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May 2015 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Zollfrank, A. A., Trevino, K. M., Cadge, W., Balboni, M. J., Thiel, M. M., Fitchett, G., Gallivan, K., VanderWeele, T. and Balboni, T. A. "Teaching health care providers to provide spiritual care: a pilot study." Journal of Palliative Medicine 18, no. 5 (May 2015): 408-414.


SUMMARY and COMMENT: In an open letter to the attendees of last week’s ACPE national conference in Atlanta, ACPE Director Trace Haythorn made special note of this month’s featured article as an example of how "the age of ACPE research is upon us," and how "[t]he entire research scene seems to be growing into a new era, one in which research-based education and practice will be assumed, and the quality of that research will be exemplary" [--see p. 2 the ACPE Research Network’s conference flyer]. A commentary in the Journal of Palliative Medicine also uses the article to talk about the state of research in the field [--see Items of Related Interest §I (below)]. Such big-picture attention to this pilot study is worth noting, but the article should also be of interest to chaplains for its particular findings of good prospects for CPE-based education for non-chaplain providers.

The article "describes a five-month program that offers one model of educating health care providers about R/S [i.e., Religious/Spiritual] care, and evaluates the frequency and confidence in providers’ provision of spiritual care following training as primary outcome measures" [p. 409] --that model being based on a Clinical Pastoral Education curriculum. The program was offered through the Chaplaincy Department at the Massachusetts General Hospital, and data collection occurred between 2003-2009 for 50 providers (including 29 nurses, 11 physicians, and 4 social workers) who completed a questionnaire at the beginning and end of their participation. Because of a lack of validated measures for spiritual care training effectiveness, the researchers developed questionnaire items addressing: ability to provide R/S care, frequency of R/S care, comfort using religious language, and confidence in R/S care [--described on p. 410].

Among the findings:

Participants reported improvements from baseline to posttraining in ability to provide spiritual care (p < .001, 33% increase…) and comfort using religious language (29% increase, p < .001). Additionally, participants reported increased frequency of R/S care provision from baseline to posttraining (75% increase, p < 0.001). Examination of the frequency of specific types of R/S care indicated increase in frequency of R/S conversations with patients (61% increase, p < 0.001); initiation of R/S conversations (83% increase, p < 0.001); and praying with patients (95% increase, p < 0.001) over time. [p. 412]
--------                   --------                   --------
Participants’ confidence in providing spiritual care improved from baseline to posttraining (36% increase, p < 0.001…). …Participants’ confidence in their ability to provide R/S care to religiously concordant (20% increase, p < 0.001) and religiously discordant patients (43% increase, p < 0.001) significantly improved. [p. 412]

Change in confidence in providing R/S care differed by religion (and this is broken out in two of several helpful tables). In general, on this point:

Improvements in participants’ confidence occurred whether the patient’s religion was concordant or discordant from the providers for participants of Protestant, Jewish, and "other" religious affiliation. However, while Roman Catholic participants reported improvements in their confidence overall, changes by patient affiliation were not significant. This difference may be due to Roman Catholic participants reporting higher baseline confidence, leaving less room for improvement; and/or it may be due to the small sample size rendering differences difficult to detect. [p. 413]

The authors conclude that the data shows the program "improves participants’ confidence in providing spiritual care for most participants independent of patient affiliation" and its "focus on integration of R/S concerns into patient care in participants’ regular work setting appears effective" [p. 413]. They acknowledge several limitations (including the use of self-report measures and a self-selection dynamic in course participation), plus a demographic sample that was predominantly Christian. Future study might include assessment of such a program’s constituent educational components and longitudinal tracking to discover lasting impact. For a pilot, however, this study evidences that a CPE model can be productively applied to non-chaplain health care providers to enhance their work, and it implicitly suggests that a program of this type is worthy of consideration by other CPE centers.

Incidental to the specific topic of the article, the introductory section includes a brief but fine listing of points about the importance and impact of spirituality on health, tied to bibliographic entries [--see pp. 1-2]. Such introductory summaries can be convenient for chaplains looking for footholds in the literature.

Note that four of the authors are chaplains: Angelika A. Zollfrank, Mary Martha Thiel, George Fitchett, and Kathleen Gallivan.


Suggestions for the Use of the Article for Student Discussion: 

At first, this study might not seem a good match for CPE student discussion, because the subject matter is about programming for non-chaplain providers. However, the article should be interesting at several levels. First, it is clearly written and relatively brief, making it easily accessible for any student. Second, it sets out a method of assessment for an educational course [p. 3] that may be a helpful parallel for students to think about in light of their own sense of educational development and change of practice. For instance, it might aid students to see more clearly how they relate to patients along the lines of concordant and discordant belief systems, and, especially regarding patients with discordant belief systems, how students may feel comfort using religious language and feel confident in their pastoral care. Also, the very basis of the study is an observation about an important "barrier to provision of R/S care" [p. 413, but see esp. p. 409], in terms of the role of non-chaplain providers. The latter is certainly fodder for discussion, playing into students’ sense of multidisciplinary teamwork in the spiritual care of patients [--see, perhaps, Items of Related Interest, §V (below)]. The group might also want to read aloud the first two paragraphs of the article and reflect on the litany of research-based statements (connected to the bibliography) regarding the importance of spiritual care. Finally, if the students were additionally to read the commentary by R. Sean Morrison, which appears in the same issue of the journal [--see Items of Related Interest, §I (below)], the group could debate his criticisms as another means of engaging the article.


Related Items of Interest:

I.   In the same issue of the journal as our featured article, R. Sean Morrison, MD, Senior Associate Editor of the Journal of Palliative Medicine, has written a critical commentary on the study. While he states that "the authors are to be strongly commended for conducting work in an incredibly important and under-researched area of health care" [p. 396], he raises five areas of contention: spirituality and religion are not treated as separate concepts, there is a lack of measures applicable to the subject matter, there is insufficient scientific evidence (because of lack of measures) to support proper guidance for palliative care teams' understanding of and intervention in patients' spiritual issues, and "as in the rest of the field of palliative care, we need effective and generalizable interventions that respect the palliative care workforce limitations (including the small number of palliative care chaplains) and the realities of medical, nursing, and social work training" [p. 397]. Morrison's points, as they may relate to the state of the field of research or to the study in particular, are of course debatable in and of themselves (e.g., Must spirituality and religion always be distinguished, and is there truly clear consensus about distinct definitions of those concepts?), but they could be a means for readers' deeper engagement of the study. Chaplains may be struck particularly, however, by the commentary's conclusion:

Like all other aspects of health care, spiritual care should be guided by scientific evidence. It is time to move beyond advocating for its inclusion in palliative care because we believe it is important and instead focus on advocating for high-quality research and research funding that will allow us to understand how we can improve total care for seriously ill persons and their families. A robust knowledge base in spiritually and religion will enable development of outcome-driven an evidence-based training programs, protocols, and targeted interventions that can be integrated into current palliative care practice. [p. 397]
See: Morrison, R. S. "'We haven't got a prayer' (or much of anything else for that matter)." Journal of Palliative Medicine 18, no. 5 (May 2015): 396-397.


II.   A brief characterization of the program in question at Massachusetts General Hospital is found on p. 409 of our featured article, but see also a more detailed description:

Todres, I. D., Catlin, E. A. and Thiel, M. M. "The intensivist in a spiritual care training program adapted for clinicians." Critical Care Medicine 33, no. 12 (December 2005): 2733-2736. [This is a report of how a special Clinical Pastoral Education program for physicians at Massachusetts General Hospital affected those physicians. Integration papers revealed that "clinical practice became infused with new awareness, sensitivity, and language; graduates learned to relate more meaningfully to patients/families of patients and discover a richer relationship with them; spiritual distress was (newly) recognizable in patients, caregivers, and self" (--from the abstract, but see also, p. 2735).]

And, for a description of the program as it exists currently, see Massachusetts General Hospital's program flyer. Additionally, see a detailed information sheet from 2014.


III.   Other recent articles of related interest involving many of the same authors as our featured article (and connected with Harvard University's Initiative on Health, Religion and Spirituality):

Balboni, M. J., Puchalski, C. M. and Peteet, J. R. "The relationship between medicine, spirituality and religion: three models for integration." Journal of Religion & Health 53,no. 5 (October 2014): 1586-1598. [(Abstract): The integration of medicine and religion is challenging for historical, ethical, practical and conceptual reasons. In order to make more explicit the bases and goals of relating spirituality and medicine, we distinguish here three complementary perspectives: a whole-person care model that emphasizes teamwork among generalists and spiritual professionals; an existential functioning view that identifies a role for the clinician in promoting full health, including spiritual well-being; and an open pluralism view, which highlights the importance of differing spiritual and cultural traditions in shaping the relationship.]

Balboni, M. J., Sullivan, A., Enzinger, A. C., Epstein-Peterson, Z. D., Tseng, Y. D., Mitchell, C., Niska, J., Zollfrank, A., VanderWeele, T. J. and Balboni, T. A. "Nurse and physician barriers to spiritual care provision at the end of life." Journal of Pain and Symptom Management 48, no. 3 (September 2014): 400-410. [(Abstract): CONTEXT: Spiritual care (SC) from medical practitioners is infrequent at the end of life (EOL) despite national standards. OBJECTIVES: The study aimed to describe nurses' and physicians' desire to provide SC to terminally ill patients and assess 11 potential SC barriers. METHODS: This was a survey-based, multisite study conducted from October 2008 through January 2009. All eligible oncology nurses and physicians at four Boston academic centers were approached for study participation; 339 nurses and physicians participated (response rate=63%). RESULTS: Most nurses and physicians desire to provide SC within the setting of terminal illness (74% vs. 60%, respectively; P=0.002); however, 40% of nurses/physicians provide SC less often than they desire. The most highly endorsed barriers were "lack of private space" for nurses and "lack of time" for physicians, but neither was associated with actual SC provision. Barriers that predicted less frequent SC for all medical professionals included inadequate training (nurses: odds ratio [OR]=0.28, 95% confidence interval [CI]=0.12-0.73, P=0.01; physicians: OR=0.49, 95% CI=0.25-0.95, P=0.04), "not my professional role" (nurses: OR=0.21, 95% CI=0.07-0.61, P=0.004; physicians: OR=0.35, 95% CI=0.17-0.72, P=0.004), and "power inequity with patient" (nurses: OR=0.33, 95% CI=0.12-0.87, P=0.03; physicians: OR=0.41, 95% CI=0.21-0.78, P=0.007). A minority of nurses and physicians (21% and 49%, P=0.003, respectively) did not desire SC training. Those less likely to desire SC training reported lower self-ratings of spirituality (nurses: OR=5.00, 95% CI=1.82-12.50, P=0.002; physicians: OR=3.33, 95% CI=1.82-5.88, P<0.001) and male gender (physicians: OR=3.03, 95% CI=1.67-5.56, P<0.001). CONCLUSION: SC training is suggested to be critical to the provision of SC in accordance with national care quality standards.]

Balboni, M. J., Sullivan, A., Amobi, A., Phelps, A. C., Gorman, D. P., Zollfrank, A., Peteet, J. R., Prigerson, H. G., Vanderweele, T. J. and Balboni, T. A. "Why is spiritual care infrequent at the end of life? Spiritual care perceptions among patients, nurses, and physicians and the role of training." Journal of Clinical Oncology 31, no. 4 (February1, 2013): 461-467. [(Abstract): PURPOSE: To determine factors contributing to the infrequent provision of spiritual care (SC) by nurses and physicians caring for patients at the end of life (EOL). PATIENTS AND METHODS: This is a survey-based, multisite study conducted from March 2006 through January 2009. All eligible patients with advanced cancer receiving palliative radiation therapy and oncology physician and nurses at four Boston academic centers were approached for study participation; 75 patients (response rate = 73%) and 339 nurses and physicians (response rate = 63%) participated. The survey assessed practical and operational dimensions of SC, including eight SC examples. Outcomes assessed five factors hypothesized to contribute to SC infrequency. RESULTS: Most patients with advanced cancer had never received any form of spiritual care from their oncology nurses or physicians (87% and 94%, respectively; P for difference = .043). Majorities of patients indicated that SC is an important component of cancer care from nurses and physicians (86% and 87%, respectively; P = .1). Most nurses and physicians thought that SC should at least occasionally be provided (87% and 80%, respectively; P = .16). Majorities of patients, nurses, and physicians endorsed the appropriateness of eight examples of SC (averages, 78%, 93%, and 87%, respectively; P = .01). In adjusted analyses, the strongest predictor of SC provision by nurses and physicians was reception of SC training (odds ratio [OR] = 11.20, 95% CI, 1.24 to 101; and OR = 7.22, 95% CI, 1.91 to 27.30, respectively). Most nurses and physicians had not received SC training (88% and 86%, respectively; P = .83). CONCLUSION: Patients, nurses, and physicians view SC as an important, appropriate, and beneficial component of EOL care. SC infrequency may be primarily due to lack of training, suggesting that SC training is critical to meeting national EOL care guidelines.]

Balboni, M. J., Babar, A., Dillinger, J., Phelps, A. C., George, E., Block, S. D., Kachnic, L., Hunt, J., Peteet, J., Prigerson, H. G., VanderWeele, T. J. and Balboni, T. A. "'It depends': viewpoints of patients, physicians, and nurses on patient-practitioner prayer in the setting of advanced cancer." Journal of Pain and Symptom Management 41, no. 5 (May 2011): 836-847. [(Abstract): CONTEXT: Although prayer potentially serves as an important practice in offering religious/spiritual support, its role in the clinical setting remains disputed. Few data exist to guide the role of patient-practitioner prayer in the setting of advanced illness. OBJECTIVES: To inform the role of prayer in the setting of life-threatening illness, this study used mixed quantitative-qualitative methods to describe the viewpoints expressed by patients with advanced cancer, oncology nurses, and oncology physicians concerning the appropriateness of clinician prayer. METHODS: This is a cross-sectional, multisite, mixed-methods study of advanced cancer patients (n=70), oncology physicians (n=206), and oncology nurses (n=115). Semistructured interviews were used to assess respondents' attitudes toward the appropriate role of prayer in the context of advanced cancer. Theme extraction was performed based on interdisciplinary input using grounded theory. RESULTS: Most advanced cancer patients (71%), nurses (83%), and physicians (65%) reported that patient-initiated patient-practitioner prayer was at least occasionally appropriate. Furthermore, clinician prayer was viewed as at least occasionally appropriate by the majority of patients (64%), nurses (76%), and physicians (59%). Of those patients who could envision themselves asking their physician or nurse for prayer (61%), 86% would find this form of prayer spiritually supportive. Most patients (80%) viewed practitioner-initiated prayer as spiritually supportive. Open-ended responses regarding the appropriateness of patient-practitioner prayer in the advanced cancer setting revealed six themes shaping respondents' viewpoints: necessary conditions for prayer, potential benefits of prayer, critical attitudes toward prayer, positive attitudes toward prayer, potential negative consequences of prayer, and prayer alternatives. CONCLUSION: Most patients and practitioners view patient-practitioner prayer as at least occasionally appropriate in the advanced cancer setting, and most patients view prayer as spiritually supportive. However, the appropriateness of patient-practitioner prayer is case specific, requiring consideration of multiple factors.]


IV.   One of our article's co-authors, Mary Martha Thiel, has also written on the idea of "spiritual generalists" (vis-à-vis chaplains as "spiritual specialists") and has co-led workshops for spiritual generalist training.

Meyer, E., Shirkey, K., Martha Thiel, M. M., Clerjuste, N. and Robinson, M. "Spiritual generalist training for interprofessional healthcare practitioners." Medical Encounter: A Publication of the American Academy on Communication in Healthcare 27, no. 2 (Winter 2014): 58 [abstract only; freely available online]. [(Abstract:) OBJECTIVE: Patients and families highly value practitioners who in- quire about their religious and spiritual needs, and seek to incorporate these perspectives into healthcare decision-making and treatment. Yet, few training approaches exist to impart these skills to frontline practitioners. We examined the efficacy of innovative, simulation-based workshops to train interprofessional practitioners as spiritual generalists who were capable of screening for spiritual strengths, listening for spiritual language, recognizing spiritual distress, accessing spiritual resources, and generating referrals to chaplaincy. METHOD: Interprofessional participants attended day-long experiential workshops incorporating didactic instruction, experiential exercises, group discussion, and realistic enactments with professional actors to educate providers about the role and requisite skills of spiritual generalists. Participants completed pre-post workshop questionnaires using a 5-point Likert scale ranging from "Not at All Able" to "Highly Able." Workshops are ongoing with a current sample of 93 interprofessional healthcare participants including physicians, nurses, social workers, psychologists, child life specialists, and medical interpreters. RESULTS: Immediately following the workshops, participants reported significantly greater perceived ability on all 15 assessed spiritual generalist skills including the ability to conduct spiritual screening, recognize spiritual distress, make referrals to chaplaincy, and document spiritual/religious issues relevant to healthcare in the medical record, among others. The mean score of the 15 spiritual general- ist skill items significantly increased from 3.68 to 4.46 (t=-12.89, p<.001). Practitioners also reported that they planned to engage patients around spiritual topics significantly more frequently following the training workshops (Mean1=3.38, Mean2=4.41, t=-9.92, p<.001). DISCUSSION: Regardless of disciplinary affiliation, it is important that healthcare practitioners be adequately equipped to function as capable, confident spiritual generalists to recognize and meet patients’ and their families’ spiritual/religious needs. This innovative training demonstrates promising efficacy for training interprofessional health- care practitioners with a skill set to function as spiritual generalists capable of conducting spiritual screening and incorporating spiritual/ religious preferences into healthcare.]

Robinson, M. R., Thiel, M. M., Backus, M. M. and Meyer, E. C. "Matters of spirituality at the end of life in the pediatric intensive care unit." Pediatrics 118, no. 3 (September 2006): e719-729. [OBJECTIVE: Our objective with this study was to identify the nature and the role of spirituality from the parents' perspective at the end of life in the PICU and to discern clinical implications. METHODS: A qualitative study based on parental responses to open-ended questions on anonymous, self-administered questionnaires was conducted at 3 PICUs in Boston, Massachusetts. Fifty-six parents whose children had died in PICUs after the withdrawal of life-sustaining therapies participated. RESULTS: Overall, spiritual/religious themes were included in the responses of 73% (41 of 56) of parents to questions about what had been most helpful to them and what advice they would offer to others at the end of life. Four explicitly spiritual/religious themes emerged: prayer, faith, access to and care from clergy, and belief in the transcendent quality of the parent-child relationship that endures beyond death. Parents also identified several implicitly spiritual/religious themes, including insight and wisdom; reliance on values; and virtues such as hope, trust, and love. CONCLUSIONS: Many parents drew on and relied on their spirituality to guide them in end-of-life decision-making, to make meaning of the loss, and to sustain them emotionally. Despite the dominance of technology and medical discourse in the ICU, many parents experienced their child's end of life as a spiritual journey. Staff members, hospital chaplains, and community clergy are encouraged to be explicit in their hospitality to parents' spirituality and religious faith, to foster a culture of acceptance and integration of spiritual perspectives, and to work collaboratively to deliver spiritual care.] [This was also featured as our November 2006 Article-of-the-Month.]


V.   Our March 2007 Article-of-the-Month addressed whether pastoral care providers recognize nurses as spiritual care providers --a question that would seem to have implications for chaplains' views on programs like the one at Massachusetts General Hospital for non-chaplain staff.


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