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August 2010 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Borneman, T., Ferrell, B. and Puchalski, C. M. "Evaluation of the FICA tool for spiritual assessment." Journal of Pain and Symptom Management 40, no. 2 (August 2010): 163-173.


SUMMARY and COMMENT: For over a decade, the FICA assessment has been a well-cited strategy for taking a patient's spiritual history, having been developed by Christina Puchalski in the latter 1990s and formally published in an article in the Journal of Palliative Medicine in 2000 [--see Related Items of Interest, §I, below]. It continues to be promoted widely in the health care literature and through the George Washington Institute for Spirituality and Health (, of which Dr. Puchalski is Founder and Executive Director. However, this instrument was not created directly from or for research, but rather as a clinical guide based upon physician experience. The popularity of FICA has thus preceded its scientific validation. The present article reports a "descriptive pilot provide preliminary clinical evaluation of [its] feasibility and usefulness" [p. 165].

This research involved 76 cancer outpatients who were enrolled in a larger study (on reducing barriers to pain and fatigue management among cancer patients). Participants were asked the open-ended FICA questions and then an additional quantitative question -- i.e., "On a scale of 0 (not important) to 5 (very important), how would you rate the importance of faith/belief in your life?" [p. 167] -- was posed as part of the FICA interview. This quantitative item was subsequently analyzed in light of items from a version of the City of Hope Quality of Life survey (which was part of the parent study), and responses to the open-ended questions were examined qualitatively to identify relevant themes.

Quantitative data are presented in an Inter-Item Correlation Matrix with items from the Quality of Life survey [Table 3, p. 169]. The result, in sum, is that "…the FICA tool was able to assess several dimensions of spirituality based on correlation with the spirituality indicators in the Cityof Hope-QOL tool, specifically spiritual activities, change in spirituality, positive life change, purpose, and hopefulness" [p. 168].

Qualitative data are summarized in four tables [--see pp. 170, 171, and 172] that list the main themes in the responses to each of the four sections of the FICA assessment. This thematic analysis "reveal[s] the depth and breadth of spirituality, and the many opportunities for addressing [a] patient's search for meaning, faith, hope, and relationships at the end of life" [pp. 170-171].

Faith/Belief/Meaning Themes (with an incidence range of 47-5 times total in the interviews*)

  • Appreciation of life and family
  • Life activities (work sense of purpose, friends, accomplishments, self-sufficiency, and productivity)
  • Faith or hope in healing or in a higher being
  • Relationship with God or serving God
  • Appreciation for everything in life
  • Reading Bible
  • No identified faith tradition or agnostic
  • Positive state of mind

Importance and Influence Theme (with an incidence range of 56-5 times total in the interviews*)

  • Faith is important or very important
  • Faith helps control stress
  • Prayer/faith as factor in treatment decisions
  • Faith equips in preparing/fighting/coping illness
  • Faith is not important/minimal importance
  • Faith helps make meaning
  • God is in control/does not give ‘‘more than we can handle’’

Community Key Themes (with an incidence range of 49-5 times total in the interviews*)

  • Family/friends
  • Church
  • Prayer
  • Does not identify with a community

Address in Care Themes (with an incidence range of 15-5 times total in the interviews*)

  • Not necessary
  • Be supportive
  • Unsure
  • Should be addressed
  • Provider should do what they believe is best
  • Chaplain availability
  • Provider should not be involved

*Consult the article for the particular incidence counts of these themes and for representative quotes.

This evaluation supports the value of FICA for spiritual assessment by "nonchaplains" [p. 165], but chaplains may also see in this tool a systematic "framework" [p. 170] that could be flexible enough for use in relation to pastoral conversation. The authors here do not specifically address pastoral practice, but they do express concerns shared by many chaplains:
Because spiritual care is important to the patient’s health and a necessary domain of quality care, this aspect of care also will be essential to demonstrate efficiency and effectiveness of care. This presents a challenge to the whole ethos of spiritual care "because as spirituality becomes rationalized and reduced to make it manageable, it begins to lose the subjective and specific human experience, which makes it significant." ...[A spiritual history] approach would allow the patient to share his/her spirituality or religion and would provide a means for obtaining measurable outcomes. [p. 164; the embedded quotation is from Cobb, M., "Assessing spiritual needs: an examination of practice," in Cobb, M. and Robshaw, V., eds., The Spiritual Challenge of Health Care (Edinburgh, UK: Churchill Livingston, 1998): 105-116.]
As work continues among physicians and nurses to evaluate FICA as an approach to "spiritual assessment and intervention" [p. 171], chaplain researchers might engage in their own study of it from a pastoral perspective, to explore its potential as an interdisciplinary means of gathering and organizing health care-relevant spiritual information.

One final note: The FICA tool used in the current research added a quantitative item, and the authors state that they "believe that having both qualitative and quantitative measures of spirituality was very beneficial and would be important in future research" [p. 168]. One area of further investigation might focus on the effect of the interjection of such a quantitative measure on the patient's experience of a discussion of spirituality otherwise marked by open-ended questions. Does a quantitative item tend to shift or shape the nature of the patient's sharing? Note that the researchers for this study chose to introduce the quantitative item after the open-ended items, even though it appears integrated into the middle of the FICA template [p. 166]. Chaplain researchers have long had a general interest in the effect of quantitative questions on pastoral interaction.


Suggestions for the Use of the Article for Discussion in CPE: 

The FICA tool is nicely laid out on p. 166 of the article, and students should read and take it for the personal experience (--in fact, even offers a self-assessment version, but it does not include the sub-section items found in the article). Discussion could consider how this assessment might play out as part of pastoral practice: Could students fill in a FICA tool after a typical pastoral conversation with a patient? What might be left out? Also, the tables summarizing qualitative data [--see pp. 170, 171 and 172] are worth examining closely. How do the illustrative quotes given there ring to chaplains' ears? This article could obviously provide an entrée to the broad subject of spiritual assessment. What is the role of a spiritual history in the practice of assessment? What are the differences between instruments used primarily for research, those developed for use by nonchaplains in clinical settings [--see a listing in the text on p. 165], and those published precisely for use by chaplains and spiritual counselors? Finally, how might a tool like FICA be valuable to referral processes? Note that "chaplain availability" is an identified theme in Table 7 [p. 172].


Related Items of Interest:

I. The FICA assessment was first widely published in: Puchalski, C. and Romer, A. L., "Taking a spiritual history allows clinicians to understand patients more fully," Journal of Palliative Medicine 3, no. 1 (2000): 129-137. This article is in the form of an interview with Dr. Puchalski. The FICA tool is given on p. 131, with the specific wording being somewhat different on most items from that of the version used in our featured article Article-of-the-Month. The tool also is available online from the GWish.


II. Our authors cite two other tools besides FICA that are suited for clinical use by nonchaplains [p. 165]: HOPE and SPIRIT (or SPIRITual History). To read more about these, see:

Anandarajah, G. and Hight, E. "Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment." American Family Physician 63, no. 1 (January 1, 2001): 81-89. [The article addresses the subject of spiritual assessment in general and explains the four components of the particular instrument: H -- Sources of hope, meaning, comfort, strength, peace, love and connection, O -- Organized religion, P -- Personal spirituality and practices, and E -- Effects on medical care and end-of-life issues.]

Maugans, T. A. "The SPIRITual history." Archives of Family Medicine 5, no. 1 (January 1996): 11-16. [The six-item tool (S -- Spiritual Belief System, P -- Personal Spirituality, I -- Integration with a Spiritual Community, R -- Ritualized Practices and Restrictions, I -- Implications for Medical Care, and T -- Terminal Events Planning) is given on p. 12, with sample questions for each item. Narrative explanations of the categories are given on pp, 12-14, along with guidance about interviews on p. 14.]

[Added 11/16/15:] Puchalski, C. M. "Formal and informal spiritual assessment." Asian Pacific Journal of Cancer Prevention: Apjcp 11, Suppl. 1 (2010): 51-7. [This article places formal spiritual history tools (e.g., FICA, HOPE, SPIRIT) in a broad context of assessment.]


III. For more on spiritual assessment formats in general, see: VandeCreek, L., "Spiritual assessment: six questions and an annotated bibliography of published interview and questionnaire formats," Chaplaincy Today 21, no. 1 (Spring/Summer 2005): 11-22. The author's annotated bibliography (pp. 16-22) lists key articles/instruments by year for both clinically-oriented formats and research-oriented formats.


IV. For more on the City of Hope Quality of Life measure, see the City of Hope Pain & Palliative Care Resource Center web page at, including the Quality-of-Life Cancer Survivor Instrument (PDF).


V. The following article describes and compares 25 spiritual history tools.

[Added 11/16/15:] Lucchetti, G., Bassi, R. M. and Granero Lucchetti, A. L. "Taking Spiritual History in Clinical Practice: A Systematic Review of Instruments." Explore: The Journal of Science and Healing 9, no. 3 (May/June 2013): 159-170. [(Abstract:) Background: To facilitate the addressing of spirituality in clinical practice, several authors have created instruments for obtaining a spiritual history. However, in only a few studies have authors compared these instruments. The aim of this study was to compare the most commonly used instruments for taking a spiritual history in a clinical setting. Methods: A systematic review of spiritual history assessment was conducted in five stages: identification of instruments used in the literature (databases searching); relevant articles from title and initial abstract review; exclusion and Inclusion criteria; full text retrieval and final analysis of each instrument. Results: A total of 2,641 articles were retrieved and after the analysis, 25 instruments were included. The authors independently evaluated each instrument on 16 different aspects. The instruments with the greatest scores in the final analysis were FICA, SPIRITual History, FAITH, HOPE, and the Royal College of Psychiatrists. Concerning all 25 instruments, 20 of 25 inquire about the influence of spirituality on a person's life and 17 address religious coping. Nevertheless, only four inquire about medical practices not allowed, six deal with terminal events, nine have mnemonics to facilitate their use, and five were validated. Conclusions: FICA, SPIRITual History, FAITH, HOPE, and Royal College of Psychiatrists scored higher in our analysis. The use of each instrument must be individualized, according to the professional reality, time available, patient profile, and settings.]



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