October 2018 Article of the Month
Sprik, P. J., Walsh, K., Boselli, D. M. and Meadors, P. "Using patient-reported religious/spiritual concerns to identify patients who accept chaplain interventions in an outpatient oncology setting." Supportive Care in Cancer (2018): 9pp., published online ahead of print, September 6, 2018.
SUMMARY and COMMENT: Screening for patients' religious/spiritual (R/S) needs can guide chaplaincy departments in the efficient use of limited resources, since in most cases having a chaplain personally assess every patient is impractical. Research around R/S screening has tended to focus on processes for referral by nurses, physicians, and others; with the hope of identifying inpatients who could benefit the most from a chaplain's visit, including those who might not make a request on their own. The present study explores the potential of a new strategy that utilizes "patient-reported outcomes (PROs) to screen patients for R/S need and to signal chaplain referral" [MS p. 2]. This approach is well-suited for the outpatient setting, where medical care is increasingly delivered and where contact with a chaplain may be made optimally by phone, but it could help all pastoral caregivers think anew about screening and the allocation of time and attention. "This exploratory study is novel and provides an important foundation for directing conversations about the future of chaplaincy care" [MS p. 4].
The purpose of the study was:
Out of 1249 patients, 412 reported at least one RS need. Following exclusion criteria, 374 patients (29.9%) provided the final sample. Among the results:
The researchers seem to view their work especially in relation to a 1999 study by Alyson Moadel, et al., of self-reported spiritual and existential needs among cancer patients [--see Items of Related Interest, §I, below], which indicated the potential value of screening items that do not use explicitly religious or spiritual language. This was a justification for Sprik and colleagues to include PRO options like concern for family and isolation [--see MS p. 2], and the wisdom of this approach appears to have been born out by findings of "prevalence of R/S concerns that do not specifically mention religion or spirituality" [MS p. 4] and the fact that PROs of that type were associated with good likelihood of interest in R/S intervention. One important difference between the work by Moadal, et al. and the current study is that the earlier one found "patients who struggle with fear of death to be least likely to request a chaplain" [MS p. 4], whereas the current research was able to connect fear of death with a likelihood of R/S intervention acceptance. On this latter point, our authors speculate that "patients are not likely to request R/S support when facing fears of death but will accept the support when it is offered" [MS p. 4], and they note that "[f]uture studies are needed to explore whether this theory is correct, as this can revolutionize the way that chaplaincy is delivered to patients with terminal or potentially terminal diagnoses" [MS p. 4].
One "surprising" result was that "indication of distress was not correlated with uptake of R/S intervention" [MS p. 4, italics added]. The authors propose that this may be a function of distress coming from practical problems like financial worries rather than existential needs. If that is the case, then chaplains who uncover such distress could play an important role in helping patients through proper referral, and someone like a nurse navigator could perhaps be most efficient in sorting out distress issues. What the authors do not do in relation to their "surprising" finding about distress, but that this reader would hold as ever a possibility for any unexpected result, is question the measure at play: was it (in this instance, the distress thermometer) somehow providing a false reading? As even a validated instrument has its limits, there is always a chance that any instrument may for some reason not be valid with a specific population at a certain time under a certain circumstance. The authors are nevertheless very good at lifting up the limits of the research and looking toward the range of future investigation, encouraging attention to such things as the particular experience level of a chaplain, how to "develop effective methods for tele-chaplaincy" [MS p. 5], and how single or multiple contacts by chaplains might influence acceptance of R/S interventions. Moreover, as this study focused on outpatients and found that the percentage indicating RS needs, while significant at around 30%, is much less than other research has found to be the case with advanced care inpatients, so that difference itself begs to be explored. [--See also Items of Related Interest, §4, below.]
This article is implicitly a challenge to chaplaincy departments to think not only about the needs of cancer patient populations and screening strategies like utilizing Patient Reported Outcomes, but about growing outpatient services and tele-chaplaincy in particular.
Developing effective tele-chaplaincy practices is an important direction for the field, as oncology care becomes increasingly an outpatient practice. This study is an important step in addressing patients who have limited opportunity to request the R/S care they need within the limited timeframe of outpatient appointments. [MS p. 5]
A handful of final comments: First, since the number of patients personally reached by phone was 241, the 120 patients who had indicated at least one R/S need and actually spoke with a chaplain represent a 50% acceptance of R/S intervention as a result of a telephone invitation. The authors do not stipulate this percentage but instead give the percentage of interest in R/S intervention in relation to the total of the final sample (i.e., 29.9%). This seems to be a function of admirable caution by the researchers who keep the focus on the effectiveness of their outreach strategy in terms of the total sample, but for this reader they have perhaps been so cautious as to hide a remarkable result. Second, The authors do not address the question of how well or easily patients were able to use an electronic tablet. Though such devices are now common, it can hardly be assumed that the interface between patients and this technology might not be an issue, whether it be advantageous or disadvantageous with subsets of any population, and the authors do state that data from 23 patients was not captured because of device application problems. In a personal communication with ACPE Research, lead author Petra Sprik relays that someone was available to the study participants to respond to any concerns while they completed the tablet-based survey, and also that some of their research team is currently exploring the use of the electronic tool itself. Third, there is a minor printing error on MS p. 5: the sentence that reads, "...this study examines patients' acceptance of interventions, rather patients' requests for chaplains" omits the word than. Fourth, the collection of tables supplied in the appendix is rich and helpful. And fifth, the bibliography is quite thorough, but more than that, the authors' command of the up-to-date state of the research is noticeable and highlighted by the unusually short timeframe between data collection and publication.
Suggestions for Use of the Article for Student Discussion:
Our featured article works out of an observation that medical care is shifting more and more toward the outpatient setting, and so this would be a good opportunity to explore with students the idea of outpatient chaplaincy in general and, of course, in relation to oncology. More specifically, what might be the opportunity to connect with outpatients in person, and what about the option of "tele-chaplaincy"? Our authors give a brief but pretty clear picture of the protocol for engaging patients over the phone [--see MS pp. 2-3], but what do students image they'd need in the way of training to work effectively over the phone? Also, what do students make of the results about the needs correlated to acceptance of an intervention, as well as the particular speculation that "patients are not likely to request R/S support when facing fears of death but will accept the support when it is offered" [MS p. 4]? And, what specifically of the finding that "patients were more likely to accept R/S counseling (25.1%), prayer (17%), and follow-up appointments (2%) via telephone than R/S counseling (4.9%) or prayer (1.2%) delivered in-person" [MS p. 5]? This study used a patient self-report via an electronic tablet to screen for needs. What would be the potential advantages and disadvantages of such a method? And, is the group surprised about the apparent significance of screening questions that do not use religious/spiritual language? Underlying the topic of screening is a broad issue of limited resources when it comes to providing chaplaincy care. Students might discuss what limits they can perceive even at this point in their experience, and how perhaps they triage patients in light of scarce time to provide care. Finally, for students interested in the more technical details of the study, the tables in the appendix are worth a close look. Table 3: Association of Patient Characteristics and Indication of R/S Concerns [MS p. 7] alone is a rich collection of information.
Related Items of Interest:
I. Our featured study makes significant references to the following research from 1999, out of the Department of Epidemiology and Social Medicine at Albert Einstein College of Medicine, Bronx, NY:
II. This recent research regarding cancer outpatients points up some of the potential complexity and difficulty in screening. Here the authors look specifically at spiritual well-being, using a quite established measure.
III. Our featured article refers to PROs or Patient-Reported Outcomes, but the literature around this type of data collection tool also uses the abbreviation PROMs, for Patient-Reported Outcome Measures. For a good and recent example of research by other chaplains who have used this approach, see the following article. Note that here the authors are applying the PROM methodology not to screen for patients' needs (as in our featured study) but to assess the outcomes of spiritual care delivered by chaplains. [For more from the authors of the following article, visit http://www.snowdenresearch.co.uk.]
IV. While it is vital for chaplains to stay "up" on the latest research, older studies often hold valuable insights. For example, just as our featured article identifies an apparent difference between the incidence of spiritual needs of outpatients (in the present study) vis-a-vis inpatients (as indicated by other research), much the same point was raised in 1993 by a research team led by Larry VandeCreek, one of the pioneers of modern chaplaincy research. VandeCreek and colleagues focused on ophthalmology outpatients but believed that the nature of the particular sample "represented outpatients with a broad range of serious medical concerns" [p. 45], beyond the ophthalmological issues they had in common.
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