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DATE DUE DATE DUE DATE DUE 6/01 c:/ClRC/DateDue.p65-p.15 A PROTOCOL FOR THE ASSESSMENT OF THE RELIGIOUS NEEDS OF PATIENTS IN THE PRIMARY CARE SETTING BY Joan Carol Berry A PROJECT Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE College of Nursing 1998 ABSTRACT A PROTOCOL FOR THE ASSESSMENT OF THE RELIGIOUS NEEDS OF PATIENTS IN THE PRIMARY CARE SETTING BY Joan Carol Berry Nursing's historical commitment to holistic care includes a commitment to meet the spiritual needs of it's patients. The religious needs of our patients in the primary care setting, as part of the spiritual assessment, are inadequately addressed due to the absence of a systematic assessment protocol. Through an extensive literature search, specific religious needs were identified and a protocol developed. The key component in the protocol,is the "Assessment Tool of Religious Beliefs and Practices For The Primary Care Patient"(ATRBP). A questionnaire, the ATRBP addresses the issues of religious affiliation and attendance at religious services, the concept of prayer in general, and prayer specific for healing. In addition it assesses the patient's desire for religious discussion with the APN. Specific guidelines are given for the use and evaluation of the protocol, as well as suggestions for possible research using the ATRBP. ACKNOWLEDGMENTS It is with great appreciation that I acknowledge those who stood with me, and beside me during the extended time it took to complete this project. My family endured the extensive musings as this project began to take shape. My good friend Michael Sturgeon was a constant encourager in the way only he could be. My good friends Li Xinhua, Long Fei, and Yan Ming were constant encourgers and a great help. Without them I would not have been able to complete this from China, on time. My project committee members: Louise Selanders, Bridget Warren, and Sue Wheeler were helpful and most of all understanding and patient as, in the middle of this process, I left the USA for an extended period of time in China. My unending gratitude however, goes to my project committee chairman, Louise Selanders. There are no words to express my appreciation for all she has done to make it possible for me to finish my project and graduate while continuing to live and work in China. Endless mailings, and gathering necessary documents required for graduation were only a couple of the practical ways she helped. But her help went beyond the practical, and began as far back as 1992 as I sought admittance to the masters program. You can do it, was a phrase I was to hear many times over the next five years. May God bless you abundantly, Louise, for all the caring you have shown to me over the years. iii TABLE OF CONTENTS LIST OF FIGURES CHAPTER 1 INTRODUCTION Role of APN Project Purpose CHAPTER 2 LITERATURE REVIEW Spirituality and Religion Religion and Health Religious Assessment and Care Prayer CHAPTER 3 CONCEPTUAL FRAMEWORK CHAPTER 4 PROTOCOL DEVELOPMENT Assessment Tool of Religious Beliefs and Practices For the Primary Care Patient CHAPTER 5 EVALUATION BIBLIOGRAPHY iv 29 36 Figure 1 Figure 2 LIST OF FIGURES The Health Belief Model cancepts adapted 19 for illness behaviors, from.§ggigb§hyigral_ Recommendations (Becker & Maiman,1975). Model showing the proposed assessment tool 20 for the assessment of religious beliefs and practices, and the goal to increase the likelihood of better meeting the primary care patient's religious needs (inside the double lines). Also shown is their relationship to the other components of the Health Belief Model as depicted in figure 1. CHAPTER 1 INTRODUCTION The nursing profession has been and continues to be committed to holistic nursing care. Holistic health views the mind, body and spirit as interdependent, as well as functioning as a whole within the environment (Jarvis, 1992). “Consideration of the whole person is the essence of holistic care" (Travis, 1986). As part of holistic care, nursing is committed to caring for the spiritual needs of patients. Even in the very early years of modern nursing, Florence Nightingale recognized that the needs of the spirit are as critical, to health, as those of the individual organs that make up the body (Swaffield, 1988). It is through formal religious practices, such as prayer and.worship, that some persons express and develop their spirituality, though the spiritual dimension is broader than organized religion (Spoeken & Carson, 1987). Assessment of- the patient's religious beliefs, and practices are an important part of a holistic assessment. An adequate assessment of a patient's spirituality includes identifying the importance of specific religious practices to the individual, and the person's perception of a relationship between one's spiritual beliefs, and his or her state of health (Carson, 1989). Prayer, and specifically prayer for healing, is receiving increased attention with the rising amount of evidence that it can be an effective intervention 1 2 to promote healing in combination with medical treatment. This increased interest, on the part of the health care community, is being reported in both scientific journals, and in the lay literature such as Newsweek, Readers Digest, and McCall's. America is a religious nation, and Americans are a praying people. A number of recent surveys reveal that: more than 90% of those polled believe in God; more than 40% attend religious services at least weekly, and nearly 20% said that religion is very important in their lives (Craige, Jr., Liu, Larson, & Lyons, 1988). The Gallup Report (1991) states that their polling statistics between 1985 and 1991 show that the number of Americans, who profess a belief in God, has been estimated at 95%, with 69% claiming to be a member of a church or synagogue, and the statistic that nine in ten Americans say they pray daily has remained remarkably stable since 1948. A Newsweek Poll, (WOodward, 1997) of 751 adults nationwide, was performed by Princeton Survey Research Associates. The results of this national telephone survey are that 29% said they prayed more than once a day, 82% said they ask for health or success for a child or family member when they pray, and 87% said that God answers prayers. Both qualitative and quantitative controlled studies regarding prayer, for the purpose of bringing healing, are now found in the professional literature. Byrds' (1988) experimental study on 393 coronary care patients showed significant results for the intervention of prayer combined ‘with medical treatment. A collection of evidence for prayer is found in Dossey's (1993) book entitled “Healing Words: The 3 Power of Prayer and the Practice of Medicine”, and according to Maugans & Wadland(1991), and Kurfees & Fulkerson (1990), there is a desire, on the part of a portion outpatients in primary care practices, to have their providers discuss religious issues with them and also to pray for them. There is evidence of both positive, and negative influences of prayer on patients' health, especially prayer for the purpose of bringing healing. This author does not advocate the use of prayer exclusive of medical treatment and nowhere in the professional or lay literature is there any encouragement, to patients or to health care professionals, to do so. There is evidence however that patients, or their advocates, have employed prayer while rejecting medical intervention (King, Sobal, & DeForge, 1988). There are incidences where parents, believing in the power of God to heal through prayer, have employed prayer without appropriate medical treatment for their children. Some have died as a result, and this has resulted in court intervention with charges of child neglect. An extensive literature search reveals that while mainstream.nursing journals contain articles and research on the aspects of faith and hope as to their effect of health, there is a paucity of writing on the assessment of religious needs, prayer, or the effect of religion on health care decisions. Using the current literature as an indicator, it is possible that in our patient population, religion and religious practices play a significant part in health care decisions, that our patients desire that we be involved in these decisions, and that the religious needs,of our patients 4 are not being met. In light of this evidence this project's focus is the development of a protocol that will assist the APN in assessing and meeting certain religious needs of her/his patients. M The Advanced Practice Nurse (APN) is charged with, and committed to, considering the patient as an integrated whole, which includes the patient's spiritual needs. The nursing assessment, and provision of nursing care are essential components of routine practice skills for Advance Practice Nurses (Griffith, 1994). The APN in primary care practice will usually see patients over time, and with various health care needs including illness prevention, health promotion, and care during illness. The actions that a person takes or doesn't take, at the time they experience a symptom or other cue to action, that may or may not bring them to their health care provider are collectively' known as health care seeking behaviors. Assessment of the health care seeking behaviors due to illness, or illness behaviors, is seen as important to help predict the promptness or delay with which a person will seek care, as well as predicting the use of non—medically approved remedies “such as prayer for healing". (Becker,ed 1974). Additionally, because the APN seeks to develop a relationship ‘with the patient that is based on mutual respect and understanding, and formulates goals for treatment together with the patient, he or she may be in the best position to perform this type of assessment. Assessment of the extent to which a patient's religious beliefs and practices are ;~* ,,. I. . I. '.4<- 5 impacting their health care decisions, as well as assessing the extent of her patient population that desires the intervention of prayer, will better equip the APN to meet the patient's religious needs which is one component of their overall spiritual needs. Increased awareness of practices that may promote or interfere with the patient seeking prompt illness care, or following treatment plans is another potential benefit of this assessment. W The purpose of this project is the development of a protocol including a “Religious Beliefs and Practices" questionnaire to be used, by a primary health care provider, as part of an initial history, in completing a systematic, and deliberate assessment of religious beliefs and practices. This assessment tool would also function, with repeated administration, as a way for the APN to assess for any changes in these beliefs and practices. The tool is based on the literature which identifies research data studying the effect of prayer for the purpose of bringing healing, patients' experiences with faith healing, and studies showing the modifying effect of religious beliefs and practices on health and health decisions. Because of the lack of nursing literature regarding the assessment of patient's religious needs, a determination that the_assessment of a patients religious needs often consists only of questions regarding religious preference in order to meet dietary and death and dying requirements, comes from a review of Nursing Textbooks (Jarvis,1992, Kozier, & Mosby,). A survey of physicians, and patients revealed that religious 6 history variables remain neglected in clinical practice (Maugans & Wadland, 1991). The Health Belief Model (Becker & Maiman, 1975), a psychosocial model developed to explain health-related behavior at the individual level of decision making, is the conceptual framework used for this project. Since the HBM's original development, it has been used by many researchers in an attempt to understand the various components of individual's health behaviors, to promote health, and prevent disease. The questionnaire that will be developed.will be an initial assessment tool designed to assist the APN in the Primary Care Setting in better meeting the religious needs of his/her patients. Chapter 2 Review of Literature 5 . '! 1.! i E 1‘ . An understanding of the relationship between the concepts of spirituality, and religion is necessary in order to understand the importance of the nursing assessment of religious beliefs and practices. A review of several definitions of spirituality, and religion is helpful. Reviewing Webster’s New Twentieth Century Dictionary's definition of spirituality, McKee (1992) states that spirituality is, "having to do with the spirit or the soul, as distinguished from the body, what is often thought of as the better part of the mind, while religion is defined as any specific system of belief, worship, conduct, etc., often encompassing a code of ethics, and a philosophy, and may include a way of perceiving and experiencing one's spirituality." Lapierre (1994) states that ”religion is often understood as what a person does in response to specific beliefs about a divine being or beings however, a person's _individua1 spirituality may or may not incorporate the rules, rituals and behaviors of a particular religious group." Goldberg (1990) distinguishes religion from spirituality in that ”religion presupposes the existence of a supreme being", and his definition of spirituality asserts “that the ultimate truth for which all of us search is simply the realization that one's separateness from everything else in the universe is an illusion." Emblen (1992), in order to differentiate between spirituality and religion, performed a 7 8 concept analysis which looked at the use of the two concepts in nursing journals from 1963 to 1990. The concepts of spirituality and religion shared eight common words from.the combined total of 116 words, which revealed that there were major differences in the two concepts. The study concluded that spirituality is currently the broader term and subsumes the aspects of religion. This project looks at religious beliefs and practices, and acknowledges that according to current definitions, a spirituality assessment includes, but is not limited to an assessment of religious beliefs and practices. E 1. . I H J I With the paucity of nursing studies on the relationship between religion and health, one looks to relevant studies of other disciplines. Though the philosophy of care in nursing and medicine is quite different, the needs of primary care patients are the same whether being seen by a physician or APN. One specific survey (Maugans, & Wedland, 1991) using convenience sampling of 150 adult outpatients in three separate family practices revealed that 30% of those surveyed felt that religion generally affected their health. Religion was also felt to be important in many specific situations including: general well-being (41%), major illness (36%), and major surgery (47%). Forty percent of these patients wanted their physician to discuss religious issues with them. Review of the literature suggests two religious variables with potential to be used as markers of distress or poor health. Attendance at religious services and prayer have been found to be positively related to improved mental and physical 9 health (Craigie, Larson, & Liu, 1990; Larson, Sherrill, & Lyons, 1992). Emotional distress and poor physical health can occur during a woman's pregnancy. Pregnancy is a stressful and emotional process, and can strain a woman's coping abilities. In a retrospective study reviewing 1,919 maternal and newborn records from a university medical center, maternal complications and neonatal intensive care unit (NICU) admissions were evaluated in light of religious affiliation. Results revealed that religious affiliation is associated with better obstetric outcomes, and after controlling for possible confounders, the association of religious affiliation and lower NICU admissions remained (King, Hueston, & Rudy, 1994). Evidence that attention to patients' religious beliefs and experiences can enhance physical healing and a feeling of general well-being, is increasing. Koenig, Bearon, & Dayringer (1992), in a study on religious coping and depression among elderly hospitalized medically-ill men, found that there were fewer rehospitalizations for elderly men that relied on religious coping mechanisms. The potential exists for religious beliefs and practices to interfere with a patient or a patients' advocate seeking care. King, Sobal, & DeForge, (1988) state evidence to this effect. In some groups whose doctrine rejects all medical care, tragic deaths have occurred as a consequence of reliance on faith healing alone. A study of one such religious group, in Indiana found a significantly higher perinatal and maternal mortality rates than in the population as a whole. Elsewhere a young boy died of meningitis while 10 being attended by a Christian Science practitioner who offered prayer exclusively, and in another instance a man suffered injury at home after stopping anti- seizure medications on the advice of a faith healer. Given the above evidence and with the current focus on health care costs, identifying practices that could be barriers to patients seeking care, as well as the ability of the primary care provider to individually tailor a patients' plan of care, is essential in order to encourage those practices that promote health and healing, and to increase the potential that a patient will follow a plan of care. E J' . E 1 2 Support for the idea that some patients want to discuss their religious beliefs and the role of prayer and faith in their care with their physician, comes from King & Bushwick's (1994) cross-sectional survey of 203 adult inpatients, and their views on the relationship between religion and health. Their questionnaire included demographic data, such as age, sex race, and health status, as well as items about religious preferences, religious beliefs, and frequency of attendance at religious services. Patients were also asked about their experiences with prayer and faith healing, and if their physician asked about their religious beliefs.Seventy seven percent said that physicians should consider their patients' spiritual needs, 37% wished that their physicians would discuss religious beliefs with them more frequently, and 48% wanted their physician to pray with them. Patients who reported faith-healing experiences were more likely to want such discussion. 11 An earlier cross-sectional study by King, etal (1988) of 212 outpatients' on their contact with and attitudes regarding faith healers had revealed that while most patients didn’t support faith healing, a significant number of patients would reveal beliefs and attitudes while still maintaining a relationship with a family physician. Thirty four percent agreed that physicians and faith healers can work together. Whether from a concern for the sensitivity of religious issues in peoples lives, or a belief in it's irrelevance, one study, focusing on prayer and health during pregnancy, found that despite evidence of the importance of of religion in many peoples lives, physicians routinely do not ask questions about religious history (Levin, Lyons, & Larson, 1993). The assessment of religious beliefs and practices is important in order to meet the needs of patients, but also because religious beliefs and practices can influence symptom recognition and attribution (positively or negatively), thereby influencing health and illness care-seeking behavior. They can have a negative influence in that the excessive guilt experienced by people viewing physical symptoms as punishment from God, and feeling that they deserve such punishment they may not seek care. From the positive perspective, the Judeo-Christian tradition is that the body is a temple belonging to God, and abuse of the body or refusal to care for the body can be seen to go against their religious doctrine. It is possible that those who hold these beliefs will be more inclined to seek care in times of illness, follow through with care plans and use health 12 promotion services (Koenig, Bearon, & Dayringer, 1989). There is an ongoing discussion of whether religion with it's beliefs and practices is a positive or negative influence on peoples health but the literature is encourages us that there is an effect. Nursing education provides excellent preparation for nurses in performing physical and psychosocial intervention skills. Piles (1990) asserts however, that preparation for providing spiritual care remains lacking in the education of nurses. ”Assessing and intervening in spiritual matters, if the patient initiates, is similar to saying I will not look at the patient's bandages unless he tells me he is bleeding". Additionally, the National Conference on Nursing Diagnosis has included spiritual distress/concern as a standard category (Piles, 1990). Given the religious nature of a large segment of the population of the United States, it is the conviction of this author that any assessment of spirituality without attention to religious beliefs and practices is inadequate. EIEXEE There are some questions that are important to think about when considering prayer as a nursing intervention:(1) does the person engage in prayer, especially prayer for healing, themselves, or seek it from others (2) is prayer perceived as helpful by the patient, (3) does the patient desire that the provider pray with them, (4) has prayer been found to be an effective intervention in nursing care? ”Most religious traditions profess some effect of prayer on physical health and there have been periods of greater and 13 lesser emphasis on prayer as a method of healing. However, in almost any period, and in any culture there has been encouragement to offer some type of prayer for the purpose of bringing healing. The tendency, in the western WOrld, to reduce explanations of health and healing exclusively to a physical-science explanation, began with the darkening of the Age of Enlightenment" (Duckro & Magaletta, 1994). In an attempt to study the effects of religion on health, many researchers have applied the method of correlation to the study of prayer as one dimension of the broader concept of religiousness. Although correlational studies cannot demonstrate a causal relationship, such studies have served to alert us to the many benefits of prayer. In a recent correlational study of patients who were about to undergo cardiac surgery, prayer was perceived as helpful regardless of orientation of control and provided physiological responses such as a decreased heart rate, decreased blood pressure, and decreased episodes of angina, (Saudia, Kinney, Brown, & WOods, 1991). Although no relationship was found between prayer and locus of control, the findings suggest that prayer is perceived as a helpful, direct-action coping mechanism and warrants support by health personnel. Bearon & Koenig (1990) in their exploratory study of older adults beliefs about God's role in health and illness, and their use of prayer in response to specific symptoms, evaluated data gathered from forty adults aged 65 to 74 as part of a more extensive study of symptom attribution, and medical help-seeking among older adults living in the 14 community. Nearly half of the respondents indicated the use of prayer. Fifty three percent of the symptomatic respondents reported praying for at least one symptom the last time they experienced it. While this study is small, it points to the possibility that many older adults see their health and illness as being at least in part attributable to God, and to some extent, open to God's intervention The previously mentioned studies by King, etal (1988), and King, etal (1994) also give evidence for the desire of patients to receive prayer as part of their health care. Experimental studies on prayer are a challenge to design given the difficulty in defining and operationalizing the concept of prayer. Probing the scientific literature for proof of the efficacy of prayer revealed over one hundred experiments that exhibited the criteria of “good science", many of which were conducted under strict laboratory conditions, over half of which showed that prayer brings about significant changes in a variety of living beings. (Dossey, 1993). The relatively recent research by Byrd (1988) mentioned briefly in the introduction exhibited the criteria of “good science". Byrd studied 393 patients in a coronary care unit. Strict experimental conditions were maintained in the double bind design, the selection of patients, and their random assignment to one of two groups. All patients received the standard medical care for their condition, and half were randomly assigned to be the focus of prayer. The prayer employed focused on the physical recovery of the patients. The striking results revealed that those prayed for suffered significantly fewer instances of congestive heart 15 failure, cardiopulmonary arrest and pneumonia. There are some limitations to the study and some would say that the 16% variance attributed to prayer is small. But just the fact that any such effect was found in a tightly controlled experiment is an encouragement to further study, and to consider prayer as a treatment intervention (Duckro 5 Magaletta, 1994) The questions of whether nursing assessment of religious beliefs and practices is effective in assisting the APN in both meeting the needs of patients and as a predictor of illness care-seeking behavior, and whether the intervention of prayer is an effective nursing intervention, is yet to be answered. It is the hope of this author that this project will play a part in moving toward that answer. Chapter 3 CONCEPTUAL FRAMEWORK Conceptual models in nursing are intended to describe or explain a concept or complex mental formulation. The model, or framework, in the form of a diagram or picture is also helpful in that it gives a visual description of a complex idea such as the concept of health. Selected nursing interventions will be determined, in a large part by the APN's beliefs about health and illness, and their ability to function effectively may be in some part related to their ability to bring their own theories to a conscious level. Once at the conscious level a theory can be examined, and modified. Development and use of conceptual models, brings these theories to a conscious level. These conceptual models, and the research based on them, enhance the base of an APN's practice.(Dery, 1979) For the purpose of this project, the conceptual model allows us to see the potential for religious beliefs and practices to influence health care decisions, pointing to the need for a religious assessment in the primary care setting. The Health Belief Model (Becker, 1974) is useful, as a guide in holistic decision making, for the APN in primary care practice. In the primary care setting it is important for the APN to be able to meet the needs of her/his patients in a holistic manner, and to develop a plan of care that is tailored to each individual. One component in this process is taking into account those beliefs and practices that are 16 17 likely to influence patients' decisions to seek care and to comply with prescribed treatment. The goal of this project is to develop a protocol and as part of this protocol to develop a tool, in the form of a questionnaire,that will assist the APN in meeting the religious needs of her/his patients, through the systematic, and deliberate assessment of their religious beliefs and practices. The HBM was originally developed in the 1950's in an attempt to address the concern with the low levels of participation in preventative health programs that were being offered free, or at very low cost (Mikhail, 1981). It is adaptable to illness care-seeking behaviors, where the cue to action is a symptom, as depicted in the HBM describing compliance with medical care recommendations, (Becker & Maiman, 1975). The HBM is well suited to identifying religious beliefs and practices (Kirn, 1991), which are included in the sociopsychological variables, and promotes lthe holistic care that is so much a part of the care provided by the APN. The HBM has been used in an attempt to clarify religion's possible roles in health care actions (Becker & Maiman, 1975), and religion's influence in studies of the HEM was considered as early as 1958 (Kirn, 1991). Divided into three categories, the HBM addresses individual perceptions, likelihood of action, and modifying factors. Modifying factors include: (1) demographic and sociopsychologic variables,(2) the threat posed by the symptom, and (3) the one or cues to action. The HEM proposes that the likelihood that a person will take action in response to a specific cue or cues is determined by the 18 individual’s psychological state of readiness to take action, and that this psycholOgical state of readiness is determined by the individuals perception of the seriousness of the identified cue and its possible consequences (Becker,& mm, 1975) . Kirscht (1974) drew attention to the importance of symptoms, as they may represent a threat to the individual and may therefore arouse health motivation or act as a cue to taking action. The possible cues to action are many and could include the illness of another, prompting preventative care, or the persons own symptom or symptoms, prompting the person to seek illness care. In either case the patients perception of any serious threat to his or her health is directly effected by the patients evaluation of the seriousness of the cue to action. Impacting directly on the perceived seriousness of the threat to one's health are the modifying factors of the demographic and sociopsychological variables. Religious beliefs and the actions that follow them, which are the focus of this project, are usually placed in this category. The desired action for this project is simply the increased likelihood of better meeting the religious needs of primary care patients. The HBM adapted for application to illness behavior,from Sociobehavioral Determinants of Compliance with the Medical Care Recommendations (Becker & Maiman, 1975), will be the specific model used for this project. It is easily adaptable to promotive and preventative behaviors as well as illness care-seeking behaviors with attention to religious beliefs and practices as the modifying factors. (See figures 1 & 2 ) INDIVIDUAL PERCEPTIQ‘IS 19 MODIFYING FACTORS V Demographic Variables Sociopeychologic Variables LIKELIHOOD OF ACTION Percieved susceptibility to disease Percieved seriousness of W \/ Peroieved benefit of seeking illness care minus Perceived cost or barrier to seeking illness care Threat posed by symptom including physical harm or loss of function Likelihood of seeking illness care ’1‘ Cues to action Symptom experience Figure 1. The Health Belief Model concepts adapted for illness behaviors, from WI. (Becker 5 Maiman,1975)- A . INDIVIDUAL PERCEPTIONS 20 MODIFYING FACTORS LIKELIHOOD OF ACTION \V Assessment Tool for the Assessment of Religious Beliefs and Practices For The Primary Care Patient Increased likelihood of meeting the religious needs of the primary care patient Perceived susceptibility to disease Perceived seriousness of symptom FIGURE 2. Threat posed by Symptom including physical harm or loss of E> function Cues to action Symptom experience Perceived benefit minus Perceived barrier to seeking Likelihood of seeking illness care Model showing the proposed assessment tool for the assessment of religious beliefs and practices and the goal to increase the likelihood of better meeting the primary care patient's religious needs (inside the double lines). Also shown is their relationship to the other components of the Health Belief Model as depicted in figure 1. Chapter 4 Protocol Development The Assessment Iggl gfi Eg1jgjgn§ Egljgfa and Practices W (ATRBP) , has been developed in an attempt to provide the APN in primary care practice with an effective, and efficient means to better meet patients' religious needs. Nursing's continued commitment to wholistic care on one hand, and the lack of specific guidelines on the assessment of religious needs in the current advanced practice nursing assessment texts on the other hand, points to the need for such an assessment tool. Increased interest in prayer as a means of healing in both the professional and lay literature also supports the timeliness of the development of such a tool for the primary care setting. In the development of this assessment tool, attention ‘was given to the basic parameters for a questionnaire as set down by Nieswiadomy(1993). She states that the length of both the questionnaire and the questions should be limited in order to maintain the respondents interest and increase the likelihood of completion. The ATRBP is one page in length with a total of twelve questions. With the exception of number seven, which includes a definition of a healing service, these questions are less than 20 words each. The recommended time of no more than 20 to 25 minutes to complete the questionnaire has also been observed to as most people can be expected to complete this tool 21 22 in 10 minutes or less. Negatively worded questions have been avoided. In addition, words that tend to be ambiguous such as "many", "usually”, "few" and, "generally”, while included in the responses, have been avoided in the questions. The response categories for all questions are collectively exhaustive and mutually exclusive. In looking at the content and format of this tool one will observe that, with the exception of the patient's name, the first question "what is your religious preference” is the only demographic question on the tool. Because the ATRBP is meant to be used as part of the initial assessment package, it was felt that it was not necessary to duplicate other demographic data. If it is to be used alone, or for the purpose of gathering research data from patients not necessarily connected with a particular practice, one should consider adding other demographic data and a cover letter. The other eleven questions are in the form of statements with a Likert type scale. Responses indicate frequency, agreement / disagreement, and quantity. Questions one and two are based on research indicating that religious affiliation and attendance at religious services is positively related to improved mental and physical health (Craigie etal, 1992). The patient's response to question three, indicates the extent to which they believe their health is effected by their religious beliefs. With a view to addressing the recent increase in prayer in general, as well as specific prayer for healing by both professionals and laity, questions four through nine address various aspects of the patients belief in and experience with prayer. Questions 23 ten through twelve deal with the extent to which the patient desires the involvement of the APN in the discussion of religious beliefs and the intervention of prayer. Developed to be used as part of the initial assessment of a new patient in the primary care setting, the appropriate use of this tool is a two step process. The first step occurs as the patient fills out the questionnaire as part of the initial assessment package of self-report forms. These forms are generally given to the patient either during or prior to the first visit to a particular primary care setting. Though the information gathered in these initial self—report forms will vary with each practice, the addition of the religious beliefs and practices questionnaire is an appropriate addition to any request for medical and social history. This first step is followed by the APN going over the questionnaire with the patient during that initial visit. Even though the second step adds to the time needed for the ATRBP assessment, it is essential in that it will increase the depth of the APN's understanding of the patient's religious needs, and in addition, the patient will know that the APN is sincerely interested in addressing their religious needs. It is also acknowledged that the ATRBP is purposely narrow in it's focus and that there are other religious issues and concepts worthy of assessment. In fact it is seen as a benefit that the discussion around this tool can, and most likely will lead to further discussion of other religious issues. This writer believes that the APN, because of her/his foundation in the philosophy and practice 24 of nursing, is the best person to assess and address the religious needs of the patient through the use of the ATRBP. However it is acknowledged that the ATRBP as part of the initial assessment package can be a useful tool for all primary care providers interested in better meeting their patient's religious needs. The time needed for the patient to complete the ATRBP questionnaire should be no more than 10 minutes. The length of time taken by the APN, in going over the questionnaire ‘with the patient, can vary according to need and time constraints. If time is limited, and if the APN deems it appropriate, she/he can choose to mention the assessment briefly and discuss it in greater detail at future visits. Meanwhile, the APN has obtained some valuable information that can be immediately helpful in treatment planning, and the patient knows that his/her religious beliefs are important to their health care provider. The ATRBP questionnaire initially administered during the initial assessment, with other self-report forms, can also stand on it's own and can be used at any time in a patient's relationship with the practice. One example of this is repeating the administration of the tool in order to determine if the patient is experiencing spiritual distress, an identified nursing diagnosis, defined as the patient's inability to carry on with his/her usual practices stemming from their spiritual beliefs or a questioning of previously held beliefs that had helped them cope with difficulties in the past (Piles, 1990). In another instance, an APN may feel that it is preferable to develop a relationship with a 25 patient before using the tool, and that it isn't appropriate for every patient. Though the ATRBP questionnaire can be used in this way, it is the position of this writer that the religious assessment is an intregal part of a complete assessment and that the use of the ATRBP as an initial assessment tool will be beneficial to any patient. As with all assessment tools, one can identify some possible problems in the use of the ATRBP. Firstly, a ' patient's inability to read at the level of the questionnaire or to comprehend the questions will invariably increase the self-reporting time, and may even require APN, or other patient advocate, to assist the patient in it's completion. This problem, however, is not particular to this tool, but is a potential problem with all self-report forms. Every attempt has been made to eliminate this problem as discussed previously. Secondly a patient may refuse to fill out the ATRBP or seem to have overlooked the tool. Once again this would add to the initial assessment time but, the APN can choose to take the added time or to set it aside for the follow-up visit. In addition, a patient's direct refusal to answer the questionnaire or a seemingly overlooked questionnaire can in itself lead to a productive discussion of the patient's religious needs. It is also acknowledged that there will be some patients that have no desire to discuss their religious needs with their health care provider and that our sensitivity to this request is equal in importance to that of the patient that desires our involvement. In evaluating the data obtained by the ATRBP in order to 26 determine the need for a nursing intervention, it is important to remember that the primary goal in using the tool is to better meet the religious needs of the patient and that this protocol is viewed as a beginning step in this process. As previously mentioned, the tool itself promotes open discussion of religious issues, as well as assessing the extent to which the patient wants this discussion and the extent to which this need is being met by the provider. Although the statements or questions on the ATRBP are set in the Likert format,the use of a scale to evaluate the data obtained is not necessary. The purpose of the format is to be able to perform, with repeated administration of the tool, an evaluation of the APN's effectiveness in meeting the patients religious needs in terms of involvement in religious issues, as well as ongoing evaluation of the persons religious needs in time of increased life stress. In evaluating the information obtained, the APN will be able to gain insight from four distinct perspectives.. Firstly, questions one and two are initially informational, but can indicate the importance of the attendance at religious services to the individual. Secondly, the first two questions along with questions three through eight can be used in an ongoing assessment of a person's spiritual health in times of increased physical, social or psychological stress. As previously discussed, a change in these beliefs and practices can occur as result of this stress leading to a decrease in the coping skills formally found useful (Piles, 1990). Nursing interventions aimed at assisting the patient in evaluating these changes, if they occur, can be initiated. 27 Thirdly, as we have seen in the literature, religious belief can both promote and interfere with care seeking behaviors (King, etal, 1988), and questions seven through nine can shed some light on a situation where the patient nappears to delay seeking medical care and/or lack the motivation to follow through with prescribed interventions. It is through this ongoing assessment, discussion, and mutual planning of treatment that the APN will be better able to meet the religious needs of the patients. Finally, questions ten through twelve deal directly with the patients desire for and satisfaction with the APN's involvement in the patient's religious issues, and with this information the APN can modify their involvement thereby leading to better meeting the individual religious needs of the patient. (See ATRBP on the following page) 28 .. . . _AsEeflnmEJ%?J%BEMN%§Jk%%§jhdflmmma§ Name: 1. WHAT IS YOUR RELIGIOUS PREFERENCE ? 2. I ATTEND RELIGIOUS SERVICES SEVERAL TIMES A WEEK EVERY WEEK ABOUT ONCE A MONTH SEVERAL TIMES A YEAR ONCE OR TWICE A YEAR NEVER 3. I BELIEVE THAT MY RELIGIOUS BELIEFS HAVE AN EFFECT ON MY HEALTH. STRONGLY AGREE SOMEWHAT AGREE STRONGLY DISAGREE SOMEWHAT DISAGREE 4. I PRAY OFTEN SOMETIMES RARELY NEVER 5. I PRAY ABOUT MY HEALTH, OR THE HEALTH OF FAMILY AND FRIENDS OFTEN SOMETIMES RAR ELY NEVER 6. I BEUEVE THAT PRAYER IS HELPFUL STRONGLY AGREE SOMEWHAT AGREE STRONGLY DISAGREE SOMEWHAT DISAGREE 7. I HAVE ATTENDED A FAITH HEALING SERVICE ( EG. ] IN WHICH A PERSON ANOINT ED SOMEONE WITH OIL OR LAID HIS HANDS ON SOMEONE AND SAID A PRAYER WITH THE EXPECTATION OF HEALING SOMEONE OFTEN SOMETIMES RARELY NEVER 8. I PRAY ABOUT MY ILLNESS BEFORE I COME TO SEE THE NURSE PRACTITIONER OR DOCTOR OFTEN SOMETIMES RARELY NEVER 9. I HAVE HAD A PHYSICAL HEALING AS A RESULT OF PRAYING OR BEING PRAYED FOR OFTEN SOMETIMES RARELY NEVER 10. MY HEALTH CARE PROVIDER DISCUSSES MY RELIGIOUS BEUEFS WITH ME OFTEN SOMETIMES RARELY NEVER 11. I WANT MY HEALTH CARE PROVIDER TO DISCUSS MY RELIGIOUS BELIEFS WITH ME MORE THE SAME AMOUNT LESS NOT AT ALL 12. I WANT MY HEALTH CARE PROVIDER TO OFFER TO PRAY WITH ME AS PART OF MY HEALTH CARE MORE THE SAME AMOUNT LESS NOT AT ALL Chapter 5 Protocol Evaluation Evaluation, the final step in the nursing process points up the importance of evaluating nursing interventions for the purpose of establishing nursing as a science as well as an art. In light of this, the evaluation of a newly developed protocol is essential. In the case of this project the evaluation will revolve around the use of the Assessment Tool of Religious Beliefs and Practices for the Primary Care Patient (ATRBP). For the purpose of this project, the desired outcome for the ATRBP is that it's use and ensuing nursing interventions, by the APN, will lead to better meeting the primary care patient's religious needs. It is acknowledged that the extent to which the APN follows up on the information obtained with the use of the ATRBP can have a direct bearing on the degree to which the patient's religious needs are met, and therefore the effectiveness of the protocol. The ability of the protocol to perform the function for which it is intended must be confirmed through a systematic evaluation process. The question then becomes, how do we determine that, after instituting the ATRBP ,we are doing a better job of meeting these needs. The result of meeting our patient's needs should be that the patient is biologically, psychologically sociologically, and spiritually in the best environment possible, so that they have the greatest potential to gain and maintain optimal health. Because 29 30 health care is a joint endeavor between a patient and those that provide their health care, we must evaluate whether we are meeting the patients's religious needs from both the perspective of the APN as well as the perspective of the patient. It is important to evaluate our effectiveness in meeting the patients religious needs from the patient's perspective because, to some extent, she/he is the best judge of whether we are successfully meeting these needs. This evaluation process will be discussed further, later in this chapter. From the perspective of the APN, the assessment of a given needs area is the beginning of meeting the patient's needs in this area. From that standpoint, just the implementation of a specific protocol to assess a person's religious needs, where there has been none, should in some measure increase the extent to which their religious needs will be met. To take this one step further we must ask ourselves does the assessment tool developed, namely the ATRBP, actually assess one's religious needs. One way to answer this question is to look at the literature review. In doing so, we can say that, one's religion is often understood by what one does in response to specific beliefs about a divine being or beings (Lapierre,1994). we also have evidence that the religious practices of religious attendance, and prayer have been found to be related to improved mental, and physical health (Craigie, etal, 1992). Additionally , religion is felt to affect peoples health generally as well as in specific situations, and there is a segment of the American population 31 that desires their primary care provider to discuss religious issues with them (Maugans & Wadland, 1991). From this we can, with some measure of conviction say that the religious needs of our patient population include but are not limited to those addressed by the ATRBP, namely the practices of religious attendance, prayer, the connection between religion and health, and the extent of the involvement of the primary care provider. The above deduction, while important and logical, must be followed up by the actual testing of the tool for it's ability to assess a persons religious needs. This question of validity and reliability of the ATRBP is not unique but is inherent in the development of any assessment tool. The methodological research necessary to establish the validity and reliability of a tool is an extensive and time consuming process, that should be undertaken if the ATRBP is to be used in the clinical practice setting. Because this protocol and thus the ATRBP has been specifically developed for use in the primary care setting, the methodological research would be most appropriately carried out in the same setting. While the testing of the tool is essential and should be carried out at some point especially if it is to be used in further research, it is , as previously mentioned, extensive and time consuming. It is suggested that prior to the institution of the methodological research necessary to establish the reliability and validity of the instrument, the protocol itself, namely the use of the tool and the APN's ensuing nursing interventions based on the information gathered in the assessment, be evaluated on it's ability to 32 meet the identified religious needs of the patient. This can be accomplished quite easily through the re-administering of the ATRBP after a specified time. The ATRBP contains twelve questions with the last three relating to the level of the APN's current involvement in religious discussion with the patient,and the intervention of prayer and the patient's desire for more or less involvement. The patients' responses to these questions will be the basis for our determination of whether we are better meeting their religious needs. For example, if on the initial use of the ATRBP, a patient indicates that the APN discusses his/her religious beliefs sometimes (question number ten) and that he/she desires that the discussion occur more or never (question number eleven), this can be compared with the answers to the same questions when the ATRBP is re- administered as an indication of whether or not the APN is better meeting their religious needs. Although the ATRBP was developed to be used as part of the initial assessment of a primary care patient on entry to the practice, it has been previously acknowledged that the use of the protocol is also appropriate at any time in the patients relationship with the APN, and for the purpose of ongoing assessment. In evaluating the protocol by means of a pre—post survey, it will be necessary for our population to come from the established patients in the primary care practice. The patients who will be involved in the evaluation process should be adults, and should number between 60 and one hundred. The number needs to be large enough to allow for those patients that will not return to the practice over the 33 evaluation interval time, but not be so large as to be unmanageable. They should be chosen randomly as they come in for scheduled appointments without regard for gender or other demographic variables. The ATRBP would be administered initially and then again after six months. The choice of the interval is somewhat arbitrary but it must be long enough to allow for subsequent patient visits. The ATRBP, being a self—report questionnaire with a very simple format, will need little introduction and can be given to the patient, by the receptionist or nurse, to fill out as he/she signs in for their appointment. Because it will not be part of the initial assessment package, it will need to be accompanied by a cover sheet that should explain simply that the purpose of the ATRBP is to address the religious needs of the patients, that the APN will discuss the assessment with the patient during their appointment, and that they should feel free to ask any questions or express any concerns at that time. It should be signed by the APN and include the instruction that the patient should answer each question by putting an x after the answer choice that most closely expresses his own idea. After both pre and post surveys have been completed it is simply a process of comparing the pre and post survey results for each patient of questions ten through twelve Obtaining the response of "the same amount" on questions eleven and twelve on the pre or post survey will indicate that the APN is meeting the patient's religious needs. Obtaining a response of more, less or not at all indicates that the APN could be doing a better job of meeting their 34 religious needs. To be able to say that the APN is better meeting the patient's religious needs with the protocol, the individual patients' responses of more, less and not at all on the pre survey would need to change to the response of the same amount, on the post survey. This use of the ATRBP is superior to using a separately developed survey that would ask the patients, prior to and after the institution of the protocol, whether their religious needs are being met with the APN having no idea how they are judging this. It is acknowledged that in using any pre/post design, that our evaluation could be in some measure contaminated by the patient's desire to answer in a socially acceptable manner. However it is thought that this potential is decreased because the ATRBP contains questions not directly identifiable to a patient's satisfaction. In evaluating this protocol for it's potential in experimental research, methodological research is both possible and advisable, as previously mentioned, in order to prove the ATRBP as a reliable measure of the religious needs of patients. If proven the identified concepts included in the tool could be seen as reliable measures of religious needs leading to further research in this area and the use of the ATRBP could be encouraged, as a means to better meet patient's religious needs. Moreover, in light of the extensive literature review performed in relationship to this project and the resulting knowledge of the paucity of nursing literature, regarding the assessment of religious beliefs and practices or the relationship between religious beliefs and practices and health it is suggested that there innumerable 35 ground floor opportunities available for nursing to build a body of information regarding the influence of religious beliefs and practices on a person's health and health care decisions. Possibly one of the most important uses of the ATRBP would be in pre-experimental research with the purpose being to describe populations of primary care patients in different geographical and economic areas. Data could be gathered regarding the extent to which certain populations believe that their religion has an effect on their health, the extent of their involvement in prayer as a means to bring healing, their desire for the involvement of their primary care provider in the discussion of religious issues with them and their desire to receive prayer in addition to traditional medical and nursing care in the primary care setting. This data can assist individual providers as well as entire practices in the awareness of the religious needs of their patients or of patients with similar demographics. LIST OF REFERENCES Bearon, L. B., & Koenig, H. G. (1990). Religious Cognitions and use of prayer in health and illness. W4 (2), 249-253. Becker, M. H., & Maiman, L. A. (1975). Socio-behavioral determinants of compliance with medical care recommendations. W43... 10-24. Becker. M. H. (Ed ) (1974) .IhuealmaelieLModelJnd. WWI... Thorofare. New Jersey: Charles 13- Slack Inc. Byrd, R. C. (1988). 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More Americans now believe in a power outside themselves. Ibe_ W151... 33-38. 36 37 Goldberg, R. S. (1990). The transpersonal element in spirituality and Psychiatry W W 9-10. Griffith, H. M., & Diguiseppi, C. (1994). Guidelines for Nurse Practitioners in practice,education,and research. nnngg_ W12... 25-38. JarviS. 9.. (1992). new . Pennsylvania: W.B. Saunders Co. Kasl, S. & Cobb, S. (1966). Health behavior, illness behavior and sick role behavior. Arghiye§_gf_finxirgnmen§al_ nglthi_lz 246-356- King, D. E., & Bushwick, B. (1994). Beliefs and attitudes of hospital inpatients about faith healing and prayer. WW (4). 349- 352- King, D. E., Sobal, J., & DeForge, B. (1988). Family practice patients' experiences and beliefs in faith healing. W (5). 505- 508- King, D. E., Sobal, J., Haggerty III, J., Dent, M., & Patton, D. (1992). Experiences and attitudes about faith healing among family physicians. W 3§_12), 158- 161. King, D. B., Hueston, W., & Rudy, M. (1994). Religious Affiliation and obstetric outcome. ' 31 (11), 1125-1128. Kim. J. M- (1991) W W (4). 321- 321- Kirscht, P. (1974). The health belief model and illness behavior- In 14- Backer (Ed MW. (pp. 60- -81). Thorofare, New Jersey: Charles B. Slack Inc. Koenig, H. G., Bearon, L. B., & Dayringer, R., (1989). Physician perspectives on the role of religion in the physician-older patient relationship. J9urnal_9f_£amily_ W (4). 441- 448. Koenig, H. G., Cohen, H. J., & Blazer, D. G. (1992). Religious coping and depression among elderly hospitalized medically-ill memwmhw 1693- 16700. 38 Kurfees, J. F., & Fulkerson, G. (1990, November). pghgyigr. Paper‘presentedlat-the Southeastern’Regional Meeting of the Society of Teachers of Family Medicine, Greenville, North Carolina. LaPierre L. L. (1994). A model for describing spirituality I9uInal_9f_Bel1s19n_and_flealth1_33 (2). 153- 161. Larson, D. B., Sherrill, K. A., & Lyons, J. S. (1992). 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New Jersey, Prentice-Hall. Piles, C. L. (1990). Providing Spiritual Care._fln;§§_ Educatori_1§ (1), 36-41. Reed, P. G. (1992). An emerging paradigm for the investigation of spirituality in nursing. _Be§e§;gh_1n_uur§1ng_ §_Health_l§i.349- 357. Saudia, T. L., Kinney, M. R., Brown, K. C., & Young-Ward, L., (1991). Health locus of control and helpfulness of prayer._flea;;_ang_Lung1_zg (1), 60-65. Soeken, K. L., & Carson, V. J. (1987). Responding to the spiritual needs of the chronically ill. (flu;§13g_glinig§_gfi_ N9I1h_Am_Iica1_221 604- 605- 39 Swaffield, L. (1988). Religious Roots. Nursing_11mea1_§4_ Taylor, R. J., & Chatters, L. M. (1991). Non organizational religious participation among elderly black adults. MW (2). 8103-111. Travis, J. W., & Ryan, R. S. (1986). Wellne§s_workbggk (2nd ed.). California: Ten Speed. Woodward, K. L. (1997, March 31). Is God listening? Mammals. 57-62. III IIIIIII IIII II IIII IIII II III II I 293 02374 9801 _