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August 2020 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


Sprik, P., Keenan, A. J., Boselli, D., Cheeseboro, S., Meadors, P. and Grossoehme, D. "Feasibility and acceptability of a telephone-based chaplaincy intervention in a large, outpatient oncology center." Supportive Care in Cancer (2020): available online ahead of print, 7/4/20.

[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.
This article is available freely online through the National Public Health Emergency Collection of the US National Library of Medicine.

SUMMARY and COMMENT: As telehealth has become an emerging norm in the COVID19 world, so telechaplaincy has received a great deal of attention in recent months. Our article here builds upon the research about strategies for outpatient chaplaincy care by Chaplain Petra Sprik and colleagues at Atrium Health (formerly Carolinas HealthCare System) in Charlotte, NC, which we featured as our October 2018 Article-of-the-Month." Among the findings of that earlier study was that oncology outpatients were more likely to accept a chaplain's intervention for religious/spiritual [R/S] counseling, prayer, and follow-up appointments by telephone than in person. The present study looks particularly at "a telephone-based chaplaincy intervention delivered as the first point of contact...[in order to]...assess the feasibility and acceptability of delivering interventions in an outpatient cancer institute using this methodology" [MS p. 2, italics added]. As such, it offers useful insights into a modality of interaction necessary not only to meet a general trend of increased outpatient volumes in American healthcare but to respond to the exigencies of a pandemic that limit inpatient connections.

As a standard clinical practice at the hospital's cancer institute, patients were asked prior to their appointment to complete a distress screening assessment that included two questions: "(1) Do you have spiritual or religious concerns? (response yes or no) and (2) Select any of the following emotional/spiritual concerns you are experiencing: struggle to find meaning/hope in life, doubts about your faith, concern for family, isolation, shame/guilt, fear of death (answers were eligible for multi-selection)" [MS p. 3]. If a patient indicated one or more R/S concerns, there was an automatic referral to a chaplain. Normally, chaplains would follow-up either in-person or by phone, but for the purposes of the current research all follow-ups were done by phone 4-12 days after the assessment. The chaplains then used a standardized script [--provided as Appendix 1 on MS p. 9] that "aimed to introduce the patient to the chaplain, address the indicated R/S concern(s) from the screener, address any additional R/S concerns identified on the phone call, and establish follow-up visits if appropriate" [MS p. 3].

Of the 711 patients who were screened between March 18 and April 26, 2019, a total of 212 were referred to a chaplain. Of those, a chaplain was successful in talking to 124, and of those, 84 agreed at the conclusion of the phone call to be emailed a survey about their experience of the call. In the end, 41 patients completed and returned the surveys. Additional data were elicited from the chaplains as to whether their phone call had included R/S interventions that "relied upon chaplain training and expertise" [MS p. 3], according to a list of items [--provided as Appendix 2 on MS p. 9]. Regarding the 124 instances when a chaplain spoke with a patient, 60 (48%) involved R/S interventions. "In cases where chaplains did not deliver R/S interventions, they had supportive conversations that did not require chaplain expertise, had patients deny R/S concern(s), had patients refuse the conversation, or were unable to deepen the conversation" [MS p. 5].

Two chaplains provided the intervention and were able to place calls to all referred patients without there being much of a problem with either the time frame for calling or with conflicts around their other clinical responsibilities. That fact, along with a successful contact rate of 61%, suggests that the telephone strategy is indeed a feasible one. However, it is worth noting that for cases where a patient was said by a family member to be unavailable, the reasons given included: "feeling too sick to answer the phone, being at a medical appointment, having a medical reason they are unable to talk or hear on the phone (such as a tracheostomy or deafness), not having enough minutes programmed on their phone, being busy, or family denying permission to talk to the patient" [MS p. 5].

Regarding the acceptability of the intervention:

Over 90% of surveyed participants were "very satisfied" with the chaplain's ability to listen to them, and to make them feel comfortable on the phone. Over half were "very satisfied" with the chaplain's ability to pray, help them tap into their inner strengths and resources, and overcome their fears and concerns on the phone.... The majority of survey participants found various aspects of the intervention to be acceptable, indicating they were "very much" satisfied with the length of the phone call, the chaplain's conveyed care, and response to spiritual and emotional concerns. The majority of participants were "not at all" scared by receiving a phone call from a chaplain, with 24% indicated some level of fear.... [MS pp. 5-6]

Moreover, in the wake of the phone contact, participants were asked how they would prefer to receive chaplain interventions, from a multiple-choice list of options. The most common preference was the telephone (30 responses), followed by an in-person visit while at a doctor's appointment (11 responses), a scheduled in-person visit specifically with a chaplain (10 responses), and communication by text (7 responses). The authors point out that "[t]his response is biased by the telephone being the mode by which they recently received chaplaincy services; however, it shows acceptability of the service delivered and the potential for this being a preferred method" [MS p. 7]. They further comment that the phone contact in this study was "much shorter than other interventions [in other studies] which offered multiple, hour-long conversations," and they propose that "future studies should address the ideal timing and length of telechaplaincy interventions" [MS p. 7].

Data for the central survey questions about the patients' experience of the telephone intervention are well presented in two figures of multiple stacked bar graphs [--see MS pp. 6-7], giving an easily visible yet rich picture of the responses. For example, to the question, "Did receiving a phone call from the chaplain scare you?" it's immediately apparent how the 71% who said "Not at all" is set against the cumulative percentage of 24% who said "Slightly" (15%), "Moderately" (7%), and "Very much" (2%). This specific finding is lifted up by the authors as "suggest[ing] that there are ways to improve the intervention," noting that "fear of receiving a call from the chaplain is a necessary barrier to address in order to deliver telephone interventions in a less distressing way" [MS p. 7].

Other data gathered addressed concerns experienced by the participants in the last seven days:

  • Concern for family (24%)
  • Fear of death (12%)
  • Religious/spiritual concerns (4%)
  • Isolation (4%)
  • Struggle to find meaning/hope (4%)
  • Shame/guilt (3%)
  • Doubts about your faith (2%).
These are compared with patients' reports of concerns that came up during the phone call [--see Table 2, MS p. 8.], with results being similar, but "[a] few patients reported experiencing concern for family, shame/guilt, and fear of death that did not report talking about those R/S concerns in the intervention" [MS p. 6]. The authors make the observation that "[m]ore study is needed to determine which R/S concerns are best addressed by telehealth versus in-person chaplaincy" [MS p. 8].

Limitations to this project include a small sample size from a single site. Also, resource limitations prevented chaplains from making more than one contact per patient. The authors are appropriately cautious about any claim of broad generalizability. However, this is the first study to trial a chaplain's non-scheduled call to outpatients as a first contact, based upon an advance patient screen for distress. It surely "adds to the emerging voice that supports telephone-based chaplaincy as an acceptable and feasible methodology" --one that has immediate and practical implications in the context of COVID19.

The bibliography of 34 references is quite current, including 8 citations from 2020 and 13 from 2017-2019.


Suggestions for Use of the Articles for Student Discussion: 

This is a well-laid-out paper that should be engaging to the full range of chaplains, from new students to experienced clinical professionals to researchers, stirring constructive thought about the potential of telechaplaincy. Discussion could begin with the broad idea of telechaplaincy itself and what experience the group has with it. What have students discovered to be problems with or barriers to calling patients at home, if they have ever done so? Were there advantages as well? The group could move into the article by going over the script [--Appendix 2 on MS p. 9]. It rests in good part on the screen for distress, so what do they think of the screening process and the two R/S items? The heart of the discussion could revolve around the responses graphed in Tables 2 and 3 [MS pp. 6-7]. Among the things that might warrant special attention would be the responses about whether a call from the chaplain scared the patient, whether there was enough privacy, and the perception of the chaplain's ability to pray over the phone. In relation to the questions about the chaplain's ability to make the patient feel comfortable and cared for over the phone, the group might want to think about how specifically they might do this themselves. The authors comment about how "short conversations likely do not provide enough time to deeply assess or address patient's R/S concern(s)" [MS p. 7]. What are the students' thoughts on the amount of time it takes for a patient interaction to venture into significant depth, and do they work strategically with that? By far the most common concern that patients said they experienced in the past seven days pertained to their families. Did this surprise anyone? Table 2 [MS p. 8] also shows that patients experienced fear of death more than the subject came up in the telechaplaincy visit. What might have been happening here? Also, the group could muse about how COVID19 may affect the needs and dynamics of telechaplaincy and how the use of Facetime-like might add new dimensions to the chaplain's "tele-" interaction. Finally, the group could consider the list of chaplaincy interventions in Appendix 2 [MS p. 9].


Related Items of Interest:

I.  Lead author Petra Sprik participated in a March 21, 2020 Chaplaincy Innovation Lab webinar on telechaplaincy: "Telehealth Chaplaincy: An Approach for Chaplains to Meet Clinical Needs during COVID-19." The event is viewable directly from the Chaplaincy Innovation Lab and on YourTube. PDFs of slides, notes, and questions are also available from the CIL, along with a page of Resources on Telechaplaincy that includes from Chaplain Sprik an "Example script" and "Telephone script for outpatient setting" that go beyond the script in our Article-of-the-Month.


II.  Telechaplaincy was also a related topic to our April 2020 Article-of-the-Month.


III.  In a chapter on "Charting Spiritual Care in Digital Health: Analyses and Perspectives," in Peng-Keller, S. and Neuhold, D., eds., Charting Spiritual Care (Springer, 2020), Simon Peng-Keller writes:

"Digital communication between healthcare professionals and patients will intensify in the coming years. Just as telemedicine and cross-clinic EMRs will be interwoven in the future, so may chaplaincy documentation be increasingly intertwined with forms of telechaplaincy (as it has been introduced, for instance, by the influential US Department of Veterans Affairs). 'Synthetic situations,' in which online and offline spaces overlap..., will be increasingly common for healthcare chaplaincy. While it is unlikely that telechaplaincy will replace the direct encounter in the sickroom, it is conceivable that in the future contact will be established digitally. It goes without saying that telechaplaincy, if part of the therapeutic concept, will also have to be recorded in EMRs." [Note: no page provided on the Springer website.]

Are chaplains nowadays documenting telechaplaincy visits as they would in-person visits?


IV.  The religious/spiritual distress items used in the initial patient screen are said [MS p. 3] to connect with constructs in the assessment presented in the following article (which was part of our June 2005 Article-of the-Month feature):

Galek, K., Flannelly, K. J., Vane, A. and Galek, R. M. "Assessing a patient's spiritual needs: a comprehensive instrument." Holistic Nursing Practice 19, no. 2 (March-April 2005): 62-69.[(Abstract:) Seven major constructs -- belonging, meaning, hope, the sacred, morality, beauty, and acceptance of dying -- were revealed in an analysis of the literature pertaining to patient spiritual needs. The authors embedded these constructs within a 29-item survey designed to be inclusive of traditional religion, as well as non-institutional-based spirituality. This article describes the development of a multidimensional instrument designed to assess a patient's spiritual needs. This framework for understanding a patient's spiritual needs hopefully contributes to the growing body of literature, providing direction to healthcare professionals interested in a more holistic approach to patient well-being.] [A PDF of this article has been made available on-line to our site by the principal author.]



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