Session 2: Spiritual Screening - Using Just One Question APC Webinar Journal Club http://www.professionalchaplains.org/apcstore/productdetails.aspx?productid=apcwebwjc Webinar Journal Club Aims Substantive aim Methodological aim the role of religion and spirituality in the meaning making process help chaplains develop and maintain research literacy Standard 12: Research The chaplain practices evidence based care including ongoing evaluation of new practices and when appropriate, contributes to or conducts research. (http://www.professionalchaplains.org) 2 Why this article? 1
Parks Meaning-making Model PEACE Source: Park, Religion and Meaning, 2005 3 Levels of Clinical Inquiry About Religion/Spirituality Screening for religious struggle or spiritual pain Rush Protocol (Fitchett & Risk, 2009) Are you at peace? (Steinhauser et al., 2006) Are you experiencing spiritual pain? (Mako et al., 2006) Religious/spiritual history taking FICA (Puchalski & Romer, 2000) HOPE (Anandarajah & Hight, 2001) Spiritual assessment 7x7 model (Fitchett, 2002) Discipline for Pastoral Care Giving (Lucas, 2001) Pastoral Diagnosis (Pruyser, 1976) Massey, Fitchett, and Roberts, 2004 Screening vs. Assessment Screening for religious struggle is an attempt to identify patients who may be experiencing religious struggle. Screening for religious struggle employs a few, simple questions, that can be asked by health care colleagues. 2
A Measure Must Be Reliable and Valid Definition Types Examples Validity The extent to which an instrument measures what it is intended to measure Reliability The degree to which repeated measurements of the same subject yield consistent results. Face validity Criterionrelated validity Internal consistency reliability items appear to measure what they are supposed to measure Compare with related constructs Cronbach s alpha The Research Summary Outline: A Guide to Reviewing the Evidence 1. Background Importance of topic Review of literature Study aims, research questions, or hypotheses 2. Research methods Sample Study Design Measures Analysis 3. Results 4. Discussion (by the study authors) 5. Critical Evaluation (your thoughts) Integration with other research 6. Clinical Implications (your thoughts) Limitations For your work? Implications for further research For the work of other clinicians? Karen E. Steinhauser, PhD Associate Professor, Department of Medicine, Duke University Medical Center Senior Fellow, Duke University Center for Aging Health Scientist, Center for Health Services Research in Primary Care, VA Medical Center, Durham 2010 Impact Factor 10.64 http://medicine.duke.edu/faculty/details/0061983 3
Prior Research by Steinhauser & Colleagues Aim Method Sample Reference Gather descriptions of a good death Qualitative, 12 focus groups Survey randomly Determine factors selected samples considered from national data important at end oflife (EoL) files (patients and families from VA) Develop measure of quality of life (QoL) Survey at EoL Validate QUAL E Explore being at peace as gateway to eliciting patient and family concerns. Survey with 1 week re test Survey Patients (3 gps), family (1 gp), providers (5 gps, incl 1 gp of chaplains; all in Durham NC) Patients w advanced chronic illness (n=340), bereaved family (n=332), MDs (n=361), other health professionals & hospice volunteers (n=429; included 120 APC chaplains) 200 outpts with adv cancer, CHF, COPD, ESRD (Durham VA, Duke hospital) 248 outpts patients with adv cancer, CHF, COPD, ESRD (Durham VA, Duke hospital) Same as above Steinhauser et al, Ann Intern Med. 2000 Steinhauser et al, JAMA. 2000 Steinhauser et al, J Palliat Med. 2002 Steinhauser et al, Palliat Support Care. 2004 Steinhauser et al, Arch Intern Med. 2006 Background for the study A practical and evidence-based approach to discussing spiritual concerns in a scope suitable to a physician-patient relationship may improve the quality of care for patients a the end of life. Such a construct [the peace item] might serve as a brief, nonthreatening gateway to eliciting patient and family concerns. Study Aims Construct something we can only measure indirectly Quantitative with numbers Life limiting Correlations example: a person who scores high on a measure of Being at Peace should also score high on other measures associated with peace. 4
Introduction After you read the introduction, what made this study seem interesting to you? Methods: Item Development Steps from past studies Asked open ended questions good and bad deaths in interviews and focus groups (qualitative research ); Took answers and created 44 items matching content e.g. be kept clean, believe family is prepared for one s death Asked to rank whether or not they found the item important with strongly disagree to strongly agree From nine selected items they found that patients rated Being at peace with God highest along with being free from pain. Methods: Item Development Steps from one more study Check correlations Look to see if peace with God is related to other items about peace; Examined the correlation of these items with each other; Implications This would mean that a person who says that peace with others is very important would also say that peace with God is very important; Asking a person about peace will pick up on areas of peace that are important to the person. 5
Items Correlate Below is a list of statements that other people with a serious illness have said may be important. Please tell me how true each statement is for you. Not at all 1 I feel at peace 1.) with myself. A little bit 2 A moderate amount 3 Quite a bit 4 Completely 5 1 2 3 4 5 2.) with personal relationships. 1 2 3 4 5 3.) With God. 1 2 3 4 5 3.) Spiritually 1 2 3 4 5 Methods: Study Design, Sample Study Design Additional analysis of cross sectional survey data Sample 248 outpts with advanced illness (CA, COPD, CHF, ESRD) Random assignment of order of recruitment Screen for mental status Sample Details (Table ) Durham VA and Duke Med Cntr Clinics Diverse in diagnoses, age, sex, race, education, site Methods: Measures Construct Measure Subscales Screening item I feel at peace(qual E) Quality of Life FACT G Physical Functional Emotional Social/Family Well Being Spiritual Well Being FACIT Sp Meaning/Peace Faith Social Support EPESE Instrumental Affective 6
Measures: QUAL-E factors Steinhauser et al Palliat Support Care. 2004 Measures: FACIT-SP items I feel peaceful. I have a reason for living. My life has been productive. I have trouble feeling peace of mind. I feel a sense of purpose in my life. I am able to reach down deep into myself for comfort. I feel a sense of harmony within myself. My life lacks meaning and purpose. I find comfort in my faith or spiritual beliefs. I find strength in my faith or spiritual beliefs. My illness has strengthened my faith or spiritual beliefs. I know that whatever happens with my illness, things will be okay. Statistical Analysis Look to see if demographic information (things like gender, ethnicity, age ) were associated with peace. For example, is being a woman associated with a higher level of peace than being a man. Why does that matter? 7
Statistical Analysis Look to see if other measures of quality of life, FACIT Sp and a social support scale, are related to the question. Why does that matter? Methods: Human Subjects Protection Approved by the institutional review boards of both Medical Centers. The study met criteria for ethical studies with human subjects. Results: Demographic Factors Peace is positively associated with age. r=0.24 No significant associations with any other demographic factors. Why does that matter? (An example of when non significance is significant.) 8
RESULTS: Construct Validity Measure Correlation* with Peace Item Significant FACT Emotional WB r = 0.52 Yes Physical WB r = 0.28 Yes Functional WB r = 0.35 Yes Social Family WB r = 0.41 Yes Social Support Instrumental r = 0.06 No Affective r = 0.08 No FACIT Sp r = 0.60 Yes Meaning/Peace r = 0.47 p<.001 Faith r = 0.51 p<.001 *Spearman rank correlations Discussion (Investigator s report) Integration with other research MD reports of barriers for discussing religion/spirituality with patients. Research about patient preferences for discussing R/S with their doctors. Implications for practice Patient s sense of being at peace may be gateway to discuss emotional and spiritual concerns. Permits patients to identify salient areas where peace is a concern. Useful for screening, not thorough spiritual history. If spiritual concerns emerge, MD can make referral to chaplain. Limitations of the study Sample limitations: racial/ethnic, geographic (religious) Further research Not discussed Critical Evaluation (our thoughts) Strengths Develops a tool for screening based on evidence from research rather than just personal experience. Builds on QUAL E and its strengths. Offers a model for a systematic development of a tool. Creates a clinically useful tool for health care providers. simple, non threatening (non religious), inclusive Weaknesses What proportion of these patients are/are not at peace? How does this screener work in clinical practice? 9
Critical Evaluation (our thoughts) Clinical Implications Could be a good tool that nurses, doctors, and other staff could use to guide referrals to chaplains. Future Research Test in clinical practice MD willingness to use, Accuracy in identifying patients in distress (not at peace) and guiding referrals Test in more diverse populations Related Research Other models for screening for spiritual concerns Prevalence of spiritual pain, distress, struggle Other research about being at peace Other Screening Tools Are you experiencing spiritual pain right now? A pain deep in your being that is not physical Yes = 61% N=57 patients with advanced cancer (prognosis < 6 months, Mako et al., 2006) Yes = 44% N=91 patients from outpt palliative care clinic at MD Anderson (Delgado-Guay et al., 2011) Spiritual Struggle Screening Protocol 3 Actions: 1. Refer for spiritual assessment re: possible RS struggle. 2. Spiritual care requested, make referral. 3. No action: no indication of RS struggle, no interest in spiritual care. Fitchett & Risk, 2009 10
Prevalence of Religious Struggle 238 patients with diabetes, cancer or congestive heart failure Fitchett et al., 2004 Prevalence of Religious Struggle Cancer patients at SCCA and Dana Farber ESRA-C (Electronic Self- Report Assessment- Cancer) 24% (171/700) cases were positive for religious struggle Maine Medical Center Group Number (%) Belief Helpful 7 (50%) Belief Not Helpful 3 (21%) Belief in Past 1 (7%) No Belief 3 (21%) 14 oncology patients, Maine Medical Center 32 Peace, Equanimity, and Acceptance in the Cancer Experience (PEACE) Scale Mack et al, Cancer 2008 11
Other Screening Tools What spiritual screening tools are being used at your hospital? How well are they working? (Use the Discussion Board to share more.) Continuing the Discussion Using the live chat room Discussion Forum http://www.professionalchaplains.org/discussionforum Contacting instructors george_fitchett@rush.edu patricia_murphy@rush.edu 35 ACPE Research Network 12
George and Pat and Research at Rush Our research website: www.rushu.rush.edu/rhhv click on Research in Religion, Health & Human Values 37 Journal Club Future Sessions Date Paper Method Sample Chochinov et al., 2009. The Crosssectional January Patients in landscape of distress in the 10, 2012 palliative care terminally ill survey March 6, 2012 May 8, 2012 Phillips et al., 2007. God's will, God's punishment, or God's limitations? Religious coping strategies reported by young adults living with serious mental illness Harris et al., 2011. The effectiveness of a trauma focused spiritually integrated intervention for veterans exposed to trauma Longitudinal survey Experimental design Young adults with serious mental illness Veterans exposed to trauma 38 Health Care Chaplaincy Improving our Care and Making our Case Through Research -.46*** Hopelessness Religious Belief.69***.17** ***p<.001, **p<.01. N = 271 Depression 39 13