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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
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