RELATIONSHIP BETWEEN RELIGION AND SPIRITUALITY AND APPLICATION OF SPIRITUALITY IN HEALTH CARE DELIVERY

1. SPIRITUALITY
AND
RELIGION
In health care
DR OGECHUKWU MBANU
FAMILY MEDICINE
DEPARTMENT
AKTH
KANO
31ST MAY 2018

2. CONTENT
• Introduction
• Religion versus spirituality
• Health care in early times
• Ancient Medicare and religion
• Two vies of healtah care
• Medicine in the era of
Christianity
• Secular medicine
• Separation of medicine and
religion
• Biopsychosocial spiritual model
• Relationship between
spirituality and medicine
/statistics
• Spiritual distress
• Spiritual care
• Spiritual assessment
• Spiritual care giving
• How to spiritual history
• Benefits of spiritual care
• conclusion

3. INTRODUCTION
• According to American Association of Family Physicians, spirituality is
defined as the way one finds meaning, hope, comfort and inner peace
in ones life
• spirituality is a fact in the lives of many people(spirit ,soul ,body)
• It is also a fact that many people use their spirituality to cope with
health issues.
• Therefore person’s spiritual practice can affect their clinical outcomes
• Religion refers to a belief system to which an individual adheres.
• It involves particular rituals and practices—the externals of our belief
system
• Religion can be organized and practiced within a community that
follows certain traditions and holds certain beliefs

4. INTRODUCTION CONT’D
•The word “spirituality” is from the Latin term “spiritus”, which
means “breath” – referring to the breath of life
• Spirituality consists of two dimensions, one transcendent of
the physical world and the other consisting of connectedness
to the physical world
•Religion-organizes the spiritual experiences of a group of
people into a system of beliefs and practices
•Many people find spirituality through religion
•Apart from religion ,some people find spirituality by
communing with nature, music, the arts, quest for scientific
truth, or a set of values and principles

5. RELIGION VERSUS SPIRITUALITY
•Sometimes used interchangeably, they are in
fact very different.
•Religion = as a set of beliefs, rituals and
practices, usually embodied within an
institution or an organization.
•Spirituality = a search for what is sacred in life,
one’s deepest values, along with a relationship
with God, or a higher power, that transcends
the self.

6. DIFFERENCE BETWEEN SPIRITUALITY AND RELIGION
Religion Spirituality
Community focused Individualistic focused
Observable, measurable, objective Less visible, measurable, subjective
Formal, orthodox organized Less formal, unorthodox,
Behavior-oriented, outward practices Emotionally-oriented, inward directed
“Good/evil” doctrine Non-doctrine oriented
Authority-directed Self-directed
Religious practices such as prayer,
reading the Quran/Bible/Torah, and
Spiritual practices such as meditating,
listening to music, and hiking

7. Major Religions in
the World
•Christianity: 1.9
billion people
•Islam: 1.1 billion
•Hinduism: 800
million
•Buddhism: 325
million
•Judaism: 13 million

9. Health Care in Early Times
Medicine & Religion
•Few interventions were possible
•Application of herbal medicines
•Religious concepts of cause and effect included
•punishment for sins
•indwelling of evil spirits
•separation of the patient from God
•or the unknowable mystery of illness

10. Ancient medicine & religion
•3000 BCE early written documents show Egyptian &
Mesopotamian healers were priests with magico-
religious concepts.
• By the 3rd century BCE , the Romans were influenced
by the Greek’s cult of Asclepius
•From 5th century BCE the cult of Asclepius grew more
popular and pilgrims flocked to its healing temples
•5th century BCE in Greek medicine, Hippocrates begins
a more scientific approach, including natural causes.

11. Ancient medicine & religion
•Asclepius – god of Medicine
,healing , rejuvenation and
physicians
•He had 5 daughters ,one of
them was Hygieia (goddess
/personification of health)
•The rod of Asclepius a snake
– intertwined staff ,remains
a symbol of medicine today
Greece – temple of asclepius

12. Ancient medicine &
religion cont’d
• Hygeia played an important part
in her fathers cult
• he was more directly associated
with healing
• She focused on prevention of
sickness and the continuation of
good health
• Her name is the source of the
word ``hygiene’’
• Nursing care and natural healing
processes grew from the
approach of Hygeia.

13. Two views of health care HYGEIA versus ASCLEPIUS
HYGEIA
• Health is the natural order of things,
• Fostered by prudent choices and wise living,
• The goal is to find balance between a sound body, a sane mind, and a calm spirit
• Medicine should discover & teach the natural laws, so we might cooperate
• By cooperating we have good health
ASCLEPIUS
• The chief role of medicine is to treat disease,
• the heroic intervener.
• The root of Interventive Medicine

14. Christian era and secular medicine
• Healings were attributed to Jesus, who sometimes linked healing with
forgiveness of sins
• By the 5th century AD, virtually all physicians were drawn from clergy
in the monastic communities.
• Secular medicine emerged in the late middle ages, but was still under
control of church.
• 1140 AD church granted first medical licenses, conditions, &
revocations.
• 1789, the French Revolution, marked the break down of religious
control over medicine.
• Cartesian: separation of mind and body
•

15. Separation of Medicine from Religion
•As science began to discover
the etiology of diseases,
former religious explanations
no longer held.
•Science and medicine began
to distance themselves from
religion & God

16. BIOPSYCHOSOCIAL-SPIRITUAL MODEL OF CARE
• Biopsychosocial model of care was proposed by Engel and White (1976)
• Extended to encompass the spiritual by Daniel Sulmasy (2002).
• Humans are intrinsically spiritual since all persons are in relationship with
themselves, others, nature, and THE SIGNIFICANT OR SACRED
• Current view of health care = Humans are BIOPSYCHOSOCIALSPIRITUAL
entities
• Illness and healing are biopsychosocial spiritual phenomena
This takes into consideration
• Scientific view of pathophysiology
• Respect for the psychological
• Perception of the social environment
• Attention to the spiritual distress and the spiritual resources of the patient

17. BIOPSYCHOSOCIAL-SPIRITUAL MODEL OF CARE
•Disease is said to be disturbance in the right
relationships that constitute the unity and
integrity of a human being.
• When one encounters a life-threatening illness,
it involves a person in his or her totality.
•This totality includes the biologic, psychological,
social and spiritual aspects

18. BIOPSYCHOSOCIAL-SPIRITUAL MODEL

19. RELATIONSHIP BETWEEN SPIRITUALITY AND MEDICINE
•In the beginning of the
21ST century, over 2,000
papers were published in
medical literature on the
benefits of spirituality in
healing and health . These
benefits include
•greater marital stability,
•less alcohol and drug use,
•lower suicide rates
•lower blood pressure
•lower cholesterol
•conservative sexual
practices
•lower sexually transmitted
diseases.
•less anxiety and
depression
•less cigarette smoking

20. SPIRITUALITY / RELIGION AND MEDICINE – STATISTICS
•Studies using spiritual and religious variables
find that religious involvement and spirituality
was associated with better health outcomes
•This was found to be so in some
•350 physical health studies
•900 mental health studies
•100 mortality studies in the past few years

21. SPIRITUALITY / RELIGION AND MEDICINE STATISTICS cont’d
•Regarding the use of spiritual/religious variables in
Medical Research
•3.5% of family practice studies
•1.1% of internal medicine studies
•11.8% of adolescent health studies
•10% of nursing mental health studies
•Neglect of religious/spiritual variables likely due to
reliance on biomedical model
•In which case physical evidence is paramount.

22. SPIRITUAL DISTRESS
• Spiritual distress occurs when individuals are unable to find sources
of meaning , hope, peace , strength and connection in life OR
• when conflicts occur, between their beliefs and what is happening in
their life
• This distress can have detrimental effect on physical and mental
health
• Potential triggers for spiritual distress
• After a trauma (such as accident or assault)
• When bad news is broken
• When a situation becomes life threatening or terminal
• When bereavement is experienced
• When a patient is isolated and receiving no visitors.

23. SPIRITUAL DISTRESS cont’d
Signs of Spiritual Distress
• Tearfulness or weeping or ask ‘why me’
• Withdrawal or lack of interest
• Restlessness or being unable to settle
• Anger
• Sudden religious leanings or abandonment of previously held belief
• Fear of being alone or falling asleep
• Cannot accept change, loss
• Expresses feeling of abandonment by religious group or God
• Feels guilty/deserving of punishment
• Feels self to be bad, sinful, unlovable
• Questions the moral or ethical implications of therapies

24. SPIRITUAL CARE
•Spiritual care has to do with recognizing and
responding to the expressions of spirituality we
encounter in our patients and their families.
•It involves compassion, presence, listening and the
encouragement of realistic hope
•It might not involve any discussion of God or religion
•According to the biopsychosocial-spiritual model,
everyone has a spiritual history

25. SPIRITUAL CARE GIVERS
•Spiritual care can be
•General – providing connection ,comfort, presence
•Specific – addressing specific concerns or needs eg
request fo regular holly communion
•Physicians and other health care providers
•Family and Friends
• hospital Imam / Chaplains
•Spiritual Leaders
•Community leaders

26. Prerequisites to Spiritual Care
•A physician needs to understand his or her own
•spiritual beliefs,
• values and
•biases in order to remain patient-centered and
non - judgmental
•Establishment of a good physician-patient
relationship
•Appropriate timing of discussions

27. SPIRITUAL ASSESSMENT
•Spiritual Assessment-is the process by which the health care
provider is able to identify a patient’s spiritual needs pertaining
to medical care
•Part of clinical evaluation which involves evaluation of the
patients perspective on spirituality ,
•whether spirituality is hurting or helping the patient
•Monitor and mitigate spiritual health risks
•Structured or Unstrcutured
• Sructured – HOPE ,FACT
• Unstructured – just having a chart and picking out the important
points

28. SPIRITUAL ASSESSMENT
•It helps the Dr to understand the spiritual resources
available to this patient for getting well
•Some of these spiritual resourses include meaning ,
purpose , trust , resilience , optimism
•HOPE ,FACT ,SPIRIT , FICA ,FAITH , KUHNS etc
•These methods are assessed based on 5 qualities :
brevity , content ,patient centeredness , credibility
,and ease of memorizing

29. KUHN’S SPIRITUAL EVALUATION
• Clifford Kuhn ,provides one of the earliest spiritual inventories that
taps into seven areas :
• Meaning
• Purpose
• Belief and faith
• Love
• Forgiveness
• Prayer
• Meditation and worship
• Each area is explored with five questions ,resulting in 35 questions
• Takes about 30 minutes to administer and is considered to take too
long to administer

30. KUHN’S SPIRITUAL EVALUATION cont’d
•Consideration of the following five belief and faith
questions makes Kuhn's spiritual inventory more
manageable
•What things do you believe in or have faith in ?
•Has this illness influenced your faith ?
•How do you exercise faith in your life ?
•How has your faith influenced your behavior during
this illness ?
•What role does your faith play in regaining your health

31. FAITH (King, 2002)
•F – Do you have a Faith or religion that is
important to you?
•A – How do your beliefs Apply to your health?
•I - Are you Involved in a faith community?
•T - How do your spiritual views affect your
views about Treatment?
•H - How can I Help you with any spiritual
concerns

32. FICA SPIRITUAL ASSESSMENT TOOL
•Christiana Puchalski (2000) developed 5 questions that can
be easily remembered using the income tax mnemonic FICA
F – Faith what is your faith tradition?
I – importance how important is your faith to
you?
C– community what is your community of faith
A – apply how do your religious and spiritual
beliefs apply to your health?
A– address how can we address your spiritual
needs

33. MAUGHANS SPIRIT SPIRITUAL HISTORY
• Todd maugans (1996 ) developed a spiritual history that covers six areas (SPIRIT)
S piritual belief system
• What is your formal religious affiliation
• Name or describe your spiritual belief system
P ersonal spirituality
• Describe the beliefs and practices of your spiritual belief system that you
personally accept
• Describe the beliefs and practices you do not accept
• What does your spirituality /religion mean to you
• What is the importance of your spirituality / religion in your daily life
I ntegration within a spiritual community
• Do you belong to any spiritual community ,What is your position or role
• What importance does this group have to you ,IS it a source of support ?

34. MAUGHANS SPIRIT SPIRITUAL HISTORY CONT’D
Ritualized practices and restrictions
• Are there specific practices that you carry out as part of your
religion e.g. prayer , or meditation
• Are there lifestyle activities or practices that your religion /
spirituality encourages or forbids
• What significance do these practices and restrictions have to you
Implications for medical care
Terminal events planning

35. THE FACT TOOL
• developed by Mark LA Rocca - Pitts, (2008)
•includes three questions (Faith, Availability and Coping)
plus an outcome (Treatment).
•provides a quick and accurate determination of whether
a person’s current health crisis impacts their spiritual
wellbeing and suggests a treatment plan if needed –
•Faith or Beliefs
•A – Availability, Accessibility, Applicability
•C – Coping or Comfort
•T – Treatment Plan

36. Specific questions IN FACT EVALUATION
• F -- What is your faith or belief?
• Do you consider yourself spiritual or religious?
• What things do you believe that give your life meaning and
purpose?
• A – Is support for your faith available to you?
• Are you part of a religious or spiritual community?
• Do you have access to what you need to apply your faith?
• Is there a person or a group whose presence and support you value
at a time like this?
• C – How are you coping with your medical situation?
• Is your faith helping you cope?
• How is your faith providing comfort in light of your diagnosis?

37. Specific questions IN FACT EVALUATION CONT’D
T – Treatment Plan
•1. Patient is coping well
• a. Support and encourage
• b. Reassess at a later date
•2. Patient is coping poorly
• a. Depending on relationship and similarity in faith/beliefs, provide
direct intervention: spiritual counseling, prayer, Sacred Scripture,
etc.
• b. Encourage patient to address these concerns with their own faith
leader
• c. Make a referral to the hospital CHAPLAIN/IMAM (DO NOT ask if
patient wants referral—let the chaplain/Imam do own assessment!)

38. HOPE Questions for Spiritual Assessment
•Ananda rajah & Hight, 2001
•H – sources of hope
•What are your sources of hope, strength, comfort, and
peace? What do you hold on to during difficult times?
•O – organized religion
•Are you part of a religious or spiritual community?
•Does it help you? How?
•P – personal spirituality and practices
•Do you have personal spiritual beliefs?
•What aspects of your spiritual practices do you find most
helpful?

39. HOPE
•E – effects on medical care and end-of-life issues
•Does your current situation affect your ability to do
the things that usually help you spiritually?
•As a doctor, is there anything that I can do to help you
access the resources that usually help you?
•Are there any specific practices or restrictions I should
know about in providing your medical care?
•If the patient is dying: How do your beliefs affect the
kind of medical care you would like me to provide over
the next few days/weeks/months

40. LET GO (Storey and Knight 1997
•L -- Listening to the patient’s story
•E -- Encouraging the search for
meaning
•T -- Telling of your concern and
acknowledging the pain of loss
•G -- Generating hope whenever possible
•O -- Owning your limitations

41. SPIR (Frick et al)
S -- Would you describe yourself – in the broadest
sense of the term – as a believing/ spiritual /
religious person?
P -- What is the place of spirituality in your life?
How important is it in the context of your illness?
I -- Are you integrated in a spiritual community?
R -- What role would you like to assign to your
doctor, nurse or therapist in the domain of
spirituality

42. CSI-MEMO (Koenig, 2002)
•CS - Do your religious/spiritual beliefs provide
comfort or are they a source of stress?
•I - Do you have any spiritual beliefs that might
Influence your medical decisions?
•MEM - Are you a MEMber of a religious or spiritual
community, and is it supportive to you?
•O - Do you have any Other spiritual needs you’d like
to talk about

43. ACP SPIRITUAL HISTORY
• By American college of physicians and American society of internal
medicine
• Comprises of four simple questions
• Is faith ( religion , spirituality ) important to you in this illness ?
• Has faith been important to you at other times in your life ?
• Do you have someone to talk to about religious matters ?
• Would you like to explore religious matters with someone
• Does not get too personal e.g. physician offer to address patients
spiritual needs
• Draw back is inability to get information in several key content areas
• Identifying spiritual needs
• Connections with spiritual community
• Beliefs affecting medical decision making

44. MATTHEW’S SPIRITUAL HISTORY
• Dale Matthews suggested that physicians ask patients three
fundamental questions as part of their initial ( in - take ) evaluation
• Is religion or spirituality important to you ?
• Does your religious or spiritual beliefs influence the way you look at your
medical problems and the way you think about your health
• Would you like me to address your religious or spiritual beliefs and practices
with you
• Brief ,easy to remember (I,I,I, = importance , influence , interaction)
• Final question is a bit personal ,suggesting a more active physician role
• Has been shortened to include only 2 questions
• Is your religion (or faith ) helpful to you in handling your illness
• What can I do to support your faith or religious comitment

45. Spiritual history taking resources
History taking
resource
Brevity Content Patient-
centeredness
Credibility Ease of
memorizing
Kuhn’s spiritual
inventory
- 7 areas,
35 questions
+ + -
Matthews spiritual
inventory
+++ 3 questions ++ + ++
FICA spiritual
assessment tool
++ 5 questions ++ ++ ++
Maugan SPIRITual
history
+ 6 areas ++ ++ ++
HOPE questionnaire + 4 areas ++ ++ ++
ACP spiritual history ++ 4 questions ++ +++ +

46. Spirituality Assessment Measures
•Used most times for research purposes
•Spiritual History Scale (Hays, 2001)
•RCOPE (Pargament, 2000)– religious coping and struggles
•Spiritual Strivings Scale (Mahoney, 2005)
• Religious Problem-Solving Styles (Pargament, et al. 1988)
•Religious Internalization (Ryan, 1993) – religious
motivation
•Spiritual Well-Being Scale (Paloutzian, 1982)
•FACIT Spiritual Well-Being Scale (Peterman, 2002)

47. How To-The Spiritual History
•Physician attitude and approach
•Sensitivity, integrity, respectfulness,
gentleness
•Sitting and listening has value
•Use patient-centered reflection rather than
providing answers to spiritual questions
•Do not impose spiritual or religious views on
patients

48. RISKS OF SPIRITUALITY
•Folly of fatalism – believe that all things has been pre
determined ,thus no need of personal input
•Refusal of vaccination
•Refusal of medical treatment
•Jehovah witness
•Engaging in dangerous practices
•Pentecostal holiness churches in Appalachia that handle
dangerous snakes and drink poison during worships
•Interference with patients civil liberties

49. Benefits of spirituality
•Healthy grieving of losses (letting go)
•Improved self-esteem and confidence
•Maximization of personal potential
•Improved relationships (with self, others and God)
•Renewed sense of meaning and purpose
•Enhanced feeling of belonging
•Improved capacity for solving problems
•Insoluble problems, continuing distress and disability are more
easily endured
•Hope renewed

50. Hindrances to spiritual assessment /spiritual care
•Lack of proper education on how to perform
spiritual assessment
•Time constraints
•Excessive work load
•Lack of experience and confidence of care
givers
•Lack of continuity of care and lack of privacy

51. CONCLUSION
• A spiritual assessment is not only about what a person believes; it is
mostly about how their faith or belief functions as a coping
mechanism.
• Religion can be one of the ways the patient expresses his or her
spirituality
• Doctors must Respect the privacy of patients with regard to their
spirituality and should not impose their own beliefs.
• Make referrals to professional chaplains /Imams , spiritual leaders as
appropriate.
• Your own spirituality can positively affect the clinician patient
relationship.
• Remember: “Cure sometimes; relieve often; comfort always.”

52. REFERENCES
• Larry C , Taking A Spiritual History Advances In Psychiatric Treatment 2007,vol
13,212-219
• Aaron S , Karen P , Spiritual Assessment American Academy Of Family Physicians
2012
• Harold G.K. Spirituality In Patient Care ,Why, What ,How ,Pennsylvania ,Templeton
Foundation Press ,2002
• Mark LA Rocca , FICA ,A Chaplain Tool for Assessing Spiritual Needs In An Acute
Care Setting, chaplaincy Today ,Journal of the Association Of Professional
Chaplains 2012, Volume 28 Number 1
• Dr David Van Denbugh ,Drvsreligion Classes ,The Spiritual Assessment
,Spirituality and Healing In Health Care RELP315
• SPIRITUALITY AND MEDICAL CARE” By DR. M. A. Odewale
• Spirituality and Medicine Dr Suleiman Yakubu
• Spirituality and Medicine Jason Lohr, MD