June 2017 Article of the Month
This month's article selection is highlighted by John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Cunningham, C. J. L., Panda, M., Lambert, J., Daniel, G. and DeMars, K. "Perceptions of chaplains' value and impact within hospital care teams." Journal of Religion & Health 56, no. 4 (August 2017): 1231-1247.
SUMMARY and COMMENT: This month's study, out of the University of Tennessee at Chattanooga and its College of Medicine, addresses a debate in some quarters of health care about the "level of reach and integration a chaplain should have within a hospital setting" [p. 1243] and the potential need for clarification of the "expansive role of pastoral care programs may take" [p. 1233]. One concern along these lines is that without "clarity regarding where the role of hospital chaplain should start and end," there is a risk that "...other members of the healthcare team, or a patient or his/her family members...[may] hold inaccurate perceptions..." [p. 1233]. The authors write: "Our primary objective with this study was to shed additional light on several issues associated with this debate" [p. 1243] and "...to explore the following research questions and expand the ways in which those involved with hospital-based pastoral care programs think about and manage the value and impact of chaplains in these environments" [p. 1233].
"We believe our findings ultimately support a more integrated and complete involvement of chaplains in the patient care process" [p. 1243].
- Research Question 1: Can all patients--even those who do not exhibit strong religious or spiritual views--benefit from spiritual care offered by a chaplain?
- Research Question 2: What are the implications of allowing chaplains full access to patient medical records?
- Research Question 3: What characteristics of chaplains and their interactions with patients have a strong impact on patient reactions to pastoral care?
After a quite full introductory section [see pp. 1231-1236], the authors explain well their process for this mixed-method study.
Between October 2014 and April 2016, data were gathered from samples of medical students (n = 169), residents (n = 80), and currently hospitalized patients (n = 225) who had recently (i.e., within the last 10 days) interacted with a hospital chaplain while working or staying in a teaching hospital in the southeastern USA. In-depth focus groups were also conducted with 17 upper year medical students and residents (all of whom also had an opportunity to complete the medical student and resident survey), in which the challenges and benefits of working alongside Chaplains in a hospital setting were discussed. All medical students, residents, and patients with possible contact with the two hospital chaplains during the time frame for this study were recruited to participate. The two full-time chaplains involved in this study had the education and training needed to provide religious/spiritual support in a hospital environment. Both chaplains were board-certified and adhered to the Common Standards for Professional Chaplaincy..." [pp. 1236-1237].
They further describe the two chaplains' patient assignments and documentation practice, plus their interaction with the medical students and residents in making referrals and in facilitating weekday multidisciplinary team rounds "to discuss patient care, to develop a treatment plan, and to establish a continuity of care at point of discharge" [p. 1237; also, see below for special comments to the Research Network from the two involved chaplains].
Among their findings:
Pertaining to Research Question 1: "At the highest level, irrespective of individual patients' religious/spiritual beliefs, there is evidence that patients found their interactions with hospital chaplains to be extremely positive" [p. 1238]. The data showed that "...79.4% of the interviewed hospitalized patients reported wanting to receive regular visits from chaplains," and "...[a]cross the entire sample of patients, the general impression of visit[s] with chaplains was that they were valuable and could not be improved aside from involving more time and opportunity for prayer" [p. 1238]. "...[E]ven patients (a) not wanting regular visits with chaplains or (b) not indicating that religion/spirituality played a significant role in their daily lives reported their interactions with chaplains to be generally helpful and supportive of an improved care and healing experience" [p. 1240]. While the authors note some data indicating variation in patient responses, they characterize the positive reaction to chaplains as "fairly consistent" [p. 1240]. The sample, though, is said to "best represent a population of patients who have fairly strong personal religious/spiritual beliefs and traditions" [p. 1238].
Exploring Research Question 2, the authors investigated attitudes of providers toward the full inclusion of chaplains in Inpatient Ward Teams (IWTs). When asked, "Do you agree/disagree that chaplains are a valuable team member when treating patients in a hospital setting?" a total of "87.57% of medical students and 93.1% of residents agreed (and <0.6% of either group disagreed)" [p. 1240]. Focus groups with these medical students and residents further indicated that "chaplains play a tremendously important role as go-betweens with family and loved ones, and also as a source of alternative, valuable perspective during interdisciplinary rounds" [p. 1240]. These focus groups also raised comments of how "...working alongside chaplains had...expanded some physicians' perspectives on the complexities of patients' lives (i.e., the patients are more than just a set of identifiable symptoms), and that "...medical students and residents understand the emotional and supportive value that chaplains offer, particularly when physicians have to deal with death, grief, and traumatic care situations" [p. 1241]. In sum, the data from providers evidenced that "the inclusion of chaplains into actual IWTs made regular and meaningful contact with chaplains more possible," and the authors state: "To our knowledge, this study provides some of the first data from the perspective of healthcare professionals (i.e., physicians and medical students) for the perceived value and utility of including chaplains as contributing members of IWTs with access to patient medical records." [pp. 1243-1244].
Finally, regarding Research Question 3, "focus group respondents clearly noted that chaplains demonstrated a high degree of empathy, authenticity and genuineness, and compassion in a more personal way than most medical doctors tend to do," and they also noted "...that it may not be beneficial to the patient for physicians to act with the same form of compassion as chaplains, thus again supporting the complementary role of chaplains as members of hospital care teams" [p. 1242]. As for the perspective of patients, interviews yielded appreciation especially for chaplains' spiritual support, availability/time spent, and compassion and empathy [--see a table of full responses on p. 1242]. Tables throughout the article provide helpful details about the results.
This study was conducted in a setting where there were two "well-trained and board-certified chaplains, working as part of a formally recognized hospital pastoral care program, and formally embedded within the IWTs during rounds and day-to-day patient care" [p. 1244]. The authors hold this up as a model: "...the consistent pattern of positive findings associated with chaplain involvement clearly indicates that what is being done in this particular hospital setting is working" [p. 1244]. They continue: "We hope that other hospitals will consider adopting a similar form of embedded chaplain program, perhaps borrowing from the methodological details we have shared about how chaplains in this study were linked to IWTs and able to enter regular SA [Spiritual Assessment] information into existing patient electronic records" [p. 1244].
While the authors start out from a place of rather polemical debate about what the role of chaplains should be, and then go on the offer clarifying insights from research suggesting that this role is "broad and essential" [p. 1245]; one of their most emphatic conclusions focuses on the "need...for clearer and more regular communication among physicians, patients, and patients' families regarding the role that hospital chaplains are trained and enabled to play within the hospital system" [p. 1244, italics added]. Indeed, "[m]ultiple responses from patients and physicians indicated that the services offered by chaplains are valuable, but that there was not a complete awareness of what these services might be" [p. 1244].
Chaplains -- like this present reader -- may experience the very debate over our role in hospitals perturbing, but that is likely because we know our own role so well. The research questions investigated here are largely already settled in many chaplains' minds, however, the concrete data may speak significantly to many others in health care. Perhaps one take-away from the present study is the importance of seeking out the questions that our health care colleagues outside of chaplaincy have about our discipline. Then, we might become better research partners with an "empirical and critical eye focused on ways in which chaplains can be most effectively utilized to improve the overall quality of patient care and resilience of other healthcare team members within hospital environments" [p. 1245].
Special Comments to the Research Network from Co-Authors Jeremy S. Lambert and Gregory Daniel, Chaplains with the Erlanger Health System (Chattanooga, TN):
[Editor's Note: Chaplains Lambert and Daniel are the two whose pastoral activity was a key element of the present study.]
From Chaplain Jeremy S. Lambert:
Without a doubt, this has been by far one of the greatest experiences in my professional career. Though my formal education, seminary training, and CPE training were all monumental in my personal and professional development; the work in creating, facilitating, and establishing this educational program for the internal medical residents challenged and stretched my understanding of outcomes-based pastoral care in ways that no other program or book could have prepared me for. Bottom line: this was hard. It was as though I was blazing a trail the entire time.
For me, the more difficult task of the project was getting buy-in from the internal medicine attendings and residents. Our program was three-fold; 1) develop and facilitate a curriculum that integrates spirituality in medicine, 2) join the medical residents as they round on our patients, and 3) develop and facilitate a multidisciplinary team meeting to better tailor a treatment plan for our patients. Because it was not the norm here in our hospital to incorporate chaplains as faculty with medical education, it was challenging to round with the physicians-in-training. However, consistently rounding with the physicians-in-training normalized rounding and improved our understanding of each other's language. Physicians-in-training began to initiate casual conversations with us and in some cases sought us out for personal counseling and debriefing. The number of referrals increased within just weeks of working closely together. They also began to have a markedly fuller understanding of the services we offered and of the additional means by which we were able to help them with patients and their families while also aiding them to creating a much-tailored treatment plan for the patient.
This program was not easy getting off the ground but has proven to be valuable in many ways to all involved. At the beginning of every academic year these challenges start over again. However, we have more support in our efforts. Interestingly, this support comes from the physicians-in-training from the previous program year. This program is doable and can be disseminated to other institutions. Thankfully, CPE helped me to see beyond my narrow view of ministry, to see opportunities to offer care to others, and from there I now understand how our care for others improves the institutions themselves. --J.S.L.
From Chaplain Daniel Gregory:
Having not conducted formal research in a clinical setting before, I faced the task of this research project with a degree of trepidation. I didn't even know where to begin! With direction and coaching from other team members (especially, Dr. Panda), I began to grasp the process more and more. I became acquainted with literature reviews, abstracts, the Internal Review Board process, the development of the methodology, consent forms, etc. Having great people with which to work made the learning curve manageable and the project enjoyable. In retrospect, conducting the research was much like any other project: break it into smaller sections and complete each section until it's done. At first I found the experience almost overwhelming, then challenging and finally extremely rewarding. I am very glad and thankful to have been part of this work. --G.D.
Suggestions for Use of the Article for Student Discussion:
This month's article might be most interesting to CPE students who have already developed a fair sense of their role in the hospital. Discussion could begin with a question of their understanding of that role and how clear they believe it to be to care team members from other disciplines. Do they believe that the chaplain's role needs greater definition? What do they think about the article's three central research questions? These questions play against a background debate described in the article's extended introductory section [see pp. 1231-1236]. What is their reaction to such a debate? The three research questions could be taken in turn to guide the group's consideration of findings, or the students could be asked broadly how the study seems to support the place and value of chaplaincy. Where do they see similarities and differences in the ways that physicians and patients/families may appreciate them? How might chaplains ourselves help others understand what we do? The article emphasizes the qualifications of the two chaplains involved with the study. How might this encourage students to think about professionalism in chaplaincy? Finally, beyond the article itself, the two chaplains who are co-authors here have offered quite personal comments about their experience with research [--see the box, above], and some discussion could attend to those thoughts on involvement with formal research.
Related Items of Interest:
I. For a broad review of the role of chaplains by an international group of authors, see:
Timmins, F., Caldeira, S., Murphy, M., Pujol, N., Sheaf, G., Weathers, E., Whelan, J. and Flanagan, B. "The role of the healthcare chaplain: a literature review." Journal of Health Care Chaplaincy published online ahead-of-print by the journal, June 21, 2017. [(Abstract:) Healthcare chaplains operate in many healthcare sites internationally and yet their contribution is not always clearly understood by medical and healthcare staff. This review aims to explore the chaplains' role in healthcare, with a view to informing best practice in future healthcare chaplaincy. Overall the extent of the provision and staffing of chaplaincy service internationally is unclear. From this review, several key spiritual and pastoral roles in healthcare emerge including a potential contribution to ethical decision making at the end of life. Healthcare chaplains are key personnel, already employed in many healthcare organizations, who are in a pivotal position to contribute to future developments of faith-based care, faith-sensitive pastoral, and spiritual care provision. They also have a new and evolving role in ethical support of patient, families and healthcare teams.]
II. For more on chaplains' access to medical records, see our November 2011 Article-of-the-Month. In addition, regarding documentation, see the following recent studies:
Johnson, R., Wirpsa, M. J., Boyken, L., Sakumoto, M., Handzo, G., Kho, A. and Emanuel, L. "Communicating chaplains' care: narrative documentation in a neuroscience-spine Intensive Care Unit." Journal of Health Care Chaplaincy 22, no. 4 (Oct-Dec 2016): 133-150. [(Abstract:) Chaplaincy care is different for every patient; a growing challenge is to ensure that electronic health records function to support personalized care. While ICU health care teams have advanced clinical practice guidelines to identify and integrate relevant aspects of the patient's story into whole person care, recommendations for documentation are rare. This qualitative study of over 400 free-text EHR notes offers unique insight into current use of free-text documentation in ICU by six chaplains integrated into the healthcare team. Our research provides insight into the phenomena chaplains record in the electronic record. Content analysis shows recurrent report of patient and family practices, beliefs, coping mechanisms, concerns, emotional resources and needs, family and faith support, medical decision making and medical communications. These findings are important for health care team discussions of factors deemed essential to whole person care in ICUs, and, by extension have the potential to support the development of EHR designs that aim to advance personalized care.]
Lee, B. M., Curlin, F. A. and Choi, P. J.
"Documenting presence: a descriptive study of chaplain notes in the intensive care unit." Palliative and Supportive Care 15, no. 2 (April 2017): 190-196. [(Abstract:) OBJECTIVE: To clarify and record their role in the care of patients, hospital chaplains are increasingly called on to document their work in the medical record. Chaplains' documentation, however, varies widely, even within single institutions. Little has been known, however, about the forms that documentation takes in different settings or about how clinicians interpret chaplain documentation. This study aims to examine how chaplains record their encounters in an intensive care unit (ICU). METHOD: We performed a retrospective chart review of the chaplain notes filed on patients in the adult ICUs at a major academic medical center over a six-month period. We used an iterative process of qualitative textual analysis to code and analyze chaplains' free-text entries for emergent themes. RESULTS: Four primary themes emerged from chaplain documentation. First, chaplains frequently used "code language," such as "compassionate presence," to recapitulate interventions already documented elsewhere in a checklist of ministry interventions. Second, chaplains typically described what they observed rather than interpreting its clinical significance. Third, chaplains indicated passive follow-up plans, waiting for patients or family members to request further interaction. Fourth, chaplains sometimes provided insights into particular relationship dynamics. SIGNIFICANCE OF RESULTS: As members of the patient care team, chaplains access the medical record to communicate clinically relevant information. The present study suggests that recent emphasis on evidence-based practice may be leading chaplains, at least in the medical center we studied, to use a reduced, mechanical language insufficient for illuminating patients' individual stories. We hope that our study will promote further consideration of how chaplain documentation can enhance patient care and convey the unique value that chaplains add to the clinical team.] [This was featured as our October 2016 Article-of-the-Month.]
Tartaglia, A., Dodd-McCue, D., Ford, T., Demm, C. and Hassell, A. "Chaplain documentation and the electronic medical record: a survey of ACPE residency programs." Journal of Health Care Chaplaincy 22, no. 2 (2016): 41-53. [(Abstract:) This study explores the extent to which chaplaincy departments at ACPE-accredited residency programs make use of the electronic medical record (EMR) for documentation and training. Survey data solicited from 219 programs with a 45% response rate and interview findings from 11 centers demonstrate a high level of usage of the EMR as well as an expectation that CPE residents document each patient/family encounter. Centers provided considerable initial training, but less ongoing monitoring of chaplain documentation. Centers used multiple sources to develop documentation tools for the EMR. One center was verified as having created the spiritual assessment component of the documentation tool from a peer reviewed published model. Interviews found intermittent use of the student chart notes for educational purposes. One center verified a structured manner of monitoring chart notes as a performance improvement activity. Findings suggested potential for the development of a standard documentation tool for chaplain charting and training.]
III. A table on p. 1242 of our featured article gives patients' responses to the question, "What was the most helpful or encouraging part of your interactions with chaplains?" In light of these responses, see our March 2008 Article-of-the-Month, regarding patients' expectations of chaplains.
IV. For more on chaplains as part of the medical team, see our December 2015 and November 2015 Article-of-the-Month pages. Also, see the following study regarding chaplain residents:
Jackson-Jordan, E., Stafford, C., Stratton, S, V., Vilagos, T. T., Janssen Keenan, A. and Hathaway, G. "Evaluation of a chaplain residency program and its partnership with an in-patient palliative care team." Journal of Health Care Chaplaincy (2017): 10pp., published online May 23, 2017, ahead of print. [(Abstract:) In 2009 a Consensus Conference of experts in the field of spiritual care and palliative care recommended the inclusion of Board-certified professional chaplains with at least 1,600 hours of clinical pastoral education as members of palliative care teams. This study evaluates a clinical pastoral education residency program's effectiveness in preparing persons to provide spiritual care for those with serious illness and in increasing the palliative care team members' understanding of the chaplain as part of the palliative care team. Results showed chaplain residents felt the program prepared them to provide care for those with serious illness. It also showed that chaplain residents and palliative care team members view spirituality as an integral part of palliative care and see the chaplain as the team member to lead that effort. Suggested program improvements include longer palliative care orientation period, more shadowing with palliative care team members, and improved communication between palliative care and the chaplain residents.]
V. For a description of the potential in a chaplain's expanded role with a care team, see the following study of a palliative care chaplain's work:
Kearney, G., Fischer, L. and Groninger, H. "Integrating spiritual care into palliative consultation: a case study in expanded practice." Journal of Religion and Health (2017): published online May 26, 2017, ahead of print. [(Abstract:) Recognizing and addressing spiritual needs has long been identified as a key component of palliative care (PC). More often than not, the provision of spiritual care involves referral to a hospital chaplain. In this study, we aim to describe the role of a PC chaplain embedded within the interdisciplinary PC team and demonstrate how this palliative chaplain role differs from that of a traditional hospital chaplain. We postulate that integrating spiritual care provision into a PC team may offer a broader spiritual care experience for patients receiving PC and begin to delineate expanded clinical roles for the palliative chaplain.]
VI. For more on physicians' views of chaplains, see our July 2011 Article-of-the-Month. And, regarding physicians personal perspective on their own work, see our May 2017 Article-of-the-Month on the "inner life" of family medicine residents.
VII. This month's study was supported in part by a 2014 grant from the Arnold P. Gold Foundation: "Transforming the Culture of Medical Education: Integrating Staff Chaplains into an Internal Medicine Training Program," which "aim[ed] to demonstrate that the integration of chaplains into the internal medicine program teaches medical students and residents to be more humanistic in their practice of medicine." The Foundation's website (www.gold-foundation.org) may be of interest to chaplains, especially for its section on Resources, which includes link to research about the value of humanism in health care and to the Literature Arts Medicine Database -- a collection of literature, fine art, visual art and performing art annotations relevant to the medical humanities, curated by the NYU School of Medicine.