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Spiritual Needs in Health Care Settings: A Qualitative Meta-

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 Spiritual Needs in Health Care Settings:
A Qualitative Meta-Synthesis
of Clients' Perspectives
David R. Hodge and Violet E. Horvath

Spiritual needs often emerge in the context of receiving health or behavioral health services.
Yet, despite the prevalence and salience of spiritual needs in service provision, clients often
report their spiritual needs are inadequately addressed. In light of research suggesting that most
social workers have received minimal training in identifying spiritual needs, this study uses a
qualitative meta-synthesis (N = 11 studies) to identify and describe clients' perceptions of their
spiritual needs in health care settings.The results revealed six interrelated themes: (1) meaning,
purpose, and hope; (2) relationship with God; (3) spiritual practices; (4) religious obligations;
(5) interpersonal connection; and (6) professional staff interactions. The implications of the
findings are discussed as they intersect social work practice and education.

KEY WORDS: meta-synthesis; religious needs; spiritual assessment; spiritual needs; spirituality

a variety of settings, including residential substance

A
s observers have noted, clients' spiritual
needs have become a "core health concept" abuse treatment programs (Carroll, McGinley, &
(Shih,Wang, Hsiao,Tseng, & Chu, 2008). Mack, 2000), emergency departments (Jang et al.,
Social work practitioners, as key players in the pro- 2004),hospitals (Reed, 1991),pédiatrie units (Feudt-
vision of health care services, are often called on to ner, Haney, & Dimmers, 2003), psychiatric wards
address clients'spiritual needs (Anderson, Anderson, (Fitchett,Burton,& Sivan, 1997),rehabilitation units
& Felsenthal, 1993; Davidson, Boyer, Casey, Matzel, (Anderson et al., 1993), cancer clinics (Balboni et
&Walden, 2008; Flannelly, Galek, & Handzo, 2005; al., 2007), hospices (Hampton, Hollis, Lloyd,Taylor,
Fletcher, 2004; Sheridan, 2009). NASW's (2001) & McMillan, 2007; Hermann, 2007), and various
Standards for Cultural Competence in Social Work Prac- outpatient settings (Astrow, Wexler,Texeira, He, &
tice enjoin practitioners to provide services that are Sulmasy, 2007; D'Souza, 2002; Moadel et al., 1999;
responsive to clients' spiritual beliefs and values, a Warner-Robbins & Christiana, 1989).
point echoed by the NASW (2008) Code of Ethics Although prevalence rates vary from setting to
standards that address religion. setting, typically the majority of respondents report
Taking clients' spiritual needs into account is an the presence of spiritual or religious needs. For ex-
integral component of holistic service provision that ample, Fitchett et al. (1997) examined the presence of
direcdy facilitates positive health outcomes. Spiritual religious needs among a sample of medical/surgical
needs often emerge in the context of receiving patients (N = 50) with a wide variety of admitting
health or behavioral health services (Nelson-Becker, diagnoses. Just over three-quarters reported hav-
Nakashima, & Canda, 2007). As clients wresde with ing three or more specific religious needs during
challenges, spirituality often becomes more salient hospitahzation.
(Koenig, 2007; Pargament, 1997). Spiritual assets This same body of research suggests that many
may be operationalized to help clients understand, cHents want health care professionals to address
cope with, or otherwise deal with the Stressors they their spiritual needs (Koslander 6<:Arvidsson,2007).
encounter on admission to the health care system Although not every client believes that spiritual
(Pargament & Raiva, 2007; Saleebey, 2006). concerns should be discussed in health care settings,
Research suggests that spiritual needs are common most clients appear to beheve that such discussion is
in health care settings (Flannelly et al., 2005).The appropriate (Arnold,Avants,Margohn,& Marcotte,
prevalence of spiritual needs has been explored in 2002; Dermatis, Guschwan, Galanter, & Bunt, 2004;

306 CCC Code: 0037-8046/11 $3.00 62011 National Association of Social Workers
Lariniore, Parker, & Crowther, 2002; Mathai &
North, 2003; Rose,Westefeld, & Ansley, 2001,2008;
Solhkhah, Galanter, Dermatis, Daly, & Bunt, 2009).
For instance, among clients {N = 79) receiving
psychiatric services, D'Souza (2002) found that 69
percent felt that practitioners should consider clients'
spiritual needs in treatment.
Failure to adequately address spiritual needs can
directly affect an array of health-related outcomes
(Balboni et al., 2007; Hermann, 2007; Koenig,
2007; Koenig, McCullough, & Larson, 2001). For
example, Astrow et al. (2007) examined the relation-
ship between addressing spiritual needs and overall
perceptions of care among a sample of outpatients
(N = 369) receiving treatment at a cancer center in
New York City. The authors found that chents who
reported their spiritual needs were not adequately
addressed reported significandy lower levels of global
satisfaction lA^ith the care they received.
The importance of this finding is accentuated by
the fact that global measures of client satisfaction are
typically understood as a proxy for the quahty of
care clients receive in health care settings (Jackson,
Chamberlin, & Kroenke, 2001; Press, 2002; Shea
et al., 2008). Research has hnked client satisfac-
tion with enhanced patient follow through, loyalty
toward service providers, profitability, and clinical
outcomes (Kaldenberg, 2001; Moscato et al., 2007;
Press, 2002). In addition, providing quality services
that satisfy clients is widely viewed as an ethical
imperative (Astrow et al., 2007).
Studies suggest that most social work practitioners
are invested in identifying and addressing chents'
spiritual needs but have received httle training in this
process (Sheridan, 2009). In a review of 15 studies
on the general topic, Sheridan found that between
66 percent and 89 percent of respondent social
workers reported receiving little or no instruction
on spirituality during their education. Similarly, con-
tent analyses of various social work literatures have
revealed minimal content on spirituality (Cnaan,
Wineburg, & Boddie, 1999; Hodge, 2002a; Hodge,
Baughman, & Cummings, 2006;Tompkins, Larkin,
& Rosen, 2006).
The lack of training may help explain why clients'
spiritual needs are often unaddressed. Although
outpatients may have access to the resources and
networks needed to address their spiritual needs ap-
propriately (Astrow et al.,2007), those with physical
or mental limitations or in inpatient settings may
experience more difficulty (Anderson et al., 1993;
H O D G E AND HORVATH / Spiritual Needs in Health Care Settings: A Qualitative Meta-Synthesis of Clients' Perspectives
Flannelly et al, 2005; Hermann,2007). For example,
one study of clients (N= 230) with advanced cancer
found that 88 percent reported that religion was
important. Of these, 72 percent reported that that
their spiritual needs were met minimally or not at
all by the medical system (Balboni et al., 2007). In
addition, 47 percent reported that their needs were
met minimally or not at all by either the medical
system or a religious community (Balboni et al.,
2007). Similarly, 45 percent of clients (N = 100) at
an inpatient rehabilitation hospital reported that not
enough attention was paid to their spiritual needs
during their stay (Anderson et al., 1993).
The relatively high levels of unmet spiritual needs
reported in these studies may have been related to
practitioner unfamiliarity with common spiritual
needs (Anderson et al., 1993). As observers have
noted, it is difficult to identify cHents'spiritual needs
without having a working knowledge of common
spiritual needs (Cavendish et al., 2006; Davidson
et al., 2008). Without an awareness of such needs,
it is easy to overlook their existence, even if one is
committed to providing holistic services (Sheridan,
2009). Information external to the paradigm in
which one has been schooled is typically hard to
identify (Kuhn, 1970).
Accordingly, the purpose of this article is to
acquaint social work practitioners with common
spiritual needs by identifying and describing chents'
perceptions of their spiritual needs in health care
settings. More specifically, we attempt to answer this
question: What type of spiritual needs do clients
commonly experience in health care settings? De-
veloping a working knowledge of common spiritual
needs can help practitioners provide better services
by heightening their ability to recognize and address
such needs (Cavendish et al., 2006; Davidson et al.,
2008; Murray, Kendall, Boyd, Worth, & Benton,
2004). Before discussing the methodology used to
answer the study's question, we review common
conceptualizations of spirituality and rehgion.
SPIRITUALITY AND RELIGION
Adults' conceptualizations of spirituality and religion
have been examined among a variety of samples
(Cohen, Thomas, & WiUiamson, 2008; Gallup &
Jones, 2000; Marier & Hadaway, 2002; Schlehoffer,
Omoto, & Adelman, 2008; Zinnbauer et al., 1997).
Spirituality is most commonly defined in terms of
an individual's connection or relationship with God
or with some other kind of transcendent being or
307
dimension. Conceptualizations of religion overlap
those offered for spirituaUty but tend to emphasize
the notion of a shared set of beliefs and practices
that have been developed and institutionalized in a
community context. Thus, spirituality and religion
are typically viewed as overlapping but distinct
constructs. In keeping with the perceived degree of
congruence between the two constructs, most adults
self-identify as both spiritual and religious.
Within these broad definitional parameters, con-
siderable diversity exists. For example, some people
define spirituality without any reference to the
transcendent (for example, in terms of the quality
of human relationships), whereas others affirm con-
ceptualizations that emphasize traditional religious
practices (for example, performing rituals from one's
faith tradition). Some adults believe that spirituality
and religion are mutually exclusive constructs, but
others view them as synonymous. Developing some
awareness of both the norms and the diversity that
exists regarding conceptualizations of spirituality and
religion may be helpful in interpreting the results
that flow from this study's methodology.
METHOD
To answer the research question, we conducted
a qualitative meta-synthesis of studies examining
clients'perceptions of their spiritual needs in health
care settings. Meta-syntheses have been used to inte-
grate qualitative findings across studies in numerous
fields, among them medicine (Sim & Madden, 2008) ;
psychotherapy (Timulak, 2007); psychiatry (Cole
& Dendukuri, 2003); education (Kasworm, 1990);
health (McCormick, Rodney, &Varcoe, 2003); sub-
stance use (Maher & Hudson, 2007); and nursing
(Finlayson & Dixon, 2008; Meadows-Oliver, 2003;
Timulak, 2007).
Meta-syntheses are designed to provide a more
comprehensive understanding of investigated phe-
nomena (Maher & Hudson, 2007;Timulak, 2007).
The comparative integration of qualitative research
yields a fuller, richer, more complete understanding
of a given phenomenon. Relative to individual stud-
ies, a meta-synthesis provides results characterized by
enhanced cogency, coherence, and pragmatic utility
in terms of informing practice decisions (Bondas
& Hall, 2007).
Study Selection Criteria
To identify studies that would acquaint practitioners
with clients' spiritual needs in health care settings.
308
we specified a number of inclusion and exclusion
criteria.To be included in the present analysis, studies
had to be qualitative inquires that explored under-
standings of clients' spiritual needs in health care
settings and featured primarily clients' perspectives.
In addition, studies had to be published in English
and peer-reviewed.
Studies were excluded if they discussed clients'
spiritual needs using quantitative instruments that
required clients to fit their experiences into prede-
termined categories, brief case studies, conceptual or
theoretical frameworks, or health care professionals'
or caregivers' perspectives about clients. Research
on spiritual coping was also excluded, because this
construct was held to be conceptually distinct from
the related construct of spiritual needs.
Studies were also excluded if they explored
perceptions of spiritual needs primarily among
clients in late life or those who were terminally
ill. Spirituality often becomes more salient among
such populations and, consequently, the spiritual
needs of such individuals may differ substantially
from those of other clients (Conner & EUer, 2004;
Dalby, 2006; Harrington, 2004). Similarly, studies
were excluded if they explored conceptualiza-
tions of spiritual needs among nonclinical patient
samples because perceptions of spiritual needs may
change on admission into health or behavioral
health systems (Pargament, 1997). One exception
was made to this criterion in the case of a study
(Conner & EUer, 2004) in which nonhospitalized
individuals—of whom 84 percent reported at least
one medical diagnosis of chronic illness—were
asked to prospectively imagine their spiritual needs
on admission to a hospital.
Search for Studies
To obtain studies that met the aforementioned cri-
teria, we conducted a computerized literature search
ofthe foDowing databases: Social Services Abstracts,
Social Work Abstracts, MEDLINE, PsycINFO,
PsycARTICLES, PsycCRITIQUES, Psychology:
A SAGE Full-Text Collection, PILOTS, Health
Sciences, Sociological Abstracts, and Sociology: A
SAGE Full-Text Collection. The keywords were
"spiritual needs," "religious needs," "spiritual con-
cerns," or "religious concerns." Titles and abstracts
were read along with reviews of related topics (Flan-
nelly et al., 2005; Okon, 2005; Sinclair, Pereira, &
Raffin, 2006). We obtained promising studies and
manually reviewed them to assess their relevance to
SocialWork VOLUME 56, NUMBER 4 OCTOBER 2011
the present analysis and to locate other potentially
germane studies.
Data Analysis
The analytic procedures used in this meta-synthesis
followed common practice among meta-synthesizers
(Bondas &Hall,2007;Finlayson &Dixon,2008;Mc-
Corniick et al, 2003). David R. Hodge conducted
the analysis and synthesis following the 10-step pro-
cess described inTable 1 .Theoretically, he was guided
by what some have called a "weak constructivist"
perspective (McCormick et al., 2003).
Violet E. Horvath provided peer debrieñng (Lietz,
Langer, & Furman, 2006). In this capacity, an impar-
tial colleague critically reviewed the implementation
of the research methods and provided feedback on
the accuracy and completeness of David R. Hodge's
implementation of the data analysis procedures.This
feedback, which helped to minimize the effects of
reactivity and bias, enhanced the credibihty and
trustworthiness of the results.
RESULTS
The search produced 11 studies. Ten to 12 studies
may represent an ideal number for a meta-synthesis
(Bondas & Hall,2007). Information on each study's
lead author, participant demographic characteristics,
spiritual traditions affirmed by participants, location,
and design is provided in Table 2, to the extent that
such information could be abstracted with reason-
able accuracy from the original articles.
Personal interviews were conducted in most of
the studies. Interviews were held before, during,
and after hospitalization. Subjects were hospitalized
for a wide variety of reasons. Potential respondents
typically used their own understanding of spiritu-
ality and religion to answer questions about their
needs in these areas. Numerous spiritual traditions
were represented, although Protestant, Catholic, and
Jewish traditions predominated, in keeping with the
demographics of the United States (Richards &
Bergin, 2000).Three studies used samples that were
drawn, or appeared to be drawn, from outside North
America (Fagerstrom, Eriksson, & Enberg, 1999;
Shih et al., 2008; Simsen, 1986). By virtue of the
design of these three studies, the data contributed
to the synthesis was comparatively minor.
In the context of discussing their spiritual needs,
clients experienced feelings of abandonment,
confusion, despair, fear, hopelessness, isolation.

Table 1: Process Used to Analyze and Synthesize Data across Studies {N = 11)
1. Read the relevant background literature. A thorough reading of the spirituality literature aids in the analysis and synthesis
process. Knowing, for example, how clients tend to conceptualize spiritualit)', or use spirituality to cope with problems, can
increase sensitivity to potentially relevant concepts.
2. Develop familiarity with the studies included in the meta-synthesis. This is an iterative process in which studies are repeatedly
examined as the meta-synthesis develops over time.
3. Approach each study as a holistic construction. Accordingly, each component of the study (for example, abstract, method,
discussion) provides useful data. Paying systemic attention to the details of each study helps one to understand and interpret the
reported results.
4. Examine descriptive and inductive themes and other units of meaning. Within each study, the themes (that is, metaphors, con-
cepts, or ideas) in the results section are contextually examined and privileged over other data. To the extent possible in a given
study, an attempt is made to "hear clients' voices" in the presented themes.
5. Transition from analysis to synthesis. With the data analyzed, the process shifts toward synthesis using the following, more
interpretively oriented, procedures:
6. Create tentative working categories within and across studies. Initially, categories are primarily provided by the studies them-
selves (for example, in the form of explicitly stated themes). However, as themes are compared and contrasted across studies—
and interfaced with the preexisting literature—new units of meaning may emerge.
7. Posit relationships across studies. As data are abstracted and juxtaposed, new relationships emerge as similar units of meaning
are identified across studies. In a recursive process, the units are continually compared with similar phenomena to identify, syn-
thesize, and classify the emerging content. New terms may be coined that capture related units of meaning across studies that,
by virtue of their breadth, may have added cogency and creditability.
8. Attempt to disconfirm hypothesized relationships. As the synthesizing process results in the creation of new categories, dis-
confirming data are actively solicited. New categories are critiqued, and alternative formulations are explored that may provide
better formulations.
9. Construct afinalsynthesis. A synthesis is developed that retains the key concepts from each study. The end result is an inte-
grated, more complete understanding of clients' spiritual needs that provides greater depth and breath relative to individual
studies.
10. Express the synthesis in a given format. Informed by the spirituality literature, terminology is used that is consistent with forms
and metaphors commonly used by clients.

HODGE AND HORVATH / Spiritual Needs in Health Care Settings: A Qualitative Meta-Synthesis of Clients'Perspectives 309
 Table 2: Studies of Clients' Perceptions of Their
Spiritual Needs in Health Care Settings (/V = 11)

Cavendish et Eight former patients, hospitalized in acute Catholic (4), Protestant New York City Interviewed at
al. (2006) care for a variety of reasons (for example, (3), other (1) metropolitan home less than three
attempted suicide, perforated bowel); 87% area months after being
female; mean age = 61 years (range = 48-91); hospitalized for seven
75% white, 25% African American to26days(Ai= 13)
Conner & Forty-four church members; 86% female; All Protestant (98% Three urban Surveyed about
Eller (2004) mean age = 56 years (range = 19-84); 100% Baptist) churches in spiritual needs
African American (of whom 84% reported at Newark, NJ; during future
least one medical diagnosis of chronic illness) New York City hospitalization
area
Conco Ten former patients, hospitalized for a variety Various Christian Charleston, SC Interviewed after
(1995) of reasons (for example, substance abuse, dominations being hospitalized.
Crohn's disease); 70% female; age range = anywhere from two
35-86 years; 100% white weeks to several years
Davidson, Twenty-two adults of different genders and Muslim, Baha'i, Catho- Hospital in San Posthospitalization
Boyer, Casey, races, including African American, Latino, lic, Protestant, Jewish, Diego County, interview in at least
Matzel, & white, Chinese, and Filipino LDS, Jehovah's Witness, CA some cases
Waiden Jewish, and possibly
(2008) others
Emhlen & Nineteen surgical patients (receiving a variety Protestant (11), Catholic NA Interviewed at the
Halstead of non-life-threatening surgeries); 63% (6), no religion (2) hospital
(1993) female; mean age = 52 years (range = 27-75)
Fagerstrom, Seventy-five patients, drawn equally from NA Hospital in west- Interviewed at the
Eriksson, medical and surgical wards; 61% male, mean ern Finland hospital
& Enberg age = 63 (range 15-98)
(1999)
Meert, Thirty-three parents (of 26 children who Protestant (21), Catholic Children's Hos- Interviewed two
Thurston, died in pédiatrie intensive care); 64% female; (7), Jewish (2), unre- pital of Michi- years after child's
& Briller median age = 40 years (range = 23-81); 55% ported (3) gan, Detroit death, at hospital.
(2005) white, 45% African American about spiritual needs
at the time of death
Möller Sixty-five formerly hospitalized psychiatric Catholic, Protestant, An inner-city Foctis/discussion
(1999) inpatients (supplemented by 27 family mem- nondenominational church and a group interviews.
bers); approximately 50% male; age range = Christian, Jewish, Native mental health sometime after
19-81 years American, Muslim, center hospitalization
Buddhist, and perhaps
other Eastern faiths
Shih, Wang, Thirty Taiwanese heart transplant recipients; NA Two medi- Interviewed before
Hsiao, mean age = 28.5 years (5Z) = 4.1) cal centers in and after operative
Tseng, & Taiwan discharge
Chu (2008)
Simsen Five hospitalized patients NA NA NA
(1986)
Taylor Twenty-one adult patients with cancer (and (with caregivers) Protes- A large south- Interviewed at
(2003) seven family caregivers); 52% female; 71% tant (14), Catholic (6), western metro- clients' bed
white and 29% African American Jewish (5)» no religion, politan area
(2), LDS (1)
Note: LDS = the Church of Jesus Christ of Latter-Day Saints; NA = not available.

uncertainty, loss, and bereavement. Admission
into the health care system was typically a difficult
experience on some level. The attendant Stressors
and spiritual needs were intertwined. The resul-
tant emotional angst served as the background for
essentially all of the interrelated spiritual needs
that emerged, which can be summarized under
the following six primary themes: (1) meaning,
purpose, and hope; (2) relationship with God; (3)
spiritual practices; (4) religious obligations; (5)
interpersonal connection; and (6) professional staff
interactions.

310 Social Work VOLUME 56, NUMBER 4 OCTOBER 2011

Meaning, Purpose, and Hope
Clients expressed a spiritual need for meaning, pur-
pose, and hope. A desire to understand and interpret
life events was commonly mentioned. Respondents
reported a need to make sense of their present cir-
cumstances, get through them, and move on.
To this end, clients used a number of strategies.
Clients expressed needs to find explanations for why
the illness or death had occurred, get over asking
"why me?", reduce the frustration associated with
reduced capabilities, recognize that others are wc)rse
off, sense the reason for their present existence,
become aware of the positive things in their situa-
tion, count their blessings, focus on the good in hfe,
conduct a life review, and try to make the world a
better place. The need to find meaning, purpose, and
hope was closely related to the following theme.
Relationship with God
A family of spiritual needs was associated with cli-
ents' relationship with God (or the transcendent).
For many clients, this relationship was the vehicle
through which they made sense of their current
situation. Their relationship with God—which
was perceived to be a subjectively experienced
reality—provided an overarching sense of meaning
and purpose. It also provided hope for the future in
the present and the hereafter.
Regarding their relationship with God, clients
reported needs to question, blame, plead, or wrestle
with God; get right with God; know, accept, or trust
God's will in the current context; understand God's
plan; trust in God for healing; be reassured of God's
presence and care; and know that God is in control
and watching over them. These felt needs were typi-
cally intertwined with the following theme.
Spiritual Practices
Directly related to the previous theme was the need
to engage in spiritual practices, which can be under-
stood as specific, regular activities that foster clients'
connection with the transcendent. These practices
are typically used by clients as a way to enhance
their relationship with God. Spiritual practices fulfill
a felt spiritual need to enhance connection with
the transcendent, which in turn strengthens clients'
ability to cope with the challenges they encounter
by, for example, providing a sense of transcendent
purpose.
Clients mentioned a number of spiritual practices.
Among these were the need for or to engage in
H O D G E AND HORVATH / Spiritual Needs in Health Care Settings: A Qualitative Meta-Synthesis of Clients' Perspectives
prayer (perhaps the most frequently mentioned spiri-
tual practice),Bible reading,meditation,meditation
on scripture, reflection, and religious services. Other
spiritual practices cited included the need to listen
to inspirational tapes and messages, hear devotional
music, read spiritually themed books, and receive
religious sacraments. These spiritual practices tend
to bleed into the next theme.
Religious Obligations
Clients also reported a number of spiritual needs
related to their specific faith traditions. In addition
to spiritual practices that facilitate connection with
the transcendent, needs were reported that flow
from the teachings of respondents' faith traditions.
Although these obligations may also be related to
clients' sense of connection with God, they are
perhaps more prescriptive in nature than are needs
that fell under the previous theme.
For example, both Jewish and Muslim respon-
dents cited requirements for, respectively, kosher
and halaad food. Other issues mentioned within
this family included the need for treatment op-
tions that avoided blood transfusions for Jehovah's
Witnesses, respect for modesty, and complementary
gender roles among Muslims and Orthodox Jews.
Members of both traditions also reported specific
practices surrounding death and burial that should
be respected.
Interpersonal Connection
In addition to a vertical connection with God or
the transcendent, clients also reported a spiritual
need for horizontal connection \vith other people.
Included in this theme was connection with clergy
members, who were often viewed as instrumental
to the proper administration of these needs. This
theme, however, also included the need for regular,
compassionate interactions with friends, family, and,
in a certain sense, those who had passed on.
Needs in this theme included the following; visit-
ing with family members; conversing with people
who share one's spiritual values; receiving prayer
from others; seeking forgiveness from people one
wronged in the past; processing events with others
who had similar experiences; receiving tangible
expressions of support and encouragement; be-
ing appreciated and loved by other people; and
someone's simple, physical presence. In the case
of children who had passed on, parents indicated
a need to maintain a sense of connection through
311
thoughts, memorials, and mementos. The need for
positive interpersonal connection was also seen in
the final, associated theme.
Professional Staff Interactions
In keeping with the importance of human interac-
tion, many clients singled out relationships with
health care providers as an area in which spiritual
needs were present. In other words, clients' reported
specific spiritual needs related to their interactions
with professional staff. Perhaps because such staff
served as the human face ofthe health care system,
clients felt specific spiritual needs that were directly
related to the quality of their relationships with
professional staff.
The concerns mentioned included the need for
friendly facial expressions, words, and body language;
interactions that communicated dignity and respect;
empathy and caring; complete and accurate medical
information; the opportunity to discuss treatment
options and their ramifications; and trust, integrity,
and a willingness to "go to bat" for clients. Some
clients wanted staff to play an active role in explicitly
addressing the themes discussed earlier (for example,
pray with clients), whereas others felt staff should
generally play a more passive, secondary role (for
example, seek to mobilize resources to address clients'
needs); the implications of this are discussed in more
depth in the following section.
DISCUSSION
In light of research suggesting that most social \vork-
ers have little training in spirituality, we conducted a
meta-synthesis to familiarize practitioners with com-
mon spiritual needs by identifying and describing
clients'perceptions of their spiritual needs in health
care settings. Six primary spiritual needs were identi-
fied and described: (1) meaning, purpose, and hope;
(2) relationship with God; (3) spiritual practices; (4)
religious obligations; (5) interpersonal connection;
and (6) professional staff interactions.
It is important to emphasize the interrelated
nature of these spiritual needs. In clients' lived
experience, these needs were often intertwined.
Concurrently, it should also be noted that not
every client experienced every need that emerged.
Rather, as is the case with the primary studies that
provided the data for the meta-synthesis, the list
of themes creates awareness regarding potential
spiritual needs that clients may experience in
health care settings.
312
Implications for Practice
The findings underscore the importance of con-
ducting spiritual assessments in health care settings
(Nelson-Becker et al., 2007). It is through the process
of conducting a spiritual assessment that spiritual
needs are typically identified (Cavendish et al., 2006).
Once identified, steps can be taken to address any
needs that emerged during the assessment process
(Hodge, 2006; Koenig, 2007).
An initial brief spiritual assessment can be con-
ducted to assess the relevance of spirituality to cli-
ent care (MoUer, 1999). A brief assessment provides
clients who have spiritual needs with a forum in
which to communicate their interest in the topic
and, concurrently, places minimal burden on those
who have no spiritual needs or are uninterested in
sharing their spiritual needs (Hodge, 2004). If the
brief assessment reveals that spirituality may be a
relevant factor in client care, then a more com-
prehensive spiritual assessment can be conducted
(Hodge, 2005).
In one sense, each assessment will reveal unique
spiritual needs, as each client's spiritual journey is
unique. The results reported in this study, however,
suggest that clients' needs tend to be oriented around
the six themes listed earlier. Familiarity with these
six themes—and common manifestations of specific
needs within each theme—can help practitioners
identify spiritual needs by sensitizing practitioners
to their possible presence (Cavendish et al., 2006;
Davidson et al., 2008). Put simply, knowing what
a given entity looks like increases the chances of
identifying it.
When interacting with client spirituality, it is im-
portant that certain guidelines be followed to ensure
ethical and professional practice (Canda & Furman,
2010; Koenig, 2007). It is particularly important that
clients' spiritual self-determination be respected
(Derezotes, 2006). Practitioners should also ensure
that they remain within the parameters of their
professional competence and consider their level
of cultural competency regarding clients' spiritual
cultures (Hodge, 2006).
The present results also highlight the profound
importance of the relationship between clients
and practitioners. Spiritual needs are typically met
within the context of relationships (Meert,Thurston,
& Briller, 2005), and in a certain sense, aU helping
relationships can be understood as at least implicitly
spiritual (Canda & Furman, 2010). Characteristics
such as empathy, warmth, and genuineness play an
SocialWork VOLUME 56, NUMBER 4 OCTOBER 201t
instrumental role in essentially all practice relation-
ships (Nalavany, Ryan, Gomory, & Laçasse, 2005).
In turn, these characteristics function to meet some
chents' spiritual needs, perhaps particularly in situ-
ations in which chents are isolated from others and
a meaningful relationship has developed with the
practitioner.
In inpatient settings, steps might be taken to
proactively identify and ehminate structural barriers.
Toward this end, practitioners might convene focus
groups with clients from various spiritual traditions
to explore chents'perceptions (Davidson et al.,2008).
Clients may, for instance, lack access to quiet places
to pray, clergy members from their own traditions,
private spaces for mediation, prayer rugs and com-
passes (for Muslims), Spanish-language Bibles, and
kosher food. By working to remove barriers and
to hnk chents to spiritual assets, social workers can
play an instrumental role in meeting clients' spiritual
needs (Canda & Furman, 2010).
Implications for Social Work Education
The Joint Commission, the nation's leading health
care accrediting organization, has incorporated spiri-
tual assessment requirements into its accreditation
standards (Koenig, 2007). Graduate programs might
acquaint students with these requirements and the
various assessment tools that have been developed
to meet these requirements. Developing familiarity
with the strengths and limitations of various brief
(Hodge, 2004; Koenig, 2007) and comprehensive
(Hodge, 2003) assessment tools helps practitioners
select the tool that best matches an individual cli-
ent's unique characteristics, preferences, and envi-
ronmental context.
Content on commonly encountered spiritual tra-
ditions could also be incorporated into curriculums
to develop some degree of familiarity with the bebefs
and norms within various traditions (Richards &
Bergin, 2000;Van Hook, Hugen, & Aguilar, 2001).
Terminology that is incongruent with, or even
uncommon within, a client's spiritual tradition can
hinder the assessment process (Hermann, 2001).
Developing knowledge, skills, attributes, and other
characteristics of cultural competency directly affect
one's abihty to identify and address spiritual needs
(Hodge, 2002c).
As part of the process of developing cultural
competency in the area of spirituality, educational
programs might expose students to various concep-
tualizations of spirituality and rehgion. Understand-
H O D G E AND HORVATH / Spiritual Needs in Health Care Settings: A Qualitative Meta-Synthesis of Clients'Perspectives
Developing knowledge, skills, attributes, and
other characteristics of cultural competency
directly affect one's ability to identify and
address spiritual needs.
ings of spirituality and rehgion have been explored
among national samples of NASW-affihated direct
practitioners (Canda & Furman, 2010) and graduate
students (Hodge & McGrew, 2006).This and other
research suggests that many social workers may
hold understandings of these constructs that differ
from those widely held among some sections of the
general pubhc (Hodge, 2002b) .This is significant, be-
cause conceptuahzations of spirituaUty and religion,
and the relationship between these two constructs,
tend to shape perceptions of needs.
For instance, some people define spirituality in a
relatively holistic, diffuse manner (Gallup & Jones,
2000). Individuals who experience themselves as
indivisible entities in whom physical, emotional,
and spiritual needs are intertwined may encounter
some difficulty describing their spiritual needs in
a concrete, detailed manner (Emblen & Halstead,
1993; Fagerstrom et al., 1999). Conversely, others
who define spirituality in more concrete terms (for
example, in terms of the quality of their immediate
human relationships) may be able to provide precise
descriptions of their needs. Educators can help stu-
dents think through the various conceptualizations
that exist, the ramifications of different conceptu-
alizations, and situations in which a referral may be
advised (Canda & Furman, 2010; Hodge, 2006).
Limitations
As is the case with other approaches, meta-syntheses
are characterized by certain limitations. Although
qualitative data are typically more open and acces-
sible than quantitative data, the data are still filtered
through a particular lens. Since meta-synthesizers
do not have access to the original data, sources of
bias in the original, primary studies (for example,
misrepresentation of clients' voices) can introduce
bias into the synthesis (Bondas & Hall, 2007).
The primary studies had a variety of designs that,
in turn, may have influenced the results (Kasworm,
1990). For instance, clients interviewed at hospi-
tals by health care professionals may be reluctant
to share spiritual needs—which may have been
313
poorly addressed—while they were receiving care
from these same professionals. Alternatively, clients
interviewed subsequent to hospitalization may have
failed to completely recall felt spiritual needs.
Debate exists among meta-synthesizers about
a number of philosophical issues (McCormick et
al., 2003). For example, some observers recom-
mend excluding some studies on the basis of their
methodological traditions due to perceived conflicts
between qualitative approaches. Similar debate exists
about the inclusion of unpublished works or "gray
literature" of unknown quality. In this study, qualita-
tive research from all methodological traditions was
eligible to be selected, and quality was assessed to
be sufficient if the study was published in a peer-
reviewedjournal.Although this choice represents a
common practice among meta-synthesizers (Bondas
& Hall, 2007), a different choice might have pro-
duced different results.
Another limitation of meta-syntheses is the diffi-
culty of using some strategies widely used to increase
rigor in qualitative studies. Member checking, for
instance, is difficult to carry out in meta-syntheses
(Padgett, 2008). Consequently, it is unknown if
participants in the primary studies would concur
with the articulation of spiritual needs produced
in this synthesis.
CONCLUSION
Spiritual needs commonly emerge in health care
settings, and many clients want practitioners to ad-
dress these needs (D'Souza, 2002; Flannelly et al.,
2005). Although addressing spiritual needs has been
linked to positive health-related outcomes (Astrow
et al., 2007; Balboni et al., 2007), in practice, clients'
spiritual needs are often unaddressed. By identifying
the needs clients commonly experience in health
care settings, this study helps equip practitioners
with knowledge needed to provide better, more
client-centered services. HSU
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