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October 2019 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
Teague, P., Kraeuter, S., York, S., Scott, W., Furqan, M. M. and Zakaria, S. "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, no. 5 (October 2019): 1833-1846. [This article is available freely online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6759628.]
SUMMARY and COMMENT: Chaplains bring many skills and talents that can be applied beyond the particular role of spiritual caregiver, and the authors of our article this month hold that "it is a worthwhile goal to expand the traditional role of the chaplain as a comforter and mediator" [p. 1844]. In this case, they report an initiative to "uniquely" [p. 1834] utilize a chaplain resident in the role of an ICU patient navigator, saying,
...we felt that a chaplain could effectively function in this role, because chaplains are typically adept at facilitating interpersonal communication, have some knowledge of community organizations that can offer patients and families support, and can also assist in overcoming barriers preventing optimal recovery and health. Chaplains are already familiar with the care needs for patients in the ICU, serving as a liaison/consultant with the medical team, managing emotional and spiritual pain, participating in end-of-life decision-making (both in and out of the ICU setting), addressing 'do not resuscitate' and withdrawal of life-support decisions, and dealing with bioethical issues. [pp. 1834, 1836]
The project was generated in the wake of a difficult case at the Johns Hopkins Bayview Medical Center that "crystalized the need for a coordinated approach to family meetings" and overall better communication [p. 1834; and see for a description of the case]. The authors report their implementation, March-December 2015, on two Intensive Care Units, and the results of an email survey of the involved physicians and nurses (152 responses from 283 invitations).
The patient navigator role fulfilled by the chaplain was tasked with:
- assisting in coordination of family meetings to increase communication among staff, patient, and family members
- connecting the patient and family to community-based resources, including faith-based communities
- helping address barriers that might exist in order to assist patients to receive proper care
- [helping with] goals-of-care meetings to enhance communication and understanding can help achieve health equity. In addition, the patient navigator is empowered to meet with patients and family members at any time to ensure understanding of medical issues and facilitate good decision-making. [--adapted from Table 1, p. 1835]
A multifaceted plan was created with online and in-person components to introduce the initiative to ICU staff to prepare them and to facilitate their participation, as well as to equip and support the designated chaplain resident.
Among the results from the survey of physicians and nurses:
...a majority of the respondents felt that the chaplain/patient navigator was useful in gathering individuals for family meetings, with physicians more inclined to agree [72% vs. 48%...]. In addition, a majority of physicians (especially...trainee physicians) agreed that the chaplain/patient navigator increased collaboration; however, the nurses were less supportive [58% vs. 38%...]. Similarly, physicians generally agreed that the chaplain/patient navigator was a helpful liaison between the patient/family and the healthcare team, while nurses were less supportive [64% vs. 35%...]. Viewpoints on the appropriateness of chaplain training/background for the patient navigator roles were most divergent, with the physicians more favorable. In contrast, a majority of nurses thought the chaplain background was not appropriate for the patient navigator role [80% vs. 42%...].
The survey further asked, "What profession is most suited for the patient navigator role?" While some respondents thought that a chaplain was an appropriate choice, a plurality of physicians favored persons with social work training, though some believed nurses most appropriate. And, "[f]or the nurses, a plurality favored physicians to take the patient navigator role, followed by nurses or social workers" [p. 1839].
Also, 63 respondents took the opportunity to write in free-text comments [--noted on p. 1840], and this qualitative data is combined with the quantitative analysis for the authors' discussion of seven "Lessons Learned":
- The dual chaplain/patient navigator role is a double-edged sword [--see pp. 1841-1842]
- While the chaplain's skill set made them "well-qualified to set up and facilitate family meetings," the role led to some dissatisfaction from families who wanted the chaplain/navigator to focus on spiritual care ("despite attempts to refer spiritual care needs to another chaplain"), causing some families to believe the chaplain/navigator was "reluctant" or not "whole-heartedly invested"; and for staff, the chaplain/navigator's need to push for attendance at meetings led them to perceive the person as "occasionally unsupportive" and even "impolite." More education about the role and more frequent check-ins with staff might have addressed such negative perceptions, or using amore experienced chaplain.
- It is imperative to clarify roles and expectations [--see p. 1842]
- "In our experience, the chaplain was often asked to address medical issues, and it was rather difficult to defer those questions and decisions to the medical team. Upon reflection, several ICU staff echoed the idea that the chaplain may have been more effective with more medical education or training in social work, or with provision of mutually agreed-upon goals and expectations, including the use of standardized scripts."
- It is critical to have all ICU staff "buy in" to the concept of a chaplain/patient navigator. [--see pp. 1842-1843]
- "[M]any ICU staff did not support the idea of a chaplain/patient navigator and did not value the paramount importance of frequent family meetings." Nurses experienced the new initiative around family meetings to compete with their direct care of patients. Physicians frequently rotated on-and-off service, making for a flow of different levels of knowledge about and investment in the model. "...[A]ny novel intervention of this type needs more frequent stakeholder education and motivation."
- Including chaplains in family meetings is beneficial [--see p. 1843]
- "...[M]any ICUs, including ours, do not routinely ask chaplains to attend multidisciplinary family meetings. Our interventions clearly allowed for more chaplain involvement, which was recognized as valuable. In many family meetings, the topics discussed were often distressing, and chaplains were helpful in offering support and spiritual guidance to patients and family members." However, the two roles of navigator and chaplain "should be separate, unless the chaplain is provided with intensive training and has the support of almost all the ICU staff."
- Interprofessional education in the ICU is important and needed [--see p. 1843]
- Though the initiative did increase interdisciplinary collaboration, it "did not have a strong interprofessional education (IPE) component, which would have helped to increase familiarity with the project, and helped various disciplines work better." Examples: experiential practice and simulation training.
- Consistent feedback and supervision of the chaplain/patient navigator is required [--see pp. 1843-1844]
- "[M]ore feedback and intensive supervision is needed for a new chaplain to succeed in this role. In addition, the chaplain's supervisors and mentors also needed more education to optimally guide the chaplain/patient navigator, as they were also actively engaged in learning about this new role. In reflection, consistent multidisciplinary supervision of the project is needed, which could consist of weekly meetings with an experienced physician, nurse, social worker, and chaplain."
- Introduce the chaplain/patient navigator into the ICU without including additional interventions [--see p. 1843]
- "[W]e simultaneously introduced a chaplain/patient navigator into the ICU along with implementing a program to increase regular multidisciplinary meetings. Although we believed that this is reasonable, in retrospect it would have been better to introduce the chaplain/patient navigator into the ICU without any specific responsibilities to organize or hold family meetings." The responsibility for family meetings could then be added later once the staff has become familiar with the idea of an expanded role and the chaplain has gained the "goodwill that can engender support."
The research team looks in conclusion toward ongoing research into "utilizing chaplain/patient navigators that build[s] on our interventions" [p. 1844].
We have mixed opinions on whether they should be in this novel role, or whether individuals from other backgrounds, such as nursing, social work, or other allied health professions, could be more effective. However, we all agree that there is a need for a strong and ongoing presence for chaplaincy in the ICU.... [pp. 1844-1855]
This is a very clearly written report of a thought-provoking, mixed-methods study. The presentation of the qualitative data is brief but rich, and the upfront explanation of the case that generated the whole project is intriguing. If there would be one thing that this reader wished would have been included, it would be a section detailing first-hand the experience of the chaplain at the center of the initiative; but that wish indicates more how intriguing the article is rather than any real deficiency. The particular results here about a chaplain/patient navigator role are illuminating, and atop that the authors' outline of how they prepared to initiate a new role for the chaplain and their emphasis on practical "lessons learned" speaks broadly to how staff understand/misunderstand chaplains' roles and makes this article relevant to any plan to expand what a chaplain does in an institution.
The bibliography of 23 references is of moderate length but solid, with 70% coming from the past 5 years.
Suggestions for Use of the Article for Student Discussion:
The article should be useful to chaplains at any level. Discussion could take into account how broad or narrow the students' institution circumscribes the chaplain's role and how the students feel that they may be either stretched or underutilized in this way. If they feel underutilized in their skills and talents, then how in particular? Can they identify with the types of things that the chaplain/patient navigator in the article does, even if it's not part of their formal responsibilities? The authors note "three anecdotes highlighting the difficulties encountered by the chaplain" [p. 1840]. Do any of these scenarios, or do any of the comments in the qualitative data section resonate? How does the article lead them to think about communication and collaboration dynamics on a patient care unit? The section on Lessons Learned provides a nice structure, if needed, to discuss the core content. Finally, the group might talk about how they understand the roles of others on the multidisciplinary team, and they might consider how to gain a better sense of what others do.
Related Items of Interest:
I. Of the references noted in our article's bibliography, the following brief research letter and article may be of special interest regarding the general idea of an expanded role of a chaplain:
Lee, A. C., McGinness, C. E., Levine, S., O'Mahony, S. and Fitchett, G. "Using chaplains to facilitate advance care planning in medical practice." JAMA Internal Medicine 178, no. 5 (May 2018): 708-710. [Between April-October 2016, a board-certified chaplain scheduled time for Advance Directive consultations in the office of one primary care physician at a primary care group practice affiliated with a community hospital in suburban Chicago. The physician introduced the patient to the project and the chaplain and invited patients' participation, and the consultation with the chaplain took place in the examination room once the physician's visit was completed. The mean time of the chaplain's consultations was 23 minutes. Of 60 patients were invited to participate, all agreed to do so, and completed an Advance Directive or provided documentation of an existing one for their medical record. The project demonstrated that it is feasible and acceptable for a qualified chaplain to conduct Advance Care Planning conversations in a medical office and that most of these conversations (80%) led to completion or documentation of Advance Directives. The physician's introduction of the chaplain was vital.] [This article is available freely online from the journal.]
Timmins, F., Caldeira, S., Murphy, M., Pujol, N., Sheaf, G., Weathers, E., Whelan, J. and Flanagan, B. "The role of the healthcare chaplain: a literature review." Journal of Health Care Chaplaincy 24, no. 3 (July-September 2018): 87-106. [(Abstract:) Healthcare chaplains operate in many healthcare sites internationally and yet their contribution is not always clearly understood by medical and healthcare staff. This review aims to explore the chaplains' role in healthcare, with a view to informing best practice in future healthcare chaplaincy. Overall the extent of the provision and staffing of chaplaincy service internationally is unclear. From this review, several key spiritual and pastoral roles in healthcare emerge including a potential contribution to ethical decision making at the end of life. Healthcare chaplains are key personnel, already employed in many healthcare organizations, who are in a pivotal position to contribute to future developments of faith-based care, faith-sensitive pastoral, and spiritual care provision. They also have a new and evolving role in ethical support of patient, families and healthcare teams.] [Note: The year of this article is incorrectly listed as 2017 in our featured article's bibliography.]
II. A recent study not cited our author's bibliography, in which physicians did not believe chaplains to be particularly helpful in challenging family meetings.
Choi, P. J., Chow, V., Curlin, F. A. and Cox, C. E. "Intensive care clinicians' views on the role of chaplains." Journal of Health Care Chaplaincy 25, no. 3 (July-September 2019): 89-98. [There is evidence that addressing the religious and spiritual needs of patients has positive effects on patient satisfaction and health care utilization. However, in the intensive care unit (ICU), chaplains are often consulted only at the very end of life, thereby leaving patients' spiritual needs unmet. This study looked at the views of 219 ICU clinicians on the role of chaplains. We found that all clinicians find chaplains helpful when a patient is dying or when the chaplain brings up religious or spiritual topics. Physicians find chaplains less helpful in other clinical scenarios such as challenging family meetings or when patients are recovering. Nurses are more likely to consult chaplains for a difficult family meeting or when patients are recovering from critical illness. Communication between clinicians and chaplains, both directly and indirectly through electronic health record notes, remains infrequent, highlighting the need for interventions aimed at improving multidisciplinary spiritual care.]
III. Regarding the larger subject of nurses' and physicians' perceptions of chaplains, see:
Fitchett, G., Lyndes, K. A., Cadge, W., Berlinger, N., Flanagan, E. and Misasi, J. "The role of professional chaplains on pediatric palliative care teams: perspectives from physicians and chaplains." Journal of Palliative Medicine 14, no. 6 (June 2011): 704-707. [(Abstract:) CONTEXT: Pediatric palliative care (PPC) specialists recognize spiritual care as integral to the services offered to seriously ill children and their families. Little is known about how PPC programs deliver spiritual care. OBJECTIVE: The goal of this pilot study was to begin to describe the role of professional chaplains in established PPC programs in children's hospitals in the United States. METHODS: In 2009 we surveyed 28 PPC programs to ascertain how spiritual care was provided. Of the 19 programs with staff chaplains who met additional study criteria, we randomly selected eight to study in detail. Based on interviews with the medical director and staff chaplain in these eight programs, we qualitatively delineated chaplains' roles in PPC. RESULTS: Twenty-four of the 28 surveyed programs (86%) reported having a staff chaplain on their clinical team. Among the 8 interviewed programs, there was considerable variation in how chaplains functioned as members of interdisciplinary teams. Despite these variations, physicians and chaplains agreed that chaplains address patients' and families' spiritual suffering, improve family-team communication, and provide rituals valued by patients, families, and staff. CONCLUSIONS: Our survey of these PPC programs found that spiritual care was typically provided by staff chaplains, and our interviews indicated that chaplains appeared to be well-integrated members of these teams. Further research is needed to evaluate how well the spiritual needs of patients, families, and staff are being met, and the organizational factors that support the delivery of spiritual care in children's hospitals.] [This article was featured on our July 2011 Article-of-the-Month page.]
Kim, K., Bauck, A., Monroe, A., Mallory, M. and Aslakson, R. "Critical care nurses' perceptions of and experiences with chaplains: implications for nurses' role in providing spiritual care." Journal of Hospice and Palliative Nursing 19, no. 1 (February 2017): 41-48. [(Abstract:) We explored critical care nurses' experiences with chaplains and perceptions of spiritual care. This was a qualitative study, using in-depth interviews and focus groups with critical care nurses at an academic medical center. Data were audio recorded, transcribed verbatim, and analyzed using inductive coding methods. The study included 31 nurses (19 interviews and 2 focus groups). Participants did not feel completely prepared for spiritual assessments; they felt the urge to consult with spiritual providers predominantly for end-of-life situations. Respondents reflected several factors in the provision of spiritual care to patients and their families, such as patient's and/or family's spiritual needs, resources available at an institution, and the nurse's own religious and/or spiritual beliefs. Nurses' perceived role of chaplains overlapped what nurses can offer as part of holistic care, such as listening, praying, and counseling. Yet, participants acknowledged they paid more attention to the physical facets of a patient's illness. Participants noted a need for better system-wide approaches to enhance nurses' capacity for spiritual care, as well as earlier spiritual assessments of patient and family spiritual needs. Future research should address how integration of the spiritual care providers into the care team can improve spiritual support of patients, families, and clinicians.] [This article was featured as our January 2017 Article-of-the-Month.]
IV. The following article on ICU family meetings (also out of Johns Hopkins) mentions the potential importance of chaplains several times.
Gay, E. B., Pronovost, P. J., Bassett, R. D. and Nelson, J. E. "The intensive care unit family meeting: making it happen." Journal of Critical Care 24, no. 4 (December 2009): 629.e1-12. [The intensive care unit (ICU) family meeting is an important forum for discussion about the patient's condition, prognosis, and care preferences; for listening to the family's concerns; and for decision making about appropriate goals of treatment. For patients, families, clinicians, and health care systems, the benefits of early and effective communication through these meetings have been clearly established. Yet, evidence suggests that family meetings still fail to occur in a timely way for most patients in ICUs. In this article, we address the "quality gap" between knowledge and practice with respect to regular implementation of family meetings. We first examine factors that may serve as barriers to family meetings. We then share practical strategies that may be helpful in overcoming some of these barriers. Finally, we describe performance improvement initiatives by ICUs in different parts of the country that have achieved striking successes in making family meetings happen.] . [This article is available freely online at https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/19327312.]
V. For the following research, the ICU family navigator was a nurse, but that nurse had specifically shadowed a chaplain as well as other members of the ICU team.
Torke, A. M., Wocial, L. D., Johns, S. A., Sachs, G. A., Callahan, C. M., Bosslet, G. T., Slaven, J. E., Perkins, S. M., Hickman, S. E., Montz, K. and Burke, E. S. "The Family Navigator: a pilot intervention to support intensive care unit family surrogates." American Journal of Critical Care 25, no. 6 (November 2016): 498-507. [(Abstract:) BACKGROUND: Communication problems between family surrogates and intensive care unit (ICU) clinicians have been documented, but few interventions are effective. Nurses have the potential to play an expanded role in ICU communication and decision making. OBJECTIVES: To conduct a pilot randomized controlled trial of the family navigator (FN), a distinct nursing role to address family members' unmet communication needs early in an ICU stay. METHODS: An interprofessional team developed the FN protocol. A randomized controlled pilot intervention trial of the FN was performed in a tertiary referral hospital's ICU to test the feasibility and acceptability of the intervention. The intervention addressed informational and emotional communication needs through daily contact by using structured clinical updates, emotional and informational support modules, family meeting support, and follow-up phone calls. RESULTS: Twenty-six surrogate/patient pairs (13 per study arm) were enrolled. Surrogates randomized to the intervention had contact with the FN on 90% or more of eligible patient days. All surrogates agreed that they would recom mend the FN to other families. Open-ended comments from both surrogates and clinicians were uniformly positive. CONCLUSIONS: Having a fully integrated nurse empowered to facilitate decision making is a feasible intervention in an ICU and is well-received by ICU families and staff. A larger randomized controlled trial is needed to demonstrate impact on important outcomes, such as surrogates' well-being and decision quality.]
VI. The following article gives a personal perspective on family meetings from a Medical ICU attending physician. Though only mentioning chaplains briefly in relation to offering prayer, this particular physician-author regularly works closely with chaplains.
DeLisser, H. "How I conduct the family meeting to discuss the limitation of life-sustaining interventions: a recipe for success." Blood 116, no. 10 (September 9, 2010): 1648-1654. [(Abstract:) The meeting with the family of a hospitalized patient dying with advanced cancer or hematologic disease in which the limitation of life-sustaining interventions is discussed can be a challenge, particularly for junior physicians. A successful conclusion to this discussion involves an outcome in which the family, without coercion or manipulation, comes to accept that the appropriate care has been provided to their loved one, while the caregivers are enabled to provide care that is goal-directed and patient-centered. This type of result can be achieved through an approach in which patient-focused recommendations are offered in the context of diligent efforts to establish and sustain trust, thoughtful preparation, and respectful discussions with the family.]
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