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May 2004 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Presbyterian, Philadelphia PA.


Flannelly, K. J., Weaver, A. J. and Handzo, G. F. [The HealthCare Chaplaincy, 307 E. 60 St., New York, NY 10022-1505;]. "A three-year study of chaplains' professional activities at Memorial Sloan-Kettering Cancer Center in New York City." Psycho-Oncology 12, no. 8 (December 2003): 760-768.


SUMMARY AND COMMENT: The theme of research into "what chaplains do" has been raised in the Newsletter pages of this site (see the Spring 2003 and Spring 2004 Newsletters), and this study by researchers at The HealthCare Chaplaincy in New York seeks to "provide an initial foundation on which to develop a process of benchmarking what interventions chaplains make for oncology patients and the frequency with which they perform them in different situations" [p. 767]. The project analyzed data collected from a total of 3570 chaplaincy visits that occurred during three two-week periods--one period each year from 1995 to 1997--at Memorial Sloan-Kettering Cancer Center in New York City. The purpose was to "to examine: 1) the distribution of chaplains' referred and non-referred visits with patients, 2) the pattern of referrals to and from chaplains, families and staff, 3) the reasons for referrals to chaplains, 4) the types of pastoral activities..., and 5) the length of chaplains' visits under various circumstances" [p. 761]. The authors' approach to the efficacy of chaplains' interventions is largely in terms of coping.

A standard form was devised by "a group of veteran, professional chaplains to capture information they thought was essential for accurately describing what a healthcare chaplain does" [p. 762]. In addition to basic data about the visit--e.g., referral source, length of visit, number of contacts, pre-op/post-op/treatment context, and some patient demographic information--there was a checklist of twelve pastoral interventions: 1) Bible reading or prayer, 2) blessing, 3) bereavement, 4) bringing a religious item, 5) crisis intervention, 6) confession/amends, 7) counseling, 8) emotional enabling, 9) faith affirmation, 10) life review, 11) religious ritual, and 12) other spiritual support. The authors comment: "While this method opens the possibility that the full characterization of activities in any given field will be lost, there was no feedback from any of the chaplains during the study indicating that they found any necessary categories missing" [p. 762]. However, as research in this area builds upon the findings of this study, further critique of the categorization of interventions would seem to be in order.

Results are well presented in nine tables that are rich with information that may be of interest to many chaplaincy programs. Items of special note to this reader were: "Nearly a fifth (19.8%) of all of the chaplains' initial contacts resulted from referrals..." [p. 762]. "Nurses made almost one quarter of all referrals and more than three quarters (82.3%) of the total from hospital staff" and "...the proportion of referrals that came from nurses increased significantly from 1995 to 1997" [p. 363]. "The most common reason chaplains were referred to patients and their families and friends was a change in diagnosis or prognosis" [p. 763, and table on p. 764]. Also, "chaplains' visits were significantly shorter pre-operatively," compared to post-operative and treatment visits [p. 766]. The mean duration of pre-operative visits with patients (alone) was 10.1 minutes (S.D. 7.5), compared to post-operative visits of 14.4 minutes (S.D. 12.2) and treatment visits of 15.0 minutes (S.D. 11.5).

Analysis of the character of actual interventions showed that chaplains were more likely to offer Bible reading and prayer and "facilitate the expression of feelings (emotional enabling)" during pre-operative visits than during post-operative or treatment visits, and the authors surmise that "chaplains clearly engage in a wider variety of interventions during post-operative and treatment visits than during pre-operative visits" [p. 764]. Among other findings: "During pastoral visits related to patients' diagnoses, chaplains appear to have engaged in more crisis intervention...and life review...than at other times. Naturally, crisis intervention appears to be used more often by response to a patient code, along with the use of faith affirmation...and emotional enabling..." [pp. 764-5].

The authors note that their study looks at a single hospital, and analysis of activity at other health care facilities is necessary before a case can be made for the generalizability of their findings. Indeed, the population of a major urban cancer-focused hospital may have distinctive characteristics, and there may be some question about how representative was the sample: the hospital's general patient population is reported to be 50% Catholic, 25% Jewish, and 15% Protestant [see p. 761], and the sample of patients studied is reported to have been 32.3% Catholic, 27.1% Jewish, and 26.0% Protestant [see p. 762]. Moreover, the study was conducted 7-9 years ago, so generalizability over time may be an additional issue. The authors also say that they "hope to take a closer look at the relationship between visit duration and specific pastoral interventions" [p. 767]. This reader found himself wondering about such relationships, in light of the findings that while pre-operative visits tended to be shorter than other types of visits, they most frequently involved the facilitation of the expression of feelings, which would seem to be a fairly time-consuming intervention. Implicit here, too, may be a question of how time constraints or freedoms may affect a chaplain's choice of interventions.

With so little research currently published on "what chaplains do" [see below, under Other Items of Interest], this work is a fine contribution to a knowledge base that needs to be expanded rapidly. It may serve as a call for other chaplaincy programs not only to compare their own activity to that revealed at Memorial Sloan-Kettering but to conduct their own assessments by rigorous scientific methodology.


Suggestions for the Use of the Article for Discussion in CPE: 

This study seems suited for discussion with CPE students relatively late in a program, when their personal experience in pastoral visitation and referral patterns may allow them some informed opinion about the findings. Of course, it may have special interest to chaplains working with cancer patients, but its appeal should not be so limited. It is well written (but unfortunately includes some typos) and does not require extensive knowledge of statistics, though the sophistication of the statistical analysis underlying the report is considerable. The study may raise consciousness in students about the content of their interventions and how they may be categorized, and this may be an especially engaging line of thought for chaplains to carry into a second year of residency or into supervisory education. The article often refers to the phenomenon of coping, and thus it may also serve as an entree to that subject.


Other Items of Interest: 

I. Three other studies, cited by Flannelly, et al. [p. 761], offering some insight into chaplaincy interventions and referrals:

Bryant, C. "Role clarification: a quality improvement survey of hospital chaplain customers." Journal of Healthcare Quality 15, no. 4 (1999): 18-20.

Gibbons, G., Retsas, A., and Pinikahana, J. "Describing what chaplains do in hospitals." Journal of Pastoral Care 54, no. 2 (1999): 210-207.

Koenig, H. G., Bearon, L. B., Hover, M., and Travis, J. L. "Religious perspectives of doctors, nurses, patients, and families." Journal of Pastoral Care 45, no. 3 (1991): 254-267.


II. Additional studies of special interest:

Rodrigues, B., Rodrigues, D., and Casey, D. L. Spiritual Needs and Chaplaincy Services: A National Empirical Study on Chaplaincy Encounters in Health Care Settings. Medford, OR: Providence Health System, 2000. xii, 76 pp. [ISBN 0-615-11110-6; available through, or contact Providence Health System, 1111 Crater Lake Ave., Medford OR 97504-6225.]

[ADDED 10/14/08]: Vanderwerker, L. C., Flannelly, K. J., Galek, K., Harding, S. R., Handzo, G. F., Oettinger, M. and Bauman, J. P. "What do chaplains really do? III. Referrals in the New York Chaplaincy Study." Journal of Health Care Chaplaincy 14, no. 1 (2008): 57-73. [Abstract: The current study examines patterns of referrals to chaplains documented in the 1994-1996 New York Chaplaincy Study. The data were collected at thirteen healthcare institutions in the Greater New York City area. Of the 38,600 usable records in the sample, 18.4% were referrals, which form the sample for the current study (N = 7,094). The most common sources of referrals were nurses (27.8%) and patients themselves (22.3%), with relatively few referrals coming from physicians and social workers. The study shows the range of patient issues that are referred to chaplains, including emotional, spiritual, medical, relationship/support, and a change in diagnosis or prognosis. Although the reasons for referral varied by hospital setting and referral source, overall, patients were referred more frequently for emotional (30.0%) than for spiritual issues (19.9%). Results are discussed in relation to the need to clarify the role of the chaplain to the rest of the healthcare team, to recognize when there is a spiritual cause of emotional distress, and to establish effective referral protocols.] NOTE: This is one of three related articles in vol. 14, no. 1 of the Journal of Health Care Chaplaincy --the other two being: Handzo, G. F., Flannelly, K. J., Kudler, T., Fogg, S. L., Harding, S. R., Hasan, Y. H., Ross, A. M. and Taylor B. E., "What do chaplains really do? II. Interventions in the New York Chaplaincy Study," (pp. 39-56) and Vanderwerker, L. C., Flannelly, K. J., Galek, K., Harding, S. R., Handzo, G. F., Oettinger, M. and Bauman, J. P., "What do chaplains really do? III. Referrals in the New York Chaplaincy Study" (pp. 57-73). For abstracts, see the Fall 2008 Newsletter (§7).


III. See also the March 2008 Article of the Month.


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