Surveys were sent out by chaplaincy organizations to their members on behalf of the research team, yielding 781 responses and a final total 699 records for quantitative analysis. In addition, the authors used maximum variation sampling to select 52 people for semi-structured, in-depth interviews, with 35 providing the sample for qualitative examination (when saturation was assessed to have been achieved). The methodology is well described on pp. 42-44, though while the survey items are indicated in a table of responses, the interview guide is not included.

Among the findings:

In 2019, ...47.4% of respondents had practiced telechaplaincy. Practice was not associated with age, gender, race, years of chaplain experience, or professional certification.... ....Chaplains who had not practiced telechaplaincy were more willing to do so if they believed it was able to meet patients' spiritual and emotional needs.... Chaplains currently in rural settings reported the highest proportion of use among community types.... Telehealth mediums other than the telephone (i.e., text, email, video- conference, other) were used more commonly by those practicing in non-healthcare versus healthcare settings.... [pp. 44 and 46]

Most often, introductory conversations were one to five minutes, while more in-depth visits lasted thirty-minutes to an hour. ...Most interviewees personally developed their practice based largely on their own vision, because of no available benchmarks or trainings. By and large, telechaplaincy was not regulated by the institution, other than needing to be HIPAA complaint, conducted on a company phone, and charted. Several chaplains were unable to describe what HIPAA compliance meant via telehealth, even though they claimed it was an institutional requirement. [pp. 46 and 48]

Chaplains used a variety of terms to describe telechaplaincy, including but not limited to e-chaplaincy, chaplaincy on-demand, virtual chaplaincy, mobile chaplaincy, and community-based chaplaincy. ...Some chaplains were confused by the term virtual chaplaincy or had perceptions that virtual implied not real. [p. 48]

The authors found a "nuanced picture of inter-related strengths and weaknesses" [p. 60] of telechaplaincy, even involving seemingly overlapping and even contradictory positions. These points are presented in two tables, with illustrative/explanatory quotes. Such strengths and weaknesses may be especially useful for department managers to consider when planning a telechaplaincy initiative, and for staff to keep in mind as they assess their experience.

STRENGTHS [--see pp. 50-51]:

1)   Extends access to experienced chaplain[s] --

• Overcomes barriers that make being in-person harder, including distance, disability, transportation, etc.
• Extends continuity of care [as in allowing for follow-up visits after hospital discharge]
• Timely response [as when an in-person visit isn't feasible in a time-critical situation]

2)   Delivers effective, appropriate spiritual care --

• High-quality care [can be done through telechaplaincy]
• Good for assessment, introducing services, and deep listening
• Comfort [by giving a "level of control and safety for a person in their home"]
• Limits bias [e.g., "Visuals that might contribute to a patient's perception of chaplain are less likely to contribute to projection."]
• Resources and interdisciplinary work [as through easy texting of resources to a patient or through convenient communication with other disciplines]

3)   Amenable --

• Preferred [as some people may just prefer a phone call with a chaplain]
• Theological or ideological agreement [e.g., a chance for "being present with the outcast"]
• Promotes refined skills [as in helping chaplains develop their listening skills]
• Flexible [since it can be done from a variety of settings]

4)   Efficient use of chaplain, patient, and system resources --

• Cost
• Time [as it eliminates the time-consuming logistics of travel]
• Relevant [as a response to changing needs and circumstances in the society]
  
  

WEAKNESSES [--see pp. 52-53]:

1)   Not as effective as in person --

• Not able to see [the] person or environment
• Limits interventions [e.g., limits facilitation of rituals]
• Feels removed [as in facing a screen rather than a person]
• Changes energy [as the chaplain is not able to walk physically into the "energy that's already in the room" of the person and work in response to that]
• Limits interdisciplinary work/resources [that are readily available in the hospital for inpatients]
• Shorter visits [as people may share information more than share in silence and pauses]
• Confidentiality [is] difficult to ensure [by not knowing who else may be listening]

2)   Not appropriate or desired by all people, circumstances, and preferences --

• Technology inaccessible/more difficult due to disabilities, access, speech differences, etc. [including people thinking the call is just some solicitation]
• Distractions [including distractions to the chaplain]
• Theological or ideological disagreement [e.g., uncertainty about the theological understanding of "community" in virtual contexts]
• Chaplain resistance [to change, in general]
• Distrust, or frustration with contact or multiple contacts [with different people from the hospital calling]
• Boundary issues [as people may persist in leaning on the chaplain]

3)   Costly --

• Technology
• Time
• Training/Systems [lacking at present]
• Risk of being sued [e.g., because the chaplain can't control who else may be privy to the content of the visit]

4)   Technological issues --

• Disruptions and errors [when the technology isn't working well]
• Quickly irrelevant [as particular technology changes]
  
  

Regarding BEST PRACTICES, the researchers identified four main themes, and constituent subthemes, from the participants' input. The subthemes are described in paragraph-length in the text [--see pp. 49, 51, 54-60] offering a fair sense of the meaning of each.

1)   Program Implementation --

• Get support from key stakeholders [e.g., "upper-level and mid-level leadership, departmental leadership, inter-disciplinary team members, information-technology support, chaplain colleagues, and potential program participants"]
• Learn from precedents [e.g., consult others who have practiced telehealth, take advantage of systems already in place, and review research in this area]
• Secure sustainable funding [e.g., "solicited donations, designated departmental funds, and reimbursement gained through company health insurance"]
• Develop an easy referral and triage process [e.g., establish screening tools and education for referrals, and pay special attention to non-English speaking patients]
• Have a safety plan [in case there is a need for emergency safety intervention]
• Practice to develop confidence and understanding [in "telehealth modalities and interventions"]
• Do not use telechaplaincy to replace in-person chaplains, or solely to save money

2) Preparation for Individual Encounters --

• Assess which modality to use [to meet the circumstances of each patient case]
• Schedule interactions [to allow for efficient contact and a chance for the recipient to prepare]
• Limit distractions [for confidentiality as well as helping with listening and presence]
• Establish relationship in-person if possible; enhance connection if not [--Build upon previous in-person visits or an introduction by someone the patient knows. Review the chart for background information.]

3)   Delivery of Interventions --

• Use a flexible script [that is HIPAA-compliant and addresses some of the common challenges of telechaplaincy]
• Define the purpose of the contact [quickly and clearly --introducing oneself, explaining the reason for calling, and noting any restrictions]
• Listen deeply [including "for background noise, slight voice modulations, and even silence"]
• Be selective with word choice [which is more crucial than during in-person encounters]
•  Pay attention to tone ["Chaplains intentionally modulated vocal tone to convey appropriate emotions"]
• Verbalize non-verbals [e.g., "I'm smiling" or "Is there something there or was that just a pause?"]
• Use open-ended questions [though "reliance on only questions felt like an interrogation"]
• Thoughtfully use silence ["in a way that felt comfortable to the recipient"]
• Use creative rituals [--While prayer was common, other rituals were possible with preparation.]
• Give the recipient control [including "giving the recipient the choice of when to meet, when/if to end the conversation, which telehealth modality to use, conversation topic, and if they wanted to receive rituals"]
• Welcome the unexpected [which some participants found "easier to do via telephone as the recipient was not able to see their non-verbal reactions"]

4)   Sustaining a Program --

• Engage in research and quality improvement projects
• Work with an interdisciplinary team
• Establish boundaries [e.g., "clearly communicating that one is not a friend, but a professional"]
• Do self-care [as some found telechaplaincy work more emotionally draining than in-person visitation]
  
  

In their Discussion section, the authors take up the issue of bias in two ways. First, they note that telechaplaincy itself is an object of bias, in light of the finding that "a substantial number of people had negative perceptions of telechaplaincy or were not willing to practice" [p. 60]. To counter this, they suggest that chaplaincy managers be proactive in educating staff about the potential benefit to patients, since evidence indicates that "chaplains [are] more likely to practice if they believed that telechaplaincy was effective at meeting recipients' spiritual needs" [p. 60]. Moreover, they advise that chaplains be incorporated into the planning process as "key stakeholders" [p. 60], that any plan avoid making telechaplaincy a sole responsibility but instead mix it with in-person encounters in the practice of individual chaplains, and that theological reasons for bias be addressed. The data revealed that while there could be a theological impetus for telechaplaincy outreach (e.g., being "present" to those who may be disconnected, isolated, or "afraid of talking to a faith representative in-person" [p. 51]), theology could also be a disincentive (e.g., "I have not yet worked all this out in my theological mind about how to be a community of connected humans virtually" [p. 53]). Second, they note how bias may have been a limiting factor in the process of the study. They took steps to limit conformity bias in responses by making the surveys largely anonymous, but selection bias may have played into the identification of the participant sample. The authors call for further research to test and refine the best practices proffered by the 35 chaplains who were interviewed.

The importance of this research lies partly in its identification of chaplains' perceptions of telechaplaincy (which should pave the way for overcoming barriers to practice) but, at least for this reader, its great value is largely in the establishment of a baseline for best practices that could be discussed within the profession and lead toward a consensus, informed by further research. The work proceeds from the recognition that "telechaplaincy has unique components to identify and address" [p. 42], above and beyond all that is required for skillful in-person chaplaincy. By the same token, however, telechaplaicy is an umbrella term for various modalities (e.g., phone but also "text, email, videoconference, other" [p. 46]) which would logically call for some special attention to the particular dynamics of each --hence, the points to "[p]ractice to develop confidence and understanding ...of telehealth modalities" [p. 54] and the need to "[a]ssess which modality to use" [p. 55]. The best practices presented here do not delve into every modality in detail, nor do they take into account the many advances in videoconferencing that have occurred through the COVID-19 pandemic, but they nevertheless set the ground for thinking about how chaplaincy may be modulated according to the means of interaction. Taken one step further, what we learn through examining the different modes of telechaplaincy may help chaplains refine best practices for other interactional circumstances, such as when wearing obstructive Personal Protective Equipment or when caring for a patient who is encumbered by some obstacle to communication.

"This study is novel in that it is the first nation-wide study of telechaplaincy practice within the United States and draws from a large sample of people." [p. 61] As such, it "supports the thoughtful integration of telechaplaincy and its promise for improving spiritual care in various settings." [p. 60]