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May 2014 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Van Voorhees, E. E., Hamlett-Berry, K., Christofferson, D. E., Beckham, J.C. and Nieuwsma, J. A. "No wrong door to smoking cessation care: a Veterans Affairs chaplain survey." Military Medicine 179, no. 5 (May 2014): 472-476.


SUMMARY and COMMENT: This month's article presents a survey of Veterans Affairs chaplains about a very specific question, but it implicitly raises larger issues about the scope of chaplains' services and chaplains' attitudes toward duties not commonly associated with a religious role. It also explicitly finds that Clinical Pastoral Education may have an effect on chaplains' attitudes toward their work in this regard.

The impetus for this research was the Veterans Affairs/Department of Defense Integrated Mental Health Strategy (IMHS) [--see Related Items of Interest, section I (below)], which involved a component "to understand the role chaplains play in addressing the mental health needs of veterans and service members," including an investigation of "the potential for collaboration among mental health professionals and chaplains" [p. 472]. The authors note at the outset that VA/DoD chaplains have reported that "they encounter mental health issues with even greater frequency than spiritual problems" and that chaplains are known to be "an important resource in the domain of substance abuse," so in this light the particular issue examined here is "whether VA chaplains would be interested and willing to be involved in smoking cessation efforts within VA" [p. 472].

A total of 321 full-time VA chaplains participated in an online Tobacco Survey that was a supplemental option to a larger web-based Chaplains Survey [--see Related Items of Interest, section II (below)]. The Tobacco Survey consisted of ten items: six addressing chaplains' comfort with "interactions involving discussions of tobacco use, readiness to quit smoking, and making a quit attempt," and four pertaining to "providing information about specific forms of smoking cessation treatment options" [p. 473; the questionnaire is given as an appendix on p. 476]. Overall responses to the questions are well illustrated in two stacked bar graphs [--see p. 474].

Among the results:

In general, survey results suggested that the majority of VA chaplains (over 80%) felt that they would feel either somewhat or very comfortable providing information about smoking cessation treatment options. Specifically, 79.5% of chaplains who responded to the survey reported that they would feel "somewhat" or "very comfortable" asking clients about their tobacco use, and 84.5% said they would feel "somewhat" or "very comfortable" acting as a source of social support during a quit attempt. Greater familiarity and interaction with mental health professionals and [use of mental health] techniques by chaplains was associated with a higher level of comfort engaging in smoking cessation-related activities with veterans. Chaplains reported a somewhat lower level of comfort engaging in the delivery of smoking cessation treatment…. [p. 475]
Also, of special interest is a finding that "VA chaplains’ comfort engaging in smoking cessation activities was…inversely associated with training in CPE..." [pp. 474-475]. On this point, the authors speculate: "It may be that chaplains who have been involved with CPE that emphasize[s] a nonjudgmental stance may be less comfortable with more directive approaches taken by health care providers" [p. 475]. Of the sample surveyed here, 74% had some CPE training [--see p. 473].

This project was developed in the "spirit of 'no wrong door' to care within the VA" and with the idea that "chaplains may be powerful yet underutilized agents of change in the efforts to address the devastating health problems associated with smoking among veterans" [p. 472]. The Tobacco Survey thus offers valuable practical data to the VA and shows the potential for chaplains' collaboration in memtal health. However, what insights and questions might this research offer for other chaplains and researchers? How comfortable might chaplains in other settings and contexts feel about utilizing their interactions with patients/clients to ask and advise them about a health-related behavior, assess the readiness of the person to change behavior and assist them to change behavior whether or not they are immediately ready [--using language from the Tobacco Survey, p. 476]? Would other chaplains feel more comfortable in taking the initiative only to provide information important to health issues? How might so broadening the scope of services by chaplains better serve those with whom we work or, to the contrary, have the effect of complicating or hindering our focus of care? What sorts of duties are chaplains asked to do outside of those traditionally and commonly associated with our role? How differently do chaplains tend to draw boundaries on the scope of services according to the institutional setting?

Van Voorhees and her colleagues encourage further research especially regarding "how chaplains’ own choices, beliefs, and behaviors related to tobacco use affect their comfort level in engaging their patients in smoking cessation-related care" [p. 475].


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

This is a brief and straightforward report of research that should be engaging for chaplaincy students generally, though it would obviously have special appeal for VA chaplains and those interested in tobacco issues. A pole of the CPE group using a few of the questions from the Tobacco Survey [p. 476] might open up discussion. Is the group in sync with the general findings of this research? What is their sense of the pros and cons of a chaplain talking about smoking cessation with a patient? How closely aligned do the students feel with the mental health providers at their institution? Do they see potential for collaboration? The article's authors say about chaplains and mental health professionals: "Though each take a different perspective and utilize different approaches, both routinely deal with veterans at crossroads in their lives when the opportunity for positive, health-oriented behavior change is great" [p. 475]. Replacing the word veterans in that sentence with the general term patients, what do students think about the basic principle being put forward here? If a patient asked a chaplain for guidance about a health subject like smoking, what sort of response do the students believe they'd give?


Related Items of Interest:

I. For more on the IMHS and VA/DoD initiatives, see "VA/DoD lead the way in integrating chaplains into mental health care," in the Winter 2013-2014 online issue of Research Currents: Research News from the U.S. Department of Veterans Affairs. [Note: While our featured article references the "Integrated Mental Health Care Strategy" on p. 472, the word care is not part of other references on pp. 473 and 475 and does not appear in VA/DoD documents.]


II. For a report from the larger Chaplains Survey, of which the Tobacco Survey was a supplemental option for participants, see:

Nieuwsma, J. A., Rhodes, J. E., Jackson, G. L., Cantrell, W. C., Lane, M. E., Bates, M. J., Dekraai, M. B., Bulling, D. J., Ethridge, K., Drescher, K. D., Fitchett, G., Tenhula, W. N., Milstein, G., Bray, R. M. and Meador, K .G. "Chaplaincy and mental health in the Department of Veterans Affairs and Department of Defense." Journal of Health Care Chaplaincy 19, no. 1 (2013): 3-21. [(Abstract:) Chaplains play important roles in caring for Veterans and Service members with mental health problems. As part of the Department of Veterans Affairs (VA) and Department of Defense (DoD) Integrated Mental Health Strategy, we used a sequential approach to examining intersections between chaplaincy and mental health by gathering and building upon: 1) input from key subject matter experts; 2) quantitative data from the VA / DoD Chaplain Survey (N = 2,163; response rate of 75% in VA and 60% in DoD); and 3) qualitative data from site visits to 33 VA and DoD facilities. Findings indicate that chaplains are extensively involved in caring for individuals with mental health problems, yet integration between mental health and chaplaincy is frequently limited due to difficulties between the disciplines in establishing familiarity and trust. We present recommendations for improving integration of services, and we suggest key domains for future research.] [This article is available online University of Nebraska Public Policy Center and the APC.]

[The Nieuwsma, J. A., et al. article is preceded in the issue by an editorial: Flannelly, K. J., "Mental health and chaplaincy in the U.S. Veterans Affairs and Defense Departments." Journal of Health Care Chaplaincy 19, no. 1 (2013): 1-2.]


III. For more especially on collaboration between VA chaplains and mental health professionals, see:

Bulling, D., DeKraai, M., Abdel-Monem, T., Nieuwsma, J. A., Cantrell, W. C., Ethridge, K. and Meador, K. "Confidentiality and mental health/chaplaincy collaboration." Military Psychology 25, no. 6 (November 2013): 557-567. [(Abstract:) Confidentiality can both facilitate and inhibit working relationships of chaplains and mental health professionals addressing the needs of service members and veterans in the United States. Researchers conducted this study to examine opportunities for improving integration of care within the Department of Defense (DoD) and Department of Veterans Affairs (VA). Interviews were conducted with 198 chaplains and 201 mental health professionals in 33 DoD and VA facilities. Using a blended qualitative research approach, researchers identified several themes from the interviews, including recognition that integration can improve services; chaplaincy confidentiality can facilitate help seeking behavior; and mental health and chaplain confidentiality can inhibit information sharing and active participation on interdisciplinary teams. Cross-disciplinary training on confidentiality requirements and developing policies for sharing information across disciplines is recommended to address barriers to integrated service delivery.]


IV. For other articles regarding VA chaplains, see:

Beder, J. and Yan, G. W. "VHA Chaplains: challenges, roles, rewards, and frustrations of the work." Journal of Health Care Chaplaincy 19, no. 2 (2013): 54-65. [(Abstract:) Chaplains working in the Veterans Health Administration have numerous roles and challenges. They work closely with other behavioral health professionals, especially social workers, to address the multiplicity of needs of the Veteran population. They are essentially an understudied subset of the military Chaplaincy service (most studies focus on those engaged in combat areas). In this exploratory qualitative study, VHA Chaplains responded to a survey to determine how they defined their role and professional challenges, what they felt were the rewards and frustrations of their work and their unique function within the VHA system. Findings showed that role differences between Chaplains and social workers and other behavioral health providers are clearly defined; rewards and challenges were diverse and frustrations were common to those working in a bureaucratic structure.]

Chang, B. H., Stein, N. R., Trevino, K., Stewart, M., Hendricks, A. and Skarf, L. M. "End-of-life spiritual care at a VA medical center: chaplains' perspectives." Palliative and Supportive Care 10, no. 4 (December 2012): 273-278. [(Abstract:) OBJECTIVE: Spiritual care is an essential component of quality palliative care. Recognizing the importance, the Department of Veterans Affairs (VA) mandates the inclusion of chaplains in a palliative care consult team (PCCT). The purpose of this study is to explain the process and content of spiritual care provided in a VA Medical Center from chaplains' perspectives. METHOD: Five Christian chaplains who provide care to patients at end of life were interviewed. Each interview was recorded and transcribed. Analysis based on the grounded theory was used to identify themes from each interview question. RESULTS: The PCCT in this study appeared to have a strong referral and communication system in which every palliative care patient was seen by a chaplain and the care plan was discussed with an interdisciplinary team. Chaplains reported providing a range of services, which addressed religious, spiritual, emotional, family, and illness concerns. Chaplains were aware of the unique spiritual needs of veterans, including working through guilt for killing in war and requiring forgiveness. Chaplains' ideas for improvement of spiritual care services included increasing time to provide care, providing bereavement care and support to families, and adding chaplains with different religious backgrounds. Chaplains reported how their own spirituality influenced the care they provided. SIGNIFICANCE OF RESULTS: Spiritual care in the VA can include a range of services and should consider the unique needs of the veteran population. Future studies can build upon our findings from chaplains to learn about the perspectives of patients, family, and other healthcare providers of spiritual care. This information would allow identification of strengths of current spiritual care practices and areas for care improvement, and ultimately could improve the well-being of patients at the end of life.]

Chang, B. H., Stein, N. R., Trevino, K., Stewart, M., Hendricks, A. and Skarf, L. M. "Spiritual needs and spiritual care for veterans at end of life and their families." American Journal of Hospice and Palliative Medicine 29, no. 8 (December 2012): 610-617. [(Abstract:) Spiritual care is an important domain of palliative care programs across the country and in the Veterans Affairs (VA) Healthcare System specifically. This qualitative study assessed the spiritual needs, spiritual care received, and satisfaction with spiritual care of both Veterans at the end of life and their families. Seventeen Veterans and 9 family members participated. They expressed a wide range of spiritual needs, including a wish of Veterans to have a better understanding of traumatic events that occurred during their combat experience. Some Veterans reported military experience enhanced their spirituality. Generally, respondents reported satisfaction with VA spiritual care, but indicated that Veterans may benefit from greater access to VA chaplains and explicit discussion of the impact of their military experience on their spirituality.]

Fletcher, C. E., Ronis, D. L., Hetzel, J. M. and Lowery, J. C. "A quick measure to guide allocation of chaplains' time with hospitalized veterans." Journal of Pastoral Care and Counseling 64, no. 4 (2010): 3.1-8 [electronic journal article designation]. [(Abstract:) Assessing veterans' desire to see a chaplain can be difficult. Due to alleged personal weakness associated with seeing a chaplain while on active duty, veterans may still be reluctant to admit a need. Additionally chaplains may be challenged with multiple time demands. We devised and correlated with known instruments a single item containing four graded responses. One correlation was strong, suggesting the question's potential for serving as a useful tool for allocation of chaplains' time.]

Kopacz, M. S. "Providing pastoral care services in a clinical setting to veterans at-risk of suicide." Journal of Religion and Health 52, no. 3 (September 2013): 759-767. [(Abstract:) The value of enhanced spiritual wellbeing has largely been overlooked as part of suicide prevention efforts in Veterans. The aim of this qualitative study is to examine the clinical pastoral care services provided by VA Chaplains to Veterans at-risk of suicide. This study was conducted using in-depth interviews with five Chaplains affiliated with a medical center located in upstate New York. This study was able to show that some at-risk individuals do actively seek out pastoral care, demonstrating a demand for such services. In conclusion, a pastoral care framework may already exist in some clinical settings, giving at-risk Veterans the opportunity to access spiritual care.]

Rosell, T. D. "Pastoral products or pastoral care? How marketplace language affects ministry in Veterans Hospitals." Journal of Pastoral Care and Counseling 60, no. 4 (2006): 363-367. [(Abstract:) The author describes a veterans hospital context of healthcare ministry in which marketplace terminology, adopted institutionally, also impacts the Chaplain Service. He highlights specific elements of this commercialization of pastoral care, such as computerized documentation of "spiritual products" delivered in increments of ten minute units. Noting the power of language both to describe and create realities, the author suggests likely risks accompanying benefits of healthcare chaplaincy carried out on marketplace terms.]

Sullivan, G., Hunt, J., Haynes, T. F., Bryant, K., Cheney, A. M., Pyne, J. M., Reaves, C., Sullivan, S., Lewis, C., Barnes, B., Barnes, M., Hudson, C., Jegley, S., Larkin, B., Russell, S., White, P., Gilmore, L., Claypoole, S., Smith, J. and Richison, R. "Building partnerships with rural Arkansas faith communities to promote veterans' mental health: lessons learned." Progress in Community Health Partnerships 8, no. 1 (2014): 11-19. [(Abstract:) Background: The Mental Health-Clergy Partnership Program established partnerships between institutional (Department of Veterans' Affairs [VA] chaplains, mental health providers) and community (local clergy, parishioners) groups to develop programs to assist rural veterans with mental health needs. Objectives: Describe the development, challenges, and lessons learned from the Mental Health-Clergy Partnership Program in three Arkansas towns between 2009 and 2012.Methods: Researchers identified three rural Arkansas sites, established local advisory boards, and obtained quantitative ratings of the extent to which partnerships were participatory. Results: Partnerships seemed to become more participatory over time. Each site developed distinctive programs with variation in fidelity to original program goals. Challenges included developing trust and maintaining racial diversity in local program leadership. Conclusions: Academics can partner with local faith communities to create unique programs that benefit the mental health of returning veterans. Research is needed to determine the effectiveness of community based programs, especially relative to typical "top-down" outreach approaches.]

Yan, G. W. and Beder, J. "Professional quality of life and associated factors among VHA chaplains." Military Medicine 178, no. 6 (June 2013): 638-645. [This was featured as our October 2013 Article-of-the-Month.]

Zullig, L. L., Jackson, G. L., Provenzale, D., Griffin, J. M., Phelan, S., Nieuwsma, J. A. and van Ryn, M. "Utilization of hospital-based chaplain services among newly diagnosed male Veterans Affairs colorectal cancer patients." Journal of Religion and Health 53, no. 2 (April 2014): 498-510. [(Abstract:) The aim of the study was to examine utilization of chaplain services among Veterans Affairs patients with colorectal cancer (CRC). In 2009, the Cancer Care Assessment and Responsive Evaluation Studies questionnaire was mailed to VA CRC patients diagnosed in 2008 (67 % response rate). Multivariable logistic regression examined factors associated with chaplain utilization. Of 918 male respondents, 36 % reported utilizing chaplains. Chaplain services were more likely to be utilized by patients with higher pain levels (OR = 1.017; 95 % CI = 0.999-1.035), younger age (age OR = 0.979; 95 % CI = 0.964-0.996), and later cancer stage (early stage OR = 0.743; 95 % CI = 0.559-0.985). Chaplain services are most utilized by younger, sicker patients.]



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