June 2017 Article of the Month
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].
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].
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 more on chaplains' access to medical records, see our November 2011 Article-of-the-Month. In addition, regarding documentation, see the following recent studies:
II. 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 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:
V. 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.
VI. 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.
If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at firstname.lastname@example.org