EVIDENCE-BASED CHAPLAINCY CARE:

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*** Hopelessness Religious Belief.17** ***p<.001, **p<.01. N = 271 Depression.69***

How Do We Know Good Spiritual Care? 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. 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

Chaplaincy: A Research-Informed Profession Standard 12: Research The chaplain practices evidence-based care including ongoing evaluation of new practices and when appropriate, contributes to or conducts research. (http://www.professionalchaplains.org)

Outline 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 Religious Belief ***p<.001, **p<.01. N = 271 -.46***.17** Hopelessness Depression.69***

What is Evidence-Based Spiritual Care? 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 Practice? 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. APA Policy Statement on Evidence-Based Practice in Psychology, 2006

AGAINST Evidence-Based Spiritual Care 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) It shouldn t be done Once pastoral care services succumb to the need to prove they can decrease the length of stay or improve patient satisfaction all will be lost. (Sulmasy, 2006)

FOR Evidence-Based Spiritual Care 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 evidencebased pastoral care.) Good stewardship of creation requires our best, evidence-based, care (Grossoehme in Fitchett & Grossoehme, 2011)

Health Care Chaplaincy Improving our Care and Making our Case Through Research -.46*** Hopelessness Religious Belief.17** ***p<.001, **p<.01. N = 271 Depression.69***

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

Can Religion and Science Co-Exist? Conflict: opposite and antagonistic, conflict Mutual independence: separate and different Dialogue: meeting on boundaries Ian Barbour, Nature, Human Nature and God, 2002 Integration

Chaplaincy: A Research-Informed Profession Standard 12: Research The chaplain practices evidence-based care including ongoing 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 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. Religious Belief -.46***.17** ***p<.001, **p<.01. N = 271 Hopelessness Depression.69***

Overview of Chaplaincy Research 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

Reviews of Chaplaincy Research Mowat, Harriet (2008). The potential for efficacy of healthcare chaplaincy and spiritual care provision in the NHS (UK): A scoping review of recent research.

My faith or spirituality has helped me through my cancer experience 100% 80% 88% 80% Black (n=914) Hispanic (n=664) White (n=6827) 65% 60% 40% 20% 15% 7% 9% 11% 5% 20% 0% very much/quite a bit somewhat not at all/a little bit N=8,405, ACS SCS II; Canada et al. 2013

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% 30% Religion became more important when symptoms worsened 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 Using faith practices Benefitting from spiritual support people He chose me cause I m strong. I understand what I have to go through. And just when I m in pain and I pray for peace... that side effects won t be too bad. My pastor s wife is one of the biggest helps because... she talks to me like I m normal. 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. Themes for 12 AYAs (age 15-28, 7 female, interviewed 2 weeks pre to 3 months posttransplant; 6 re-interviewed 1 yr post-transplant); Ragsdale et al., 2014

"I want to know more about this" Pargament et al 2000 21

Percent with Item 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 17.4 purpose Not feeling worthwhile or valued 17.0 Feeling have not made meaningful 11.9 contribution Not being able to accept things as they 11.5 are Concerns regarding spiritual life 6.3 Distress in 253 Palliative Care Patients (90% Canadian, 10% Australian) Chochinov et al., 2009

Spiritual Distress 50% with no or little distress 23% with distress in 3+ Chaplain ratings of spiritual distress for 113 palliative care in-patients at MD Anderson. Hui et al., 2011

Spiritual Distress in Older Medical Rehab Patients 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 From Monod et al., 2012; n=203 geriatric patients in medical rehabilitation, Switzerland

Screening for R/S Struggle BRIGHTEN Participants (n=188) Is R/S important to you as you cope with your illness? YES (82%) How much strength or comfort do you get from your R/S right now? NO (18%) Has there ever been a time when R/S was important to you? All that I need (41%) Less than I need or none at all (41%) YES (9%) NO (9%) R/S Struggle Path 1 R/S Struggle Path 2

Screening for Religious Struggle Study Mako et al, 2006 Delgado Guay et al., 2011 Center Calvary Hospice, NYC MD Anderson Patients Inpatients w advanced Palliative care outpt cancer 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)?

Implications of Screening for Spiritual Pain QUESTION How did you decide which patients to see this week? How did staff you work with determine who to refer and who not to refer? What evidence did you generate this week that your spiritual care made a difference in measurable patient outcomes? How many chaplains does your institution/service need? IMPLICATION FOR SPIRITUAL CARE Good stewards of scarce resources Protocol for screening and referral Accountability and documentation Can estimate level of spiritual acuity and staffing needs

Interest in Spiritual Care (n= 364 oncology outpatients, Israel) Predictors of Interest in Spiritual Care Spirituality (ref = Not spiritual) OR Somewhat spiritual 4.17 Very spiritual 8.35 Religiousness (ref = Secular) Traditional 1.79 Schultz et al., 2014 Religious 2.41 Prior experience with spiritual care (ref = No) Yes 3.9 Understand spiritual care (ref = No) Yes 2.9

Preferences about Chaplain Visits* 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 Piderman et al, 2010, N=1591

Patient s Ratings of Reasons for Wanting to See a Chaplain (N=1,591) 90% 78% 71% 69% 60% 62% 59% Percent 'very' or 'somewhat' important 30% 44% 39% 0% 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

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

Chaplain Case Studies Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy George Fitchett and Steve Nolan, Editors 2015, Jessica Kingsley Publishers http://www.jkp.com/usa/spiritualcare in practice.html

Outcome Oriented Care Spiritual Care Profile Concept of Holy Meaning Hope Community Discipline for Pastoral Care Giving Arthur Lucas, 2001

Satisfaction Scores for Patients Visited and Not Visited by Chaplains (New York City) 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) Likelihood of your recommending this hospital to others (1 5) Would you recommend this hospital to your friends and family? (1 4) Degree to which hospital staff addressed your spiritual needs (1 5) Degree to which hospital staff addressed your emotional needs (1 5) Marin et al. 2015 8.80 ± 0.02 8.97 ± 0.07* 4.59 ± 0.01 4.67 ± 0.03 3.70 ± 0.01 3.77 ± 0.02* 4.23 ± 0.01 4.38 ± 0.04** 4.38 ± 0.01 4.44 ± 0.04 *p <.05. **p <.01.

Measures of Outcomes: Patient/Family Satisfaction Sample (study) 356 family members of patients who died in ICU, Seattle (Wall et al, 2007) 275 family members of patients who died in ICU, Seattle (Johnson et al., 2014) Findings Rating spiritual care as excellent was associated with higher ratings of satisfaction with ICU care overall Chaplains care was associated with increased overall family satisfaction with ICU care and with satisfaction with decisionmaking in the ICU

Effect of Chaplain Visit on COPD Patient Anxiety Intervention Gp (N=25) Control Gp (N=24) Mean Anxiety Score (0-63) 30 20 10 0 22.08 19.68 11.58 6.56 p=0.05 Baseline Anxiety Discharge Anxiety Source: Iler et al. (2001).

Measures of Outcome: QoL (& treatment preferences & cost of care) Avg QoL= 19, SD=7.9 N=299 patients; Balboni et al, 2010

Bi-Lingual Chaplains Physicians Physicians emphasize chaplain contribution to key outcomes Address spiritual suffering Improve family-team communication Chaplains Chaplains emphasize process (presence) Chaplains provide a listening, supportive presence Chaplains comment on outcomes Physicians are aware of process Lyndes et al., J Health Care Chaplaincy, 2012; Fitchett et al, J Palliat Med., 2011;

The Changing Chaplaincy Paradigm Period Early 20 th century Mid 20th century Early 21 st century Paradigm for Chaplaincy Pastoral care as response to individual sin Chaplaincy was shaped by Rogerian model of client centered counseling Pastoral care as response to individual need (Gleason) Research informed, outcomeoriented chaplaincy (Lucas, 2001) Gleason, 1998; Fitchett et al., 2014

Next Steps for Research-Informed Chaplaincy 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 Watch for the JRC website soon

A Research Agenda for Chaplaincy Priority Evaluate screening tools used to identify patients with spiritual needs Develop and evaluate conversation models for spiritual conversations Evaluate the effectiveness of spiritual care Develop and evaluate spiritual interventions Determine the prevalence of spiritual distress Rank 1 st 2 nd 3 rd 4 th 5 th Selman et al 2014, n=807 clinicians

Chaplain Education and Certification Need to teach research literacy skills in CPE residency programs Create research journal clubs in chaplaincy departments Demonstrate research literacy for chaplaincy certification CPE Centers CPE Systems All Programs Margin of Error Any Research Education Yes Some No Total 3 (14%) 5 (24%) 13 (62%) 21 0 (0%) 2 (40%) 3 (60%) 5 3 (12%) 7 (27%) 16 (62%) 26 12% 17% 19% Fitchett et al, 2012

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 TRANSFORMING CHAPLAINCY Promoting Research Literacy for Improved Patient Outcomes Co led by George Fitchett (Rush) & Wendy Cadge (Brandeis) www.researchliteratechaplaincy.org Together these initiatives will create over 800 research literate chaplains strengthening understandings of religion, spirituality and health and transforming chaplaincy as a profession. Phase 1 July 1, 2015 - June 30, 2016 Phase 2 July 1, 2016 June 30, 2019

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

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 46

Health Care Chaplaincy Improving our Care and Making our Case Through Research -.46*** Hopelessness Religious Belief.17** ***p<.001, **p<.01. N = 271 Depression.69***

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