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July 2011 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Cadge, W., Calle, K. and Dillinger, J. "What do chaplains contribute to large academic hospitals? The perspectives of pediatric physicians and chaplains." Journal of Religion and Health 50. no. 2 (June 2011): 300-312.

Fitchett, G., Lyndes, K. A., Cadge, W., Berlinger, N., Flanagan, E. and Misasi, J. "The role of professional chaplains on pediatric palliative care teams: perspectives from physicians and chaplains." Journal of Palliative Medicine 14, no. 6 (June 2011): 704-707.


SUMMARY and COMMENT: This month's two featured articles focus on chaplaincy in pediatric care, but both contain insights that go beyond the pediatric setting, especially in the theme of the difference of perspective between chaplains' own understanding of their work and the perception of physicians. Also, both were co-authored by chaplains and others with degrees in ministry (Fitchett, Lyndes, Berlinger, and Dillinger), and they share one co-author (Cadge).

"The Role of Professional Chaplains on Pediatric Palliative Care Teams…" begins by noting that "little is known about how PPC [Pediatric Palliative Care] programs meet the spiritual needs of their patients and families" [p. 704]. So, this pilot study's aims were "to describe how spiritual care is provided in established PPC programs describe the role of staff chaplains in these programs" [p. 704]. In the first of two phases of the project, 28 programs were identified by an expert advisory committee. Then from these, 8 well-established programs were selected for deeper analysis in a second phase, including semistructured interviews with the chaplain and medical director.

Among the results: of the original 28 programs, 25 (89%) had a staff chaplain as a member of the palliative care team, and two of the remaining three indicated that the "chaplaincy department was needed" [p. 705]. Interviews for the eight select programs in Phase 2 revealed three models of chaplaincy involvement: "a staff chaplain on the PPC team who saw most most new cases and participated regularly in PPC rounds," "unit chaplains [who] cared for any PPC patients on their units" (including one instance of a unit chaplain acting as a liaison to the PPC program), and use of "a clinical pastoral education student chaplain to care for PPC patients and families and attend rounds" [p. 705]. The only measures used for evaluating the quality of chaplains' care were patient satisfaction surveys.

At the core of the article are findings about perspectives on the work and role of chaplains from physicians and from chaplains themselves. Medical directors described the work of chaplains along three lines: the relief of patients' and families' spiritual suffering, the improvement of communication between families and care teams regarding goals of care, and support of the care team itself. However, while "[c]haplains' reports of their contributions to the PPC team were broadly similar to the physicians',…the chaplains tended to focus on the process of their work rather than on how it led to good outcomes" [p. 706; italics added]. "For instance, one chaplain said, 'I try to emphasize a ministry of presence more than anything else and to be a consistent or trustworthy presence in the child's journey'" [p. 706].

This point of difference between emphases on process or on outcomes seems -- to this reader -- a key finding, because it may illustrate a source for subtle tensions between chaplains and many physicians who support them. Leaders of the pediatric palliative care programs here clearly appreciate the work of chaplains, but perhaps for different reasons. Chaplains' awareness of the perspective of such supporters -- rather then just the perspectives of those who are not supportive -- may be important for the growth of chaplaincy as a profession.

The theme of differing perspectives is elaborated in "What Do Chaplains Contribute to Large Academic Hospitals." Cadge and her colleagues state that "before we can understand who chaplains work with, what they do, and which medical professionals refer to them, we need to know more qualitatively about how medical professionals see and understand their work" [p. 310]. The study focused on pediatrics at 13 highly reputed academic medical centers in the US, interviewing 30 pediatric physicians and 22 chaplains.

We find that physicians generally see chaplains as part of interdisciplinary medical teams and work with them around certain topics, most frequently related to death. Physicians expect chaplains to conduct rituals and to provide information and counseling for families. Physicians tend to assess chaplains’ contributions positively but express concern about how chaplains negotiate religious diversity. Chaplains see themselves doing all the things physicians describe, but frame their contributions less in terms of discrete tasks and more in terms of their distinct perspectives related to wholeness, presence and healing. Chaplains generally see themselves making broader contributions to patient care than do physicians, and explain their contributions in broader frames using a vocabulary distinct from that of physicians. [pp. 301-302]

While physicians describe chaplains working with [pediatric] patients in terms of their tasks -- rituals, support, and counseling -- chaplains conceive of their own work more broadly in terms of the perspectives they bring. These approaches are not contradictory but different in emphasis and language. Physicians tend to see chaplains helping individual patients and families while chaplains see their contributions more broadly in terms of a holistic healing dimension they bring to the hospital. This broader perspective often leaves chaplains feeling like they could be called more often or in more situations than they are presently because they see themselves as bringing more to patient care than physicians recognize. [p. 309]
The particulars of these various perspectives are treated at length in sections on Physicians' Approach to Chaplains [pp. 304-305], Physicians' Work with Chaplains [pp 305-307], and Chaplains' Approach to Their Work [pp. 307-309]. The latter section is noteworthy on its own as a good description of how many chaplains champion the holistic values of pastoral care --potentially a rich area of common interest with other professionals.

One curious finding in the interviews was physicians' concern about how chaplains handle religious diversity: "None of the physicians described their interactions with chaplains negatively, but several raised concerns around how religious diversity is addressed by the chaplains and the hospital more generally," with some "concerned about one religious tradition dominating another" [pp. 306-307]. This is striking in light of the observation by Cadge, et al. that "[c]haplains in large academic medical centers tend to be religiously progressive as a group, due in part to the interfaith nature of their work" [p. 310].

These [physicians'] concerns likely reflect the patients and families physicians see and the different religious and spiritual demographics between the physicians who are mostly not affiliated with a particular tradition and the chaplains who are primarily Protestant. Physicians’ concerns about religious diversity are particularly interesting, given that very few of the chaplains interviewed spoke in tradition-specific language when describing their work and contributions. [p. 309]
While this study examines the perspectives of individuals, the researchers come in the end to note how the work of chaplains in an institution may be greatly influenced by the organizational and operational structure of the institution. They suggest that future work not just explore "what chaplains do" but "adopt a more institutional approach asking how chaplains are institutionally positioned, how what they can do is shaped by that positioning, and what factors internal and external to the institutions help to explain variation between institutions" [p. 310].

Each of this month's featured articles moves in its own directions, but each also complements the other in theme and findings. The shorter one by Fitchett, et al. offers significant insights for a pilot study. The longer one by Cadge, et al. takes a narrative approach necessary to give a full sense of the qualitative data, opening with an anecdote and containing a helpful Background section. They happen to have been published in the same month, but both would be well read together under any circumstances for how they stir thought on the perceptions of chaplaincy in general and illuminate pediatric chaplaincy in particular.


Suggestions for the Use of the Article for Discussion in CPE: 

The combined text of these two articles amounts to only about 12 pages (not including reference sections), so the assignment of both for a CPE discussion seems quite reasonable. These pieces are very readable and should appeal to chaplains beyond the pedicatric palliative care setting. Discussion could focus on how students personally believe they are perceived by physicians, and then how their belief comports with data in the studies. Also, specifically how might students think about their role and function differently from the physicians who they've found supportive? Does the section of the article by Cadge, et al. on Chaplains' Approach to Their Work [pp. 307-309] ring true to them? What might be some strategies to help physicians and other non-chaplains understand better what chaplains do? The study by Fitchett, et al. discovered that the only evaluation of the quality of chaplains' care in the sample was through patient satisfaction surveys [--see p. 706], but might there be some other means of evaluating this work such that the nature and importance of chaplaincy is made more apparent to physicians or anyone involved in health care?

Related Items of Interest:

I. Both of our featured articles refer to the following study which, while it focuses on the experiences of parents of children who had died in a Pediatric Intensive Care Unit, makes very good points about the chaplain's role in the multidisciplinary team, especially in terms of what it means to be a spiritual care specialist vis-à-vis a spiritual care generalist: see Table 3 -- Roles and Tasks of Spiritual Care Generalists and Specialists [p. 726] and Table 4 -- When a Spiritual Generalist Should Consult A Chaplain [p. 727]. The article was featured as our November 2006 Article of the Month.

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.


II. For more on how chaplaincy is found in hospitals in the US, see the July 2008 Article of the Month:

Cadge, W., Freese, J. and Christakis, N. A. "The provision of hospital chaplaincy in the United States: a national overview." Southern Medical Journal 101, no. 6 (June 2008): 626-630.


III. For more on the practical position of chaplains in hospitals, see:

de Vries, R., Berlinger, N. and Cadge.W. "Lost in Translation: Using Sociology to Help Define Chaplaincy’s Role in Health Care." Hastings Center Report 6 (November-December 2008): 23-27. [The article is available freely online from the Hastings Center as part of a separately published set of essays. See pp. 9-13 of Can We Measure Good Chaplaincy? A New Professional Identity Is Tied to Quality Improvement. The other essays in the collection may also be of interest, especially Martha Jacobs' "What Are We Doing Here? Chaplains in Contemporary Health Care," on pp. 1-4.]


IV. For studies of physicians' experiences of working with chaplains and of views about the role and importance of chaplains from hospital directors, hospital administrators, and department directors, the following open nicely the topic in the literature:

Fitchett, G., Rasinski, K., Cadge, W. and. Curlin, F. A. "Physicians’ experience and satisfaction with chaplains: a national survey." Archives of Internal Medicine 169, no. 19 (October 26, 2009): 1808-1810.

Flannelly, K. J., Galek, K., Bucchino, J., Handzo, G. F. and Tannenbaum, H. P. "Department directors' perceptions of the roles and functions of hospital chaplains: a national survey." Hospital Topics 83, no. 4 (2005): 19-27.

Flannelly, K., Handzo, G., Galek, K., Weaver, A., and Overvold, J. "A national survey of hospital directors’ views about the importance of various chaplain roles: Differences among disciplines and types of hospitals." The Journal of Pastoral Care and Counseling 60, no. 3 (Fall 2006): 2213-225.

Flannelly, K. J., Handzo, G. F., Weaver, A. J. and Smith W. J. "A national survey of healthcare administrators' views on the importance of various chaplain roles." Journal of Pastoral Care & Counseling 59, nos. 1–2 (2005): 87–96.


V. The featured article by Fitchett, et al. concludes that the data "suggest that integration of chaplains on these [Pediatric Palliative Care] teams may reduce barriers to optimal spiritual care identified in an earlier survey of pediatric chaplains including lack of staffing, colleagues not trained in how to make referrals, and late referrals" [p. 706]. The earlier study referred to is:

Feudtner, C., Haney, J. and Dimmers, M. A. "Spiritual care needs of hospitalized children and their families: a national survey of pastoral care providers’ perceptions. " Pediatrics 111, no. 1 (January 2003): e67-72. [This article is available freely online through the journal Pediatrics.]


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