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July 2012 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Sharma, R. K., Astrow, A. B., Texeira, K. and Sulmasy, D. P. "The Spiritual Needs Assessment for Patients (SNAP): development and validation of a comprehensive instrument to assess unmet spiritual needs." Journal of Pain & Symptom Management 44, no. 1 (July 2012): 44-51.


SUMMARY and COMMENT: The authors of this month's article have set out to "develop an instrument to assess the spiritual needs of patients in a concrete, refined, comprehensive, systematic, valid, and reliable way" [p. 45]. Their 23-item measure takes into account the challenges of population diversity and a lack of consensus about the concept of spirituality and is presented as a tool with "potential for use in both clinical and research settings" [p. 49]. They propose a strategy for clarifying "spiritual needs" according to three domains -- psychosocial, spiritual, and psychological -- that may allow for the tailoring of spiritual care "with greater precision" [p. 49].

The Spiritual Needs Assessment for Patients (SNAP) was developed and piloted at Maimonides Cancer Center in Bay Ridge, Brooklyn, NY. A list of potential questionnaire items was created by drawing upon existing research, the insights of chaplains represented in the literature, and the authors' personal clinical experience. Cognitive pretesting was conducted with a convenience sample of 15 ambulatory oncology patients [see p. 46], "to assure that the items meant to patients what they were intended to mean by experts" [p. 49] and to give an opportunity for direct patient input for additional items. Test-retest reliability involved 38 patients, and final validation data were collected from 47 patients. The methodology is well described [see esp. pp. 45-46], though a 2009 abstract of early testing states more explicitly a few details of the authors' first steps [--see Items of Related Interest, #I, below].

At the heart of their approach is an attempt to disambiguate the term "spiritual needs" by considering psychosocial, spiritual, and religious components.

We considered psychosocial needs as those that are largely psychological, but are intimately related to the spiritual, such as help with stress. The inclusion of a psychosocial needs domain allowed us to have an internal comparison point for the spiritual and religious needs domains. We defined spiritual needs as those that directly concern an individual’s relationship with transcendent questions, such as meaning, hope, forgiveness, and peace. Similarly, we considered religious needs as those that directly concern the exercise of religion, such as reading religious texts, conducting religious rituals, or talking with clergy. [pp. 45-46]
With regard to these domains, the authors were interested in identifying needs "with which patients would like help" [p. 49], making the instrument intentionally quite practical for patient care. The 23 items follow from the stem question, "How much would you like help with the following?" (--responses given according to a four-point Likert scale for "very much," "somewhat," "not very much," and "not at all"):


Items, by domain, for the Spiritual Needs Assessment for Patients (SNAP)*

  • Psychosocial needs
    • Getting in touch with other patients with similar illnesses?
    • Relaxation or stress management?
    • Learning to cope with feelings of sadness?
    • Sharing your thoughts and feelings with people close to you?
    • Worries you have about your family?
  • Spiritual needs
    • Finding meaning in your experience of illness?
    • Finding hope?
    • Overcoming fears?
    • Personal meditation or prayer practices?
    • Your relationship with God or something beyond yourself?
    • Becoming closer to a community that shares your spiritual beliefs?
    • Coping with any suffering you may be experiencing?
    • The meaning and purpose of human life?
    • Death and dying?
    • Finding peace of mind?
    • Resolving old disputes, hurts, or resentments among family or friends
    • Finding forgiveness?
    • Making decisions about your medical treatment that are in keeping with your spiritual or religious beliefs?
  • Religious needs
    • Visits from clergy of your faith community?
    • Visits from a hospital chaplain?
    • Visits from fellow members of your faith community?
    • Religious rituals such as chant, prayer, lighting candles or incense, anointing, or communion?
    • Someone to bring you spiritual texts such as the Torah, Qu’ran (Koran), Bible, Analects of Confucius, or Tibetan Book of the Dead?
*Items have been listed with permission of the authors.


Construct validity…was assessed by comparing each of the subscale scores with the following general spiritual needs assessment question: "Are your spiritual needs being met?" Compared with those who answered in the affirmative, participants who answered "no" had significantly higher mean scores on the total SNAP (66.3 vs. 49.4, P = 0.03) and on the spiritual needs subscale (39.0 vs. 28.3, P = 0.02). There also was a trend for participants with unmet spiritual needs to have slightly higher mean scores on the religious needs subscale (12.3 vs. 9.0, P = 0.06). The mean scores on the psychosocial needs subscale were not different for those who reported unmet spiritual needs compared with those who did not (13.2 vs. 11.9, P = 0.47). [pp. 47-48]
The testing suggests that the domains are "three different but related constructs, and that psychosocial and religious needs bear different degrees of overlap with the subscale we designed to capture the construct we suggest is most forthrightly designated as 'spiritual needs'" [p.49]. Moreover, the instrument overall showed excellent internal reliability and very promising test-retest reliability. Cronbach’s alpha for the total SNAP was 0.95, with the psychosocial subscale being 0.74, the spiritual subscale being 0.93, and the religious being 0.86. The test-retest correlation coefficient for the total scale was 0.69 (P < 0.001).

Limitations of the study include a relatively small sample size recruited from a single institution. Also, it is the observation of this reader that while the sample was quite diverse, it did not reflect a true cross-section of the general population (e.g., it was 57.5% Catholic, compared with a recent Pew survey putting the number of Catholics in the US at 23.9%). SNAP appears to be worthy of further validation for wider application, and the authors express a special interest in exploring responsiveness to spiritual interventions. One potential strength of this measure is that it was developed with attention to the presence of a significant percentage of patients who identify as "spiritual but not religious," (--interestingly, 68% of the sample described themselves in this way), and so it may be especially useful for work with that demographic. The instrument has also been validated for a Chinese population [--see Items of Related Interest #II, below].

One final comment: in this test sample, 15% reported that they had unmet spiritual needs, and 19% indicated wanting help meeting their spiritual needs [see p. 47]. The authors do not focus on the significance of these figures, which come from a general question asked in addition to the SNAP items. Estimates of patients' unmet spiritual needs in the research literature have varied with conceptualizations, instruments, and populations [--see Items of Related Interest #III, below]. These particular results from the present study are certainly deserve to be kept in mind.

Chaplains wishing to use the SNAP for research or clinical application should contact the article's corresponding author: Rashmi K. Sharma, MD, MHS, Division of Hospital Medicine, Northwestern University, 211 E. Ontario St., 07-734, Chicago, IL 60611; e-mail:

[Link update: The link given in the bibliography as citation #24 for the Joint Commission FAQ regarding spiritual assessment no longer works. See instead HERE.]


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

While this month's article would seem to be of special interest to researchers and professional caregivers, CPE students should appreciate that the SNAP was developed with input from chaplains. Discussion could focus on the instrument itself: its domain structure and the content of the 23 items. Does the SNAP seem to cover all the pertinent bases? What is the relationship between the three domains? Are there "spiritual needs" enumerated here that students hadn't considered much before? In several ways, this article lines out valuable lessons in methodology, especially the need to consider diverse populations, the importance of making sure that "items meant to patients what they were intended to mean by experts" [p. 49], and the value of a practical approach to assessing something that is conceptually complex. Discussion could also turn to the assessment of patients who consider themselves "spiritual but not religious." This validation study used the question, "Are your spiritual needs being met?" What do students think about such a straightforward yet general question? Those students who are unfamiliar with statistics should be able to read around the technical content of the article and follow well the overall narrative.


Related Items of Interest:

I. An early abstract of testing of the present instrument was published in a supplement of the Journal of General Internal Medicine, from the 2009 meeting of the Society of General Internal Medicine. Note that the abstract refers to the instrument as the SNAPS instead of the SNAP.

Sulmasy, D. P., Texeira, K., Hantman, I, Astrow, A. B. "The Spiritual Needs Assessment for Patients Survey (SNAPS): development and initial psychometric testing." Journal of General Internal Medicine 24, suppl. 1 (April 2009): s194-195. [(Abstract:) BACKGROUND: Research about health care and spirituality has concentrated on the relationship between patients’ baseline spiritual and religious attitudes and behaviors and their health outcomes. Little has been done to assess the actual spiritual needs of patients. METHODS: We have developed a 23-item scale to assess patients’ spiritual needs. We began with an instrument developed by Moadel, et al., winnowing out the less specifically spiritual items and altering their response categories, which were unusual and difficult to score. We changed to an ordered categorical response scale of "Very much," "Somewhat," "Not very much," and "Not at all," and added further items derived from a published but unvalidated needs assessment tool developed by chaplains and items based on the clinical experience of the investigators. We next validated this instrument by subjecting it to iterative revision based on successive waves of cognitive pre-testing with 15 subjects before settling on a final version. This instrument was then pilot tested in a convenience sample of 32 patients at an urban cancer center. We assessed test-retest reliability by Spearman correlation in a subset of these subjects re-interviewed within two weeks. Internal consistency was assessed using Cronbach’s α on the total scale and also on the three subscales: Psychospiritual, Spiritual, and Religious needs. RESULTS: The mean age of subjects was 58.2 years. The sample was racially and religiously diverse: 53% were white, 22% black, 16% Hispanic, and 9% Asian or other; 59% were Catholic, 6% Jewish, 6% Protestant, 3% Buddhist, 3% Muslim, 3% Hindu, and 13% Other religions. Thirty-four percent were college-educated; 16% were on Medicaid or uninsured; 25% had breast cancer and 19% lung cancer. A majority (63%) described themselves as spiritual but not religious; 28% attended religious services at least once per week; and 13% reported that their spiritual needs had not been met. While slightly skewed towards the "Not at all" category, there was a wide distribution of responses on each item, and the lowest proportion of combined "Very much" and "Somewhat" responses was 26% for the need for "religious texts." The overall Cronbach α was 0.96 for all 23 items. The α for the Psycho-spiritual needs subscale (5 items, eg, "relaxation or stress management")=0.82; for the Spiritual subscale (13 items, eg, "Finding meaning in your experience of illness")=0.95; for the Religious subscale (5 items, eg, "Visit from a chaplain")=0.90. Test-retest reliability was good, with a maximum Spearman’s ρ of 0.76 and only 4 items with ρ<0.2. CONCLUSION: We conclude that the Spiritual Needs Assessment for Patients Survey (SNAPS) is a tool with validity, consistency, and reliability. While further psychometric testing is warranted, this instrument may prove useful in assessing the actual spiritual needs of patients.]


II. An abstract of the validation of a translation of the present instrument appears in the American Society of Clinical Oncology's proceedings of its annual meeting for 2011 (Post-Meeting Edition). Note that the abstract refers to the instrument as the SNAPS instead of the SNAP.

Astrow, A. B., Wang, S., Huang, Y., Xu, Y., Weedon J. and Sulmasy, D. "The Spiritual Needs Assessment for Patients Survey (SNAPS): Translation into Chinese and psychometric testing." Journal of Clinical Oncology 29, no. 15, suppl. (May 20, 2011): e19589. [(Abstract:) Background: Previous research has focused on the relationship between spiritual and religious attitudes and health outcomes. Little has been done to assess patients’ spiritual needs, especially among Asian immigrants. We report on a new Chinese translation of our previously validated 23-item scale to assess patients’ spiritual needs (J Gen Intern Med 2009 24 (S1): S194-5). Methods: A bilingual Chinese-American MD translated the SNAPS questionnaire, which was then revised after review by a focus group of 8 bilingual staff (7 Mandarin, 3 Cantonese). Further revisions followed back translation by an independent bilingual individual and cognitive pre-testing with 8 Chinese cancer patients. We then administered SNAPS to a convenience sample of 30 Chinese patients at the Maimonides Cancer Center. We assessed test/re-test reliability and Cronbach's α, and correlated scores with response to the question, "Are your spiritual needs being met?" Results: Mean age 56; 63% with no religious belief; 83% self-described as spiritual but not religious; 70% no high school education; 77% with Medicaid. Overall Cronbach α was 0.89. The α for the psychospiritual subscale (5 items, eg, "relaxation or stress management, etc/") = 0.58 with test/re-test correlation 0.57; spiritual subscale (13 items, eg, "Finding meaning in your experience of illness, etc.") = 0.83 with test/-re-test correlation 0.70; religious subscale (5 items, eg, "Visit from chaplain, etc.") = 0.91 with test/re-test correlation 0.77. All three subscales showed moderately high needs (psychospiritual: mean = 13.7±3.5 out of 20; spiritual: 28.5±8.8 out of 52; religious: 8.3±4.4 out of 20, with higher scores indicating greater needs). In contrast to the English instrument, there was no correlation between a higher score on the spiritual needs subscale and negative response to the question, "Are your spiritual needs being met?" (p = 0.38). Conclusions: The Chinese SNAPS is reliable and internally consistent. Lack of correlation between SNAPS scores and the "spiritual needs" item suggests that our instrument may capture patient needs that Chinese patients would not readily describe as spiritual, whether due to cultural differences or educational level.]


III. The bibliography in this month's article offers a good selection of what might be called "foothold" articles in the assessment of patients' spiritual needs. For a sense of the variety of ways that the incidence and types of unmet spiritual needs have been measured, see especially the following:

Astrow, A. B., Wexler, A., Texeira, K., He, M. K. and Sulmasy, D. P. "Is failure to meet spiritual needs associated with cancer patients' perceptions of quality of care and their satisfaction with care?" Journal of Clinical Oncology 25, no. 36 (December 20, 2007): 5753-5757. [(Abstract:) PURPOSE: Few studies regarding patients' views about spirituality and health care have included patients with cancer who reside in the urban, northeastern United States. Even fewer have investigated the relationship between patients' spiritual needs and perceptions of quality and satisfaction with care. PATIENTS AND METHODS: Outpatients (N = 369) completed a questionnaire at the Saint Vincent's Comprehensive Cancer Center in New York, NY. The instrument included the Quality of End-of-Life Care and Satisfaction with Treatment quality-of-care scale and questions about spiritual and religious beliefs and needs. RESULTS: The participants' mean age was 58 years; 65% were female; 67% were white; 65% were college educated; and 32% had breast cancer. Forty-seven percent were Catholic; 19% were Jewish; 16% were Protestant; and 6% were atheist or agnostic. Sixty-six percent reported that they were spiritual but not religious. Only 29% attended religious services at least once per week. Seventy-three percent reported at least one spiritual need; 58% thought it appropriate for physicians to inquire about their spiritual needs. Eighteen percent reported that their spiritual needs were not being met. Only 6% reported that any staff members had inquired about their spiritual needs (0.9% of inquiries by physicians). Patients who reported that their spiritual needs were not being met gave lower ratings of the quality of care (P = .009) and reported lower satisfaction with care (P = .006). CONCLUSION: Most patients had spiritual needs. A slight majority thought it appropriate to be asked about these needs, although fewer thought this compared with reports in other settings. Few had their spiritual needs addressed by the staff. Patients whose spiritual needs were not met reported lower ratings of quality and satisfaction with care.]

Balboni, T. A., Vanderwerker, L. C., Block, S. D., Paulk, M. E., Lathan, C. S., Peteet, J. R. and Prigerson, H. G. "Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life." Journal of Clinical Oncology 25, no. 5 (February 10, 2007): 555-560. [(Abstract:) PURPOSE: Religion and spirituality play a role in coping with illness for many cancer patients. This study examined religiousness and spiritual support in advanced cancer patients of diverse racial/ethnic backgrounds and associations with quality of life (QOL), treatment preferences, and advance care planning. METHODS: The Coping With Cancer study is a federally funded, multi-institutional investigation examining factors associated with advanced cancer patient and caregiver well-being. Patients with an advanced cancer diagnosis and failure of first-line chemotherapy were interviewed at baseline regarding religiousness, spiritual support, QOL, treatment preferences, and advance care planning. RESULTS: Most (88%) of the study population (N = 230) considered religion to be at least somewhat important. Nearly half (47%) reported that their spiritual needs were minimally or not at all supported by a religious community, and 72% reported that their spiritual needs were supported minimally or not at all by the medical system. Spiritual support by religious communities or the medical system was significantly associated with patient QOL (P = .0003). Religiousness was significantly associated with wanting all measures to extend life (odds ratio, 1.96; 95% CI, 1.08 to 3.57). CONCLUSION: Many advanced cancer patients' spiritual needs are not supported by religious communities or the medical system, and spiritual support is associated with better QOL. Religious individuals more frequently want aggressive measures to extend life.]

Davison, S. N. and Jhangri, G. S. "Existential and supportive care needs among patients with chronic kidney disease." Journal of Pain & Symptom Management 40, no. 6 (December 2010): 838-843. [(Abstract:) CONTEXT: Living with chronic kidney disease (CKD) is associated with spiritual distress and frequently precipitates a search for meaning and hope; yet, very little is known about these patients' spiritual needs. OBJECTIVES: To describe the nature, prevalence, and predictors of spiritual and supportive care needs in CKD. METHODS: Prospective cohort study of 253 CKD patients who completed a seven-item spiritual and seven-item supportive care needs assessment. RESULTS: Patients reported a mean (standard deviation [SD]) number of 2.9 (2.6) spiritual needs, with 69.1% of patients reporting at least one spiritual need. The mean (SD) number of supportive care needs was 3.5 (2.1), with 91.4% of patients reporting at least one of these needs. Thirty-two percent of the patients had high spiritual needs (defined as reporting >=5 of the seven needs). Similarly, 37% of the patients reported high supportive care needs. Neither spiritual nor supportive care needs were associated with age, gender, race, marital status, dialysis modality, time on dialysis, or comorbidity. CONCLUSION: These patients had substantial spiritual and supportive care needs. There were no clear predictors of high spiritual or supportive care needs, highlighting the importance of evaluating all CKD patients for unmet needs. Health professionals will need to better understand and attend to CKD patients' spiritual needs to optimize quality care.]

Hampton, D. M., Hollis, D. E., Lloyd, D. A., Taylor, J. and McMillan, S. C. "Spiritual needs of persons with advanced cancer." American Journal of Hospice & Palliative Medicine 24, no. 1 (February-March 2007): 42-48. [(Abstract:) Spiritual needs, spiritual distress, and spiritual well-being of patients with terminal illnesses can affect their quality of life. The spiritual needs of patients with advanced cancer have not been widely studied. This study assessed the spiritual needs of 90 patients with advanced cancer who were newly admitted to hospice home care. They completed a demographic data form and the Spiritual Needs Inventory shortly after hospice admission. Scores could range from a low of 17 to a high of 85; study scores were 23 to 83. Results showed great variability in spiritual needs. Being with family was the most frequently cited need (80%), and 50% cited prayer as frequently or always a need. The most frequently cited unmet need was attending religious services. Results suggest the importance of a focus on the spiritual more than the religious in providing care to patients at the end of life.]

Hermann, C. P. "The degree to which spiritual needs of patients near the end of life are met." Oncology Nursing Forum 34, no. 1 (Jan 2007): 70-78. [(Abstract:) PURPOSE/OBJECTIVES: To determine to what degree the spiritual needs of patients near the end of life are met. DESIGN: Descriptive. SETTING: One inpatient and five outpatient hospices. SAMPLE: 62 female and 38 male hospice patients with a mean age of 67 years; 74% were dying from cancer. METHODS: Each subject completed the Spiritual Needs Inventory and rated life satisfaction via the Cantril ladder. MAIN RESEARCH VARIABLES: Spiritual needs and life satisfaction. FINDINGS: Women, patients residing in a nursing home or an inpatient hospice unit, and patients with lower levels of education reported a higher number of unmet spiritual needs. Needs that could be met independently by patients and were not related to functional status were met at a higher rate than those that were dependent on others and on functional status. CONCLUSIONS: Spiritual activities are important to patients who are near the end of life, but these patients may have a variety of unmet spiritual needs that depend on many factors, including the care setting. IMPLICATIONS FOR NURSING: Nurses must recognize the importance of spirituality to patients near the end of life. Assessment for specific spiritual needs can lead to the development of interventions to meet those needs. Meeting patients' spiritual needs can enhance their quality of life.]

Moadel, A., Morgan, C., Fatone, A., Grennan, J., Carter, J., Laruffa, G., Skummy, A. and Dutcher, J. "Seeking meaning and hope: self-reported spiritual and existential needs among an ethnically-diverse cancer patient population." Psycho-Oncology 8, no. 5 (September-October 1999): 378-385. [(Abstract:) Spiritual beliefs and practices are believed to promote adjustment to cancer through their effect on existential concerns, including one's personal search for the meaning of life and death, and hope. This study sought to identify the nature, prevalence, and correlates of spiritual/existential needs among an ethnically-diverse, urban sample of cancer patients (n=248). Patients indicated wanting help with: overcoming my fears (51%), finding hope (42%), finding meaning in life (40%), finding spiritual resources (39%); or someone to talk to about: finding peace of mind (43%), the meaning of life (28%), and dying and death (25%). Patients (n=71) reporting five or more spiritual/existential needs were more likely to be of Hispanic (61%) or African-American (41%) ethnicity (vs. 25% White; p<0.001), more recently diagnosed (mean=25.6 vs. 43.7 months; p<0.02), and unmarried (49% vs. 34%; p<0.05), compared with those (n=123) reporting two or fewer needs. Treatment status, cancer site, education, gender, age, and religion were not associated with level of needs endorsement. Discriminant analysis found minority status to be the best predictor of high needs endorsement, providing 65% correct classification, p<0.001. Implications for the development and delivery of spiritual/existential interventions in a multi-ethnic oncology setting are discussed.]


IV. For overviews of measures of spirituality, see the following articles noted in our Fall 2011 and Winter 2012 Newsletters:

Gijsberts, M. J., Echteld. M, A., van der Steen, J. T., Muller, M. T., Otten, R. H., Ribbe, M. W. and Deliens, L. "Spirituality at the end of life: conceptualization of measurable aspects--a systematic review." Journal of Palliative Medicine 4, no. 7 (2011): 852-863. [See the note of this article in our Network's Winter 2012 Newsletter, §10.]

Meezenbroek, E. de J., Garssen, B., van den Berg, van Dierendonck, D., Visser, A. and Schaufeli, W. B. "Measuring spirituality as a universal human experience: a review of spirituality questionnaires." Journal of Religion and Health 51, no. 2, (2012): 336-354. [See the note of this article in our Network's Fall 2011 Newsletter, §6. This is an open access article.]

Monod, S., Brennan, M., Rochat, E., Martin, E., Rochat, S. and Bula, C. J. "Instruments measuring spirituality in clinical research: a systematic review." Journal of General Internal Medicine 26, no. 11 (November 2011): 1345-1357. [See the note of this article in our Network's Fall 2011 Newsletter, §6.]

Sessanna, L., Finnell, D. S., Underhill, M., Chang, Y.P. and Peng, H. L. "Measures assessing spirituality as more than religiosity: a methodological review of nursing and health-related literature." Journal of Advanced Nursing 67, no. 8 (August 2011): 1677-1694. [See the note of this article in our Network's Fall 2011 Newsletter, §6.]


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