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May 2023 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA


Campbell, D., Robison, J. G. and Godsey, J. A. "Standardized spiritual screening increases chaplain referrals through the EMR: a nurse-chaplain collaboration for holistic acute healthcare." Journal of Holistic Nursing 41, no. 1 (March 2023): 30-39.

SUMMARY and COMMENT: This month's article was chosen especially for students and clinical chaplains new to the prospect of conducting research. It shows how a busy chaplain took a research-minded approach to addressing an issue for his department, developing a study in partnership with allied professionals. This project was undertaken in 2008 [--see Related Items of Interest, §I, below], so it does not take into account the important research on spiritual screening that has been done in more recent years, but the results are still worth consideration, particularly as they represent how a hospital found an effective means not only to increase dramatically the number of patient referrals to chaplains but to "streamline the referral process and [make] the management of referrals throughout the hospital timelier and more efficient" [p. 37]. Perhaps more importantly, though, like many of our Articles-of-the-Month, this one suggests an empirical process that transcends the immediate results and that should help many chaplains envision how they might take action on their own questions and problems, regarding spiritual screening and beyond, through a scientifically grounded method.

To highlight the authors' process, this reader would like to break it down by steps, offering a comment on each.

STEP 1: The authors used the occasion of a change of practice at the hospital -- in this case, the transition from paper charting to an Electronic Medical Record -- to think about areas for possible improvement. A nurse-chaplain team noted that the only spiritual screening tool at their institution was a single question to patients upon admission about a desire to see a chaplain. "Both nurses and chaplains found this single screening question to be ineffective since the patient's answer to the screening question did not provide enough meaningful information for the responding chaplain to understand or prioritize the spiritual need or issue" [p. 33]. A second area identified was a "lack of a formal process for automatically generating referrals to Pastoral Services so spiritual needs could be promptly reported and appropriately addressed" [p. 33]. COMMENT: Any plan of change in a hospital's structures or procedures creates opportunities for empirical assessment and investigation, usually in a quest for greater effectiveness/efficiency on some level. The identification of problems is often rooted in practical experience, and chaplains may well be aware of inefficiencies in their workflows, but mobilizing a project and institutional support for a corrective course can be easiest when done as part of a larger institutional program for innovation. Here, reevaluating the single screening question led to the issue of referrals, as the chaplain recognized how Pastoral Services received requests with insufficient information in order to triage calls. Their project aimed to increase both the provision of effective spiritual care and the efficiency of Pastoral Services in providing that care.

STEP 2: A newly formed Spiritual Research and Development Committee (SRDC), "consist[ing] of an interprofessional team of chaplains, nurses, physicians, information technologists (IT), and a Family Advisory Committee member," was operationalized "to create, implement, and evaluate a concise electronic spiritual screening instrument, completed by nursing staff, which could simultaneously generate a referral to the Pastoral Services Department" [p. 33]. COMMENT: Changes in hospitals can also be a chance for institutional networking and for various departments to consider their interdisciplinary collaboration. In the present instance, the common partnership between chaplains and nurses was reinforced by the spiritual screening project. In the course of the project, other departments like Information Technology were drawn in as well. And, this was done by the creation of a formal, working committee that would have the potential to lay a foundation for additional departmental projects by being a collection of stakeholders and experts.

STEP 3: A review of the spirituality and health research literature was done to discover a "concise spiritual screening tool" [p. 33] that could be implemented. However, at the time [in 2008], this review turned up no published studies that seemed to fit the needs of the hospital. Therefore, the "interprofessional initiative was [begun] to: (1) create a standardized, electronic, evidence-based instrument to be housed within the EMR for spiritual screening conducted by nurses at the time of patient admission, (2) create an electronic screening process to be used by nurses to automatically generate referrals for chaplaincy visits at the time of patient admission, as indicated or requested, and (3) increase the overall number of patients receiving chaplain referrals in the acute care setting" [p. 33]. COMMENT: A literature review is an essential step in any research project, in order to capitalize upon what has already been done on a question and to recognize gaps in the knowledge base that would implicitly call for investigation and give invitation for future publication. The goal for the SRDC was not to conduct research, but rather research was the means for accomplishing its practical goals, consistent with the culture of empiricism in healthcare, whereby work processes are assessed, sanctioned, and continually improved. A good literature review can make a chaplaincy project stand out and guide it toward a significant outcome.

STEP 4: Finding no ready answer in the literature to their screening concerns, the researchers then drew upon the wisdom of related literature about assessment and history-taking, looking especially at three instruments: HOPE (Anandarajah & Hight), FAITH (King), SPIRIT (Maugans), and FICA (Puchalski). "After carefully reviewing these four instruments, SRDC members identified ten questions they felt could be the most relevant for translation into a spiritual screening instrument" [p. 34, and see Table 1 on p. 35 for the list of all questions]. COMMENT: When a literature review does not yield ready solutions to a question or issue, it can still become a good source for a project's advancement. The authors distinguished "screenings" from "assessments" and "histories," but the closeness of the conceptualizations suggested how the latter two might inform a plan focused on the principal idea. At this juncture, SRDC members became a kind of panel of experts to channel the value of published work on assessments and histories into an actionable list of candidate questions that could be refined through a patient survey. Research is typically a creative combination of advance planning and step-by-step exploration.

STEP 5: The ten candidate questions were then rolled into a survey for patients, and the principal investigator sought and received approval from the hospital's Institutional Review Board (IRB) as well as all parties who would have vested interests (i.e., the Director of Pastoral Services, Medical Chief of Geriatric Services, Chief Nursing Officer, and Professional Practice Council). The survey asked patients [--see p. 34]:

  •  Review each of the 10 question options and choose the top three (rank) that could help best prioritize your spiritual needs and guide your healthcare.
  •  Evaluate (rate) how helpful or meaningful each of the 10 spirituality screening questions are in identifying or communicating your unique spiritual needs (0-4 Likert scale).
  •  Include any additional questions not found on the screening tool which could have been useful in identifying your spiritual needs.
COMMENT: Instrument development can be labor intensive, but the next logical step for the SRDC was to create a patient survey. In order to do that in a hospital setting, where most patients are not there to be subjects of spirituality research, requires buy-in from the IRB, various administrators, and others with interests in the people who would comprise the study sample, in order to be good, ethical stewards of patients' willingness and efforts to participate. Having patients weigh in on ten screening questions would seem a manageable but not insignificant commitment of time and energy for sick individuals, but their input on this project was crucial to the end product being best suited to real-world use.

STEP 6: "A total of 101 patients from medical-surgical or step-down units were interviewed by investigators. No data was collected from any patient who declined study participation" [p. 36]. Some demographic data on the sample was also collected (i.e., gender, ethnic background, religious background, and marital status). "A PhD-prepared nurse researcher and two graduate assistants analyzed survey findings" [p. 35]. COMMENT: As a function of research ethics, the rights of vulnerable patients must be protected, and so the authors emphasize here that any information from people who refused to participate was not used. Also, specifically qualified researchers were engaged to ensure the quality of the analysis of the data that patients provided. The number of participants (101), is a reasonable sample size for the degree of generalization sought for a single hospital project, but the authors do recognize that this number would be "small" [p. 37] for claims of broader generalization and note this as a limitation to the study. What demographic information to collect is always an issue, because demographic questions can swell the overall survey and stretch patients' experience of participation.

STEP 7: "The SRDC reviewed survey results and narrowed the options from the 10 questions described on the survey tool down to the four spiritual screening questions study participants had acknowledged were the most meaningful for identifying their spiritual needs. The SRDC made slight modifications to these four questions so each could be concisely displayed in the EMR without losing the questions' major components" [p. 35]. In this step, two screening questions that were recommended by the study participants were excluded for being "too qualitative in nature," such that they would "make the tool less concise and difficult to standardize in the EMR" [p. 35]. The excluded questions were: "What is there in your life that gives you internal support, or what sustains you and keeps you going?" and "Is this environment welcoming to your cultural, religious, or spiritual beliefs? If not, what can we do?" COMMENT: The SRDC again takes the role of a panel of experts to parlay the study results into a brief screening tool to be incorporated into the EMR. This step of fine-tuning must be done with caution to protect the empirical integrity of the survey findings. Moreover, it is not uncommon for some results to be judged to be more valuable to the goals of the project than others. In this case, two recommended questions were omitted from the final screening tool, though the SRDC did not dismiss their overall value. "The decision was made for the essence of these questions to be addressed, in person, by the chaplain during the time of his/her initial patient visit" [p. 36].

STEP 8: Information Technology staff integrated the four questions into the EMR, with referrals automatically generated to Pastoral Care. The questions:

  1.  Do your spiritual/religious/cultural beliefs act as a source of comfort and strength and help you cope with a crisis?
  2.  Do you have any spiritual/religious/cultural practices and/or customs that can better help us take care of you?
  3.  Do you have any spiritual/religious/cultural requests or concerns at this time that we can help you with?
  4.  Would you like us to contact your clergy?
COMMENT: The final questions needed to be added to the computer process used by nurses, and this required the work of technology specialists who not only had to add the questions to the EMR but figure out the technical mechanism by which patient data would trigger referrals and could be tracked for summary evaluation of the project. Of course, nurses would need to be educated on using the new screening, and chaplains would need to know how to work with the new referral process.

STEP 9: Subsequent analysis of the data collected by Pastoral Services indicated that, following the implementation of the Standardized Spiritual Screening and Referral program, the number of referrals increased 149% between 2011 and 2012 (from 1305 to 3245) and 689% over the period 2011-2019 (from 1305 to 10,294 annually). To complement this success on the referral font, the researchers looked toward another project for the psychometric analysis of the instrument, to test the validity of the questions. COMMENT: The numbers indicate success for the project, and "engaging patients as a source of data during instrument design helps to ensure the content validity and practical usefulness of an instrument" [p. 37]. However, the authors note that the screening questions still warranted further study for psychometric analysis in order to be most sure of their validity. Valuable research, it might be said, leads to increasingly valuable research.

The break-down of the steps in the project suggests how even a relatively straightforward hospital research initiative can entail a great deal of work, but an underlying message here is that the project was feasible for a busy clinical chaplain when he was able to partner with an interdisciplinary team. In a private communication from the principal author, Chaplain Duane Campbell related that the reason there was a delay in publication was because of the challenge of finding the time necessary for that trans-clinical (and often quite time-consuming) further step. Actually, the success of the project led to such an increase in referrals that Pastoral Services at the hospital had to increase its staff (per diem and volunteer) of chaplains in order to keep up. The authors give some emphasis to the role of the Joint Commission on Accreditation of Healthcare Organizations in promoting "spiritual assessment" [pp. 31-32], but they do not report how the success of the screening project may have played into later Joint Commission surveys [--and see Related Items of Interest, §VI, below] or other effects of the project's implementation.

This reader would have preferred the text of the finally-published article to have contextualized the original work in light of research that has been done since 2008, but the report is an interesting contribution to the literature and is worth the attention of chaplains rethinking their institutions' mechanisms for spiritual screening and referral. The questions developed for the EMS are notable, but the project's basic idea of generating instruments with the help of feedback from the hospital's own patients may be a model for customizing a spiritual screen to the setting of an institution.

Our Articles-of-the-Month primarily highlight very recent studies, almost all works having been published in the past month or two and many being featured ahead-of-print. This month's selection, newly published but from a much earlier date, speaks to the potential value of older works. We tend to read research for the latest thinking on a subject, but the power of the empirical results of any study begins to fade even before publication, particularly in the Social Sciences. What is enduringly important about research articles is the way they describe how researchers sought to tackle a question or problem --and the ingenuity and wisdom and passion they brought to their venture, which can guide and inspire readers for future investigations. It is for this reason that the full twenty-year catalog of Article-of-the-Month features is available to chaplains.


Suggestions for Use of the Article for Student Discussion: 

Discussion could begin with a consideration of how spiritual screening, assessment, and history-taking may be different yet related. Are students clear about the idea of screening? Then, perhaps the group could look at the original ten candidate questions [--see the left-hand column of Table 1, p. 35] and everyone could offer thoughts on which items might be the best screens. Does the group's opinion match with the results of the patient survey? The "old" screen at the hospital asked, "Do you want to see a chaplain?" [p. 33], but none of the project's four final screening questions explicitly mention a chaplain. Should they? Also, how does the group feel generally about the procedure by which nurses would conduct a standardized spiritual screen that would then generate a referral for a chaplain? If the group is open to more personal sharing, discussion could venture into whether anyone has ever been a patient and personally experienced a spiritual screening from that angle? What initial and ongoing opportunities were there during the hospitalization for spiritual needs to be expressed and/or spiritual support to be requested? Finally, would the members of the group want to invest the time and effort to pursue a chaplaincy-related issue like spiritual screening through a research-informed process, or do they believe they would probably just think about the issue and move ahead with their own ideas as a matter of expediency? What do they see as the value of a step-by-step process like the one described in the article?


Related Items of Interest:

I.  The 2008 date for the commencement of this project is not stated in the article but was noted in a personal communication with this editor from principal author Chaplain Duane Campbell, in response to a question about the original literature search. Interestingly, it was right after 2008 that spiritual screening began to emerge as a notable topic in the literature, and there has of course been important research in this area since that time which is not considered in the present article. Most prominent among subsequent studies (but note especially the study by King, et al.):

Bahraini, S., Gifford, W., Graham, I. D., Wazni, L., Bremault-Phillips, S., Hackbusch, R., Demers, C. and Egan, M. "The accuracy of measures in screening adults for spiritual suffering in health care settings: a systematic review." Palliative and Supportive Care 18, no. 1 (February 2020): 89-102 [(Abstract:) OBJECTIVE: Guidelines for palliative and spiritual care emphasize the importance of screening patients for spiritual suffering. The aim of this review was to synthesize the research evidence of the accuracy of measures used to screen adults for spiritual suffering. METHODS: A systematic review of the literature. We searched five scientific databases to identify relevant articles. Two independent reviewers screened, extracted data, and assessed study methodological quality. RESULTS: We identified five articles that yielded information on 24 spiritual screening measures. Among all identified measures, the two-item Meaning/Joy & Self-Described Struggle has the highest sensitivity (82-87%), and the revised Rush protocol had the highest specificity (81-90%). The methodological quality of all included studies was low. SIGNIFICANCE OF RESULTS: While most of the identified spiritual screening measures are brief (comprised 1 to 12 items), few had sufficient accuracy to effectively screen patients for spiritual suffering. We advise clinicians to use their critical appraisal skills and clinical judgment when selecting and using any of the identified measures to screen for spiritual suffering.] [This was our August 2019 Article-of-the-Month, featured ahead-of-print.]

Blanchard, J. H., Dunlap, D. A. and Fitchett, G. "Screening for spiritual distress in the oncology inpatient: a quality improvement pilot project between nurses and chaplains." Journal of Nursing Management 20, no. 8 (December 2012): 1076-1084. [(Abstract:) AIMS: A quality improvement initiative of nursing/chaplain collaboration on the early identification and referral of oncology patients at risk of spiritual distress. BACKGROUND: Research shows that spiritual distress may compromise patient health outcomes. These patients are often under-identified, and chaplaincy staffing is not sufficient to assess every patient. The current nursing admission form with a question of 'Any spiritual practices that may affect your care?' is ineffective in screening for spiritual distress. METHOD(S): Ten nurses on the oncology unit were recruited and trained in a two-question screening tool to be utilized upon admission. RESULTS: Six nurses made referrals; a total of 14 patients. Four (28%) were at risk of spiritual distress and were assessed by the chaplains. CONCLUSIONS: Nurses are interested in the spiritual well-being of their patients and observe spiritual distress. They appreciate terminology/procedures by which they can assess more productively the spiritual needs of their patients and make appropriate chaplain referrals. IMPLICATIONS FOR NURSING MANAGEMENT: The use of a brief spiritual screening protocol can improve nursing referrals to chaplains. The better utilization of chaplains that this enables can improve patient trust and satisfaction with their overall care and potentially reduce the harmful effects of spiritual distress.] [This was our January 2013 Article-of-the-Month.]

Fitchett, G., Murphy, P. and King, S. D. W. [Rush University Medical Center, Chicago, IL; and Seattle Cancer Care Alliance, WA]. "Examining the validity of the Rush Protocol to screen for religious/spiritual struggle." Journal of Health Care Chaplaincy 23, no. 3 (July-September 2017): 98-112. [(Abstract:) Effective deployment of limited spiritual care resources requires valid and reliable methods of screening that can be used by nonchaplain health care professionals to identify and refer patients with potential religious/spiritual (R/S) need. Research regarding the validity of existing approaches to R/S screening is limited. In a sample of 1,399 hematopoietic stem cell transplant survivors, we tested the validity of the Rush Protocol and two alternative versions of it. The negative religious coping subscale of the Brief RCOPE provided the reference standard. Based on the Protocol, 21.9% of the survivors were identified as having potential R/S struggle. The sensitivity of the Protocol was low (42.1%) and the specificity was marginally acceptable (81.3%). The sensitivity and specificity of the two alternative versions were similar to those for the unmodified Protocol. Further research with the Rush Protocol, and other models, should be pursued to develop the best evidence-based approaches to R/S screening.]

Grossoehme, D. H. "Development of a spiritual screening tool for children and adolescents." Journal of Pastoral Care and Counseling 62, nos. 1-2 (Spring-Summer 2008): 71-85. [(Abstract:) A chaplain's ability to provide care where it is most needed depends upon some method of pastoral triage. Screening for spiritual needs of children and adolescents has been a largely neglected area. A Delphi panel developed elements to be included in a tool to screen 10-18 year olds' spiritual needs and resources. The Delphi panelists were informed of survey results of school-aged children and adolescents' opinions on spiritual issues important to them if they were hospitalized. A case study of the tool's use was conducted with a convenient sample of children and adolescents. Subsequent pilot use of the tool by five pediatric chaplains demonstrated the tool's utility in identifying patients' spiritual issues, ability to serve as a springboard to deeper discussion, and as a basis for initiating discussion of spiritual concerns with other disciplines on the healthcare team. Feedback indicates the potential clinical usefulness of this tool for hospitalized children and adolescents.]

Grossoehme, D. H., Teeters, A., Jelinek, S., Dimitriou, S. M. and Conard, L. A. "Screening for spiritual struggle in an adolescent transgender clinic: feasibility and acceptability." Journal of Health Care Chaplaincy 22, no. 2 (2016): 54-66. [(Abstract:) Spiritual struggles are associated with poorer health outcomes, including depression, which has higher prevalence among transgender individuals than the general population. This study's objective was to improve the quality of care in an outpatient transgender clinic by screening patients and caregivers for spiritual struggle and future intervention. The quality improvement questions addressed were whether screening for spiritual struggle was feasible and acceptable; and whether the sensitivity and specificity of the Rush Protocol were acceptable. Revision of the screening was based on cognitive interviews with the 115 adolescents and caregivers who were screened. Prevalence of spiritual struggle was 38-47%. Compared to the Negative R-COPE, the Rush Protocol screener had sensitivities of 44-80% and specificities of 60-74%. The Rush Protocol was acceptable to adolescents seen in a transgender clinic, caregivers, and clinic staff; was feasible to deliver during outpatient clinic visits, and offers a straightforward means of identifying transgender persons and caregivers experiencing spiritual struggle.]

King, S. D. W., Fitchett, G., Murphy, P. E., Pargament, K. I., Harrison, D. A. and Loggers, E. T. "Determining best methods to screen for religious/spiritual distress." Supportive Care in Cancer 25, no. 2 (February 2017): 471-479. [(Abstract:) PURPOSE: This study sought to validate for the first time a brief screening measure for religious/spiritual (R/S) distress given the Commission on Cancer's mandated screening for psychosocial distress including spiritual distress. METHODS: Data were collected in conjunction with an annual survey of adult hematopoietic cell transplantation (HCT) survivors. Six R/S distress screeners were compared to the Brief RCOPE, Negative Religious Coping subscale as the reference standard. We pre-specified validity as a sensitivity score of at least 85 %. As no individual measure attained this, two post hoc analyses were conducted: analysis of participants within 2 years of transplantation and of a simultaneous pairing of items. Data were analyzed from 1449 respondents whose time since HCT was 6 months to 40 years. RESULTS: For the various single-item screening protocols, sensitivity ranged from 27 (spiritual/religious concerns) to 60 % (meaning/joy) in the full sample and 25 (spiritual/religious concerns) to 65 % (meaning/joy) in a subsample of those within 2 years of HCT. The paired items of low meaning/joy and self-described R/S struggle attained a net sensitivity of 82 % in the full sample and of 87 % in those within 2 years of HCT but with low net specificities. CONCLUSIONS: While no single-item screener was acceptable using our pre-specified sensitivity value of 85 %, the simultaneous use of meaning/joy and self-described struggle items among cancer survivors is currently the best choice to briefly screen for R/S distress. Future research should validate this and other approaches in active treatment cancer patients and survivors and determine the best times to screen.] [This was our November 2016 Article-of-the-Month, featured ahead-of-print.]

Kopacz, M., Bishop, T. M., Ayre, A., Boska, R. L., Goldstrom, D., Tomberlin, D., Baxter, S., Dunlap, S. and Harris, J. I. "Feasibility of using moral injury screening instruments in VA chaplaincy spiritual assessments." Journal of Health Care Chaplaincy 28 (2022, Suppl. 1): S89-S100. [(Abstract:) Some veterans experience symptoms of moral injury after being exposed to the ethical and moral challenges associated with military service. While it is well known that moral injury is associated with an increased risk for suicide as well as other mental health concerns, few tools exist to systematically screen for moral injury in chaplaincy settings. This preliminary study examines the psychometric properties as well as feasibility of applying two new moral injury screening tools that could be used with routine spiritual assessments, purposefully designed to assess for moral injury in chaplaincy settings at Department of Veterans Affairs (VA) Medical Centers. The results provide preliminary psychometric evidence to support the reliability and validity of these two new screening tools, which were shown to be feasible for use in VA chaplaincy settings.]


II.  The following review considers spiritual screening in light of assessment and history-taking and in the larger context of clinical intervention. See especially pp. 442-445.

Balboni, T. A., Fitchett, G., Handzo, G. F., Johnson, K. S., Koenig, H. G., Pargament, K. I., Puchalski, C. M., Sinclair, S., Taylor, E. J. and Steinhauser, K. E. "State of the science of spirituality and palliative care research part II: screening, assessment, and interventions." Journal of Pain and Symptom Management 53, no. 3 (September 2017): 441-453. [(Abstract:) The State of the Science in Spirituality and Palliative Care was convened to address the current landscape of research at the intersection of spirituality and palliative care and to identify critical next steps to advance this field of inquiry. Part II of the SOS-SPC report addresses the state of extant research and identifies critical research priorities pertaining to the following questions: 1) How do we assess spirituality? 2) How do we intervene on spirituality in palliative care? And 3) How do we train health professionals to address spirituality in palliative care? Findings from this report point to the need for screening and assessment tools that are rigorously developed, clinically relevant, and adapted to a diversity of clinical and cultural settings. Chaplaincy research is needed to form professional spiritual care provision in a variety of settings, and outcomes assessed to ascertain impact on key patient, family, and clinical staff outcomes. Intervention research requires rigorous conceptualization and assessments. Intervention development must be attentive to clinical feasibility, incorporate perspectives and needs of patients, families, and clinicians, and be targeted to diverse populations with spiritual needs. Finally, spiritual care competencies for various clinical care team members should be refined. Reflecting those competencies, training curricula and evaluation tools should be developed, and the impact of education on patient, family, and clinician outcomes should be systematically assessed.] [NOTE: This article is the second half of a two-part review, the first being: Steinhauser, K. E., Fitchett, G., Handzo, G. F., Johnson, K. S., Koenig, H. G., Pargament, K. I., Puchalski, C. M., Sinclair, S., Taylor, E. J. and Balboni, T. A., "State of the science of spirituality and palliative care research part I: definitions, measurement, and outcomes," Journal of Pain and Symptom Management 53, no. 3 (September 2017): 428-440.]


III.  Assessments or histories whose elements were used in this month's study to generate items for the spiritual screening were:

HOPE [--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]
- H:   Sources of hope, meaning, comfort, strength, peace, love and connection
- O:   Organized religion
- P:   Personal spirituality and practices
- E:   Effects on medical care and end-of-life issues

FAITH [--see: King, D. E., "Spirituality and medicine," in M. B. Mengel, W. L. Holleman, & S. A. Fields (Eds.), Fundamentals of clinical practice: A textbook on the patient, doctor, and society, pp. 651-669; New York: Plenum, 2002]
- F:   Do you have a Faith or religion that is important to you?
- A:   How do your beliefs Apply to your health?
- I:   Are you Involved in a church or faith community?
- T:   How do your spiritual views affect your views about Treatment
- H:   How can I Help you with any spiritual concerns?

SPIRIT [--see: Maugans, T. A., "The SPIRITual history," Archives of Family Medicine 5, no. 1 (January 1996): 11-16]
- S:   Spiritual belief system
- P:   Personal spirituality
- I:   Integration with a spiritual community
- R:   Rituals and restrictions spirituality requires for health care
- I:   Implications of spirituality and religion for me
- T:   Terminal events planning (end-of-life issues)

FICA [--see: 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]
- F:   Faith, Belief, Meaning
- I:   Importance and Influence of religious and spiritual beliefs and practices to the individual
- C:   Community or Church connections
- A:   Address/Action in the context of medical care


IV.  Nurse-chaplain collaboration was key to the project that led to this month's study. For more on that topic, see:

Taylor, E. J. and Li, A. H. "Healthcare chaplains' perspectives on nurse-chaplain collaboration: an online survey." Journal of Religion and Health 59, no. 2 (April 2020): 625-638. [Among the findings of this online survey of members of the Association of Professional Chaplains were that just over half of the chaplains wanted nurses to conduct a spiritual screening and to inquire whether patients wished a visit from a chaplain, that chaplains who are stationed on a specific unit were more positive the spiritual screenings/histories by nurses on that unit, compared to chaplains who worked throughout a hospital.] [This was our January 2020 Article-of-the-Month, featured ahead-of-print.]


V.  It took years before this month's study made it into print, but at least it has been published. Many studies never get published and thus compound the File Drawer Problem, sometimes called the File Drawer Effect. The term was coined by Harvard psychologist Robert Rosenthal in the 1979 article, "The 'File Drawer Problem' and tolerance for null results," Psychological Bulletin 86, no. 3, pp. 638-664 [available online]. The problem refers to how the research literature presents a selective and skewed representation of total numbers of studies on a particular topic, because many never make it out of researchers' file drawers. This is especially the case for studies that do not confirm the researchers' hypotheses, but publication can be delayed (as in our current article) or never achieved for many reasons. For more on this, see the following recent article:

Lishner, D. A. "Sorting the file drawer: a typology for describing unpublished studies." Perspectives on Psychological Science: A Journal of the Association for Psychological Science 17, no. 1 (2022): 252-269. [(Abstract:) A typology of unpublished studies is presented to describe various types of unpublished studies and the reasons for their nonpublication. Reasons for nonpublication are classified by whether they stem from an awareness of the study results (result-dependent reasons) or not (result-independent reasons) and whether the reasons affect the publication decisions of individual researchers or reviewers/editors. I argue that result-independent reasons for nonpublication are less likely to introduce motivated reasoning into the publication decision process than are result-dependent reasons. I also argue that some reasons for nonpublication would produce beneficial as opposed to problematic publication bias. The typology of unpublished studies provides a descriptive scheme that can facilitate understanding of the population of study results across the field of psychology, within subdisciplines of psychology, or within specific psychology research domains. The typology also offers insight into different publication biases and research-dissemination practices and can guide individual researchers in organizing their own file drawers of unpublished studies.]


VI.  This month's article states, "The Joint Commission on Accreditation of Healthcare Organizations (TJC), the largest healthcare accrediting body in the United States, requires the administration of a spiritual assessment" [p. 32], but the reality of Joint Commission standards for acute care hospitals has not been quite so categorically clear. In 2008/2009 there were standards that specifically called for religious/spiritual assessments for patients at the end of life, patients in treatment for alcoholism and substance use, and patients receiving treatment for emotional and behavioral disorders, and curiously there was one standard that explicitly mentioned religious beliefs in relation to a required assessment of patients' learning needs. Beyond that, the standards are generally concerned with hospitals' respect for patients rights that may or may not involve religion/spirituality. [See a summary chart of the 2008 and 2009 standards.] For 2023, the standards require even less with regard to an assessment. [See a summary of the 2023 standards.]