October 2004 Article of the Month
Clark, P. A., Maxwell, D. and Malone, M. S. "Addressing patients' emotional and spiritual needs." Joint Commission Journal on Quality and Safety 29, no. 12 (December 2003): 659-670.
NOTICE OF ARTICLE AVAILABILITY ON-LINE: This month's featured article is available on-line through the SmartPatient.me site at http://smartpatient.me/wp-content/uploads/2012/10/addressing_es_needs.pdf.
SUMMARY AND COMMENT: The article this month was selected for three reasons. First, it is from the Joint Commission Journal on Quality and Safety, a publication of the Joint Commission on Accreditation of Healthcare Organizations, and thus has the powerful imprimatur of JCAHO. Second, it presents findings from analysis of data from the widely used and influential Press Ganey patient satisfaction surveys. Third, it implicitly raises an important question for pastoral care researchers: What is the relationship between the concepts of emotional needs, psychological or psychosocial needs, and spiritual needs?
Since many health care chaplains work in or with institutions accredited through JCAHO, the present article is of practical value as the most elaborate statement on spirituality that has come from a JCAHO source. It should be seen to stand along side of the briefer but more official statements in the various JCAHO Handbooks, which detail the standards for accreditation, and the clarification of Spiritual Assessment that is presented on their web site under Frequently Asked Questions. [Added 2/20/05:] Note: This FAQ was updated in 2008. See a comparison of the 2004 and the 2008 content. [Added 2/20/05:] Also, the February 2005 issue of the JCAHO publication, The Source (vol. 3, no. 2) addresses "Evaluating Your Spiritual Assessment Process" [see pp. 6-7] --available on-line through the website of the Association for Professional Chaplains, at www.professionalchaplains.org/files/resources/reading_room/evaluating_your_spiritual_assessment_process.pdf.
The article generally supports the ideas that spiritual needs are prevalent among patients and that they impact patient outcomes [though some very old studies are cited: see p. 661 and citations #44 and #45] and overall patient satisfaction with an institution, which in turn has financial implications. The authors consider spiritual care broadly, as an issue for all staff (and revolving largely around empathic communication), but they do particularly support chaplaincy [p. 664], drawing primarily on Larry VandeCreek's and Marjorie Lyons' 1997 Ministry of Hospital Chaplains: Patient Satisfaction [see Other Items of Interest, below]. They emphasize multidisciplinary care, stating, "An isolated chaplaincy/pastoral care team exclusively responsible for patients' emotional and spiritual needs will be unlikely to influence organization-wide behaviors and processes needed to address patients' emotional and spiritual needs" [p. 664]. The last third of the article is devoted to suggestions for improving institutional responsiveness to patients' emotional and spiritual needs, including practical advice on language to use with patients.
The core of research presented in the article is from an analysis of the Press Ganey 2001 National Inpatient Database of responses to satisfaction surveys from over 1.7 million patients from 33% of all hospitals in the US. One standard item on the Press Ganey survey at that time asked about "the degree to which staff addressed your emotional/spiritual needs" [p. 660]. Results indicate that:
The item about "the degree to which staff addressed your emotional/spiritual needs" was shown to be highly correlated with three other items on the surveys: "response to concerns/complaints made during your stay," "staff effort to include you in decisions about your treatment," and "staff sensitivity to the inconvenience that health problems and hospitalization can cause" [p. 663]. Two moderately correlated items were: "how well staff worked together to care for you" and "staff concern for your privacy" [p. 663]. Data are presented in several very clear tables.
In all of this, there is implicitly a question about the relationship between--and potential delineation between--the concepts of emotional needs and spiritual needs. The Press Ganey survey item puts them together, making interpretation difficult unless one assumes the terms are synonymous. Indeed, the authors here seem to use these terms (along with psychological needs and psychosocial needs) with varying degrees of distinction at various times. The authors state that there are "parallels between perceptions of emotional and spiritual needs" and that "emotional and spiritual needs...interrelate on a clinical level" [p. 660], but it is the sense of this reader that the terms are lumped together without a sufficient disclaimer about the potential difficulties of doing so.
Of course, a lack of clarity of terms seems a perennial problem in the discussion of spirituality and health, and the present article probably does better than most in working constructively amid the conceptual confusion in the field. However, the fact that the Press Ganey survey item has been changed as of February 2004 to omit the reference to spiritual, and to read now: "degree to which hospital staff addressed your emotional needs"--leaving institutions the option to ask separately about the "degree to which hospital staff addressed your spiritual needs" [see p. 1 of the "Press Ganey knowledge summary" in the Other Items of Interest, below]--indicates that the survey company itself came to recognize that the compound nature of the old wording was problematic for interpretation. Conceptual issues like these play directly into methodological ones for researchers.
The authors, all three of whom work for Press Ganey, give a very readable overview of the potential importance of spirituality to patients, inasmuch as spiritual needs are closely connected to emotional ones. The article is very practical in its approach, and it is practical in its value to chaplains working in institutions where JCAHO and Press Ganey are key elements in the course of business. For researchers, it raises intriguing connections between spiritual and emotional needs, and the recent revision of the Press Ganey survey, setting up separate streams of data on these two connected types of patient-perceived needs, appears ripe for further analysis.
Suggestions for the Use of the Article for Discussion in CPE:
If your institution uses Press Ganey surveys, this month’s article would offer a good entrée to the topic of patient satisfaction data at the beginning of a CPE program or a chance to delve deeper into the topic later on. If your institution further collects data from a non-standard item about spiritual needs in particular (since, as of 2004, the standard item asks only about emotional needs), there could be some comparison of scores. Press Ganey scores have been know to fluctuate month-to-month or quarter-to-quarter in ways that are hard to understand, but trends may be discernable that could be the focus of discussion (and perhaps for quality improvement planning). The article's main point, that patients’ emotional and spiritual needs are connected to patients’ perceptions of other aspects of hospitalization, could help students see how their work may play into a complex of interactions that affect patients’ experiences, and how pastoral care is part of a multidisciplinary effort. Advanced students may be able to reflect upon how they hear from patients about responsiveness to complaints/concerns, inclusion in the process of treatment decisions, and the inconveniences of illness and hospitalization--areas that are correlated with emotional and spiritual needs in the Press Ganey data. Students should also find useful the extensive bibliography (148 references), though it strikes this reader as less current than it may first appear. The research methodology used by Press Ganey is likely too involved for student discussion, but students could be challenged to think about just how they would try to measure patient satisfaction regarding pastoral care or general staff attention to spiritual needs.
Other Items of Interest:
[ADDED 12/20/07]: 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.]
[ADDED 1/29/06]: Benjamins, M. R. "Does religion influence patient satisfaction?" American Journal of Health Behavior 30, no. 1 (January-February 2006): 85-91. [This study of data from a nationally representative survey of older adults in the US found that "higher levels of religious salience are significantly related to being very satisfied with one's health care, even after demographic, social, and health variables are taken into account" (--from the article's Abstract).]
[ADDED 12/27/05]: Mann, J. R., McKay, S., Daniels, D., Lamar, C. S., Witherspoon, P. W., Stanek, M. K. and Larimore, W. L. "Physician offered prayer and patient satisfaction." International Journal of Psychiatry in Medicine 35, no. 2 (2005): 161-170. [In this randomized controlled trial (n=137) from the University of South Carolina School of Medicine, over 90% of the sample of patients in a family practice setting who were offered physician-led prayer accepted, but there was no measured affect on patient satisfaction.]
Nussbaum, G. B. "Spirituality in critical care: patient comfort and satisfaction." Critical Care Nursing Quarterly 26, no. 3 (July-September 2003): 214-220.
VandeCreek, L. and Lyon, M. A., eds. Ministry of Hospital Chaplains: Patient Satisfaction. Binghamton, NY: Haworth Pastoral Press, 1997. This title was published simultaneously as The Journal of Health Care Chaplaincy 6, no. 2 (1997). [Reviewed by Mark E. Jensen in The Journal of Pastoral Care 53, no. 1 (Spring 1999): 120-122.]
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