Moral Injury, Spiritual Care and the Role of Chaplains: An Exploratory Scoping Review of Literature and Resources

This scoping review considered the role of chaplains with regard to 'moral injury'. Moral injury is gaining increasing notoriety. This is due to greater recognition that trauma (in its various forms) can cause much deeper inflictions and afflictions than just physiological or psychological harm, for there may also be wounds affecting the 'soul' that are far more difficult to heal-if at all. As part of a larger research program exploring moral injury, a scoping review of literature and other resources was implemented utilising Arksey and O'Malley's scoping method (Int J Soc Res Methodol 8(1):19-32, 2005) to focus upon moral injury, spirituality (including religion) and chaplaincy. Of the total number of articles and/or resources noting the term 'moral injury' in relation to spiritual/religious issues (n = 482), the results revealed 60 resources that specifically noted moral injury and chaplains (or other similar bestowed title). The majority of these resources were clearly positive about the role (or the potential role) of chaplains with regard to mental health issues and/or moral injury. The World Health Organization International Classification of Diseases: Australian Modification of Health Interventions to the International Statistical Classification of Diseases and related Health problems (10th revision, vol 3-WHO ICD-10-AM, Geneva, 2002), was utilised as a coding framework to classify and identify distinct chaplaincy roles and interventions with regard to assisting people with moral injury. Several recommendations are made concerning moral injury and chaplaincy, most particularly the need for greater research to be conducted.

Recent Progress in Chaplaincy-Related Research

In light of the continued growth of chaplaincy-related research this paper presents an overview of important findings. The review summarizes research in six broad areas: what chaplains do; the importance of religion and spiritual care to patients and families; the impact of chaplains' spiritual care on the patient experience; the impact of chaplain care on other patient outcomes; spiritual needs and chaplain care in palliative and end of life care; and chaplain care for staff colleagues. It concludes with a description of several innovative and important new studies of chaplain care and notes areas for future investigation.

Burnout and Resilience Among Neurosciences Critical Care Unit Staff

BACKGROUND

Preventing burnout and promoting resiliency are important for health professionals' well-being and quality of patient care, as individuals with high levels of burnout are more likely to self-report suboptimal patient interactions. The purpose of this study was to characterize resiliency and burnout among health care professionals in the neurosciences critical care unit (NCCU) at a tertiary care center.

METHODS

All NCCU clinical staff were invited to participate in a Qualtrics^® electronic survey between November 2016 and August 2017. The survey assessed burnout using the abbreviated Maslach Burnout Inventory (aMBI) and resiliency using the ten-question Connor-Davidson Resilience Scale (CD-RISC 10). Higher scores on each aMBI subsection (range 0-18) indicate higher levels of each characteristic; larger resiliency scores (range 0-40) indicate higher resiliency. Categorical variables were compared using the Chi-square test and continuous variables using the Mann-Whitney U test or independent samples t test.

RESULTS

A total of 65 participants (65/70, 93%) were included in the final analysis. Of respondents, 49 (75%) were nurses, 49 (75%) were female, and mean age was 34 years. Median emotional exhaustion, depersonalization, and personal accomplishment scores were as follows: 8 (IQR 6-11), 3 (IQR 0-6), and 15 (IQR 13-16). High emotional exhaustion scores and high depersonalization scores were reported in 45% (n = 29) and 28% (n = 18) of participants, respectively. Longer time working in the NCCU (1-5 years vs. less than 1 year) was independently associated with higher emotional exhaustion scores (p = 0.012). When compared to agnostic/atheist backgrounds, Catholicism was independently associated with higher personal accomplishment scores (p = 0.026). The median resiliency score was 31 (IQR 28-36). Older age was independently associated with higher resiliency scores (p = 0.044).

CONCLUSIONS

This study is the first to characterize levels of burnout and resiliency among NCCU providers. A significant minority of participants reported high levels of emotional exhaustion and depersonalization, with those working longer in the NCCU more likely to experience emotional exhaustion. Efforts to improve the current work environments to optimally support the emotional needs of staff are needed to allow care providers to thrive and to promote longevity among NCCU providers.

Feasibility and acceptability of a telephone-based chaplaincy intervention in a large, outpatient oncology center

Purpose

Telechaplaincy (the use of telecommunications and virtual technology to deliver spiritual and religious care by healthcare chaplains or other religious/spiritual leaders) is a relatively novel intervention that has increasingly been used in recent years, and especially during COVID-19. Telephone-based chaplaincy is one mode of telechaplaincy. The purpose of this study was to (1) describe telephone-based chaplaincy interventions delivered as the first point of contact to patients who screen positive for religious/spiritual concern(s) using an electronic data system, and (2) assess the feasibility and acceptability of delivering interventions in an outpatient cancer institute using this methodology.

Methods

Patients were screened for religious and spiritual (R/S) concern(s) using an electronic data system. Patients indicating R/S concern(s) were offered a telephone-based chaplaincy intervention and asked to complete a survey assessing acceptability of the intervention. Feasibility and acceptability data were collected.

Results

Thirty percent of screened patients indicated R/S concern(s). Telephone-based chaplaincy interventions were offered to 100% of eligible patients, establishing contact with 61% of eligible patients, and offering chaplaincy interventions to 48% of those patients. Survey participants report high acceptability of the offered intervention.

Conclusion

This is the first study examining feasibility and acceptability of telephone-based chaplaincy with oncology patients. Telephone-based chaplaincy is feasible and acceptable within an outpatient oncology setting, supporting the promise of this interventional strategy. Further research is needed to refine practices.

Moral Injury: Contextualized Care

Amidst the return of military personnel from post-9/11 conflicts, a construct describing the readjustment challenges of some has received increasing attention: moral injury. This term has been variably defined with mental health professionals more recently conceiving of it as a transgression of moral beliefs and expectations that are witnessed, perpetrated, or allowed by the individual. To the extent that morality is a system of conceptualizing right and wrong, individuals' moral systems are in large measure developmentally and socially derived and interpreted. Thus, in seeking to provide care and aid in reintegration for combat veterans, it is necessary to consider communities that have contributed to an individual's formation and that might have participated in the interpretation of his/her suffering. This can take many forms, but given that morality is often complexly intertwined with issues of religion, faith, and spirituality for many individuals, and recognizing that much of the current focus on moral injury is emanating out of healthcare contexts, we devote particular attention to how chaplains might be more intentionally engaged in healthcare systems such as the Veterans Health Administration to provide non-judgmental, person-centered, culturally-relevant care rooted in communities of practice to veterans with moral injury.

Theory and practice of chaplain's spiritual care process: A psychiatrist's experiences of chaplaincy and conceptualizing trans-personal model of mindfulness

BACKGROUND

Of various spiritual care methods, mindfulness meditation has found consistent application in clinical intervention and research. "Listening presence," a chaplain's model of mindfulness and its trans-personal application in spiritual care is least understood and studied.

AIM

The aim was to develop a conceptualized understanding of chaplain's spiritual care process based on neuro-physiological principles of mindfulness and interpersonal empathy.

MATERIALS AND METHODS

Current understandings on neuro-physiological mechanisms of mindfulness-based interventions (MBI) and interpersonal empathy such as theory of mind and mirror neuron system are used to build a theoretical framework for chaplain's spiritual care process. Practical application of this theoretical model is illustrated using a carefully recorded clinical interaction, in verbatim, between chaplain and his patient. Qualitative findings from this verbatim are systematically analyzed using neuro-physiological principles.

RESULTS AND DISCUSSION

Chaplain's deep listening skills to experience patient's pain and suffering, awareness of his emotions/memories triggered by patient's story and ability to set aside personal emotions, and judgmental thoughts formed intra-personal mindfulness. Chaplain's insights on and ability to remain mindfully aware of possible emotions/thoughts in the patient, and facilitating patient to return and re-return to become aware of internal emotions/thoughts helps the patient develop own intra-personal mindfulness leading to self-healing. This form of care involving chaplain's mindfulness of emotions/thoughts of another individual, that is, patient, may be conceptualized as trans-personal model of MBI.

CONCLUSION

Chaplain's approach may be a legitimate form of psychological therapy that includes inter and intra-personal mindfulness. Neuro-physiological mechanisms of empathy that underlie Chaplain's spiritual care process may establish it as an evidence-based clinical method of care.

The Palliative Care Chaplain as Story Catcher

The role of the professional chaplain on the palliative care team in the health care setting formalizes the concern for the emotional, spiritual, and social well-being of the care recipients and their caregivers. The chaplain also has a peculiar role on the team, in that her most fundamental task is her intentional listening-and-hearing of the other person's story. One palliative chaplain introduces herself as a Story Catcher to care recipients, in an effort both to overcome the resistance some may have to her presence on the team and communicate her essential role and intent in providing spiritual care. This self-appointed sobriquet resonates with the author's embrace of the theory and practice of the late theologian, educator, and civil rights activist Nelle Morton, who coined the phrase "hearing into speech" to describe the process by which another person, through being truly heard and entering into a relationship with the hearer, claims her/his own truth, hope, and identity in the face of adversity. The chaplain as Story Catcher functions as the agent of healing and hope for those who choose to tell their stories and are heard, as they resist their illness and death rather than submit to its indignity.

The Intersection of Neurology and Religion: A Survey of Hospital Chaplains on Death by Neurologic Criteria

BACKGROUND

To enhance knowledge about religious objections to brain death/death by neurologic criteria (BD/DNC), we surveyed hospital chaplains about their experience with and beliefs about BD/DNC.

METHODS

We distributed an online survey to five chaplaincy organizations between February and July 2019.

RESULTS

There were 512 respondents from all regions of the USA; they were predominantly Christian (450 of 497; 91%), board certified (413 of 490; 84%), and employed by community hospitals (309 of 511; 61%). Half (274 of 508; 56%) of the respondents had been involved in a case in which a family objected to BD/DNC on the basis of their religious beliefs. In 20% of cases involving a religious objection, the patient was Buddhist, Hindu, Jewish, or Muslim. Most respondents believed that a person who is declared brain dead in accordance with the American Academy of Neurology standard is dead (427 of 510; 84%). A minority of respondents believed that a family should be able to choose whether an assessment for determination of BD/DNC is performed (81 of 512; 16%) or whether organ support is discontinued after BD/DNC (154 of 510; 30%). These beliefs were all significantly related to lack of awareness that BD/DNC is the medical and legal equivalent of cardiopulmonary death throughout the USA and that organ support is routinely discontinued after BD/DNC, outside of organ donation.

CONCLUSIONS

Hospital chaplains, who work at the intersection between religion and medicine, commonly encounter religious objections to BD/DNC. To prepare them for these situations, they should receive additional education about BD/DNC and management of religious objections to BD/DNC.

Defining and Operationalizing Chaplain Presence: A Review

Presence is a vaguely defined word often used by chaplains to describe their work with patients, families, and staff. The current literature defines presence as a process of creating a trusting atmosphere for nonjudgmental and compassionate sharing in another's story. Presence has no apparent agenda, much flexibility, and requires emotional vulnerability in the chaplain interactions. This presents four problems: distinguishing chaplain presence from presence by other providers; dependence on chaplain vulnerability in the encounter; difficulty of assessing impact on patient/family care; and clearly communicating the importance of presence to the interprofessional team. An operational definition is provided including parameters for care and intended outcomes.

The Role of the Chaplain as a Patient Navigator and Advocate for Patients in the Intensive Care Unit: One Academic Medical Center's Experience

Effective communication between intensive care unit (ICU) staff, and patients and their families, can help increase understanding, trust, and goals-of-care decisions. Many strategies focus on enhancing communication by increasing family meetings or adding patient navigators. In our ICU, we implemented both strategies, uniquely appointing a chaplain for the patient navigator role. We then surveyed ICU staff on their perceptions of the chaplain/patient navigator, which yielded several valuable insights. Although all staff supported a strong chaplaincy presence, many had concerns about the dual chaplain/patient navigator role. Based on our mixed results, we encourage further exploration to optimize the chaplain role in the ICU.

Integrating Spiritual Care into Palliative Consultation: A Case Study in Expanded Practice

Recognizing and addressing spiritual needs has long been identified as a key component of palliative care (PC). More often than not, the provision of spiritual care involves referral to a hospital chaplain. In this study, we aim to describe the role of a PC chaplain embedded within the interdisciplinary PC team and demonstrate how this palliative chaplain role differs from that of a traditional hospital chaplain. We postulate that integrating spiritual care provision into a PC team may offer a broader spiritual care experience for patients receiving PC and begin to delineate expanded clinical roles for the palliative chaplain.

Patient Appreciation of Student Chaplain Visits During Their Hospitalization

Spiritual care is associated with improved health outcomes and higher patient satisfaction. However, chaplains often cover many hospital units and thus may not be able to serve all patients. Involving student chaplains in patient spiritual care may allow for more patients to experience the support of spiritual care. In this study, we surveyed 93 patients hospitalized on general medical units at a tertiary care center who were visited by nine student chaplain summer interns. The results indicated that the majority of patients appreciated student chaplain visits and these encounters may have positively influenced their overall hospital experience. Thus, student chaplains could be a way to extend valuable spiritual care in settings where chaplaincy staff shortages preclude access.

National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care, Fourth Edition: Why is This Important to Chaplains?

The Clinical Practice Guidelines for Quality Palliative Care, fourth edition were recently published. Through the involvement of the Association of Professional Chaplains and the HealthCare Chaplaincy Network, this is the first time that any chaplains have been an official party to the development of these guidelines. The expectation set by the guidelines is that all health care professionals (including all chaplains) caring for people living with serious illness at any stage of illness, at any age, and in any setting will integrate core palliative care principles and best practices into their routine care and have sufficient training to complete an assessment of the patient and address common sources of suffering. The article presents a summary of the content of the guidelines and their implications for clinical practice and training with emphasis on the practice and training of professional chaplains.

Examining Factors Associated with Utilization of Chaplains in the Acute Care Setting

Hospitalized persons want their spiritual needs addressed and discussed by the healthcare team, but medical providers and nurses lack the necessary training. Patients want chaplaincy care, but very few receive it, and little is known about utilization factors. To identify the population characteristics associated with the utilization of chaplaincy services, hospitalization data from March 2012 to July 2017 were analyzed (N = 15,242 patients). Religiously affiliated individuals and those with the most acute health needs were more likely to receive chaplaincy care and received more total care. Patient-centered healthcare models may need to evaluate strategic integration of spiritual care beyond reactive spiritual care provision.

Implementing Integrated Mental Health and Chaplain Care in a National Quality Improvement Initiative

This column describes the development, implementation, and outcomes of a quality improvement learning collaborative that aimed to better integrate chaplaincy with mental health care services at 14 participating health care facilities evenly distributed across the U.S. Department of Veterans Affairs and Department of Defense. Teams of health care chaplains and mental health professionals from participating sites sought to improve cross-disciplinary service integration in six key domains: screening, referrals, assessment, communication and documentation, cross-disciplinary training, and role clarification. Chaplains and mental health providers across all facilities at participating sites were significantly more likely post-collaboration to report having a clear understanding of how to collaborate and to report using a routine process for screening patients who could benefit from seeing a professional from the other discipline. Foundational efforts to enhance cross-disciplinary awareness and screening practices between chaplains and mental health professionals appear particularly promising.

Moral Injury and the Absurd: The suffering of moral paradox

Drawing upon qualitative and construct validity evidence within MI research and the oral histories of combat-exposed Veterans, this paper explores the role of moral paradox (MP) as a precondition of moral injury (MI). Research is recommended to clearly delineate MP as a causative factor leading to more intractable cases of MI in the definitional literature, beyond the recognized impact of perpetration and betrayal-based conditions. Veteran stories collected during the normal course of providing spiritual care to combat-exposed Veterans and used by permission will provide insight into the theoretical concepts and interrelations of MP; proposed here as: circumstances in which moral obligations and/or ethical values come into conflict, forcing a choice between sides, none of which can be honored without violating the other. Acquainted with religious traditions that elucidate the perplexity and liberating effects of paradox, the work of Chaplains will also be recommended to address the problem of MP in wartime situations, highlighting the efficacy of acceptance-based spiritual interventions and therapeutic programs. Psychological and spiritual interventions that facilitate self-transcendence and non-dual awareness through experiential acceptance and a subscale measuring paradox-induced injury will be recommended for future research as well.

Australian Chaplaincy Support of Health Care Staff: Presence, Professional and Relational

The aim of the research was to explore how health care staff experienced support from hospital chaplains. The context for the study was two acute care hospitals in the South Australian Government's public health system: one paediatric, the other adult. The research utilised semi-structured interviews that were transcribed and analysed and coded using established methodologies for qualitative studies. The results and subsequent analysis revealed two overarching themes which emerged from the narratives of staff members. Support from chaplains was perceived as being (i) part of the hospital institution, (ii) a participant in the overall care team, (iii) as a symbolic presence, and (iv) available in the diverse settings of education, crisis and trauma events and debriefings. Chaplaincy support was experienced in relational and spontaneous care in serendipitous meetings with staff or at a workstation which was experienced as inclusive and respectful.

Lifting the Lid on Chaplaincy: A First Look at Findings from Chaplains' Case Study Research

Since the publication of Chaplain Rhonda Cooper's case study in 2011, chaplain case studies have become part of the chaplaincy research agenda. Chaplains from North America, Europe and Australia have published almost 30, and this article offers a first look at the findings that are emerging from these cases. Locating chaplains' case studies at the juxtaposition of 'outcome oriented chaplaincy' and so-called 'process-oriented chaplaincy', the article argues chaplains' case studies dissolve what is a false dichotomy. Utilizing an analytical framework provided by ongoing debate among psychotherapists, the article argues that the emerging data suggests chaplaincy manifests features that are common to psychotherapy but also that there are significant factors specific to chaplaincy. From this analysis, the article observes the case studies paint a picture of chaplaincy care as a religious intervention. However, contemporary chaplaincy exists within a rapidly changing context, where increasing numbers of people are religiously unaffiliated. The article concludes by suggesting that chaplains' case study research poses significant theological, ethical and existential questions to chaplaincy about how to respond to its changing context. The article ends with a call for chaplaincy care to be radically and explicitly remodeled as care for the human spirit regardless of religious affiliation.

Mapping the healthcare chaplaincy workforce: a baseline description

Changing U.S. demographics and the growing emphasis on diversity in the healthcare workforce requires professional healthcare chaplains to examine the characteristics of its own workforce. Previous research suggested that chaplains were mainly Caucasian/White and Mainline Protestant. To explore further, this paper presents a baseline sketch of the workforce and identifies important differences among board-certified chaplains (BCCs), certified educators, certified educator candidates (CECs), and clinical pastoral education (CPE) students. Although missing data quickly became the central story of the analysis and thus requires caution in comparison, the preliminary results suggest BCCs and Certified Educators are older and Whiter/more Caucasian than CECs and CPE students. At least one-third of chaplains and Certified Educators identify as Mainline Protestant, but students and CECs reported greater variation in religious affiliation. Chaplains may be similar to users of healthcare and hospitalized persons in terms of gender and race/ethnicity. Recommendations include suggestions for improving the data infrastructure of professional chaplaincy organizations.

Spiritual Care of Inpatients Focusing on Outcomes and the Role of Chaplaincy Services: A Systematic Review

OBJECTIVE

To identify demographic trends associated with patient utilization and healthcare provider request for spiritual care services and to describe the impact of spiritual care on the quality of life (QoL), spiritual well-being (SWB) and level of satisfaction (SAT) of hospitalized patients.

PATIENTS AND METHODS

A systematic search of Ovid MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, was combined with review of relevant bibliographies. A total of 464 titles and abstracts were reviewed. Data were independently extracted by reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data on the effects of spiritual interventions on QoL, SWB and SAT were extracted, along with demographic data reflecting chaplain services. The results of the studies are presented narratively and in a qualitative manner.

RESULTS

Observational or experimental studies investigating chaplain utilization demographics (n = 12), patient satisfaction (n = 9) and QoL/SWB (n = 3) were included. Perceived severity of illness, average length of stay and older age were consistently found to be predictors of higher need for spiritual care. Receipt of spiritual care was correlated with increased patient and family satisfaction, independent of clinical outcome. Chaplain interventions were associated with improvement in perceived QoL and SWB. In spite of this, healthcare workers rarely attempt to explore the patient's or family's need for spiritual care, with the majority of chaplaincy consults occurring in the final day of the patient's life, potentially leading to a failure to meet the spiritual needs of non-terminal patients who have spiritual trauma related to their resolving illnesses.

CONCLUSION

Attention to the spiritual needs of hospitalized patients is an essential yet often overlooked aspect of patient care. Chaplains serve as spiritual care specialists whose services can enhance the hospital experience, improve patient satisfaction and help to bridge potential gaps between the patient and medical providers.

The Warrior's Journey Intervention: A Chaplain-Led Motivational, Preparatory Exercise for Enhancing Treatment Success

Outcome literature has shown poor treatment engagement in efficacious, evidence-based post-traumatic stress disorder (PTSD) programs among returning veterans with combat-related psychological symptoms and calls for the development of motivational, preparatory exercises that circumvent stigma-related barriers and are delivered before or during the orientation phase of treatment. The psychological states of hope, meaning, and guilt have been found to impact motivation for treatment and the development and maintenance of post-trauma pathology and symptom severity. Given a chaplain's less stigmatized role, as compared to mental health providers, and proficiency in assessing these states and providing interventions that mediate change, often before a veteran is enrolled in a PTSD treatment program, this paper introduces a brief, chaplain-led, preparatory exercise called the "Warrior's Journey Intervention" (WJI). This narrative based, meaning-making exercise is designed to improve motivation for treatment and mitigate post-trauma symptoms by impacting hope, meaning, and guilt through use of a universally shared, metaphoric story of trauma recovery. A case study will demonstrate use of the intervention, observe its effects, and analyze mechanisms of change. Research is recommended at the end of the article to test the hypothesis that the intervention promotes motivation for treatment and reduces symptoms of PTSD and Moral Injury (MI). A standardized manual for the exercise is available from author.

The Language of Compassion: Hospital Chaplains' Compassion Capacity Reduces Patient Depression via Other-Oriented, Inclusive Language

Objectives

Although hospital chaplains play a critical role in delivering emotional and spiritual care to a broad range of both religious and non-religious patients, there is remarkably little research on the best practices or "active ingredients" of chaplain spiritual consults. Here, we examined how chaplains' compassion capacity was associated with their linguistic behavior with hospitalized inpatients, and how their language in turn related to patient outcomes.

Methods

Hospital chaplains (n = 16) completed self-report measures that together were operationalized as self-reported "compassion capacity." Next, chaplains conducted consultations with inpatients (n = 101) in five hospitals. Consultations were audio-recorded, transcribed, and analyzed using Linguistic Inquiry Word Count (LIWC). We used exploratory structural equation modeling to identify associations between chaplain-reported compassion capacity, chaplain linguistic behavior, and patient depression after the consultation.

Results

We found that compassion capacity was significantly associated with chaplains' LIWC clout scores, a variable that reflects a confident leadership, inclusive, and other-oriented linguistic style. Clout scores, in turn, were negatively associated with patient depression levels controlling for pre-consult distress, indicating that patients seen by chaplains displaying high levels of clout had lower levels of depression after the consultation. Compassion capacity exerted a statistically significant indirect effect on patient depression via increased clout language.

Conclusions

These findings inform our understanding of the linguistic patterns underlying compassionate and effective chaplain-patient consultations and contribute to a deeper understanding of the skillful means by which compassion may be manifest to reduce suffering and enhance well-being in individuals at their most vulnerable.

Complex Moral Injury: Shattered Moral Assumptions

An infographic model of moral injury (MI) is introduced in this conceptual paper that distinguishes the development of a worldview discrepancy-induced genus of MI, called complex moral injury (C-MI), from a standard expression of moral injury (S-MI), clearly delineated as perpetration-focused and a violation of moral belief in the contemporary view. It builds upon a previous essay that examined the potential of paradoxical circumstance (e.g., clashes of value, competing moral expectations, and moral paradox) to inflict MI among military personnel during wartime (Fleming in J Relig Health 60(5):3012-3033, 2021). Accordingly, it heeds Litz et al.'s recommendation to expand the research of MI beyond the effects of perpetration and investigate the impact of morally injurious events that shake one's core moral beliefs about the world and self (Litz et al. in Clin Psychol Rev 29(8):695-706, 2009). A review of definitional, scale, and qualitative studies shows evidence of a nuanced and complex form of MI that presents as moral disorientation and is a response to a disruption and subsequent failure of foundational moral beliefs to adequately appraise ethical problems and inform moral identity. Interrelations between MI, assumptive world, and meaning theories suggest the mechanism of C-MI and potential therapies. Case studies from a Veterans Administration hospital in the United States and a walk through the diagram will help illustrate the model. Clinical implications of a definition that includes morally injurious events that shatter fundamental moral assumptions are discussed. The role of chaplains in facilitating acceptance and meaning-making processes is recommended for C-MI recovery. Acknowledging the model's need for empirical support, a plausible scale is discussed for future research.

Beyond the 12 steps: Integrating chaplaincy services into Veteran Affairs substance use specialty care

Background: Interprofessional training is increasing in focus within medical education. Although substance use treatment has long been interprofessional in nature, chaplaincy has been relatively absent in outpatient settings. Since 2013, the Veterans Health Administration has supported an Interprofessional Advanced Fellowship in Addiction Treatment (IAFAT), with 7 sites nationally recruiting across multiple health care disciplines. In the fall of 2017, Veteran Affairs Connecticut Healthcare System (VACHS) became the first such fellowship to expand its recruitment to include chaplain fellows. We seek to share rationale for recruiting chaplains, current curriculum and curricular needs, and the potential roles of chaplains in outpatient addiction treatment. Methods: Collaborating with the office of chaplaincy education, we describe the process of chaplain recruitment, incorporation into a new treatment setting, and supervision, and we report on the feasibility of this innovative training initiative. Results: During the first year, the chaplain fellow has developed and maintained a new clinical service in an outpatient substance use disorder (SUD) specialty care setting, delivering over 150 hours of group and individual treatment to veterans. He has provided 12 presentations to staff on the role of a chaplain and other related topics, as well as written an article on the topic of addiction for a clergy audience. Anecdotally, staff satisfaction has been high, and the current chaplain is helping to recruit for his replacement. Limitations: As a feasibility pilot project, there is no outcome and very limited quantitative data. Conclusions: Chaplain fellows can be successfully incorporated into outpatient SUD clinics with a noticeable degree of fellow, staff, and patient satisfaction.

Staff Perceptions of Chaplains in a Neurosciences Critical Care Unit

Hospital chaplains often visit critically ill patients, but neurosciences critical care unit (NCCU) staff beliefs surrounding chaplains have not been characterized. In this study, we used Qualtrics^® to survey 70 NCCU healthcare workers about their attitudes toward chaplains in the NCCU. Chaplains were seen positively by staff but were less likely to be viewed as part of the care team by staff with more than five years of NCCU experience. The results of this study will allow chaplaincy programs to target staff education efforts in order to enhance the care provided to patients in critical care settings.