2014). Make it
stick: The science of successful learning. Cambridge, MA: The Belknap
Press of Harvard University Press.
Chibnall, J. T., & Duckro, P. N. (2000). Does exposure to issues of spiri-
tuality predict medical students’ attitudes toward spirituality in medi-
cine? Academic Medicine, 75(6), 661.
Colbert-Getz, J. M., Fleishman, C., Jung, J., & Shilkofski, N. (2013). How
do gender and anxiety affect students’ self-assessment and actual perfor-
mance on a high-stakes clinical skills examination? Academic Medicine,
88(1), 44-48.
Ehman, J. W., Ott, B. B., Short, T. H., Ciampa, R. C., & Hansen-
Flaschen, J. (1999). Do patients want physicians to inquire about their
spiritual or religious beliefs if they become gravely ill? Archives of In-
ternal Medicine, 159(15), 1803-1806.
Ernecoff, N. C., Curlin, F. A., Buddadhumaruk, P., & White, D. B. (2015).
Health care professionals’ responses to religious or spiritual statements
by surrogate decision makers during goals-of-care discussion. JAMA In-
ternal Medicine, 175(10), 1662-1669.
Ledford, C. J. W., Seehusen, D. A., Canzona, M. R., & Cafferty, L. A. (2014).
Using a teaching OSCE to prompt learners to engage with patients who talk
about religion and/or spirituality. Academic Medicine, 89(1), 60-65.
Levinson, W., Roter, D. L., Mullooly, J. P., Dull, V. T., & Frankel, R. M.
(1997). Physician-patient communication: The relationship with
malpractice claims among primary care physicians and surgeons.
JAMA Internal Medicine, 277(7), 553-559.
Lo, B. M., Devine, A. S., Evans, D. P., Byars, D. V., Lamm, O. Y.,
Lee, R. J., ., & Walker, L. L. (2011). Comparison of traditional versus
 Religious and Spiritual Assessment
high-fidelity simulation in the retention of ACLS knowledge. Resuscita-
tion, 82(11), 1440-1443.
Post, S. G., Puchalski, C. M., & Larson, D. B. (2000). Physicians and pa-
tient spirituality: Professional boundaries, competency, and ethics.
Annals of Internal Medicine, 132(7), 578-583.
Puchalski, C. M., Blatt, B., Kogan, M., & Butler, A. (2014). Spirituality
and health: The development of a field. Academic Medicine, 89(1),
10-16.
pp 314-320  Clinical Simulation in Nursing  Volume 13  Issue 7
320
Puchalski, C. M., & Larson, D. B. (2000). Developing curricula in spiritu-
ality and medicine. Academic Medicine, 73, 970-974.
Puchalski, C., & Romer, A. L. (2000). Taking a spiritual history allows cli-
nicians to understand patients more fully. Journal of Palliative Medi-
cine, 3, 129-137.
Stewart, M. A. (1995). Effective physician-patient communication and
health outcomes: A review. Canadian Medical Association Journal,
152(9), 1423-1433.