July 2022 Article of the Month
Russell, J., Quaack, K. R. and Nunez, J. "Chaplain reported plans for end-of-life care conversations: role clarity for the spiritual care specialists." Journal of Health Care Chaplaincy (2022): online ahead of print, 6/26/22.
SUMMARY and COMMENT: An old issue for chaplains is how much advance planning and goal setting should go into patient interactions, how much preparation maximizes benefits, and how much it could set an agenda that affects the chaplains' ability to be present in the patient's moment. Our featured study this month -- out of the Communication departments at California State University (Long Beach) and the University of Texas (Austin) -- is relevant in part to that issue, exploring how chaplains plan and approach "conversational engagement" [MS p. 2] in end-of-life (EOL) cases and how chaplains' goals figure into "curated plans" [MS p. 4, passim]. The intent here is to gain insight into the role(s) chaplains may play on palliative care teams and the "conversational quality" [MS p. 3] of their work. The authors' analysis is guided by a "multiple goals theoretical framework" [MS p. 2] regarding complex communications, which should be thought-provoking for all chaplains. This article builds upon a theme of communication that was explored in the previous Article-of-the-Month (--see June 2022).
The theory here around multiple goals provides a lens through which communication can be understood in terms of task goals (i.e., "taking an action directed at accomplishing a specified end and is often the object toward which communication is directed" [MS p. 2]), identity goals (i.e., "centraliz[ing] the individual roles and values of the vested parties" [MS p. 3]), and relational goals (i.e., "associated with the development and maintenance of connections with others" [MS p. 3]).
According to the multiple goals theoretical perspective, in complex communicative situations, the number of relevant goals increase which may account for the difficult nature of EOL discussions.... A multiple goals framework further posits that interactions addressing the primary task while simultaneously adhering to relevant identity and relational goals are deemed more effective...relative to those with a singular goal orientation. In the domain of EOL conversations, prior research on goal-directed behavior demonstrates that communicators able to effectively navigate multiple relevant goals report higher quality conversations with enhanced conversational satisfaction and hopefulness.
Two research questions drove this project: What is the relative frequency of task, identity, and relational goals of chaplains in planning for conversations about EOL care? ...and... What topics are present in chaplain curated plans for EOL conversations? [See MS p. 4.] A total of 69 chaplains were recruited from listservs of the Coalition for Compassionate Care, Hospital Chaplains Ministry Association (HCMA), and HealthCare Chaplaincy Network (HCCN). The authors note, "These organizations are not representative of all chaplains in the United States" [MS p. 12], but they propose that this sample is adequate for this "preliminary step" [MS p. 13] in investigating the subject matter. All data were collected via an online process. Participants were presented with a patient scenario:
You have a patient living in a skilled nursing facility with a terminal illness. Their spouse is no longer living. They have a remaining life expectancy of less than a year. While they have full capacity to make decisions, you are asked to have a discussion with the patient about his or her EOL treatment options so that the medical staff aiding the patient is clear about what the patient wants. [MS p. 4]And then participants were directed as follows:
Please design a plan to communicate to the patient about their options for life-sustaining treatment. In this plan, please write (a) how you would engage in the conversation with the patient and (b) what specifically you would plan to discuss. Please be as detailed as possible in your plan generation. [MS p. 4]
Among the findings and implications from the qualitative (grounded theory) analysis:
The authors parlay their findings into a case supporting chaplains' value on the interdisciplinary care team: "Recognizing the need to fully understand the patient and their story is a valued asset that chaplains can bring to the care team efforts" [MS p. 11], and "The heavy integration of establishing rapport and eliciting patient preferences within chaplain curated plans speaks to the unique benefits their role brings to the interdisciplinary care team" [MS p. 11-12]. They extend this to a particular vision of a "complementary approach" with physicians: "The physician or member of the medical team can inform the patient of treatment options available, while chaplains can help make sense of the options through the lens of patient values and identity" [MS p. 12].
This study concentrated on the "difficult conversations" [MS p. 2] pivotal to good end-of-life care, but this reader's mind went immediately to how such research could have wider significance. First, it highlights a sophistication in chaplains' approaches to patient/family communication, and multiple goals theory may indeed be a productive means to conceptualize and improve many different interactions in chaplaincy practice --and might be usefully applied in Clinical Pastoral Education. Second, while the methodology here revolves around the use of curated plans for patient conversations and is attentive to task goals in such planning, it allows for an appreciation of chaplains' prioritization of relational goals. Moreover, while the data come from a directive to "design a plan to communicate to the patient" [MS p. 4], the study does not necessarily rule out the validity of a plan that is cautious about imposing a limiting agenda on an interaction. The old issue of how advance planning for conversations may affect the practice and experience of chaplaincy is here enriched with some new data for consideration. Additionally, this research should encourage greater dialogue between chaplains and physicians in general, recognizing what each may bring to the total interdisciplinary team interaction with patients and families. If this reader has one concern about the article, it would be about the authors' final word here: "Awareness of content that chaplains are more prone to cover provides opportunities to clarify where other interdisciplinary team members can contribute without being redundant" [MS p. 13, emphasis added]. A certain amount of role overlap may actually be healthy, as overspecialization in communication may risk undermining the holistic complexity of interpersonal interaction and the patient experience. Future research should carry this study forward, examining how chaplains pursue communication goals in less abstract and more real-world contexts.
The bibliography contains 50 citations, including five from 2021.
Suggestions for Use of the Article for Student Discussion:
This month's article should be engaging to a wide spectrum of chaplains: students, career professionals, educators and those with a research focus; though multiple goals theory may not be useful to students very early in their programs. It could be read in tandem with the June 2022 Article-of-the-Month, also on communication. While it is naturally geared to palliative care circumstances, it should be engaging for chaplains in a variety of settings, and it could be especially interesting for chaplains other specialized settings (e.g., behavioral health) to compare and contrast their professional situations with that of palliative care when it comes to communication dynamics. Discussion might begin with a look at the introduction of the Multiple Goals theoretical framework [MS pp. 2-4], beginning with the declaration, "Communication is a goal-driven process" [MS p. 2]. What do they make of the division of goals into relational, identity, and task orientations? Can they identify their own predilections in terms of these three? How might these relate to their sense of a theory of chaplaincy? What is their reaction to the suggestion that managing multiple goals in clinical conversations is associated with a higher quality of interaction and better outcomes? Turning to the list of content topics [--see Table 2, MS p. 7], which stand out to the students as prominent in their practice? Are there other content topics that, from their experience, seem absent from this list? Do any seem out of place for their own practice? The study notes that the need to introduce and/or clarify the role of chaplain was "not a predominant theme" [MS p. 12] in the results, though a third of the participants expressed this need. How much attention do the students feel they need to give to this identity goal in patient/family interaction? What do the students think they might do with the ideas raised by this research? Members of the group could be asked to state, in turn, one personal takeaway from the discussion.
Related Items of Interest:
I. Relevant to the evidence here about chaplains sophistication around communication, note that among the findings of the December 2021 Article-of-the-Month was chaplains' self identification as "skilled communicators" with an "ability to practice skills grounded in theory" [--see MS p. 13 of White, K. B., Combs, R. M. and Decker, H. R., "Board certification of professional chaplains: a qualitative study of stakeholder perspectives," Journal of Health Care Chaplaincy (2021): online ahead of print, 6/1/21].
II. Our authors this month cite the work of Jane Jeuland, George Fitchett, Dena Schulman-Green, and Jennifer Kapo in "Chaplains working in palliative care: who they are and what they do" [Journal of Palliative Medicine 20, no. 5 (May 2017): 502-508; and the March 2017 Article-of-the-Month] regarding chaplains' roles on palliative care teams. Findings from that earlier study included: "Chaplains who always serve PC [i.e., Palliative Care] are far more likely to address goals of care (70%) than chaplains who occasionally serve PC (43%)," and "[t]hey are also twice as likely to facilitate communication between patients, family, and the healthcare team (65%) than occasionally involved counterparts (34%)" [p. 507]. This suggests that solid integration of particular, regular chaplains into care teams may be a key factor in the effectiveness of the chaplain's role and efficiency of communication.
III. Regarding chaplains' management of identity goals, especially in light of felt needs around self-introduction and role clarification, readers may be interested in these two past Articles-of-the-Month.
IV. Our present article's bibliography provides good leads for further reading about Multiple Goals Theory, including Van Scoy, L. J., Scott, A. M., Reading, J. M., Chuang, C. H., Chinchilli, V. M., Levi, B. H. and Green, M. J., "From theory to practice: measuring end-of-life communication quality using multiple goals theory," Patient Education & Counseling 100, no. 5 (May 2017): 909-918; which was cited as a Related Items of Interest for our November 2017 Article-of-the-Month. However, chaplains may want to look particularly at the following recent study by two of our featured authors, examining how Social Workers may approach conversational goals in end-of-life contexts. Eliciting information about patients' spiritual values, beliefs, and traditions stand among the goal-related interests of some Social Workers.
V. The idea of "snowball sampling" [MS p. 12] in research is, to put it most simply, taking advantage of connections between members of a population in order to gain greater access to that population. It may be done either by asking study recruits either to share an invitation to participate in the study or to provide researchers with contact information about others who may be interested in the study. For more on this concept/methodology in general, see the following trio of invited commentaries on the subject from the perspective of sociological methodology:
It is worth noting that the 2017 SAGE Encyclopedia of Communication Research gives an example of research into chaplains as part of its section on Snowball Subject Recruitment, in the larger context of how a snowball approach to recruitment could apply to a purposive form of nonrandom sampling. The example refers to a researcher's interest in chaplains' perspectives on the provision of spiritual care in hospitals for ill patients. Purposefully specifying chaplains in the study sample excludes other spiritual care providers, narrowing the sample, even if still employing a snowball recruitment process. [This is principally an online publication, but see print pages 1614-1616.]
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