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Role Clarification: Who Assesses Spirituality?
To be complete, holistic care should include assessing patients’ spiritual needs. This spiritual assessment process is typically done either by a screening completed by a non-chaplain or a spiritual assessment administered by a clinical pastoral care giver–a chaplain. This premise presents several questions: 1) What is the role of non-chaplains in the spiritual assessment process? 2) What skills or expertise are needed by non-chaplains to administer spiritual screenings? And 3) What are the differences between spiritual screening and spiritual assessment?
The purposes of this article are (1) to argue that the profession of clinical chaplaincy is necessary for assessing spiritual needs of patients who have been referred to the Chaplaincy after an initial spiritual screening and (2) to show that special training is needed when non-chaplains are involved in the spiritual screening process.
In health care today, a whole-person care approach is being advocated. This means that clinicians are encouraged to view persons through many “lenses”--physical, emotional, psychological, social and spiritual. These varying lenses allow for a patient to receive different approaches to their care. “Good health care is incomplete without each of these aspects” (Cook, 2001).
Because addressing the spiritual dimension of each patient is recognized as necessary, if one believes in holistic care, the prerequisite of having clinically trained professionals available is essential. Who then is qualified to collect and assess information for treatment of spiritual needs? It has been argued that, though spiritual distress is an acknowledged phenomenon, no “specialized training” is needed to recognize and meet some if not all of a patient’s spiritual needs (Di Meo, 1991). However, research by VandeCreek and McSherry (1993) found that some nurses don’t feel comfortable discussing spiritual matters with their patients. It would seem then that involvement by someone trained to address spiritual needs would be beneficial. Chaplains are the clinical professionals qualified by specialized training and experience to both identify and respond to spiritual issues.
Training by chaplains is needed for nurses and other clinical persons, particularly to instruct in the identification of spiritual pain, and when to refer to the chaplain. One survey revealed that many nurses did not fully understand the role of the chaplain, and they requested more in-service training (Bryant, 1993); in another study, 94% of nurses felt pastoral care was a professional resource and as many as 78% made referrals to chaplains (VandeCreek & McSherry, 1993). While nurses may feel that chaplains are a vital resource, not all understand the role of the chaplain. This lack of understanding impacts directly upon pastoral care delivery.
Hospital chaplains continue to express concern that their clinical role as the experts chiefly responsible for addressing spiritual issues has not yet gained the acknowledgment of many professional groups—that their clear role in medicine is being chiefly responsible for addressing the spiritual issues as they relate to health problems. Like social workers, chaplains hope for and work toward achievement of autonomy, being respected as a clinical discipline that provides significant and essential care to the patient. In reality, it often occurs that where chaplains expect to perform assessments and diagnoses as professionals in their own domain, other groups expect a shared arena (Cowles, 1995).
The delineation of function is important to address because of the contemporary holistic model. In hospitals, professional individual skills are used to enhance the outcome of the patient’s plan of care. In order to do this, the inter-disciplinary approach is utilized. Therefore, it is vital that each discipline acknowledges the importance of the other. This serves to acknowledge that some functions overlap such as collecting sundry information, reporting on a patient’s pain, or asking about advance directives. “Pastoral care does not occur in a void, but within a matrix of social processes” (Klugh, 2000). Therefore, just as a physician, nurse or social worker provides specialized care to the patient, so also does the chaplain as a specialist. The role of the chaplain helps and encourages the patient toward spiritual growth (Streed) which ultimately influences healing (Matthews, 1998).
A role is the set of expectations others have for the occupant of a position. The role of the chaplain pertains to people’s perceptions about how chaplains ought to act in a given situation. People’s expectations of the chaplain's role may be limited. They may feel that chaplains are there to pray and bless but not to make diagnoses or make judgements.
Chaplains can reduce role confusion first by defining what it is they are uniquely qualified to do. Secondly, chaplains must demonstrate competence in areas such as spirituality assessment, pastoral psychotherapy, spiritual interventions and bioethics, to name a few. Thirdly, chaplains must be engaged with other disciplines, and cultivate relationships with management to educate all of them on what it is chaplains contribute to holistic health care. Finally, chaplains clarify their role and successfully differentiate its distinctiveness in the larger system by stressing the legitimacy of its religious perspective (Furniss, 1994).
In modern times, when a person feels sick, s/he may go to a health care giver to get a diagnosis and prescribed treatment. Ill parishioners are often diagnosed by a medical doctor or a psychiatrist, who knows more than the pastor does about assessing human beings when they complain of physical or mental problems. But do patients know that they can have their situation viewed from another perspective that would work in concert with the medical model? If they knew, would certain persons want to have a more complete assessment of themselves, turning to the chaplain for expert help in making a diagnosis for their troubles? Would they want a chaplain, rather than some other specialist to guide them in their search for wellness or meaning? What if they wanted a pastoral-theological framework rather than a medical or social perspective? What if they wanted to be in several professional hands at once (Pruyser, 1976)? When holistic care is advocated and spirituality is considered important, then the next step is to ensure that patients know what specialty provides clinical pastoral care. That specialty is the chaplaincy.
Again, pastoral care occurs in a matrix of social processes (Klugh, 2000). It is the chaplain who is trained to provide spiritual support across organizational boundaries and across faith groups while respecting individualized spirituality. Many persons turn to spiritual resources during illness and other painful experiences, finding them helpful; thus the need to identify spiritual distress is not only important, but it begs another issue--the need for a process and identified roles to provide appropriate interventions by competent pastoral care givers (Burton & VandeCreek).
Due to limited resources, chaplains are not always able to meet every patient at intake. Utilizing a referral model that employs a type of “spiritual triage” is one way of dealing with resource constraints (see Klugh, 1999) .
A spiritual screening is an attempt to determine preliminary spiritual information about a patient from answers that the patient has given to selected queries. A screening suggests a short inquiry in order to determine whether further care is needed in a particular area or if a referral is indicated. Naturally, busy practitioners are concerned about the time commitment required to obtain a spiritual history. In some situations, requisite data can be collected incrementally over a period of several visits as a matter of on-going pastoral care (Maugans, 1996).
The formation of screening questions will most effectively originate from the specialists to whom the patient may be referred. Examples could include dentistry, social service, mental health, cardiology or clinical chaplaincy. In other words, because the receiving discipline has special expertise, it is best suited to provide criteria which other disciplines can use to make decisions for referral needs. The results of a spiritual screening (triage) will likely differ based on the knowledge and comfort of the person asking the questions.
The nursing profession has made a major contribution to chaplaincy in the form of its 1978 Spiritual Diagnosis Taxonomy. While this taxonomy is not a substitution for qualitative assessment of a patient’s spiritual life, which clinical chaplains do, it does provide a language which chaplains and nurses can use in common to describe levels of spiritual need (Stoddard). During the intake process the nurse observes the patient, reflects on his/her observations, and allows the patient to either validate or correct his or her perceptions. Although a nurse can ask a patient spiritually related questions that can provide clues to a person’s beliefs and concerns, the nurse is not trained to know what those clues mean. The items that the nurse observes may have significant religious meaning but such observations need further clarification ( Carson, 1989). This describes a type of spiritual screening. In other words, the nurse is trying to determine something about the patient’s spirituality. Screening suggests a short examination in order to select or to determine whether further referral is needed. A non-chaplain can administer a spiritual screening, but even this requires special training.
A common understanding of the screening instrument, its purpose and value as a referral tool, and competency in its application with patients require specialized preparation, regardless of the religious background of the intake personnel. This training is appropriately provided by clinical pastoral care givers.
Assessment is akin to screening but implies an analysis of collected data or a thoroughness that screening does not. An assessment involves additional time and skill. A spiritual assessment, for example, involves noting how theological understandings coupled with various belief structures affect the individual’s present physical or psychological pain. Presumably, nurses have time to take a screening of patients’ spiritual concerns during the intake process, but it is probable that they do not have the time and qualifications to assess the meanings of what they learn or observe. Therefore, there is a strong need to refer to the appropriate clinical specialty, where more time and expertise is allowed for further assessment. A nurse’s personal understanding and attitude toward such profound questions as the meaning of life, suffering, and death will affect the attention given to patients’ spiritual needs (Highfield & Cason, 1983). The hospital chaplain understands the workings of the heart (emotions) and the language of the soul (theology) as well as a working knowledge of the body (Driscoll, 1994); therefore, s/he is the appropriate clinician to further assess the patient.
Theoretical perspectives guide spiritual assessments and interventions in situations of spiritual need and distress. One perspective is theology. Through theology, the chaplain gains a broader understanding of the spiritual dimension by addressing a person’s beliefs about the nature of God or acknowledged Higher Power and the authority or guidance provided by this Higher Power. A person’s theology serves to shape beliefs about life and the meaning of these experiences (Farran, Fitchett, Quiring-Emblen, & Burck, 1989).
The activities of clinical chaplains include diverse interactions with patients and families, professional staff, and community members. While chaplain staffing is an on-going challenge, teaming with nursing to address the spiritual dimension of a patient’s care is essential. Nurses can and do have a valuable, though limited, role and function in taking spiritual screenings. S/he helps to identify need through asking questions and observing behaviors of the patient related to spiritual issues, but because of limitations of time and the lack of specialized professional training, a referral to chaplaincy is appropriate.
Chaplains are the appropriate clinical discipline to conduct thorough spiritual assessments, which may include any or all of the following: spiritual history, religious formation, various spiritual injuries, theodicy, faith questions, crisis of faith, god-concepts/images, concepts of death, spiritual direction, life summaries, hope building, alienation from God, suffering and much more. The clinical chaplain is the trained professional who has the theological and philosophical training along with the clinical skills through individual and group training to thoroughly appraise a person’s spiritual health.
This article seeks to provide a definition of spiritual screening and of spiritual assessment along with delineating the roles of non-chaplains and chaplains in the giving of holistic health care. Limited resources such as time and personnel greatly affect the delivery of care in institutions. Therefore streamlining processes that allow for optimum utilization of providers is paramount. All specialists, physicians, nurses, social workers and chaplains, are needed for the good of the patient. It is essential that each discipline has a familiarity with the other disciplines in order to know when to make a referral and to whom to refer.
Just as all clinicians are trained to assess physical pain, all would benefit from being trained to be aware of spiritual pain. But just as physical pain is further assessed by nursing and the physician, a clinically trained chaplain is prepared to further assess (treat) a patient’s spiritual pain. Clinical chaplains are trained to provide individualized interventions while maintaining appropriate boundaries with the patient. Others, not professionally trained, run the risk of violating sacred boundaries.
Dr. Jack Klugh is a board certified chaplain with the Association of Professional Chaplains and the National Association of Veterans Affairs Chaplains. Currently, he is the Chief of Chaplain Service at the VA Medical Center in Fargo, North Dakota. Academically, he has a Doctor of Ministry degree from Garrett Evangelical Theological Seminary, Evanston , IL in Pastoral Counseling/Psychotherapy. In 1998 he received the VA Secretary’s National Award for Excellency in Chaplaincy. He and his wife Tina have been married for 26 years. They have four children, Sarah 25, Leah, 24, Cynthia, 22, and Jack, 20.
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