March 2009 Article of the Month
Bay, P. S., Beckman, D., Trippi, J., Gunderman, R. and Terry, C. "The effect of pastoral care services on anxiety, depression, hope, religious coping, and religious problem solving styles: a randomized controlled study." Journal of Religion and Health 47, no. 1 (2008): 57-69
SUMMARY and COMMENT: This monthís article has been chosen as an excellent model of quantitative research by a chaplain (as part of an interdisciplinary research team). It offers an unusually high degree of specificity regarding its methodology and in its explanation of a pastoral care intervention, such that other chaplains may be able both to consider the particular pastoral intervention involved and the outcomes evidenced. Within its admitted limits [--see p. 67], this study is a significant contribution to understanding some of the practical effects of pastoral care services and their possible role in connections between religion and health.
A word at the outset about the principal author, Paul S. Bay, DMin:
He is Cardiovascular Care Chaplain for Clarian Health Partners which includes Indiana University Hospital, Methodist Hospital, and Riley Hospital for Children. In addition to being a Board Certified Chaplain he is also a Clinical Member of the American Association for Marriage and Family Therapy. He is the recipient of a National Institute for Healthcare Research, John Templeton Spirituality & Medicine Award and other grants of the Religion and Spiritual Integration Values of Clarian Health. Paul currently divides his time between research and patient care through the cardiovascular interdisciplinary team and heart transplant team. [--from biographical information, p. 69]He conducted the clinical interventions for the present study, consisting of four pastoral visits with patients plus one with their family members. ("When he was not available, a trained substitute conducted the visits" [p. 62].)
The study analyzed data from 170 cardiac bypass surgery patients (out of a total sample of 485, though only 311 met inclusion criteria, and 207 were initially enrolled), with 85 randomized into the intervention group and 85 in a control group. The pastoral intervention was as follows:
The chaplain standardized each pastoral visit by listening to the patientís concerns and by asking one question focusing on a theme previously identified by the authorsÖ [listed in a table on p. 63]. In the pre-surgical visit, the chaplain provided supportive pastoral care concerning the patientsí self-acknowledged spiritual/psychological needs. The second visit was a family support visit during the patientís surgery. The third visit, usually on the second or third day after the surgery, helped patients identify and discuss their hopes. The fourth visit aided the patients in thinking about a positive personal future by using their religious and psychological resources. The fifth visit focused on feelings of grief related to the limitations imposed by the disease and previous personal loses. These five visits constituted a mean of 44 minutes with each patient/family. [p. 62 (and see also p. 60 for a related description)]The effect of the intervention was measured by a battery of questionnaires (i.e., the Hospital Anxiety and Depression Scale, the Herth Hope Index, the Brief RCOPE, and the Religious Problem Solving Scale) administered prior to surgery and at one and six months after surgery. Data was also gathered regarding each patientís "post-surgical length of stay in the hospital, the number of unscheduled physician office visits after the surgery, whether the patient was readmitted to the hospital, and the cost of the hospitalization" [p. 62]. The researchers "hypothesized that the provision of pastoral care services to cardiac bypass patients would cause significant changes in selected affective responses to the disease and surgery (anxiety, depressive symptoms, and hope), cause changes in religious coping processes, and influence the medical course of recovery" [p. 60].
a marginally significant difference in the positive religious coping scores between groups over time (p = .081), however, there was a significant difference in the positive religious coping scores between groups at the 6 months time point (p = .026). Similarly, there was a marginally significant difference in the change in negative religious coping scores between groups over time (p = .056), and a significant difference in negative religious coping scores between groups at the 6 months time point (p = .021). Positive religious coping decreased over time in the control group and increased in the intervention group. Negative religious coping increased over time in the control group and decreased in the intervention group.... [pp. 64-65]No significant differences were detected for the other factors measured, and the authors address these results in detail [--see pp. 65-67]. They conclude that in retrospect their hypotheses that the pastoral intervention would affect anxiety, depression, or hope were not supported by the literature and were therefore not well grounded in the first place [--see p. 67].
The significance of the results concerning coping are summed up:
In the literature, increased positive religious coping is associated with fewer symptoms of psychological stress...and better mental health.... Negative religious coping is tied to depression, poorer quality of life and psychological symptoms.... This suggests that pastoral care services, as defined and delivered in this project, improve the patientsí emotional/spiritual adjustment to the surgery. In contrast, those who received no pastoral care services from the chaplain demonstrate religious coping that is linked to more problematic adjustments.
For this reader, it is important that the study supports a link between a pastoral intervention and positive/negative coping, but it is even more important -- for future research -- that the authors have so clearly lined out their methodology (including the pastoral intervention) and thoroughly explain their thinking. In the background of all research into chaplaincy interventions is the question of what a chaplain actually does or can do. Here, we have an example of a specific intervention that can now be debated in pastoral care circles, replicated, or modified, all in light of rigorously obtained data. For future research, the study bolsters the prospects for using the popular Brief RCOPE, and it serves to pose a challenge of determining whether the effects pastoral care in such areas as anxiety, depression, and hope may yet be captured but by a different methodology.
Suggestions for the Use of the Article for Discussion in CPE:
This is an exceptionally well-written article that should be accessible to CPE students, in addition to staff chaplains and researchers. All elements of its structure are clearly developed and explicated, from the authorís thinking behind the choice of topic and methodology to the explanation of results. Students new to research have here an illustration of the process of doing research, including ethical issues involved. Therefore, this article would seem to be a good choice for engaging students in a discussion of research as an activity. And, while it is far too elaborate a study for students to replicate, it may be a model of the elements of research that have a place in any good study. Regarding the particulars of this study, students may wish to discuss the pastoral intervention used, comparing that to whatever form or strategy they presently use. The menu of questions to be asked by the chaplain in the study (--see Table 2, p. 63) implicitly raises the issue of the role of questions in pastoral visitation. Also, the article opens up the subject of religious coping, and students may want to think about this as a concept and as a focus for pastoral assessment. Note that the fourteen items of the Brief RCOPE are listed in Table 1 on p. 62 (though the table refers to the measure as the Short RCOPE).
Related Items of Interest:
I. For a thorough exposition of the RCOPE measure, from which the Brief RCOPE is derived, see: Pargament, K. I., Koenig, H. G. and Perez, L. M., "The many methods of religious coping: development and initial validation of the RCOPE," Journal of Clinical Psychology 56, no. 4 (August 13-27, 2001): 519-543. For another Article-of-the-Month that employed the Brief RCOPE, see: November 2004: Fitchett, G., Murphy, P. E., Kim, J., Gibbons, J. L., Cameron, J. R. and Davis, J. A., "Religious struggle: prevalence, correlates and mental health risks in diabetic, congestive heart failure, and oncology patients," International Journal of Psychiatry in Medicine 34, no. 2 (2004): 179-196, which also delves generally into the subject of religious coping. For a very brief introduction to religious coping, see Pargament, K. I. and Ano, G. G., "Spiritual resources and struggles in coping with medical illness," Southern Medical Journal 99, no. 10 (October 2006): 1161-1162.
II. For another recent article piloting a spiritual intervention with a cardiac population -- a music and guided imagery intervention not dependent upon chaplains or conducted in relation to surgery -- see the August 2008 Article-of-the-Month: Delaney, C. and Barrere, C., "Blessings: the influence of a spirituality-based intervention on psychospiritual outcomes in a cardiac population," Holistic Nursing Practice 22, no. 4 (July/August 2008): 210-219.
III. Note especially the small study cited in this month's featured article (on pp. 59-60) as a rare example of a clinical trial examining pastoral services: Iler, W. M., Obenshain, D. and Camac, M., "The impact of daily visits from chaplains on patients with chronic obstructive pulmonary disease (COPD): a pilot study," Chaplaincy Today 17, no. 1 (2001): 5-9.
IV. For a classic study using an intervention by chaplains, see: Florell, J. L., "Crisis-intervention in orthopedic surgery: empirical evidence of the effectiveness of a chaplain working with surgery patients," Bulletin of the American Protestant Hospital Association 37, no. 2 (1973): 29-36; reprinted in VandeCreek, L., ed., "Spiritual Needs and Pastoral Services: Readings in Research (Journal of Pastoral Care Publications, Inc., 1995): 23-32. The intervention was based upon the "primary stance of the chaplain" [p. 24 in VandeCreek], focusing on patients' feelings and anxieties, and it was augmented by an intervention that provided patients with practical information about hospitalization. The intervention was shown to influence patients' anxiety, use of pain medication, calls for the nurse, and length of stay. Also, in relation to patients in a control group, those patients receiving the intervention showed higher pre-operative anxiety but lower post-operative anxiety.
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