Journal of Health Care Chaplaincy

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Coordinating assessment of spiritual needs:

a cross-walk of narrative and psychometric
assessment tools used in palliative care

Kathleen R. Perry, Heather A. King, Ryan Parker & Karen E. Steinhauser

To cite this article: Kathleen R. Perry, Heather A. King, Ryan Parker & Karen E. Steinhauser
(2021): Coordinating assessment of spiritual needs: a cross-walk of narrative and psychometric
assessment tools used in palliative care, Journal of Health Care Chaplaincy, DOI:
10.1080/08854726.2021.1904653

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Published online: 28 Apr 2021.

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JOURNAL OF HEALTH CARE CHAPLAINCY
https://doi.org/10.1080/08854726.2021.1904653

Coordinating assessment of spiritual needs: a cross-walk of

narrative and psychometric assessment tools used in
palliative care
Kathleen R. Perrya , Heather A. Kinga,b,c, Ryan Parkerd , and
Karen E. Steinhausera,b,c
a
Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health
Care System, Durham, NC, USA; bDepartment of Population and Health Sciences, Duke University
Medical Center, Durham, NC, USA; cDepartment of Medicine, Duke University Medical Center, Durham,
NC, USA; dChaplain Service, Durham VA Health Care System, Durham, NC, USA

ABSTRACT KEYWORDS
Addressing spiritual needs of patients in healthcare settings Chaplain; health care;
improves patient experiences and clinical outcomes; however, non- interdisciplinary; measure-
chaplain providers typically assess spiritual needs differently (quanti- ment tools; religious care;
spiritual care
tative psychometric) than healthcare chaplains (long form narrative)
and thus there is little shared language or cross-disciplinary evalu-
ation frameworks across disciplines. This discrepancy impedes the
provision of both team-based and patient-centered care. This paper
used scoping review methodology to illustrate the overlap between
narrative and psychometric assessment tools, comparing four narra-
tive tools against eight psychometric tools. The SpNQ-120 and Brief
RCOPE demonstrated consistent domain coverage across the four
chaplain narrative tools. This work provides preliminary resources to
aid clinicians and researchers in choosing an appropriate tool.
Additionally, for those who do not work closely with chaplains, it
provides a sense of what domains chaplains prioritize, from their
professional and lived experience, in assessing the spiritual life of the
patient. This improves interdisciplinary communication, and there-
fore, patient care.

Introduction
Assessing spiritual needs is an essential component of comprehensive palliative care,
and may be addressed, differentially, by members of the interdisciplinary team. We
know that addressing spiritual needs is important to patients and is associated with
patient quality of life (QOL) as well as being associated with outcomes such as utiliza-
tion of aggressive treatments and cost (Balboni et al., 2007, 2011, 2013). Done properly
and shared across disciplines, spiritual assessment and subsequent care provide an
opportunity to improve continuity of care and inform treatment choices (Balboni et al.,
2007). Unfortunately to date, there is no gold standard across disciplines for spiritual
assessment, nor is there consistency within disciplines of how to assess spiritual needs.

CONTACT Kathleen R. Perry kathleen.perry@alumni.duke.edu Center of Innovation to Accelerate Discovery and

Practice Transformation (ADAPT), Durham VA Health Care System, 411 W. Chapel Hill St., Suite 600, Durham, NC,
27701, USA
ß 2021 Taylor & Francis Group, LLC
2 K. R. PERRY ET AL.

Chaplains tend to use a variety of narrative frameworks, clinicians, a variety of spirit-

ual history frameworks, and researchers, a variety of psychometrically informed
approaches. We do not know how these various approaches could inform one another.
With such inconsistency, the team loses the capacity for internal and external account-
ability, and patient care suffers. Palliative care approaches to spiritual care across the
team can be fragmented and disparate.
Chaplains, the team members with depth of professional spiritual care expertise, have
developed a variety of narrative assessment tools to aid them in conducting a holistic
spiritual assessment and creating a care plan (Fitchett, 2002; Lyon, 2002; Pruyser, 1976;
Shields, Kestenbaum, & Dunn, 2015). Chaplains have been trained in narrative assess-
ment, where patients’ stories are the primary fount of information. Chaplains then link
elements of those stories to domains of spiritual challenge and growth. Medical team
clinical spiritual assessments focus on gathering actionable information that offers
immediate spiritual support (such as the presence of a religious community) and guides
the team in how a patient’s beliefs inform treatment decisions, particularly life-
sustaining treatments. Psychometric tools assess spiritual care needs by using multiple
Likert-type items, demonstrated to correlate with latent constructs, to measure domains
thought to comprise patient spirituality, such as purpose or meaning. They are most fre-
quently used in research studies of patient spirituality and, to our knowledge, are rarely
linked to chaplaincy frameworks and therefore offer little explicit guidance for the spir-
itual care professionals. As a result, there is a communication gap between disciplinary
approaches that impede our ability to share common spiritual assessment information
and ensure continuity in spiritual care. To move forward, we need an understanding of
how these various spiritual assessment approaches relate to one another, and how infor-
mation gathered in tools can be crosswalked between frameworks.
Previous systematic reviews have offered comparisons and contrasts of psychometric
tools for spiritual assessment, for use in health care settings generally, and palliative
care specifically (Monod et al., 2011; Selman, Harding, Gysels, Speck, & Higginson,
2011). However, their reviews focused on spiritual outcome measures validated in
patient populations, and did not explore how the psychometric, fixed response meas-
ures, could be linked with chaplain narrative assessment strategies. Some work has been
done to look at the domains covered by fourteen psychometric tools used in end-of-life
populations, but those domains were not connected to the assessments used by chap-
lains (Gijsberts et al., 2011).
The purpose of this research was to address this gap by mapping tools that prioritize
patient-centered responses and are utilized in clinical and research settings by non-
chaplains onto narrative-based chaplaincy frameworks. In doing so, we aimed to iden-
tify the domains that are mutually prioritized by both chaplains and non-chaplains, and
to identify domains prioritized by chaplains that may be under-represented in psycho-
metric tools more commonly used by healthcare clinicians and researchers. It is our
hope that such cross-disciplinary crosswalk will lead to a more robust understanding of
how the different fields can improve communication within the healthcare team to sub-
sequently improve patient experience and outcomes.
 JOURNAL OF HEALTH CARE CHAPLAINCY 3

Materials and methods

We applied principles from scoping review methodology to illustrate the domain over-
lap between narrative-based spiritual assessment tools and psychometric based spiritual
assessment tools (Arksey & O’Malley, 2005). This method has frequently been used to
understand the extent, range, and characterization of assessment tools used in clinical
settings, including one study looking at measures focused on dignity in palliative and
end of life care, without the burden of a full systematic review (Bilgic et al., 2018;
Cervato et al., 2020; Johnston, Flemming, Narayanasamy, Coole, & Hardy, 2017;
Sacramento-Pacheco, Duarte-Cl
ıments, G
omez-Salgado, Romero-Mart
ın, & S
anchez-
G
omez, 2019). The scoping review approach includes the following stages, each of
which was represented in our work: (1) identifying the research question, (2) identifying
relevant studies, (3) study selection, (4) charting the data, (5) collating, summarizing
and reporting the results (Arksey & O’Malley, 2005).

Stage 1: identifying the research question

The research question for this study grew out of a larger study led by Steinhauser to
develop a spiritual assessment tool for veterans in palliative care. As such, our research
aim was shaped by conversations with chaplain stakeholders and advisors for the
Palliative Care Spiritual Assessment Tool project (henceforth referred to as PC-SAT)
(Steinhauser et al., 2019). Our review sought to answer the question: “What are the key
measurement tools used to assess spirituality in palliative care populations in both clin-
ical and research settings?”

Stage 2: identifying relevant studies

In order to identify relevant studies, we adopted the approach laid out by Arksey &
O’Malley by utilizing different sources: electronic databases, reference lists, and utilizing
existing networks and knowledge of the field (Arksey & O’Malley, 2005). PubMed was
searched using keywords in order to identify relevant studies, and reference lists of rele-
vant articles were scanned in order to find additional citations. Additionally, we initially
considered psychometric tools that were included in the grant for PC-SAT as compari-
son measures (Steinhauser et al., 2019). The grant included tools and assessments ori-
ented for use in palliative care settings, as well as those developed specifically for
veterans. Inclusion of preliminary tools and assessments were verified by stakeholders
in the PC-SAT project (Steinhauser et al., 2019). See Table 1 in Results for selected nar-
rative assessment tools.

Stage 3: tool selection

Systematic reviews found in the above step were subsequently identified, summarized,
and compared to ensure that the most frequently cited tools were included, in order
that this work be as relevant as possible for both researchers and clinicians. Given that
this work was originally done as part of the grant to develop a new spiritual assessment
tool for veterans, studies were also given additional weight to be included if they were
4 K. R. PERRY ET AL.

Table 1. Description of selected narrative assessment frameworks.

Narrative assessment model Defining aspects Domains
Ministerial Diagnosis Model—Pruyser Created for parish-based pastoral care, Seven domains: awareness of the
(Pruyser, 1976) and the ability for repeated sessions. holy, providence, faith, grace or
Draws the most explicitly from gratefulness, repentance/
Protestant theology. repenting, communion/
community, and sense
of vocation.
7
7 Model for Spiritual Based on a multi-dimensional foundation Seven spiritual dimensions: belief
Assessment—Fitchett and included in a larger assessment of and meaning, vocation and
(Fitchett, 2002) seven holistic dimensions. obligation, experience and
emotions, courage and growth,
rituals and practice, community,
and authority and guidance.
Diacresis Model—Lyon (Lyon, 2002) Based on the premise that human beings Seven core needs: dignity, power,
have certain core needs that when off- freedom, love, meaning,
balance, can result in a variety of celebration, and rest.
symptoms, including spiritual distress.
These core needs are essential to any
human being. Lyon also makes
connections to Christian sacramental
theology, for those patients for whom
such connections might be meaningful
in spiritual care.
Spiritual-AIM Model—Shields, Provides a conceptual framework that Three primary spiritual needs:
Kestenbaum, & Dunn (Shields guides the chaplain to evaluate an  Meaning & Direction
et al., 2015) individual’s primary unmet spiritual  Self-Worth & Belonging
need and devise and implement a plan to Community
for addressing that need.  Reconciliation/To Love and
Be Loved

being consulted in the development of the PC-SAT. In the end, eight tools were
included, four primarily used in clinical settings, and four that are primarily used as
research tools. See Table 2 in Results for selected psychometric tools.

Stage 4: charting the data

Charting the data began with a thorough review of each of the four narrative assess-
ment frameworks, in order to establish a comprehensive understanding of each of the
domains, definitions, and examples. Areas that lacked clarity were addressed with chap-
lains involved in the project. Second, we reviewed each psychometric spiritual assess-
ment/history tool using descriptive content analysis, sorting individual items of each
tool into the appropriate domains of each narrative framework (Allen, 2020). Items
were sorted into one of the following categories for each of the frameworks: (1)
Explicitly covered, (2) Not explicitly covered, but had the potential to be addressed in
liminal items, and (3) Not addressed. Open-ended questions included in the tools were
analysed with the following question in mind: “Does this question have the potential to
open up discussion in this domain?” The initial sorting of items was done by one
researcher, and ambiguous items were flagged and reviewed by a chaplain stakeholder.
We resolved points of disagreement by consensus and created four tables (one for each
narrative assessment framework) as a result of this process (R. Richards & Hemphill,
2018). Since the different psychometric tools had a large range of items (5–85 items),
we considered it inappropriate to simply report the number of items from each tool
Table 2. Description of selected psychometric tools.
Number
Type of tool Tool Population Spiritual constructs measured of items Scoring
Research- SpNQ-20 (B€ussing, Recchia, Patients with chronic Religious needs, existential needs, 20 Respondents indicate whether each
oriented tools Koenig, Baumann, & diseases, elderly inner peace needs, and giving/ statement is a spiritual need for them
Frick, 2018) populations, and stressed generativity needs. (Yes/No), and if yes, score strength of
healthy populations. need on 3-point Likert scale: somewhat,
strong, very strong. Mean scores
calculated for each sub-scale.
FACIT-SP (Peterman, Patients with cancer and Meaning, peace, and the role of 12 5 point Likert scale ranging from
Fitchett, Brady, other chronic illnesses. faith for persons living with disagreement to agreement. Subscales
Hernandez, & chronic illnesses are summed to create a total score.
Cella, 2002)
Spiritual Well Being Scale A large variety of The respondent’s religious well- 20 6-Point Likert-type scale ranging from
(Luna, Horton, Sherman, populations, including being (their perception of their “strongly disagree” to “strongly agree.”
& Malloy, 2017; patients with chronic relationship to God), and their Overall score is computed by summing
Paloutzian, Ellison, illnesses, college existential well-being (their the responses to all twenty items after
Peplau, & Perlman, 1982) students, and individuals ability to access matters of reversing the negatively worded items. It
with substance ultimate concerns). ranges from 20 to 120, with a higher
use disorders. score representing greater spiritual well-
being (Malinakova et al., 2017).
Brief RCOPE (Pargament, Hospitalized elderly patients Positive religious coping: a secure 14 4 point Likert scale, ranging from “not at
Feuille, & Burdzy, 2011) and college students. relationship with a all” to “a great deal.” Mean scores are
transcendent force, a sense of calculated for the two subscales, and
spiritual connectedness with can range from 7 to 28.
others, and a benevolent
worldview
Negative religious coping:
underlying spiritual tensions
and struggles within oneself,
with others, and with
the divine.
Clinically- SDAT (Monod et al., 2010) Hospitalized, Four dimensions: Meaning, 5 Spiritual needs For each dimension, the treating chaplain
oriented tools geriatric patients. Transcendence, Values, and rates the level of corresponding needs
Psychosocial Identity. from unmet spiritual needs, to fully met
on a four point Likert scale (0–3 for
each dimension). A summative global
score of spiritual distress ranges from 0
JOURNAL OF HEALTH CARE CHAPLAINCY

(no spiritual distress) to 15 (severe

spiritual distress)
(continued)
5
 6

Table 2. Continued.
Number
Type of tool Tool Population Spiritual constructs measured of items Scoring
GES Questionnaire (Benito Patients in palliative care. Intrapersonal, interpersonal and Six initial open-ended Non-open ended questions are on a five-
et al., 2014) transcendent dimension questions establish point Likert scale. Item means
rapport with patients, are calculated.
and followed by an
eight scored items.
K. R. PERRY ET AL.

MD Anderson (Hui Patients with advanced The continuum sub-scales are: 7 It consists of seven sub-scales, scored on a
et al., 2011) cancer admitted to an despair-hopeful, broken-whole, five-point scale (2 to þ2), to comprise
in-patient palliative dread-courage, alienated- a total distress score ranging from 0 to
care unit. connected, meaningless- 10. Spiritual distress is considered
meaningful, guilt/shame- present if patients had 2 or more of the
accepted, and following distress domains.
helpless-empowered.
Spiritual Assessment Tool Veteran patients receiving Includes Koenig’s modifications to 85 The Religiosity Index Items are scored on a
(Berg, 1994) care in a Veterans Kasl’s Religiosity Index, 4 or 5 item Likert scale. They are
Administration Rokeach’s Ultimate Values Test, converted into standardized scores
Medical Center. the Spiritual Injury Scale and before summing. The Ultimate Values
the Holmes/Westberg Personal Test is a rank-order scaling of 36 values,
Health Inventory, which covers 18 terminal and 18 instrumental. The
the following areas: personal Spiritual Injury Scale items are scored on
event or change, marital a 4-point Likert scale (never, sometimes,
relationship, household events, often, very often). Scores are summed
vocational event, financial for a total score. The Holmes/Westberg
change, and Personal Health Inventory Scale items
spiritual dimension. are yes/no items. Each item is given a
particular value, and summed. Subscales
totals are then summed to create a total
personal health inventory score.
 JOURNAL OF HEALTH CARE CHAPLAINCY 7

Table 3. Ministerial Diagnosis Model vs. psychometric tools.

Awareness Grace or Repentance/ Communion/ Sense of
Total # of the Providence Gratefulness Repenting Community vocation
of items Holy (%) (%) Faith (%) (%) (%) (%) (%)
Clinically-oriented tools
SDAT 4 25.0 50.0 25.0 0.0 0.0 25.0 0.0
GES 14 7.1 7.1 0.0 0.0 7.1 28.6 21.4
MD Anderson 7 14.3 42.9 14.3 0.0 28.6 14.3 14.3
Berg 85 3.5 3.5 2.4 0.0 3.5 16.5 12.9
Research-oriented tools
SpNQ-20 20 35.0 25.0 15.0 20.0 5.0 40.0 20.0
FACIT-SP 12 8.3 8.3 25.0 0.0 8.3 0.0 33.3
Spiritual Well- 20 30.0 30.0 25.0 0.0 0.0 0.0 15.0
Being Scale
Brief RCOPE 14 14.3 14.3 7.1 7.1 14.3 35.7 7.1
Average 17.2 22.6 14.2 3.4 8.4 20.0 15.5
Note. The percentages in each cell refer to the percentage of the total number of items from that psychometric assess-
ment that captures the domain indicated by the column. Complete lack of coverage, or where there are no items
from a psychometric assessment that cover a particular domain, is highlighted by a shaded grey cell.

that addressed each particular domain. Therefore, we reported what percentage of a psy-
chometric assessment’s items either explicitly covered or had the potential to cover a
particular domain of a narrative assessment, in order to estimate “coverage” of a par-
ticular domain. For example, the cell in Table 3 that corresponds with “SDAT” and
“Awareness of the Holy” that reads 25.0% indicates that one-quarter of the SDAT’s four
items (or one item) captures the “Awareness of the Holy” domain in the Ministerial
Diagnosis Model.

Stage 5: collating, summarizing, and reporting the results

Following that process, as part of stage 5, matrix techniques were utilized in order to
summarize the coverage of each of the narrative assessments’ domains across the differ-
ent tools (Miles & Huberman, 1994). The matrices were reviewed and approved by each
of the team members, in a manner similar to Arksey and O’Malley’s recommended con-
sultation exercise (Arksey & O’Malley, 2005).

Results
Representation of chaplain assessment domains in psychometric tools
Eight psychometric spiritual assessment tools (four developed primarily for use in
research and four for use in clinical settings) were crosswalked against the four chaplain
narrative assessments in order to find areas of overlap in the different spiritual domains
of interest. Table 1 and Table 2 respectively describe the selected narrative assessment
models and psychometric tools.

Ministerial Diagnosis Model—Pruyser (Pruyser, 1976)

Of Pruyser’s seven domains, “Grace or Gratefulness” was by far the most underrepre-
sented in the psychometric tools, followed closely by “Repentance and Repenting.”
“Providence” was the domain with the greatest amount of coverage. SpNQ-20 had the
8 K. R. PERRY ET AL.

Table 4. 7
7 Model for Spiritual Assessment vs. psychometric tools.

Belief Vocation Experience Courage Rituals Authority
and and and and and and
Total # of meaning obligations emotion growth practice Community guidance
items (%) (%) (%) (%) (%) (%) (%)
Clinically-oriented tools
SDAT 4 50.0 25.0 25.0 50.0 0.0 25.0 25.0
GES 14 28.6 14.3 0.0 7.1 0.0 21.4 7.1
MD Anderson 7 14.3 14.3 28.6 28.6 0.0 42.9 0.0
Berg 85 9.4 9.4 8.2 4.7 5.9 20.0 0.0
Research-oriented tools
SpNQ-20 20 20.0 15.0 30.0 5.0 30.0 35.0 20.0
FACIT-SP 12 25.0 0.0 16.7 8.3 0.0 0.0 33.3
Spiritual Well-Being 20 55.0 5.0 30.0 15.0 0.0 0.0 15.0
Scale
Brief RCOPE 14 28.6 7.1 21.4 14.3 7.1 7.1 7.1
Average 28.5 11.8 19.5 17.3 4.9 19.9 8.3
Note. The percentages in each cell refer to the percentage of the total number of items from that psychometric assess-
ment that captures the domain indicated by the column. Complete lack of coverage, or where there are no items
from a psychometric assessment that cover a particular domain, is highlighted by a shaded grey cell.

largest number of items that overlapped with “Grace or Gratefulness,” although the
Brief RCOPE did have one item in that domain, respectively. Two domains were cov-
ered by all eight tools, “Awareness of the Holy” and “Providence.”
Of the eight tools, the SpNQ-20 and the Brief RCOPE were the only three that had
items addressing each of Pruyser’s seven domains.
In comparing those tools that are clinically-oriented vs. research-oriented, there was
not a substantial amount of differentiation, although research-oriented tools had more
coverage in the “Awareness of the Holy, “Faith,” and “Grace or Gratefulness” domains.
See Table 3 for more details.

7
7 Model for Spiritual Assessment—Fitchett (Fitchett, 2002)

Of Fitchett’s seven spiritual domains, “Rituals and Practice” was by far the most under-
represented in the psychometric tools. The exception to this was the SpNQ-20, which
had several measures that addressed this domain. “Authority and Guidance” was also
underrepresented in the measurement tools, although the SDAT had did have one item
that overlapped with that domain. “Experience and Emotion” and “Community” were
the domains with the most coverage.
Of the eight psychometric tools, the SpNQ-20, and the Brief RCOPE were the only
two that had items addressing each of Fitchett’s seven domains.
In comparing those tools that are clinically-oriented vs. research-oriented, the clinic-
ally-oriented tools had more coverage in the “Courage and Growth,” and “Community”
domains. The research-oriented tools had slightly more coverage in the “Belief and
Meaning,” “Experience and Emotion,” and “Rituals and Practice” domains. See Table 4
for more details.

Diacresis Model—Lyon (Lyon, 2002)

Of Lyon’s seven domains, “Dignity” was by far the most underrepresented in the psy-
chometric tools, followed closely by “Celebration.” SpNQ-20 had the largest number of
 JOURNAL OF HEALTH CARE CHAPLAINCY 9

Table 5. Diacresis Model vs. psychometric tools.

Total # of Dignity Power Freedom Love Meaning Celebration Rest
items (%) (%) (%) (%) (%) (%) (%)
Clinically-oriented tools
SDAT 4 0.0 25.0 0.0 50.0 25.0 25.0 25.0
GES 14 14.3 21.4 21.4 14.3 7.1 7.1 7.1
MD Anderson 7 0.0 28.6 28.6 14.3 14.3 0.0 14.3
Berg 85 0.0 1.2 4.7 2.4 2.4 2.4 1.2
Research-oriented tools
SpNQ-20 20 5.0 10.0 15.0 15.0 10.0 10.0 15.0
FACIT-SP 12 8.3 16.7 8.3 0.0 25.0 8.3 25.0
Spiritual Well-Being Scale 20 20.0 5.0 5.0 20.0 25.0 20.0 10.0
Brief RCOPE 14 7.1 14.3 14.3 35.7 7.1 14.3 7.1
Average 6.8 15.3 12.2 19.0 14.5 10.9 13.1
Note. The percentages in each cell refer to the percentage of the total number of items from that psychometric assess-
ment that captures the domain indicated by the column. Complete lack of coverage, or where there are no items
from a psychometric assessment that cover a particular domain, is highlighted by a shaded grey cell.

items that overlapped with “Grace or Gratefulness,” although the Brief RCOPE did have
one item in that domain, respectively. Three domains were covered by all eight tools,
“Power,” “Meaning,” and “Rest.”
Of the eight tools, four of them, the GES, the Spiritual Well-Being Scale, the SpNQ-
20, and the Brief RCOPE, had items addressing each of Lyon’s seven domains.
In comparing those tools that are clinically-oriented vs. research-oriented, the clinic-
ally-oriented tools had more coverage in the “Power” domain. The research-oriented
tools had slightly more coverage in the “Dignity” and “Celebration” domains. See Table
5 for more details.

Spiritual-AIM Model—Shields, Kestenbaum and Dunn (Shields et al., 2015)

The Spiritual-AIM models differ the most significantly from the other three frameworks,
both in its number of domains (three instead of seven), and how each of the identified
needs are associated with a primary spiritual task for the patient, and a plan for embodi-
ment of the chaplain, in order to move the patient forward to a desired or proposed out-
come. This builds on previous frameworks discussed that focus primarily on identifying
the spiritual needs of the patients, without further frameworks to move them towards an
outcome. Due to the differences between Spiritual-AIM and the other frameworks, it was
expected that the coverage would not be as disparate between the domains as some of the
other frameworks. All the psychometric tools covered each of the three domains:
“Meaning & Direction,” “Self-Worth & Belonging to Community,” and “Reconciliation/To
Love and Be Loved.” Of these, “Meaning & Direction” had the most coverage across the
items. In comparing those tools that are clinically-oriented vs. research-oriented, there was
equitable coverage in the “Self-Worth & Belonging to Community” and “Reconciliation/
To Love and Be Loved” domains, but the research-oriented tools had far greater amount
of coverage in the “Meaning and Direction” domain.” See Table 6 for more details.

Discussion
This research compared four chaplain narrative assessment tools and eight psychometric
spiritual assessment tools—four developed primarily for use in research and four for
10 K. R. PERRY ET AL.

Table 6. Spiritual AIM Model vs. psychometric tools.

Self-Worth & Reconciliation/To
Meaning & Belonging to Love and be
Total # of items Direction (%) Community (%) Loved (%)
Clinically-oriented tools
SDAT 4 50.0 50.0 50.0
GES 14 35.7 28.6 14.3
MD Anderson 7 28.6 42.9 42.9
Berg 85 12.9 5.9 12.9
Research-oriented tools
SpNQ-20 20 50.0 45.0 40.0
FACIT-SP 12 83.3 33.3 25.0
Spiritual Well- 20 80.0 10.0 10.0
Being Scale
Brief RCOPE 14 21.4 21.4 57.1
Average 45.2 29.6 31.5
Note. The percentages in each cell refer to the percentage of the total number of items from that psychometric assess-
ment that captures the domain indicated by the column.

use in clinical settings. We found significant yet heretofore unexplored overlap between
dimensions in each of the tools representing different categories. Two tools, SpNQ-20,
and Brief RCOPE, demonstrated consistent domain coverage across all four chaplain
frameworks. Coverage of a chaplain framework domain did not appear to be correlated
with the content of a particular domain. Each chaplain framework, except for Spiritual-
AIM, did have one or two domains that were severely underrepresented across the eight
tools. Likewise, it does not appear that psychometric tools are universally lacking in one
particular type of domain prioritized by chaplain frameworks. The lack of complete
coverage by most of the psychometric tools indicates a disconnect between the priorities
of the chaplains versus the priorities of researchers and clinicians when it comes to
assessing the spiritual journey of a patient.
This work provides preliminary resources to aid clinicians and researchers in choos-
ing a spiritual psychometric tool specific to their setting. Considering whether assess-
ment aims are more research or clinically oriented is an important first step in
choosing an appropriate tool. SpNQ-20 and Brief RCOPE were the research tools with
the most consistent coverage across the different domains. As healthcare continues to
move towards more interdisciplinary team-based care, it is worth researchers and clini-
cians’ time to review some of the heavily used narrative spiritual frameworks by chap-
lains when choosing which psychometric tool to use.
For researchers, especially those who might not be working as closely with chaplain
colleagues, this work provides a road map for thinking about what data needs to be col-
lected in order to meet the needs of a potential study. Likewise, when clinicians are
choosing an assessment tool, by thinking critically about the needs of the team and their
patients, they can assess what sort of information that would be useful to chaplains
based on what they prioritize in their own narrative assessments. For example, if a
researcher or chaplain wanted to choose a psychometric tool that assessed the “Grace
and Gratefulness” domain of the Ministerial Diagnosis Model, they would see that
SpNQ-20 or Brief RCOPE covers that domain, and therefore those two would be their
best options. Researchers and clinicians can utilize spiritual assessment tools that better
fit their own and their chaplain colleague’s research and clinical needs. For example, a
psychometric tool might be properly utilized as a screener or as a background tool that
 JOURNAL OF HEALTH CARE CHAPLAINCY 11

a patient could complete on their own, providing preliminary data for the chaplain to
work with prior to the patient encounter.
In response to the premise of this research and these findings, this research team is
developing a spiritual assessment tool for veterans in palliative care. The PC-SAT is
based on qualitative work with chaplains, clinicians, patients in palliative care, and
bereaved family members (Steinhauser et al., 2019) The domains for the tool were
crosswalked with the narrative spiritual assessment tools included in this research in
order to ensure continuity between the goals of spiritual assessment between chaplains,
and the clinicians and researchers who will employ this tool. It is currently being vali-
dated in a population of veterans in palliative care that will test full psychometric prop-
erties and inform item reduction.
There are several limitations associated with this study. This was not a thoroughly
systematic review of the literature in choosing which chaplain frameworks and psycho-
metric tools would be included in this scoping review. However, the frameworks and
tools chosen were agreed upon by interdisciplinary stakeholders and collaborators to be
representative of the field. More research could be done to look at the development of
the different psychometric tools, and their attention to patients’ expressed spirituality
and chaplains’ work throughout that development process.
This scoping review and subsequent descriptive content analysis identified significant
gaps of representation of chaplains’ domains of interest across selected research-oriented
and clinically-oriented psychometric tools. However, there are some tools that do cover
the domains of interest for chaplains across several different chaplain frameworks, spe-
cifically the SpNQ-20 and Brief RCOPE, both which are research-oriented tools. Future
work may include the development of a tool with a clinical orientation that takes into
account the domains prioritized by chaplains’ narrative assessments, and can improve
communication on spiritual assessment between disciplines. This is the approach being
taken with the development of the PC-SAT, which at the point of publication, is under-
going validation and is forthcoming (Steinhauser et al., 2019). This project has positive
implications for interdisciplinary work between chaplains, researchers, and non-chaplain
clinicians. In choosing which psychometric tools to utilize, researchers and clinicians
can have a clearer sense of how the information they’re collecting aligns with the spirit-
ual domains of interest for chaplains. Additionally, with this new knowledge of the
overlap of current tools, this project can move forward the development of new tools
that reflect the lived professional experience of chaplains and the spiritual lives of
their patients.

Acknowledgments
We would like to thank first and foremost, the veterans who make this research possible. We’d
also like to thank our chaplain colleagues, whose lived experience enhances the validity and use-
fulness of our work.

Disclosure statement
No potential conflict of interest was reported by the author(s). The content is solely the responsi-
bility of the authors and does not necessarily reflect the position or policy of the U.S.
12 K. R. PERRY ET AL.

Department of Veterans Affairs, U.S. government, or Duke University. The sponsor played no
role in study design, collection, analysis or interpretation of the data; in the writing of this manu-
script or in the decision to submit the manuscript for publication.

Funding
This work was supported by the U.S. Department of Veterans Affairs, Veterans Health
Administration, Office of Research and Development, Health Services Research and Development
Service [IIR 15-365] and by the Center of Innovation to Accelerate Discovery and Practice
Transformation (ADAPT) [CIN 13-410] at the Durham VA Health Care System.

ORCID
Kathleen R. Perry http://orcid.org/0000-0001-9987-2711
Ryan Parker http://orcid.org/0000-0002-3788-0414
Karen E. Steinhauser http://orcid.org/0000-0002-3084-711X

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