EvidenceBased Spiritual Care:

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• Evidence-Based Spiritual Care
• Desirable? Feasible?
• How Do We Get There?
• Spiritual Care Summit 09 Workshop
• February 3, 2009

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Goals

• The goals of the workshop were for participants
  to
• 1. Become familiar with the case for and against
  evidence-based spiritual care.
• 2. Be able to describe 1 example of
  evidence-based spiritual care.
• 3. Be able to describe 3 steps that are necessary
  for healthcare chaplaincy to become an
  evidence-based profession.

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Description

• In this workshop a panel of leaders in spiritual
  care research addressed the challenges of moving
  toward evidence-based spiritual care. The topics
  they covered included
• Is evidence-based spiritual care desirable?
• Is it feasible?
• Are there any examples of it?
• What will it take to make healthcare chaplaincy
  an evidence-based profession?

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The Panelists

• Thomas St. James OConnor, ThD
• Daniel Grossoehme, DMin, BCC
• Michele LeDoux Sakauri, D.Min.
• George Fitchett, PhD, BCC
• Barbara Brumleve, SSND, PhD was the Moderator.

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Evidence-Based Spiritual Care

• Thomas St. James OConnor, ThD
• Professor, Delton Glebe Chair,
• Pastoral Counselling, WLS/WLU
• CPE PCE Supervisor, CAPPE,
• St. Josephs Health Care, Hamilton, Ontario
• toconnor_at_wlu.ca

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What is it?

• Judicious use of scientific evidence on
  spirituality and religion in the spiritual care
  and therapy of patients/clients.
• Different levels of evidence not all are
  regarded as equal.
• McMaster University (Hamilton, Ont, an originator
  of evidence based health care), various levels of
  evidence are noted (OConnor Meakes, 1998)

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• 1. Quantitative research with Randomized Control
  Trials (RCT) that are replicated is the highest
  form of evidence.
• 2. Qualitative research studies
• 3. Case Studies
• 4. Theoretical discussion
• 5. Anecdotal evidence with an emphasis on
  clinical wisdom.

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• All the evidence needs to be critically reviewed
  - there are studies which are poorly done with
  questionable findings.
• At McMaster, huge debate over evidence. One of
  the former assistant deans of the faculty of
  health sciences, and now a CEO, offers
  interesting insight - what kind of evidence and
  for whom.

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• Evidence as the result of the search for truth
  (OConnor, 2002b) whether in science, theology,
  social sciences, therapy, spiritual care.
• Job of chaplain and pastoral counselor is to
  offer the best service to clients/patients
• That means implementing and using the best
  evidence in spiritual care and therapy.

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Oxymoron or Paradox

• Some believe evidence-based spiritual care is an
  oxymoron (OConnor, 2002a) two different
  paradigms that cannot meet. How to measure grace
  and spiritual care?
• Paradox exist can work together.
• Ian Barbours four relationships between science
  religion - Religion and Science a) conflict
  b) separate and different c) meeting on the
  boundaries d) integration.
• Evidence based spiritual care exists in the last
  two relationships.

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My Experience

• Mixed - I like it and endorse it knowing that one
  ought to be searching the research for good
  evidence that will help clients.
• Yet, the spiritual care relationship offers a
  unique context that is different from a doctor
  implementing solid evidence.
• Importance of clinical wisdom and intuition.
• Challenge of reading research the gap

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Steps to Lessening the Gap

• Require my students in the internship at St.
  Joes to take a graduate course in research.
  Required to do a literature review on spiritual
  care on a clinical population.
• Then they are required to put their literature
  review into a poster present it at WLU, the
  hospital, a conference and/or to peers.
• Huge anxiety over this some students give up on
  it but many complete it. Some have won awards
  from the Society for Pastoral Counselling
  Research (SPCR) for their posters.

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Citations

• OConnor, T Meakes, E (1998). Hope in the
  midst of challenge Evidence based pastoral care.
  The Journal of Pastoral Care 52(4), 359-368
• OConnor, T (2002a). Is evidence based spiritual
  care an oxymoron. Journal of Religion and Health
  41(3), 253-261
• OConnor, T.(2002b). The search for truth Case
  for evidence based chaplaincy. Journal of Health
  Care Chaplaincy, 13(1), 185-194.

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Evidence-based Pastoral Care

• Daniel H. Grossoehme, D.Min., BCC
• Assistant Professor, Division of Pulmonary
  Medicine
• Staff Chaplain II, Department of Pastoral Care
• Cincinnati Children's Hospital Medical Center
• Cincinnati, Ohio
• Daniel.Grossoehme_at_cchmc.org

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Introduction Desirable?

• Yes
• The lack of demonstrated outcomes leads other
  healthcare team members to
• Ignore religion/spirituality altogether
• Reduce it to generic psychological mechanisms
  that any other discipline can handle (no unique
  contributions)
• Language of the medical center like St. Paul in
  Athens, we need to deliver our message in words
  they understand

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Introduction Feasible?

• Yes
• People already in place doing this work
• In fact, needs to be done by the theologian in
  residence on the healthcare delivery team, not
  (just) by psychologists of religion, etc
• Easy, no lack of shared definitions

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Examples

• Exist already, but gaps are huge, especially in
  pediatrics

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Examples Questions about how to deliver
interventions

• A) If we offer it, they will come
• (1) Pargaments spiritually-based group
  interventions (advertised publicly for college
  students and HIV women) voluntary, outpatient
  setting
• (2) Hausmans study of (voluntary) time spent in
  chaplains groups at adolescent residential
  treatment center for delinquentstime spent
  linked to less restrictive living situation one
  year later.
• (3) On-line religion/spirituality (r/s) support
  group for women w/ breast cancer

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Examples Questions about how to deliver
interventions

• B) I know what works!
• (1) gt40 studies link negative religious coping
  with poorer health outcomes. Demonic attribution
  is a RCOPE styleif a mother tells me that the
  Devil caused her adolescents Sickle Cell disease
  because of her lack of devotion.do I try to
  intervene by changing her attributionwhen it
  may be normal theology in her church? (Cotton
  et al., in preparation)
• (2) A parent tells me in Cystic Fibrosis Clinic
  during an assessment conversation using FICA
  that, We havent been to church in a whileI
  know we probably should How proactive should
  the chaplain be in offering the observation that
  regular attenders seem to have better health
  outcomes?

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How to move the profession there (other than by
an act of God)

• 1) Assessments
• a) Fitchetts work that those at spiritual risk
  are the least frequent requesters of pastoral
  care while those who already have more r/s
  resources than needs are the most frequent
  requesters
• b) Need to identify those at spiritual risk
  (or whatever term one uses)
• c) Need to assess. At least in pediatrics, that
  means assessing the familythe child may be just
  fine but the parents.or vice-versa

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2) Reframing issues (especially as in case with
parent in cystic fibrosis clinic above) calls
for a more proactive or assertive chaplaincy
than (mere) Rogerian listening that most of us
were trained to offer a) Bay, 2006 study b)
Work of Donald Capps (Reframing, 1990)
How to move the profession there (other than by
an act of God)
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How to move the profession there (other than by
an act of God)

• 3) Culture shift
• a) Low percentage of clergy/chaplains have
  science undergrad majors not a language they/we
  speak (or value?)
• b) Explicit assessments uncommon
• c) Not part of our training
• (1) Assessment
• (2) Pastoral diagnosis
• (3) Intervention as active and gt Rogerian sharing

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Conclusion
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Bibliography References Cited

• Bay, P. and S. S. Ivy (2006). "Chaplaincy
  research a case study." J Pastoral Care Counsel
  60(4) 343-52.
• Hausmann, E. (2004). "Chaplain contacts improve
  treatment outcomes in residential treatment
  programs for delinquent adolescents." Journal of
  Pastoral Care Counseling 58(3) 215-224.
• Iler, W. L., D. Obenshain, et al. (2001). "The
  impact of daily visits from chaplains on patients
  with chronic obstructive pulmonary disease
  (COPD) a pilot study." Chaplaincy Today 17(1)
  5-11.

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Evidence Based Spiritual Care Desirable?
Feasible? How Do We Get There?

• Michele Le Doux Sakurai, D.Min. B.C.C.Mission
  Fellow, Trinity Health Systems
• Director, Mission Services,
• Saint Alphonsus Medical Center
• Boise, Idaho
• MICHSAKU_at_sarmc.org

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2002 Dissertation Project Ministry of
PresenceNaming What Chaplains Do at the
Bedside

• Study Parameters
• Certified Chaplains
• Practice directed by Ethical and Religious
  Directives (either certified by NACC or works in
  Catholic Healthcare)

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Study Tools and Limitations

• A verbatim from Acute Care, Hospice and Long Term
  Care
• Surveys that were both qualitative and
  quantitative
• Study participants were self-selecting NOT A
  RANDOMIZED STUDY

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Study Results Demography

• 72 of 101 surveys returned and assessed
• 28 males (3 Protestant Clergy 8 R.C. Priests)
• 44 women (3 Protestant Clergy 21 Religious)
• 11 CPE Supervisors
• Years as a Chaplain
• Range 1-33 years
• Average 11.2 years
• 22 states represented
• Arenas of Care
• Acute Care
• Hospice
• Long Term Care/AL/Retirement Communities
• Parish
• Physician Offices
• Behavioral Health/Forensics
• Teaching

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Study Results, Part 1 An Emerging Model

• Key Components of Ministry of Presence
• ROLE Attending to Suffering
• VIRTUE (that guides relationship)
  Compassion/Acceptance
• ASSESSMENT VEHICLE Inviting Story/Dialogue
• INTERVENTIONAL OPTIONS
• Listening Presence-------Reframing/Facilitating

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Part 2 Do Chaplain Interventions Make a
Difference?

• Identifying Spiritual Pain through the Use of a
  Likert-type scale
• Despair Hope
• 1 2 3 4 5
• Estrangement Reconciliation
• 1 2 3 4 5
• Grief Gratitude
• 1 2 3 4 5
• Anxiety Peace
• 1 2 3 4 5
• Abandonment Reconnection
• 1 2 3 4 5

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Part II Measuring Spiritual Pain

• Identifying Spiritual Pain through the Use of a
  Likert-type scale
• At the beginning of the patient visit Ive
  sinned, Im not sorry and God doesnt like
  sinners who dont repent.
• Estrangement X Reconciliation
• 1 2 3 4 5
• At the conclusion of the visit Its OK to pray
  even when I sin?
• Estrangement X Reconciliation
• 1 2 3 4 5
• Difference between the beginning and the end of
  the visit
• Estrangement 2 Point Shift towards
  Reconciliation

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Part II Results Despair to Hope

• Shift
• Acute Care (n 69) 2.40 (n65)
• Hospice (n 70) 1.62 (n57)
• LTC (n 70) 1.30 (n49)
• (Bold indicates that 90 of participants believed
  that this issue was significant to the patient in
  the interaction)

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Part II Results Estrangement to Reconciliation

• Shift
• Acute Care (N 69) 1.62 (n46)
• Hospice (n 70) 1.98 (n70)
• LTC (n 70) 1.50 (n56)
• (Bold indicates that 90 of participants believed
  that this issue was significant to the patient in
  the interaction)

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Other Issues Identified

• Pain to comfort
• Fear to assurance
• Denial to acceptance
• Meaningless to meaningful

• Anger to peace
• Absurdity to meaning
• Doubt to faith
• Confusion to clarity

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Shift towards Healing What is it Chaplains Do?

• Inviting Story
• Non-judgmental presence
• Behaviors that give chaplains credibility
• Honesty
• Openness
• Ability to risk/be vulnerable
• Willingness to assist in facilitating the inner
  resources of the other

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SummaryBenefits of a Spiritual Pain Scale

• The scale parallels Pain Scale used in many
  hospitals and fits into established paradigm
• An imbedded tool in the electronic chart is not
  required measurement can be documented in the
  narrative chart note
• Once refined, the scale can be used as an
  outcomes tool.

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Evidence-Based Spiritual CareHow Do We Get
There?

• George Fitchett, D.Min., Ph.D.
• Department of Religion, Health, and Human Values
• Rush University Medical Center
• Chicago, Illinois
• george_fitchett_at_rush.edu
• http//www.rushu.rush.edu/rhhv

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How Do We Get There?
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Chaplaincy A Research-Informed Profession
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Source Anton T. Boisen Explorations of the Inner
World A Study of Mental Disorder and Religious
Experience (Willett, Clark Company, 1936)
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Health care chaplains risk becoming ineffective
and marginalized unless we become a research
informed profession.
A Research-Informed Profession
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A Research-Informed Profession

• When health care chaplaincy is a research
  informed profession
• All health care chaplains will be research
  literate
• Some health care chaplains will be qualified to
  collaborate in research conducted by health care
  colleagues (co-investigators)
• A few health care chaplains will be qualified to
  lead research projects (principal investigators)

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A Research-Informed Profession

• What is a research literate chaplain?
• A research-literate chaplain has the ability to
  read, understand, and summarize a research study
  and to explain its relevance for his/her ministry.

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A Research-Informed Profession

• How do we become a research-informed profession?
• Wait for leaders and researchers to get us there?
• Members demand and participate in a
  transformation of the profession?

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A Research-Informed Profession

• What steps are needed to transform health care
  chaplaincy into a research-informed profession?
• A new requirement for board certification is a
  two page summary of a research study
  demonstrating an understanding of the research
  and its application to ones ministry.
• All board certified chaplains report 10 hours of
  research-related CE a year for the next 5 10
  years.

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A Research-Informed Profession

• Implications of this transformation
• Need to teach research literacy skills in CPE
  residency programs
• Need to increase CE offerings about research
• introduction to research
• research relevant to health care chaplaincy

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Board Updates Vision Statement

• The APC Board of Directors has adopted the
  following new vision statement for the
  association
• Strengthen the professional competency of
  chaplains, so that chaplains will demonstrate
  quality outcomes to those they serve. Demonstrate
  the distinctive value of professional chaplaincy,
  which can be communicated to external
  stakeholders and result in the promotion of
  professional chaplaincy and social justice.
  (posted November 24, 2008)

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Chaplaincy boards make commitment to
research-informed profession
A New Vision Statement

• The boards of 3 major US spiritual care
  organizations, the APC, NACC, and ACPE, announced
  a commitment to transform health care chaplaincy
  into a research-informed profession in the next
  ten years.
• A spokesperson announced that conversations are
  underway with several major foundations to
  provide support to help implement this
  transformation.

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Begin with Cases

• Developing evidence about spiritual care should
  begin with detailed case studies, not clinical
  trials.

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Begin with Cases

• The foundation for evidence about spiritual care
  is detailed case studies.
• These case studies must describe
• Who the patient was the population
• What the chaplain did the intervention
• What changed the outcome

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Begin with Cases

• These case studies must describe
• Who the patient was the population
• What the chaplain did the intervention
• What changed the outcome
• Where is this evidence?
• How many published cases can we point to that
  include this evidence?

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Begin with Cases

• What steps are needed to develop detailed a body
  of case studies that can provide evidence about
  the effects of spiritual care?
• A new requirement for board certification is a
  detailed case study.
• Every 5 years all board certified chaplains must
  present a detailed case study for peer review.

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Begin with Cases

• Would it be helpful to publish a book of cases?
• These case studies must describe
• What the chaplain did the intervention
• Who the patient was the population
• What changed the outcome
• Please contact me if you would like to contribute
  to a casebook.
• george_fitchett_at_rush.edu