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August 2016 Article of the Month
This month's article selection is highlighted by John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Robinson, M. R., Thiel, M. M., Shirkey, K., Zurakowski, D. and Meyer, E. C. "Efficacy of training interprofessional spiritual care generalists." Journal of Palliative Medicine 19, no. 8 (August 2016): 814-821.


SUMMARY and COMMENT: This month's article reports the effectiveness of a single-day workshop "to educate a variety of front-line clinicians to function as spiritual care generalists throughout [a] hospital" [p. 819]. The concept of spiritual care generalists (compared to that of chaplains as spiritual care specialists) holds that "[a]ll members of the healthcare team can learn to screen for spiritual strengths and spiritual distress and incorporate basic spiritual resources into the patient care plan" [p. 815] and has been developed by the earlier work of several of our authors [--see Items of Related Interest, §I, below]. The workshop, involving chaplains as faculty, suggests an educational model for broad application and further investigation.

Data were collected from 115 participants of workshops at Boston Children's Hospital between October 2011 and April 2013, for which "[e]ach participant completed self-report pre- and post-questionnaires on the day of the workshop, and an on-line follow-up questionnaire three months after training" [p. 816]. Final analysis rested on the responses of 79 participants (68.6%) who completed all three questionnaires, though no significant difference in selection or non-response bias was found between those who completed all three and those who did not [--see p. 817]. Participants self-reported demographic information, "degrees of religiosity, spirituality, and agnosticism/skepticism/atheism on five-point Likert scales" [p. 816] and, at all three longitudinal points, a Likert rating of their spiritual care generalist skills according to a 15-item listing [--see p. 818]:

A) Spiritual screen and care plan skills:
      1) do spiritual screen (FICA)
      2) identify spiritual strengths and resources
      3) identify spiritual distress
      4) identify appropriate interventions in care setting and community
      5) develop care plan with customized spiritual support
      6) document spiritual strengths and/or distress in chart

B) Provision of spiritual care skills:
      1) practice compassionate and respectful presence
      2) establish appropriate boundaries
      3) access chaplaincy resources
      4) refer to spiritual specialist
      5) discuss spiritual strengths and/or distress with team

C) Professional development:
      1) recognize how spirituality affects patients’ health care decisions and values
      2) identify ethical issues in interprofessional spiritual care
      3) feel comfortable as a spiritual generalist in your clinical role
      4) understand role of spirituality in one’s own professional life
This listing, developed by the authors in light of previous work by Christina Puchalski [--see Items of Related Interest, §II, below], is at the heart of this workshop project and should be of special interest to chaplains both as an explication of the spiritual care generalist role and as a set of educational goals for clinician education.

The components of the workshop are described:

The curriculum included brief, focused didactic presentations…, a slideshow of photographs taken within the hospital setting to highlight S/R environmental cues to cultivate increased awareness and observational skills, and brief educational videos demonstrating the use of the Puchalski [FICA] spiritual screening tool [--see Items of Related Interest, §III, below]. A written case allowed participants to practice use of the FICA tool in pairs. Three realistic simulated case enactments with professional actors as patients or family members followed…. In two of the realistic enactments, participant volunteers practiced spiritual generalist skills. The third enactment provided participants an opportunity to witness spiritual care being offered at a spiritual specialist’s level by a professional chaplain. [pp. 815-816]
Didactic topics are noted in a table [p. 816], and the article is linked online to supplementary material giving the scenarios of the three realistic simulated enactments and the timed agenda for the entire workshop. Among the findings:
  • "Participants showed significant mean improvement in their overall Total Ability Score [i.e., summary score of all 15 Spiritual Care Generalist skill items] as a spiritual generalist immediately postworkshop ( p < 0.001) and at 3 months ( p < 0.001)." [p. 817]
  • "Although the initial degree of improvement tended to be larger immediately postworkshop, 14 out of 15 skills remained significantly higher at three months compared to preworkshop." [pp. 817-818]
  • "The largest improvements included all six skills in the domain of Spiritual Screen and Care Plan." [--see the listing above, and p. 818]
  • "The postworkshop survey completed on the day of the workshop revealed that 98.6% of respondents would recommend the workshop to others in the same clinical role." [p. 818]
  • "The workshops had a heightened learning effect on female clinicians and those who perceived their personal level of spirituality to be low." [p. 818]
  • "Participants frequently reported gaining a better understanding of the role of chaplaincy, as well as how and when to make referrals." [p. 819]
  • "A consistent theme in postworkshop evaluations was the discovery that spirituality need not be religious and that spiritual issues can be expressed and responded to in secular or religious language." [p. 819]
  • [F]requently cited [by participants] was the discovery that one need not be a religious or spiritual person to respect and skillfully support the spirituality of another." [p. 819]
Results suggest that this curriculum "is both efficient and effective in training clinicians from across disciplines to learn basic-level spiritual care skills" [p. 819], and is a six-hour alternative to other educational models requiring much greater time commitments. The authors recognize that even for a compressed program, "[t]he long-term financial sustainability of these workshops remains a challenge" [p. 819], but they make a practical case for pressing ahead, just from a chaplaincy perspective:
Board-certified chaplains are typically a scarce hospital resource. Freed from routine spiritual screening, chaplains can be utilized more judiciously for the complex or high-risk cases involving spiritual distress, palliative and end-of-life care, or belief-based opposition to the medical treatment plan. [p. 819]
Suggestions for further testing of the present model include the use of observational measures and ratings of clinicians by patients/families [--see p. 819]. This reader was struck by the fact that establishing appropriate boundaries was the one skill that did not sustain improvement at the three-month point and wondered if that was a spiritual care skill especially vulnerable to confusion or erosion within the culture of healthcare. Perhaps future longitudinal investigation could explore which skills are easiest to inculcate for other disciplines, since the authors do observe that "[s]ome participants discovered that many of the clinical skills already in their professional repertoire--such as good listening, visual observation skills, and a compassionate presence--are essential ingredients of a generalist's spiritual caregiving repertoire" [p. 819]; and which skills might require some more intensive workshop strategy to root in non-chaplain providers.

Special comment to the Network from co-author Mary Martha Thiel, Director of Clinical Pastoral Education at Hebrew SeniorLife in Boston:

I have been interested in training healthcare providers in spiritual care ever since Sr. Sheila Hammond and I started CPE for Healthcare Professionals at Massachusetts General Hospital in the '90s. In recent years, I have been part of a spiritual care research and teaching group at Boston Children's Hospital, with a similar focus. This article describes the efficacy of a one-day training "On Becoming a Spiritual Generalist" designed for frontline caregivers. While few clinicians can take the time to do a unit of CPE, many can take a day to participate in a workshop. We use many modalities of teaching, including realistic enactments with professional actors, in which workshop participants play themselves in their own roles, trying out their new knowledge about being a spiritual generalist. The final enactment of the day has a professional chaplain demonstrate her work with a very complex case. Workshop participants learn how to enhance their own practice, and when and how to refer to professional chaplains. This article shows how effective our program has been in teaching generalist spiritual care competencies, and offers an educational model more feasible for many institutions to offer than CPE for Healthcare Professionals. Chaplains engaging our clinician colleagues around spiritual care is an important way to increase interdisciplinary teamwork, receive appropriate specialist referrals, and for patients to receive the quality spiritual care they need and deserve. --MMT


Suggestions for the Use of the Article for Student Discussion: 

By focusing on spiritual care generalists, this article could help CPE students think about how their role as specialists may play into a cooperative and multidisciplinary approach to spiritual care, and their potential working relationship with non-chaplain providers. In this way, the article may be well suited for students in their first or second units, and the enumeration of generalist skills could challenge such newer students to assess their own skill levels. Do they think they’re able to meet a generalist standard? Do they have a sense of what in involved in going beyond that standard to one of a specialist? The listing of skills on p. 818 (in the caption to Figure 2) might best be excerpted as a handout to make it easier to visualize for the purposes of discussion. Similarly, the workshops didactic topics [Table 1, p. 816] could be a checklist of sorts for students to consider. The authors offer the three simulation scenarios in online supplementary material, and these could be discussed in detail or even enacted by the group. Turning to the research aspects of the article, what do students make of the findings that "the workshops had a heightened learning effect on female clinicians and those who perceived their personal level of spirituality to be low" [p. 818, and see also p. 817]? Looking at methodology, what is the value of longitudinal data collection, in general? What sort of observational behavioral measures might be used in future research?


Related Items of Interest:

I.  Mary R. Robinson, Mary Martha Thiel, and Elaine C. Meyer previously collaborated on the following earlier articles that explained the concept of the spiritual care generalist:

Robinson, M. R., Thiel, M. M. and Meyer, E. C., "On being a spiritual care generalist." American Journal of Bioethics 7, no. 7 (July 2007): 24-26. [This brief piece is a response to an article in the same issue of the journal (Kuczewski, M. G., "Talking about spirituality in the clinical setting: Can being a professional require being personal?" pp. 4-11) and lines out basic points about the role of a spiritual care generalist, training, and the "optimal use of chaplains" (p. 25).]

Robinson, M. R., Thiel, M. M., Backus, M. M. and Meyer, E. C. "Matters of spirituality at the end of life in the pediatric intensive care unit." Pediatrics 118, no. 3 (September 2006): e719-729. [This article contains succinct tables of "Roles and Tasks of Spiritual Care Generalists and Specialists" (Table 3, p. e726), "Suggested Sample Assessment Questions for Spiritual Care Generalists and Specialists" (Table 4, p. e727), and "When a Spiritual Generalist Should Consult A Chaplain" (Table 5, p. e727). Note too, the interesting table of "Complementary Roles of Community Clergy and Hospital Chaplains" (Table 2, p. e724). This article was featured as our November 2006 Article-of-the-Month. (Abstract:) OBJECTIVE: Our objective with this study was to identify the nature and the role of spirituality from the parents' perspective at the end of life in the PICU and to discern clinical implications. METHODS: A qualitative study based on parental responses to open-ended questions on anonymous, self-administered questionnaires was conducted at 3 PICUs in Boston, Massachusetts. Fifty-six parents whose children had died in PICUs after the withdrawal of life-sustaining therapies participated. RESULTS: Overall, spiritual/religious themes were included in the responses of 73% (41 of 56) of parents to questions about what had been most helpful to them and what advice they would offer to others at the end of life. Four explicitly spiritual/religious themes emerged: prayer, faith, access to and care from clergy, and belief in the transcendent quality of the parent-child relationship that endures beyond death. Parents also identified several implicitly spiritual/religious themes, including insight and wisdom; reliance on values; and virtues such as hope, trust, and love. CONCLUSIONS: Many parents drew on and relied on their spirituality to guide them in end-of-life decision-making, to make meaning of the loss, and to sustain them emotionally. Despite the dominance of technology and medical discourse in the ICU, many parents experienced their child's end of life as a spiritual journey. Staff members, hospital chaplains, and community clergy are encouraged to be explicit in their hospitality to parents' spirituality and religious faith, to foster a culture of acceptance and integration of spiritual perspectives, and to work collaboratively to deliver spiritual care.]


II.  The 15 Spiritual Care Generalist skills were developed by our authors after consultation with Christina Puchalski, MD, Director of the George Washington Institute for Spirituality and Health (Washington, DC), who has led national and international efforts to establish spiritual care standards and competencies, especially for palliative care. For a foothold in Dr. Puchalski’s work on this front, see:

Puchalski, C., Ferrell, B., Virani, R., Otis-Green, S., Baird, P., Bull, J., Chochinov, H., Handzo, G., Nelson-Becker, H., Prince-Paul, M., Pugliese, K. and Sulmasy, D. "Improving the quality of spiritual care as a dimension of palliative care: the report of the Consensus Conference." Journal of Palliative Medicine 12, no. 10 (October 2009): 885-904. [This is a report of a seminal consensus conference held February 17-18, 2009, in Pasadena, CA, which lines out models of spiritual care and recommendations for professional development. For present purposes, see especially Table 7: Guide for Interprofessional Collaborative Spiritual Care (p. 898) and the section on Training and Certification (pp. 899-900).]

Puchalski, C. M., Blatt, B., Kogan, M, and Butler, A. "Spirituality and health: the development of a field." Academic Medicine 89, no. 1 (January 2014): 10-16. [This commentary in a special theme issue of Academic Medicine gives a brief overview the development of the field of Spirituality & Health and a particular program initiative, and includes an Appendix (pp. 14-16) of "National Competencies in Spirituality and Health for Medical Education." (Abstract:) Spirituality has played a role in health care for centuries, but by the early 20th century, technological advances in diagnosis and treatment overshadowed the more human element of medicine. In response, a core group of medical academics and practitioners launched a movement to reclaim medicine's spiritual roots, defining spirituality broadly as a search for meaning, purpose, and connectedness. This commentary describes the history of the field of spirituality and health-its origins, its furtherance through the Medical School Objectives Project, and its ultimate incorporation into the curricula of over 75% of U.S. medical schools. The diverse efforts in developing this field within medical education and in national and international organizations created a need for a cohesive framework. The National Competencies in Spirituality and Health-created at a consensus conference of faculty from seven medical schools and reported here for the first time-answered that need. Also reported are some of the first applications of these competencies-competency-linked curricular projects. This issue of Academic Medicine features articles from three of the participating medical schools as well as one from an additional medical school. This commentary also describes another competency application: the George Washington Institute of Spirituality and Health-Templeton Reflection Rounds initiative, known as G-TRR, which has provided clerkship students with the opportunity, through reflection on their patient encounters, to develop their own inner resources to address the suffering of others. This commentary concludes with the authors' proposals for future directions for the field.]

Puchalski, C. M., Vitillo, R., Hull, S. K. and Reller, N. "Improving the spiritual dimension of whole person care: reaching national and international consensus." Journal of Palliative Medicine 17, no. 6 (June 2014): 642-656. [This is a report of the January 2013 international consensus conference in Geneva, Switzerland, which built upon earlier consensus conferences (e.g., the 2009 conference, noted in the citation above). See especially the brief sections on Clinical Care and Education (pp. 646-647) for a sense of the status of the development in the field. (This was our June 2014 Article-of-the-Month.)]


III.  For more about the FICA assessment (noted in this month's article on pp. 815, 816, and 818), see our August 2010 Article-of-the-Month: Borneman, T., Ferrell, B. and Puchalski, C. M., "Evaluation of the FICA tool for spiritual assessment," Journal of Pain and Symptom Management 40, no. 2 (August 2010): 163-173.


IV.  The workshop at the center of this month's article was an offering of the Institute for Professionalism and Ethical Practice, directed by Elaine C. Meyer, with Mary Robinson and Mary Martha Thiel among the faculty. The Institute grew out of the Program to Enhance Relational and Communication Skills (PERCS) at Boston Children's Hospital. Our article notes: "Pedagogical principals that guide PERCS workshops include the following: creating a safe learning environment; emphasizing the moral and relational dimensions of healthcare; suspending healthcare hierarchy; valuing reflection and self-awareness; and honoring multiple interprofessional perspectives" [p. 815]. The current published description of the workshop is as follows:

Clinicians often feel unprepared and lack confidence when recognizing, assessing and responding to the spiritual concerns of patients and their families. Although spiritual care is increasingly considered an integral part of high quality health care, there is mounting evidence that few health care professionals have received adequate preparation in this area. This full-day workshop will introduce clinicians from a range of disciplines and experience levels to the art and basic skills of spiritual care. Participants will learn to: assess patient's spiritual needs, recognize signs of spiritual distress, identify spiritual talk in both secular and religious language, build a vocabulary to respond to spiritual concerns of both patients and families, become familiar with ethical guidelines for spiritual care, and recognize when to make a referral for more in-depth spiritual care. Each workshop will include focused didactic presentations, opportunities to practice spiritual assessment and care with professional actors in realistic hospital scenarios, followed by group discussion. Participants will be encouraged to reflect on their personal and professional experiences, and how these can influence their development as spiritual care generalists. [--from the website]


V.  On a related note, regarding competency-based curricula for medical education, see our April 2011 Article-of-the-Month: Anandarajah, G., Craigie, F. Jr., Hatch, R., Kliewer, S., Marchand, L., King, D., Hobbs, R. 3rd. and Daaleman, T. P., "Toward competency-based curricula in patient-centered spiritual care: recommended competencies for family medicine resident education," Academic Medicine 85, no. 12 (December 2010): 1897-1904.



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