EVIDENCE-BASED CHAPLAINCY CARE : Transforming Our Practice George - - PDF document

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EVIDENCE-BASED CHAPLAINCY CARE:

Transforming Our Practice

George Fitchett, DMin, PhD, BCC

Department of Religion, Health and Human Values Rush University Medical Center, Chicago, IL george_fitchett@rush.edu

• .46***

.69*** Hopelessness Depression Religious Belief .17**

***p<.001, **p<.01. N = 271

Tradition – We have always done it

this way.

Policy – This is the way we are

supposed to do it.

Education – I was taught to do it this

way.

How Do We Know Good Spiritual Care? Personal Experience/Trial and Error

– I tried several ways and this this one works best.

Intuition – Doing it this way feels right to me. Research – There is evidence this is the best way to do it.

From Hundley, 1999

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Standard 12: Research The chaplain practices evidence-based care including

• ngoing evaluation of new

practices and when appropriate, contributes to or conducts research.

(http://www.professionalchaplains.org)

Chaplaincy: A Research-Informed Profession

• 1. Evidence-Based Care: What is it?
• 2. Evidence-Based Care: Against it &

for it

• 3. Ways of Knowing: Religion and

Science

• 4. Types of Research Evidence
• 5. Overview of Chaplaincy-Related

Research

• 6. Next Steps for Research-informed

Chaplaincy

Outline

• .46***

.69*** Hopelessness Depression Religious Belief .17**

***p<.001, **p<.01. N = 271

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“Evidence-based spiritual care is the use of scientific evidence on spirituality to inform the decisions and interventions in the spiritual care of persons”

Tom O’Connor (2002). Journal of Religion and Health

What is Evidence-Based Spiritual Care?

Evidence-based practice in psychology is the integration of

• the best available research

with

• clinical expertise
• in the context of patient

characteristics, culture, and preferences.

What is Evidence-Based Practice?

APA Policy Statement on Evidence-Based Practice in Psychology, 2006

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It can’t be done God, the Spirit, presence, prayer, etc. are much too big and always will be mysteriously beyond our attempts to measure and

• quantify. (Stiger, 2002)

AGAINST Evidence-Based Spiritual Care

It shouldn’t be done Once pastoral care services succumb to the need to prove they can decrease the length of stay

• r improve patient satisfaction all will be lost.

(Sulmasy, 2006) “Evidence from research needs to inform our pastoral care. To remove the evidence from pastoral care can create a ministry that is ineffective or possibly even harmful”

(O’Connor TSJ and Meakes E. 1998. The first article to use the term “evidence- based” pastoral care.)

FOR Evidence-Based Spiritual Care

Good stewardship of creation requires

• ur best, evidence-based, care

(Grossoehme in Fitchett & Grossoehme, 2011)

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Health Care Chaplaincy Improving our Care and Making our Case Through Research

• .46***

.69*** Hopelessness Depression Religious Belief .17**

***p<.001, **p<.01. N = 271

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Source: Anton T. Boisen Explorations of the Inner World: A Study of Mental Disorder and Religious Experience (Willett, Clark & Company, 1936)

Conflict: opposite and antagonistic, conflict Mutual independence: separate and different Dialogue: meeting on boundaries Integration Can Religion and Science Co-Exist?

Ian Barbour, Nature, Human Nature and God, 2002

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Standard 12: Research The chaplain practices evidence-based care including

• ngoing evaluation of new

practices and when appropriate, contributes to or conducts research.

(http://www.professionalchaplains.org)

Chaplaincy: A Research-Informed Profession

• Research Literacy

All health care chaplains should be research literate

• Research Collaboration

Some health care chaplains will be qualified to collaborate in research conducted by health care colleagues (co-investigators)

• Research Leadership

Some health care chaplains will be qualified to lead research projects (principal investigators)

Chaplaincy: A Research-Informed Profession

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A research-literate chaplain has the ability to read, understand, and summarize a research study and to explain its relevance for his/her spiritual care.

• .46***

.69*** Hopelessness Depression Religious Belief .17**

***p<.001, **p<.01. N = 271

Chaplaincy: A Research-Informed Profession

• 1. Importance of R/S for

patients

• 2. Patient/family R/S coping and

R/S needs

• 3. Patient/family preferences for

spiritual care

• 4. Describe what chaplains do
• 5. Effect of spiritual care on

important outcomes

Overview of Chaplaincy Research

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Reviews of Chaplaincy Research

Mowat, Harriet (2008). The potential for efficacy

• f healthcare chaplaincy and spiritual care

provision in the NHS (UK): A scoping review of recent research. 88% 7% 5% 80% 9% 11% 65% 15% 20% 0% 20% 40% 60% 80% 100%

very much/quite a bit somewhat not at all/a little bit

My faith or spirituality has helped me through my cancer experience

Black (n=914) Hispanic (n=664) White (n=6827)

N=8,405, ACS SCS II; Canada et al. 2013

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Religious Coping among Persons with Persistent Mental Illness (N=406)

65% Religion helped to cope with symptom severity (to a large or moderate extent) 48% Religion became more important when symptoms worsened 30% Religious beliefs and activities were “the most important things that kept [them] going”

Tepper et al. (2001) Psychiatric Services, p. 662

Religious/Spiritual Perspectives of Adolescents & Young Adults Receiving BMT

Believing God has a reason “He chose me ’cause I’m strong. I understand what I have to go through.” Using faith practices “And just when I’m in pain and I pray for peace. . . that side effects won’t be too bad.” Benefitting from spiritual support people “My pastor’s wife is one of the biggest helps

• because. . . she talks to me like I’m normal.”

Themes for 12 AYAs (age 15-28, 7 female, interviewed 2 weeks pre to 3 months post- transplant; 6 re-interviewed 1 yr post-transplant); Ragsdale et al., 2014

“We learned that AYA patients were utilizing R/S far more than we suspected. Our data. . . suggest that chaplains should be proactive in asking AYA patients about their understanding and use of faith.”

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"I want to know more about this"

Pargament et al 2000

Item Percent with distress Not able to carry out important roles 37.5 Feeling no longer who I was 36.4 Feeling of not having control 29.2 Feeling uncertain 26.9 Feeling a burden to others 24.1 Feeling depressed 22.5 Worried about future 20.9 Feeling of unfinished business 19.4 Feeling life no longer has meaning or purpose 17.4 Not feeling worthwhile or valued 17.0 Feeling have not made meaningful contribution 11.9 Not being able to accept things as they are 11.5 Concerns regarding spiritual life 6.3

Distress in 253 Palliative Care Patients (90% Canadian, 10% Australian) Chochinov et al., 2009

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23% with distress in 3+

Spiritual Distress

Chaplain ratings of spiritual distress for 113 palliative care in-patients at MD

• Anderson. Hui et al., 2011

50% with no or little distress From Monod et al., 2012; n=203 geriatric patients in medical rehabilitation, Switzerland 65% some distress 27% some distress in all 5 dimensions 22% severe distress in at least one dimension 60% of severe unmet needs were for Life Balance

Spiritual Distress in Older Medical Rehab Patients

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Is R/S important to you as you cope with your illness? YES (82%) NO (18%) How much strength or comfort do you get from your R/S right now? Has there ever been a time when R/S was important to you? All that I need (41%) NO (9%) Less than I need or none at all (41%) R/S Struggle Path 1 YES (9%) R/S Struggle Path 2

BRIGHTEN Participants (n=188) Screening for R/S Struggle

Study Mako et al, 2006 Delgado Guay et al., 2011 Center Calvary Hospice, NYC MD Anderson Patients Inpatients w advanced cancer Palliative care outpt clinic Sample size 57 91 Yes % 61% 44% Median (IQR) 3 (1, 6) Mean 4.7

Are you experiencing spiritual pain right now?

Spiritual pain is a pain deep in your soul (being) that is not physical

How would you rate your overall spiritual pain

0 (none) – 10 (worst)?

Screening for Religious Struggle

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QUESTION IMPLICATION FOR SPIRITUAL CARE How did you decide which patients to see this week? Good stewards of scarce resources How did staff you work with determine who to refer and who not to refer? Protocol for screening and referral What evidence did you generate this week that your spiritual care made a difference in measurable patient

• utcomes?

Accountability and documentation How many chaplains does your institution/service need? Can estimate level of spiritual acuity and staffing needs

Implications of Screening for Spiritual Pain

Predictors of Interest in Spiritual Care OR Spirituality (ref = Not spiritual) Somewhat spiritual 4.17 Very spiritual 8.35 Religiousness (ref = Secular) Traditional 1.79 Religious 2.41 Prior experience with spiritual care (ref = No) Yes 3.9 Understand spiritual care (ref = No) Yes 2.9

Interest in Spiritual Care (n= 364 oncology

• utpatients, Israel)

Schultz et al., 2014

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Want at least 1 visit 70%

Daily visits 18% Visit every few days 38% Weekly visit 13%

Not at all 17% Expect visit without requesting 39%

*14% missing

Preferences about Chaplain Visits*

Piderman et al, 2010, N=1591

78% 71% 69% 62% 59% 44% 39% 0% 30% 60% 90% Remind me of God's care and presence Offer support to family or friends Be with me at times of particular anxiety or uncertainty Pray and/or read scripture or sacred texts Listen to me Administer religious ritual or sacrament Counsel me regarding moral/ethical concerns or decisions Percent 'very' or 'somewhat' important

Patient’s Ratings of Reasons for Wanting to See a Chaplain (N=1,591)

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What Chaplains Do in Palliative Care

Proportion of chaplains who report activity often, frequently or always Activity All Chaplains (n=382) Chaplains who work in PC >86% (n=64)

Chaplain Craft Build relationship 76% 87% Provide ritual support 64% 59% Death and Dying Care for dying or deceased patient/family 69% 76% Goals of Care Patient's/loved one's goals of care 55% 70% Facilitate communication between patient/family and team 46% 65% Family conflict 30% 41% Existential & Spiritual Distress Existential questions/ spiritual distress 49% 57% Why me 25% 29% Loss of faith 9% 11%

National survey of chaplains who work at least 15% time in palliative care

What Do Chaplains Do?

http://www.advocatehealth.com/body.cfm?id=9&eformid=120%20 Massey et al., 2015

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Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy George Fitchett and Steve Nolan, Editors

2015, Jessica Kingsley Publishers http://www.jkp.com/usa/spiritual‐ care‐in‐practice.html

Chaplain Case Studies

Discipline for Pastoral Care Giving – Arthur Lucas, 2001

Profile

• Concept of Holy
• Meaning
• Hope
• Community

Outcome Oriented Care Spiritual Care

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Not‐visited by Chaplain (N = 8,480) Visited by Chaplain (N = 498) Overall rating of care given at hospital (1‐5) 4.63 ± 0.01 4.72 ± 0.03** What number would you use to rate this hospital during your stay? (0‐10) 8.80 ± 0.02 8.97 ± 0.07* Likelihood of your recommending this hospital to others (1‐5) 4.59 ± 0.01 4.67 ± 0.03 Would you recommend this hospital to your friends and family? (1‐4) 3.70 ± 0.01 3.77 ± 0.02* Degree to which hospital staff addressed your spiritual needs (1‐5) 4.23 ± 0.01 4.38 ± 0.04** Degree to which hospital staff addressed your emotional needs (1‐5) 4.38 ± 0.01 4.44 ± 0.04

Satisfaction Scores for Patients Visited and Not Visited by Chaplains (New York City)

*p < .05. **p < .01. Marin et al. 2015

Sample (study) Findings 356 family members of patients who died in ICU, Seattle

(Wall et al, 2007)

Rating spiritual care as excellent was associated with higher ratings of satisfaction with ICU care overall 275 family members of patients who died in ICU, Seattle

(Johnson et al., 2014)

Chaplains’ care was associated with increased overall family satisfaction with ICU care and with satisfaction with decision‐ making in the ICU

Measures of Outcomes: Patient/Family Satisfaction

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19.68 6.56 22.08 11.58 10 20 30 Baseline Anxiety Discharge Anxiety Mean Anxiety Score (0-63)

Intervention Gp (N=25) Control Gp (N=24)

p=0.05 Source: Iler et al. (2001).

Effect of Chaplain Visit on COPD Patient Anxiety

Avg QoL= 19, SD=7.9

N=299 patients; Balboni et al, 2010

Measures of Outcome: QoL (& treatment preferences & cost of care)

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Lyndes et al., J Health Care Chaplaincy, 2012; Fitchett et al, J Palliat Med., 2011;

Physicians Chaplains Physicians emphasize chaplain contribution to key outcomes Chaplains emphasize process (presence) Address spiritual suffering Chaplains provide a listening, supportive presence Improve family-team communication Chaplains comment on

• utcomes

Physicians are aware of process

Bi-Lingual Chaplains The Changing Chaplaincy Paradigm

Period Paradigm for Chaplaincy Early 20th century  Pastoral care as response to individual sin Mid‐20th century  Chaplaincy was shaped by Rogerian model of client‐centered counseling Early 21st century  Pastoral care as response to individual need (Gleason)  Research‐informed, outcome‐

• riented chaplaincy (Lucas, 2001)

Gleason, 1998; Fitchett et al., 2014

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JOINT RESEARCH COUNCIL Chartered by the Association of Professional Chaplains, with organizational partners:  Association for Clinical Pastoral Education  Canadian Association for Spiritual Care  HealthCare Chaplaincy Network  National Association of Catholic Chaplains  Neshama: Association of Jewish Chaplains  Scottish Association of Chaplains in Healthcare  Spiritual Care Australia

Next Steps for Research-Informed Chaplaincy

Watch for the JRC website soon

Priority Rank Evaluate screening tools used to identify patients with spiritual needs 1st Develop and evaluate conversation models for spiritual conversations 2nd Evaluate the effectiveness of spiritual care 3rd Develop and evaluate spiritual interventions 4th Determine the prevalence of spiritual distress 5th

Selman et al 2014, n=807 clinicians

A Research Agenda for Chaplaincy

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• Need to teach

research literacy skills in CPE residency programs

• Create research

journal clubs in chaplaincy departments

• Demonstrate

research literacy for chaplaincy certification

Chaplain Education and Certification

Fitchett et al , 2012

Any Research Education Yes Some No Total CPE Centers 3 (14%) 5 (24%) 13 (62%) 21 CPE Systems 0 (0%) 2 (40%) 3 (60%) 5 All Programs 3 (12%) 7 (27%) 16 (62%) 26 Margin of Error 12% 17% 19%

Phase 1 – July 1, 2015 - June 30, 2016 Phase 2 – July 1, 2016 – June 30, 2019

Core activities

• 16 Templeton Chaplain

Research Fellowships

• Research literacy curriculum

development grants to 70 CPE residency program

• Free online continuing

education Introduction to Research course for members of chaplaincy organizations Co‐led by George Fitchett (Rush) & Wendy Cadge (Brandeis)

Together these initiatives will create over 800 research literate chaplains strengthening understandings of religion, spirituality and health and transforming chaplaincy as a profession.

TRANSFORMING CHAPLAINCY

Promoting Research Literacy for Improved Patient Outcomes www.researchliteratechaplaincy.org

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http://www.healthcarechaplaincy.org/docs/publications/templ eton_research/hcc_research_handbook_final.pdf

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APC Webinar Journal Club 6 Future Sessions

Dates Keeping Up With Important Research for Chaplains Session 1, September 20, 2016 Session 2, November 15, 2016 Session 3, January 10, 2017 Session 4, March 14, 2017 Session 5, May 9, 2017 Open to all

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Health Care Chaplaincy Improving our Care and Making our Case Through Research

• .46***

.69*** Hopelessness Depression Religious Belief .17**

***p<.001, **p<.01. N = 271

When it’s over, I want to say: all my life I was a bride married to amazement.

from When Death Comes by Mary Oliver