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October 2022 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


Tartaglia, A., Corson, T., White, K. B., Charlescraft, A., Jackson-Jordan, E., Johnson, T. and Fitchett, G. "Chaplain staffing and scope of service: benchmarking spiritual care departments." Journal of Health Care Chaplaincy (2022): online ahead of print, 9/14/22.

[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: This month's article presents important benchmarks for hospital chaplaincy departments and is "the first to identify hospitals' increasing chaplaincy staffing levels" [MS p. 13] in recent years. While data collection occurred during April-June 2021, participants were asked to report on the situation of their departments in January-February 2020, in order so as to avoid the "interruptions in service and variations in staffing [that] resulted from the COVID-19 pandemic" [MS p. 5]. The study also illustrates an interesting and potentially useful approach to sampling: focusing on the "honor roll" hospitals identified by the magazine, US News & World Report [--see Related Items of Interest, §I, below].

This research was prompted in part by an inquiry at one hospital department regarding staffing benchmarks [--see MS p. 14], and the researchers indicate that there was general interest among department directors/managers about staffing and scopes of service, contributing to the 100% participation rate of departments approached. The purposeful sampling of the "20 honor roll hospitals listed by U.S. News and World Report Best Hospitals 2020-2021" follows a strategy used by other researchers [--see Related Items of Interest, §I, below] that highlights chaplaincy departments in the nation's "top-performing hospitals...selected through a well-documented process" [MS p. 5]. Indeed, hospitals regularly tout their standing in this ranking, which has been running since 1990 and has popularly come to be accepted as an indicator of quality, though the magazine itself is careful to point out that the highest-ranking hospitals may not always provide the best care in any particular type of service [--see the US News & World Report web page for "How and Why We Rank and Rate Hospitals"]. Our present authors acknowledge that data from "a small number of predominantly urban academic medical centers" [MS p. 14] may be a limitation of their study, but the idea of surveying departments from institutions of marked prestige in order to establish chaplaincy benchmarks seems methodologically reasonable and practically very savvy.

After piloting the survey process at two medical centers not part of the final group, "[d]ata were gathered via Zoom/telephone employing a structured survey instrument with the spiritual care directors/managers at the 20 honor roll hospitals..." [MS p. 4]. A 76-item survey questionnaire yielded a great deal of benchmarking information that goes beyond the detail of this summary, but the following sample of results should give a sense of the findings about department features, activities, and staffing:

  • "Nineteen (95%) of the hospitals maintained a formal chapel with 15 chapels suitable for interfaith use. Twelve (60%) had a meditation space separate from a formal chapel." [MS p. 6]

  • "Eleven managers (55%) regularly reported aggregated counts of department activities to their supervising administrator including the number of chaplain visits (50%, n=10), reason for chaplain requests (25%, n=5), and length of chaplain visits (20%, n=4). ...[O]nly two (10%) routinely reported specific data on staff support...." Seventeen managers (85%) "collected department activity data for internal purposes with the number of visits/visits per chaplain (n=10), reason for chaplain visit (n=8), and data on staff support (n=7) being among the most common." [MS p. 7]

  • "Thirteen (65%) departments provided some level of routine outpatient care of which four had dedicated chaplains and the remaining nine serving either by request or referral. ...Dedicated outpatient chaplains were specifically assigned to palliative care and oncology." [MS p. 8]

  • "The majority (65%, n=13) provided 24/7 in-house chaplain presence of which five maintained 'working coverage' with at least one chaplain awake and working through the evening and night hours." [MS p. 8]

  • "Thirteen of the hospitals (65%) have adopted a formal spiritual screening for inpatient care that would trigger a chaplain referral." [MS p. 8]

  • "All 20 hospitals expected chaplains and CPE residents to chart on all visits using a specific template. ...[N]o hospitals allowed volunteers or community clergy chart access." [MS p. 8]

  • "Three departments (15%) expected chaplains to visit all new admissions with four others (20%) expecting chaplains to visit new admissions in selected clinical areas such as palliative or intensive care." [MS p. 8]

  • "Regular (a few times per week) attendance by chaplains at unit health team rounds was expected at 11 hospitals (55%), with four (20%) indicating occasional (a few times a month) attendance." [MS p. 8]

  • "Routine surgical preoperative care was expected at seven (35%) hospitals." [MS p. 8]

  • "In 70% (n=14) of hospitals, chaplains were expected to attend every code during normal business hours, but only in nine (45%) after hours. Seven departments (35%) were expected to respond to all emergency department traumas 24/7. Seven (35%) of the 20 hospitals expected that chaplains would attend every death 24/7. Five departments (25%) respond to all codes, traumas, and deaths 24/7 by protocol." [MS p. 9]

  • "Staff support was identified as a priority by all 20 managers for chaplains responding to a death." [MS p. 9]

  • "Six departments (30%) regularly coordinate efforts with the local organ procurement organization, two (10%) complete death paperwork, and one department (5%) notifies decedent affairs." [MS p. 9]

  • "Fourteen departments (70%) provided regularly scheduled worship services in the chapel and/or multi-faith space." [MS p. 9]

  • "The majority (75%, n=15) of spiritual care departments offered memorial services for families of patients who died in the hospital, with nine providing them annually, five bi-annually or quarterly, and one by request only." [MS p. 9]

  • "Seven departments (35%) provided ongoing bereavement services. Notes or cards (n=4), support groups (n=4), memory boxes (n=2), and phone calls (n=1) were among the types of follow-up bereavement support services reported." [MS pp. 9-10]

  • "Four departments (20%) used volunteers as 'visitors' who promoted or screened for interest in chaplain visitation." [MS p. 11]

Our authors observe an "absence of standardization in the scope of services provided by spiritual care departments within a sample of high-performing hospitals": "[s]ervices such as chaplains dedicated to outpatient care, expectations on seeing new admissions, involvement with advance directives, and managing after-hours responsibility for deaths, codes, and traumas varied considerably" [MS p. 12]. However, "Departments were consistent in providing unit-based coverage and maintained well-established referral systems," and all managers "understood [that] support for patients and families in making complex ethical issues [was] an important chaplain function" [MS p. 12]. In terms of a typology of chaplaincy departments as either professional, transitional, or traditional:

...[M]ost spiritual care departments in this study share many of the characteristics of the "professional" typology as they are consistently staffed by trained and certified chaplains who are paid by the institution and remain committed to patient/family care as a first priority. In addition, the majority of spiritual care managers were well-integrated and reported at a high level within their respective organizations. While most departments in the study utilized students to provide a good deal of the spiritual care, sufficient CPE educators were available to provide close supervision. The use of volunteers was clearly defined, limited, and not part of the provision of core services. Departments in this study that might be better characterized as "transitional" appeared to be working toward higher departmental visibility and greater integration into their organizations. [MS pp. 13-14]

Staffing levels were discovered here to have increased in relation to data from earlier research, and the authors speculate about this finding, both in terms of how it may have been a function of the various methodologies used in this and other studies and how it may suggest factors at play in the development of the field, including the growth of palliative care services and recognition of the potential role of chaplains in dealing with traumatic situations and organizational change. The authors further comment that management at such "honor roll" hospitals as participated in this study might be responsive to the advance of research that points to the value of chaplains. Nevertheless, an analysis of staffing remains complex (e.g., how to count the staffing contribution of CPE students). Decisions about how to approach the issue are addressed in the Measures section of this paper [--see MS p. 6] as well as in the Results section [--see MS p. 13]. Several tables [--see MS pp. 11-12] break down the staffing statistics, and Table 4 [MS p. 12] is of particular interest in connecting the staffing numbers to a list of activities.

The authors hold that "chaplain staffing levels are a factor of chaplain integration into an organization and the functions the organizations expect chaplains to fulfill" [MS p. 14], and they draw upon the advice of Wendy Cadge in her influential 2012 book Paging God: Religion in the Halls of Medicine, saying, "It is...incumbent upon spiritual care leaders to recognize Cadge's observation about the importance of spiritual care managers becoming 'familiar with the language and priorities of [their] healthcare system' well as focusing on the strategic goals of an organization and exploring with administrators how chaplains can play a strategic role in meeting them" [MS p. 14]. They also emphasize "trust-building with hospital executives around mission-critical issues" [MS p. 15] to support chaplaincy integration into an organization. This study extends previous work by various researchers to benchmark how chaplaincy departments are staffed and function, and the background to this venture is nicely laid out in the introductory sections [MS pp. 2-4] and substantiated in the bibliography of 51 citations. Given the great variety of organizational contexts for departments across the US, the goal of benchmarking while not falling into apples-to-oranges comparisons seems as difficult as it is advisable, but the strategy of focusing on a listing of "top hospitals" may be especially useful, as institutions understandably wish to be associated with celebrated systems of care. Obviously, too, the COVID-19 pandemic was an obstacle for this research, but the investigators appropriately sought to gather data that described departments prior to the disruptions in this country. That may still present a risk for "recall bias" [MS p. 14], and the lingering or permanent alterations in the landscape of healthcare and the effects on chaplaincy departments remain to be seen, yet the data here not only establish a "point of reference for further study" [MS p. 15] but should be valuable to chaplaincy departments at an opportune time when hospitals are emerging from limited operations and perhaps rethinking their services. Note that a companion article, "Staff care: the role of healthcare chaplains" is also forthcoming from our authors.

One final note: The article does not specify the hospitals comprising the US News & World Report "Honor Roll" for 2020-2021, and the link given in the References goes to the magazine's general web page for its rankings, which provides only the information for the current year. However, the listing for 2020-2021 is a matter of public record (--see, for instance, Becker's Hospital Review, which also links to an extensive description of the methodology employed by US News & World Report at that time), and is as follows:

  1)  Mayo Clinic (Rochester, Minn.)
  2)  Cleveland Clinic
  3)  Johns Hopkins Hospital (Baltimore)
  4)  NewYork-Presbyterian Hospital-Columbia and Cornell (New York City) --TIE
  4)  UCLA Medical Center (Los Angeles) --TIE
  6)  Massachusetts General Hospital (Boston)
  7)  Cedars-Sinai Medical Center (Los Angeles)
  8)  UCSF Medical Center (San Francisco)
  9)  NYU Langone Hospitals (New York City)
10)  Northwestern Memorial Hospital (Chicago)
11)  University of Michigan Hospitals-Michigan Medicine (Ann Arbor)
12)  Brigham and Women's Hospital (Boston)
13)  Stanford Health Care-Stanford Hospital (Palo Alto, Calif.)
14)  Mount Sinai Hospital (New York City)
15)  Hospitals of the University of Pennsylvania-Penn Presbyterian (Philadelphia)
16)  Mayo Clinic-Phoenix
17)  Rush University Medical Center (Chicago)
18)  Barnes-Jewish Hospital (Saint Louis) --TIE
18)  Keck Medical Center of USC (Los Angeles) --TIE
20)  Houston Methodist Hospital


Suggestions for Use of the Article for Student Discussion: 

Some students may not feel a sense of relevance between their individual work and overarching benchmarks for departmental operations, but that may be reason enough to engage CPE groups on the subject of institutional standards and potential expectations. This is another and important angle on the question, "What do chaplains do?" Discussion might be affected by whether the CPE program is located at one of the participating hospitals, but inclusion in the US News & World Report listing is hardly necessary for this research to be of interest. First, what piece of information reported here is most surprising to the students? Do any of the data provide an oh-now-I-understand moment for students who have questioned the activities of their department? Do any of the findings challenge students to think about what more they could be doing? For instance, does the finding about departments' bereavement services [--see MS pp. 9-10] suggest any new ideas? There's a noteworthy finding of discrepancy from previous research regarding chaplains' involvement with Advance Directives [--see MS p. 12], so what is the group's experience here? While there is a great deal of information in this article, what else might the group be curious about that they'd like to gain a sense of benchmarks in the profession? Is there any aspect of the life of their department that they'd like to track quantitatively, and why? How could the students partner better with departmental leadership in collecting data that is already being asked of them? Finally, Figure 1 [MS p. 10] displays differences between department activity triggered by requests or protocols. What might be the pros and cons of working through protocols vis-a-vis requests, in general?


Related Items of Interest:

I.  Other chaplaincy research that has used the US News & World Report hospital listing as their target sample:

Cadge, W. and Ecklund, E. H. "Prayers in the clinic: how pediatric physicians respond." Southern Medical Journal 102, no. 12 (December 2009): 1218-1221. [This study used in-depth interviews with 30 academic pediatricians and pediatric oncologists at top US hospitals. (From the abstract:) In close to 100% of cases when the subject of prayer came up in clinical contexts, it was patients and families who raised it. Patients and families mostly talked about prayer in response to a seriously ill or dying child. When it was raised, pediatric physicians responded to prayer by participating; accommodating but not participating; reframing; and directing families to other resources.]

Ecklund, E. H., Cadge, W., Gage, E. A. and Catlin, E. "The religious and spiritual beliefs and practices of academic pediatric oncologists in the United States." Journal of Pediatric Hematology/Oncology 29, no. 11 (November 2007): 736-774. [This study compares data from surveys of 77 pediatric oncology faculty (from a total sample of 122) working in 13 "honor roll" hospitals, as designated by US News and World Report, with data from the General Social Survey. Results (--see the Abstract, p. 736): "Eighty-five percent of pediatric oncology faculty described themselves as spiritual. In all, 24.3% reported attending religious services 2 to 3 times a month or more in the past year. Twenty-seven percent of pediatric oncologists believed in God with no doubts. In all, 52.7% believed their spiritual or religious beliefs influence interactions with patients and colleagues. Among the general public 40.1% reported attending religious services 2 to 3 times a month or more in the past year (P<0.01) and 60.4% believed in God with no doubts (P<0.001). Conclusions: Although many have no traditional religious identity, large fractions of pediatric oncology faculty described themselves as spiritual. This may have implications for the education of pediatric oncologists and the spiritual care of seriously ill children and their families." (The article is preceded by a commentary: Walco, G. A., "Religion, spirituality, and the practice of pediatric oncology," on pp. 733-735.)]

Goldstein, H. R., Marin, D. and Umpierre, M. "Chaplains and access to medical records." Journal of Health Care Chaplaincy 17, nos. 3-4 (2011): 162-168. [(Abstract:) This study was initiated by a Pastoral Care Department of a large academic medical center in order to establish hospital chaplaincy policies and procedures. Four basic questions were asked about professional hospital chaplains and record keeping. The results of the survey show that the standard of practice is that chaplains access the medical record, enter notes in the record, have access to the electronic medical record, and that no special credentialing beyond Clinical Pastoral Education (CPE) is required for chaplains to have this access.] [The article was featured as our November 2011 Article-of-the-Month.]


II.  Lead author Alexander Tartaglia has offered his own summary and commentary on this article for the October 6, 2022 issue of the Transforming Chaplaincy News, available online. Also, early results of this month's research were presented at an October 2021 Transforming Chaplaincy webinar by Alexander Tartaglia and Kelsey White. See "Spiritual Care at the US News Top 20 Hospitals: Preliminary Findings" on YouTube.


III.  Our article notes [--see MS p. 2] the so-called White Paper edited by Larry VandeCreek and Lauren Burton, "Professional Chaplaincy: Its Role and Importance in Healthcare" (2001). It was, at the time, an important description of chaplaincy -- a joint project of the The Association for Clinical Pastoral Education, The Association of Professional Chaplains, The Canadian Association for Pastoral Practice and Education, The National Association of Catholic Chaplains, and The National Association of Jewish Chaplains -- and was used to raise awareness of the discipline. It still deserves reading. It is available online.


IV.  One of the findings of our April 2022 Article-of-the-Month -- Antoine, A., Fitchett, G., Marin, D., Sharma, V., Garman, A., Haythorn, T., White, K., Greene, A. and Cadge, W., "What organizational and business models underlie the provision of spiritual care in healthcare organizations? An initial description and analysis," Journal of Health Care Chaplaincy 28, no. 2 (April-June 2022): 272-284 -- was that "[w]hen chaplain managers talked about data it was more about advocating for staffing and budget and less so about what to learn from data or how to use it to streamline processes" [p. 280]. The study involved interviews with 4 chaplain managers and 11 institutional executives from 18 hospitals strategically chosen from the Midwest, South, and Pacific Northeast. The fact that none of the executives interviewed mentioned studies connecting the work of chaplains to outcomes for patients and families suggested to those authors that "research is not yet influential for staffing decisions" [p. 282]. Nevertheless, that study also turned up an anecdote of how institutional leaders at a faith-based organization came to expand chaplaincy staffing after becoming aware of staffing levels at competing secular hospitals [--see p. 281]. Such an anecdote would seem to support the idea that hospital management is sensitive to comparisons to other institutions, thereby bolstering the approach of our current Article-of-the-Month to look at "top hospitals" for benchmarking.



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