The Priority List: An Evidence-Based Approach to Selecting Patients for Chaplain Visits

This paper examines three methods chaplains have historically used to identify patients they should see: rounding, referral, and protocol-based systems. Mercy Health is in the initial stages of adopting an expanded protocol-based system known as "the priority list." Central to the idea is the proposal and testing of clinical indicators that patients would benefit from chaplain support. Practical steps are offered for other pastoral departments in the development, implementation, and interpretation of their own lists.

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.

"The Patient Is Dying, Please Call the Chaplain": The Activities of Chaplains in One Medical Center's Intensive Care Units

CONTEXT

Patients and families commonly experience spiritual stress during an intensive care unit (ICU) admission. Although most patients report that they want spiritual support, little is known about how these issues are addressed by hospital chaplains.

OBJECTIVES

To describe the prevalence, timing, and nature of hospital chaplain encounters in ICUs.

METHODS

This was a retrospective cross-sectional study of adult ICUs at an academic medical center. Measures included days from ICU admission to initial chaplain visit, days from chaplain visit to ICU death or discharge, hospital and ICU lengths of stay, severity of illness at ICU admission and chaplain visit, and chart documentation of chaplain communication with the ICU team.

RESULTS

Of a total of 4169 ICU admissions over six months, 248 (5.9%) patients were seen by chaplains. Of the 246 patients who died in an ICU, 197 (80%) were seen by a chaplain. There was a median of two days from ICU admission to chaplain encounter and a median of one day from chaplain encounter to ICU discharge or death. Chaplains communicated with nurses after 141 encounters (56.9%) but with physicians after only 14 encounters (5.6%); there was no documented communication in 55 encounters (22%).

CONCLUSION

In the ICUs at this tertiary medical center, chaplain visits are uncommon and generally occur just before death among ICU patients. Communication between chaplains and physicians is rare. Chaplaincy service is primarily reserved for dying patients and their family members rather than providing proactive spiritual support. These observations highlight the need to better understand challenges and barriers to optimal chaplain involvement in ICU patient care.

Family involvement at the end-of-life and receipt of quality care

CONTEXT

Most patients will lose decision-making capacity at the end of life. Little is known about the quality of care received by patients who have family involved in their care.

OBJECTIVES

To evaluate differences in the receipt of quality end-of-life care for patients who died with and without family involvement.

METHODS

We retrospectively reviewed the charts of 34,290 decedents from 146 acute and long-term care Veterans Affairs facilities between 2010 and 2011. Outcomes included: (1) palliative care consult, (2) chaplain visit, and 3) death in an inpatient hospice or palliative care unit. We also assessed "do not resuscitate" (DNR) orders. Family involvement was defined as documented discussions with the health care team in the last month of life. We used logistic regression adjusted for demographics, comorbidity, and clustered by facility. For chaplain visit, hospice or palliative care unit death, and DNR, we additionally adjusted for palliative care consults.

RESULTS

Mean (SD) age was 74 (±12) years, 98% were men, and 19% were nonwhite. Most decedents (94.2%) had involved family. Veterans with involved family were more likely to have had a palliative care consult, adjusted odds ratio (AOR) 4.31 (95% CI 3.90-4.76); a chaplain visit, AOR 1.18 (95% CI 1.07-1.31); and a DNR order, AOR 4.59 (95% CI 4.08-5.16) but not more likely to die in a hospice or palliative care unit.

CONCLUSION

Family involvement at the end of life is associated with receipt of palliative care consultation and a chaplain visit and a higher likelihood of a DNR order. Clinicians should support early advance care planning for vulnerable patients who may lack family or friends.

Pain control and chaplaincy in Aotearoa New Zealand

This paper summarizes the results of 100 New Zealand health care chaplains with regard to their involvement in issues concerning pain control within the New Zealand health care context. Both quantitative (via survey) and qualitative methods (in-depth interviewing) were utilized. The findings of this study indicated that approximately 52 % of surveyed hospital chaplains had provided some form of pastoral intervention directly to patients and/or their families dealing with issues concerning pain and that approximately 30 % of hospital chaplains had assisted clinical staff with issues concerning pain. NZ chaplaincy personnel involved in pain-related issues utilized a number of pastoral interventions to assist patients, their families and clinical staff. Differences of involvement between professionally stipended hospital chaplains and their volunteer chaplaincy assistants are noted, as are the perspectives of interviewed chaplains about their pastoral interventions with issues relating to pain. Some implications of this study with respect to chaplaincy utility, training and collaboration with clinical staff are noted, as are comparisons with international findings.

Utilization of hospital-based chaplain services among newly diagnosed male Veterans Affairs colorectal cancer patients

The aim of the study was to examine utilization of chaplain services among Veterans Affairs patients with colorectal cancer (CRC). In 2009, the Cancer Care Assessment and Responsive Evaluation Studies questionnaire was mailed to VA CRC patients diagnosed in 2008 (67 % response rate). Multivariable logistic regression examined factors associated with chaplain utilization. Of 918 male respondents, 36 % reported utilizing chaplains. Chaplain services were more likely to be utilized by patients with higher pain levels (OR = 1.017; 95 % CI = 0.999-1.035), younger age (age OR = 0.979; 95 % CI = 0.964-0.996), and later cancer stage (early stage OR = 0.743; 95 % CI = 0.559-0.985). Chaplain services are most utilized by younger, sicker patients.

Hospitalized young adults' expectations of pastoral interventions

The objective of this analysis of 4500 inpatients was to identify the experience and expectations of 18-35 year olds regarding chaplain visitation and to compare results with data from older adults. 71% of young adults reported wanting to be visited by a chaplain; 45.5% were visited; 68% indicated that this was important. Young adults value chaplains' role as a sign of God's care and presence (77.4%), in providing support for family (73.6%), being present during times of anxiety (66.0%), and praying/reading scripture with them (62.3%). Results were similar to older respondents, but young adults were more likely to value ethical counsel from chaplains (58.5% vs. 38.2%). This study provides clinically relevant information and suggestions for further research.

Teaching research in clinical pastoral education: a survey of model practices

The Association of Professional Chaplains (APC) developed Standards of Practice for Acute and Long-term settings. Standard 12 promotes research-literate chaplains as important for the profession. Since many chaplains receive training in clinical pastoral education (CPE) residency programs, the aim of this study was to identify model practices for the teaching of research in such programs. Using a purposeful sample, this study identified 11 programs that offered "consistent and substantive" education in research. Common features included the existence of a research champion, a culture supportive of research, and the availability of institutional resources. The study identified models and methodologies that CPE programs can adopt.

Who needs chaplain's visitation in general hospitals? Assessing patients with psychosocial and religious needs

Owing to the declining length of patients' hospital stay in recent years, chaplains need evidence-based criteria to decide which patients are likely to have the greatest psychosocial and/or religious-spiritual needs. Therefore, the present pilot study aims at sorting out evidence-based criteria to assess patients with lack of coping resources. A total of 610 patients in the German-speaking part of Switzerland were surveyed with regard to their psychosocial health. The results suggest that lack of vitality (including health condition), lack of support and lack of faith (including spiritual struggle) are valid and reliable criteria for chaplains as internal triggers for pastoral visitation.

2009 Spiritual Care Collaborative survey results on continuing education

Continuing education for chaplains, pastoral counselors and clinical pastoral educators is important for maintaining and advancing professional competency. Pastoral professionals who visited the Spiritual Care Collaborative (SCC) website to register for a conference were asked to complete a questionnaire on continuing education. Results of the survey show that continuing education, both in-person and through electronic means, were clearly ranked as the most important activities the SCC partner organizations could provide in the future. Additionally, continuing education preferences vary depending upon constituent groups. These findings have implications for the design of future educational programs.

A quick measure to guide allocation of chaplains' time with hospitalized veterans

Assessing veterans' desire to see a chaplain can be difficult. Due to alleged personal weakness associated with seeing a chaplain while on active duty, veterans may still be reluctant to admit a need. Additionally chaplains may be challenged with multiple time demands. We devised and correlated with known instruments a single item containing four graded responses. One correlation was strong, suggesting the question's potential for serving as a useful tool for allocation of chaplains' time.

Parents' Use of Nonmedical Support Services in the Neonatal Intensive Care Unit

Parents frequently identify the need for support while their infant is in the Neonatal Intensive Care Unit (NICU), however, they may simultaneously distance themselves from traditional family and friend support. Recognizing this, many NICUs provide additional nonmedical support services such as social workers, chaplains/religious counselors, and support groups. This article, part of a larger research study, suggests an inverse relationship between social support and the use of supportive services. In addition, parents in this study appear to use support services less often than would be anticipated based on their reports of utility. Suggestions are provided to potentially improve desirability/accessibility of these services.

Withdrawal of life support and chaplaincy in Australia

OBJECTIVE

To explore the role of health care chaplains in providing pastoral care to patients, their families and clinical staff considering decisions to withdraw life support.

METHODS

Quantitative data were obtained retrospectively from a survey of 327 Australian health care chaplains (both staff and volunteer chaplains) to initially identify chaplaincy participation in withdrawal-of-life-support issues. Qualitative data were subsequently obtained by in-depth interview of 100 of the surveyed chaplains and thematically coded using the World Health Organization Pastoral Intervention (WHO-PI) codings to explore chaplains' roles.

RESULTS

Over half the staff chaplains surveyed (57%) and over a quarter of the volunteer chaplains (28%) indicated that they had been involved with patients or their families in withdrawal-of-life-support decisions. Over a third of staff chaplains (37%) and 16% of volunteer chaplains had assisted clinical staff concerning withdrawal-of-life-support issues. The qualitative data revealed that chaplains were involved with patients, their families and clinical staff at all levels of pastoral intervention, including "pastoral assessment", "pastoral ministry", "pastoral counselling and education" and "pastoral ritual and worship". The specific nature of chaplaincy involvement varied considerably depending on the idiosyncratic issues faced by patients, families and clinical staff. These activities indicated that pastoral care could be provided for the support and benefit of patients, their families and clinical staff facing a complex bioethical issue.

CONCLUSIONS

Through a variety of pastoral interventions, some chaplains (mostly staff chaplains) were involved in assisting patients, their families and clinical staff concerning withdrawal-of-life-support issues and thus helped ensure an holistic approach within the health care context. Given this involvement and the future potential benefit for patients, families and clinical staff, there is a need to develop continuing education and research on pastoral care and chaplaincy services.

Pain control and chaplaincy in Australia

This paper summarizes the experiences of 327 Australian health care chaplains with regard to their involvement in issues concerning pain control within the health care context. The findings indicate that approximately 60% of surveyed chaplains had provided some form of pastoral intervention directly to patients and/or their families dealing with issues concerning pain, and that approximately 36% of chaplains had assisted clinical staff with issues concerning patient pain. Differences of involvement between volunteer and staff chaplains are noted, as are the perspectives of chaplaincy informants regarding their role in relation to pain control. Some implications of this study with respect to chaplaincy utility and training are noted.

A three-year study of chaplains' professional activities at Memorial Sloan-Kettering Cancer Center in New York city

The pastoral-care interventions of chaplains at Memorial Sloan-Kettering Cancer Center were documented during two-week periods in each of three years. The study describes the pattern of referrals to and from chaplains and the kinds of interventions performed during the chaplains' contacts with patients and their families and friends. Nearly a fifth of all chaplain interventions were the result of referrals. The vast majority of staff referrals to chaplains came from nurses, with the frequency and proportion of referrals from nurses significantly increasing over time. More than a third of all chaplain contacts were with friends and family without the patient present, and over 40% of referrals to chaplains were for the friends and family of patients. Pastoral visits were significantly shorter when patients were not present. In particular, pastoral-care interventions were found to differ according to the patient's religion and the circumstances of the chaplain's visit to the patient (i.e. patient status). Visit duration also varied by patient status, with pre-operative visits being significantly shorter than post-operative or treatment visits.

An analysis of referrals to chaplains in a community hospital in New York over a seven year period

The study analyzed the pattern of referrals to chaplains in a suburban hospital over a 7-year period. Nurses made more than half of all the referrals to chaplains, with nursing accounting for 81.74% of referrals from staff members other than pastoral care workers and volunteers. Social workers and physicians made 11.74% and 4.08% of referrals, respectively. The number of referrals from social workers (r=.86, p<.05), nurses (r=.68, p<.10) and other staff (r=.69, p<.10) increased across years, with the exception of physicians. Three quarters of referrals were requests for chaplains to visit patients and one quarter were requests to visit with family or friends. A significant difference was found in the percentage of referrals made for patients and family/friends by staff members (p<.05), with social workers making a higher percentage of referrals for relatives and friends (34.1%), compared to nurses (26.74%) and physicians (27.27%). The most common presenting problems for which patients were referred to chaplains were anxiety, depression, and pregnancy loss. The rate of referrals for patients over the entire study period was 39.04 per 1000 patient stays.

End-of-life issues and spiritual histories

BACKGROUND

Patients facing end-of-life issues have spiritual concerns that may have an impact on their medical decision-making.

METHODS

To determine whether physicians address spiritual concerns in this context, we reviewed the charts of 92 elderly hospitalized patients facing decisions regarding resuscitation status or feeding tube placement.

RESULTS

The average age of the participants was 72.4 years and 51% of them were female. Only 6.5% of the patients had spiritual histories documented in their charts; 29% had either a spiritual history or some mention of chaplain or psychiatrist involvement.

CONCLUSION

Spiritual concerns of many patients facing end-of-life decisions are not being addressed.

Questions posed to hospital chaplains by palliative care patients

CONTEXT

Questions of vital importance are actualized when facing one's own death. Studies on patient need for a hospital chaplaincy as an integral part of hospital care are lacking.

OBJECTIVE

To categorize the three most important questions patients pose to hospital chaplains at the end of life and to assess the degree to which hospital staff should be able to handle them.

DESIGN AND SETTING

A Swedish national survey using an open-ended questionnaire and content analysis.

PARTICIPANTS

One hundred seventy-two Swedish hospital chaplains (national coverage, 74% response rate). Categories developed from open-ended questions. Categories of questions posed to hospital chaplains.

RESULTS

Five main categories were identified: meaning (34%); death and dying (21%); pain and illness (13%); relationships (15%); and religious issues (8%). Questions of a general existential nature concerned with meaning-related issues and with death and dying were frequently the primary issue. Many questions dealt with pain, fear of suffocation, and illness in general (i.e., questions that the palliative team should be able to handle). Only 8% of the issues were explicitly religious and these were often third-hand choices.

CONCLUSION

The role of the hospital chaplaincy has changed. Today it entails specialized competence and is needed in existential discussions with different patients in crisis, regardless of their personal faith or lack of faith. Nonetheless, physicians and other staff members should be able to handle many of the questions that are of a more general/medical character.

How has health care reform affected professional chaplaincy programs and how are department directors responding?

No published studies were identified that describe the impact of health care reform on professional chaplaincy departments in hospital settings. Results from a random sample (N = 370) of department directors indicate that 45 percent report no budgetary consequences, 27 percent have experienced budgetary cutbacks, and 17 percent describe departmental growth. The cutbacks most often involve the loss of staff chaplain positions. Directors also describe past and future strategies for resisting downsizing trends.

Spiritual care in the hospital: who requests it? Who needs it?

Reports the results of a survey of general medical and surgical patients (N=202) who were asked if they wanted to have a chaplain talk with them, have a chaplain pray with them, and/or receive the sacrament of communion. Discusses the implications of the findings for hospital chaplains.

Patient and family perceptions of hospital chaplains

While most hospitals provide chaplaincy services for patients, families, and staff, these services are seldom studied and their contribution is poorly understood. A questionnaire created by the College of Chaplains of the American Protestant Health Association was mailed by an insurance company to patients recently dismissed from the hospital, requesting evaluation of three non-medical services (social services, chaplaincy, and patient representatives) and how well the spiritual needs for support/counseling, prayer, and sacraments were met. Responses revealed that, in comparison to the other two non-medical services, patients receive more visits from chaplains, evaluate these visits as more important (p less than 0.000), and report that these visits meet their expectations more highly (p less than 0.000). Regression analyses demonstrate that when the chaplain meets the patient's need for support/counseling, the respondent is more likely to select the hospital again (p = 0.04) and recommend it to others (p = 0.05). Similarly, when chaplains meet the family's need for support/counseling, the respondent is likely to choose the hospital again. Since chaplains clearly make an important contribution to patients, their families, and the hospital, administrators should review the adequacy of their chaplaincy services in the light of these data.

Chaplaincy in Europe

Provides an overview of chaplaincy programs and concerns in Europe, along with descriptions of chaplaincy associations in Finland, Holland, and Italy.

Supplier-induced demand for pastoral care services in the general hospital: a natural experiment

Assesses the effects the elimination of a pastoral care training program and a reduction in staff had on referral rates for pastoral care. Results showed a decrease in referrals initiated by pastoral care staff but an increase in pastoral care referrals initiated by medical staff and patients. Notes that when pastoral care staff were less available, the demand for their services became more apparent.

Pastoral research in a hospital setting: a case study

Provides a summary of research procedures and outcome data of a utilization review of the pastoral services of a large university medical center. Notes particularly the value of such a project both in terms of concrete knowledge gained and in terms of serendipitous discoveries leading to further research.

Religious support from parish clergy for hospitalized parishioners: availability, evaluation, implications

Reports the results of interviews with a random sample (N = 500) of hospital patients responding to the following questions: What percentage of hospital patients consider themselves part of a church or synagogue? How many patients identify a specific parish clergy or some other source who could provide them pastoral support? How many patients received pastoral support during hospitalization from clergy or some other person, and by visit or phone call (excluding hospital chaplains)? How do hospital patients evaluate the helpfulness of these pastoral visits? Discusses the results of the survey, implications for pastoral caregivers, and suggests future research possibilities.

Religious perspectives of doctors, nurses, patients, and families

Reports the results of a survey examining religious denomination, belief in a higher power, church attendance, and religious coping among physicians (N = 130), nurses (N = 39), patients (N = 77), and families (N = 60). Differences are noted and discussed. Notes that while a large proportion of patients and families found religion to be the most important factor enabling them to cope, only a small percentage of physicians felt that way. Observes that the results of this and other studies may indicate a gap in religious orientation between health care providers and patients and that such a gap could hinder the recognition of and proper care for spiritual needs in the hospital setting.

Cancer nurses' perspectives on spiritual care: implications for pastoral care

Explores nurses' perspectives regarding collaboration with chaplains and clergy in the provision of spiritual care to persons with cancer. Reports results of a survey via questionnaire of a random sample of Oncology Nursing Society members. Concludes that although a majority of the respondents report referring patients in spiritual need to clergy and chaplains, a significant minority did not do so. Notes that results secured from these respondents bring to surface several aspects of the collaborative relationship between nurses and chaplains and clergy.

Measuring the spiritual needs of hospital patients and their families

Uses four psychometric instruments in an attempt to measure the spiritual needs of general hospital patients, family members, and persons from the community. Infers that the data suggest that family members tend to be more involved in a search for meaning than are patients and community persons. Discusses implications of the results for pastoral caregivers.

Perceptions and practices of registered nurses regarding pastoral care and the spiritual need of hospital patients

Reports the findings of a questionnaire survey designed to examine the impact of pastoral care on patient care and job satisfaction of registered nurses (N-280) employed in a metropolitan hospital. Suggests that educational strategies be explored as a way of broadening the perspectives of nurses regarding reasons for consulting pastoral care departments.

How patients perceive the role of hospital chaplains: a preliminary exploration

OBJECTIVE

An exploratory study of the attitudes of hospital patients to the service provided by hospital chaplains.

DESIGN

Questionnaire study of hospital inpatients in December 1992.

SETTING

One large teaching hospital in London.

PATIENTS

180 hospital inpatients in 14 different general wards, 168 (93%) of whom agreed to take part.

MAIN MEASURES

Attitudes to chaplains and their role contained in 12 questions developed during a pilot study on hospital inpatients (16) and staff (14) and their relation to patients' age, sex, length of hospital stay, and religious beliefs, according to Kendall rank order correlations.

RESULTS

Of 168(93%) respondents, 72(43%) were women; mean age of patients was 63.1 (SD 16.8) years. Forty five (27%) were inpatients of three days or less and 22(13%) for one month or more. 136(81%) were Christian; 17(10%) atheist, agnostic, or had no religion; and 15(9%) were of other religions. In general, patients showed positive attitudes towards the role of hospital chaplains and to the services they provided. The correlation analysis showed that there was a significant tendency for older patients, those who had been inpatients for longer, and those with religious beliefs to be more sympathetic to the role of hospital chaplains.

CONCLUSIONS

Hospital chaplains provide a service which is appreciated by patients. This study provides a simple instrument for assessing patients' attitudes to chaplains.

The chaplain's role in bioethical decision-making

With advances in medical technology, difficult questions of "What should be done?" and "Who should decide?" are a daily occurrence in hospitals. This paper reports the results of a survey of Canadian chaplains with respect to their involvement in bioethical decision-making. The survey suggests that chaplains make a significant contribution to discussion and resolution of bioethical dilemmas. Using a case study, the paper elaborates on the chaplain's role in bioethical decision-making, and indicates how such participation can influence both cost containment and risk management.

Role clarification: a quality improvement survey of hospital chaplain customers

The following article describes a quality improvement survey that examined the role nurses, patients, and patients' families expect the hospital chaplain to play when they use the chaplain's services. The results of the questionnaire suggest that patients and nurses sometimes see the role of the chaplain differently. There are times when nurses readily call a chaplain to help with a problem on a unit. There are other times when nurses are reluctant to ask for the chaplain, but patients would be most appreciative of the chaplain's presence. This article explores these situations and gives suggestions for ways to use a chaplain's expertise more effectively.

Pastoral needs and support within an inpatient rehabilitation unit

Because patients reported concerns regarding the adequacy of pastoral service delivery during their inpatient rehabilitation hospitalization, a study was performed to ascertain the patient's pastoral needs and the extent of pastoral services provided. After discharge from the inpatient rehabilitation hospital, patients were surveyed as to their perceived religious and spiritual needs, as well as to the extent of religious, spiritual, and pastoral services provided during their inpatient stay. The majority of responders (74%) reported their religious and spiritual beliefs were important. Forty-five percent of responders indicated not enough attention was repaid to their religious or spiritual needs, whereas only 1% felt that too much attention was paid. A majority of patients (54%) desired pastoral visitation. Other needs were elicited, including expanded pastoral services, increased staff empathy for the patient's spiritual and religious needs, and improved availability of church or synagogue services or sacraments. Many Jewish patients reported concerns of being punished by God, whereas Christian patients were concerned that God was unaware of their personal needs. Some responders, regardless of personal faith, were also troubled with fears of death, God's failure to heal, and loss of purpose in life. There is a clear need to establish a mechanism to identifying the religious and spiritual needs of each individual patient. These needs must be considered with both sensitivity and compassion by all members of the rehabilitation staff. The rehabilitation facility must also develop a mechanism to identify pastoral care resources available within the hospital and local community, and to assure that the patient's needs are addressed.

The valuation of pastoral care by hospital administrators: a survey of selected for-profit and non-profit institutions

This paper reports on a study of 600 hospital administrators, half of which were in non-profit institutions and half of which were in hospitals owned or managed by the Hospital Corporation of America. The project was designed to identify what differences, if any, existed between surveyed administrators in both types of institutions in their valuation of pastoral care. No significant differences were found between the two groups of administrators in the valuation of pastoral care. All administrators were found to be concerned about the quality of patient care and to value aspects of care such as pastoral care which are personal and difficult to quantify.

The marketing of pastoral care and counseling, chaplaincy, and clinical pastoral education

Offers ten approaches pastoral care persons might use to confront the growing health care crises facing the United States. As a response, the Executive Director of the Association for Clinical Pastoral Education outlines alternatives to traditional CPE settings which could be utilized to address creatively the many changes in health care delivery systems.