Funding:
Funding for this project provided by Supportive Care Coalition: Pursuing Excellence in Palliative Care, the Catholic Health Association of the United States, and a continuation grant from the research “Spirituality in Health and Healing,” Sr. Diana Bader, OP, PhD, principal investigator.

Acknowledgements:
Special thanks to the retreat faculty, pilot sites, project teams and patients who participated in this initiative and without whom this work would not have been possible.

ABSTRACT

Objective of Study
This descriptive pilot study was designed to demonstrate the positive benefits of  addressing spiritual concerns during daily  care of patients. The study was conducted  in five faith-based hospitals and two secular  hospitals. Its purposes were to foster (a)  recognition by hospital staff and administration  that spirituality is an essential component  of health care; (b) spiritual care  competencies and accountability measures;  (c) enhanced professional competencies in  compassionate presence to patients and  colleagues; (d) systematic assessment of  patient spiritual concerns; (e) integration of  chaplains as key member of the interdisciplinary  team; and (f ) enhanced team building  based on spiritual values of service to  others. 

Methods Used 
Development of education strategies, organizational  change strategies, and implementation  of spiritual screening using the  FICA tool (© Christina Puchalski, 1996)  were core to the project's success.

Leadership team members attended a  planning and educational retreat at which  they developed action plans. The principal  investigator, project coordinator, and  research team members followed up with  a structured visit to each site to lend support  to the team's action plans. Cross-site  conference calls facilitated knowledge  transfer. 

While there was variation across all  sites, common intervention strategies  included: 

• Physician and staff education on spiritual  care and spiritual assessment 
• Rituals during work shift to focus on one's  calling to the profession and on finding  meaning in the practice of the profession 
• Posting of inspirational messages 
• Sharing of positive practices and examples  of spiritual care 
• Use of symbolic reminders of the spirituality  initiative
• Posting photos of the staff to strengthen  the sense of the groups as an interdisciplinary  team working together 

Summary of Results 
Repeat quantitative measures of patient  and staff outcomes did not indicate significant  changes over the year of the project.  However, the qualitative narratives indicated  the success of this project as perceived  by team members and patients. Sites  reported a “culture change” on the work  unit. They described a more positive culture  and a stronger sense of teamwork. As  one participant said, “It's as if we have  permission to be present to spiritual issues  for ourselves and each other.” Sites shared  powerful narratives of addressing spiritual  concerns. These included being fully present  to patients' concerns; praying with  patients appropriately; taking spiritual histories;  support from the administration for  caring attitudes; and compassionate presence  for patients—not just efficiency and  an economic bottom line. 

Conclusion 
Addressing spiritual concerns in the  process of providing patient care is feasible  for all caregivers, within the current  limits of staffing and time and regardless  of the type of hospital facility.  Reintegration of the spiritual focus of care  benefits the physicians and staff providing  care (and may, therefore, be an antidote  to staff stress and burnout), improves  patients' satisfaction with care, and  increases both patients' and staff's sense  of connection and compassion.  

The Hospital-Based Spirituality Initiative:  Creating Healing Environments


INTRODUCTION

Many patients complain about the increasingly impersonal approach they encounter in hospitals and health care organizations. Individuals facing challenges in their health and well-being often turn inward to reflect on the meaning of their illness and their life, as well as to search for purpose and hope. This search for explanation, meaning, and purpose is integral to each individual, and influences the impact of illness on the patient and his or her family. This focus on what makes life meaningful leads, in turn, to a consideration of one's spirituality. Spirituality is universal to all individuals and may be viewed as the individual's continuous search for meaning and transcendence in life, especially during times of illness and pain. For some, spirituality includes religious practices; for others it may include nature, art, music, family, or community.1

Yet today's health care providers are ill-equipped to care for the spiritual dimension in patients' lives, and this is reinforced by a health care system that is frequently lacking in personalized and compassionate health care services. Indeed, today's health care system is in crisis; cost pressures affect patients and professionals alike. Increasingly, insurance limitations on reimbursements and rising malpractice costs push physicians to see more patients each day and shorten the length of their visits with patients. Hospitals, in an attempt to contain costs, have been forced to cut staff. Social workers and nurses comment that they would like to do more direct patient care, but, as a result of heavy caseloads and documentation requirements, spend a disproportionate amount of time on paperwork. Consequently, patient dissatisfaction and physician and other clinician burnout are often high.

The search for a solution to this depersonalization of health care led to the THE HOSPITAL-BASED SPIRITUALITY INITIATIVE: Creating Healing Environments, an innovative demonstration project designed to test ways of restoring the heart and humanity to health care by reintegrating an awareness of spirituality and spiritual caring into the role of each care provider. Health care professionals who attend to the spiritual dimension of their patients' lives find that they not only provide more personalized care to their patients; they nurture their own spiritual awareness and growth as well.

Rationale for the Project

Numerous studies have demonstrated the importance of the physician-patient relationship to health care outcomes.2 3 4 5 6 7 Nurses have always been rooted in care delivered from a compassionate, caring framework, yet many nurses find that difficult to do in the current health care delivery system.

Historically, medicine has been rooted in service values. Physicians and nurses made house calls, often becoming an integral part of the patients' and families' lives. Care was centered on the patient until technological advances of the 20th century changed the face of medicine. With the advent of new medical technologies, diseases could be diagnosed accurately and treated successfully and people began to live longer, healthier lives. Medical and nursing education reflected this change: Courses on empathy and compassion increasingly were replaced with courses on basic and clinical sciences. In the 1980s, patients started to complain about their dissatisfaction with the health care system, noting that physicians were becoming more mechanistic and less “human.”8 As a result, the Association of American Medical Colleges (AAMC) undertook a project entitled “the Medical School Objectives Project.” The aim of this project was to determine the best way to train physicians for a 21st century in which technology would continue to dominate progress, but also one in which patients' needs for caring and compassionate health care professionals could still be met. The first report concluded that the number one attributes for physicians were altruism and compassion. “Physicians . . . should understand their patients' stories in the context of their beliefs, family and cultural values.”9 The result of the AAMC endeavors has been an increase in courses on patient-centered care and physician-patient communication. Courses on professionalism remind physicians of their calling to the service of others and their ethical obligation to enter into partnership with their patients in order to achieve the best possible outcomes for their patients.

Another innovation in medical education has been the development of courses on spirituality and health. In 1992, there were only three such courses; in 2004, almost 90 of the 125 medical schools in the United States offered courses in spirituality and health. The main focus of these courses is to teach students that the spiritual dimension of health care is not an amenity. It is essential to the care of patients.10 Students learn how to communicate with patients compassionately and how to be sensitive to patient's spiritual values. Importantly, spirituality is recognized as the core of the caring relationship between health care professional and patient/family.11 12 13 14 Through examining their own spirituality, students explore not only how they relate to and care for patients but also how they care for themselves and find meaning in their own professional lives. This latter point has profound implications for practicing physicians, nurses, and other health care providers, many of whom speak of loss of meaning in their professional lives. If a provider were to have that sense of meaning and purpose rekindled, he or she might have a more gratifying professional life and also impact patients more positively and compassionately.

Courses on spirituality and health are rooted in a theoretical and ethical framework. Ethical standards in medicine,  nursing, and social work speak to the obligation of the health care professional to attend to all dimensions of the patient's care—the spiritual as well as the physical and psychosocial—as grounded in the biopsychosocial model of care.15 The American College of Physicians consensus panel determined that it is the physician's obligation to attend to all dimensions of a patient's suffering, including spiritual or existential suffering. 16 As mentioned above, health care in the United States grew out of religious values rooted in service to others. Hence, compassionate, holistic care is the foundation of health care in this country. Finally, the inclusion of spirituality in care is central to the precepts of patientcentered care, in that spirituality and religion can impact shared-decision making. Good care involves respect for patients' values and beliefs, and involvement of a larger community of caregivers (such as faith-based communities) is often important in good patient care.17

The concepts of spirituality and “presence” are closely related and, many would argue, almost inseparably intertwined. Roach provides an insight about the relationship between spirituality and being a caring presence. She writes, “Spirituality and caring are reciprocal. Spirituality is a movement into relationship, manifesting itself in caring, in a healing encounter with others.”18 In other words, the encounter has an intention of healing and includes relationship or connection between people. Burkhardt concurs: “Being with another with a conscious desire to bring love and healing to the interaction is a manifestation of spirit—thus we integrate spirituality into care through our intentional presence with one another.”19

Many nursing scholars have focused on understanding presence and its relationship to spiritual care and suffering. In a research synthesis article, Fredriksson described the distinction between “being with” and “being there” for the patient. Presence, touch, and listening were essential for the person to perceive caring in the interaction. “Being there” included contact that brought the intention of the nurse (caregiver) to the patient.20 It is about the caregiver doing to the patient. “Being with” included concepts of gift and invitation. The caregiver is bringing the gift of self and offering the invitation to the patient for a relationship. The caregiver needs to know whom they are spiritually in order to bring that gift to the interaction. In a Delphi study, Wolf, et al., were able to develop a standard of care for caring— which, to date, has been neither well understood nor widely adopted.21 Boykin and Schoenhofer describe care that supports the spirit as the essence of caring.22

Although spiritual support is an intervention that is described as a role that is both appropriate for and expected of nurses, nurses often lack the preparation for undertaking this responsibility unless they have attended universities that have a focus on caring and caring interactions. In nurses' practice areas, there is little support for “being with” or “presence.” Organizations tend to focus more on the tasks of care giving and less on a relationship- centered focus of care. The Essentials of Baccalaureate Education for Professional Nursing Practice identifies illness and disease management as core knowledge and includes the statement:
“Course work or clinical experiences should provide the graduate with the knowledge and skills to: demonstrate sensitivity to personal and cultural influences on the individual's reactions to the illness experience and end of life care; assist patients to achieve a peaceful end of life; and anticipate, plan for, and manage phsical, psychological, social and spiritual needs of the patient and family/caregiver." 23 The following values and assumptions undergird professional nursing's contract with society:

• Humans manifest an essential unity of mind, body, and spirit.
• Human experience is contextually and culturally defined. 
• Health and illness are human experiences.
• The presence of illness does not preclude health, nor does optimal health preclude illness.
• The relationship between nurse and patient involves participation of both in the process of care.
• The interaction between nurse and patient occurs within the context of the values and beliefs of the patient and the nurse.
• Public policy and health care delivery systems influence the health and wellbeing of society and professional nursing.24

Increasingly, health care organizations are recognizing the importance of the role of spirituality in health: Data as well as patient narratives support the importance of spirituality in the care of patients. Several studies have shown an association between spirituality and the will to live,25 depression,26 quality of life at the end of life27 and mortality.28 A recent national ethics consensus conference on spiritual care29 defined spiritual care as essential to health care. Furthermore, meeting participants concluded that spiritual care is interdisciplinary care; all health care professionals need to address patients' spiritual needs. While recognizing the important role of chaplains as trained spiritual care professionals who can work with the interdisciplinary team in more advanced spiritual care of patients, all persons interacting with the ill or injured person and family need to have an approach that honors the spiritual dimension of the person and is sensitive to the spirit. Health care professionals do spiritual care by being fully present to patients and their families. Spiritual care—broadly defined—is therefore a part of the responsibility of all direct and indirect caregivers and requires development of competence and comfort. Spiritual care competencies and accountabilities can be defined and measured. Professional spiritual care may be required to assist those expressing even mild spiritual pain and distress. Spiritual screening/assessment should be consistently done and may be enhanced by using a standardized format, such as the FICA tool.

One of the comments that faculty and students in medical school courses on spirituality and health make is that, while they are learning important values and practices, the health care systems in which they practice (hospitals, nursing homes, outpatient offices, etc.) do not reflect the material that is being taught. In an effort to improve the health care system, we developed the Hospital-Based Spirituality Initiative to prepare interdisciplinary teams of health care leaders from each of the pilot sites so they could develop programs for their physicians and staff. Specifically, sites developed training programs to teach staff how to address spiritual issues with patients, how to care for themselves and manage their stress, and how to make institutional changes that would support a more caring, relationship- centered approach to care.

Project Purpose and Goals
 
The purpose of this pilot project was to develop and test strategies that encourage ownership of the professional responsibility for addressing spiritual concerns of patients by interdisciplinary health care professionals and to better understand the organizational values and infrastructure that support increasing the spiritual care provided by caregivers. Developing programs that address the spirituality of professional caregivers as well as patients is integral to this process. Health care professionals have remarked that their own spirituality supports them in finding meaning in their profession and that addressing the spirituality of patients triggers in themselves questions about their own spirituality.

Goals of the project were to:

• Develop a process that is reproducible, effective, and respectful of available resources
• Promote development of personal spiritual competencies in direct caregivers and indirect care providers
• Encourage development of enhanced individual competencies in being a healing presence for whole-person care
• Demonstrate effectiveness of the process in supporting staff and improving patient/family experiences
• Develop and test strategies to apply those competencies in the work environment when caring for people with chronic or life-threatening illness and injury
• Develop and provide peer mentoring and coaching as the participants “model, teach, encourage” others in skill development and providing fully present care Integrate chaplains as key member of the interdisciplinary team.
• Develop work environment structures and institutional competencies that reinforce practice of consistent compassionate presence to the whole person.
• Develop structured patient assessment process and expectations

Sites and Methods

The pilot project was conducted in five faith-based hospitals and two secular hospitals, all of which had volunteered to participate. Each of the seven pilot sites selected one nursing unit to participate in the project. These units were those in which seriously ill patients—those with cancer, cardiac disease, and other complex medical conditions—were likely to receive care.

Prior to the initiation of the project, leadership teams from each of the pilot sites participated in a two-day retreat. Each of the sites was strongly encouraged to send a team with the ability to effect change within the organization and unit. The teams included the facility's medical director, director of nursing or unit manager, director of pastoral care, social worker, and clinical leader. The purposes of the retreat were to:

• Describe the pilot project and expectations for site participation
• Develop a common understanding of spirituality
• Explore personal spiritual issues
• Experience spiritual care and presence
• Understand the importance of spiritual care for patients and families
• Acknowledge the interdisciplinary responsibility for spiritual care
• Foster development of the interdisciplinary team
• Discuss how to create a care environment for patients and colleagues that fosters relationship-centered spiritual care
• Design interventions to be implemented at each site

The retreat was designed to be highly interactive, experiential, and reflective. Among the content areas presented by faculty were: What is spirituality?, the distinction between spirituality and religion, the importance of spirituality to patients and health, and being fully present to others. Presentations were followed by opportunities to reflect, for example by journaling. Some experiences, such as practicing being fully present to others, were structured as dyads; others involved group discussion and sharing.

During the retreat, each of the teams was asked to begin discussing how to create a work environment that supported their own and their patients' spiritual natures, one in which they wanted to practice, and one that they wanted their patients to experience. Faculty recognized that a boilerplate program would not work at diverse sites with unique needs. Because faculty wanted to encourage ownership and commitment from the site, they allowed each hospital develop a program that was suited for its particular environment. The teams were expected to return to their sites and develop plans that would introduce the concepts they learned to the pilot unit.

Over the course of the project, research team members made one-day site visits to each of the participating hospitals. Site visits served to generate interest in the initiative, surface issues in implementing individual site plans, and encourage discussion of possible approaches to challenges. In addition, monthly conference calls involving participants from all sites maximized cross-site knowledge transfer and addressed specific challenges and opportunities experienced by the sites.

Sites
 
Mountain Viuew Regional Medical Center, Las Cruces, NM
Providence St. Vincent Medical Center, Portland, OR
St. Agnes Medical Center, Baltimore, MD
St. Elizabeth's Helath Center, Youngstown, OH
St. Patrick Hospital and Health Sciences Center, Missoula, MT
St. Vincent Hospital, Indianapolis, IN
The George Washington University - UHS Medical Center, Washington, DC

Evaluation Method

The question of effectiveness was asked of both professionals and patients. Patients and staff were asked to answer questionnaires at baseline, three months, six months, and 12 months. Data were collected by a research nurse or assistant after the project was approved by the institutional review board or the committee responsible for research at each site and by Providence Health & Services and George Washington University. Questionnaires designed for this project asked questions about the following:

• Attitudes about spiritual care in the clinical setting
• Spirituality, religiosity, attitudes, and spiritual practices of the health care professionals and patients
• Stress level of health care professionals
• Health professional's satisfaction with work place environment and job
• Patient satisfaction with spiritual focus of care encounters with physicians and other health care professionals
• Staff vacancy and turnover rates
• Trust in providers

Completed forms did not have any patient identification information on them and were sent to Supportive Care Coalition: Pursuing Excellence in Palliative Care in Portland, Oregon, for data entry. The signed informed consents were sent to George Washington Institute for Spirituality and Health in Washington, DC. The aggregate Excel data file was sent to George Washington University for data analysis. Overall, the project was designed to answer, though narratives and questionnaire data, the following questions:

• Can an intervention be designed that improves staff outcomes such as burnout, turnover, and depression?
•  Will the intervention improve staff comfort with integration of personal spirituality in the work environment?
• Can an intervention be designed that improves the staff response to the spiritual needs of patients in hospital settings?
• Will the intervention improve such patient outcomes as patient satisfaction, trust in provider, and spiritual care?

Anticipated Outcomes

It was expected that by participating in this project, patients, staff, and the organization itself could expect certain changes. For patients, those anticipated outcomes included improved satisfaction with care and improved experience with communications about health care. Staff were expected to experience increased work satisfaction and decreased work stress, increased comfort and skills in providing spiritual care, and an increase in team strength and communication. Anticipated organizational outcomes included improved retention and decreased turnover, the adoption of performance competencies, an increase in spiritual care referrals, and creation of policy and procedural standards supportive of staff behaviors of compassionate presence.

Site Interventions

While there was variation across all sites in the interventions that were undertaken and in the exact processes used to implement them, there were also common themes for the interventions. All sites sought to strengthen the interdisciplinary team, to focus on changes in organization standards to support spiritual care, and to integrate systematic assessment of spiritual concerns into the assessment of patient needs.

Taking a Spiritual History: The FICA Tool

Obtaining a spiritual history is one way a caregiver can learn what is deeply important to a patient. In discussing the patient's spirituality, the caregiver enters the domain of that which gives the patient meaning and purpose in life and how he or she copes with stress, illness, and dying. The spiritual history affords the patient the space and opportunity to address his or her suffering and hopes. A spiritual history validates the importance of a patient's spirituality, giving the patient “permission” to discuss his or her spirituality, assuming that he or she desires to do so.

The FICA tool, developed in 1996 by Christina Puchalski, MD, one of this report's coauthors, can help a caregiver structure the questions he or she will ask in taking a spiritual history for adults and children. Some sites developed strategies to integrate spiritual assessment into the admission process. Many developed strategies to integrate the FICA tool into usual practice by physicians and nurses.

FICA is not meant to be used as a checklist, but rather as a guide that helps the caregiver start spiritual histories, indicating what he or she should listen for as patients talk about their beliefs. Above all, FICA shows physicians and other caregivers how to steer a conversation toward spiritual issues, issues involving meaning and value. During such a history, a patient may relate to the caregiver his or her spiritual or religious beliefs, fears, dreams, and hopes. The spiritual history can be done in the context of a routine history, or at any time in the patient interview, usually as a part of the social history.

FICA Spiritual Assessment Tool*

The aconym FICA can help structure questions in taking a spiritual history:
F—Faith, Belief, Meaning I—Importance and Influence C—Community A—Address/Action in Care

F—Faith, Belief, Meaning “Do you consider yourself spiritual or religious?” or “Do you have spiritual beliefs that help you cope with stress?” If the patient responds “no,” the physician might ask, “What gives your life meaning?”

I—Importance and Influence “What importance does your faith or belief have in your life? Have your beliefs influenced you in how you handle stress? Do you have specific beliefs that might influence your health care decisions?”

C—Community “Are you a part of a spiritual or religious community? Is this of support to you and how? Is there a group of people you really love or who are important to you?” Communities such as churches, temples, and mosques can serve as strong support systems for some patients.

A—Address/Action in Care “How should the health care provider address these issues in your health care?” Referral to chaplains, clergy and other spiritual care providers.

© Copyright, Christina M. Puchalski, MD, 1996  For more information on patient spirituality and the role of spirituality in health care, contact The George Washington Institute for Spirituality and Health: www.gwish.org

*Adapted with permission from Puchalski CM, Romer, AL. Taking a spiritual history allows clinicians to understand patients more fully. J of Pall Med 2000;3:29-37. © Copyright, Christina M. Puchalski, MD, 1996

Other Interventions

In addition to implementing routine spiritual assessments in the care of their patients, the sites adopted a variety of interventions aimed at reintegrating an awareness of spirituality and spiritual caring in the role of the health care provider.

Staff education was a major component of site interventions. Education covered such areas as how to take a spiritual history, exploration of one's own spiritual nature, and how to identify opportunities for providing spiritual care in the course of practice. Use of narratives was a particularly useful tool for illustrating the integration of spiritual care in regular practice. Some staff educations sessions took place in a retreat environment, which also worked well for the development of interventions. Other formats included “lunch and learn” sessions or weekly “brown bag” sessions.

Many of the other interventions were aimed at supporting the staff as the project matured and at helping to deepen staff understanding of spiritual care concepts. Sites developed their own rituals to honor their work as caregivers. Either at the beginning or at some point during the shift, the shared ritual allowed all present to refocus on their calling to the work. By meeting regularly to talk about their own experiences in providing spiritual care, caregivers got an opportunity for reinforcement and positive role modeling. Other reminders of the spiritual nature of caregiving included the posting of inspirational messages and the use of symbolic reminders of the spirituality initiative. Sites created small symbols employing hearts, beads, and other similar items, which they used to acknowledge one another as caregivers. Many sites posted photographs of each team member to strengthen their sense of belonging to an interdisciplinary team working together to provide care of body, mind, and spirit.

While all sites had strong physician champions working with the teams, they should continue to develop strategies for fully integrating physicians into the spirituality initiative. These include educational strategies as well as quality improvement strategies.

Narrative Results

Sites reported a “culture change” on the work unit with a more “positive” culture and a stronger sense of teamwork. As one participant said, “It's as if we have permission to be present to spiritual issues for ourselves and each other.” Managers reported perceptions of improved staff satisfaction and a decrease in sick days taken by staff. Several leadership teams reported closer interdisciplinary relationships on the pilot units. Additionally, sites shared powerful narratives of providing spiritual care as part of their care—for example, taking a spiritual history and discovering important information about the patient that affected the treatment plan, arranging for pets to visit when someone was approaching the end of life, celebrating an anniversary with a patient prior to surgery, praying with the patient, or taking the time to be fully present to patients' fears and suffering.

One of the challenges reported across several sites was developing strategies to help staff differentiate spiritual care from good customer service. In discussions with the investigators and site chaplains, many site team members talked of customer service approaches and meeting the social needs of patients and families as spiritual care. While those are kind, service-oriented activities, addressing spiritual concerns is inclusive of—but also transcends—that type of care. Sites found that using narratives of care and having the chaplain help make the spiritual component of the care more overt worked well to help distinguish between customer service and spiritual care.

Baseline Questionnaire Data

It is noteworthy that there were no statistically significant differences among sites at baseline, even though some sites had already undergone workplace spirituality initiatives prior to this project. Demographics indicated that staff and patients were primarily Caucasian and Christian. Both staff and patients reported themselves to be religious (staff 75 percent, patients 89 percent) and spiritual (staff 91 percent, patients 92 percent). Of the 225 staff who responded to the questionnaire, 56 percent were RNs, 9 percent were CNAs, 8 percent were chaplains, and 7 percent were physicians.

What was also of note at baseline was the patient perception that very few professionals asked about spiritual concerns, even though professionals reported that assessing/identifying spiritual care is a standard of care within their disciplines (76 percent).

At baseline, professionals scored low on the 7-item burnout scale [mean=0.82 (s.d.=.67) on a 0-4 scale, alpha=.79] and fairly high on the satisfaction with work scale. Eighty percent rated overall satisfaction with their work as “good” or “very good.” Professionals also reported that the organization had an explicit commitment to spiritual care (80 percent agree or strongly agree), but a lower proportion reported support for “providing spiritual care” (64 percent agree or strongly agree).

Change scores at three months and six months showed few statistically significant differences from baseline. However, there were slight (but nonsignificant) increases at six months in patients' report that professionals asked about spirituality: from 4 percent at baseline to 11 percent at six months for doctors, and 19 percent at baseline to 30 percent at six months for RNs. Patients also reported slightly less fear and anxiety at three and six months. At six months, patients reported slightly higher scores [mean=7 (baseline) and mean=7.7 (6-months)] on a 6-item Spiritual Dimension Scale (alpha=.71) and attendance at a weekly religious meeting (30 percent at baseline to 52 percent at six months).

Questionnaire Final Results
 
Twelve-month follow-up data were discouraging, with one noteworthy exception. The number of patients responding “no” to the question whether chaplains asked about spiritual concerns decreased. At baseline, 68 percent reported that chaplains did not ask about their spiritual beliefs or concerns, whereas at the 12-month follow-up only 53 percent reported not speaking with a chaplain. There were no other statistically significant changes from baseline among the patient groups. As for health care professionals, there was a significant decrease in participation from baseline to 12-month follow-up among chaplains (17 percent to 1 percent) and physicians (15 percent to 0 percent). No other changes from baseline were found to be statistically significant.

Discussion and Limitations

It is clear from physician, staff, and patient comments that the interventions tested in this study made an impact. Culture changes were noted, patient satisfaction scores were increased in one site, staff sick days decreased, and staff felt more satisfied at work. Given that this was a pilot study, it is not surprising that these narrative statements were not adequately reflected in the quantitative data. Numbers at each site were small. Due to difficulties in data collection at the sites and in administering the survey, the survey did not follow the same staff over time. The patients at each site also differed from sampling to sampling. Furthermore, the fact that the interventions differed from site to site introduced many variables. Other limitations included several concerns about response bias and homogeneity of the sites of the pilot project. It is also important to note that there was a decline in professional responses over time and thus the results reported for professionals represent a small number (N=226; N=99). Further, there may have been a response bias by staff because they were participating in the spirituality project. Also, the fact that this pilot project included mostly Catholic-sponsored health care organizations may have introduced a bias.

Other concerns are associated with the questionnaires and with the use of quantitative approaches to determine changes experienced by staff and patient. The staff and patient questionnaires had limited prior use. Some of the sub-scales had been tested, whereas other items were developed for this project and either may not have been sensitive enough to capture changes or did not reflect items of importance to the respondents. At this point in our understanding of the importance of spiritual assessment and interventions, the capture of qualitative data has not been fully explored, and it may be premature to focus on gathering quantitative data. As one professional said, “When staff say that the unit ‘feels different' that is a very powerful statement of the change.”

Another limitation may be the research design. Data were treated as discrete data points, and there was no effort to collect longitudinal data for either patients or staff. This was a weakness in the design even though the demographics indicate similarity across all time points. Furthermore, there was a legitimate reason for the design chosen, since the goal was to track cultural and environmental changes, not individual changes. Finally, the evaluation time-points may not reflect actual time since interventions were initiated. The different sites initiated interventions at different times, and there was no way to determine the relationship between any change score and the timing of specific interventions. The notable intervention contributing to change may have been the site visits during which an emphasis was placed on systematically asking about spiritual issues; slight increases were noted six months after those visits.

Finally, to close such a study at 12 months was likely to be premature, precluding the capture of evidence of cultural changes. Cultural changes require time, and many sites did not fully implement designed interventions until six months into the project.

In spite of the limitations of the pilot study, it is clear from staff and patient narratives that these interventions made some impact in the health care environments. At site visits, staff began to support the notion that spirituality is essential to the care of patients and also to the health care professionals themselves. Spirituality, at its core, supports the call of health care professionals of all disciplines to altruistic service and to the provision of compassionate and loving care to patients and their families. But it also requires attention to, and awareness of, spiritual values and spiritual practice by those health care professionals, before culture change can occur. Further studies are underway to elucidate how to measure this change and how to develop some standardized interventions.

Lessons Learned and Recommendations for Next Steps
 
Sites reported that the leadership retreat for the interdisciplinary leadership team was essential to their success. It created a common understanding of spirituality and responsibility for spiritual care across disciplines. It also provided reflective time so they could begin to develop strategies for implementation of interventions on the pilot units. Although many organizations have spirituality-in-the-workplace initiatives, this project focused on spiritual care for the patient and family as well as staff. Positive outcomes were reported by patients and by professionals. Integration of a spiritual assessment as an essential component of all patient care planning was important to the success of the work at each site. Further, according to the narratives, focusing on respect and care for the caregiver as well as the patient and family was important. Each site developed its own strategies for the initiative and needed to do so to make the initiative successful. This also helped the organization build its own expertise as the sites developed strategies to further the scope of the work. Finally, developing educational strategies and organizational expectations for integration of spiritual care was necessary to nurture and sustain the initiative.

Sites reported strong administrative support for this initiative and the development of strong leadership teams for the work. They noted the importance of the interdisciplinary approach and the need to integrate physician colleagues, while acknowledging some challenges in doing so successfully.

Conclusion
 
Many health care organizations state that the value of respect for each individual caregiver, patient, and family is important. This is especially true for Catholic health care. The spirituality initiative provides one approach in making this a visible strategic initiative. Although the data do not fully answer the question of how well the project demonstrated the effectiveness of achieving the goals it was designed for, the narratives indicate that the project did move toward achievement of those goals. Indeed, it may have been unrealistic to achieve quantatitative changes demonstrating a cultural change in the short time of one year. 

Pilot sites reported that they were able effectively integrate spiritual care into the roles of all caregivers without allocating additional time for care. This approach to demonstrating respect for persons was reported to have a positive effect on the staff and on the units in which it was implemented. Narratives described perceived increases in patient satisfaction, staff satisfaction, lower staff turnover, and eagerness to work on the pilot units, as demonstrated by waiting lists of staff desiring to work on the pilot units. Finally, sites report strategies for continuing the work locally and strategies to extend the initiative within the organization.

Reintegrating spirituality into health care holds promise both as a way of addressing the needs of patients and families as whole human beings with complex needs and of enriching the work of health care professionals who also share a spiritual nature.

Further Information:
For further information, contact the George Washington Institute for Spirituality and Health, Christina Puchalski, MD, at 202-496-6409 or hcscmp@gwumc.edu (www.gwish.org is the institute's web site) or the Supportive Care Coalition: Pursuing Excellence in Palliative Care, Sr. Karin Dufault, SP, RN, PhD, Executive Director. E-mail: Karin.Dufault@providence.org; or phone: 503-215-5053.

REFERENCES
1. Association of American Medical Colleges (AAMC). Learning Objectives for Medical Student Education: Guidelines for Medical Schools, Medical School Objectives Project (MSOP). Washington, DC: Association of American Medical Colleges; 1998.
2. Poulton DC. Use of the consultation satisfaction questionnaire to examine patients' satisfaction with general practitioners and community nurses. Br J Gen Pract. 1996;46:26-31.
3. Carter WB, Inui TS, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis: II. identifying effective patient behavior. Med Care. 1982;20:550-566.
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7. Mira JL, Aranaz J. Patient satisfaction as an outcome measure in health care. Med Clin. (Barc); 2000;114 Supp13:26-33.
8. AAMC. Learning Objectives for Medical Student Education.
9. Ibid.
10. Association of American Medical Colleges & The George Washington Institute for Spirituality and Health. The Development and Dissemination of Physician/Patient Guidelines on Ethical Parameters for Incorporating Spirituality into Medical Education and Health Care Consensus Meeting. Washington, DC: Association of American Medical Colleges; 2003, in press.
11. Association of American Medical Colleges. Report III - Contemporary Issues in Medicine: Communication in Medicine, Medical School Objectives Project (MSOP III). Washington, DC: Association of American Medical Colleges; 1999;p. 25.
12. Sulmasy D. A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist. 2002;42:24-33.
13. Lo B, Quill TE, Tulsky JA, for the ACPASIM End-of-Life Care Consensus Panel. Discussing palliative care with patients. Ann Intern Med. 1999;130:744-749.
14. Institute for Alternative Futures. Patientcentered Care 2015: Scenarios, Vision, Goals & Next Steps. Alexandria, VA: Picker Institute; 2004.
15. Sulmasy D. Ibid
16. Lo et al, Ibid.
17. Institute for Alternative Futures, Ibid.
18. Roach SM. Caring ontology: ethics and the call of suffering. International J for Human Caring. 1998 (2):31. 19. Burkhardt MA. Reintegrating spirituality into health care. Altern Ther Health Med. 1998;4:128.
20. Fredriksson L. Modes of relating in a caring conversation: a research synthesis on presence touch and listening. J Adv Nurs. 1999;30:1167-1176.
21. Wolf ZR, Freshwater D, Miller M, Jones RAP, Sherwood G. A standard of care for caring: A Delphi study. Int J Human Caring. 2003;7:34-42.
22. Boykin A, Schoenhofer S. Nursing as Caring: A Model for Transforming Practice. Boston: Jones and Bartlett; 2001.
23. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional nursing Practice. Washington, DC:American Association of Colleges of Nursing; 1998: p. 13.
24. American Nurses Association. Nursing's Social Policy Statement, 2nd ed. Washington, DC:American Nurses Association; 2003: p.3.
25. Tsevat J, Puchalski C, et. al. Spirituality and Religion in Patients with HIV/AIDS. Vancouver: Society of General Internal Medicine; 2003.
26. Reed P. Response to “The relationship between spiritual perspective, social support, and depression in caregiving and non-caregiving wives.” Sch Inq Nurs Pract. 1994;8:391-397.
27. Cohen SR, Mount BM, Strobel MG. The McGill quality of life questionnaire: a measure of quality of life appropriate for people with advanced disease. Pall Med. 1995;9:207-219.
28. Levin JS, Larson DB, Puchalski CM. Religion and spirituality in medicine: research and education. JAMA. 1997;278:792-793).
29. Puchalski CM, Anderson MB, Lo B, et. al. Ethical guidelines for spiritual care. Association of American Medical Colleges, in press.


Retreat Faculty

Thomas J. Butler, MDiv Executive Director, Lilly Endowment Grant Mount St. Mary's University, Emmitsburg, MD Mary Matthiesen Founder, Courage to Choose Courage to Care, Sausalito, CA
Edward McCormack, PhD Director of Continuing Education Washington Theological Union, Washington, DC Sylvia McSkimming, RN, PhD Former Executive Director Supportive Care Coalition: Pursuing Excellence in Palliative Care
Christina Puchalski, MD, MS Founder and Director, George Washington Institute for Spirituality and Health Associate Professor of Medicine and Health Care Sciences, The George Washington University School of Medicine
Michael Stillwater Co-Founder and Director, Companion Arts Novato, CA
Carol Taylor, RN, PhD Director, Center for Clinical Bioethics Georgetown University
Paul Tschudi, MA, LPC Director, End of Life Care Programs The George Washington University School of Medicine