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July 2022 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


Russell, J., Quaack, K. R. and Nunez, J. "Chaplain reported plans for end-of-life care conversations: role clarity for the spiritual care specialists." Journal of Health Care Chaplaincy (2022): online ahead of print, 6/26/22.

[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: An old issue for chaplains is how much advance planning and goal setting should go into patient interactions, how much preparation maximizes benefits, and how much it could set an agenda that affects the chaplains' ability to be present in the patient's moment. Our featured study this month -- out of the Communication departments at California State University (Long Beach) and the University of Texas (Austin) -- is relevant in part to that issue, exploring how chaplains plan and approach "conversational engagement" [MS p. 2] in end-of-life (EOL) cases and how chaplains' goals figure into "curated plans" [MS p. 4, passim]. The intent here is to gain insight into the role(s) chaplains may play on palliative care teams and the "conversational quality" [MS p. 3] of their work. The authors' analysis is guided by a "multiple goals theoretical framework" [MS p. 2] regarding complex communications, which should be thought-provoking for all chaplains. This article builds upon a theme of communication that was explored in the previous Article-of-the-Month (--see June 2022).

The theory here around multiple goals provides a lens through which communication can be understood in terms of task goals (i.e., "taking an action directed at accomplishing a specified end and is often the object toward which communication is directed" [MS p. 2]), identity goals (i.e., "centraliz[ing] the individual roles and values of the vested parties" [MS p. 3]), and relational goals (i.e., "associated with the development and maintenance of connections with others" [MS p. 3]).

According to the multiple goals theoretical perspective, in complex communicative situations, the number of relevant goals increase which may account for the difficult nature of EOL discussions.... A multiple goals framework further posits that interactions addressing the primary task while simultaneously adhering to relevant identity and relational goals are deemed more effective...relative to those with a singular goal orientation. In the domain of EOL conversations, prior research on goal-directed behavior demonstrates that communicators able to effectively navigate multiple relevant goals report higher quality conversations with enhanced conversational satisfaction and hopefulness.

Assessing goals is one approach to better understand EOL communication. Goals offer insight to what is prioritized and integrated in curating plans for broaching EOL discussions with terminally ill patients. Exploring frequencies of such goals underscores communicative trends and unique occupational orientations. EOL conversations are inherently complex and surface potentially conflicting task, relational, and identity concerns. As such, examining responses for the presence of multiple goals provides evidence for communication skill and offers indicators for conversational quality. [MS p. 3]

Two research questions drove this project: What is the relative frequency of task, identity, and relational goals of chaplains in planning for conversations about EOL care? ...and... What topics are present in chaplain curated plans for EOL conversations? [See MS p. 4.] A total of 69 chaplains were recruited from listservs of the Coalition for Compassionate Care, Hospital Chaplains Ministry Association (HCMA), and HealthCare Chaplaincy Network (HCCN). The authors note, "These organizations are not representative of all chaplains in the United States" [MS p. 12], but they propose that this sample is adequate for this "preliminary step" [MS p. 13] in investigating the subject matter. All data were collected via an online process. Participants were presented with a patient scenario:

You have a patient living in a skilled nursing facility with a terminal illness. Their spouse is no longer living. They have a remaining life expectancy of less than a year. While they have full capacity to make decisions, you are asked to have a discussion with the patient about his or her EOL treatment options so that the medical staff aiding the patient is clear about what the patient wants. [MS p. 4]
And then participants were directed as follows:
Please design a plan to communicate to the patient about their options for life-sustaining treatment. In this plan, please write (a) how you would engage in the conversation with the patient and (b) what specifically you would plan to discuss. Please be as detailed as possible in your plan generation. [MS p. 4]

Among the findings and implications from the qualitative (grounded theory) analysis:

  • "Within chaplain curated plans, topics were most frequently relational goal oriented (95.7%). ...Most plans also integrated identity goals (82.6%) including content concerning patient individuality, autonomy, and provider role clarity. Task oriented goals were present in 66.7% of plans and involved content with a designated step or action to take." [MS p. 6]

  • "In addition to general occurrence of goals within plans, of interest were the consideration and negotiation of multiple goals. Of plans provided, 53.6% encompassed all three broad goal orientations with task, identity, and relational elements. Other plans integrated both relational and identity goals (24.6%), task and relational goals (10.1%), and task and identity goals (2.9%)." [MS p. 6]

  • "Content within chaplain reported plans coded with relational orientation included: developing rapport, liaison, emotional comfort, and reference to communication approach. ...Developing rapport (72.5%) integrated chaplain efforts to establish a relational base for engaging in more intimate conversations. Approaches included inquiring about life experiences, inviting patients to tell their story, and elicit information about what experiences shape their current situation. ...Chaplain planned approaches included liaison (53.6%) or reference to serving as a coordinator between various members vested in the care process including: patient, family, medical team, and faith/clergy support. Liaison efforts between the patient and medical team included identifying gaps in understanding, reporting of patient updates and requests, and seeking out where additional resources from other roles were needed. ...Reference to providing emotional comfort was present in 47.8% of chaplain curated plans. Emotional comfort encompassed responses aimed to elicit feelings or concerns as well as offer support, encouragement, and reassurance in the dying process. ...Reference to communication approach (31.9%) regarded chaplains responses centered on the communication style or approach to the patient interaction as well including how the discussion will take place." [MS pp. 7-8]

  • "Content within chaplain reported plans coded with an identity orientation included: patient preferences, role clarification, and establish surrogate decision maker. ...Of chaplain generated plans, 71.0% integrated patient preferences. Chaplains indicated surveying treatment options as a means for patients to indicate what aligned with their goals. Patient preferences also manifested in chaplain driven efforts for a patient to describe their vision of the final stages of life. ...Role clarification (33.3%) included responses where chaplains sought to introduce self and their position on the care team, clarify the function of their position, checked role-acceptability, and sought out role permissions. ...Establish surrogate decision maker (17.4%) involved chaplain responses that aim to identify an individual who would speak on the patients' behalf...." [MS p. 8]

  • "Plans containing topics with a task orientation included: assessing the patients' knowledge of condition, documentation, and soliciting unfinished business. ...Responses that included assessing patients' knowledge of the condition (43.5%) included intention to investigate patient perception or understanding of their medical state. ...Documentation (40.6%) encompassed any reference to charting what information was discussed with the patient. Documentation practices ranged from informal notes to completing information on an advance direction or other tool aimed to document patient EOL care preferences (e.g., POLST). ...Soliciting unfinished business (8.7%) included chaplain efforts to identify residual concerns or tasks that the patient wished to address and/or accomplish in their final days. These inquiry efforts had a nonmedical focus and included a desire to identify any final wishes before passing." [MS p. 9]

  • "The high rate of relational oriented plans is noteworthy as studies indicate that rapport among patient and providers enables a more trusting relationship with the medical team and can promote patient adherence" [MS p. 10]

  • "Chaplains' descriptions of their plans also revealed an adherence to identity goals of both patient and provider." [MS p. 10] ...While not a predominant theme, approximately a third of respondents indicated the need to introduce and/or clarify their role as a chaplain. This finding is significant given the documented limitations and barriers associated with a lack of understanding around chaplain responsibilities." [MS p. 12]

  • "Compared to relational and identity focused plans, chaplains were less likely to prioritize task goals. These findings are significant in a few ways. First, the deemphasis of task-orientation contrasts with existing goals-related research describing task goals as the principal focus of the communicative encounter. ...This finding is also significant in shedding light on differing roles members have on the interdisciplinary team. ...In examining curated plans, physicians report greater priority on providing medical information specific to treatment options, whereas chaplains prioritize a more holistic and relational approach to care." [MS p. 10]

  • "The frequency of plans integrating multiple goals was also of interest. Over half of chaplain reported plans integrated relational, identity, and task components. This prevalence rate is promising as the multiple goals framework posits that effective communication is premised on satisfying multiple goals simultaneously in a communicative exchange.... Existing research has attributed positive patient outcomes such as increased patient decision-making efficacy and conversational satisfaction with EOL conversations in which communicators successfully manage multiple goals...." [MS p. 10]

  • "Results of this study suggest that chaplains are cognizant of EOL complexity and approach conversations with attention to the interplay of such [relational, identity, and task] goals." [MS p. 11]

The authors parlay their findings into a case supporting chaplains' value on the interdisciplinary care team: "Recognizing the need to fully understand the patient and their story is a valued asset that chaplains can bring to the care team efforts" [MS p. 11], and "The heavy integration of establishing rapport and eliciting patient preferences within chaplain curated plans speaks to the unique benefits their role brings to the interdisciplinary care team" [MS p. 11-12]. They extend this to a particular vision of a "complementary approach" with physicians: "The physician or member of the medical team can inform the patient of treatment options available, while chaplains can help make sense of the options through the lens of patient values and identity" [MS p. 12].

This study concentrated on the "difficult conversations" [MS p. 2] pivotal to good end-of-life care, but this reader's mind went immediately to how such research could have wider significance. First, it highlights a sophistication in chaplains' approaches to patient/family communication, and multiple goals theory may indeed be a productive means to conceptualize and improve many different interactions in chaplaincy practice --and might be usefully applied in Clinical Pastoral Education. Second, while the methodology here revolves around the use of curated plans for patient conversations and is attentive to task goals in such planning, it allows for an appreciation of chaplains' prioritization of relational goals. Moreover, while the data come from a directive to "design a plan to communicate to the patient" [MS p. 4], the study does not necessarily rule out the validity of a plan that is cautious about imposing a limiting agenda on an interaction. The old issue of how advance planning for conversations may affect the practice and experience of chaplaincy is here enriched with some new data for consideration. Additionally, this research should encourage greater dialogue between chaplains and physicians in general, recognizing what each may bring to the total interdisciplinary team interaction with patients and families. If this reader has one concern about the article, it would be about the authors' final word here: "Awareness of content that chaplains are more prone to cover provides opportunities to clarify where other interdisciplinary team members can contribute without being redundant" [MS p. 13, emphasis added]. A certain amount of role overlap may actually be healthy, as overspecialization in communication may risk undermining the holistic complexity of interpersonal interaction and the patient experience. Future research should carry this study forward, examining how chaplains pursue communication goals in less abstract and more real-world contexts.

The bibliography contains 50 citations, including five from 2021.


Suggestions for Use of the Article for Student Discussion: 

This month's article should be engaging to a wide spectrum of chaplains: students, career professionals, educators and those with a research focus; though multiple goals theory may not be useful to students very early in their programs. It could be read in tandem with the June 2022 Article-of-the-Month, also on communication. While it is naturally geared to palliative care circumstances, it should be engaging for chaplains in a variety of settings, and it could be especially interesting for chaplains other specialized settings (e.g., behavioral health) to compare and contrast their professional situations with that of palliative care when it comes to communication dynamics. Discussion might begin with a look at the introduction of the Multiple Goals theoretical framework [MS pp. 2-4], beginning with the declaration, "Communication is a goal-driven process" [MS p. 2]. What do they make of the division of goals into relational, identity, and task orientations? Can they identify their own predilections in terms of these three? How might these relate to their sense of a theory of chaplaincy? What is their reaction to the suggestion that managing multiple goals in clinical conversations is associated with a higher quality of interaction and better outcomes? Turning to the list of content topics [--see Table 2, MS p. 7], which stand out to the students as prominent in their practice? Are there other content topics that, from their experience, seem absent from this list? Do any seem out of place for their own practice? The study notes that the need to introduce and/or clarify the role of chaplain was "not a predominant theme" [MS p. 12] in the results, though a third of the participants expressed this need. How much attention do the students feel they need to give to this identity goal in patient/family interaction? What do the students think they might do with the ideas raised by this research? Members of the group could be asked to state, in turn, one personal takeaway from the discussion.


Related Items of Interest:

I.  Relevant to the evidence here about chaplains sophistication around communication, note that among the findings of the December 2021 Article-of-the-Month was chaplains' self identification as "skilled communicators" with an "ability to practice skills grounded in theory" [--see MS p. 13 of White, K. B., Combs, R. M. and Decker, H. R., "Board certification of professional chaplains: a qualitative study of stakeholder perspectives," Journal of Health Care Chaplaincy (2021): online ahead of print, 6/1/21].


II.  Our authors this month cite the work of Jane Jeuland, George Fitchett, Dena Schulman-Green, and Jennifer Kapo in "Chaplains working in palliative care: who they are and what they do" [Journal of Palliative Medicine 20, no. 5 (May 2017): 502-508; and the March 2017 Article-of-the-Month] regarding chaplains' roles on palliative care teams. Findings from that earlier study included: "Chaplains who always serve PC [i.e., Palliative Care] are far more likely to address goals of care (70%) than chaplains who occasionally serve PC (43%)," and "[t]hey are also twice as likely to facilitate communication between patients, family, and the healthcare team (65%) than occasionally involved counterparts (34%)" [p. 507]. This suggests that solid integration of particular, regular chaplains into care teams may be a key factor in the effectiveness of the chaplain's role and efficiency of communication.


III.  Regarding chaplains' management of identity goals, especially in light of felt needs around self-introduction and role clarification, readers may be interested in these two past Articles-of-the-Month.

Lindholm, K. "Handling stereotypes of religious professionals: strategies hospice chaplains use when interacting with patients and families." Journal of Pastoral Care and Counseling 71, no. 4 (December 2017): 284-290. This was our January 2018 Article-of-the-Month. [This research by Kristin Lindholm, a professor of communication, revealed a number of strategies that hospice chaplains have used to manage their identity in such a way as to minimize patients'/families' resistance to them, including how they introduce themselves and their relationship to the larger care team. See esp. pp. 287-290.]

Soroka, J. T., Collins, L. A., Creech, G., Kutcher, G. R., Menne, K. R. and Petzel, B. L. "Spiritual care at the end of life: Does educational intervention focused on a broad definition of spirituality increase utilization of chaplain spiritual support in hospice?" Journal of Palliative Medicine (2019): online ahead of print, 4/12/19. This was our May 2019 Article-of-the-Month. [This study tested the effectiveness of a printed card to be given to hospice patients and families, explaining the nature and role of the chaplain on the hospice team. The idea raises the question of whether some aspects of chaplains' goals around their identity may be accomplished by such means preceding/external to the initial personal encounter.]


IV.  Our present article's bibliography provides good leads for further reading about Multiple Goals Theory, including Van Scoy, L. J., Scott, A. M., Reading, J. M., Chuang, C. H., Chinchilli, V. M., Levi, B. H. and Green, M. J., "From theory to practice: measuring end-of-life communication quality using multiple goals theory," Patient Education & Counseling 100, no. 5 (May 2017): 909-918; which was cited as a Related Items of Interest for our November 2017 Article-of-the-Month. However, chaplains may want to look particularly at the following recent study by two of our featured authors, examining how Social Workers may approach conversational goals in end-of-life contexts. Eliciting information about patients' spiritual values, beliefs, and traditions stand among the goal-related interests of some Social Workers.

Russell, J. and Quaack, K. "A Multiple Goals approach to exploring social worker conversational plans for advance care treatment with terminally ill patients." Journal Of Social Work In End-Of-Life & Palliative Care 17, no. 4 (October-December 2021): 278-295. [(Abstract:) Social workers play an integral role in end-of-life planning and patient outcomes, and yet how social workers approach such conversations with patients is not well understood. The current study employed a cross-sectional design to examine social worker planned communication about end-of-life care using a multiple goals framework. Recruited from online listservs, a content analysis was conducted with social worker curated plans (n = 20) for end-of-life conversations. Plans were coded for topics and content alignment with instrumental, identity, and relational goal types. Topics found were related to eliciting patient goals and the utilization of written resources. A substantial percentage of social workers also noted the inclusion of other parties in the conversation. Findings suggested that content was predominately instrumental (i.e. task-oriented) with an overwhelming majority adhering to multiple conversational goals. Plan content affords insight to occupational orientation and prioritization during conversations with patients. Further, identifying how the majority of planned responses integrate multiple goals simultaneously gives credence to existing research regarding enhanced conversational effectiveness when social workers are present on the palliative care team.]


V.  The idea of "snowball sampling" [MS p. 12] in research is, to put it most simply, taking advantage of connections between members of a population in order to gain greater access to that population. It may be done either by asking study recruits either to share an invitation to participate in the study or to provide researchers with contact information about others who may be interested in the study. For more on this concept/methodology in general, see the following trio of invited commentaries on the subject from the perspective of sociological methodology:

Goodman, L. A. "Comment: On respondent-driven sampling and snowball sampling in hard-to-reach populations and snowball sampling not in hard-to-reach populations." Sociological Methodology 41, no. 1 (August 1, 2011): 347-353.

Heckathorn, D. D. "Comment: Snowball versus respondent-driven sampling." Sociological Methodology 41, no. 1 (August 1, 2011): 355-366. [This article is available online from the National Library of Medicine.]

Handcock, M. S. and Gile, K. J. "Comment: On the concept of snowball sampling." Sociological Methodology 41, no. 1 (August 1, 2011): 367-371. [The text of this article is available online from the National Library of Medicine.]

It is worth noting that the 2017 SAGE Encyclopedia of Communication Research gives an example of research into chaplains as part of its section on Snowball Subject Recruitment, in the larger context of how a snowball approach to recruitment could apply to a purposive form of nonrandom sampling. The example refers to a researcher's interest in chaplains' perspectives on the provision of spiritual care in hospitals for ill patients. Purposefully specifying chaplains in the study sample excludes other spiritual care providers, narrowing the sample, even if still employing a snowball recruitment process. [This is principally an online publication, but see print pages 1614-1616.]



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