By JULIE MINDA
There has been increasing recognition in the chaplaincy field over the last few decades that chaplaincy practice should be grounded in research and that chaplains should use evidence-based approaches to their work. However, it can be difficult to equip chaplains — most of whom do not have formal research training — to seek out, understand, apply and perhaps contribute to chaplaincy research.
That is according to George Fitchett, a professor and director of research in the department of religion, health and human values at Rush University Medical Center in Chicago. He co-directs the Transforming Chaplaincy Project, which aims to increase the ranks of research-oriented chaplains in the U.S.
In Fitchett's view, all chaplains should become research-literate so that they can understand and apply research on the best practices in spiritual care to their work. And, there's also an opportunity for chaplains with the ability and interest to learn to produce original research.
Fitchett spoke to Catholic Health World about chaplaincy research and evidence-based chaplaincy practice.
Why should health care chaplains practice evidence-based care?
I think the first reason why chaplains need to be involved in a research-informed approach to care is that it's one way to be sure we're providing the best quality care possible.
The second reason it's important is that health care is very much shaped by evidence, and we need to be able to communicate with our health care colleagues about what we're doing, why we're doing it, and how it contributes to important outcomes for patients. We need to be able to describe that to them in the language of research so that they can better understand the important contributions we're making.
What would you say to chaplains concerned they don't have the time to conduct original research?
We're not looking for every chaplain to be a researcher. Staff chaplains do not have to change their job description, go back to school, get a degree in research. But, to move the profession ahead, we do need to have opportunities for all the staff chaplains to develop research literacy as part of their chaplaincy education, and we do need opportunities for a small group of chaplains to get more in depth research education.
Research is a very time-intensive activity, and research education takes time as well. What is required is for spiritual care programs and departments to recognize the importance of research and recognize the importance of a kind of basic research education for their staff members.
How would you achieve that?
What we need in the profession is for every chaplain to be able to read and understand research articles and critically assess whether the research was well done or not and then to be able to think about the application of that research in their own chaplaincy practice.
We also need to get more chaplains who do have research training involved in advancing the research and advancing the dissemination of the research. And they need research partners. These partners could include other chaplains or psychologists, nurses or other clinicians who are experienced in conducting research — in designing studies and measuring results. The partners can be at the chaplain's own facility, at other health care organizations, in academia — it varies.
Chaplains need protected time to do the research.
And, organizations need dollars to support the people who are doing the work. It's hard to get funding for chaplaincy-related research. So a very important kind of building block for moving all of this ahead will be donors and sponsors and people who see the value of chaplaincy-related research.
What's the scope and structure of chaplaincy research?
There is a wide range of research types that chaplains can access and contribute to, including narrative case studies on specific encounters with patients, facility-level studies of how well particular approaches work, joint studies among several facilities to test such approaches and then large, multimillion dollar studies involving numerous facilities. Those large studies are often undertaken with the involvement of academics to scientifically test the validity of protocols.
I think chaplaincy research is accelerating. More and more chaplains are recognizing the need for research and are beginning to try to find opportunities to get a research education. Also, in the last five years, we've turned a corner in which people have begun to realize that chaplain researchers are important contributors to our profession. There's a lot of momentum and a lot of important growth going on.
What are the priority areas for research?
We have to have thoughtful approaches to screening for spiritual needs or for spiritual pain or for spiritual distress and we need more research — though there's some being done — and Catholic chaplains can contribute to that.
We also need to develop clinical condition-specific approaches to spiritual assessment that will yield a kind of quantified estimate of unmet spiritual need. And by having that kind of approach to spiritual assessment, chaplains will be able to document whether or not the spiritual care they are providing has actually reduced the unmet spiritual need or reduced the spiritual pain or distress.
How are Catholic systems doing, when it comes to chaplaincy research?
I have a feeling it hasn't caught on as far as it needs to yet in part because research is often not a key component of faith-based hospitals, unless they are linked to academic medical centers. It is hard for chaplaincy to take the lead of bringing research into the enterprise.
But hopefully that's going to change in the next five years, and we'll see a number of large Catholic health systems realize that best practices in spiritual care need to be informed and shaped by the developing research in spiritual care. And, hopefully, they'll begin to commit resources to help chaplains and others not only do the research but to disseminate the research to their staff chaplains and others.
What resources would you recommend to chaplains?
All the chaplaincy organizations provide webinars and workshops at their annual meetings, and those are all important resources. The Transforming Chaplaincy Project has a website, researchliteratechaplaincy.org. The main journal in the field is the Journal of Health Care Chaplaincy. Another resource is the Association for Clinical Pastoral Education Research Network at ACPEresearch.net. Every month they pick a research article about studies taking place around the world and write a summary of it. Those articles of the month are archived. It's a good way to get into research on chaplaincy work for someone who's a novice.
What are simple things chaplains can do to become more research-literate?
One of the other things that we've encouraged to help chaplains develop research literacy is to organize research journal clubs, where once a month, or every other month, or every third month, members of the department read a research article together and talk about the implications for their clinical practice. And sometimes the department has a chaplain who knows enough about research to explain some of the tough details. Some journal clubs have reached out to colleagues from other departments who have a background in research to get help with that.
Is the evidence-based, research focus being taught in clinical pastoral education?
About five or eight years ago, my colleagues and I did a study in which we took a sample of clinical pastoral education residency programs and asked them whether or not they were teaching research at all, just a little, an introduction, something substantive. At that point we found about 12 percent of the CPE residency programs were teaching research literacy which was really fairly discouraging — to develop a research-informed profession we need to have all people who are going through chaplaincy training to be exposed to research literacy. That led to us putting together the Transforming Chaplaincy Program and the core team development grants for CPE. A year ago we gave out grants to 23 organizations that included 38 CPE centers that have begun this year teaching research literacy in their CPE programs and we'll do the same thing again within the next few months.
Hopefully the next generation of chaplains take for granted that research literacy is part of chaplaincy preparation. Ten years ago that would have been a pretty strange notion.
What would you advise Catholic health systems and facilities, about how to improve their chaplaincy work, and better equip their chaplains?
I think the first step is to ensure that all the chaplains in the organization are developing research literacy and to provide resources to help with the development of research literacy — through workshops, continuing education activities, and journal clubs — and often the first step in the development of research literacy is helping people talk about the reasons why research is important for chaplaincy. You know, I take it for granted that every chaplain knows that and I've been talking to people about it for 10 years, but there are a lot of chaplains who haven't had a chance to be part of those conversations, to hear the rationale for this, to have clarification — that this doesn't mean they have to do research, it doesn't mean they have to treat everyone the same, it doesn't mean they have to kind of diminish their own expertise and creativity — and so those are important conversations to have.
Spiritual care is often described in terms of the process — that the chaplain provides a ministry of presence, that the chaplain provides an empathetic and supportive relationship for the people in crisis and distress and spiritual support. An important cutting edge for the profession is to actually help chaplains learn to augment the language they currently use to describe the process of their care to supplement that with a language that also can describe the outcomes associated with that care.
What impact can chaplaincy work have on patient satisfaction?
When there are chaplain visits there are higher levels of patient-family satisfaction in general across institutions for all patients discharged from the institution who answered satisfaction surveys.
There has been an important set of studies from University of Washington that found that for families whose loved one died in the intensive care unit, if there had been spiritual care for the patient and family during that patient's intensive care unit stay there's a higher level of family satisfaction with the care that was provided at the end of life — both overall satisfaction with that care and specifically satisfaction with spiritual care.
One of the reasons that is so important is that for a certain proportion of families whose loved one died in an ICU in the six to 12 months after that patient's death there are high levels of emotional distress and in some cases emotional distress that is high enough to qualify for a diagnosis of PTSD.
So it's possible actually that the spiritual care that's being provided for those patients and families in the ICU — that we see then as causing them to report higher levels of satisfaction with that care — it may well be that not only are those families more satisfied, they may be suffering less emotional distress afterwards.
Are you aware of chaplains working more with quality improvement or process improvement experts at their facilities, to bridge the gap between quality improvement and chaplaincy practice?
Process improvement and quality improvement generally are in my thinking small research projects. The difference between a quality improvement project and a research project is that the quality improvement project tends to be designed to improve care at that one facility. And what makes it research is if it was designed to improve care generally.
And where we are with chaplaincy-related research is that if a team got together and figured out ways to improve screening or triage to determine which patients coming into the oncology clinic were experiencing spiritual pain — if at one hospital some chaplains collaborated with the quality improvement team and developed some way to improve that, on one hand it's not research because it's just done at one center, but in our profession it could be a very important contribution to the profession. And hopefully they would do a workshop about it or write an article about it so that others of us who are faced with similar challenges could see how that particular institution met that challenge and could build on that. So quality improvement and process improvement projects are very important contributions to chaplaincy research.
What is the scope of the types of research chaplains could undertake?
There are three approaches to advancing chaplaincy research: small, medium and large.
We need quality improvement projects that are done at a particular institution, and we need people to hear about them so another institution can replicate and perhaps revise them and build them up and strengthen them. So that's an example of moving the research in the field ahead in a small but important way.
Large projects are multimillion dollar projects that are conducted across multiple centers with large research teams and multiyear projects to really build important interventions or test approaches to spiritual assessments.
Medium projects are ones that could be done for $10,000 to $20,000 up to several hundred thousand dollars, where you have a research-informed chaplain with advanced research literacy, time for — and commitment to — research, and a connection with a research team.
One piece of research that we haven't talked about is case study research. Over the last five years I've been working with colleagues to help them write and publish article-length, chapter-length case studies about the work that they do. Many of our colleagues in nursing and medicine and health care administration have a sense that what we do is important but they actually are not well informed about the details of what we do. So we think that having detailed action case studies available in chaplaincy and other literature can play a very important role there in helping our health care colleagues make better decisions about referrals to us and about allocating resources to support us. So that's a kind of research that doesn't require any statistical training and it's the kind of research that many staff chaplains could participate in, and the chaplaincy journals are quite open to publishing that kind of thing.
What's the scope of the Transforming Chaplaincy Project?
We're sending 16 chaplains, who are taking two years off their work, to get master's degrees in research so that they can come back and advance chaplaincy research. We're giving grants to CPE programs to help them develop research literacy components in the education of CPE students in their programs.
The work is funded by a four-year grant from the Templeton Foundation; we're in the second year. We could use more support to continue it beyond the current funding, but it's not clear that the Templeton Foundation will continue it. For us to send 16 chaplains to get master's degrees is a great start, but we could use an additional several million to send some of those chaplains to get doctoral degrees in research and to continue to expand the master's education as well. A cohort of chaplains with advanced research education could continue to conduct and disseminate research about chaplains to strengthen the care for patients and families.
Visit chausa.org/pastoralcare/overview for CHA resources for chaplains.
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