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December 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


Boska, R. L., Dunlap, S., Bishop, T. M., Goldstrom, D., Tomberlin, D., Baxter, S., Kopacz, M., Quigley, K. S. and Harris, J. I. "Chaplains' perspectives on standardizing spiritual assessments." Psychological Services (2022): online ahead of print, 12/5/22.

[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. References are to manuscript [MS] page numbers.]

SUMMARY and COMMENT: A goal of the Research Article-of-the-Month is not only to feature major studies but to point up modest projects that are likely to be overlooked by the wider chaplaincy community but that may pose interesting questions for further study or topics for clinical discussion that could then generate additional research. This month's article reports an investigation that is limited both in size and scope, in the particular context of chaplaincy within Veterans Affairs Medical Centers, but it touches upon a subject affecting chaplains in general: the experience of producing spiritual assessments from clinical encounters, especially in light of research-driven trends in health care around the standardization of assessments and their documentation. The article comes from Psychological Services, the official publication of the Division of Psychologists in Public Service (Division 18) of the American Psychological Association [--see Related Items of Interest, §V, below].

Seventeen chaplains from a Veterans Health Administration facility in the Southeastern US were invited to participate in focus groups; ultimately, seven participated in two groups. The only requirement was that the chaplains have at least two years of experience in the VHA chaplaincy setting [--see MS p. 2]. The research was conceived as "a preliminary effort to expand the literature by empirically investigating how chaplains conduct spiritual assessments, their perspectives on standardized spiritual assessments, and their opinions on future integration of empirically validated measures" [MS p. 2]. This was part of a larger qualitative study considering the development of new spiritual assessment protocols relevant to moral injury. The moral injury emphasis is particular to the VHA context here, though it has wider implications in the field of Spirituality & Health [--see Related Items of Interest, §IV, below]. The focus group protocol and data analysis processes are described succinctly by the authors [--see MS pp. 2-3 and 6; and see Related Items of Interest, §II and §III, below], including:

The chaplains were asked to describe their experiences conducting spiritual assessments and their recommendations related to (a) perceived difficulties they identified with implementing a new spiritual assessment template, (b) preferences for using a spiritual assessment template, (c) openness to including empirically validated instruments as part of the spiritual assessment, (d) the chaplain's perspectives on incorporating validated measures to current spiritual assessment procedures or creating a new instrument for spiritual assessments, and (e) perceived difficulties of using a standardized spiritual assessment.

Results are provided in two tables [MS pp. 4-6 and 7-8], with extensive quotes from participants, and are summarized in the text:

The chaplains in our study described discomfort in using standardized templates as primary tools, but appeared open to having a more standardized secondary questionnaire if the chaplain chooses. If the more standardized approach were to be taken, the chaplains within our focus groups emphasized the need to have an interdisciplinary approach to developing the tools and to have chaplaincy involvement with the development. [MS p. 8]

Regarding the specific question of "How open would chaplains be to include empirically validated instruments?" three themes emerged: 1) they would be "[v]ery open," but 2) they "[d]o not want to be locked in" and 3) "[d]o not want to go down a list of questions" [MS p. 7]. To characterize this data another way: "Chaplains indicated an acceptance of integrated spiritual assessment as long as they would continue to have flexibility allowing them to engage with veterans in a conversational way" [MS p. 9]. It may be significant to note the participants' sense of how a spiritual assessment was to be used in the hospital. They generally acknowledged its value for spiritual care planning and thus its usefulness for chaplains themselves, but one theme of the data was that the assessment was aimed largely at the interdisciplinary team --something to be discussed in rounds coordinating the interdisciplinary effort [--see MS p. 5]. While the audience one has in mind for an assessment and its documentation would seem to be an important factor in how one engages the activity, this dynamic is not a point brought up by the participants nor is it commented on by the study's authors. It may be implicit in chaplains' desire to be included in assessment development, but it could be an area for further investigation. The authors' own recommendations for further study highlight collaboration between chaplaincy and behavioral health and "research into the implementation of standardized spiritual assessments" [MS p. 9], especially as such assessments may accommodate some flexibility in the approach of a chaplain. They moreover encourage research with larger and more diverse samples, in light of the limits of the present study in terms of the small sample size and its demographics ("primarily from conservative non-Catholic Christian denominations" [MS p. 9]).

This article indicates an overarching theme of chaplains' interest in maintaining an openness of structure and flexibility in practice during the clinical encounter, and how this can potentially be in some tension with standardized assessments and their documentation, even when there is receptivity to the idea of standardization. It's worth noting that there are two issues here: one is about standardized assessments per se, and the other is about incorporating empirically grounded elements in those standardized assessments. For this reader, chaplains' buy-in to any standardized and/or empirically-based practice would appear to be a most practical topic for chaplaincy dialogue as well as for research. The VHA system may be one of the more manageable professional contexts for dialogue and research on the topic, because the system already has well-developed processes for assessment and care in which chaplains are part, and because there are some fairly well-established themes around which spiritual assessment may revolve, like moral injury. Nevertheless, the basic issue of how standardization can potentially benefit or burden a chaplain's work with patients would be relevant to chaplains everywhere. Are assessment strategies at any one institution closely aligned with documentation forms? What documentation elements may be about information other than spiritual assessment? What elements can be said to be empirically substantiated? Do assessment expectations of a chaplain guide or constrain clinical interactions, and is the effect common to all chaplains at that institution or to only a subset and, if so, why? Do concerns about introducing new, standardized assessments revolve around the nature of the assessments themselves or mainly around the uncertainty and disruption that comes with change (e.g., learning a new process)? If chaplains prefer conversational approaches to assessment, how might that be translated efficiently into language and documentation that has sufficiently standardized meaning, chaplain-to-chaplain, chaplain-to-other professional, and institution-to-institution? In recent years, there has been a strong, research-driven development of standardized, empirically tested assessments for chaplains' use [--see Related Items of Interest, §I, below], with most seeming to being positively received; but what has been the lived experience of them in clinical encounters -- for chaplains and for patients -- and how has this shaped chaplains' perspectives on them? This month's article may encourage a helpfully clarifying discussion beyond the VHA, as chaplains seek to find a proverbial sweet-spot between structure and flexibility.

Two final thoughts: First, study participants observed that the relationship between patients and chaplains was significantly different from patients' relationships with other providers: that it is "more relational" [MS p. 8]. This suggests a larger question of whether a goal of preserving that difference may limit some professional activity that would impinge upon the nature of the difference. That question may be applied to actions around assessment, but it could also apply to any number of other actions that, in and of themselves, may be understood as valuable but that nevertheless may have larger implications for the patient-chaplain relationship. Second, the participants in the study appeared to distinguish spiritual assessment from the more general activity of "chaplaincy consultation" [MS p. 6]. This raises the additional question of whether spiritual assessment should be a distinct activity and, if so, does it require a role shift on the part of the chaplain within a visit or between visits? What is the experience -- for chaplains and patients -- if the chaplain moves noticeably from listener to assessor (or interlocutor) and vice-versa? What interactional strategies might be aimed at optimally managing any such experiential shift?

The bibliography of 32 citations contains five from 2021 and one from 2022 and is geared largely to work with veterans.


Suggestions for Use of the Article for Student Discussion: 

This month's article would obviously have resonance with VHA chaplains, but for other chaplains the extensive quotes (in the tables) and the summary themes paint a fairly good picture of the professional world of the participants. This may be a good starting point for group discussion: Can you identify with the study either in terms of the participants' practice of chaplaincy or their views on standardization? What specific themes seem familiar and pertinent, as noted in tables 2 and 3? Do people agree with the definition of spiritual assessments offered at the top of MS. p. 2? What are the standard elements for assessment and documentation in place at your institution, and how do you manage the institution's expectations around these structures of discernment and communication? It may be constructive to pose to the group the same 15 questions presented to the study participants (listed in tables 2 and 3), essentially turning the student group into a kind of an impromptu focus group, though the wording particular to veterans would need to be adjusted. The group's educator/leader could alternatively just select certain questions out of the list. Are answers to these questions quickly offered, or is there debate or confusion within the group? Is the group comfortable with how spiritual assessment is handled in their institution? Where are there points of tension? Chaplains with more experience in research might want to discuss the authors' thinking about sample size [MS p. 3] and the methodology relating to data analysis and protection against bias.


Related Items of Interest:

I.  The development of spiritual assessments offering a level of standardization has energized a great deal of research in recent years. Good examples may be found in our Articles-of-the-Month for June 2021 [Woggon, F., Arlyck, M., Maddox Hill, S. and Small Stokes, L., "The development of an outcome oriented and research informed spiritual care assessment and documentation form for the electronic health record in an adult hospital setting," Journal of Health Care Chaplaincy 28, no. 3 (July-September 2022): 400-414] and September 2019 [Fitchett, G., Pierson, A. L. H., Hoffmeyer, C., Labuschagne, D., Lee, A., Levine, S., O'Mahony, S., Pugliese, K. and Waite, N., "Development of the PC-7, a quantifiable assessment of spiritual concerns of patients receiving palliative care near the end of life," Journal of Palliative Medicine 23, no. 2 (February 2020): 248-253].


II.  "The present study used a specific interview structure based on Proctor et al. (2011) implementation theory..." [MS p. 3]. The Proctor et al. model was chosen for its potential in assessing "implementation for new procedures in organizational settings" [MS p. 3]. It may thus have usefulness for other research by and for chaplains, or just as an aid in thinking more clearly about the language used to describe outcomes. See the following original article by Proctor et al. and an article looking at the model ten years on.

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R. and Hensley, M. "Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda." Administration and Policy in Mental Health and Mental Health Services Research 38, no. 2 (2011): 65-76. [(Abstract:) An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of "implementation outcomes" distinct from service system and clinical treatment outcomes. This paper proposes a heuristic, working "taxonomy" of eight conceptually distinct implementation outcomes--acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability--along with their nominal definitions. We propose a two-pronged agenda for research on implementation outcomes. Conceptualizing and measuring implementation outcomes will advance understanding of implementation processes, enhance efficiency in implementation research, and pave the way for studies of the comparative effectiveness of implementation strategies.] [This article is available freely online from the National Library of Medicine.]

Lengnick-Hall, R., Proctor, E. K., Bunger, A. C. and Gerke, D. R. "Ten years of implementation outcome research: a scoping review protocol." BMJ Open 11, no. 6 (2021): e049339 [electronic journal article designation]. [(Abstract:) A 2011 paper proposed a working taxonomy of implementation outcomes, their conceptual distinctions and a two-pronged research agenda on their role in implementation success. Since then, over 1100 papers citing the manuscript have been published. Our goal is to compare the field's progress to the originally proposed research agenda, and outline recommendations for the next 10 years. To accomplish this, we are conducting the proposed scoping review. METHODS AND ANALYSIS: Our approach is informed by Arksey and O'Malley's methodological framework for conducting scoping reviews. We will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We first aim to assess the degree to which each implementation outcome has been investigated in the literature, including healthcare settings, clinical populations and innovations represented. We next aim to describe the relationship between implementation strategies and outcomes. Our last aim is to identify studies that empirically assess relationships among implementation and/or service and client outcomes. We will use a forward citation tracing approach to identify all literature that cited the 2011 paper in the Web of Science (WOS) and will supplement this with citation alerts sent to the second author for a 6-month period coinciding with the WOS citation search. Our review will focus on empirical studies that are designed to assess at least one of the identified implementation outcomes in the 2011 taxonomy and are published in peer-reviewed journals. We will generate descriptive statistics from extracted data and organise results by these research aims. ETHICS AND DISSEMINATION: No human research participants will be involved in this review. We plan to share findings through a variety of means including peer-reviewed journal publications, national conference presentations, invited workshops and webinars, email listservs affiliated with our institutions and professional associations, and academic social media.] .] [This article is available freely online from the journal.]


III.  Our featured study employed the Hamilton Rapid Turnaround Technique in its qualitative methodology, and the authors cite a recent article co-authored by Alison B. Hamilton:

Hamilton, A. B. and Finley, E. P. "Qualitative methods in implementation research: an introduction." Psychiatry Research 280 (2019): 112516 [electronic journal article designation]. [(Abstract:) Qualitative methods are a valuable tool in implementation research because they help to answer complex questions such as how and why efforts to implement best practices may succeed or fail, and how patients and providers experience and make decisions in care. This article orients the novice implementation scientist to fundamentals of qualitative methods and their application in implementation research, describing: 1) implementation-related questions that can be addressed by qualitative methods; 2) qualitative methods commonly used in implementation research; 3) basic sampling and data collection procedures; and 4) recommended practices for data analysis and ensuring rigor. To illustrate qualitative methods decision-making, a case example is provided of a study examining implementation of a primary care-based collaborative care management model for women Veterans with anxiety, depression, and PTSD.] [This article is available freely online from the journal.]

However, readers may be in interested in a presentation by Dr. Hamilton: "Qualitative Methods in Rapid Turn-Around Health Services Research," available through the US Department of Veterans Affairs. The video format of this 2013 seminar is no longer supported, but the audio, transcript, and slides are available. The presentation is not focused on spiritual care, yet it does address the methodology quite practically for researchers.


IV.  Moral injury was the subject of our September 2018 Article-of-the-Month, but the following selection of articles published since then (--some by our featured authors, and some cited in our featured article) may be of special interest to chaplains:

Alexander, D. W. "Walking together in exile: medical moral injury and the clinical chaplain." Journal of Pastoral Care and Counseling 74, no. 2 (June 2020): 82-90. [(Abstract:) This article examines various sides of the recent discussion about establishing a medical category within the "moral injury" discourse. Essential differences between the nature and development of moral injury among physicians and combat veterans are acknowledged. Essential similarities are also explored. Case notes from a 3-year encounter between a clinical chaplain and a disoriented physician are offered as an illustration of how moral injury interventions with veteran populations can inform care for physicians experiencing burnout.]

Ames, D., Erickson, Z., Geise, C., Tiwari, S., Sakhno, S., Sones, A. C., Tyrrell, C. G., Mackay, C. R. B., Steele, C. W., Van Hoof, T., Weinreich, H. and Koenig, H. G. "Treatment of moral injury in U.S. Veterans with PTSD using a structured chaplain intervention." Journal of Religion and Health 60, no. 5 (October 2021): 3052-3060. [(Abstract:) Moral injury is a complex phenomenon characterized by spiritual, psychological, and moral distress caused by actions or acts of omission inconsistent with an individual's moral and ethical values. We present two cases from an ongoing randomized controlled trial of a spiritually integrated structured intervention delivered by chaplains for individuals suffering from moral injury. Chaplains met with Veterans for twelve 50-min sessions that each focused on a specific domain of moral injury. Participants were asked to complete validated scales assessing symptoms of moral injury and PTSD, including the PTSD Checklist for DSM-5 (PCL-5), Moral Injury Symptom Scale-Military Version Short Form, and Moral Injury Symptom Scale-Military Version Long Form. We report on two Veterans who completed the intervention and demonstrated significant improvement in moral injury and PTSD symptoms.]

Boska, R. L., Dunlap, S., Kopacz, M., Bishop, T. M. and Harris, J. I. "Understanding moral injury morbidity: a qualitative study examining chaplain's perspectives." Journal of Religion and Health 60, no. 5 (October 2021): 3090-3099. [(Abstract:) Moral injury tends to be conceptualized through an interplay of psychological and religious concerns. Recent qualitative research has begun utilizing chaplains to bolster the understanding of moral injury within veterans. The current study examined qualitative data regarding how moral injury is viewed through the lens of Chaplain Services within the Veterans Health Administration (VA). Specifically, chaplains were asked to describe how moral injury presents, what kinds of complaints veterans voice with regard to moral injury, and how moral injury impacts social functioning. Chaplains highlighted how moral injury is a pervasive issue affecting veterans across multiple domains. Clinical implications discussed further.]

Cenkner, D. P., Yeomans, P. D., Antal, C. J. and Scott, J. C. "A pilot study of a moral injury group intervention co-facilitated by a chaplain and psychologist." Journal of Traumatic Stress 34, no. 2 (2021): 367-374. [(From the abstract:) Moral injury, an experience of betrayal or transgression of moral values, continues to receive attention because of its associations with psychiatric disorders, including posttraumatic stress disorder and suicidality. There is growing recognition that moral injury may require novel interventions that involve religious or spiritual paradigms. This pilot study presents feasibility data and exploratory outcomes for 40 veteran participants across seven cohorts who participated in a novel 12-week moral injury group (MIG) over 35 months. The MIG was cofacilitated by a Veterans Affairs chaplain and psychologist and designed to reduce distress and improve functioning in individuals with histories of morally injurious experiences from military service. The intervention included a ceremony in which participants shared testimonies of their moral injury with the general public. Recruitment feasibility and retention were high, with participants completing an average of 9.45 (SD = 2.82) sessions of the 12-week group, and 32 participants (80.0%) attending nine or more sessions and the community healing ceremony. Exploratory analyses revealed medium effect sizes...for reductions in depressive symptoms, improvements in psychological functioning, and self-compassion after the intervention, with small effect anticipated directions for personal growth and spiritual struggles. The results were not impacted by participant engagement in concurrent psychological treatments. Taken together, these findings support the feasibility of the MIG, the potential merit of an interdisciplinary approach to addressing moral injury, and justification for further research into the efficacy of this approach.]

Drescher, K. D., Currier, J. M., Nieuwsma, J. A., McCormick, W., Carroll, T. D., Sims, B. M. and Cauterucio, C. "A qualitative examination of VA chaplains' understandings and interventions related to moral injury in military veterans." Journal of Religion and Health 57, no. 6 (December 2018): 2444-2460. [(Abstract:) This study examines VA chaplains' understandings of moral injury (MI) and preferred intervention strategies. Drawing qualitative responses with a nationally-representative sample, content analyses indicated that chaplains' definitions of MI comprised three higher order clusters: (1) MI events, (2) mechanisms in development of MI, and (3) warning signs of MI. Similarly, chaplains' intervention foci could be grouped into three categories: (1) pastoral/therapeutic presence, (2) implementing specific interventions, and (3) therapeutic processes to promote moral repair. Findings are discussed related to emerging conceptualizations of MI, efforts to adapt existing evidence-based interventions to better address MI, and the potential benefits of better integrating chaplains into VA mental health service delivery.]

Hodgson, T. J., Carey, L. B. and Koenig, H. G. "Moral injury, Australian veterans and the role of chaplains: an exploratory qualitative study." Journal of Religion and Health 60, no. 5 (October 2021): 3061-3089. [(Abstract:) Military personnel deployed to war zones or assigned to other morally challenging military duties are likely to be exposed to potentially morally injurious events (PMIE) that may inflict a moral injury (MI). This qualitative study formed 'Phase 1' of a larger study into PMIEs experienced by Australian veterans and the potential pastoral/spiritual care role of chaplains. Two seminars were conducted that involved 10 veterans being interviewed and audio recorded about their deployment experiences to evaluate whether there was any evidence among Australian veterans of a PMIE. Narrative data analysis indicated that all participants had been exposed to, or were involved in, a PMIE of one kind or another. Seven key themes were identified from the analyzed qualitative data: (i) immoral acts, (ii) death and injury, (iii) betrayal, (iv) ethical dilemmas, (v) disproportionate violence, (vi) retribution and (vii) religious/spiritual issues. Given this preliminary PMIE evidence identified, there is a need for further research, as well as the development of a suitable moral injury assessment scale appropriate for Australian veterans. Furthermore, given the ethical, moral, and spiritual issues involved, the implementation of a rehabilitation program suitable for Australian veterans which can be provided by chaplains is also suggested-namely 'Pastoral Narrative Disclosure.' It is argued that moral injury needs to be recognized, not just as an issue affecting individual personnel and their families, but is also a community health, organizational and government responsibility.]

Jones, K. A., Freijah, I., Carey, L., Carleton, R. N., Devenish-Meares, P., Dell, L., Rodrigues, S., Madden, K., Johnson, L., Hosseiny, F. and Phelps, A. J. "Moral injury, chaplaincy and mental health provider approaches to treatment: a scoping review." Journal of Religion and Health 61, no. 2 (April 2022): 1051-1094. [(Abstract: The aim of this research was to describe the evidence examining the approaches taken by mental health providers (MHPs) and chaplains to address symptoms related to moral injury (MI) or exposure to potentially morally injurious events (PMIEs). This research also considers the implications for a holistic approach to address symptoms related to MI that combines mental health and chaplaincy work. A scoping review of literature was conducted using Medline, PsycINFO, Embase, Central Register of Controlled Trials, Proquest, Philosphers Index, CINAHL, SocINDEX, Academic Search Complete, Web of Science and Scopus databases using search terms related to MI and chaplaincy approaches or psychological approaches to MI. The search identified 35 eligible studies: 26 quantitative studies and nine qualitative studies. Most quantitative studies (n = 33) were conducted in military samples. The studies examined interventions delivered by chaplains (n = 5), MHPs (n = 23) and combined approaches (n = 7). Most studies used symptoms of post-traumatic stress disorder (PTSD) and/or depression as primary outcomes. Various approaches to addressing MI have been reported in the literature, including MHP, chaplaincy and combined approaches, however, there is currently limited evidence to support the effectiveness of any approach. There is a need for high quality empirical studies assessing the effectiveness of interventions designed to address MI-related symptoms. Outcome measures should include the breadth of psychosocial and spiritual impacts of MI if we are to establish the benefits of MHP and chaplaincy approaches and the potential incremental value of combining both approaches into a holistic model of care. ]

Koenig, H. G. and Al Zaben, F. "Moral injury: an increasingly recognized and widespread syndrome." Journal of Religion and Health 60, no. 5 (October 2021): 2989-3011. [(Abstract:) Moral injury (MI), originally discussed in relationship to transgressing moral beliefs and values during wartime among military personnel, has expanded beyond this context to include similar emotions experienced by healthcare professionals, first responders, and others experiencing moral emotions resulting from actions taken or observations made during traumatic events or circumstances. In this article, we review the history, definition, measurement, prevalence, distinctiveness, psychological consequences, manifestations (in and outside of military settings), and correlates of MI in different settings. We also review secular psychological treatments, spiritually integrated therapies, and pastoral care approaches (specific for clergy and chaplains) used to treat MI and the evidence documenting their efficacy. Finally, we examine directions for future research needed to fill the many gaps in our knowledge about MI, how it develops, and how to help those suffering from it.]

Kopacz, M., Bishop, T. M., Ayre, A., Boska, R. L., Goldstrom, D., Tomberlin, D., Baxter, S., Dunlap, S. and Harris, J. I. "Feasibility of using moral injury screening instruments in VA chaplaincy spiritual assessments." Journal of Health Care Chaplaincy 28 (2022, Suppl. 1): S89-S100. [(Abstract:) Some veterans experience symptoms of moral injury after being exposed to the ethical and moral challenges associated with military service. While it is well known that moral injury is associated with an increased risk for suicide as well as other mental health concerns, few tools exist to systematically screen for moral injury in chaplaincy settings. This preliminary study examines the psychometric properties as well as feasibility of applying two new moral injury screening tools that could be used with routine spiritual assessments, purposefully designed to assess for moral injury in chaplaincy settings at Department of Veterans Affairs (VA) Medical Centers. The results provide preliminary psychometric evidence to support the reliability and validity of these two new screening tools, which were shown to be feasible for use in VA chaplaincy settings.]

Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L., Frankfurt, S., Zerach, G. and Levi-Belz, Y. for the Moral Injury Outcome Scale Consortium. "Defining and assessing the syndrome of moral injury: initial findings of the Moral Injury Outcome Scale Consortium." Frontiers in Psychiatry (2022): 13:923928 [online journal article designation]. [(Abstract:) Potentially morally injurious events (PMIEs) entail acts of commission (e.g., cruelty, proscribed or prescribed violence) or omission (e.g., high stakes failure to protect others) and bearing witness (e.g., to grave inhumanity, to the gruesome aftermath of violence), or being the victim of others' acts of commission (e.g., high stakes trust violations) or omission (e.g., being the victim of grave individual or systemic failures to protect) that transgress deeply held beliefs and expectations about right and wrong. Although there is a proliferation of interest in moral injury (the outcome associated with exposure to PMIEs), there has been no operational definition of the putative syndrome and no standard assessment scheme or measure, which has hampered research and care in this area. We describe an international effort to define the syndrome of moral injury and develop and validate the Moral Injury Outcome Scale (MIOS) in three stages. To ensure content validity, in Stage I, we conducted interviews with service members, Veterans, and clinicians/Chaplains in each country, inquiring about the lasting impact of PMIEs. Qualitative analysis yielded six operational definitions of domains of impact of PMIEs and components within domains that establish the parameters of the moral injury syndrome. From the domain definitions, we derived an initial pool of scale items. Stage II entailed scale refinement using factor analytic methods, cross-national invariance testing, and internal consistency reliability analyses of an initial 34-item MIOS. A 14-item MIOS was invariant and reliable across countries and had two factors: Shame-Related (SR) and Trust-Violation-Related (TVR) Outcomes. In Stage III, MIOS total and subscale scores had strong convergent validity, and PMIE-endorsers had substantially higher MIOS scores vs. non-endorsers. We discuss and contextualize the results and describe research that is needed to substantiate these inaugural findings to further explore the validity of the MIOS and moral injury, in particular to examine discriminant and incremental validity.]

Wortmann,, J. H., Nieuwsma, J. A., King, H. A., Fernandez, P., Jackson, G. L., Smigelsky, M. A., Cantrell, W. and Meador, K. G. "Collaborative spiritual care for moral injury in the veterans Affairs Healthcare System (VA): Results from a national survey of VA chaplains." Journal of Health Care Chaplaincy 28 (2022, Suppl. 1): S9-S24. [(Abstract:) The psychospiritual nature of moral injury invites consideration regarding how chaplains understand the construct and provide care. To identify how chaplains in the VA Healthcare System conceptualize moral injury, we conducted an anonymous online survey (N = 361; 45% response rate). Chaplains responded to a battery of items and provided free-text definitions of moral injury that generally aligned with key elements in the existing literature, though with different emphases. Over 90% of chaplain respondents indicated that they encounter moral injury in their chaplaincy care, and a similar proportion agreed that chaplains and mental health professionals should collaborate in providing care for moral injury. Over one-third of chaplain respondents reported offering or planning to offer a moral injury group. Separately, nearly one-quarter indicated present or planned collaboration with mental health to provide groups that in some manner address moral injury. Previous training in evidence-based and collaborative care approaches appears to contribute to the likelihood of providing integrated psychosocial-spiritual care. Results and future directions are discussed, including a description of moral injury that may be helpful to understand present areas of emphasis in VA chaplains' care for moral injury.]


V.  In 2021, Psychological Services called for manuscripts for a special issue on spiritually integrated care and collaboration with chaplaincy as they could be applied in organized care settings, especially in federal and state settings (--see the announcement via the Chaplaincy Innovation Lab site). To date, the following papers are online ahead of print by the journal, in addition to our featured article:

Cadge, W., Lawton, A. and Xanthos, D. "Chaplains in federal and state organizations: an institutional note." Psychological Services (2022): online ahead of print, 11/10/22. [(Abstract:) Spiritually integrated care that includes collaborations among chaplains, psychologists, and other health care professionals can have a profound effect on people's lives. To facilitate this care, scholars and policy makers need to understand where chaplains work and how they are (or are not) formally a part of institutions, particularly those funded by the state and federal government. This article offers a short history of chaplaincy and provides snapshots about where chaplains work as federal and state employees in three sample states: Massachusetts, Illinois, and California. This institutional perspective is integral to understanding where and how chaplains are staffed and where collaborations are possible.]

Captari, L. E., Hydinger, K. R., Sandage, S. J., Choe, E. J., Bronstein, M., Stavros, G., Shim, P., Kintanar, A. R., Cadge, W. and Rambo, S. "Supporting chaplains on the frontlines of the COVID-19 pandemic: a mixed-method practice-based pilot intervention study." Psychological Services (2022): online ahead of print, 7/14/22. [(Abstract:) During the coronavirus disease 2019 (COVID-19) pandemic, chaplains have played a pivotal role in patient, family member, and staff care. However, little empirical attention has been given to (a) the potential toll of frontline spiritual care on chaplains' mental health and occupational functioning as well as (b) the development of interventions that can help ameliorate these risks and promote resilience. Using a mixed-method practice-based design, we conducted a pilot study (n = 77) to evaluate a novel spiritually integrated support group intervention for chaplains across multiple industries, which consisted of five Zoom-based sessions co-facilitated by psychotherapists. Participants completed pre- and post-intervention measures of traumatic stress, burnout, spiritual/moral struggles, flourishing, resilience, and overall experience in the group. Qualitative findings elucidated the salience of peer support, therapeutic group processes, and key intervention components that warrant further study. Quantitative results indicated significant (a) decreases in burnout and spiritual/moral struggles from pre- to post-intervention as well as (b) increases in sense of resilience and flourishing. Findings of this pilot study offer preliminary evidence for the use of a spiritually integrated group model to decrease isolation, address moral and spiritual distress, and promote resilience among chaplains.]

Cooper, D. C., Evans, C. A., Chari, S. A., Campbell, M. S. and Hoyt, T. "Military chaplains and mental health clinicians: overlapping roles and collaborative opportunities." Psychological Services (2022): online ahead of print, 4/7/22. [(Abstract:) Military chaplains and mental health clinicians have unique professional roles and functions within the Department of Defense. However, they also have intersecting roles in delivering care to service members with mental health issues. Although diagnosis and treatment of clinical disorders is the primary focus of mental health clinicians, military chaplains are often the first contact made by service members seeking help for mental health concerns, due in part to issues of greater accessibility, ensured confidentiality, and less stigma. There is growing recognition of the importance of spirituality in the well-being and readiness of service members, as many mental health issues have a spiritual dimension. As a result, chaplains and mental health clinicians often address many of the same issues, albeit with different approaches. This review examines overlap in the work of chaplains and mental health clinicians and contrasts their complementary treatment approaches. These overlapping issues and complementary approaches highlight the potential for greater collaboration between these two professional groups, which could be beneficial for the care of service members.]



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