EVIDENCE-BASED CHAPLAINCY CARE: Transforming Our Practice

George Fitchett, DMin, PhD, BCCDepartment of Religion, Health and Human Values

Rush University Medical Center, Chicago, ILgeorge_fitchett@rush.edu

-.46***

.69***

Hopelessness

Depression

Religious Belief

.17**

***p<.001, **p<.01.N = 271

Tradition – We have always done it this way.

Policy – This is the way we are supposed to do it.

Education – I was taught to do it this way.

How Do We Know Good Spiritual Care?

Personal Experience/Trial and Error– I tried several ways and this this one works best.

Intuition – Doing it this way feels right to me.

Research – There is evidence this is the best way to do it.From Hundley, 1999

Standard 12: ResearchThe chaplain practices

evidence-based care including ongoing evaluation of new practices and when appropriate, contributes to or conducts research.

(http://www.professionalchaplains.org)

Chaplaincy: A Research-Informed Profession

1. Evidence-Based Care: What is it?2. Evidence-Based Care: Against it &

for it3. Ways of Knowing: Religion and

Science4. Types of Research Evidence5. Overview of Chaplaincy-Related

Research6. Next Steps for Research-informed

Chaplaincy

Outline

-.46***

.69***

Hopelessness

Depression

Religious Belief

.17**

***p<.001, **p<.01.N = 271

“Evidence-based spiritual care is the use of scientific evidence on spirituality to inform the decisions and interventions in the spiritual care of persons”

Tom O’Connor (2002). Journal of Religion and Health

What is Evidence-Based Spiritual Care?

Evidence-based practice in

psychology is the integration of

•the best available research

with

•clinical expertise

•in the context of patient

characteristics, culture, and

preferences.

What is Evidence-Based Practice?

APA Policy Statement on Evidence-Based Practice in Psychology, 2006

It can’t be doneGod, the Spirit, presence,

prayer, etc. are much too big and always will be mysteriously beyond our attempts to measure and quantify. (Stiger, 2002)

AGAINST Evidence-Based Spiritual Care

It shouldn’t be doneOnce pastoral care services succumb to the need

to prove they can decrease the length of stay or improve patient satisfaction all will be lost. (Sulmasy, 2006)

“Evidence from research needs to inform our pastoral care. To remove the evidence from pastoral care can create a ministry that is ineffective or possibly even harmful” (O’Connor TSJ and Meakes E. 1998. The first article to use the term “evidence-based” pastoral care.)

FOR Evidence-Based Spiritual Care

Good stewardship of creation requiresour best, evidence-based, care

(Grossoehme in Fitchett & Grossoehme, 2011)

Health Care ChaplaincyImproving our Care and

Making our CaseThrough Research

-.46***

.69***

Hopelessness

Depression

Religious Belief

.17**

***p<.001, **p<.01.N = 271

Source: Anton T. Boisen Explorations of the Inner World: A Study of Mental Disorder and Religious Experience (Willett, Clark & Company, 1936)

Conflict: opposite and

antagonistic, conflict

Mutual independence:

separate and different

Dialogue: meeting on

boundaries

Integration

Can Religion and Science Co-Exist?

Ian Barbour, Nature, Human Nature and God, 2002

Standard 12: ResearchThe chaplain practices

evidence-based care including ongoing evaluation of new practices and when appropriate, contributes to or conducts research.

(http://www.professionalchaplains.org)

Chaplaincy: A Research-Informed Profession

• Research Literacy All health care chaplains should be research literate

• Research CollaborationSome health care chaplains will be qualified to collaborate in research conducted by health care colleagues (co-investigators)

• Research LeadershipSome health care chaplains will be qualified to lead research projects (principal investigators)

Chaplaincy: A Research-Informed Profession

A research-literate chaplain has the ability to read, understand, and summarize a research study and to explain its relevance for his/her spiritual care.

-.46***

.69***

Hopelessness

Depression

Religious Belief

.17**

***p<.001, **p<.01.N = 271

Chaplaincy: A Research-Informed Profession

1. Importance of R/S for patients

2. Patient/family R/S coping and R/S needs

3. Patient/family preferences for spiritual care

4. Describe what chaplains do5. Effect of spiritual care on 

important outcomes

Overview of Chaplaincy Research

Reviews of Chaplaincy Research

Mowat, Harriet (2008). The potential for efficacy of healthcare chaplaincy and spiritual care provision in the NHS (UK): A scoping review of recent research.

88%

7% 5%

80%

9% 11%

65%

15%20%

0%

20%

40%

60%

80%

100%

very much/quite a bit somewhat not at all/a little bit

My faith or spirituality has helped me through my cancer experience

Black (n=914) Hispanic (n=664) White (n=6827)

N=8,405, ACS SCS II; Canada et al. 2013

Religious Coping among Persons with Persistent Mental Illness (N=406)

65% Religion helped to cope with symptom severity (to a large or moderate extent)

48% Religion became more important when symptoms worsened

30%Religious beliefs and activities were “the most important things that kept [them] going”

Tepper et al. (2001) Psychiatric Services, p. 662

Religious/Spiritual Perspectives of Adolescents & Young Adults Receiving BMTBelieving God has a reason

“He chose me ’cause I’m strong. I understand what I have to go through.”

Using faith practices“And just when I’m in pain and I pray for peace. . . that side effects won’t be too bad.”

Benefitting from spiritual support people

“My pastor’s wife is one of the biggest helps because. . . she talks to me like I’m normal.”

Themes for 12 AYAs (age 15-28, 7 female, interviewed 2 weeks pre to 3 months post-transplant; 6 re-interviewed 1 yr post-transplant); Ragsdale et al., 2014

“We learned that AYA patients were utilizing R/S far more than we suspected.

Our data. . . suggest that chaplains should be proactive in asking AYA patients about their understanding and use of faith.”

21

"I want to know more about this"

Pargament et al 2000

ItemPercent with 

distressNot able to carry out important roles  37.5Feeling no longer who I was  36.4Feeling of not having control 29.2Feeling uncertain  26.9Feeling a burden to others 24.1Feeling depressed 22.5Worried about future 20.9Feeling of unfinished business  19.4Feeling life no longer has meaning or purpose

17.4

Not feeling worthwhile or valued  17.0Feeling have not made meaningful contribution

11.9

Not being able to accept things as they are

11.5

Concerns regarding spiritual life 6.3

Distress in 253 Palliative Care Patients (90% Canadian, 10% Australian)

Chochinov et al., 2009

23% with distress in 3+

Spiritual Distress

Chaplain ratings of spiritual distress for 113 palliative care in-patients at MD Anderson. Hui et al., 2011

50% with no or little distress

From Monod et al., 2012;  n=203 geriatric patients  in medical rehabilitation, Switzerland

65% some distress

27% some distress in all 5 dimensions

22% severe distress in at least one dimension

60% of severe unmet needs were for Life Balance

Spiritual Distress in Older Medical Rehab Patients

Is R/S important to you as you cope with your illness?

YES (82%)

NO (18%)

How much strength or comfort do you get from

your R/S right now?

Has there ever been a time when R/S was important to

you?

All that I need (41%)

NO (9%)Less than I need or none at all (41%)

R/S Struggle Path 1

YES (9%)

R/S Struggle Path 2

BRIGHTEN Participants (n=188)

Screening for R/S Struggle

Study Mako et al, 2006Delgado Guay et al., 

2011Center Calvary Hospice, NYC MD Anderson

PatientsInpatients w advanced 

cancerPalliative care outpt 

clinicSample size 57 91Yes % 61% 44%Median (IQR) 3 (1, 6)Mean  4.7

Are you experiencing spiritual pain right now? Spiritual pain is a pain deep in your soul (being) that is not physicalHow would you rate your overall spiritual pain 

0 (none) – 10 (worst)?

Screening for Religious Struggle

QUESTIONIMPLICATION FOR SPIRITUAL CARE

How did you decide which patients to see this week?

Good stewards of scarce resources

How did staff you work with determine who to refer and who not to refer?

Protocol for screening and referral

What evidence did you generate this week that your spiritual care made a difference in measurable patient outcomes?

Accountability and documentation

How many chaplains does your institution/service need?

Can estimate level of spiritual acuity and staffing needs

Implications of Screening for Spiritual Pain

Predictors of Interest in Spiritual Care ORSpirituality (ref = Not spiritual)

Somewhat spiritual 4.17

Very spiritual 8.35

Religiousness (ref = Secular)

Traditional 1.79

Religious 2.41Prior experience with spiritual care (ref = No)

Yes 3.9Understand spiritual care (ref = No)

Yes 2.9

Interest in Spiritual Care (n= 364 oncology outpatients, Israel)

Schultz et al., 2014

Want at least 1 visit 70% Daily visits 18% Visit every few days 38% Weekly visit 13%Not at all 17%Expect visit without requesting 39%*14% missing

Preferences about Chaplain Visits*

Piderman et al, 2010, N=1591

78%

71% 69%

62%59%

44%

39%

0%

30%

60%

90%

Remind me ofGod's care and

presence

Offer support tofamily or friends

Be with me attimes of particular

anxiety oruncertainty

Pray and/or readscripture orsacred texts

Listen to me Administerreligious ritual or

sacrament

Counsel meregarding

moral/ethicalconcerns ordecisions

Percen

t 'very' or 'somew

hat' im

portant

Patient’s Ratings of Reasons for Wanting to See a Chaplain (N=1,591)

What Chaplains Do in Palliative CareProportion of chaplains who report activity often, frequently or always

ActivityAll Chaplains

(n=382)Chaplains who work in

PC >86% (n=64)Chaplain CraftBuild relationship 76% 87%Provide ritual support 64% 59%Death and DyingCare for dying or deceased patient/family 69% 76%Goals of CarePatient's/loved one's goals of care 55% 70%Facilitate communication between patient/family and team 46% 65%

Family conflict 30% 41%Existential & Spiritual DistressExistential questions/ spiritual distress 49% 57%Why me 25% 29%Loss of faith 9% 11%

National survey of chaplains who work at least 15% time in palliative care

What Do Chaplains Do?

http://www.advocatehealth.com/body.cfm?id=9&eformid=120%20Massey et al., 2015

Spiritual Care in Practice: Case Studies in

Healthcare ChaplaincyGeorge Fitchett and Steve Nolan, Editors 

2015, Jessica Kingsley Publishershttp://www.jkp.com/usa/spiritual‐care‐in‐practice.html

Chaplain Case Studies

Discipline for Pastoral Care Giving – Arthur Lucas, 2001

Profile• Concept of Holy• Meaning• Hope• Community

Outcome Oriented Care Spiritual Care

Not‐visited by Chaplain(N = 8,480)

Visited by Chaplain(N = 498)

Overall rating of care given at hospital (1‐5) 4.63 ± 0.01 4.72 ± 0.03**

What number would you use to rate this hospital during your stay? (0‐10)

8.80 ± 0.02 8.97 ± 0.07*

Likelihood of your recommending this hospital to others (1‐5)

4.59 ± 0.01 4.67 ± 0.03

Would you recommend this hospital to your friends and family? (1‐4)

3.70 ± 0.01 3.77 ± 0.02*

Degree to which hospital staff addressed your spiritual needs (1‐5)

4.23 ± 0.01 4.38 ± 0.04**

Degree to which hospital staff addressed your emotional needs (1‐5)

4.38 ± 0.01 4.44 ± 0.04

Satisfaction Scores for Patients Visited and Not Visited by Chaplains (New York City)

*p < .05. **p < .01.Marin et al. 2015

Sample (study) Findings

356 family members of patients who died in ICU, Seattle(Wall et al, 2007)

Rating spiritual care as excellent was associated with higher ratings of satisfaction with ICU care overall 

275 family members of patients who died in ICU, Seattle(Johnson et al., 2014)

Chaplains’ care was associated with increased overall family satisfaction with ICU care and with satisfaction with decision‐making in the ICU

Measures of Outcomes: Patient/Family Satisfaction

19.68

6.56

22.08

11.58

0

10

20

30

Baseline Anxiety Discharge Anxiety

Mea

n A

nxie

ty S

core

(0-6

3)

Intervention Gp (N=25) Control Gp (N=24)

p=0.05

Source: Iler et al. (2001). 

Effect of Chaplain Visit on COPD Patient Anxiety

Avg QoL= 19, SD=7.9

N=299 patients; Balboni et al, 2010

Measures of Outcome: QoL(& treatment preferences & cost of care)

Lyndes et al., J Health Care Chaplaincy, 2012; Fitchett et al, J Palliat Med., 2011;

Physicians Chaplains

Physicians emphasize chaplain contribution to key outcomes

Chaplains emphasize process (presence)

Address spiritual suffering

Chaplains provide a listening, supportive presence

Improve family-team communication

Chaplains comment on outcomes

Physicians are aware of process

Bi-Lingual Chaplains

The Changing Chaplaincy ParadigmPeriod Paradigm for ChaplaincyEarly 20th

century Pastoral care as response to individual sin

Mid‐20th century

Chaplaincy was shaped by  Rogerian model of client‐centered counseling

Early 21st 

century

Pastoral care as response to individual need (Gleason)

Research‐informed, outcome‐oriented chaplaincy (Lucas, 2001)

Gleason, 1998; Fitchett et al., 2014

JOINT RESEARCH COUNCIL

Chartered by the Association of Professional Chaplains, with organizational partners: Association for Clinical Pastoral Education  Canadian Association for Spiritual Care  HealthCare Chaplaincy Network  National Association of Catholic Chaplains  Neshama: Association of Jewish Chaplains  Scottish Association of Chaplains in Healthcare  Spiritual Care Australia

Next Steps for Research-Informed Chaplaincy

Watch for the JRC website soon

Priority RankEvaluate screening tools used to identify patients with spiritual needs 1st

Develop and evaluate conversation models for spiritual conversations 2nd

Evaluate the effectiveness of spiritual care 3rd

Develop and evaluate spiritual interventions 4th

Determine the prevalence of spiritual distress 5th

Selman et al 2014, n=807 clinicians

A Research Agenda for Chaplaincy

• Need to teach research literacy skills in CPE residency programs

• Create research journal clubs in chaplaincy departments

• Demonstrate research literacy for chaplaincy certification

Chaplain Education and Certification

Fitchett et al , 2012

Any Research Education

Yes Some No Total

CPE Centers 3 (14%) 5 (24%) 13 (62%) 21

CPE Systems 0 (0%) 2 (40%) 3 (60%) 5

All Programs 3 (12%) 7 (27%) 16 (62%) 26

Margin of Error 12% 17% 19%

Phase 1 – July 1, 2015 - June 30, 2016Phase 2 – July 1, 2016 – June 30, 2019

Core activities• 16 Templeton Chaplain Research Fellowships• Research literacy curriculum development grants to 70 CPE residency program• Free online continuing education Introduction to Research course for members of chaplaincy organizations 

Co‐led by George Fitchett (Rush) & Wendy Cadge (Brandeis)

Together these initiatives will create over 800 research literate chaplains strengthening understandings of religion, spirituality and health and transforming chaplaincy as a profession.

TRANSFORMING CHAPLAINCYPromoting Research Literacyfor Improved Patient Outcomes

www.researchliteratechaplaincy.org

http://www.healthcarechaplaincy.org/docs/publications/templeton_research/hcc_research_handbook_final.pdf

46

APC Webinar Journal Club 6Future Sessions

DatesKeeping Up With Important Research for Chaplains

Session 1, September 20, 2016

Session 2, November 15, 2016

Session 3, January 10, 2017

Session 4, March 14, 2017

Session 5, May 9, 2017

Open to all

Health Care ChaplaincyImproving our Care and

Making our CaseThrough Research

-.46***

.69***

Hopelessness

Depression

Religious Belief

.17**

***p<.001, **p<.01.N = 271

When it’s over, I want to say: all my life I was a bride married to amazement.from When Death Comesby Mary Oliver