Social Group Work with Cardiac Patients (Haworth Social Work in Health Care)

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The hospice movement in the United States became distinguished from that in Britain, according to Stephen Connor's Hospice: Practice, Pitfalls and Promise , by "a greater emphasis on use of volunteers and more focus on psychological preparation for death". Since then, the hospice industry has rapidly expanded. This growth has accompanied the AIDS epidemic and the aging of the population, with related illnesses. As the hospice industry has expanded, so, too, has the concept of hospice care.

The goal of hospice agencies in the United States is to provide comfort to the patient and heighten quality of life. Hospices typically do not perform treatments that are meant to diagnose or cure an illness, [13] and they do not seek to hasten death or, primarily or unduly, to extend life. Many hospice patients, though not all, [20] have made decisions against receiving CPR should their heart or breathing stop.

In some cases, medical professionals may feel conflict in attempting to provide it. Some confusion still exists as to what treatments a patient may receive in hospice care. Hospices may provide treatments that have been traditionally regarded as curative, including radiation therapy or antibiotics , if these are administered to improve quality of life. Another aspect of the hospice philosophy is that the care is patient-centered, to treat the whole patient. Many healthcare agencies in the US market themselves as patient-centered; for hospice, this patient-directed care is integral and interwoven throughout the care which is provided.

In order to qualify for hospice care, a patient must have certification from two physicians that he or she has less than six months to live if his or her disease runs its natural course; usually the patient's primary physician and the Hospice Medical Director will provide this certification.

Many physicians are slow to refer to hospice care, waiting until they are absolutely certain of a terminal prognosis. Some physicians believe that the patient must have a six-month prognosis or less to receive hospice care, while others are overly optimistic in their assessment of prognosis, presuming treatment will be more effective than it is. The average length of stay in hospice before a patient dies was 26 days in and 19 days in In the average stay was 57 days and the median length was 22 days. Such late admission is inconsistent with the process of hospice, which is to alleviate patient distress over a period of time, based on time for patients and family members to develop relationships with the hospice team.

Some people believe that only individuals suffering from cancer or AIDS can receive hospice care. Hospice in the United States developed around the model of cancer care, with a relatively predictable pattern of deterioration. Any diagnosis that would be an acceptable cause of death on a death certificate is, if expected to be terminal, an acceptable diagnosis for hospice care. In order to qualify for hospice, a patient has to be certified as having a prognosis of less than six months to live. Sometimes patients live longer. Medicare patients who receive the hospice benefit must waive other Medicare benefits that could prolong life.

At the end of these two benefit periods, the hospice team will evaluate whether or not the patient continues to have a prognosis of less than six months to live. Commercial insurers, managed care program providers, and Medicaid often have their own regulations regarding re-certification.

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When the hospice re-certifies a six-month or less prognosis, this is based on the patient's current condition. Not all hospices are able to serve every population. While pediatric hospice options are expanding, as of many adult-oriented hospice programs remained ill-prepared to handle younger populations. The primary diagnosis for children in hospice treatment is cancer, but, like the adult population, children may enter hospice for a variety of conditions, including AIDS, prematurity , congenital disorder , cerebral palsy , cystic fibrosis , or "death-inducing trauma", such as automobile accidents.

The recommended model of hospice for children differs from that of adults. In , the committees on Bioethics and Hospital Care for the American Academy of Pediatrics jointly released a recommendation that palliative care for children should be provided for any life-threatening condition from the point of diagnosis, whether death is the prognosis or not, as the benefits of palliative care can be offered concurrently with curative treatment. Insurance providers may restrict access to hospice care to pediatric patients undergoing life-extending treatment.

The cost of hospice care may be met by health insurance providers, including Medicare or Medicaid for eligible Americans. A lower rate is paid for home care, with a higher rate paid for round-the-clock nursing care in order to get a patient's symptoms under control. Most commercial health insurances and Medicaid have a hospice benefit as well. There may be a co-pay required by commercial health insurance providers depending on individual plans. Once a patient is enrolled in hospice, the hospice becomes the insurance payor for that patient for any hospice-related illnesses.

However, if the patient were to see a podiatrist , this would be billed through their regular insurance. Hospice is a competitive business. In , The remaining 4. In order to receive payments for hospice patients under Medicare or Medicaid, a hospice must be certified by the Centers for Medicare and Medicaid Services , and in However, some agencies do not seek certification or voluntarily relinquish it. For one example, an agency that is entirely supported through donations or relies on volunteer staff might not choose to seek certification.

Routine home care is the most common level of care provided. Routine care may be provided at a nursing home or assisted living facility, [54] although the majority of hospice patients are treated at home. Continuous Care is a service provided in the patient's home.

General inpatient care is an intensive level of care which may be provided in a nursing home, a specially contracted hospice bed or unit in a hospital, or in a free-standing hospice unit. Although there is a limit to how long Medicare will cover this level of care, it is usually provided for brief periods of time, with five to seven days being the average.

Respite Care sometimes referred to as respite inpatient is a brief and periodic level of care a patient may receive. Respite is a unique benefit in that the care is provided for the needs of the family, not the patient. Should a family member need a "break" from caregiving, or if a vacation is planned, then this level of care may be provided.

During respite, the patient is transferred from the home to an institutional setting; this can be a nursing home, assisted living, hospital or an inpatient hospice unit. In this way, the only difference between respite and routine care is that the hospice pays the room and board charges of the facility. Should a patient receive respite in an inpatient hospice unit the care would be similar to what other patients of the hospice unit receive. Respite is provided for a maximum of five days every benefit period.

The hospice interdisciplinary team is the core service which every hospice provides to patients and families. The problems that are being treated may or may not relate to other issues being addressed by individual team members. Interdisciplinary team approach involves all members of the team working together towards the same goal, which in this case is to afford patients a comfortable dying experience and families the support they need in coping with this.

In an interdisciplinary team approach, there can often be role blending by members of the core team, who may take on tasks usually filled by other team members. The hospice team is required by Medicare to meet every 14 days. During this team meeting, patient needs are discussed and planned for the next two weeks. Team members include hospice medical directors, physicians, pharmacists , registered nurses, social workers, counselors, home health aides, and volunteers.

The majority of discharges from hospice are due to the death of the patient, although hospice treatment may not end then as care also provides for a period of bereavement counseling for the family afterward. If it is determined at the time of review that a patient's prognosis may be greater than six months, the patient is de-certified discharged from hospice. Should the patient's condition worsen once discharged from hospice they can be readmitted to hospice. A patient may be discharged by revocation if he or she chooses to relinquish the hospice benefit.

However, not all hospitalizations of patients require revocation; should the admitting diagnosis to the hospital be unrelated to the condition for which they are in hospice, the patient may remain on hospice while undergoing treatment for it. Transfer of hospice does not involve a discharge from hospice in general, but a discharge from the current hospice provider to another one. Occasionally a hospice will be unable to provide care to a patient, either due to philosophical differences with the patient or due to a safety issue.

Such causes could include disruptive or abusive behavior from the patient or other persons in the patient's home or refusal to cooperate with the hospice program. As indicated, hospice is frequently under-utilized and often not taken advantage of until very late in a patient's illness. The reasons for this have as much to do with financial considerations as with the psycho-social difficulty in choosing hospice. A study found that with proper case management hospice access could be liberalized without additional costs to insurers.

From Wikipedia, the free encyclopedia. See also: Children's hospice. Hospice: Practice, Pitfalls, and Promise. University of Texas. Retrieved Metzger The Case Manager's Training Manual. Buffalo News. Archived from the original on March 6, Scripps Howard News Service. Archived from the original on Refuerzo Innovations in Hospice Architecture. Dying, Death, and Bereavement. Allyn and Bacon. Hospice is a type of care focusing on improving or maintaining quality of life, as opposed to extending life Kowalski Textbook of Basic Nursing 9 ed.

Hospice care does not speed death, nor does it unduly prolong life Assisted suicide and euthanasia are not components of hospice care in the U. Gormally, Luke Cambridge University Press. The work of a hospice is aimed not primarily at extending life but at making it more comfortable by palliative care.

Family Medicine Examination and Board Review 2 ed. McGraw Hill Professional. Despite popular belief, a hospice patient need not agree to a DNR status upon receiving the hospice benefit; however, hospice agencies are permitted to have different admission criteria and some require a DNR status for admission. Nghiem Medicare does not require a DNR order, but it does require palliative, not curative, treatment.

Some hospice organizations may require a DNR order before enrollment. Weinreb; Joel S. Policzer McGraw-Hill Professional. In response to this demand, national surveys of hospital staff, chaplains, administrators, and program directors illustrate the wide range of roles that chaplains throughout the U.

The acute health care context requires that all services, including chaplaincy, be informed by credible research-based evidence. Professional chaplaincy currently has very little quality research to direct its clinical practice. To guide and improve chaplaincy practice and further integrate spiritual care into health care, clinical investigations specific to the profession are needed to provide a basis for chaplaincy practice.

Chaplains, just like all other health care professionals, must develop patient-centered care research. Without this research, spiritual and religious care will continue to be informed only by anecdotes, opinion, and beliefs whose validity remains untested. There is not one operational definition of spirituality that is appropriate for all contexts or research settings.

If one definition is even possible, it has not yet become clear what the preferred definition would be. This need not impede definition of spiritual care, however, and research in this area should be guided by a well-crafted definition of spiritual care in order to provide some definitional boundaries and coherence to the developing field. We use the following definition:. Chaplaincy care is specialized spiritual care provided by board certified chaplains. A number of published studies and descriptions of what chaplains do and where they practice have been helpful in describing the scope and breadth of chaplaincy practice.

Acute care chaplaincy practice includes ministry to patients and their families, hospital administration and staff. Chaplains in acute care often work as a liaison with the religious community, especially when helping the bereaved. While there seems to be some homogeneity in the types of ministry engaged in, there also seems to be considerable heterogeneity that is influenced by environmental factors such as the type of hospital or the denomination and training of the chaplain.

For example, hospitals can be community hospitals, general hospitals, rehabilitation hospitals or cancer care hospitals.

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Chaplains vary in terms of their education and professional identity, for instance a chaplain in a hospital can range from being a full-time board certified chaplain, to a volunteer patient visitor, to an individual studying to be a chaplain. Finally, while there is increasing information on what chaplains do, there is virtually no evidence for how well they do it and the impact on those with whom they are engaged.

With quality being such a central issue in modern health care, the profession of chaplaincy is challenged to provide convincing evidence for its methods and outcomes. Studies are needed to better understand how patients secure access to a chaplain e. This is important because research shows that not everyone experiencing spiritual struggle receives chaplain attention.

Research is needed to look beyond the actual requests for a chaplain as stated i. Research is also needed to identify how the overall resources of the hospital impact on chaplain referrals. For example, a hospital with a robust chaplaincy department but a weak social work department may generate many more referrals to chaplains for emotional issues than a hospital where the situation is reversed.

In some hospitals, chaplains bear primary responsibility in guiding patients about advance directives. In other hospitals, that task falls to patient representatives or social workers. Finally, in many hospitals, the referral pattern to chaplains appears to be related to interests and skills of particular chaplains on the staff.

The review of the literature reveals many significant gaps in the research which would bear future study. Many of these studies would be epidemiologic and descriptive in nature since much of the landscape of chaplaincy care is in need of elaboration. Others have to do with impact and require intervention studies.

The major gaps listed below need to be addressed if empirical findings are to guide delivery of spiritual care. Health care in the United States is becoming patient-centered, holistic and wellness focused. Patients and families want their religious and spiritual values, beliefs and practices included in their care decisions and processes.

However, very often this goal is not achieved. A major reason for this gap is the lack of research-based knowledge about how to deliver desired spiritual care effectively and efficiently. Even where spiritual care is available and provided, even sometimes by routine protocols, there is virtually no research-informed evidence for how that care may contribute predictably to positive health outcomes.

Thus, there is currently no way to determine if and how spiritual care contributes value to the health system or to maximize that value. Without apparent value-added, spiritual care will increasingly be left out of the health care equation. The professional board-certified chaplain is becoming the spiritual care leader on the health care team in charge of helping the team integrate spiritual care into the treatment process.

For spiritual care to be most helpful to the patient and family, the chaplain must produce, and be informed by, substantial research evidence that documents effective chaplaincy interventions that promote healing and health, such as by reducing emotional and spiritual distress, improving coping with illness, and improving the quality of life. Research on the efficacy of chaplaincy care is beginning to grow and is largely confined to the acute care setting. Much needs to be done to describe the current state of who chaplains are, where they work, and what they do.

The literature review and gap analysis presented here states only the major and most important potential areas to study. Essentially, what is in this paper for the first time is a description of a new and rapidly emerging field. It is also a field which, with the proper evidence base, could be integral to the restructuring of health care in the U.

A way to do meaningful research in spiritual care and specifically in chaplaincy care can and must be found so that the spiritual and religious needs of patients and families can be fully integrated into health care through the work of the professional chaplain. It is clear that a much more intentional and focused effort is needed. This effort should have at least two major objectives.

First, it ought to catalyze the development of new research capability and competence in this field to provide research capacity in the field over the long term. A network must be established to coordinate the efforts of these research groups. Second, it must follow a targeted, systematically planned research agenda to maximize the progress toward the goal. The current document lays out this research agenda.

By documenting and critiquing the research that has been done to date and naming the gaps in that research from both methodological and results perspectives, an outline is provided for the research agenda for the efficacy of chaplaincy care. Going forward, this research needs to increase in volume, specificity and methodological sophistication. It must recognize the rapidly expanding venues in which U. The gap analysis makes clear that there is a great need for descriptive and pilot studies as well as for the development and validation of appropriate measures and interventions.

There also may be existing data bases whose potential could be aggregated to good effect. It would also be possible to identify and describe situations generally regarded as centers of best practice in chaplaincy. Until this goal is reached, spiritual care and chaplaincy care will not be able to evaluate or establish their value.

Research studying chaplaincy care in acute care settings can range in theory across many hospitals and patients with acute or chronic illnesses. Since chaplaincy research has only begun to accumulate, there is a significant danger that research will not proceed in a focused and organized manner. If study questions, methods and outcomes are carefully chosen they will build upon and integrate with other work in the field of spiritual care. One way to support a focused research agenda is to fund research through one or more central consortia, which would set the research agenda, fund studies through a Request for Proposals process, and promote communication and capacity building among the research groups.

The consortium would be advised by clinical and research leaders in chaplaincy who would set the basic parameters of the research, monitor its progress, and serve as mentors to new researchers. Along with situating the research within a consortium, it will also be essential to establish some focus for the research agenda itself in order to produce significant progress in the field.

While there is no consensus on what the interventions and outcomes should be for health care chaplaincy, involvement of chaplains in palliative care and end-of-life care is often mentioned and accepted as a major focus of chaplaincy involvement and referral Galek, et al. Another relevant set of studies pertain to Dignity Therapy, a narrative legacy intervention designed for the terminally ill, that has been subjected to rigorous methodological studies that demonstrate positive impact on patient and family well-being Chochinov Thus, focusing the research agenda in the area of palliative care and end-of-life care opens the possibility of demonstrating value in an area of care where that value and efficacy are already often assumed and where much current attention is being focused by policy makers and the general public.

It is hoped that this document offers a helpful roadmap for developing research that can guide the full and optimal integration of spiritual care into the health care enterprise. The firm establishment of an evidence-informed professional chaplaincy is the key to this integration. Health care is evolving from an exclusive concentration on the physical dimension of illness to a more holistic model which takes into account the psychosocial, and increasingly the spiritual Meador, ; Puchalski and Ferrell, ; Sulmasy, Coincident with this trend is the emergence of health care chaplaincy as a profession comprised of chaplains who are increasingly ready to be the spiritual care leader on the health care team.

Chaplains are theologically trained and accountable to their religious denomination. They are clinically trained to be sensitive to, and respectful of, patient cultural and spiritual needs. They adhere to a code of ethics and operate according to standards of practice.

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However, professional chaplaincy is at a crossroads and without quality research to direct clinical practice, professional chaplains will continue to be informed largely by opinion, and anecdote. To guide and improve chaplaincy practice and further integrate spiritual care into health care, research findings specific to the profession are needed to provide an empirical basis for chaplaincy care.

Fulfilling the obligation to practice with the best tools available requires guidance gained through supervised practice that has been informed by experience that in turn has been supported by research. Chaplains must make patient-centered care informed by research a priority to be taken seriously by other health care professionals. Without this research, spiritual and religious issues will continue to be neglected in the care of the patient and family. This report is inspired by a landmark report entitled The potential for efficacy of healthcare chaplaincy and spiritual care provision in the NHS UK Mowat, That report proposed to collect and assess the evidence for the efficacy of chaplaincy in the National Health System of the United Kingdom.

The current project has the same aim for the U. Additionally, it will propose a research agenda to build on current evidence, and begin a process to firmly establish professional chaplains as contributing members of the health care team. Thus, this report will not only describe what is and what has been, but it will lay out a road map for moving professional health care chaplaincy into a future, one that enables professional chaplains to make a much greater contribution to health care in the United States.

The overall goal of this paper is to provide a thorough review of the research on the efficacy of chaplaincy care in acute health care because most research is in acute care. This analysis will also highlight the gaps in this evidence from conceptual, methodological, and outcomes perspectives.

The identified gaps will inform the outline of the research agenda in this area of spiritual care so that professional chaplaincy can become a fully research informed profession that makes a substantive contribution to the quality of health care in the United States. Like Mowat, which limited its scope to research in the U. The practice of health care chaplaincy in the United States and Canada has only minor differences despite the differences in the health care systems.

However, the North American practice is significantly different from Europe and other parts of the world due mainly to the prevalence of well established clinical training programs for chaplains in North America. This difference in training has led to a multifaith model of practice in the U. A difference in use of titles is also appearing between the U. In the U. Outside the U. In addition, there are considerable differences between the U. In addition, the review of the research will be limited to acute care medicine chaplaincy studies. This is the context in which virtually all of the research has been conducted.

Citing the very occasional studies outside of this context would make conclusions about the body of research in general more difficult since the issues in other kinds of health care such as long term care and mental health are potentially quite different. Research outside the acute care context will be occasionally cited when the findings fill an important gap or seem generalizable to acute care. Research in other contexts, especially hospice and outpatient settings, is one of the many gaps in the overall research which needs to be addressed going forward.

A review of the extensive literature on the influence of spirituality and religion on health is beyond the scope of this report. For the purposes of this report, the findings of the research reviewed by Koenig, McCullough, and Larson , and others since, that there exists a salutary connection between positive spirituality and religion and positive health outcomes will be accepted. In a landmark study, Fitchett, Rybarczyk, DeMarco and Nicholas found that people undergoing rehabilitation in a medical facility who were both religious and angry with God were much slower to recover than other patients.

Fitchett, Murphy, Kim, Gibbons, Cameron and Davis found that people who struggle with an adverse life event and simultaneously struggle with their religious beliefs experience greater levels of depression and emotional distress. With all of the above in mind, the survey of the major literature documenting chaplaincy interventions was done as follows. Also, RSS feeds from Pubmed with the search terms anywhere in the text of newly indexed Pubmed publications were received via email whenever a new publication was added to the search engine.

This searching yielded a handful of articles that documented an actual intervention administered uniquely by a chaplain. These are reviewed below. In addition to specific intervention research conducted by chaplains we surveyed research on, and definitions of, chaplain, spirituality, pastoral care, spiritual care and chaplaincy care in an attempt to bring some clarity to a large and debated arena. Over time, the term spirituality has been defined in widely divergent ways.

The Dictionary of Pastoral Care and Counseling , which has a distinctly Christian perspective, provides several examples of this divergence even among Christian traditions. An Eastern Orthodox Christian perspective sees spirituality as the continual human attempt to live in communion with God in mind, heart, body and soul by seeing clearly and living rightly Hopko, A Protestant view shares this vision of spirituality and emphasizes the practice of piety and love of both each other and unbelievers Hinson, Buddhist, Jewish and Muslim viewpoints might highlight additional aspects of spirituality.

In addition to definitions of spirituality that have roots in a particular religious tradition, there are definitions of spirituality that are not tied to a particular tradition. Several widely quoted definitions of spirituality have been proposed in the medical, nursing and psychological research literature Edwards. The definitions have some commonalities, mainly around finding or making meaning in life, relationships with others, community life, and differentiating spirituality from religion.

However, no single definition of spirituality has been widely accepted in the research literature. Mowat acknowledges the need for better definitions of spirituality and religion, and reviews the Hollins opinion piece which states that religion is spiritual and leads Mowat to suggest that to separate religion from spirituality is to end up in a room without doors. However, it is clear that there is not one definition of spirituality that is appropriate for all contexts or research settings. Any research in this area should be guided by a very carefully crafted definition of spirituality, and it is premature in the context of chaplaincy care to insist on a specific definition of spirituality.

Nevertheless, some definitional boundaries are needed to provide greater coherence to the developing field. Beliefs, practices, virtues, experiences, relationships, motivations, art, nature, war — virtually any part of life, positive or negative- can be endowed with sacred status. By defining the sacred so broadly, it is recognized that spirituality encompasses a wide range of phenomena of interest, both traditional and nontraditional.

However, by placing the sacred at the core of spirituality, the distinctiveness of this dimension is highlighted and provides clearer definitional boundaries. After all, without a sacred substance, spirituality would be indistinguishable from other constructs within medicine, nursing, psychology, and social work, such as health, well-being, community, meaning, hope, and authenticity. It is not a static set of beliefs or practices; rather it changes and evolves over time. In this sense, spirituality can be thought of developmentally.

Consciously or unconsciously, people are drawn to spirituality to discover something of sacred value in their lives, sustain a relationship with the sacred, and, at times, transform their relationship with what they hold sacred Pargament, Theoretical and empirical studies make clear that spirituality is a multi-dimensional construct, holding multiple consequences e. Glock, ; Idler et al. While some choose to express their spirituality apart from organized religious settings, many people prefer to practice their spirituality within the context of an established religious tradition.

Others seek out non-traditional social outlets for their spirituality, such as healing groups, meditation groups, yoga groups, step groups, and most recently online discussion groups. And many people disengage from religious institutions for a period of time only to seek out other like-minded individuals at a later point in time with whom they can share their spiritual interests. In any case, spirituality always expresses itself in a larger social, cultural, and religious milieu. Both spirituality and religion are dynamic, multi-dimensional, multi-level, and multi-valent processes.

And both are concerned about issues of tremendous value and significance. In terms of function, religion is directed toward a broader array of significant goals than spirituality. Religion serves the important function of facilitating spirituality itself indeed, it is the spiritual character of its mission that makes religious institutions so distinctive , but religion serves other functions as well, including those that are psychological, social, and physical.

In contrast, spirituality focuses on one particular goal or destination, the sacred, however that might be defined by the individual. With respect to context, religion is more circumscribed than spirituality. In contrast, as noted above, although spirituality can be a vital part of traditional religious life, it can also be embedded in non-traditional contexts. One of the places where the evidence for spiritual care as part of holistic care is fairly strong is in the area of spiritual and religious needs. The research is consistent in documenting that patients in acute health care settings do have spiritual and religious needs, that religion and spirituality are often central to their coping, and that they generally want those needs attended to in the treatment process.

Fitchett, Meyer and Burton documented how often people might need spiritual support. They interviewed patients admitted to either a general or surgical medical unit in an urban hospital. Patients were asked what religion they were affiliated with, and if they desired one of three spiritual care services: to talk with a chaplain, to have a chaplain pray with them, or to receive the sacrament of communion. Sixty-eight percent of the patients claimed a religious affiliation and seventy-two percent reported that religion was a source of great strength and comfort to them.

Thirty-five percent of the sample requested one or more of the spiritual care services, and those who requested services tended to engage more frequently in religious practices and derive more comfort from religion overall. These findings suggest that while many people derive great comfort and support from religion they do not always ask for spiritual help in the hospital.

In addition to spiritual needs, people have religious needs. Fifty-eight percent of people with cancer engage in religious practices to help them cope with their illness Alcorn et al. However, little if any progress has been made on building and testing theories and models for the practice of chaplaincy. This gap may have to do with the fact that most chaplains consider their practice largely a function of their own individuality and thus, not subject to any generalizable theory.

It is also essential to note that, while progress with regard to these basic structures has been significant in the recent past, we do not know the proportion of people who work as chaplains who are board certified. Thus, there is no regulatory or financial business case for the inclusion of professional chaplains in health care settings.

These terms are often used interchangeably in the literature leading to confusion. For purposes of clarity, in this reviewchaplaincy care is care provided by a board certified chaplain or by a student in an accredited clinical pastoral education program e. All such care is provided by an individual who is mindfully aware of sacred matters that arise during the delivery of chaplaincy care. The issues are understood through beliefs about God, higher powers, and other cultural or religious belief systems -areas of knowledge that chaplains are versed in by virtue of their education and experience.

Thus, spiritual care will be defined as helping the patient maximize their relationship with that which is sacred in the service of their healing. The term, pastoral care,has been historically used within the Christian tradition to refer tocare provided by clergy. This care is founded in theology and expressly concerned with a cure of a soul Mills, Pastoral care is more like an intensive discourse between one or more persons seeking guidance in moral or spiritual concerns from the faith leader Mills, Pastoral care is encountered in relationship based on an understood system of shared beliefs, values, and behaviors.

Using these definitions, chaplaincy care is the part of spiritual care practiced by chaplains. Chaplains focus on their awareness of the sacred, listen and observe how the sacred is experienced by the patient. They are then prepared to move from being mindful and present in that awareness into supporting the sacred for the patient in their coping. The chaplain also brings to the team and the organization skills in spiritually, theologically, and culturally competent care, some of which can be modeled and taught to individuals on the team.

The chaplain also provides spiritual care to the members of the organization and acts as a leader in patient-centered holistic care. While some consensus is emerging conceptually with regard to the above definitions, much of the literature uses the terms interchangeably or without clear distinctions. The definitions above signal a significant shift in the model for delivery of professional health care chaplaincy in the U.

Traditionally, chaplaincy in acute health care has been delivered by community clergy who minister exclusively to patients of their faith tradition. The major emphasis has been on providing for religious needs and rituals. Thus, care for the spirit has been the exclusive province of the clergy. Further, the chaplain has been focused exclusively on care of the patient and family and not at all on integrated institutional initiatives and communicating with the health care team. The advent of bioethics committees, the concern for patient satisfaction, the awareness of the impact of cultural influences, and, finally, the full advent of patient-centered care broadened the general understanding of spiritual care into a realm that all members of the health care team need to participate in.

The more widespread availability of clinically trained multifaith chaplains has increasingly allowed the chaplain to be more fully integrated as the spiritual care professional on the health care team rather than simply being the community religious professional. While this new model is gaining wide acceptance and provides better congruence with the processes by which health care is currently provided, its efficacy and outcomes remain untested. Chaplaincy care has historically not been, in general, theory driven. Where theory is used at all, it is generally borrowed from other professions.

Many chaplains resist the idea of theory outright, considering it an infringement on the sanctity of their relationships with their patients. Fitchett in press has proposed a system of case analysis for chaplains which could easily and naturally lead inductively to theory in chaplaincy. Chaplains begin by being present with a patient, so that the chaplain is open to creating new meaning with the one who suffers Millspaugh, a.

To be truly authentic, and have a therapeutic relationship with an individual, four things are required. The first three are: being congruent; being positive and accepting; and being empathic. A fourth characteristic, presence, can arise from those three to enable the therapist to be truly and completely present in the moment with the individual. Geller and Greenberg studied presence, as suggested to be important for study by Rogers himself in an interview in Baldwin, by asking ten psychotherapists to describe the experience of presence with clients.

Their results suggest that there are three domains to be mindful of in therapeutic presence: preparing the situation for experiencing presence; activities that enable the experience of presence; and unconditional positive regard which is the actual experience of presence. Referring to Geller and Greenberg , Chaplain Kit Hall has developed and uses an evaluation form to help her prepare to offer presence to those she visits Hall, Harvey, Brown, Crawford, and Candlin employed decision analysis to describe the activity that surrounds the preparation for presence, and the depth that happens in the conversation that takes place between the chaplain and patient.

During the conversation, the chaplain conveys a polite and attentive stance that allows the patient to self-disclose what is troubling her or what is on her mind. This polite stance is known as linguistic politeness, and it is more complicated than everyday politeness. A chaplain skilled in linguistic politeness knows how to not threaten the conversation partner by speaking inappropriate words.

Chaplains converse in a way that allows the patient to speak about great difficulties without losing face. Simply to be passively present at the bedside is no longer enough of a description of this intervention. Greater detail of the practice of presence and a therapeutic result must be documented to happen with some reliability because of that presence.

Clinical pastoral education aims to teach chaplains to become aware of themselves when entering into a relationship with another person, in this case, a patient or family member. There is explicit training in ethical behavior and experiential training in self reflection, reflective listening, and learning through engaging in reality and with other humans Holifield, From the very beginning of the clinical training programs, in the first half of the twentieth century, chaplains have blended clinical technique with theological and psychological theory to optimally meet people where they are in their need.

Despite its long history and wide spread acceptance as the central training model for chaplains, there is limited research on the outcomes of CPE. In a review of 39 studies Derrickson found that students gain autonomy and self-awareness as a result of participating in CPE. Fitchett and Gray found that CPE students showed positive change in counseling resources, facilitative relations and non-judgmental acceptance.

These improvements were greater for students with no prior CPE experience and for students with fewer years of professional ministry. This research needs to be replicated and more investigation is needed into the role of skills developed in CPE, the use of these skills in chaplaincy delivery, and the impact of these skills on patient outcomes. There are a few examples of endeavors to establish chaplaincy best practice. Pruyser proposed an example of ministry practice informed by diagnostic classifications.

VandeCreek and Lucas edited a volume devoted to outcome-oriented chaplaincy, a method of focusing chaplaincy practice beyond the core of pastoral presence and relationship to include assessment and measurement of patient outcomes. Research directly investigating the implementation of this approach and its impact of in chaplaincy is greatly needed. In addition to standards of practice for chaplains, the standards for specific kinds of patient care are increasingly requiring that spiritual care needs be met. Hospital standards set forth in by The Joint Commission JC , which accredits most US hospitals, require hospitals to address the spiritual needs of patients Joint Commission, The standards for palliative care from the National Quality Forum specify the inclusion of spiritual care in the delivery of palliative care, but do not specifically include chaplaincy National Quality Forum, The National Comprehensive Cancer Network NCCN guidelines for practice in adult cancer pain specify evaluations of patient spiritual and religious considerations.

The guidelines for palliative care mention chaplains as a part of the interdisciplinary team, and the guidelines for distress management require the inclusion of a certified chaplain experienced in psychosocial aspects of cancer NCCN, There are a number of published descriptions of what chaplains do. These descriptions are helpful in describing the scope and breadth of chaplaincy practice including ministry to families, working with the bereaved, use of various interventions, and use of religious rituals and prayer.

However, many of these studies are restricted to a few hospitals e. New York Chaplaincy Study or particular practice settings like oncology or neonatology. Further, while it is clear that some chaplains do each of these practices, it is not clear how widespread any of them are. Finally, while there is increasing evidence describing what chaplains do, there is virtually no evidence for how well they do it and what results ensue.

With quality being such a central issue in modern health care, this is a serious gap in our knowledge. Chaplains address patient issues and concerns such as existential questions, spiritual pain and the sacred. They are able to work with religious patients as well as the increasing number of patients without a specific religious identity Newport, b. Chaplains engage patients and help them reframe their situation to reduce suffering.

Chaplains begin with a focus on the patient and the current situation, and assess all factors that could be potentially contributing to stress and suffering. They propose a plan to address the spiritual suffering, help the person immediately, and then follow-up with a plan to ensure benefits. This conceptualization again suggests how the role of chaplains is changing. In the past, the chaplain could truly have no agenda because they were not seen as contributing to the general plan of care.

As this presumption disappears, chaplains increasingly are seeing themselves and being seen as professionals with a definite agenda- to promote spiritual healing. To promote spiritual healing, many chaplains conduct a spiritual assessment and create a spiritual care plan which is not to be confused with a spiritual screening. Fitchett and Canada have helpfully differentiated spiritual screening, spiritual history, and spiritual assessment. Screening is a few simple questions asked by any health care personnel that identify a person in serious spiritual crisis and who needs immediate referral to a chaplain.

Spiritual history taking requires more time and more questions to identify specific religious needs and resources of the patient. The assessment requires the training of the professional chaplains and should only be done by someone with that training. The chaplain should assess the degree to which the patient may be experiencing issues of purpose and meaning, loss of any of the many aspects of self control, or spiritual pain and suffering Millspaugh, a. There is currently no research to determine how often chaplains actually do a formal spiritual assessment vs.

Nor is there extensive research on the content of assessments. There is no research on the relationships between assessment content, interventions, and outcomes. VandeCreek and Lucas proposed a system that includes all three, but there does not seem to be any research on whether the components wind up being related in any way. As electronic medical records become universal, it may well be that chaplains will be automatically called upon to assess and help specific patients as part of the hospital protocol which will require specific assessment methods LaRocca-Pitts, Again, this lack of predictability and consistency is likely to be an issue in any research on chaplaincy care.

Interestingly, a new perspective on what chaplaincy care might offer comes from the research of a psychiatrist, Harvey Chochinov, who developed Dignity Therapy DT; Chochinov, In most instances, these transcripts will be left for family or loved ones, and form part of a personal legacy that the patient will have actively participated in creating. The intervention was well tolerated, even in the sickest patients. The sessions averaged 55 minutes range: Notably, protocol burden was not an issue for patients, perhaps because they only spoke to issues important to them.

Potentially adverse events, such as revealing a hurtful reality insensitively, occurred but were all sufficiently well managed that none reported negative consequences. Staff responses to the trial have been uniformly, overwhelmingly positive. Practitioners felt it was a viable treatment option, especially in circumstances of existential distress. A phase 3 trial of DT has been completed Harvey Chochinov, personal communication. This personal report from Dr.

Differences were not detected on depression, anxiety and grief scales. Randomly selected cases were also captured and are being subjected to qualitative analysis studies; preliminary data indicate high levels of appreciation expressed differently from features captured on available scales.

For instance, one woman, hearing from her dying father for the first time that he loved her, expressed its value as priceless. Possible explanations for the dramatically positive personal report and the null findings for psychiatric conditions are several; a prominent possibility is that the intervention is primarily spiritual.

If so, possibly DT would be most suitably administered by chaplains. Current studies are evaluating the impact of DT on settledness and peacefulness regarding life-sustaining-care and terminal care decisions. Thirteen percent of respondents never referred to clergy or pastoral care providers. While this study is informative, it does not specifically ask about chaplains, nor is there a way to determine the rate of actual referral. There is some evidence of physicians having a positive attitude in general toward chaplains.

Chaplains were judged to be important for all of the listed roles with end-of-life care and emotional support being the most highly valued. Hospital administrators with chaplaincy care departments suggested additional roles for chaplains not on the list, such as drug counseling and teaching multicultural sensitivity, community liaison and outreach, crisis counseling and debriefing for staff, grief and bereavement counseling, advanced directives education, participating on a palliative care team, and handling organ and tissue donation requests.

Galek, Flannelly, Koenig and Fogg surveyed a national sample of directors of medical, nursing, social services and chaplaincy care departments. Directors of chaplaincy care felt it was more important than the other directors to refer patients to chaplains. Directors in psychiatric hospitals were less likely to refer to chaplains than other directors. These findings suggest that there is a general consensus that chaplains must be doing something to address these needs. Staff referred patients to chaplains for many different reasons.

Other reasons included crying, depression, and difficult decision. Problematically these reasons for referrals are not clearly exclusive of one another, for instance pregnancy loss is an event that could also involve crying, depression, or anxiety and require the support and pastoral care of a chaplain. Only three kinds of referrals hint at what chaplains might be doing: referrals for pastoral care and support; patient advocacy or assistance; and religious item or ritual.

Patients were more likely to be referred for anxiety, depression and pregnancy loss while family members were seen due to death of patient, bereavement, and support and pastoral care. Again it should be noted that these reasons for referral are not exclusive and can be collapsed, into depression and anxiety for patients and death and bereavement for families. Vanderwerker et al. Spiritual concerns were indicated only if a patient clearly exhibited spiritual distress or requested religious items. It is entirely possible that emotional reasons for referrals could have been unrecognized spiritual issues, i.

Reasons for referral are also markedly different depending on whether or not the person was asking for a chaplain. Weinberger-Litman, Muncie, Flannelly and Flannelly studied intent to refer patients or families to chaplains in nurses in one hospital in New York City. Nurses were provided with short statements describing different patient or family situations the nurse might encounter on the job, such as having a family dealing with the death of a patient, the removal of life support from a patient, or emotional discussions with a palliative care patient.

Nurses were asked how likely they were to refer to a chaplain to help in each situation. Nurses were moderately or very likely to refer in situations that dealt with death, grief and negative emotions. The nurses were only slightly likely to refer patients who were upset about quality of care or patients who were being non-compliant in taking medications, two situations that can escalate to crisis situations in which chaplains are often called Johnson, Finally, Galek, et al. The most common reason for a referral to a chaplain was that the patient requested a visit.

Patients and families most often requested the visit to meet religious needs, including prayer and religious ritual needs. The next most frequently stated needs were related to illness or treatment and end-of-life issues, followed by emotional issues, such as depression, distress or anxiety, and pre-operation needs. When staff referred chaplains to patients, the chaplains most often observed negative affect such as grief, sadness and anxiety. This might be because doctors, nurses, social workers and other staff were more likely to refer a patient to a chaplain for emotional or end-of-life issues.

Whereas patients or family members asked for chaplains to visit more often for religious needs or medical issues, and the most common affect reportedly seen by chaplains was gratitude. These surveys on referrals provide for some general impressions on what is expected from chaplains. Hospital administrators and staff tend to refer patients to chaplains to get them help with emotional issues, end-of-life, and death and dying issues, while patients and families request a chaplain and expect chaplains to help with religious, spiritual, and emotional needs. While this is important initial evidence about what chaplains are hoped or expected to provide, it is not clear what chaplains actually do or how well they do it.

A prayer request could be due to religious, spiritual or social needs of the patient or the particular perceptions of the person making the request e. The list of reported situations to which chaplains are referred and, to some extent the interventions they make, can also be significantly affected by factors unrelated to the unique training and contributions of chaplains. Thus, a hospital with a very robust chaplaincy department but a very weak social work department will likely generate many more referrals to chaplains for emotional issues than a hospital where the situation is reversed.

In some hospitals, chaplains bear primary responsibility for talking to patients about advance directives. In other hospitals, that task falls to patient advocates or social workers. In many hospitals, the referral pattern to chaplains is significantly related to the interests and skills of the particular chaplains on the staff.

Finally, the referral categories are often poorly defined and are not standardized across studies. The data for these studies was obtained through chaplain self-report: chaplains completed a form each time they made a visit to a patient or family member. The form required predetermined information about who they visited, how long they visited and what they did during their visit. In one study, Handzo et al. It is important to keep in mind that the data reported in this series of studies consisted of self-reports on a predetermined form by chaplains and chaplain students.

Furthermore, the form was filled out by individuals with considerable difference in professional abilities and education. The intervention information does not differentiate between interventions done by board certified chaplains or students. It is possible that the methods used by each group were significantly different in delivery and outcome. There was only a limited glossary to define terms. There was no documented corroboration with patients on the reason for referral or patient needs. In another study in one oncology hospital, chaplain activity varied depending of diagnosis and circumstances of the visit Flannelly, Weaver and Handzo, Scripture reading occurred most often during pre-op visits and faith affirmation and emotional enabling occurred more frequently with family member of patients in respiratory arrest.

In addition, type of activity varied depending on the religious tradition of the patient. These activities changed in priority somewhat during treatment visits. Emotional enabling was the most frequent activity with the chaplain for these latter three groups during treatment. For instance, the ministry to Muslim patients was conducted almost entirely by the Imam Flannelly, Weaver and Handzo, Also, as with prayer, there was significant variability of each activity across chaplains despite the fact that all were CPE trained.

Thus, there is great need for additional research to explore whether these differences will be sustained or were an artifact of the one study. Montonye and Calderone examined chaplain reports of their activities in a bed acute care hospital in Massachusetts. In this study, the chaplains included board certified chaplains, chaplaincy students and Roman Catholic priests. The staff reported patient needs, chaplain interventions, and patient outcomes over a two year period for each patient seen.

The reports were limited to drop-down responses on a computer screen for each category. Chaplains and visitors made determinations of needs in dialogue with those being helped. There were some differences in types of interventions engaged in depending on whether the intervention was provided by a CPE student, interfaith chaplain, or Roman Catholic priest. However, patients were assigned to chaplains or priests based on degree of difficulty and chaplain skill sets, so no definitive conclusions about interventions and kind of chaplain can be made. Visits before a surgery or at the death of a patient incorporated prayer for most patients, and Muslim and Catholic patients received prayer more often than Protestant or Jewish patients.

Professional chaplains have a foundational clinical background that should enable them to anticipate a need for prayer and to ask patients what they would like to pray for. In addition to prayer, chaplains, based on their training, develop rituals which are acceptable to people from a variety of spiritual traditions. Rituals bring communal meaning to chaos. For example, chaplains may develop non-religious ritual services for dying patients. These studies begin to give a picture of what chaplains do, however, they mostly deal with one or a small number of hospitals in roughly the same geographic area, the Midwest to North Atlantic states.

Despite the apparently adequate sample sizes, it is still likely that the reported activities were significantly affected by the peculiarities of individual hospitals rehabilitation hospital vs. It is expected that more research will replicate and expand these findings. As such, they should be intimately involved in treatment decisions.

Chaplains can and often do play a valuable role in bridging this gap. Indeed, Gillman and his colleagues see chaplains as a vital link between family members and the treatment team, especially in critical care situations.

The Social Care Elf

Only eight percent of families with an infant in the NICU interacted with a chaplain. Eighty-three percent of chaplain-initiated visits were for non-decedent care for the support of the parents of an extremely ill child. Nurses and physicians reported that, in addition to the above, chaplains helped with the assessment of parental coping, comforted the medical staff, and took part in morally problematic decisions in the NICU.

Although it appears that chaplains saw more family members than patients, the percentages are somewhat inflated due to counting each family member present during a single patient visit. For example, if there were four family members in the room with a patient when a chaplain visited, the patient was counted once, and family contacts were counted as four. Even though the study also measured the frequency of worship services and sacramental functions, and estimated the time spent in each, it did not identify the extent that patients, family, or staff benefitted from these activities.

Neither did the report examine what was done during the visits or identify how often families or patients received follow-up visits. Broccolo and VandeCreek interviewed next-of-kin, asking two open-ended questions that inquired about what the chaplain did or said, and the degree to which the contact with the chaplain was helpful.

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The descriptions of what the chaplain did fell into five categories: providing comfort and support, assisting with the details of death, being a temporary family member, making meaningful contact, and being a spiritual doula for the deceased to make the transition from this life to the afterlife. The chaplains in these studies rate such types of activities as being more important than performing religious rituals or services. Administrators who were surveyed shared the same perspective as chaplains about the importance of providing emotional support to family members.

Much of the evidence on ministry to families basically states the obvious e. Again, while we know something about the kinds of situations that chaplains are called to be part of, we continue to know very little about what they do in those situations and what outcomes those interventions produce. Research into chaplaincy outcomes falls roughly into two general categories - patient satisfaction studies and outcome studies of actual chaplaincy interventions. The patient satisfaction studies are generally stronger methodologically than the outcome studies and tend to show that chaplain visits have a positive effect on overall patient satisfaction.

However, in general, they do not give any indication of whether the patient benefits from the visits. It is also not clear whether the same results could not have been achieved by professionals from other disciplines or trained volunteers. The outcome studies are very few in number and most have serious methodological shortcomings. Thus, we have included some research from outside the inpatient acute care setting to obtain a broader horizon of chaplaincy research. In terms of levels of evidence, the research literature does not offer well established findings to date.

All studies are in need of targeted and enhanced replication, and most are only suggestive and certainly not conclusive. A table summarizing pertinent studies of patient satisfaction with chaplaincy may be found in Appendix Two, Table 1, and chaplaincy outcome studies can be found in Appendix Two, Table 2. Spiritual care is an important facet of overall health care. Families rated the facilities more positively when spiritual care needs were met.

In another study, Astrow, Wexler, Texeira, He and Sulmasy found that patients who did not have their spiritual care needs met were less satisfied with their health care. Those goals are often influenced by spirituality and religion Phelps et al. Chaplains are the professionals with special training to offer competent spiritual care. Parkum surveyed patients from six hospitals to compare the helpfulness of different nonmedical support services.

Approximately two thousand former hospital patients or family members who were surveyed returned the mailed questionnaire. VandeCreek examined visits by clergy and chaplains and the frequency of religious service attendance, both in the hospital and before hospitalization, among other variables, in relation to satisfaction. Results indicated that older individuals, those with lower education levels, those who attended church before hospitalization, and those who had shorter stays were more likely to rate satisfaction with chaplaincy care higher than those individuals with more education, those who did not attend church, and those who had longer hospital stays.

The chaplain was seen by many as a person with spiritual sensitivity and someone who helped people find ways to cope. Overall satisfaction was correlated with all measures of chaplain activity. Gibbons, Thomas, VandeCreek and Jessen examined the satisfaction with chaplain and spiritual services of over patients who had recently left the hospital.

Just under half of the former patients had received a visit from a chaplain, and half of these had also been visited by clergy. About a third received a visit from a social worker, and a third from a patient representative. It must be noted, however, that ratings of importance and expectations met were on a scale of 1 to 10, and the level of importance for chaplains was 5 and expectations was 6.

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This study also looked at spiritual needs, such as the need for support and counseling for patient and family, the need for prayer, and need for sacraments. Support and counseling needs being met were associated with recommending the hospital to others and selecting the hospital again. Meeting prayer and sacramental needs were not related to recommending the hospital to others. Notable limitations of this study were a VandeCreek and Connell further examined, using the same dataset as Gibbons et al. These were all rated around 6 on a scale of 1 to 10, with sacraments for Catholics being rated as 7.

There were significant differences between Catholics and Protestants in several of the outcome measures. As in Gibbons et al. There is no comparison of chaplains with social workers, patient representatives or clergy. The authors conclude that patients were satisfied with the services rendered. Flannelly, Oettinger, Galek, Braun-Storck and Kreger evaluated the impact of chaplaincy services by focusing on the satisfaction with chaplains in a hospital that specialized in orthopedic surgery. Only patients who requested a visit from the chaplain at check-in were visited by a chaplain.

Interventions used by chaplains varied across patients and included praying, listening and providing help to overcome fears. While there is good evidence now that patients like chaplains and that chaplains have a positive effect on patient satisfaction scores, it is not at all clear what chaplains do, or could do better, that patients find helpful or satisfying.

Many of the activities listed in the studies are not clearly defined. Chaplain helpfulness on average was rated between very good and excellent. This highlighted the fact that many family members did not know what to expect from a chaplain. The majority of those who were helped had a lasting positive impression of the chaplain and the help they received. Chaplains have been involved in research both investigating the impact of their ministry on individuals as well as assisting others as part of an interdisciplinary team.

There are a few studies worth mentioning in detail in this section. Chaplains helped deliver spiritual interventions as part of an effort to improve quality of life in advanced cancer patients Rummans et al. Patients were randomly enrolled in either a treatment as usual condition or an intervention condition.

While in the hospital and undergoing radiation treatments for advanced cancer the intervention patients received at least five and up to eight minute intervention sessions that included physical therapy, cognitive, emotional, social and spiritual interventions, and minutes of guided relaxation. Intervention patients also received a page manual with written materials that covered all of the eight manualized sessions.

The treatment as usual control group received the same standard of medical care, including meetings with their oncologist and support group resources. At four weeks follow-up, intervention patients were reporting significantly greater quality of life than patients in the control group. Ratings of spiritual well-being were also significantly higher in the intervention group at four weeks. Notably, the control group decreased in quality of life and spiritual well-being from baseline to week four. By five months follow-up these differences were no longer significant, as the control returned to baseline levels, as did the intervention group.

Although the spiritual domain was the domain to show the most improvement it is not possible to document the influence of the chaplain on this process. The chaplain was part of a comprehensive care team that included three physicians, a social worker, a nurse, a pharmacist, a psychologist, an art therapist, and a volunteer coordinator. The chaplain was responsible for offering spiritual and psychological support.

Patients were offered support groups and weekly telephone contacts from medical and pharmacy students. Unfortunately, it is impossible in this study to estimate the particular contribution of the chaplain, or any individual professionals involved in patient care, to the overall improvement in patient well-being.

Faith and Field: The Ethical Inclusion of Spirituality within the Pedagogy of Social Work

Even though there is much diversity in setting, population served, and activities engaged in, several studies have attempted to measure the impact of chaplaincy on patient and family outcomes. Baker conducted an intervention study in a church-related continuing care retirement community in an effort to demonstrate the efficacy of pastoral care in treating depression and the negative impacts of changes in life circumstances. He divided the elderly participants into three groups; individuals taking anti-depressant medication, individuals at-risk for depression and individuals selected after a weekly religious service.

Each of these three groups was again divided into two groups; those receiving weekly pastoral visits and those not receiving weekly pastoral visits. There were no limits on the kinds of pastoral care provided to the adults in the pastoral care group. The pastoral visits lasted about 30 minutes each and continued for 26 weeks. The visits were conducted by four ordained ministers who were serving area congregations, two ministers had a minimum of one unit of clinical pastoral education and two had no clinical training.

Nancy R. Hooyman and Amanda Barusch

Religiosity, religious practice, spiritual well-being, self-transcendence, depression and social participation were all measured before the pastoral visits began, after six months of visits, and three months after visits ceased. Group averages did change in expected ways that suggest a positive impact of pastoral visits. Pastoral visits were associated with higher religious and spiritual well-being scores and lower depression scores at post-test.

Compared to the control group, the pastoral visit group had significantly higher religious and spiritual well-being at posttest. However, there were no significant differences between groups at three months follow-up, and in fact, the pastoral visit group had the highest average levels of depression at follow-up compared to the control group. The results of this study should be considered descriptive in nature, due to the nonstandard reporting of group sizes, means, and statistical results, multiple comparisons made using a t test which increases the chance of identifying a group difference as significant when it is not, and the examination of subgroups not originally identified before the start of the study.

The results of this study are suggestive and in need of replication. Each chaplain followed a protocol for each visit. Also at 6 month follow-up, negative religious coping on the RCOPE as seen in statements that reflected feelings of abandonment and questioning of God, was significantly lower in the intervention group compared to the control group. This is an important finding, given that patients with negative religious coping and struggle are at a higher risk for health complications Fitchett et al.

However, the meaningfulness of these differences is to be determined, given that the magnitude of these average differences is quite small- on average no more than the equivalent of one point on a scale that can range from a score of 7 to Additionally, there was no significant difference between the intervention group and control group in level of depression over time, likely due to the fact that the levels of depression of participants in this study were at the low end of the normal range and not in the clinical range.

The other mental health outcomes measured- anxiety, hope, and religious problem solving, showed no differences between the intervention group and control group over time or at any point in time. Thus, while the chaplaincy intervention did not have the expected impact on mental health, the same intervention may yield much different results in patients with more compromising illness manifestations, for whom there would be more room for improvement on psychological measures of well-being and distress.

In a study with patients with a more compromising diagnosis the impact of chaplaincy care was more dramatic. Chaplain visits to patients with chronic obstructive pulmonary disease COPD in an inpatient setting were studied by Iler, Obenshain and Camac They are often admitted to the hospital when the disease flares, and they can remain hospitalized for a considerable length of time, and require substantial hospital resources.

Those that agreed to participate were given the Beck Anxiety Scale both at admission and at discharge. Participants were assigned to one of two groups, patients who received daily chaplain visits during the hospital stay and patients who did not. Chaplain activities were not standardized across patients or visits and lasted approximately 20 minutes.

On average, 4. At discharge, patients were also asked about their satisfaction with the hospital and whether they would recommend the hospital to others. Patients who received chaplain visits had significantly lower anxiety, shorter hospital stays, and were more satisfied with the hospital stay than patients who did not receive chaplain visits.

While it appears that chaplain visits were responsible for very good outcomes, several limitations to this study should be kept in mind. No causal conclusion can be made regarding chaplaincy care specifically. It is not possible to know if the effects are specific to chaplaincy care. That said, this is the one study where we believe that the outcomes presented are defensible methodologically and statistically. Other studies exist that are often cited as evidence for the beneficial effects chaplaincy care that prove, upon closer examination, to be documenting no care, or care of another kind.

In one study, patients about to undergo orthopedic surgery were provided regular hospital care, emotionally supportive care by a chaplain, or emotionally supportive care and information about the treatment by a chaplain. The outcome measures were degree of anxiety, length of stay and other physiological patient measures Florell, Patients who received either support condition left the hospital sooner, made fewer calls for help to the nurses' station, and had lower anxiety, respiration, heart rate and lower pain medication needs than the patients who received regular hospital care.

There are a number of limitations of this study, including patient assignment to conditions, and most notably the lack of detail on whether the chaplains provided spiritual care or general support and information. It is possible that anyone who gave general support and information could have effected a change, hence the chaplain intervention in the study would not have been unique to chaplaincy care. The first study is the Florell study cited above.

While it is true chaplains were involved and provided care, there is no evidence that what the chaplain did was unique to being a chaplain: a social worker or psychologist could also have done what the chaplain did in the intervention. In the second study by McSherry , men who were more religious, as affirmed on a questionnaire, were more likely to leave the hospital sooner. This finding has nothing to do with a chaplain providing care, and it is not clear that the chaplain was involved at all with the patients. The same might be said of the other two patient stories noted in this report.

These studies highlight the importance of identifying the unique intervention contribution of the chaplain, the measurement of that intervention, and the specific outcomes that can not be expected from the interventions of others on a health care team. None of the studies that look at referrals or activities reach a high level of evidence for the efficacy of chaplaincy. Most of the studies equated chaplaincy students with board certified chaplains and volunteers. These studies represent the extent of the outcomes research in chaplaincy care in the United States.

There is a fairly uniform finding that patients like chaplains. What they like about them is generally unknown, although there are indications that those who have experienced chaplains find them spiritually sensitive and supportive. There are no clear patient outcomes studies that document the efficacy of the unique aspects of chaplaincy care, as opposed to spiritual care provided by an interdisciplinary team. The amount and type of outcomes research conducted so far has not yielded well-established findings in any area.

Several recent trends in health care will impact on chaplaincy research going into the future. Firstly, increasing attention at a national level is being paid to palliative care.

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