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October 2018 Article of the Month
 
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA

 

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.

[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. References are to manuscript [MS] page numbers.]

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:

  1. to describe the prevalence and correlates of patient-reported R/S concerns in outpatient oncology patients
  2. to estimate the associations of R/S concerns with acceptance of an R/S intervention offered by telephone [--see MS p. 2]
This was a "retrospective analysis of data collected at Levine Cancer Institute--Morehead (LCI-M), a large, outpatient, cancer center in Charlotte, North Carolina" [MS p. 2], from March 1, 2017 to May 9, 2017, drawing on PRO information provided through an electronic tablet prior to medical appointments. "[S]even R/S needs were selected from a list of pre-established PRO options on the screening tool application" [MS p. 2]:
  • Concern for family
  • Fear of death
  • Isolation
  • Struggle to find meaning/hope
  • Spiritual or religious concern
  • Shame/guilt
  • Doubts of faith
"Patients also were assessed for depression with the Patient Health Questionnaire-2 Scale (PhQ2), anxiety with the Generalized Anxiety Disorder Scale-2 Item Scale (GAD2), and distress with the distress thermometer (DT)" [MS p. 2]. Additional data came from chaplain telephone calls to each patient who had indicated at least one R/S need, noting whether the patient was receptive and, if so, what interventions the patient seemed to desire: e.g., "R/S counseling over the telephone, offering prayer or R/S ritual during the call, scheduling an R/S counseling appointment, or a follow-up telephone call" [MS p. 3]. Our authors describe well the process for the chaplain's phone call [--see MS p. 3].

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:

  • "Perhaps the most important finding of this study is that patients who indicated struggle to find meaning and hope in life or fear of death were the most likely to accept R/S interventions." [MS p. 4]
  • "...[P]atients with anxiety, depression, and distress were more likely to indicate R/S need, but only patients indicating anxiety were more likely to accept an R/S intervention." [MS p. 4]
  • "The most frequently indicated R/S concern was concern for family (74.6%), followed by fear of death (27.5%)." [MS p. 3]
  • "Females were more likely than males to indicate at least one R/S concern...and to indicate isolation" [MS p. 3 and Table 1 on MS p. 6]
  • "Patients indicating at least one spiritual concern were more likely to indicate high distress (p < 0.001), anxiety (p < 0.001), and depression (p < 0.001)." [MS p. 3]
  • "...[P]atients 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]

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.


Special Comment to ACPE Research by Chaplain Petra J. Sprik (Petra.Wahnefried@atriumhealth.org), Levine Cancer Institute, Charlotte, NC:

This is my first published research article and project. It evolved out of an issue that I encountered in clinical practice: I was required to telephone all patients that indicated a religious/spiritual need on the screening tool to offer chaplain interventions, and it was amounting to more patients than I could call within my allotted work hours. Rather than be overwhelmed by the issue, I chose to engage it. I wanted to know how best to direct tele-chaplaincy services to those who need it most. In figuring this out, I could do my job better and perhaps benefit other chaplains who might encounter the same issue. I am thankful for a team of coworkers that helped me ground my questions in solid research practice. With their assistance, I discovered that providing spiritual care to outpatients via tele-health methods is an under-researched, critical need in the modern healthcare setting. My passion for research was ignited. I continue to approach the clinic with curiosity about how to improve practice to impact patients positively. I am currently engaging in my second research project to further understand virtual chaplaincy. My advice to all chaplains is: engage clinical problems with curiosity, and reach out to knowledgeable coworkers to help you do this well.


 

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:

Moadel, A., Morgan, C., Fatone, A., Grennan, J., Carter, J., Laruffa, G., Skummy, A. and Dutcher, J. "Seeking meaning and hope: self-reported spiritual and existential needs among an ethnically-diverse cancer patient population." Psycho-Oncology 8, no. 5 (September-October 1999): 378-385. [(Abstract:) Spiritual beliefs and practices are believed to promote adjustment to cancer through their effect on existential concerns, including one's personal search for the meaning of life and death, and hope. This study sought to identify the nature, prevalence, and correlates of spiritual/existential needs among an ethnically-diverse, urban sample of cancer patients (n=248). Patients indicated wanting help with: overcoming my fears (51%), finding hope (42%), finding meaning in life (40%), finding spiritual resources (39%); or someone to talk to about: finding peace of mind (43%), the meaning of life (28%), and dying and death (25%). Patients (n=71) reporting five or more spiritual/existential needs were more likely to be of Hispanic (61%) or African-American (41%) ethnicity (vs. 25% White; p<0.001), more recently diagnosed (mean=25.6 vs. 43.7 months; p<0.02), and unmarried (49% vs. 34%; p<0.05), compared with those (n=123) reporting two or fewer needs. Treatment status, cancer site, education, gender, age, and religion were not associated with level of needs endorsement. Discriminant analysis found minority status to be the best predictor of high needs endorsement, providing 65% correct classification, p<0.001. Implications for the development and delivery of spiritual/existential interventions in a multi-ethnic oncology setting are discussed.]

 

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.

Gerhart, J., Fitchett, G., Lillis, T. A., Kuzel, T. M., Lo, S. S., Penedo, F., Weldon, C. B. and Diaz, A. "Brief spiritual well-being screening is nonlinearly related to psychological distress in ambulatory cancer patients." Psycho-Oncology (2018): 4pp.; published online ahead of print, September 6, 2018. [This is a brief report of a study employing the Functional Assessment of Chronic Illness Therapy - Spirituality Subscale (FACIT-SP) to screen for spiritual well-being. "It was hypothesized that higher levels of SWB would be linearly related to lower levels of psychological distress and other supportive oncology concerns. Paradoxically, patients endorsing no SWB tended to report lower levels of supportive oncology concerns than those endorsing one or 2 sources of SWB. If SWB is truly a protective factor against cancerÔÇÉrelated distress, it would be expected that those with an absence of SWB would be a greatest risk for supportive oncology concerns. The lack of linear relationships between SWB and supportive oncology concerns in the current screener indicates that the SWB measure is not optimized for screening in its current form." [MS p. 2]

 

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.]

Snowden, A. and Telfer, I. "Patient reported outcome measure of spiritual care as delivered by chaplains." Journal of Health Care Chaplaincy 23, no. 4 (October-December 2017): 131-155. [(Abstract:) Chaplains are employed by health organizations around the world to support patients in recognizing and addressing their spiritual needs. There is currently no generalizable measure of the impact of these interventions and so the clinical and strategic worth of chaplaincy is difficult to articulate. This article introduces the Scottish PROM, an original five-item patient reported outcome measure constructed specifically to address this gap. It describes the validation process from its conceptual grounding in the spiritual care literature through face and content validity cycles. It shows that the Scottish PROM is internally consistent and unidimensional. Responses to the Scottish PROM show strong convergent validity with responses to the Warwick and Edinburgh Mental Well-Being Scale, a generic well-being scale often used as a proxy for spiritual well-being. In summary, the Scottish PROM is fit for purpose. It measures the outcomes of spiritual care as delivered by chaplains in this study. This novel project introduces an essential and original breakthrough; the possibility of generalizable international chaplaincy research.]

 

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.

VandeCreek, L., Benes, S. and Nye, C. "Assessment of pastoral needs among medical outpatients." Journal of Pastoral Care 47, no. 1 (1993): 44-53. [This study of 70 ophthalmology outpatients and 70 hospitalized medical/surgical/obstetrical inpatients in a large tertiary care hospital, plus 70 healthy volunteers from the community found that "the spiritual needs of outpatients...demonstrate greater similarity to healthy persons in the community than to hospital inpatients" (p. 53). The authors do not take from this any cause for devaluing the importance of pastoral care to outpatients but rather a challenge to discover how best to discern which outpatients may have pressing needs. "The results from this project suggest that attention to existential vacuum, goal-seeking, and depressive symptoms are particularly relevant" (p. 52), and that ministry might best "focus on the specific pastoral needs of those with chronic, organic disease which is affecting their whole person" (p. 53).

 

 


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