Winter 2007 Newsletter
On-Line Newsletter Volume 5, Number 2
Published January 31, 2007
Edited by Chaplain John Ehman, Network Convener
Network members are encouraged to submit articles for upcoming issues
of the Newsletter, which is published three times a year: Fall, Winter, and Spring-Summer.
The Spring-Summer 2007 issue is scheduled to be posted in early June.
Table of Contents
- Demonstrating the Contribution of Clinical Pastoral Care to Lawsuit Prevention: A Boilerplate Research Proposal, by John J. Gleason
- Use of Standardized Patients in CPE and Research at the VCU Program in Patient Counseling
- Chaplains at the Christiana Care Health System Collaborate on Research with the Helen F. Graham Cancer Center
- Thoughts on Theory and Method in Chaplaincy Research, by Jackson Kytle
- Web Find: Milestones --Newsletter from the John Templeton Foundation
- Special Issue of the Journal of General Internal Medicine
- Article on Self-Transcendence in Maslow's Hierarchy of Needs
1. Demonstrating the Contribution of Clinical Pastoral Care to Lawsuit Prevention: A Boilerplate Research Proposal, by John J. Gleason
Hospital clinical chaplains well know that their caregiving frequently contributes to the prevention of costly lawsuits. This is especially true of their work in expediting communication between physicians and families in crisis moments. Solid evidence to that effect would give appropriate recognition to this vital contribution, thereby justifying more adequate financial resources for clinical pastoral services.
The hypothesis of this boilerplate research proposal is that a controlled study of hospital records will show a statistically significant lower percentage of lawsuits having been generated from cases including two or more clinical pastoral interventions in comparison with similar cases involving only one or no clinical pastoral intervention(s).
The statistical and ethical expertise available within a particular hospital should assist in institution-specific project design and execution toward a report of publishable quality.
If the frequency of lawsuits among randomly selected cases involving two or more clinical pastoral interventions is indeed found to be statistically significantly lower than in comparable cases involving only one or no pastoral intervention(s), the hypothesis will be affirmed.
Appropriate adjustments to the Department of Pastoral/Spiritual Care budget should follow, with attention to the ratio of dollar amounts paid out in one cohort in legal settlements in relation to dollars saved in the other cohort. Dollars saved should then be taken into account in determining the cost of each unit of clinical pastoral care rendered.
2. Use of Standardized Patients in CPE and Research at the VCU Program in Patient Counseling
Standardized patients--actors who are trained to present a patient scenario realistically and consistently in interactions with health care providers--have been used in medical and nursing training programs for decades now. They allow educators to control the elements of a clinical situation and focus on specific issues, and they provide a common base for comparing student performance. In recent years, standardized patients have been employed at the Medical University of South Carolina and the University of Kentucky College of Medicine in research on teaching medical students about spiritual issues in patient care [see: King, D. E., et al., "Implementation and assessment of a spiritual history taking curriculum in the first year of medical school," Teaching and Learning in Medicine 16, no. 1 (2004): 64-68 and Musick, D. W., et al., "Spirituality in medicine: a comparison of medical students' attitudes and clinical performance," Academic Psychiatry 27, no. 2 (2003): 67-73]. This education strategy would seem to have potential for Clinical Pastoral Education.
In our Fall 2006 Newsletter, the report of "Current Research Initiatives by the Program in Patient Counseling at Virginia Commonwealth University" [see §2] noted a research project exploring the use of standardized patients in CPE, led by ACPE Supervisor Alexander Tartaglia and Diane Dodd-McCue, Associate Professors at the VCU Program in Patient Counseling. Seventeen CPE students participated in the study, in which a videotaped standardized patient (SP) experience both preceded and followed a training session. The recorded interviews were then analyzed to assess students' communication responses in pastoral interaction --specifically how they used listening, facilitating, and directing responses. Among the findings, as shared by the investigators for this Newsletter: The post-training SP experience showed that students used a wider range of facilitating responses and more open-ended vs. closed-ended questions than beforehand. Also, students generally--in both SP experiences--used listening most commonly in the first phase of the interaction, facilitating most commonly in the second phase, and directing most commonly in the third phase.
From this pilot venture, Tartaglia and Dodd-McCue find indication that: 1) Simulation utilizing standardized patients is a valid method to measure objective communication styles for pastoral care students. 2) Effectiveness of simulation in clinical pastoral education mirrors that observed in other clinical professions. 3) Simulation provides an alternative teaching methodology to supplement use of role-play, the verbatim, and direct observation by faculty. 4) This studyís impact of Clinical Pastoral Education training on student functioning shows preliminary benefits worth further investigation.
Regarding the benefits of using standardized patients in CPE, the authors note:
- Immediacy of clinical material available
- Immediacy of feedback to students
- Student self-observation, reflection, and self-supervision demonstrated early
- Decreased student anxiety and defensiveness
- Student peer group bonding through common, observable experience
- Immediacy of instructor observation of student functioning
- Development of an objective instrument for individual and group supervision
This project is in the process of being written up for publication.
3. Chaplains at the Christiana Care Health System Collaborate on Research with the Helen F. Graham Cancer Center
The Department of Pastoral Services of Christiana Care Health System (Newark and Wilmington, Delaware) has teamed with researchers from the Helen F. Graham Cancer Center there to explore the impact of a therapeutic intervention involving chaplains. "This is the first time the two departments collaborated on research, and we were very happy to work together," reports co-principal investigator Cindy Waddington, RN, MSN, AOCN, clinical nurse specialist at the Cancer Center. Four chaplain residents conducted "life marker" interviews with participants --this is a kind of reminiscence therapy by which patients are helped to identify and evaluate thoughts and feelings about major events in the course of their lives, such that they may find a sense of direction within themselves in the midst of crises such as cancer diagnoses. "Chaplains often sit and listen to patients talk about their lives and how they will move forward under new and trying circumstances," notes Timothy D. Rodden, MDiv, MA, BCC, Director of Pastoral Services. Therefore, chaplains fit quite well into this interventional study. Preliminary data analysis suggests that the interviews were valuable to patients, especially regarding affect and coping. The project is currently being written up for publication.
Christiana Care's Department of Pastoral Services only began its full-time residency program in September 2005, but it straightaway incorporated research as a component of its CPE curriculum. Their case illustrates the opportunity for chaplains to work with allied researchers in today's climate of broad interest in the study of spirituality and health and, in the process, to make significant contributions to our understanding of the ways by which chaplains promote healing.
4. Thoughts on Theory and Method in Chaplaincy Research, by Jackson Kytle, PhD
[Dr. Kytle is Vice President for Academic Affairs at The HealthCare Chaplaincy (New York City) and author of To Want to Learn.]
In July 2006, I wrote to my colleagues at The Chaplaincy to share with them my first impressions of chaplaincy research, as a body of work, since my coming to the Joan B. and William G. Spears Research Center. I wanted to stimulate our collective thinking about how we define quality in chaplaincy research and about research priorities. When the Spears Research Center was established, The Chaplaincy made a statement that the profession of chaplain could be advanced by scholarship --that asking the right questions and applying the best methods in research were of vital importance, both for the evolving profession of chaplain and for our own organization's mission and reputation. I share now my pensée with you, the wider audience of the Research Network, with the hope of broadening this discussion about the state of chaplaincy research, its needs, and its place in our various institutions.
To begin, let me ask two questions:
- First, what are the most pressing questions for theory development whose answers, if they could be found, would most benefit patients, families, and chaplains?
- Second, which methodological advances are most needed?
Journals are numerous in every academic discipline, some say too numerous. While peer-reviewed journals serve important functions, many articles are published that are not contributions except to one's list of "pubs." Worse, practitioners may not find the information useful. We want chaplains to understand and use research, but one reason why practitioners "don't like" research is that the articles they do read are either abstruse or not connected to practice. While many practitioners are not prepared to read statistical research, to be sure, that is not always the reason for the disconnect, in my experience. The questions are just not pertinent, the writing is not engaging, and too much emphasis is placed on method. Some of the Discussion sections I've read in articles look like the authors are chasing correlation coefficients more than thinking about vital questions for praxis.
Published studies may use datasets with small sample sizes of 100 or so and with questionable return rates for mailed surveys. If the authors have a 35% return (for which they sometimes congratulate themselves!) and they don't estimate how their obtained sample departs from population parameters, the use of inferential statistics, strictly speaking, is moot. The question of generalizing from sample to population is not relevant. Why report "p" values? Some authors use a significance coefficient as if it were a measure of strength of effect when a different logic is intended. The General Linear Model, as I remember it, has a set of assumptions that researchers disregard. When these assumptions are violated, modest datasets are not adequate foundations upon which to apply advanced statistical routines like factor analysis. There are other threats to validity. Few of the empirical studies regarding chaplaincy issues I've seen that use attitude scales as dependent variables include controls for agreement response set or social desirability, which combined would account for some of the observed variance.
Part of the problem may be the desire by an insecure as well as evolving profession to establish its legitimacy by aping empirical methods from psychology and sociology, disciplines that followed the same path to acceptance by borrowing, sometimes inappropriately, from the natural sciences and medicine. Criticism also could be directed at qualitative studies in chaplaincy journals as well as the essays on clinical issues or personal experience, some of which strike a newcomer as having a defensive tone to them. An essential element of the logic of social research is conservative, to rule out mistaken hypotheses, not to defend a particular profession by looking for positive correlations.
So, the important work of chaplains needs advances in theory as well as the appropriate use of high-quality methods, whether quantitative or qualitative. I hope that we can develop "new" theory and "innovative" methods, regardless of type. With this in mind, I pose below a number of questions that may help us think about the way ahead.
NEEDED ADVANCES IN THEORY
- What is "spiritual health"? If we say that a life is "in balance," what do we mean?
- How do we distinguish between spiritual health and spiritual distress? Is this one dimension or two different constructs? How would change in either direction be measured?
- How does spiritual health connect to mental health and classic psychological attributes like depression and anxiety, two dimensions that are well studied? Is it possible to be spiritually healthy and depressed or anxious? What do we think the causal paths are?
- What connection exists between spiritual health (including distress) and physical health?
- What is "spiritual care"? What are the essential elements in that care, and how would they be measured? How would different roles on the treatment team define this variable? For example, in one study I've seen, spiritual care seemed to vary with personalized treatment by the staff. Does spiritual care differ from individualized care and, if so, in what ways?
- How do chaplains, in particular, define "spiritual care?" More generally, how do they define the role they occupy and its norms and values?
- What do patients expect from a "chaplain"? Expectancy effects are so powerful in human relations, and we've all heard people ask what a contemporary chaplain does. What are the expectations for this role? Chaplain is a powerful word in our culture, but what does it mean to patients: That they are really, really sick? That someone will preach to them or try to convert them? That they can have a meaningful conversation with a friendly, warm person at a time of need? It might be a contribution to study patient and family and staff expectations.
- Spiritual care may be provided by other roles on the ward or even be the result of the
integration of services broadly. If this is true, how does it work?
- The role of chaplain is one role in a treatment team. What is the role set surrounding a patient and his or her family? What are the important similarities and differences among the following roles: nurse, medical doctor, social worker, hospital administrator, psychologist, and chaplain?
- What are the essential transactions between patient and chaplain, between family and chaplain, and between ward staff and chaplain?
- What is the function of sacred space in the chaos and anonymity of the modern hospital?
Perhaps what Thomas Moore calls the "presence, radiant presence" of a chaplain is calming, apart from what he or she says or does. Listening and just being there are two important understandings. Sacred space is also aided by physical space. How space is designed and used contributes to the feelings and behavior of people using it. Sacred space also might be stimulated by physical space, such as a chapel.
- What are the differences in perspective, transactions, and desired outcomes of a psychotherapist compared to a chaplain? How would we study the difference?
- More generally, what would we do if we wanted to stimulate theory-building by which to strengthen chaplain practice?
NEEDED ADVANCES IN METHODS
- Longitudinal studies that let us assess causal relations are rare and would be an important contribution. Think of the Midtown Restudy [--see: Srole, L., "Measurement and classification in socio-psychiatric epidemiology: Midtown Manhattan Study (1954) and Midtown Manhattan Restudy II (1974)," Journal of Health and Social Behavior 16, no. 4 (December 1975): 347-364] and the classic Framingham study of heart disease [--see: Kannel, W. B., et al., "An investigation of coronary heart disease in families: the Framingham Offspring Study," American Journal of Epidemiology 110, no. 3 (September 1979): 281-290] that followed its panel from 1948-1998. This work is expensive but powerful. How would one imagine a study with our population? Would it get to the right questions?
- Experimental studies may not be practical, but I wonder how one might be constructed to test some of our theories. Students in residence might be subjects.
- Developing attitude scales and other measures is important, and this work should continue. Regarding the specific measures we already have, what are the next steps?
- Well conceived qualitative studies make a contribution because, in part, more readers can connect with the narrative than with regression coefficients. What would we do if we wanted to sponsor more studies of this type? How are qualitative or phenomenological studies received by the field?
- Should we consider using secondary data analysis of high quality data sets like the General Social Survey?
I realize that the earnest questions of a newcomer to our evolving field of inquiry are far easier to enumerate than to answer. My purpose is to stimulate collegial debate and conversation, and to find better questions.
5. Web Find: Milestones --Newsletter from the John Templeton Foundation
Many of us miss Science and Theology News, which ceased publication in print and on the web after the August 2006 issue. It was an excellent means of staying abreast of news, conferences, and grants related to spirituality and health research (and much more). However, in its absence, chaplain researchers may find useful the Milestones monthly newsletter from the John Templeton Foundation. It is available on the web at http://www.templeton.org/milestones/issuearchive.asp. As described on the John Templeton Foundation website, "Milestones...highlights timely events, new initiatives, current research, awards and conferences here and abroad, featuring interviews with the principals involved."
6. Special Issue of the Journal of General Internal Medicine
In December 2006, the Journal of General Internal Medicine issued a special supplement (vol. 21, Supplement 5), presenting 8 papers that offer "a state-of-the-art look at both quality of life and spirituality/religion from 2 longitudinal studies involving a total of 550 patients with HIV from Cincinnati OH, Washington DC, Pittsburgh PA, and Miami FL" [p. S1], along with a brief preface and editorial. The contents of the issue are as follows:
Tsevat, J., "Spirituality/Religion and quality of life in patients with HIV/AIDS," pp. S1-2.
Bosworth, H. B., "The importance of spirituality/religion and health-related quality of life among individuals with HIV/AIDS," pp. S3-4.
Cotton, S., Puchalski, C. M., Sherman, S. N., Mrus, J. M., Peterman, A. H., Feinberg, J., Pargament, K. I., Justice, A. C., Leonard, A. C. and Tsevat, J., "Spirituality and religion in patients with HIV/AIDS," pp. S5-13.
Cotton, S., Tsevat, J., Szaflarski, M., Kudel, I., Sherman, S. N., Feinberg, J., Leonard, A. C. and Holmes, W. C., "Changes in religiousness and spirituality attributed to HIV/AIDS," pp. S14-20.
Yi, M. S., Mrus, J. M., Wade, T. J., Ho, M. L., Hornung, R. W., Cotton, S., Peterman, A. H., Puchalski, C. M. and Tsevat, J., "Religion, spirituality, and depressive symptoms in patients with HIV/AIDS," pp. S21-27.
Szaflarski, M., Ritchey, P. N., Leonard, A. C., Mrus, J. M., Peterman, A. H., Ellison, C. G., McCullough, M. E. and Tsevat, J., "Modeling the effects of spirituality/religion on patients' perceptions of living with HIV/AIDS," pp. S28-38.
Mrus, J. M., Leonard, A. C., Yi, M. S., Sherman, S. N., Fultz, S. L., Justice, A. C. and Tsevat, J., "Health-related quality of life in veterans and nonveterans with HIV/AIDS," pp. S39-47.
Kudel, I., Farber, S. L., Mrus, J. M., Leonard, A. C., Sherman, S. N. and Tsevat, J., "Patterns of responses on health-related quality of life questionnaires among patients with HIV/AIDS," pp. S48-55.
Sherman, S. N., Mrus, J. M., Yi, M. S., Feinberg, J. and Tsevat, J., "How do patients with HIV/AIDS understand and respond to health value questions?" pp. S56-61.
Ironson, G., Stuetzle, R. and Fletcher, M. A., "An increase in religiousness/spirituality occurs after HIV diagnosis and predicts slower disease progression over 4 years in people with HIV," pp. S62-68.
7. Article on Self-Transcendence in Maslow's Hierarchy of Needs
A most engaging article on Abraham Maslow's famous "hierarchy of needs" appeared in the December 2006 issue of the Review of General Psychology [vol. 10, no. 4, pp. 302-317]: "Rediscovering the Later Version of Maslow's Hierarchy of Needs: Self-Transcendence and Opportunities for Theory, Research, and Unification," by Mark E. Koltko-Rivera, PhD. The author argues that the classic 1943 formulation of the hierarchy--i.e., physiological, safety, love, esteem, and self-actualization needs that underlie human motivation--should be emended in light of indicators of Maslow's later thinking to include a sixth and highest level of need/motivation: namely, self-transcendence. While the concept of self-transcendence may be closely connected to that of self-actualization, primary sources suggest that Maslow came to see it as a distinct step beyond the "healthiness" of self-actualization (even though in this scheme the self-transcendent person could perhaps have value-pathology symptoms that a self-actualized person would not). The self-transcendent person moves beyond the "well-adjusted, differentiated, and fulfilled individual self or ego" in order to "seek communion with the transcendent, perhaps through mystical or transpersonal experiences" [p. 306]. Connections between self-transcendence and spiritual experience are strong, with Maslow's thinking on the subject traced through his interest in "peak experiences," and the author addresses the pertinence of the revised hierarchy for theory and research regarding the psychology of religion and spirituality [--see pp. 311-312] and cross-cultural issues that often involve spiritual aspects [pp. 312-313], among other areas of study and practice.
Pastoral care and research is not directly addressed in the article, but there would seem to be several significant implications of a "rectified version of Maslow's motivational theory" [p. 309ff] for chaplains. In a personal communication, Dr. Koltko-Rivera has noted that it makes self-transcendence a legitimate goal for clinical intervention and a "next place to go" for even a fully self-actualized person. Also, Maslow's hierarchy would seem relevant in general for pastoral care in hospitals--in that a patient's place on the hierarchy may shape how he or she would be open to pastoral interaction and how a chaplain might develop a care plan. For pastoral care research here, an instrument would be required that assesses a person's place on the revised hierarchy, and the author has written that such an instrument is currently under development. Further news of Dr. Koltko-Rivera's work will be posted in future Newsletters. To contact the author directly, write to: Mark E. Koltko-Rivera, PhD, Executive Vice-President and Director of Research, Professional Services Group, Inc., PO Box 3390, Winter Park, FL 32790-3390; firstname.lastname@example.org.
The author additionally explores how a revision of Maslow's hierarchy may affect theory and research on worldviews, and chaplains may be interested in his recent and extensive review of "The Psychology of Worldviews," in the March 2004 issue of the Review of General Psychology [vol. 8, no. 1, pp. 3-58], which is presently available freely on-line at www.apa.org/pubs/journals/features/gpr-813.pdf. [Note (added 3/16/07): Dr. Koltko-Rivera has also written "Religions influence worldviews; worldviews influence behavior: a model with research agenda," --an address upon his receiving the 2006 Margaret Gorman Early Career Award (for innovative research in the psychology of religion) from the Psychology of Religion Division of the American Psychological Association. The address is available on-line in the divisionís Newsletter, vol. 32, no. 1.]