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August 2011 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Williams, J. A., Meltzer, D., Arora, V., Chung, G. and Curlin, F. A. "Attention to patients' religious and spiritual concerns: predictors and association with patient satisfaction." Journal of General Internal Medicine 26, no. 11 (November 2011): 1265-1271.


SUMMARY and COMMENT: This large study out of the University of Chicago-Pritzker School of Medicine fills a gap in the research about attention to patients' religious/spiritual concerns: "[N]o studies to date have examined the prevalence of desires for attention to R/S concerns among hospitalized patients and then followed up post-discharge to determine whether these needs were actually met and by whom" [p. 1266]. Data from 3,141 internal medicine patients at the University of Chicago Medical Center were analyzed (out of 11, 620 patients approached, and 6,808 who agreed to participate but who did not sufficiently complete surveys). A 37-item interview was administered upon enrollment and then a 55-item interview by phone 30 days post-discharge. "Attempts [were] made to identify proxy respondents for patients unable to consent to the interview" [p. 1266].

Key questions asked of patients included:

  • "Some patients would like to discuss religious or spiritual concerns with someone while in the hospital. Was that true for (you/PATIENT)?"
  • "While (you were/PATIENT was) in the hospital, did anyone talk with (you/him/her) about religious or spiritual issues?"
  • [--if YES to the second question, then:] "Was it (check all that apply): (a) one of the hospital physicians; (b) a hospital chaplain; (c) a member of (your/his/her) own religious community; (d) someone else." [--see p. 1266]
Other questions assessed for religious attendance, intrinsic religiosity, spirituality, health status, and patient satisfaction (adapted from the Duke Religion Index, the Brief Multidimensional Measure of Religiousness/ Spirituality, the Medical Outcomes Study 12-Item Short Form, and the Picker-Commonwealth patient satisfaction survey). Additional data were collected from other hospital sources.

Among the findings:

Forty-one percent of patients (n = 1,135) reported that they would have liked to discuss religious or spiritual concerns with someone while in the hospital, and 32% (n = 889) indicated that some such discussion did occur. Among the latter, 8% (n = 70) spoke with a physician, 61% (n = 541) spoke with a chaplain, 12% (n = 109) spoke with a member of their own religious community, and 12% (n = 107) spoke with someone else. ...[P]atients who desired discussions of spiritual issues, and those who had them, did not entirely overlap. In fact, half (561/1,135) of the patients who desired a discussion did not have one (this group represents 20% of patients overall), and one in four (315/1,633) patients who did not desire a discussion had one anyway (11% of patients overall). [p. 1267]
[P]atients who reported having discussed spiritual issues with someone while in the hospital were significantly more likely to give superior ratings on all four satisfaction measures, regardless of whether or not they had desired such a discussion. ...In a final post-hoc analysis, we found that the discipline (physician, chaplain, religious community, other) of the person with whom the patient discussed R/S issues was not significantly associated with ratings of satisfaction on any of the four measures (p>0.2 for all). [p. 1268]

A table [p. 1270] shows associations between R/S discussions and patients' more positive ratings for satisfaction with doctors' care, confidence and trust in doctors, sense of coordination and team work among doctors and nurses, and overall hospital care. This is one of five very rich tables contained in the article.

The data does not appear to reveal any glaring predictors of unmet desire for discussion of R/S concerns, though patients who were assessed as being more intrinsically religious tended to have such an unmet desire. A number of demographic associations turned up regarding either having desired or had a discussion of R/S concerns: e.g., African-Americans were slightly less likely to have had a discussion, while women and older patients were more likely. However, the authors conclude, "Although these associations are intriguing, they do not seem large enough to warrant singling out any of these categories from broader efforts to address patientís R/S concerns" [pp. 1269-1270].

The most immediate value of this study, for this chaplain reader, lay in the findings that a full 41% of patients may desire a discussion of R/S concerns, that "many more inpatients desire conversations...than actually experience such conversations" [p. 1270], and that R/S discussions were associated with greater satisfaction scores even for patients who did not indicate a desire for discussion. The most curious finding was that it did not seem to matter whether the discussion was with a chaplain or another health care provider. Surely this deserves further investigation.

One final observation --almost an aside: the authors twice say [pp. 1265 and 1268] that the Joint Commission on Accreditation of Healthcare Organizations wants all patients to receive a spiritual assessment, but this assertion is based on sources from 2004 and 2005 which do not accurately portray current JCAHO standards for accreditation. JCAHO's hospital requirements for a spiritual assessment per se are limited to patients receiving end-of-life care or treatment for behavioral health and substance abuse issues, and in the context of an assessment of factors affecting patient education. (Spiritual assessment is given greater emphasis in the standards for home care/hospice.) Otherwise, accreditation standards only note the importance of sensitivity to religious or spiritual concerns. See a summary of standards for Hospitals. In 2010, the organization issued "Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals," which suggests asking all patients in general about "cultural, religious, or spiritual beliefs or practices that may" [--see, p. 15], but the document has yet to influence accreditation standards in this area. That being said, this point about JCAHO requirements does not affect any findings in our featured article or diminish the value of the work.


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

While students may have difficulty interpreting the statistics-rich tables in the article, they should have no trouble reading the well laid out narrative explanation of the study and results. Possible questions for discussion include: Does the finding that 41% of patients want some discussion of religious concerns seem low or high to you, from your work around the hospital? How might you explain the association between such a discussion and patient satisfaction ratings? What do you make of the finding that the association with satisfaction was not dependent upon the specific discipline of the staff member addressing religious/spiritual concerns? Do the identified predictors of a patient having had a discussion of religious/spiritual concerns hint at biases, specific gaps in care, or any reasonable triggers for such a discussion? Do higher satisfaction ratings of patients who did not desire to have a discussion but who had one anyway speak to the idea of unsolicited pastoral care visits? Finally, the authors propose that "for many patients it may not be enough to address emotional concerns without specifically asking about R/S issues" [p. 1270]. What might this say about raising explicitly religious/spiritual issues in pastoral visitation?


Related Items of Interest:

I. For more on patients' views about the discussion of religious/spiritual issues with physicians, see the September 2004 Article-of-the-Month page.


II. Our authors refer [p. 1270] to the article by Paul A. Clark, et al., "Addressing patients' emotional and spiritual needs," Joint Commission Journal on Quality and Safety 29, no. 12 (December 2003): 659-670. This article was highlighted for our October 2004 Article-of-the-Month page.




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