In 2004, a hospital in Maine was perplexed by the number of female Muslim patients canceling outpatient appointments. The hospital's effort to reach out to the community ultimately uncovered the cause: The hospital's gowns were too skimpy. They conflicted with the patients' religious and cultural beliefs about modesty.
This is not the only way religion shows up as a factor in healthcare. Religion also emerges around every day health issues including reproductive health, diet and hygiene. In contrast to the frequent assumption that religion is only an issue during the final stages of end-of-life care, it actually becomes relevant far more often. In fact, during doctor visits or hospital stays, many healthcare providers are overlooking key information that is influencing their patients' activities and health decisions.
When providers lack such knowledge, there can be unintended results such as violating a patient's trust and religious beliefs. Consider:
- The nurse who is unaware of Sikhs' religious practice of keeping hair uncut, shaves a Sikh patient's beard and trims his hair so that he is "cleaned up"
- A food service employee serves a plate of meatballs to an elderly woman - a lifelong vegetarian who also is a Hindu patient with dementia
- Hospital staff delay treatment of a Sabbath-observant Jewish patient because she declines to sign admitting forms, which causes the patient to become agitated and delays the urgent care she needs
In a country where 84% of the population self-identifies with a wide variety of religious beliefs and practices, the failure to address religion results in a serious knowledge gap and decreased patient satisfaction. By incorporating awareness of the impact of religion into organizational culture and training, hospitals can reverse this trend and increase their market share by becoming a provider of choice.
In 2011, a study published in the Journal of General Internal Medicine found that inpatients who discussed their religious and/or spiritual concerns with their physicians - regardless of whether they had initially indicated a desire for such a discussion - were more likely to rate their care at the highest level on four different measures of patient satisfaction.
As a measure of quality care, patient satisfaction is important. And it can no longer be denied that addressing religious needs in appropriate circumstances is relevant and one of the ways that healthcare providers can positively impact patient satisfaction.
Increase Market Share
Improving patient satisfaction also has financial implications. For one thing, the Centers for Medicare and Medicaid Services now ties the new Value-Based Purchasing Program to incentive payments related to patient satisfaction. There are, however, other business-related reasons why it matters.
Healthcare institutions can also increase their market share by actively addressing patients' religious and spiritual beliefs and practices. Patients who perceive that a hospital is not respecting or accommodating their religious beliefs and practices - including observance of holy days, end-of-life rituals and dietary needs - will talk about their experiences in the community and, when possible, seek care at hospitals where they know their beliefs are respected.
The hospital in Maine increased its market share by building a relationship with the Muslim community and designing a hospital gown that more fully covers a patient's body. As a result, the number of Muslim women seeking preventative care increased significantly. The result was a win-win. Beyond building patient loyalty, the hospital avoided the expensive emergency room admissions costs from patients who delayed seeking care.
In more extreme cases, ignoring religious beliefs and practices can result in expensive, time- consuming lawsuits. For example, recently, a hospital in New York State made headlines when a woman suffering from brain cancer requested that she be removed from life support. Her parents, both devout Christians, went to court to stop doctors from removing their daughter's feeding tube. In accordance with their faith, the parents believed that removing life support is suicide, and suicide would condemn their daughter to hell. Timely and in-depth discussions with both patients and family around end-of-life care can reduce and sometimes avoid these types of confrontations and the distress it inflicts on patients, families and providers.
While religion is personal, and each patient will have discrete needs and benefit from an individualized approach, there are some better practices that hospitals can adopt for addressing the religious needs of their patient populations:
1. Track Religious Demographics
Healthcare institutions need to become religio-culturally competent. The key first step toward this component of cultural competence is developing a system that tracks the religious demographics of the patient population. To collect relevant data, hospitals might have to add or modify existing admissions forms and train staff and should do so in accordance with the advice of their legal counsel.
2. Community Outreach
Hospitals can use collected data as a springboard for outreach to religious communities needing their services. Religious community leaders (both clergy and community activists) can be key resources in identifying community healthcare needs, as well as partners in service modifications, programs or initiatives.
3. Take a Spiritual History
In the same way that taking a physical, sexual, and social history is a standard part of initial patient assessments, hospitals should require that spiritual histories become part of all in-take interviews.
Better practices include cultural competence professionals training all clinicians how to respectfully and sensitively discuss the topic of religion with their patients. Similarly, it is important for hospital executives to create systems to accurately document and transfer this knowledge so that it is institutionalized and not limited to a few team members.
Although clinicians struggle with severe time limitations, some of these practices can be implemented in ways that ultimately save time. At the very least, clinicians should ask patients: "Are there any religious or spiritual practices related to your health that you would like me to know about so I can better care for you?"
Even if the patient does not have a response at the time of the interview, this simple approach lets the patient know that religion is a safe topic to discuss with his or her physician - and that can make all the difference.
4. Prayer and Proselytizing
One issue that often emerges in healthcare institutions, which benefits from clear policies and guidelines, involves what to do (and not do) about prayer and proselytizing. The strict definition of "proselytizing" is what occurs when one person attempts to convince another of the correctness of his/her religious beliefs. In the context of a healthcare setting, the definition needs to be understood more broadly.
The patient-provider relationship is complex, with healthcare professionals in a position of authority. For many patients, healthcare professionals' words carry extra weight. Moreover, many patients may not want to differ with a provider for fear of seeming disrespectful or difficult.
Consider the phlebotomist who, while drawing blood from a patient, asks the patient whether he has accepted Jesus Christ. Is the question simple or coercive? What if the phlebotomist only asks what the patient thinks about religion? Either way, the question involves inappropriate proselytizing. The question came from a person in position of authority, not the patient. This can lead to discomfort, patient dissatisfaction, distress and, on occasion, litigation.
A System-wide Approach
For a healthcare institution to truly become religio-culturally competent, its efforts must take a system-wide approach:
- Hospital leadership must be fully committed to cultural competency education at all levels of the institution
- Healthcare providers should be trained to understand that each patient may or may not have religious beliefs that influence their choices for care and their needs as patients. As part of this training, they should learn ways to communicate and inquire about these issues without crossing the line into proselytizing
- Key staff, from administrators and admissions staff to security guards and housekeeping, who interact with patients outside of a clinical role must also be trained to recognize the role that religion plays in patients' health care decisions
- Staff should be made aware of all the resources available - community leaders, pastoral care, the hospital's office of diversity and inclusion, bloodless surgery programs - and know how and when to access these resources
Hospitals that commit to respecting and accommodating the religious needs of their patients - and of their employees - place themselves on the cutting edge of patient care. These efforts will improve care and increase reimbursements based on patient satisfaction, increase market share and decrease costly litigation.
Joyce S. Dubensky, JD, CEO, Tanenbaum Center for Interreligious Understanding, a non-sectarian, secular organization, is known for leading the Center to new firsts - including the first comprehensive guide on the intersection of religion and healthcare, the first toolkit on religious diversity for workplace managers (used by global Fortune 500 companies), the first collection of compelling life stories of Tanenbaum's "Peacemakers in Action," and establishing a global "Peacemakers' Network." Previously, Dubensky served as the first General Counsel and created the legal department for UJA-Federation of Jewish Philanthropies of New York, and as the deputy executive director at the Greater New York office of the National Conference for Community and Justice. The Tanenbaum Center for Interreligious Understanding (http://Tanenbaum.org) promotes mutual respect with practical programs that bridge religious difference and combat prejudice in areas of health care, armed conflict, education and workplace settings.