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July 2015 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


McCormick, S. C. and Hildebrand, A. A. "A qualitative study of patient and family perceptions of chaplain presence during post-trauma care." Journal of Health Care Chaplaincy 21, no. 2 (2015): 60-75.


SUMMARY and COMMENT: This month's article reports a study conducted during a CPE Residency at the Maine Medical Center (Portland, ME) by Steven C. McCormick, EdD, along with staff chaplain Alice A. Hildebrand, MDiv. This is a more methodologically thorough and conceptually rich piece than one would expect from a residency project, owing to the authors' particularly advanced skills, as it offers not only a picture of how patients and families "perceive and experience various chaplain traits and practices" [p. 61] but "weave[s]" the analysis into an assessment model incorporating psychological theory.

The study analyzed semi-structured, audio-taped interviews from "a purposeful sampling of 25 patients, and in some cases loved ones and family members, who received hospital chaplain visits during post-trauma care at a 637-bed Level One Trauma Center" [p. 62]. Interviews began with the invitation, "Talk about the experience you went through that resulted in you being here and what that was like for you" [p. 65], with clarification of responses guided by a number of pre-set follow-up questions [--listed on p. 65]. The use of grounded theory research methodology is well described, including caution about the possible influence of the researchers' own backgrounds, roles and perspectives, and an effort at checks and balances to validate findings (for example, having some participants read and comment on their transcripts and the coding of the content, consulting nurses who were not involved with the study, and even soliciting feedback from hospital staff members from other cultures [--see p. 66]).

As the transcript contents were coded, three themes began to emerge during interviews 9 through 13: "traits of the chaplain that patients sought in the presence of the chaplain, traits in the chaplain that described what patients required for relationship with the chaplain, and traits in the chaplain that contributed to patients’ efforts to find meaning in their experiences" [p. 65].
Participants described presence in short phrases and single words, essentially listing traits of character they desired in a chaplain. They expanded upon these traits by describing certain chaplain qualities and actions necessary to the formation of a relationship with the chaplain. Many also spoke about what chaplains said or did that contributed positively to their own efforts to find meaning in their experiences. All but two participants stated that they valued the chaplain visits and experienced these visits as an important part of their recovery. [p. 66]
The authors explicate at length the three themes of presence, relationship, and meaning [--see pp. 66-72], giving no fewer than 34 vivid quotes from participants and commenting on their significance for chaplains' practice. They go on, in their Discussion section, to note that participants experienced the traits they valued in chaplains "not in a static form, but in the active process of relationship building" --a "dynamic process [that] occurred over a series of visits…[or]…could be seen in the course of one visit" [p. 72]. The illustrative analysis of the three themes constitutes the core of the article, addressing the researchers' intent of "[u]nderstanding the nature and impact of such chaplaincy care from the perspective of the patient or family member" and expanding the "limited research on the impact of traumatic stress on spirituality or spiritual care needs" [p. 61]

However, there is another dimension to this article. The authors state that the design of their interview questions was influenced by their prior work, which had led them to "believe that it is vitally important to assess the developmental level at which a patient is functioning in three key areas: motivation, belief system, and attachment/autonomy" [p. 62], drawing on the psychological theories of Abraham Maslow (primary motivation), James W. Fowler and John H. Westerhoff (faith development), and Donald W. Winnicott (primary attachment). Then seeing their study findings in relation to the insights they've gleaned from psychological theory, they create a "holistic spiritual care assessment model" [p. 73] for chaplains which "provides a basis for assessing the state of mind of the patient or family member and choosing what intervention to offer" [p. 72]. The model integrates the themes of the study with those of the theorists into a 3-by-3 grid, given as a table [p. 73] and explained. For example:
Individuals who are in the shock of a trauma or who are struggling with bad news are likely to be located on the basic presence level of the table. Their motivation may be dominated by physical needs such as critical medical care and safety. Patients or family members may ask very simple faith related questions, reflecting basic understandings often explored in childhood. "Why did this happen to me? Where is God?" In the context of this level of distress, the individual may seek a temporary strong attachment to a particular trusted caregiver. [p. 73]
The authors continue, following the course of the patient experience as the physical trauma stabilizes: needs may develop past the theme of presence and turn more toward the theme of relationship and then perhaps subsequently toward the theme of meaning, although individuals "often vacillate in their progress through these levels" [p. 73].

McCormick and Hildebrand are clearly committed to research as the pathway "to describe the unique contributions of chaplains to spiritual care, to identify best chaplaincy practices to optimize patient and family health outcomes, and to test the efficacy of chaplaincy care" [p. 61], and they propose their assessment model, informed by their research, believing that it "can contribute to evidence-based spiritual care practice" [p. 74]. They conclude with a broad statement of encouragement for research and of their hope for the field:
Future quantitative research should advance these findings, with the goal of developing and validating an assessment instrument to guide chaplain interventions, improving patient outcomes that drive key hospital performance metrics. Such research evidence is critical to ensuring and enhancing the role of spiritual care on the care team. [p. 74]
This article is practice-minded and future-minded. In the end, the authors challenge chaplains to consider the broad issue of research and the prospects for evidence-based pastoral care as much as they invite readers to reflect on their findings. The fact that such an article would come from within a residency program also indicates how CPE may be a locus for envisioning the place of research in the field of chaplaincy.


Suggestions for the Use of the Article for Student Discussion: 

While the article is written clearly and engagingly, it may be suited to more advanced students for whom the study and its application may resonate with their clinical experience, or with students at a trauma center for whom the focus of the study may connect directly with their patient population. Yet, both the findings and the proposed model for spiritual assessment are relevant beyond a trauma population and should be meaningful to any CPE context. The many points and quotes in the Results section give a great deal of material to stir discussion about how patients or families might relate to a chaplain in terms of their needs for presence, relationship, and meaning. Be sure to consider some of the cautionary points in the section. Discussion of the proposed holistic spiritual care assessment model may involve a walk-through of the illustration provided on p. 73, and students could be asked to think of examples from their own experience of how they've seen patients manifest the three highlighted needs, though the supervisor (or an invited facilitator) may have to explain more about the psychological theorists. For those interested in methodology, there is much to work with in the article, including the authors' steps to protect against their own unintended biases and to validate their findings. The article is obviously a good entrée to a discussion of grounded theory. Some specific points about methodology (e.g., how social desirability and acquiescence may affect what a patient says and the "power differential" [p. 64] between a patient and a researcher or chaplain) have implications for pastoral visitation, generally. Finally, the background issue of the role of research and the idea of evidence-based practice for chaplains may draw students' attention, as may the conceptualization of pastoral interventions as treatments [--see, for instance, p. 61]


Related Items of Interest:

I. Our authors cite Daniel Grossoehme's "Overview of qualitative research" [Journal of Health Care Chaplaincy 20, no. 3 (2014): 109-122] as an especially useful resource for chaplains on grounded theory. See our August 2014 Article-of-the-Month page for more on that piece.

[Note: Grounded theory methodology is not uncommon in spirituality and health research. For some other examples of grounded theory research the we've featured on the Network website, see the Articles-of-the-Month pages for December 2014, November 2012, and December 2007.]


II. The theme of the effect of trauma on patient spirituality was first explored by the Network with our May 2005 Articles-of-the-Month. One line of thought in this literature concerns the concept of Post-Traumatic Growth, about which the following recent, large study may be a good introduction:

Tsai, J., El-Gabalawy, R., Sledge, W. H., Southwick, S. M. and Pietrzak, R. H. "Post-traumatic growth among veterans in the USA: results from the National Health and Resilience in Veterans Study." Psychological Medicine 45, no. 1 (January 2015): 165-179. [(Abstract:) BACKGROUND: There is increasing recognition that, in addition to negative psychological consequences of trauma such as post-traumatic stress disorder (PTSD), some individuals may develop post-traumatic growth (PTG) following such experiences. To date, however, data regarding the prevalence, correlates and functional significance of PTG in population-based samples are lacking. METHOD: Data were analysed from the National Health and Resilience in Veterans Study, a contemporary, nationally representative survey of 3157 US veterans. Veterans completed a survey containing measures of sociodemographic, military, health and psychosocial characteristics, and the Posttraumatic Growth Inventory-Short Form. RESULTS: We found that 50.1% of all veterans and 72.0% of veterans who screened positive for PTSD reported at least 'moderate' PTG in relation to their worst traumatic event. An inverted U-shaped relationship was found to best explain the relationship between PTSD symptoms and PTG. Among veterans with PTSD, those with PTSD reported better mental functioning and general health than those without PTG. Experiencing a life-threatening illness or injury and re-experiencing symptoms were most strongly associated with PTG. In multivariable analysis, greater social connectedness, intrinsic religiosity and purpose in life were independently associated with greater PTG. CONCLUSIONS: PTG is prevalent among US veterans, particularly among those who screen positive for PTSD. These results suggest that there may be a 'positive legacy' of trauma that has functional significance for veterans. They further suggest that interventions geared toward helping trauma-exposed US veterans process their re-experiencing symptoms, and to develop greater social connections, sense of purpose and intrinsic religiosity may help promote PTG in this population.]


III. Some other recent articles of possible interest regarding trauma:

Calder, A., Badcoe, A. and Harms, L. "Broken bodies, healing spirits: road trauma survivor's perceptions of pastoral care during inpatient orthopaedic rehabilitation." Disability and Rehabilitation 33, nos. 15-16 (2011): 1358-1366. [(Abstract:) PURPOSE: The aim of this article is to present findings from an Australian study that explored road trauma survivors' perceptions of spirituality and of a hospital-based pastoral care service throughout their inpatient rehabilitation. All participants had experienced severe orthopaedic injury. METHOD: A mixed-method research design was used. The survey method elicited demographic, pastoral care contact and hospitalisation data. It included the Posttraumatic Growth Inventory (PTGI; Tedeschi and Calhoun 1996) and an adapted World Health Organisation Pastoral Intervention (WHO 2002) coding schema (Constitution of the World Health Organisation, basic documents, supplement. 45 ed.). An interview method was used to elicit information about participants' prior and current experiences of faith and spirituality, expectations, and experiences of the pastoral care service, and perceptions of the role of pastoral care in their rehabilitation. RESULTS: A thematic analysis of both quantitative and qualitative data identified nine core themes of supportive pastoral care. Pastoral care was seen as a valued and supportive intervention. Participants who completed the PTGI reported at least some degree of posttraumatic growth. CONCLUSIONS: Further research is recommended to examine the role and efficacy of pastoral care that is integral to road trauma recovery support.]

Shinall, M. C. Jr. and Guillamondegui, O. D. "Effect of Religion on End-of-Life Care Among Trauma Patients." Journal of Religion and Health 54, no. 3 (June 2015): 977-983. [(Abstract:) Evidence suggests that religiousness is associated with more aggressive end-of-life (EOL) care among terminally ill patients. The effect of religion on care in more acutely life-threatening diseases is not well studied. This study examines the association of religious affiliation and request for chaplain visit with aggressive EOL care among critically injured trauma patients. We conducted a retrospective review of all trauma patients surviving at least 2 days but dying within 30 days of injury over a 3-year period at a major academic trauma center. Time until death was used as a proxy for intensity of life-prolonging therapy. Controlling for social factors, severity of injury, and medical comorbidities, religious affiliation was associated with a 43 % increase in days until death. Controlling for these same variables, chaplain request was associated with a 24 % decrease in time until death. These results suggest that religious patients receive more aggressive, and ultimately futile, EOL care and that pastoral care may reduce the amount of futile care consumed.]

Waldron-Perrine, B., Rapport, L. J., Hanks, R. A., Lumley, M., Meachen, S. J. and Hubbarth, P. "Religion and spirituality in rehabilitation outcomes among individuals with traumatic brain injury." Rehabilitation Psychology 56, no. 2 (May 2011): 107-116. [[(Abstract:) OBJECTIVE: The long-term consequences of traumatic brain injury affect millions of Americans, many of whom report using religion and spirituality to cope. Little research, however, has investigated how various elements of the religious and spiritual belief systems affect rehabilitation outcomes. The present study sought to assess the use of specifically defined elements of religion and spirituality as psychosocial resources in a sample of traumatically brain injured adults. PARTICIPANTS: The sample included 88 adults with brain injury from 1 to 20 years post injury and their knowledgeable significant others (SOs). The majority of the participants with brain injury were male (76%), African American (75%) and Christian (76%). MEASURES: Participants subjectively reported on their religious/spiritual beliefs and psychosocial resources as well as their current physical and psychological status. Significant others reported objective rehabilitation outcomes. ANALYSES: Hierarchical multiple regression analyses were used to determine the proportion of variance in outcomes accounted for by demographic, injury related, psychosocial and religious/spiritual variables. RESULTS: The results indicate that religious well-being (a sense of connection to a higher power) was a unique predictor for life satisfaction, distress and functional ability whereas public religious practice and existential well-being were not. CONCLUSIONS: The findings of this project indicate that specific facets of religious and spiritual belief systems do play direct and unique roles in predicting rehabilitation outcomes whereas religious activity does not. Notably, a self-reported individual connection to a higher power was an extremely robust predictor of both subjective and objective outcome.]


IV. Our article's co-author, Alice A. Hildebrand has also written a chapter in the new book by George Fitchett and Steve Nolan (eds.), Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy (London/Philadelphia: Jessica Kingsley Publishers, 2015). See Hildebrand's "'I can tell you this, but not everyone understands' --Erica, mother of a 2-year-old girl with cancer," pp. 51-68. This is a case study that "explores a spiritual care relationship that developed over a year and a half" [p. 51] with a patient at the Maine Medical Center (Portland, ME).


V. While not a report of research, readers may be interested in a recent piece in the Journal of Emergency Medicine [48, no. 6 (June 2015): 751-753] by Christina Bodemann, a CPE Resident at the Lutheran Medical Center (Brooklyn, NY): "Seeing eye to eye: becoming the chaplain in the emergency department of a Level I Trauma Center." The author offers personal reflection and half a dozen brief vignettes of her experience with patients and staff.



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