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April 2022 Article of the Month
 
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA

 

Antoine, A., Fitchett, G., Marin, D., Sharma, V., Garman, A., Haythorn, T., White, K., Greene, A. and Cadge, W. "What organizational and business models underlie the provision of spiritual care in healthcare organizations? An initial description and analysis." Journal of Health Care Chaplaincy 28, no. 2 (April-June 2022): 272-284.

 

SUMMARY and COMMENT: This month's article expands our understanding of chaplaincy integration into US hospitals by bringing a broad "organizational dimension" [p. 282] to what we know from research into healthcare chaplains' work at a more individually-focused level. In doing so, the study should stir thinking about how business models and structural dynamics may affect the integration of chaplaincy care and what may help chaplaincy departments thrive in an institutional environment. The authors suggest that gathering and translating empirical data to administrative leadership may be a key to success.

Semi-structured interviews of 20-45 minutes were conducted with 14 chaplain managers and 11eleven institutional executives from 18 hospitals in three strategically chosen areas of the county: the Midwest, South, and Pacific Northeast. They represented non-governmental facilities that were for-profit (1), academic (4), community (4), and faith based (9) [--see p. 276 and Table 2, p. 277]. Participants responded to the following questions:

Has the hospital ever considered having local clergy provide spiritual care rather than chaplains? Are there times in the hospital when chaplains are always called? How do you think about cost and revenue in relation to the work of chaplains? What type of data, if any, does the spiritual care department keep about chaplains' activities? [p. 275]
"Transcripts were loaded into Atlas.Ti, a qualitative software program (Version 8), and analyzed inductively following the principles of Grounded Theory" [p. 275, and see Related Items of Interest, §III, below].

Results are largely presented along three lines. Among the findings:

A) HOW ARE CHAPLAINS STAFFED AND INTEGRATED ACROSS HOSPITALS?

In all 18 hospitals studied, professional chaplains were used primarily in order to deliver care, and 10 (56%) had CPE programs. However, to cover 24/7, "they also utilize[d] per diem staff, Clinical Pastoral Education (CPE) residents and interns, local clergy, and volunteers" [p. 276]. In 16 of the hospitals, board certified chaplains provided the majority of coverage, and "nearly all sought to hire board certified chaplains" [p. 276]. "In only one case, the only for-profit hospital in our sample, was there only one full-time professional chaplain who managed over a dozen volunteers" [p. 276]. Sixteen hospitals (89%) "had times when chaplains were always called which clustered around themes: interpersonal acuities within the hospital, and patient, family or staff events" and 7 (39%) had a "policy that required chaplains to be called to all deaths, especially when families are present" [p. 278].

As to why executives and managers used chaplains instead of relying on local clergy, there seemed to be three reasons: "1) chaplains provide quality care, 2) they are reliable and responsive to emergent patient and staff needs and, 3) have clinical training and experience working within a complex environment" [p. 278]. With concern for the quality of care, managers saw...

...CPE is the chief differentiator because, as one chaplaincy manger stated, "you go to CPE to learn how to work with people. Clinically trained chaplains are more effective in their interpersonal skills, in their own self-awareness, such things as transference and other kinds of dynamics that happen in the helping professions. The residency just helps people understand boundaries, professional boundaries." As one executive at a hospital with the region's number 1 trauma center noted, "it is beneficial to have chaplains rather than clergy provide spiritual care because they are part of an intact team that hands off to each other...." [p. 278]

B) HOW DO CHAPLAINS ENGAGE IN THE INSTITUTIONS THEY SERVE?

Chaplain managers and executives indicated that they "think about the value of chaplains in terms of their emotional and moral benefit to patients, family and staff weighed alongside the financial cost of running the department" [p. 279]. "Almost all of the spiritual care departments studied listed different initiatives related to patients who are actively dying or at the end of life" [p. 279]. In addition to supporting patients, chaplain managers noted initiatives and programs whereby chaplains support staff. "Some chaplain managers see their work as increasing the bottom line of the healthcare organization in indirect ways including staff retention, patient satisfaction, and shortening length of stay; ...[and when] asked how they think chaplains could increase revenue, these managers spoke of advanced directives, and creative ways for chaplains to harness growing outpatient needs for spiritual care" [pp. 279-280].

"Executives, in comparison, either talk about chaplaincy in terms of its cost like any other non-revenue generating department or employ a variety of terms to frame the work chaplains do as 'cost avoidant'" [p. 280], including the idea of indirect fiscal impact. "One executive summed up the dominant perspective by stating chaplains are 'not a lot of money for a lot of value'" [p. 280].

Mirroring some of the response from the chaplain managers, executives also spoke about the value of chaplaincy in relation to the potential to generate revenue or mitigate costs to the hospital in terms of crisis management, readmission rates, advanced directives, staff retention, and the revenue from Medicare pass through which only relates to CPE students and their educators. [p. 280]

C) APPROACHES TO ORGANIZATIONAL EFFECTIVENESS, IMPROVEMENT, AND QUALITY?

"When chaplain managers talked about data it was more about advocating for staffing and budget and less so about what to learn from data or how to use it to streamline processes" [p. 280]. "Chaplain managers and executives alike acknowledge challenges and opportunities for quantifying the value and impact of chaplains" [p. 280].

The most common practice across chaplaincy departments was that chaplain managers use dashboard measures from the electronic medical record to track frequency of chaplains making patient visits, which units and staff are paging, and what kind of consults and deaths happen in the hospital. Many departments are complementing the use of medical records with data from patient satisfaction surveys or information they gather on their own through survey tools and spreadsheets. Many chaplain managers acknowledged that surveys and tracking patient interactions do not capture all that they do with staff and how they participate within the hospital more broadly. To address this, chaplain managers described creating shadow systems like Excel programs to track what electronic medical records do not track for chaplains such as teaching, staff support, and how they serve the community, for example. [pp. 280-281]
"Some executives related the value of spiritual care to their organization's mission and strategy, [and] [t]he four faith-based healthcare systems appeared to have an easier time connecting the work of chaplains to the mission of the hospital" [p. 281]. The study authors observe that there was significant variation in reporting structures for chaplaincy departments, which may affect how issues of chaplains' effectiveness and quality improvement are approached and processed within institutions. They summarize: Chaplains' success depends on dynamics within their employing organizations, the people to whom they report, the ways they are integrated into the organization, and the culture in which they work" [p. 282].

One of the more noteworthy conclusions from this study is that "[d]espite overwhelming attention to evidence and data in healthcare organizations, there is also little evidence that the executives interviewed here draw on data about chaplains to make budgetary and other decisions" [p. 282].

[The] findings suggest that growing attention to research and evidence among chaplains is not filtering up to the executives to whom they report and who make budgetary and other decisions. None of the executives mentioned studies that connect the work of chaplains to outcomes for patients and families, suggesting that this research is not yet influential for staffing decisions.
With this in mind, the authors not only encourage chaplain managers to bring studies and data to executives even if those executives are not asking for it, but to work to develop "[c]lear measures tied to organizational goals, strategic plans or vision statements..." [p. 282].

The article includes two brief but illustrative examples of how chaplaincy departments are integrated into organizations [--see pp. 278-279] and an insightful anecdote of how institutional leaders at a faith-based organization came to increase chaplaincy staffing after becoming aware of staffing levels at competing secular hospitals [--see p. 281]. Overall, the article paints a picture of significant variations in the place of chaplaincy departments within institutional structures, in addition to the particular differences in perspectives and inclinations of individual chaplain managers and executives. The small sample size limits the generalizations that can be drawn from the study, but the need for greater connection between the practice of chaplaincy in a hospital and the processes by which that practice is funded seems clear. The task of translating the value of chaplaincy to those at some institutional distance to it surely deserves focused attention, and the present article should implicitly invite chaplain managers into greater dialogue with peers on this issue.

One final comment: The chaplain managers interviewed here appear to conceive of the connection between their departments and executives almost entirely in terms of the reporting relationships that might be depicted on an organizational chart. Yet, one of the core valuations of chaplains in healthcare institutions is how they work in a "complex environment" [pp. 272, 278, and 282], which implies multidisciplinary/interdisciplinary dynamics as much as technical complexity. This reader is left to wonder how many chaplaincy departments make use of allied departments to help translate the work of chaplains up the institutional hierarchy. What data might other departments be gathering about -- or that could be of use to -- chaplains? And, how might other departments value chaplains in ways that they do not assess formally but by which they could bear witness through organizational channels? Our authors observe: "While some branches of the military think about chaplains as force multipliers, that enable front line members of the military to perform better, that is not the way healthcare organizations have thought about chaplains" [p. 274]. Might there be potential for allied disciplines within healthcare to recognize how chaplains help them to perform better?

The bibliography contains 27 references, the latest being two from 2020.


 

Suggestions for Use of the Article for Student Discussion: 

This month's article might strike many potential readers as having a very narrow target audience, largely perhaps of chaplain managers. However, it should be of interest to any professional chaplain, and it should help students think more about their work as part of the business of healthcare. Are they aware of the need to translate the value of their work to non-chaplains, and -- if so -- how might they go about that? Do they ever bring empirical evidence into their discussions with other disciplines or administrators, or bring up research articles? The group could be asked: If you imagine a conversation with a nurse manager, what might you say to convey the value of what you do? Would such a conversation differ from one you might imagine having with an organizational executive? Would you be able to assert the importance of your work beyond how you feel it to be important? Is there data that you wish you had handy? Do students see their patient care documentation as a compilation of data that could be mined for multiple purposes? Is there some aspect of their work that seems especially difficult to measure, and do they have any ideas about how to measure such things? What research have they read lately that could be useful in translating their work to others? Do they understand how their educational work stands in relation to their institution's expectations of productivity? How do they conceive of their work in terms of cost and revenue? What of the article did the students find most surprising? Discussion might be augmented by some presentation by a chaplain manager (or a guest) about the business-side of healthcare in general and of their particular institution.


 

Related Items of Interest:

I.  Some data from this month's featured study was also published in the Southern Medical Journal, to which there was a related comment [--see: Ho, J. Q., Fishman, J. R. and Kuschner, W. G., "Chaplaincy and hospital ethics committees," Southern Medical Journal 114, no. 1 (November 2021): 726].

Antoine, A., Fitchett, G., Sharma, V., Marin, D. B., Garman, A. N., Haythorn, T., White, K. and Cadge, W. "How Do Healthcare Executives Understand and Make Decisions about Spiritual Care Provision?" Southern Medical Journal 114, no. 4 (April 2021): 207-212. [(Abstract:) OBJECTIVES: This pilot study explores how healthcare leaders understand spiritual care and how that understanding informs staffing and resource decisions. METHODS: This study is based on interviews with 11 healthcare leaders, representing 18 hospitals in 9 systems, conducted between August 2019 and February 2020. RESULTS: Leaders see the value of chaplains in terms of their work supporting staff in tragic situations and during organizational change. They aim to continue to maintain chaplaincy efforts in the midst of challenging economic realities. CONCLUSIONS: Chaplains' interactions with staff alongside patient outcomes are a contributing factor in how resources decisions are made about spiritual care.] [This article is available online.]

 

II.  Our authors note a 2004 survey of hospital executives as key prior research for understanding that group's perspective [--see: Flannelly, K. J., Handzo, G. F. and Weaver, A. J., "Factors affecting healthcare chaplaincy and the provision of pastoral care in the United States," Journal of Pastoral Care and Counseling 58, nos. 1-2 (2004): 127-130*], but the following brief 2014 report of a survey within Catholic circles might also be of some interest:

Lichter, D. A. "CHA chaplaincy surveys offer key insights." Health Progress 95, no. 5 (September-October 2014): 57-59. [National surveys of Catholic health care executives and clinical staff were conducted in 2012, using the database of the Catholic Health Association (CHA) of the United States, to understand their views of chaplains and spiritual care services. Among the findings: health care executives ranked "the purpose and value of spiritual care and professional chaplaincy" as follows: 1) Providing patient and family support; 2) Demonstrating Catholic identity/mission; 3) Treating the whole person; and 4) Providing staff support. Comparatively, the most frequent responses from clinical staff regarding the "purpose and value of spiritual care and professional chaplaincy" were: 1) Patient and family support; 2) Essential for treatment of the whole person; 3) Support staff; and 4) Important (with little clarification). Also, while "executives want to know how chaplains' services contribute to patient satisfaction and how they support and educate staff on their role in spiritual care..., [c]linicians want to know more about the specific roles and responsibilities, training and credentialing of chaplains."]. [This article is available online from the journal.]

*Note: Data from the Flannelly, et al. article was also presented in a report the following year: Flannelly, K. J., Weaver, A. J., Handzo, G. F. and Smith, W. J., "A national survey of health care administrators' views on the importance of various chaplain roles," Journal of Pastoral Care and Counseling 59, nos. 1-2 (Spring-Summer 2005): 87-96.

 

III.  The research this month used the Atlas.Ti software program to help analyze interview transcripts. For more on this program, see the Atlas.Ti website. For other examples of research pertinent to chaplaincy that also used this software program, see the following:

Abu-Ras, W. "Muslim chaplain's role as perceived by directors and chaplains of New York City hospitals and health care settings." Journal of Muslim Mental Health 6, no. 1 (2011): NP [online journal]. [(Abstract:) As more hospitals acknowledge the importance of spiritual care, there is an increasing demand for chaplains who can meet patients' spiritual needs. While most empirical studies thus far have focused on changes in chaplaincy services, and on the role of non-Muslim chaplains, very few have addressed the religious diversity among hospital chaplains and their roles in serving a diverse population. This study will be the first to examine the roles Muslim chaplains play in New York City hospitals and health care settings in general, and in serving Muslim patients in particular, as perceived by pastoral care directors and both Muslim and non-Muslim chaplains. This study used a mixed method of qualitative and quantitative, including a cross-sectional survey administered to 56 pastoral care directors and in-depth interviews with 33 Muslim and non-Muslim chaplains. Univariate and bivariate statistical analysis were used to analyze the quantitative data and a grounded thematic approach was employed to analyze the qualitative data. Results show that seven roles examined in this study were rated by most directors as being somewhat important to moderately important. The highest perceived importance mean given to Muslim chaplains' roles were handling directive education and organ donation (mean = 3.49, SD = 1.95), prayers (mean = 3.14, SD = 1.37), and providing emotional support to patients and their families (mean = 3.13, SD = 1.35). The perceived roles and activities are also different based on the location of the hospitals, the educational level of the directors, and faith affiliation of the directors and chaplains. The implication of this study is that addressing the cultural, racial, and ethnic disparities in health care settings, including chaplaincy services, is an important factor that could seriously impact health beliefs and behaviors.] [This article is available online from the journal.]

Cadge, W. "Training healthcare chaplains: yesterday, today and tomorrow." Journal of Pastoral Care and Counseling 2019, Vol. 73(4): 211-221. [(Abstract:) This article invites theological school educators, clinical pastoral education educators, representatives of the professional healthcare chaplaincy organizations, and social scientists to begin a shared conversation about chaplaincy education. To date, we find that theological educators, clinical educators, professional chaplains, and the healthcare organizations where they work are not operating from or educating toward a common understanding of what makes healthcare chaplains effective. Before we identify five key questions that might help us be in shared conversation and move towards educating the most effective chaplains, we briefly describe the history of education for healthcare chaplaincy. We then describe what we learned in interviews in 2018 with 21 theological and 19 clinical educators who are educating healthcare chaplains in theological schools and clinical pastoral education residency programs, year-long educational programs in hospitals and other settings that focus on preparing people for staff chaplain jobs. Their different approaches and frames inform the five questions with which we conclude.]

Muehlhausen, B. L., Foster, T., Smith, A. H. and Fitchett, G. "Patients' and loved ones' expectations of chaplain services." Journal of Health Care Chaplaincy (2021): online ahead of print, 4/15/21. [This was featured as our May 2021 Article-of-the-Month.]

Muehlhausen, B. L. "Spirituality and vicarious trauma among trauma clinicians: a qualitative study." Journal of Trauma Nursing 28, no. 6 (November-December 2021): 367-377. [This was featured as our November 2021 Article-of-the-Month.]

van Dijke, J., Duyndam, J., van Nistelrooij, I. and Bos, P. "'We need to talk about empathy': Dutch Humanist chaplains' perspectives on empathy's functions, downsides, and limitations in chaplaincy care." Journal of Pastoral Care and Counseling (2022): online ahead of print, 1/24/22. [This was featured as our February 2022 Article-of-the-Month.]

 

 


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