[Editor's Note: The following is a draft paper that responds to an item in the Spring 2003 Newsletter that called for discussion of the identification of pastoral care interventions for research by more detailed specifications than have been in use. For more information on the draft paper, and to offer your own thoughts on the subject to the author, e-mail: firstname.lastname@example.org. The author makes clear that the draft paper, obviously, does not represent an official position of the federal government or the National Institutes of Health.]
I. INTRODUCTION AND SUMMARY
As John Ehman observed in the Spring 2003 Newsletter, the empirical usefulness and validity of research on institutional chaplain visits to patients will not be convincing unless what happens in those visits is specified in some reasonable level of detail. Consequently, the design of research studies will need a methodology for the detailed specification of chaplain interventions and a consistent, unambiguous terminology for describing chaplain visits with patients and institutional clients. What is proposed in this paper is a four-part template for the specification of a chaplain visit. The first part of the template is a statement of the purpose of the visit; the second part is a description of the structure or sequence of steps to be followed in the visit; the third part is a presentation of the cognitive content of the communication between the chaplain and the patient; and the fourth part is a specification of the outcomes intended for the visit, described in concrete operational terms.
II. A METHOD FOR SPECIFYING CHAPLAINCY INTERVENTIONS
I propose here a template for the specification of types of chaplain activities and interventions with patients. This is intended to be only a pragmatic first step in specifying chaplain visits in greater detail--one way to begin to specify what a chaplain does. Specifying professional practice patterns in some detail should permit more precise identification of differences in chaplains' practices and reduce ambiguities in the terms used to describe them. A chaplaincy practice pattern is more than a list of activities and types of interventions with patients. Each of the activities or interventions with patients in a specific practice pattern can be identified by its purpose, the structure of the activity, the cognitive content of the communications used to achieve the outcome with the client or others, and the observable outcome by which the activity would be rated as successful or less than successful.
There are a number of types of chaplain interventions in visits with patients that together define operationally the care that chaplains provide. The White Paper: Professional Chaplaincy--Its Role and Importance in Healthcare, published in 2001 by the major professional chaplaincy organizations, compiled the statements of many chaplains on what the scope of activities of chaplains was or should be, but none of the activities in the list was described in detail. A conjecture is that different chaplains would elaborate what those individual activities entailed in somewhat different, or even very different ways. Ambiguity in the future can be avoided by developing detailed specifications of the activities and interventions that describe the differing practices and approaches to chaplaincy care, and by referring to these approaches by agreed-upon terms that do not carry with them implied semantics from the practices and experiences of different faith communities.
III. THE FOUR COMPONENTS IN GREATER DETAIL
The Purpose of the Activity: Each of the types of chaplain interventions with a patient would be categorized by its purpose. Interventions designed for achieving the same purpose belong in the same general category of intervention. Some examples of purpose categories would be patient visits for spiritual assessments, discussion of advance directives, responding to a referral from a nurse or clinician, discussion of end of life issues, performing a religious rite or ordinance, spiritual counseling, providing spiritual support when a patient has received bad news, conveying a message from the patient's congregation or pastor, etc. As with any activity, the key issue is whether the purpose of the activity is achieved. The purpose of the intervention distinguishes the visit from other kinds of visits, defined in terms of their different purposes. Interventions intended to achieve the same general purpose, of course, can differ operationally by the other three characteristics: structure, cognitive content, and outcome indicators.
The Structure of the Activity: The structure includes the component parts of the activity and the sequence of steps involved. There is no assumption that the steps would be rigidly adhered to in practice. The steps would provide the "plan" which the chaplain takes into the encounter with the patient. As the encounter progresses, the chaplain may depart from the plan as alternative opportunities for achieving the purpose are perceived. The ways in which a chaplain intervention for a particular purpose category would go about achieving that purpose are likely to vary, depending on the responses of the patient and the chaplain's experience-based understanding of how the interaction with the patient is progressing toward the desired outcome.
The Cognitive Content of the Communications Involved in the Activity: The topics that the chaplain is prepared to discuss or explain in the meeting with the patient, and the conceptual framework used in assessing the patient's responses in the interaction, represent the cognitive content of the chaplain's communication with the patient in order to achieve the purpose of the intervention. Some purpose categories can have very well-defined cognitive content, such as a visit for discussing advance directives. Other purpose categories can have much broader cognitive content, drawing on the extensive pastoral experience of the chaplain. An intervention in a particular category of purpose may well have cognitive content that differs from chaplain to chaplain, based on a chaplain's denominational background, education, experience, and specific objectives for the patient visit resulting from previous visits to that patient.
The Outcome Intended by the Activity: The specification of the outcomes intended for the visit should be stated in concrete operational terms. The statement of the outcomes should be in terms of the observable indicators that the outcome has or has not been achieved, or by the measures by which the intervention would be rated as successful, less than successful, or not successful in achieving the purpose of the patient visit. The purpose of the visit is specified in a general categorical way; the outcome, however, should be specified in terms of observable concrete facts that can be verified empirically. We would expect different chaplaincy practice patterns to define the intended outcome of a chaplain's intervention for a particular purpose category of visit in a way that is consistent with the chaplain's theological, philosophical, and psychological education and pastoral experience.
For each type of visit defined by its purpose, the topics of conversation between the chaplain and the patient may evolve in different directions for many reasons. The different ways in which the chaplain attempts to achieve the purpose of the visit will vary based on the chaplain's background, training, experience, and interests, as well as the background, experience, and interests of the patient. The orientation, experience, and faith community background of a chaplain very likely will influence the specific ways in which an intervention is conducted. A chaplain is expected to adjust and adapt the conversation to the patient, and to select for discussion the specific topics in the cognitive content that match the disposition and background of an individual patient. There are many ways in which the chaplain may adapt the content of the discussion to the patient's viewpoints in order to achieve the purpose and the desired outcome of an intervention.
What this four-part template for specifying chaplain interventions intends to accomplish is not to put constraints on a chaplain's resourcefulness in addressing the needs of an individual patient, but to describe the general patterns that a chaplain has developed through education and experience for handling patient visits in specific purpose categories. The template is intended to make explicit the implicit "plan" that the chaplain has in mind at the entry point to the intervention. For purposes of research, a patient visit must have sufficient specification in order to be replicated by other chaplains. The four-part template outlined above offers one approach to providing a specification that can enable another chaplain to conduct patient visits according to the same design, even though there will be adaptations within that design.
IV. AN ILLUSTRATIVE EXAMPLE: S. J. C. LEE'S OUTLINE OF THE SPIRITUAL ASSESSMENT INTERVENTION
An illustrative example of the use of this template for specifying a chaplain visit with a patient can be synthesized from Simon J. Craddock Lee's description of CPE students' spiritual assessment of patients in his article, "In a Secular Spirit: Strategies of Clinical Pastoral Education," [Health Care Analysis 10, no. 4 (December 2002): 339-356; featured by Larry VandeCreek as the ACPE Research Network's October 2003 Article-of-the-Month].
In this article, Lee's description of how the CPE students in a community hospital conduct spiritual assessment interventions with patients offers enough detail to fill in and partially illustrate the four-part template methodology. The quotations below are intended to illustrate where in the article Lee provides a hint or statement that would indicate an aspect of the spiritual assessment visit. A spiritual assessment in Lee’s article, generally speaking, is a visit by a chaplain to inquire about the patient's holistic needs, religious or existential interests, and the religious practices or other spiritual activities that would make the patient's stay in the hospital more spiritually rewarding. The assessment, so broadly conceived, is to identify how to help the patient cope with the adverse experiences likely to be associated with the hospital stay. Lee stated:
I will lay out the strategies of CPE to demonstrate that pastoral concepts are applied both to patient care and to the development of the chaplain's professional identity. At these two hospitals sites [in the ethnographic study], the central element of chaplaincy technology is the spiritual assessment model which defines the chaplain's task through a summary of the whole person that is the patient. ...The assessment model used here is oriented toward ascertaining a person's core spiritual needs, which are broken down into three typologies: 1) self-worth, 2) reconciliation, and 3) meaning and direction. [p. 344]
There may well be other steps that are involved in the process, and there may be broader cognitive content than what Lee described in his article; but the details he included suggests the following four-part template specification of the spiritual assessment intervention as practiced by the CPE students:
The Purpose of the Activity: Lee suggested that the CPE approach is to obtain a "diagnosis" of the patient's spiritual condition--to assess the patient's religious and spiritual needs. He refers to "a summary of the whole person that is the patient" and notes, "The assessment model used here is oriented toward ascertaining a parson's core spiritual needs" [p. 344]. It is "a way to initiate dialogue with patients and...a summary device to explain their perspective on patients' care to other members of the interdisciplinary team" [p. 348].
The Structure of the Activity: The structure includes the component parts of the activity and the sequence of steps, along with a specification of the relationships of the activity to other activities. As an example, the Lee article outlines a spiritual assessment intervention in roughly seven component steps, including the spiritual assessment's relationship to other activities [p. 345]:
- a) Consider the patient's diagnoses and staff comments on the patient:
- Prior to the assessment visit, the chaplain examines the patient's diagnoses and staff comments on the patient: the chaplain "proceed[s] from the medical diagnosis, staff comments and personal assumptions" [p. 345].
- b) Formulate a hypothesis or initial assessment of the patient's needs before the visit:
- The chaplain formulates a hypothesis or initial assessment of which of the three categories relating to core spiritual needs the patient will be in before meeting the patient: "the chaplain uses the framework of core spiritual needs to formulate an initial assessment of a patient as he walks into a patient room" [p. 345].
- c) Start the dialogue with the patient with three typologies of spiritual problems:
- The chaplain uses the three types of issues as a starting point for a dialogue with the patient: "The typologies are presented as a starting point to determine an initial attitude and approach so that chaplains have a starting point for dialogue" [p. 345].
- d) Narrow down the diagnosis to one core or principal problem:
- The chaplain narrows down the diagnosis to one core or principal problem: "An individual may have characteristics of all these needs, but this approach to CPE maintains that the core spiritual need emerges in crisis and renders other character traits secondary concerns" [p. 344].
- e) Intervene with the chaplain response appropriate for that principal problem:
- The chaplain intervenes with the response appropriate for that principal problem: this "enables [the chaplain] to make the most of interactions constrained by daily patient volumes and limited staffing" [p. 345].
- f) Summarize the diagnosis and intervention in the patient's chart after the visit:
- After the meeting, the chaplain summarizes the diagnosis and intervention and records it in the patient's chart: "the model addresses both the drive to standardize spiritual care as a process, and the need to articulate what chaplains provide for patients in a way that can be summarized" [p. 345].
- g) Communicate the assessment of the patient to the interdisciplinary team:
- The chaplain communicates his or her assessment of the patient to other members of the interdisciplinary team: the chaplain "communicate[s] to other members of the interdisciplinary care team" [p. 345].
- h) Communicate what has been provided for the patient to the patient's family, if appropriate:
- The chaplain may choose to communicate what has been provided for the patient to the patient's family: in Lee's description, the chaplain "communicated to...the patient's family" [pp. 345-346].
The Cognitive Content of the Communications Involved in the Activity: In Lee's illustration, the cognitive contents are the three types of core spiritual problem: "three typologies: (1) self-worth, (2) reconciliation, and (3) meaning and direction" [p. 344].
A person whose core spiritual need is self-worth will often talk about the experience of their illness or injury as an inconvenience to other people (family and friends, even health care providers). Such an individual will often blame himself; for example, someone with injuries as a result of domestic violence may speak about the behaviors that provoked the abuser to strike out. A chaplain will seek to assist such a patient in recognizing the legitimacy of his own needs and inherent value as a person living in community with others. [p. 344-345]
A person whose core spiritual need is reconciliation will often attribute the cause of her illness or injury to others--family, co-workers, or even "the system." Such an individual is often identified by nurses as the "difficult patient" who may have lashed out during attempts to assist the patient. Chaplains talk about a patient's need to be "reconciled with self and other," the family or community. A provider may recall an encounter with a substance abuser on repeated visits to the emergency room who rants about the economy as the source of her trouble and will resist acknowledging her own decisions around drugs or alcohol use. A chaplain would seek to encourage such a patient to recognize her own role in her predicament with an aim to taking steps to enact change and accept assistance from others. [p. 345]
The third typology is reported more infrequent relative to the other two core spiritual needs. A person with a core spiritual need for meaning and direction is often unclear about the source or an illness or injury, or how to make sense of it in the context of their particular life circumstances. Even patients who attribute the etiology of their illness to fate or biology (e.g., infectious agents) may express confusion or uncertainty about their experience or attempt to interpret implications for their life in general. Chaplains will seek to help such a patient interpret her experience and determine how she might move forward differently based on the meaning she gives to her crisis. [p. 345]
Proceeding from the medical diagnosis, staff comments and personal assumptions, the chaplain uses the framework of core spiritual needs to formulate an initial assessment of a patient as he walks into a patient room. The typologies are presented as a starting point to determine an initial attitude and approach so that chaplains have a starting point for dialogue. One CPE supervisor encourages residents to focus on the process as "mapping a life trajectory." [p. 345]
The Outcome of the Activity: The spiritual assessment described by Lee will be considered successful if by it the chaplain:
- a) has gained knowledge of the patient's core spiritual need:
- "the core spiritual need emerges in crisis and renders other character traits secondary concerns" [p. 344],
- b) has provided the patient with some initial counseling appropriate to the need:
- "enable[d] them to make the most of interactions constrained by daily patient volumes and limited staffing" [p. 345],
- c) has developed summary information for communication to the interdisciplinary team:
- the chaplain has "communicated to other members of the interdisciplinary care team" [p. 345], and
- d) communicated to family members, if appropriate:
- in Lee's description, the chaplain "communicated to...the patient's family" [p. 345-346].
Lee, of course, does not elaborate these brief phrases and clauses into the full sentences and paragraphs that would be needed for a coherent specification of the chaplain visit for the purpose of a spiritual assessment. The phrases and clauses provide the indicators of aspects of the intervention that would be specified clearly in a specification of the chaplain visit in accordance with the four-part template.
Also, Lee does not suggest that this particular way of conducting a spiritual assessment visit is the usual way that chaplains conduct this type of intervention in other health care institutions. It is presented as one way of conducting a spiritual assessment that he observed in his ethnographic analysis of one institution's CPE program.
V. CHAPLAINCY PRACTICE MODELS
Successive chaplain visits to the same patient have a cumulative and synergistic effect that also needs to be defined and specified as part of a research design. A research program will seldom focus on just a single chaplain visit, but will be concerned with the effectiveness of the sequence of chaplain visits to the same patient or institutional client, with the sequence understood as an integrated system of interventions. Just as the individual visits need to have detailed specifications and descriptions of the purpose of the visit, the structure, the cognitive content, and the outcomes intended, so the sequence of visits also will need to be identified in terms of its overall purpose: the purpose that cannot be achieved by a single visit, but only by the synergistic effects of the individual visits that make up the sequence. What may be called a chaplaincy practice model would link together specified interventions in order to achieve synergy and a cumulative benefit for the patient that no individual intervention, by itself, could.
The chaplain's chaplaincy practice model would consist of the framework of chaplain visits that a chaplain would put together to achieve a desired overall result. Just as the individual interventions in a chaplaincy practice model can be grouped and distinguished by their individual purposes, by their structures and cognitive content, so the structure of the sequence of interventions, and the cumulative cognitive content of the individual chaplain visits, need to be identified in research designs. Within a chaplaincy practice model for obtaining a particular result, the purposes of the individual chaplain visits can be recognized as interdependent, with the purposes of each visit being seen as intermediate purposes, with each visit in the sequence preparing for and laying the groundwork for the next visit in the sequence. The individual visits in the sequence, therefore, are intermediate steps toward the overall purpose. The sequence of visits, or chaplaincy practice model for an overall result, is a purpose-based group of interventions.
The further question then becomes how the detailed operational description of each of these individual chaplain visits in the sequence can be combined in a specification of a chaplaincy practice model for a particular desired result. Also, for any given chaplaincy practice model that specifies the purpose categories of interventions to be combined in a sequence of visits, there can be significant variability in the structure, cognitive content, and criteria for measuring outcomes, not only between different chaplains, but also in the practice of an individual chaplain.
The specification of this "model" sequence of chaplain visits may need to be accomplished in a way different from merely combining the detailed operational descriptions of the component chaplain visits. But practical experience in specifying individual chaplain visits will be needed first before decisions can be made about what will be the best way to specify a purpose-based sequence of interventions, or chaplaincy practice model. The method of specifying chaplaincy interventions described above may be considered a first step toward developing a consensus among professional chaplains on how to specify chaplain interventions with patients.