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August 2018 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA


Nash, P., Roberts, E., Nash, S., Darby, K. and Parwaz, A. A. "Adapting the Advocate Health Care Taxonomy of Chaplaincy for a pediatric hospital context: a pilot study." Journal of Health Care Chaplaincy (2018): 15pp., published online ahead of print, July 27, 2018.

[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. References are to manuscript [MS] page numbers.]


SUMMARY and COMMENT: In 2015, chaplains at Advocate Health Care in Chicago, IL, introduced a 100-item taxonomy aimed at standardizing terminology about the work of chaplaincy [--see Items of Related Interest, §I, below]. While it was developed out of research in a palliative care context, it has held promise for broad application and further development. This month's featured article reports efforts at the Birmingham Children's Hospital in the United Kingdom to expand and adapt that taxonomy to a pediatric acute care setting as "the first step in a process to help...develop a bespoke pediatric electronic recording tool..." [MS p. 13]. This research is notable for its suggestion of interventions, methods, and intended effects that may be particular to pediatric chaplaincy; its finding of the usefulness of much of the original taxonomy, even in a very different healthcare environment; and its sense of needs for future study.

The present study set out to generate new taxonomy items first through a literature review that identified nine papers [--see Items of Related Interest, §VI, below], and especially through previous research by the principal author in the pediatric setting [--see Items of Related Interest, §II, below].

Members of the team who formulated additional items based on research had extensive experience of pediatric chaplaincy or studying child spirituality. Two experienced pediatric chaplains reviewed the lists in the light of their knowledge and the final version to trial was agreed. [MS p. 5]
Twenty-six additional items were identified in light of the categories of intended effects (goals and outcomes), methods (what chaplains did), and interventions (concrete items); following the structure of the Advocate model. [--see MS p. 4]
...[M]ost additions were made in the area of intended effects. This reflects the team's concepts regarding their reasons for performing chaplaincy in the way that they do and what is distinctive about working with children and young people. There were far fewer additional methods and interventions than intended effects, which suggest that there are many core skills and interventions that are shared by chaplains in differing healthcare settings. [MS p. 5, and see also MS p. 10]

Full lists of the proposed additions for each category are provided in tables [--see MS pp. 4 and 5], but examples are:

  • demonstrate kindness and compassion (--intended effects)
  • feel part of a community (--intended effects)
  • enhancing spiritual wellbeing (--intended effects)
  • mediate between patient and family (--intended effects)
  • explore identity (--methods)
  • explore worldview (--methods)
  • leave a gift (--interventions)
  • engage in participative spiritual care activity (--interventions)

The cumulative taxonomy was subsequently tested by 12 chaplains who completed 80 audit forms from visits with 65 patients, selecting the items applicable for the interaction and/or writing in an item not on the list. The audit form, including the augmented taxonomy is helpfully given as an appendix [--see MS pp. 14-15], with the new pediatric items distinguished in italics.

Among the results, the top ten items selected were as follows [--see the listing on MS p. 9; in the table immediately below, information has been consolidated from the results narrative]:

Build relationship of care and support
Intended Effects
Offer emotional support
Demonstrate care and concern
Intended Effects
Active listening
Establish rapport and connectedness
Intended Effects
Demonstrate kindness and compassion
Intended Effects
Convey a calming presence
Intended Effects
Lessen someone's feeling of isolation
Intended Effects
Feel part of a community
Intended Effects
Acknowledge current situation

The five most commonly selected items came from the original Advocate taxonomy, about which the authors comment: "This suggests an overlap in core chaplaincy skills that are useful regardless of the context of the chaplaincy and may also offer an insight into curricula for training and how chaplaincy may be distinctive from other caring professions" [MS p. 10]. And, regarding the selection of the other five by the pediatric chaplains: "These are areas that may reflect the different context of chaplaincy but perhaps also the different healthcare systems operating in the United States and United Kingdom" [MS p. 10]. They further observe that "in the pediatric taxonomy's top 10, most are from the original Advocate list, which reinforces the strong correlation between different types of health care chaplaincy" [MS p. 10], however they note that some items from the total Advocate list were never selected by a chaplain in this study, which "does imply that they do not form part of common pediatric chaplaincy practice" [MS p. 12].

Other key observations from the authors may point the way to further research and refinement of the tool:

  • "[T]here was a large discrepancy between the number of children under five years old in the hospital, and the number included in the audit. This might be accounted for by the number of responses that did not specify the age of the child, or may indicate that chaplains tend to visit older patients. However, it could also be because the taxonomy form was not suited to record interactions with young children." [MS p. 12]
  • The audit suggested that "more items relating to families would be useful" [MS p. 12]. Free text responses "often made reference to family members who were present," so, "[o]ne future direction for research into a pediatric taxonomy would be to consider how interactions with families can be itemized to be included in the taxonomy" [MS p. 12].
  • As part of the audit, chaplains were asked how they identified the needs of patients and families. Questions related to that part of the audit are given in the text [--see MS p. 6], but the analysis of that data is said to have been reserved for a separate article. Nevertheless, the researchers encourage further exploration of how issues of assessment may relate to the taxonomy.
  • No participant selected the item of "celebrate religious festival." While chaplains certainly do celebrate religious festivals, they may do so primarily in a corporate context. "This suggests some of the wider elements of chaplaincy are not captured by a taxonomy and additional thought as to how to record these wider activities needs to be given in respect of establishing an evidence base for pediatric chaplaincy" [MS p. 12].

The research team at BCH also recognizes the importance of testing the effectiveness of what chaplains do, and they plan to parlay their work on the taxonomy into a further project to develop a Patient Recorded Outcome Measure.

[Editor's Note: The ahead-of-print version of this article contains some manuscript errors: e.g., incorrect table number references in multiple places, and the first sentence of the first full paragraph on MS p. 10 should begin, "There were only two of the pediatric specific options which more than 50% of people picked, these were: 'demonstrate kindness and compassion' and...." However, these issues should pose no real problem to reading the article, until the final version is published.]


Suggestions for Use of the Article for Student Discussion: 

While this article is especially well-suited for CPE programs in pediatric hospitals, the core content should be beneficial to any chaplains who have contact with children. The tables of proposed additions [--see MS pp. 4 and 5] and the one of top 10 selected items [--see MS p. 9] should be quite thought-provoking. The students could quickly scan the tables and say which items stand immediately out to them. Looking at the smaller lists could be an entreé to the total taxonomy that might be a bit intimidating at first glance, with over 100 items. Hopefully, discussion should lead students to consider the original taxonomy and to read next the article that introduced it [--see Items of Related Interest, §I, below]. Also, the group could think together about how this research, which was ostensibly focused on the distinctiveness of one setting for chaplaincy, found some affirmation of how much chaplains in different clinical and cultural contexts may have in common. Finally, the group could discuss the potential application of such a taxonomy. The authors certainly make a case for its usefulness, but can the students envision themselves using it? Can they think of examples of how a lack of consistent terminology may have been problematic to their communication about their work, even to other chaplains? Do they understand the practical value when doing research?


Related Items of Interest:

I.  The original study introducing the Advocate taxonomy:

Massey, K., Barnes, M. J., Villines, D., Goldstein, J. D., Pierson, A. L., Scherer, C., Vander Laan, B. and Summerfelt, W. T. "What do I do? Developing a taxonomy of chaplaincy activities and interventions for spiritual care in intensive care unit palliative care." BMC Palliative Care 14 (2015): 10 [electronic journal article designation]. [(Abstract:) BACKGROUND: Chaplains are increasingly seen as key members of interdisciplinary palliative care teams, yet the specific interventions and hoped for outcomes of their work are poorly understood. This project served to develop a standard terminology inventory for the chaplaincy field, to be called the chaplaincy taxonomy. METHODS: The research team used a mixed methods approach to generate, evaluate and validate items for the taxonomy. We conducted a literature review, retrospective chart review, focus groups, self-observation, experience sampling, concept mapping, and reliability testing. Chaplaincy activities focused primarily on palliative care in an intensive care unit setting in order to capture a broad cross section of chaplaincy activities. RESULTS: Literature and chart review resulted in 438 taxonomy items for testing. Chaplain focus groups generated an additional 100 items and removed 421 items as duplications. Self-Observation, Experience Sampling and Concept Mapping provided validity that the taxonomy items were actual activities that chaplains perform in their spiritual care. Inter-rater reliability for chaplains to identify taxonomy items from vignettes was 0.903. CONCLUSIONS: The 100 item chaplaincy taxonomy provides a strong foundation for a normative inventory of chaplaincy activities and outcomes. A deliberative process is proposed to further expand and refine the taxonomy to create a standard terminological inventory for the field of chaplaincy. A standard terminology could improve the ways inter-disciplinary palliative care teams communicate about chaplaincy activities and outcomes.]


II.  Other research by Paul Nash:

Darby, K., Nash, P. and Nash, S. "Understanding and responding to spiritual and religious needs of young people with cancer: Kathryn Darby and colleagues explore ways to support this patient group by focusing on non-medical aspects of care." Cancer Nursing Practice 13, no. 2 (March 2014): 32-37. [(Abstract:) Aim: To identify the spiritual and religious needs of young people with cancer, and to explore some implications of these for enhancing patient care. Method: Semi-structured interviews were conducted with nine young people aged between 11 and 16, as well as seven of their parents. Eight oncology staff participated in two focus groups. The first explored their understanding of the spiritual and religious needs of patients, the second tested initial findings. Data were analysed thematically by a multidisciplinary academic team. Findings: Spiritual needs were classified under personal issues, relationships and attitude, and environment. Religious needs were identified as hope, resilience, ritual, connection, use of language and world view. Conclusion: Young people's spiritual and religious needs should be assessed on an ongoing basis, with staff being supported to undertake such assessment through the use of relevant tools, activities and a discussion of appropriate language. Identification of strategies, time and staff availability to help young people process difficult emotions may be beneficial. Gestures of kindness can make a difference to patients' wellbeing and their feelings of connectedness, hope and resilience. Developing a community and culture setting is also important. A positive physical environment can contribute to young people's self-esteem, feeling valued, comfort and building a community.]

Nash, P., Darby, K. and Nash, S. "The spiritual care of sick children: reflections from a pilot participation project." International Journal of Children's Spirituality 18, no. 2 (2013): 148-161. [(Abstract:) The authors are a multi-disciplinary team of chaplains, one with a counselling qualification, and an academic with a research background in spirituality and youth work. A pilot participation project undertaken at Birmingham Children's Hospital (UK) focused on increasing the understanding of the spiritual needs of sick children and young people and involving children and young people in improving the service and provision of spiritual and religious care to them. Views from children, young people and parents were sought with the intention of developing resources and training that help facilitate the meeting of spiritual and religious needs of children and young people in hospital. Within the wider chaplaincy team are chaplains from the six major world faiths and this project considers spiritual needs of children and young people who perceive themselves as belonging to a faith group or not. Reflections from the pilot include identifying ten principles and practices to inform the spiritual care of sick children and proposing the concept of interpretive spiritual encounters as a tool for spiritual care. The pilot study indicated that being more proactive in offering spiritual care enhanced the quality of service offered by Chaplaincy.]

Nash, P. and McSherry, W. "What is the distinctiveness of paediatric chaplaincy? Findings from a systematic review of the literature." Health and Social Care Chaplaincy 5, no. 1 (2017): 16-32. [(Abstract:) A systematic review of the literature was undertaken to identify the distinctiveness of paediatric chaplaincy. Four representative databases were searched using key words and Boolean searches: Proquest Nursing and Allied Health Source, Psychinfo, Cumulative Index of Allied Health Literature (CINAHL) and American Theological Library Association (ATLA). Inclusion and exclusion criteria were applied to identify pertinent literature. The search resulted in the identification of 96 items. These were retrieved and reviewed. A narrative approach to thematic analysis was adopted. This lead to the creation of four broad themes; relating to and supporting families including those receiving palliative, end of life and bereavement care; supporting children including spiritual and religious care; working as a part of multidisciplinary/ professional team; staff support and self-care. The findings suggest there is a notable lack of research undertaken by paediatric chaplains. Suggestions for education, practice and further research are offered.]


III.  Principal author Paul Nash presented on "Developing a Taxonomy for Pediatric Chaplaincy: The Advocate Health Care Model," at the April 23-25, 2018 Caring for the Human Spirit Conference in New Orleans, LA. His PowerPoint presentation is available online, along with other presentations at the conference and various additional resources, through the Interfaith Care Association of Manitoba.


IV.  A recent study out of Ottawa, Canada, regarding chaplains' interventions and outcomes:

Strang, V. P. "An e-chart review of chaplains' interventions and outcomes: a quality improvement and documentation practice enhancement project." Journal of Pastoral Care and Counseling 71, no. 3 (September 2017): 183-191. [(Abstract:) In Canada, the spiritual care landscape in health care settings is becoming more regulated and standardized documentation is part of this rigorous environment. Staff chaplains at The Ottawa Hospital participated in a Quality Improvement project that aimed to advance patient-centered care through better charting practices. A sample of 104 spiritual-care assessments that had been posted on the patient electronic health record was examined. This chart review focused on chaplains' activities that were reported as interventions as well as chaplain-reported outcomes for the patient. These interventions and outcomes were coded into discreet categories in order to get a better sense of the activities and the impact of their work. The chaplains' electronic charting content and practices were evaluated. Chaplains found that the Quality Improvement process was beneficial as they updated their electronic templates in order to meet the new reporting requirements of the College of Registered Psychotherapists of Ontario.]


V.  The Advocate Taxonomy and the question of categorizing "what chaplains do" were also considered in the March 2017 Article-of-the-Month. On a related note, Chaplain Gordon Hilsman (now retired from the Franciscan Health System in Tacoma, WA) presented a poster at the 2006 ACPE conference (Honolulu, HI) that paired chaplains' functions with patient needs and possible study outcomes. He had worked from a study of the actual experiences of CPE students, and the "functions" identified here would would seem speak to the same goal of specifying chaplains' activities as Advocate taxonomy, though more immediately directed at implications for research. See a summary of his Spiritual Patient Needs, Chaplain Functions, and Outcomes for Study along with 21 specific categories of patients' needs, expressed in patients' own words. Hilsman has since published Spiritual Care in Common Terms: How Chaplains Can Effectively Describe the Spiritual Needs of Patients in Medical Records (London and Philadelphia, PA: Jessica Kingsley Publishers, 2017).


VI.  [Added 8/23/18:] A table of nine papers identified from the literature search is available by clicking HERE. (This information was not supplied in the original online version of the article but rather communicated subsequently by author Paul Nash to the Article-of-the-Month Editor.)



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