June 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
Klitzman, R., Garbuzova, E., Di Sapia Natarelli, G., Sinnappan, S. and Al-Hashimi, J. "Hospital chaplains' communication with patients: characteristics, functions and potential benefits." Patient Education and Counseling (2022): online ahead of print, 5/10/22.
[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: Columbia University psychiatrist and bioethicist Robert Klitzman is a prolific researcher, and in July 2021 he presented a Chaplaincy Innovation Lab webinar on Perspectives on Chaplaincy from Outside the Profession [--see Related Items of Interest, §I, below]. In this month's article, he and his team explore critical and beneficial functions of chaplaincy in health care through the lens of communication. This study is valuable for its explication of the breadth of chaplains' activity through and beyond traditional roles of spiritual care, with implications for hospital administrators, physicians, nurses, and others; but it also should help chaplains think precisely about their importance as communicators in "increasingly fractured and overwhelmed healthcare systems" [MS p. 7].
Twenty-one chaplains were interviewed by phone, from a convenience sample of the Association of Professional Chaplains in 2020-2021. Methodology turned upon grounded theory, with the number of interviews determined during the process by the authors' assessment of data saturation. Twelve participants were interviewed "more than once in order to cover the questions in the semi-structured interview guide, since some interviewees responded at greater length than did others to the questions posed" [MS p. 3]. Data analysis is succinctly described [--see MS p. 3].
Results are outlined in a figure detailing unique characteristics, beneficial functions, and implications [Figure 1, MS p. 4] and described in the text by theme, with a variety of case anecdotes. Among the findings:
- "...[I]n increasingly fractured medical systems, chaplains often have relatively more time than other staff to speak to patients and families at length, which can reveal critical information." [MS p. 3]
- "Chaplains, standing outside the medically-trained team, bring different perspectives, taking more 'holistic' views of the patient." [MS p. 3] In this way, the chaplain might reframe a patient's story for the staff to widen their understanding for the patient's treatment. This can be especially the case when a chaplain might be motivated by religious values to pay attention to and interpret to staff the position of needy and vulnerable patients. [--see MS p. 4]
- Chaplains may obtain vital information from families and patients, "elicit[ing] key aspects and contexts of a patient's or family's treatment preferences that may conflict with the medical team's opinion, and offering insight to staff about "where the family is coming from." [MS p. 4] Moreover, "[a] chaplain can not only help staff understand a patient's perspectives, but help patients and families comprehend, in terms they can appreciate, the staff's point of view as well." [MS p. 5]
- Chaplains can potentially facilitate understanding between the medical team and patients/families that can get lost when conflicts flare. They can also "serve as direct mediators or 'go-betweens' when conflicts erupt. ...These clashes can arise when distrust mounts, especially when patients are from cultures or religious traditions with which staff have less intimate experience. ...Chaplains eliciting and valuing patients' and families' points of view can...build trust and help mediate such conflicts." [MS p. 5]
- "Obtaining information about a patient's or family's point of view can...facilitate appropriate medical decision-making." [MS p. 5] And, "[c]haplains at times discover information that can...assist physicians in diagnosing and treating the patient." [MS p. 5]
- "A chaplain can also maintain openness and have a relative lack of an a priori rigid agenda per se, therefore providing 'fresh eyes' and perspectives on patients and families that can prove beneficial, especially with patients who may face prejudices [or faulty assumptions] from providers." [MS p. 5]
- "Chaplains can also leverage power they have within an institution, drawing on contacts with other, senior providers to try to influence members of a particular medical team" [MS p. 5], to counter bias or group think.
- "...[C]haplains can also make key psychosocial interventions that other team members, focused on the immediate medical problem at hand, may not have time and/or inclination to do." [MS p. 6]
The authors summarize:
These data suggest how communication by chaplains can improve patient care in several crucial ways that have not been previously described: bringing particular perspectives that can help in getting to know patients better and thus in learning and conveying to medical teams vital information that can assist in diagnosis, treatment and resolution of conflicts. These roles in communication are increasingly important, given the increasingly fractured and rapidly changing healthcare systems, with heightened pressures and stresses of managed care, decreasing amounts of time doctors have with their patients, and time constraints faced by other providers. In seeking to make healthcare systems as effective as possible, these chaplains' roles in communication are thus critical to recognize, encourage, and more fully draw on. [MS p. 6]
The amount of time that chaplains are said to have for in-depth communication, compared to the time availability of other health care providers, is repeatedly mentioned and seems a key factor. However, while the data come from working chaplains and their real-world experience, this reader would comment that chaplains, too, may become increasingly vulnerable to time pressures that can come with increasing involvement in operational structures (which our authors encourage). One particular suggestion is for chaplains to be integrated into rounds [--see MS pp. 6 and 7], but rounds can be quite time-consuming elements to incorporate into a work schedule. Also, our present article recalls a previous study of the use of chaplains as "patient navigators" [--see MS p. 6], yet that study itself describes the role in question as so "time-consuming" as to be in tension with the time required for spiritual care services [--see p. 1841 of Teague, P. et al. (2019), "The role of the chaplain as a patient navigator and advocate for patients in the intensive care unit: one academic medical center's experience," Journal of Religion and Health 58(5):1833-46 (NOTE: this was our October 2019 Article-of-the-Month)]. This would seem to be an area for further research regarding trends in the demands on chaplains' time with any expansion of roles.
Within just the area of communication, the present study reveals how chaplains may offer critical contributions to patient care in "crucial and invaluable ways" [MS p. 7] in addition to traditional roles, but "[t]he present data suggest...that chaplains may at times on their own take on some of these roles and activities in informal, if not formal ways, both implicitly and explicitly, in both planned and inadvertent approaches, working closely and collaboratively with the medical team either as significant parts of what they do or only when they sense the need" [MS p. 6]. The authors thus hold not only that hospital administrators, physicians, nurses, and others "need to more fully recognize and appreciate how chaplains can play these crucial roles, communicating in open-ended, patient-centric ways that can assist in understanding, diagnosing, and treating patients" [MS p. 7] but that "[a]s a field, chaplaincy should thus more fully and frequently recognize, pursue and potentially further develop these critical activities, explicitly addressing and encouraging these functions and aiding chaplains in performing these roles" [MS p. 7].
One particular strength of the article is the inclusion of anecdotes illustrating the interview data: nine paragraph-long stories by the participants that express some of the complex situations in which a chaplain's ability to take in and communicate information can support effective overall patient care. The authors also do a nice job in setting up their topic within the context of some of the "obstacles" [MS p. 2] that chaplains routinely face in the course of their practice, like disconnection with physicians or marginalization within institutions [--see the Introduction, MS p. 2]. Chaplain readers should sense here a quite subtle understanding of their professional world by these researchers coming from outside of it.
The period of data collection (2020-2021) overlaps with the COVID-19 pandemic. The authors do not remark on how this may have affected participants' sharing, but they do comment that "[i]n July 2020, during the height of the initial surge of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS), for the first time, established codes for chaplain services -- but only for the VA system, and these codes remain non-billable" [MS p. 2; and see Related Items of Interest, §III, below].
Suggested future research [--see MS p. 7] emphasizes international comparative studies of chaplains' roles and the effect of educational efforts.
The bibliography of 46 citations is very current, including references to 2 articles and 11 Internet resources from 2022. The bibliography does not contain other works by Robert Klitzman that address chaplaincy [--see Related Items of Interest, §II, below].
Suggestions for Use of the Article for Student Discussion:
This is a very readable article that should be usable with all levels of chaplain students. The authors present the material clearly and explain their methodology for data collection and analysis in easy-to-understand terms. Extended quotes from the participants flesh out and personalize the data, and this may be a good place to start for discussion: What of the nine case anecdotes most grabbed students' attention? From there, discussion could be widened to the various major points of the findings, and the figure detailing relatively unique characteristics, beneficial functions, and implications [Figure 1, MS p. 4] could be helpful here (though note that the table -- at least in the pre-print version of the article available online -- appears to end with an incomplete point about "differences"). How salient is the idea of communication in the minds of the chaplains as they think about their work, and how does this affect the way they think of their professional practice? Do they believe they have sufficient time for good communication with patients and families? The group could also look at some of the sample questions of the semi-structured interviews [Table 2, MS p. 4], perhaps especially: "What have been your most rewarding experiences/cases as a chaplain? What were the most difficult?" and "Do you feel there are aspects of your work that other medical staff do not appreciate?" The authors highlight the value of chaplains providing "fresh eyes" [MS pp. 5, 6, and 7] that can bring an enlightening perspective about patients to staff. Do the students envision this as a potential contribution to patient care, and how. Conversely, are their own perspectives ever widened the views of others on care teams, and do students' own prejudices and assumptions about patients ever come to light through the "fresh eyes" of others? Finally, as a bit of an aside, the group could consider the authors' explanation of the terms religion and spirituality [MS p. 2].
Related Items of Interest:
I. On July 6, 2021, Robert Klitzman presented a one-hour Chaplaincy Innovation Lab webinar on Perspectives on Chaplaincy from Outside the Profession. His focus is the topic, "Doctor, will you pray for me? How patients create meaning, purpose and hope," drawing on his previous studies [--see Related Items of Interest, §II, immediately below], but he includes some of the themes that we see in our featured Article-of-the-Month. The webinar is available directly from the Chaplaincy Innovation Lab site or from YouTube.
II. Other academic journal articles by Robert Klitzman that may be of special interest are listed below. Chaplains may also be interested in a 2021 opinion piece that Dr. Klitzman wrote for CNN: "The 'amazing grace' of chaplains in the pandemic," (available online).
Klitzman, R., Al-Hashimi, J., Di Sapia Natarelli, G., Garbuzova, E. and Sinnappan, S. "How hospital chaplains develop and use rituals to address medical staff distress." SSM - Qualitative Research in Health 2 (2022): 100087 [online journal article designation] [NOTE: This is an open access article.] [(Abstract:) Physicians and nurses face high levels of moral distress and burnout, exacerbated by the COVID-19, yet are often busy, without time for extended interventions. Hospital chaplains have recently been asked to assist staff, but many questions arise concerning whether they do so, and if so, how and when, and whether they may vary in doing so. Thirty-one telephone interviews of approximately 1 h each were conducted with 21 board-certified chaplains to examine these and related issues. Respondents reported how they help staff, often creating, on their own, innovative kinds of practices that appear to take the form of rituals. These rituals vary in audience (physicians, nurses and/or other staff, with or without patients or families), form (from open-ended to structured), formality (from formal to informal), timing (at hospital discharge, time of death or after death), duration (from a few minutes to longer), frequency (from once to several times or ongoing), content (expressing and/or reframing feelings and experiences), and activities (e.g., talking, eating and/or making commemorative objects). Such rituals can help staff cope with death, grief, and other stresses. Challenges arise, including hospital leaders' wariness, resistance or lack of support, and staff time constraints, making briefer sessions more practical. These data highlight how chaplains can assist staff through use of rituals, and learn from innovations/initiatives devised by colleagues elsewhere. Chaplains can thus enhance what they do as individuals and as a profession. These data have critical implications for future research, education and practice for physicians, nurses, hospital administrators, chaplains and others.]
Klitzman, R. "How infertility patients and providers view and confront religious and spiritual issues." Journal of Religion and Health 57, no. 1 (February 2018): 223-239. [(Abstract:) Questions arise concerning whether and how religion affects infertility treatment decisions. Thirty-seven infertility providers and patients were interviewed. Patients confront religious, spiritual, and metaphysical issues coping with treatment failures and religious opposition from clergy and others. Religion can provide meaning and support, but poses questions and objections that patients may try to avoid or negotiate-e.g., concealing treatment or changing clergy. Differences exist within and between religions. Whether and how much providers discuss these issues with patients varies. These data, the first to examine several key aspects of how infertility providers and patients confront religious/spiritual issues, have important implications for practice, research, guidelines, and education.]
Klitzman, R. "Doctor, will you pray for me? Responding to patients' religious and spiritual concerns." Academic Medicine 96, no. 3 (2021): 349-354. [(Abstract:) Religion and spirituality in the United States have been shifting, and physicians are treating patients with increasingly diverse beliefs. Physicians' unfamiliarity with these beliefs poses critical challenges for medical education and practice. Despite efforts to improve medical education in religion/spirituality, most doctors feel their training in these areas is inadequate. This article draws on the author's conversations with providers and patients over several years in various clinical and research contexts in which religious/spiritual issues have arisen. These conversations provided insights into how patients and their families commonly, and often unexpectedly, make religious/spiritual comments to their providers or question their providers about these topics, directly or indirectly. Comments are of at least 9 types that fall within 4 broad domains: (1) perceiving God's role in disease and treatment (in causing disease, affecting treatment outcomes, and knowing disease outcomes), (2) making medical decisions (seeking God's help in making these decisions and determining types/extents of treatment), (3) interacting with providers (ascertaining providers' beliefs, having preferences regarding providers, and requesting prayer with or by providers), and (4) pondering an afterlife. Because of their beliefs or lack of knowledge, doctors face challenges in responding and often do so in 1 of 4 broad ways: (1) not commenting, (2) asking strictly medical questions, (3) referring the patient to a chaplain, or (4) commenting on the patient's remark. Medical education should thus encourage providers to recognize the potential significance of patients' remarks regarding these topics and to be prepared to respond, even if briefly, by developing appropriate responses to each statement type. Becoming aware of potential differences between key aspects of non-Western faiths (e.g., through case vignettes) could be helpful. Further research should examine in greater depth how patients broach these realms, how physicians respond, and how often medical school curricula mention non-Western traditions.]
Klitzman, R. "Typologies and meanings of prayer among patients." Journal of Religion and Health 61, no. 2 (April 2022): 1300-1317. [(Abstract:) Religion often aids patients, but critical questions arise concerning how patients approach issues regarding prayer. In-depth interviews suggest 12 key patient decisions and aspects of prayer-who prays, to whom (e.g., explicitly to "God" or not), for whom (for self or others), for what (e.g., for symptom reduction), when (regularly or only during crisis), where, what to say (pre-specified language or spontaneous), how consciously planned or not, with what expectations and outcomes, what to call it, and in what social contexts (e.g., how others view one's prayers). These data have implications for future research, clinical practice of physicians, nurses, chaplains, and other allied healthcare providers, and patient education.]
Klitzman, R. L. and Daya, S. "Challenges and changes in spirituality among doctors who become patients." Social Science and Medicine 61, no. 11 (December 2005): 2396-2406. [(Abstract:) Though spirituality can help patients cope with illness, several studies have suggested that physicians view spirituality differently than do patients. These issues have not been systematically investigated among doctors who become patients, and who may be able to shed critical light on this area. We interviewed fifty doctors from major urban US centers who had become patients due to serious illnesses about their experiences and views relating to religion and spirituality before and after diagnosis, and we explore the range of issues that emerged. These physician-patients revealed continua of forms and contents of spirituality. The forms ranged from being spiritual to start with; to being spiritual, but not thinking of themselves as such; to wanting but being unable to believe. Some continued to doubt and, perhaps relatedly, appeared depressed. The contents of beliefs ranged from established religious traditions, to mixing beliefs, or having non-specific beliefs (e.g., concerning the power of nature). One group of doctors felt wary of organized religion, which could prove an obstacle to belief. Others felt that symptoms could be reduced through prayer. At times, self-assessments of spirituality were difficult to make or inaccurate. Questions surfaced concerning whether and how medical education could best address these issues, and how spirituality may affect clinical work. This study is the first that we know of to examine spirituality among physicians when they become patients. Obstacles to physicians' attentiveness to the potential role of spirituality arose that need to be further explored in medical education and future research. Increased awareness of these areas could potentially have clinical relevance, strengthening doctor-patient relationships and communication, and patient satisfaction.] [NOTE: This work was subsequently expanded into a book: When Doctors Become Patients (Oxford University Press, 2008).]
III. Our featured study notes that in July 2020, the Centers for Medicare & Medicaid Services (CMS) established codes for chaplain services. See the US Department of Veterans Affairs press release: "VA health care first to have Centers for Medicare & Medicaid Services codes for chaplain care" and the associated link to the CMS Summary for Bi-Annual 2020 Meeting [--see pp. 45-46]. The development was also covered at the time by the Chaplaincy Innovation Lab. On June 10, 2022, CMS again took up the issue of these codes, for proposed revision, at their First Biannual 2022 Healthcare Common Procedure Coding System (HCPCS) Public Meeting [--see pp. 14-16].
IV. For those taken with the case anecdotes in this month's study, see the case study that was featured in our May 2018 Article-of-the-Month.
Murphy, J. N. "The chaplain as the mediator between the patient and the interdisciplinary team in ethical decision making: a chaplaincy case study involving a quadriplegic patient." Health and Social Care Chaplaincy 5, no. 2 (2017): 241-256. [(Abstract:) Patients who have life changing injuries may have repeated hospitalizations. Because staff often change it may be difficult for these patients to build trusting relationships with care team members. This can cause problems when the patient faces difficult ethical decisions. The chaplain is sometimes in a unique position to build trust with the patient and to help the patient use spirituality and a sense of values in making these decisions. The following case study demonstrates this with "Wayne," a spinal cord injury patient in his early twenties. Because of Wayne's relationship with me as I visited with him over multiple admissions, as his chaplain, I was able to mediate between Wayne and the treatment team when he faced with an ethical decision.]
V. Our authors use the term, "thick description" in the explanation of their qualitative method [--see MS p. 2]. For those who are unfamiliar with the term, the following may be helpful:
Ponterotto, J. G. "Brief note on the origins, evolution, and meaning of the qualitative research concept 'thick description'." The Qualitative Report 11, no. 3 (2006): 538-549. [(Abstract:) The origins, cross-disciplinary evolution, and definition of "thick description" are reviewed. Despite its frequent use in the qualitative literature, the concept of "thick description" is often confusing to researchers at all levels. The roots of this confusion are explored and examples of "thick description" are provided. The article closes with guidelines for presenting "thick description" in written reports.] [This article is available online from the journal website.]