February 2019 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
White, K. B., Murphy, P. E., Jeuland, J. and Fitchett, G. "Distress and self-care among chaplains working in palliative care." Palliative & Supportive Care (2019): online ahead of print, February 11, 2019.
[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: This month's article offers a new and different analysis of data previously used for a profile of chaplains working in palliative care and their professional activities [--see Items of Related Interest, §I, below]. Like that earlier report, the present one has relevance for chaplains working beyond the palliative care context: establishing benchmarks for professional self-understanding within the chaplaincy community at large. In this case, attention is directed "(1) to describe the spiritual and work-related distress levels of chaplains who work at least part-time in PC [palliative care]; (2) to describe these chaplains' self-care activities and the extent to which they debriefed clinical experiences with colleagues; and (3) to examine personal and work-related factors that might be associated with the chaplains' distress and self-care activities" [MS p. 2]. Palliative care is an increasingly expanding area of service, involving many chaplains without dedicated palliative care positions, and this work entails risks from distress that may not only impact caregivers personally but their effectiveness (e.g., decreased empathy). Some research has indicated that chaplains overall tend to have low levels of distress and a wide range of coping strategies, but previous studies "have not specifically examined the distress levels of chaplains in PC or their self-care practice" [MS p. 1].
Members of the Association of Professional Chaplains, the National Association of Catholic Chaplains (NACC), the National Association of Veterans Affairs Chaplains, and Neshama: The Association of Jewish Chaplains were invited to complete an online survey during February-April 2015. Among the items were 20 addressing distress, informal self-care, formal self-care, and debriefing [--see Table 2, MS p. 4, for a complete listing]. Out of 531 responses to the applicable questions, 322 met inclusion criteria. Only 14.6% of respondents had full-time dedicated palliative care positions, and another 40.1% had half-time dedicated positions.
Among the findings:
- "Some chaplain distress seems prevalent in more than one-third of the sample." [MS p. 7]
- "Acute spiritual distress (loss of faith) was rare (9.3%), but one-third of the participants experienced Distress from Theodicy and a majority (61%) reported feeling worn out in the past 3 months." [MS p. 7]
- "Chaplains working in PC frequently use Informal Self-care strategies...." [MS p. 7] "A large majority...identified exercising (80.1%), using other spiritual activities (84.1%), eating healthy (92.5%), or spending time with family/friends (92.9%) once a week or more." [MS p. 6]
- "Informal Self-care was inversely associated with Professional Distress and Distress from Theodicy." [MS p. 6 and also 7]
- "...[O]ne-half of the chaplains reported no involvement in Formal Self-care (e.g., counseling, spiritual direction); however, nearly one-third (31.1%) reported at least monthly spiritual direction, and more than one-quarter (27.4%) reported at least monthly counseling." [MS p. 6] "[V]ery few use employee assistance program services." [MS p. 7]
- "Approximately one-third of the chaplains reported at least weekly debriefing with a non-chaplain PC colleague (38.2%) or a non-PC chaplaincy colleague (32%)," though 35.4% "reported not having chaplaincy colleagues." [MS p. 6]
- "A unique finding identified that one in five chaplains reported not having a spiritual care supervisor available for debriefing." [MS p. 8]
- "Items predictive of Professional Distress included an increase in the percent of time spent in PC, more frequent goals of care conversations, and identifying as male." [MS p. 6]
- "Experience as a chaplain also did not predict distress, which is inconsistent with previous studies of chaplains..., but similar to studies of PC professionals. ...[G]reater time spent in PC was associated with greater distress. The associations between chaplain activities and distress are difficult to interpret, but suggest some relation with distress." [MS p. 7]
- "...[A] chaplain's exposure to death did not predict increased Professional Distress or Distress from Theodicy." [MS p. 7]
The Discussion section of the article seems, to this reader, unusually brief for a study with a fair number of key findings, some of them appearing to point in differing directions. The authors acknowledge that the higher incidence of distress here, in contrast to other studies of chaplains generally, may be due to the palliative care context, yet exposure to death in particular did not correlate with distress. And the relationship between chaplains' activities and distress is said to be "difficult to interpret" [MS p. 7]. However, the very fact that distress was reported in more than one-third of the sample is noteworthy. In light of this, the results about self-care may be of special interest to readers, including the affirmation that Informal Self-care could be an effective course of action for many. The gap in resources for debriefing for a significant minority of chaplains may be especially worrying. And, while acute spiritual distress (loss of faith) is said here to be "rare," an incidence of 9.3% of this sample strikes this reader as a warranting close attention. One effect of this study may be to direct more research toward the role of theodicy in chaplains' lived experience of work.
The authors note various limitations, including the possibility of sampling bias, use of a measure of distress and self-care that had not been formally validated, and a cross-sectional design that precludes causal analysis. Still, this "first in-depth examination of distress, self-care, and debriefing activities of chaplains working in PC" [MS p. 7] provides good a deal of data (nicely organized in 5 extensive tables) and insights to fill in more of the picture of the people who constitute the profession. Because the authors in many instances compare their findings with those of studies of others working in palliative care, the article may implicitly suggest that chaplains in specialized fields might consider whether they are closer to other chaplains not in their field or to non-chaplains colleagues on their multidisciplinary teams.
Suggestions for Use of the Article for Student Discussion:
Before students read this article, it may be useful to ask them to stay mindful of how they see themselves in the findings or not, and then begin discussion on that point. For this reason, the article may be most useful with students who have had at least a little time in the field. What findings can they relate to the most? Referring to Table 2 [MS p. 4] may be helpful in this regard. How does the article have the effect of urging self-care, and does it suggest areas of self-care that might be worth pursuing proactively if they do not occur naturally as options? Are the students aware of employee assistance programs in their institution? The group could discuss theodicy as a factor in distress and muse about what could mitigate it as a stressor. What might lie behind the inverse association of self-care to theodicy? The article employs the term chaplaincraft, and it is briefly characterized [MS p. 6], but do students have a sense of the concept? [Note: In the previous article based on this same survey -- see Items of Related Interest, §I, below -- the term is defined as "the primary activities of chaplaincy, such as building relationships, providing ritual support (e.g., prayer), introducing spiritual care, and connecting patients with communities of faith."] The group could additionally think about the differences between Spiritual Distress and Professional Distress. For students with experience in research, the tables are a wealth of information.
Related Items of Interest:
I. The previous study from the same survey to collect data from palliative care chaplains was featured as our March 2017 Article-of-the-Month:
Jeuland, J., Fitchett, G., Schulman-Green, D. and Kapo, J. "Chaplains working in palliative care: who they are and what they do." Journal of Palliative Medicine 20, no. 5 (May 2017): 502-508. [(Abstract:) BACKGROUND: Palliative care (PC) programs utilize chaplains to address patients' spiritual care needs; however, there is no comprehensive description of chaplaincy in PC programs nationally. OBJECTIVE: To describe chaplains working in PC across the United States, including their integration on the PC team and visit content. DESIGN: National online survey conducted February-April 2015. SUBJECTS: We invited participation from hospital-based chaplains belonging to four national professional chaplain associations who spent 15% or more of their working hours with PC teams. Measure(s): We developed a 41-item survey to investigate main outcomes of chaplain demographics, practice information, integration into the PC team, and visit content. RESULTS: 531 valid responses were received. We report on respondents who were full-time chaplains (n = 382). Almost half were women (46%), and the majority was Protestant (70%). The average number of PC patients seen per day was 5.2 (SD = 3.5, range 1-30). Half (52%) reported frequently participating in PC rounds. Primary chaplain activities were relationship building (76%), care at the time of death (69%), and helping patients with existential issues or spiritual distress (49%). Over half (55%) reported addressing goals of care 60% of the time or more. DISCUSSION: This survey provides the first description of chaplains working in PC across the United States. We describe chaplains' critical role in attending to relationship building, care for the dying, and goals of care conversations. Our results highlight how the chaplains' level of involvement in PC affects the content of their visits. Our study suggests that when chaplains are more involved in PC teams, they provide more comprehensive support to PC patients and their families.]
II. Other Articles-of-the-Month that may be relevant to the topic of chaplains' distress and self-care include:
Galek, K., Flannelly, K. J., Greene, P. B. and Kudler, T. "Burnout, secondary traumatic stress, and social support." Pastoral Psychology (2011): 60, no. 5 (October 2011): 633-649. [October 2011 Article-of-the-Month.] [(Abstract:) The current study examines the extent to which selected work-related variables differentially predict burnout and secondary traumatic stress (STS) and the degree to which social support mitigates both of these occupational stress syndromes. Multiple regression performed on responses from 331 professional chaplains found that: (1) the number of years worked in the same employment position was positively associated with burnout but not STS; (2) STS, but not burnout, was positively associated with the number of hours spent per week counseling patients who had had a traumatic experience; and (3) social support was negatively related to burnout and STS. Only specific sources of social support (supervisory support and family support), however, were negatively associated with burnout. Results highlight the need for counselors to be attuned to not only their clients but also to their own inner dynamics in order to mitigate the possible deleterious effects of their work.]
Hernandez, P., Gangsei, D., Engstrom, D. "Vicarious resilience: a new concept in work with those who survive trauma." Family Process 46, no.2 (June 2007): 229-241. [September 2007 Article-of-the-Month .] [(Abstract:) This study explores the formulation of a new concept: vicarious resilience. It addresses the question of how psychotherapists who work with survivors of political violence or kidnapping are affected by their clients' stories of resilience. It focuses on the psychotherapists' interpretations of their clients' stories, and how they make sense of the impact that these stories have had on their lives. In semistructured interviews, 12 psychotherapists who work with victims of political violence and kidnapping were interviewed about their perceptions of their clients' overcoming of adversity. A phenomenological analysis of the transcripts was used to describe the themes that speak about the effects of witnessing how clients cope constructively with adversity. These themes are discussed to advance the concept of vicarious resilience and how it can contribute to sustaining and empowering trauma therapists.]
Hotchkiss, J. T. and Lesher, R. "Factors predicting burnout among chaplains: compassion satisfaction, organizational factors, and the mediators of mindful self-care and secondary traumatic stress." Journal of Pastoral Care and Counseling 72, no. 2 (June 2018): 86-98. [July 2018 Article-of-the-Month.] [This study predicted Burnout from the self-care practices, compassion satisfaction, secondary traumatic stress, and organizational factors among chaplains who participated from all 50 states (N = 534). A hierarchical regression model indicated that the combined effect of compassion satisfaction, secondary traumatic stress, mindful self-care, demographic, and organizational factors explained 83.2% of the variance in Burnout. Chaplains serving in a hospital were slightly more at risk for Burnout than those in hospice or other settings. Organizational factors that most predicted Burnout were feeling bogged down by the "system" (25.7%) and an overwhelming caseload (19.9%). Each self-care category was a statistically significant protective factor against Burnout risk. The strongest protective factors against Burnout in order of strength were self-compassion and purpose, supportive structure, mindful self-awareness, mindful relaxation, supportive relationships, and physical care. For secondary traumatic stress, supportive structure, mindful self-awareness, and self-compassion and purpose were the strongest protective factors. Chaplains who engaged in multiple and frequent self-care strategies experienced higher professional quality of life and low Burnout risk. In the chaplain's journey toward wellness, a reflective practice of feeling good about doing good and mindful self-care are vital. The significance, implications, and limitations of the study were discussed.]
Spidell, S., Wallace, A., Carmack, C. L., Nogueras-Gonzalez, G. M., Parker, C. L. and Cantor, S. B. "Grief in healthcare chaplains: an investigation of the presence of disenfranchised grief." Journal of Health Care Chaplaincy 17, no. 1 (January 2011): 75-86. [May 2011 Article-of-the-Month.] [Abstract:) We examined how chaplains respond to grief and determined the prevalence of disenfranchised grief (i.e., grief that is not or cannot be acknowledged or supported by society) in healthcare chaplains. We conducted an online survey of members of the Association of Professional Chaplains. Of 3131 potential participants, 577 (18%) responded to the survey. In response to grief in the workplace, chaplains stated they would have low energy (78%), feel sad or moody (63%), feel like they had no time for themselves (44%), go through the motions (41%), and distance themselves from others (31%). As an indicator of disenfranchised grief, 21% of chaplains felt that their grief was not supported and affirmed in the workplace and 63% listed circumstances of death about which they felt very uncomfortable hearing or talking about. The results suggest that grief, and disenfranchised grief in particular, may be an important concern to address in healthcare chaplaincy.]
Yan, G. W. and Beder, J. "Professional quality of life and associated factors among VHA chaplains." Military Medicine 178, no. 6 (June 2013): 638-645. [October 2013 Article-of-the-Month.] [(Abstract:) Chaplains play a unique role in the Veterans Affairs (VA) health care systems and have numerous responsibilities. Compassion satisfaction (CS), compassion fatigue (CF), and burnout (BO) are three major phenomenons that have been documented in other helping professions, but little is known about VA Chaplains' professional quality of life. This study examines a national sample of VA Chaplains and their professional quality of life along with associated factors. Two-hundred and seventeen VA Chaplains completed an anonymous Internet survey, and regression analyses were conducted to determine which variables affect professional quality of life. On average, participants report high levels of CS and low levels of CF and BO. Gender, perceived support from VA administration, and mental health (MH) integration were significant predictors for CS. MH integration and perceived support significantly affected CF. Age, MH integration, and perceived support affected BO. Significant interaction effects were found for CF and BO. In summary, younger Chaplains and Chaplains who report low levels of collaboration with MH professionals are most likely to develop CF and BO. This supports continued support from the VA for interdisciplinary initiatives and mentorship of younger Chaplains.]
III. See also this recent study:
Oliver, R., Hughes, B. and Weiss, G. "A study of the self-reported resilience of APC chaplains." Journal of Pastoral Care and Counseling 72, no. 2 (June 2018): 99-103. [(Abstract:) Approximately 5000 members of the Association of Professional Chaplains were surveyed using the Professional Quality of Life instrument in order to assess levels of Compassion Satisfaction and Compassion Fatigue and its associated subscales, Burnout and Secondary Traumatic Stress; 1299 surveys were completed. The most significant finding of this study is that Board Certified Chaplains have remarkably low scores of Burnout and Secondary Traumatic Stress and significantly high levels of Compassion Satisfaction.]
IV. Regarding theodicy in the present context, see:
Currier, J. M., Drescher, K. D., Nieuwsma, J. A. and McCormick, W. H. "Theodicies and professional quality of life in a nationally representative sample of chaplains in the veterans' health administration." Journal of Prevention and Intervention in the Community 5, no. 4 (October-December 2017): 286-296. [(Abstract:) This study examined the role of theodicies or theological/philosophic attempts to resolve existential dilemmas related to evil and human suffering in chaplains' professional quality of life (ProQOL). A nationally representative sample of 298 VHA chaplains completed the recently developed Views of Suffering Scale (Hale-Smith, Park, & Edmondson, 2012 ) and ProQOL-5 (Stamm, 2010 ). Descriptive results revealed that 20-50% endorsed strong theistic beliefs in a compassionate deity who reciprocally suffers with hurting people, God ultimately being responsible for suffering, and that suffering can provide opportunities for intimate encounters with God and personal growth. Other results indicated that chaplains' beliefs about human suffering were differentially linked with their sense of enjoyment/purpose in working with veterans. These results suggest that theodicies might serve as a pathway to resilience for individuals in spiritual communities and traditions in USA, particularly for clinicians and ministry professionals who are committed to serving the needs of traumatized persons.]