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Tuesday
Jan162018

Standardized Methods of Education within Clinical Training for Chaplaincy

This article originally appeared in the January 16, 2018 issue of PlainViews®, the online journal published by HealthCare Chaplaincy Network and is published here with permission.

The Need for Evidence-Based Education

In recent years, professional chaplaincy has begun seeking to base itself on evidence-based practice in order to align with other health care disciplines and the current health care environment.  According to Masic’s definition, “Evidence Based Medicine (EBM) represents integration of clinical expertise, patient’s values and best available evidence in process of decision making related to patients health care”.[1]  Evidence-Based Practice (EBP), according to Satterfield “incorporates each discipline's most important advances and attempts to address remaining deficiencies”.[2]   In a study by Weng and colleagues on the implementation of evidence-based practice across medical, nursing, pharmacological and allied health professionals, they stated:

Evidence-based practice (EBP) is clinical practice consistent with the current best evidence. Implementation of EBP mainly involves four sequential steps first, framing a clear question based on a clinical problem; second, searching for relevant evidence in the literature; third, critically appraising the validity of contemporary research; and fourth, applying the findings to clinical decision-making. There are increasing examples illustrating that EBP can help healthcare professionals improve care quality.   Implementing EBP by all health professionals is thus needed.”[3]

One of the challenges of both evidence based knowledge and evidence based practice is teaching how to achieve the application of those skills in clinical care.[4] [5] [6]  However, many health care disciplines including medicine, nursing, social work, nursing assistants[7],   and others are integrating evidence based knowledge and practice into their standardized curriculums.

Evidence based knowledge and practice are not new concepts for professional chaplaincy, but rather ones that were first introduced in 1998: “Evidence from research needs to inform our pastoral care. To remove the evidence from pastoral care can create a ministry that is ineffective or possibly even harmful”.[8]  O’Connor defined evidence-based spiritual care as “the use of scientific evidence on spirituality to inform the decisions and interventions in the spiritual care of persons”[9] and argued that chaplaincy and science are not opposed.  A great deal of research has been done in the past twenty years to explore the practice and outcomes of chaplaincy to determine outcomes that have become the basis of evidence-based practice.

The Need for Standardized Training and Curriculum

However, what has been missing is the same focus to link evidence-based best practices to a standardized curriculum in the clinical and educational training of chaplains.  In other words, while the profession is working to be evidence-based in its practice of chaplaincy, relying on reputable research to determine the best choices of care for persons, it has failed to apply the same process to the education and training of chaplains.  This is despite 60 years of calls by chaplain educators, practitioners, leaders, and researchers across the profession to engage in dialogue regarding the standardization of education and training processes in preparation for certification and practice.   

In the education world, there are specific definitions applied to the concept of knowledge.[10]  Content knowledge is the body of knowledge and information that teachers teach and that students are expected to learn in a given content area; it includes the facts, concepts, theories, and principles that are taught and learned in specific academic courses rather than to related skills which are also learned in order to put content knowledge into practice.[11]   In all professions, particularly health care, there is a tension between content or theoretical knowledge (“know that”) and practice knowledge (“know-how”) [12] in the quest to prepare students to provide effective, value-added, and quality care to patients and families.   Health care disciplines, with the exception of chaplaincy, have integrated the two by not only acknowledging the tension, but incorporating both kinds of knowledge into their education and credentialing processes.

Chaplaincy has very little research regarding its education processes.  There has been no investigation or study of how many units of clinical training or what academic degrees have produced the best combination of content/theoretical and practice knowledge to make a competent chaplain.  The efficacy or impact of religious endorsement, required by some chaplaincy certification associations, has not been examined.  The elements of curriculum content taught in clinical training have not been investigated or examined to determine what topics are needed to provide competent chaplaincy care nor have efforts been made to standardize that curriculum.  Meanwhile, other health care disciplines including medicine, nursing, social work, physical therapy, and others,[13] [14] [15] [16] [17] have embraced standardized education, including evidence-based knowledge and practice

History of Chaplaincy Training and Education

For decades, chaplaincy training, or Clinical Pastoral Training (CPE) has relied primarily upon practice knowledge that focuses on the person of the chaplain, how he or she develops their “inner self”, and in turn how that self-growth impacts the ways in which chaplaincy care is provided. Content or theoretical knowledge – the facts, concepts, theories, and principles that are necessary to effective practice and patient benefit, have not been standardized or made consistent within the field and so cannot be standardized in chaplaincy training.[18] 

The earliest call to “better measure the effectiveness of clinical pastoral training so we have more objective standards”[19] came from Thomas in 1958.  At that time the focus of CPE was in partnership with theological schools to train (Christian) ministers how to be more effective in parish ministry. Even then, “there were very different views of how and where clinical training should contribute to theological education and how the movement should be organized” according to Jernigan.[20]  In the early 1970s, Meiburg addressed the need for “greater precision in relating educational structures to instructional objectives.”[21]  Aist continued to ask this question as he asked numerous questions:

“Do we emphasize the self-development of the student for general ministry? Or do we focus on the acquisition of specific competencies for ministry that might be utilized in specialized settings?  Should our educational programs themselves have built-in closure points or do the various types of certification offered by cognate groups offer a sufficient closing process?   And what about the thorny issue of curriculum content? Not only how we teach, but what we teach.”

“Our subjective intuitions have by and large served us well in certification, but there is growing recognition of the need to make the process more objective and to more clearly specify the levels of knowledge and skill that the candidate must acquire.”[22]

In the eighties, as the effort to include CPE as an integral part of theological education diminished, the focus increased on training chaplains, supervisors, and lay leaders.[23]   As clinical pastoral education faced this shift in its historical purpose, supervisory educators such as Hilsman addressed the questions that were being asked. 

“Supervisors and department directors are asking, ‘What competencies will need to be taught to both established and aspiring chaplains, and how will current training methods be altered to help them assimilate the new learning?’”

“Two reasonable first steps in the process of preparing chaplains for integrated system spiritual care work will be 1) to acknowledge the need for new learnings, and (2) to identify competencies that promise to be useful in emerging health care structures.”[24]

Fitchett and Gray found in 1994 that “CPE assessment focuses on curricular objectives, student learning outcomes, and individualized contracts for learning as the basis for training and evaluation. Traditionally CPE outcomes are evaluated qualitatively, using the personal testimony or subjective interpretation by CPE supervisors and students.”[25]  This was confirmed by a study done by VandeCreek, Hover, and Gleason in 2001, in which they found that quantitative CPE outcomes relied predominantly on self-reported instruments.[26]

By 2000, clinical training education had formally moved to discussions between the Association for Clinical Pastoral Education with other organizations concerned with professional chaplaincies, particularly the Association of Professional Chaplains and the National Association of Catholic Chaplains.[27]    This created a renewed dialogue regarding CPE as professional training and the implications for its education processes.

Ford and Tartaglia (2006) spoke to the development of standards for spiritual assessment, specific training in interdisciplinary care, and the emerging need for research education.[28]  By doing so, they clearly challenged the historical paradigm that focused solely on personal development in chaplaincy education to include and emphasize content knowledge in order to prepare chaplains to provide effective and quality care to patients and families.  

Little[29] continued to question whether clinical training (CPE) was professional training for chaplaincy, with a profession being defined as “requiring specialized knowledge and often long and intensive academic preparation' and professionalism as 'the conduct, aims or qualities that characterize or mark a profession or professional person'” as described by Cornett.[30] To describe the two types of knowledge needed for competent practice and for these definitions, Little turned to Eraut, and while the terms differ from “practice and content/theoretical knowledge” used by Wintz, the descriptions are the same:

“There are two types of esoteric knowledge essential for competent professional practice. Eraut describes the first type as propositional knowledge that is the knowledge which underpins or enables professional action and belongs to the academic forum where the discourse is about facts, ideas and theories. The second type is the practical knowledge, which is the practical know-how inherent in the action itself and cannot be separated from it, for example, knowing to play a musical instrument.  This practical knowledge is more difficult to codify and assess than propositional knowledge because of its more 'intuitive' nature. However, Eraut believes that both types of knowledge are essentially the same, claiming that knowing how to use a theory or fact is the result of observing the outcome of its use. Furthermore, these two sets of knowledge are not completely exclusive of each other as students acquire practical knowledge during propositional learning and propositional knowledge during practical training.”[31]

Little summarized the outcome of professional education as “a person who has competently mastered the necessary propositional and practical knowledge has formed a professional identity including the integration of the values of public service and autonomy and can be trusted to practice with integrity.”[32]  In relation to traditional clinical training (CPE), Little stated several issues which he believed needed to be addressed:

“The action/reflection method is excellent for understanding the pastoral interaction but does not necessarily facilitate the further development of the propositional knowledge base.”

 “Trainees' presentations for supervision broadly determine the content of the CPE program curriculum rather than the curriculum determining the program content. This can mean that some areas of pastoral care do not present themselves in the actual course. This limitation of the action/reflection methodology restricts the ability to provide a well-rounded professional education curriculum.”

“CPE tends to leave trainees to gather this knowledge unsystematically through their experiences with patients and from other sources that can be erroneous. This is inadequate for professional education.”

“For a valid assessment, the certifying organization [and church authorities] need to define as unambiguously as possible the range of experience and the professional (propositional and practical) knowledge they require at the conclusion of training and set those requirements out as standards for achievement. In addition, standard methods of assessing those standards need elucidation.”

 “Lacking standardization, there is no professionally acceptable common standard of competence.”

 “Assessment of professional competence requires a system of grading.”[33]

Other professional clinical educators continued to raise the issue of historical clinical training as objective and lacking standardization.  Jackson-Jordon and Moore (2010) suggested that BCCI competencies be used as the basis for a CPE-based curriculum intentionally focused on the preparation for professional chaplaincy.[34]  In 2012, sociologist Wendy Cadge[35] suggested that future chaplaincy training not be organized on what were the existing platforms but rather learn from methods used by other professionals that demonstrate professional competency, propositional knowledge, and objective outcome-oriented clinical practice in order to standardize the quality of care that is provided.

 In an article describing the use of standardized patients in order to enhance objectivity in the measurement of behavioral communication styles of students, Tartaglia and Dodd-McCue found that it was a valid method.  In addition, their study emphasized “the merits of systematically evaluating interview behaviors by categories and sub-categories.  The checklist evaluation allows for identification of major response categories as well as student utilization of sub-categories in the interview process. Reliance on self-report by CPE students, historically emphasized in pastoral training, is enhanced by an observer's relatively more objective assessments (and quantification) using the checklist categories.” [36]

Massey[37], in observing the need for transformation in chaplaincy training, stated in 2014 that “The process of training chaplains has changed little over several decades. More recently, some involved in healthcare chaplaincy have perceived that new models are needed in forming, training, and evaluating chaplains.”  Describing the historical provision of spiritual care, he called for chaplaincy to “study itself to learn what measurable outcomes of its work can be found.”  While acknowledging the importance of CPE in the early formation of persons for ministry, Massey suggested: “it may be ill designed to deliver the techniques, skills, and advanced competencies needed to work in professional chaplaincy.”   In addition, he pointed out that:

“As it is, the structure of CPE itself only delivers the same territory over and over again—and importantly, that territory is centered on personal formation, not on professional competence.”

“The standards governing what constitutes a unit of CPE are written intentionally broadly to leave plenty of room for differences of style and pedagogical philosophy.”  “While the standards are helpfully broad, they do present in their simplicity a dichotomy of educational activity and clinical practice that is itself an unhelpful concept.”  “No standards exist for what should constitute a residency, how many units of CPE it should include, or what measurable outcomes should accompany successful completion of a residency.”

“What is missing is specific training on techniques and procedures in the delivery of healthcare chaplaincy and the exploration of how specific techniques and practice patterns can deliver improved patient outcomes.” “A re-designed curriculum would surface the full inventory of chaplain-associated knowledge that would be imparted through a variety of pedagogical techniques. The successful student would master the body of propositional knowledge and be able to capably demonstrate this mastery. One could envision a healthcare chaplain competencies test through which a chaplain candidate would demonstrate mastery of this propositional knowledge of chaplaincy intended effects.”

Fitchett, Tartaglia, Massey and colleagues also questioned the relationship of clinical education training models to fulfil the need to train towards professional competencies. A disconnect between clinical training and the competencies needed by professional chaplains was revealed by two 2015 studies of ACPE accredited residency program.  In the first, less than half of recently accredited or re-accredited CPE residency programs specifically addressed the twenty-nine professional competencies assessed for certification as a board certified chaplain (BCC) by the Association of Professional Chaplains, one of several certifying professional associations. “At a time of growing recognition of the important role of chaplains in the care of patients and families, there are no consensus guidelines for how healthcare chaplains should be trained and no organization exercising oversight for the development of such guidelines.”[38]

In the second, it was found that only “only nineteen percent of those centers use an electronic medical record pastoral care documentation tool grounded in a published theoretical model. Combined with the apparent lack of consensus among the pastoral care organizations, these findings contribute to the current environment where chaplains often sit on the periphery of the dialogue between spirituality and healthcare.”[39] 

Tartaglia encouraged the exploration of a learning/training model for the education of health care chaplains. “As with any educational model, we would begin with the expected outcomes. What knowledge and skills need to be learned? What methods should be employed in imparting those learning outcomes? Then we would ask what structures would need to be put in place to maximize the opportunity for such learning.”   “Adding another level of accreditation to [ACPE] programs that wish to train healthcare chaplains will require compromises in order to establish a standardized curriculum through joint effort among groups” (those that educate and those that certify).[40]

While the concerns chaplaincy educators and practitioners have raised since 1958 have been framed in in different ways, the central issue has remained the same.  Curriculum, training, and testing needs to be standardized in order to remove inconsistencies in the education and certification of professional chaplains.  The lesson is clear from all other health care disciplines that when candidates are tested to measure a person’s comprehension of evidence-based content or theoretical knowledge of their field, pass objective observations of their ability to demonstrate it through practice knowledge, the person has met the requirements needed to practice in their field and will reliably provide quality care.[41] 

Attempts at Change throughout the Decades

The history [42] [43] [44] [45] [46] [47]  of educating, training, and certifying chaplains has a long and complicated history, which is too complex for this article, however it began as part of the education provided through Protestant Christian seminaries to white male students in the mid-1920s. In his history, Thorton described clinical pastoral education as providing practical training to complement the theological knowledge seminarians received in order to prepare them as pastors in ministry. Freeman elaborated by describing clinical pastoral education as developing “psychological education for professional functioning”.   Several groups were established to provide educational training, each with their own style and curriculum. Four of those groups, after much debate, joined together to form the Association of Clinical Pastoral Education in 1967.  However, other groups have continued to emerge to establish and provide training with various focuses on what was taught as well as methods, which has often resulted in discord, conflict, splits, and even lawsuits.  Today there are dozens of organizations offering clinical pastoral education training.   As a result, there is no one curriculum or educational process that is standardized across the profession.

The Current Development of Standardized Evidence-Based Chaplaincy Education and Training

After nearly sixty years of questioning and calls for dialogue by researchers, educators, and leaders between numerous chaplaincy education and certification bodies to resolve these issues which proved unsuccessful, the HealthCare Chaplaincy Network (HCCN) and its affiliate, the Spiritual Care Association (SCA) which was created in 2016, stepped up to integrate evidence-based best practice into the education and training of chaplains in more explicit ways.  By exploring the research successful models of health care education across disciplines, the SCA patterned much of its structure to incorporate elements of the training of competent physicians, nurses, physician assistants, nurse practitioners, social workers, physical therapists, and other professional clinicians.   In doing so, the historical appeals by leaders, researchers, and educators within professional chaplaincy that have spanned decades are finally being heard and responded to with evidence-based chaplaincy training and education.

HCCN, who has provided accredited clinical pastoral education (CPE) since 1972, has incorporated standardized curriculum into its education process.  This addresses the need for chaplaincy to follow the example of other health care professions by creating a process that mirrors their more objective process to assure that a person has both the knowledge and clinical skills to delivery evidence-based quality process, structure, and outcomes for spiritual care.  

The Spiritual Care Association (SCA), which certifies chaplains and provides ongoing education opportunities, developed a standardized clinical knowledge-based test as is required within other health care disciplines. The SCA Standardized Clinical Knowledge Test was developed, following the example of other health care professions, by using international subject matter experts, evidence-based knowledge gained through research, the input of senior chaplain leaders, and the most rigorous standards. The scoring is completely objective. The test has now been determined to have a high degree of reliability. The knowledge that is tested is outlined for the candidate ahead of time and is publicly available, thus allowing educators and candidates to fully prepare without any uncertainty about the content of the Standardized Clinical Knowledge Test.  For example, questions in the test include health care ethics, basics of world religious/spiritual systems, and spiritual assessment models, grief concepts and processes, and effective communication skills in working with patients, families, and interdisciplinary team members.[48] The test is easily altered so it can be updated regularly in order to integrate new knowledge and research as it is developed.

As part of the SCA certification and credentialing processes the Clinical Knowledge test is coupled with a Simulated Patient Encounter. These encounters are scored against a list of objective observable behaviors also derived from evidence that are shared with the candidate in advance so he or she is aware of the professional elements being assessed. Simulated patients (SP) are extensively used in medical, nursing, pharmacy, other health discipline education and increasingly in CPE programs to allow students to practice and improve their clinical and conversational skills for an actual patient encounter.[49] [50] [51]

Presently, HCCN and SCA are the only chaplaincy organizations to develop, publically announce and make available a standardized curriculum that incorporates evidence-based knowledge and practice.   They are also the only known organizations who have publically and personally invite other chaplaincy education and certification associations to participate in dialogue and collaboration around the work of developing a comprehensive standardized evidence-based method of chaplaincy training and education that will be used across all organizations. While many groups have joined into the discussion and are both implementing and contributing to the integration of the curriculum, there remains several groups that have refused to participate, and the lack of collaboration and communication continues to the detriment of providing consistent quality-based, value-added care to patients and families as well as health care staff.

Summary

For six decades, chaplaincy leaders, educators, and researchers have called for the examination of the profession’s process of education and training in preparation for certification within the profession including the incorporation of evidence-based knowledge and practice.  While research into evidence-based outcomes for chaplaincy care began to occur, there was little effort to apply the same process to the training, education, and eventual certification of chaplains.  In 2016, the Spiritual Care Association, which is founded on the call for evidence-based best practice throughout all elements of spiritual and chaplaincy care, patterned its structure and system to develop curriculum, clinical training, and a certification process which reflects that integration. Several chaplaincy education and certification association groups have joined the process, yet many have declined invitations to participate in the dialogue. One think tank, made up of representatives.  The questions that have permeated the field of professional chaplaincy education and practice for six decades of how to standardize curriculum, as well as how to focus efforts of all to embrace collaboration rather than noncooperation and competition continues. 

For Discussion

 1. What educational themes throughout the sixty year call to standardization within the training of professional chaplaincy are consistent?  Which are not?  Which are applicable to today’s health care environment

2. What has been your experience of standardized curriculum throughout your own chaplaincy education?

3. What has been your experience of standardized curriculum education when you compare your knowledge and skills with those of chaplaincy colleagues?

4.  Evidence-based knowledge and practice is integrated through all other health care disciplines.   Why should it be integrated in professional chaplaincy?  Why not?

5. In what ways do you practice evidence-based knowledge and practice in your chaplaincy work?

6. What specific steps would you take to encourage the chaplaincy community, including the various education, certification, and membership groups, to work collaboratively to establish standardized education for the chaplaincy profession?

 

Rev. Sue Wintz, BCC, is Director, Professional and Community Education at HealthCare Chaplaincy Network and the managing editor of its publication PlainViews®, the preeminent online professional journal for chaplains and other spiritual care providers. She has a major role in the development, design, writing, and instruction of HCCN’s professional continuing education offerings. Sue has over 35 years of clinical, administrative, educational design, development and teaching experience in the provision of professional chaplaincy and spiritual care in health care and congregational settings. She is board certified by the Spiritual Care Association and the Association of Professional Chaplains.  Sue is a past president of the Association of Professional Chaplains, and in 2013 was given APC’s highest honor – the Anton Boisen Professional Service Award.

Rev. Brian Hughes, BCC, is a chaplain advocate and consultant with HealthCare Chaplaincy Network (HCCN). He has worked clinically in New York, Texas, Arizona, and Pennsylvania, and served in leadership positions within the Association of Professional Chaplains. He has contributed to the writing of recent HCCN White Papers including Spiritual Care and Nursing: A Nurse's Contribution and Practice[SW1]  and Spiritual Care: What it Means, Why It Matters in Health Care[SW2] . Brian also coordinates and presents the annual "Best Chaplaincy Papers" webinar each spring. He lives in Dallas, Texas, with his wife and two elementary-school-aged children.

 


[1] Masic I, et al.  2008.  Evidence Based Medicine – New Approaches and Challenges. 2008.  Acta Inform Med.  16(4).  219-225.

[2] Satterfield J, et al.  2009.  Toward a Transdisciplinary Model of Evidence-Based Practice. 2009.  Milbank Q.  87(2).  268-390.

[3] Weng YH, et al.  2013.  Implementation of Evidence-Based Practice across Medical, Nursing, Pharmacological, and Allied Health Professionals:  A Questionnaire Survey in Nationwide Hospital Settings.  2013. Implement Sci.  8(112).

[4] Hole GO, et al.  Educating Change Agents: A Qualitative Descriptive Study of Graduates of a Master’s Program in Evidence-Based Care.  2016.  BMC Med Educ.  16(71).

[5] Thomas A, et al.  Students’ Attitudes and Perceptions of Teaching and Assessment of Evidence-Based Practice in an Occupational Therapy Professional Master’s Curriculum:   A Mixed Methods Study.  BMC Med Ed. 2017. 17(1):64.

[6] Hankemeier DA, et al.  Perceptions of Approved Clinical Instructors:  Barriers in the Implementation of Evidence-Based Practice. 2013.  J Athl Tain. 48(3).  382-93.

[7] National Association for Practical Nurse Education and Service, Inc.  Standardized Practical Nursing Curriculum .2009.http://www.napnes.org

[8] O'Connor, T. and Meakes, E. 1998. Hope in the midst of challenge: Evidence-based pastoral care.  J Pastoral Care, 52(4): 359–368.

[9] O’Connor T.  1002. The Search for Truth: The Case for Evidence-Based Chaplaincy.”  2002. J Pastoral Care. 13(1).  185-194.

[10] Wintz S.  2017.  Knowledge and Professional Chaplaincy Practice.  PlainViews. Vol 14. No 11.  November 22, 2017.  HealthCare Chaplaincy Network. Web.  http://www.plainviews.org. 

[11] The Glossary of Education Reform.  http://edglossary.org/content-knowledge/

[12] Defining Nursing Knowledge.  Nursing Times.  2005.  https://www.nursingtimes.net/roles/nurse-educators/defining-nursing-knowledge/203491.article

[13] Association of American Medical Colleges.  Medical Education. 2018. https://www.aamc.org/initiatives/meded/

[14] National League of Nursing.  NLN Competencies for Graduates of Nursing Programs. 2018.  http://www.nln.org/professional-development-programs/competencies-for-nursing-education/nln-competencies-for-graduates-of-nursing-programs

[15] Wintz S.  2017. 

[16] Council on Social Work Education.2018.  https://cswe.org/About-CSWE

[17] American Physical Therapy Association.  Education Leadership Partnership.  2018. http://www.apta.org/ELP/

[18] Wintz S.  2017.

[19] Thomas J.  Evaluations of Clinical Pastoral Training and “Part-Time” Training in a General Hospital.1958.  J Pastoral Care.  12:1. 28-38.

[20] Jernigan H. Clinical Pastoral Education:  Reflections on the Past and Future of a Movement. 2002.  J Pastoral Care Couns.  54:4. 377-392.

[21] Meiburg A.  Conjoint Clinical Education:  An Interdisciplinary Experiment. 1971.  J Pastoral Care. 25(2). 116-121.

[22] Aist C.  Standards:  A View from the Past and Prospects for the Future.  1983.  J Pastoral Care.  27:1. 6067.

[23] Jernigan H. 2002.

[24] Hilsman G.  Grafting Clinical Pastoral Education:  Teaching Competencies for the New Spiritual Care Work. 1987.  J Pastoral Care.  51:1. 3-12.

[25] Fitchett & Gray, 1994.  Evaluating the outcome of clinical pastoral education: A test of the clinical ministry assessment profile. Journal of Supervision and Training in Ministry, 15: 3-22.   

[26] VandeCreek, Hover, and Gleason. 2001. Quantitative outcomes of clinical pastoral education: A review of the literature. Journal of Supervision and Training in Ministry.  12:132-147.

[27] Jernigan H. 2002

[28] Ford T and Tartaglia A.  The Development, Status, and Future of Healthcare Chaplaincy.  2006.  Southern Medical Journal, 99, 675–679.

[29] Little NK.  Clinical Pastoral Education as Professional Training: Some Entrance, Curriculum and Assessment Implications.  2010. J Pastoral Care Counsel. 64(3) 5. 1-8.

[30] Cornett, B. S. 2006. A principal calling: professionalism and health care services, Journal of Communication Disorders, 39, (4) Jul-Aug 2006, pp. 301-309.

[31] Eraut, M., 1994. Developing professional knowledge and competence. London: Routledge Falmer.15.

[32] Little NK.  2010.

[33] Little NK.  2010

[34] Jackson-Jordon B and Moore K.  2010.  Chaplaincy Certification Standards as a Curriculum Resource in Clinical Pastoral Education.  Retrieved from http://www.professionalchaplains.org/files/resources/reading_room/chap_cert_stds_curriculum_resource_cpe.pdf

[35] Cadge W.  Paging God:  Religion in the Halls of Medicine.  2012.  Chicago, IL.  The University of Chicago Press.

[36] Tartaglia A.  Dodd-McCue D.  Enhancing Objectivity in Pastoral Education:  Use of Standardized Patients in Video Simulation.  2010. J Pastoral Care Counsel 64(2):2.1-10.

[37] Massey K.  Surfing through a Sea Change: The Coming Transformation of Chaplaincy Training.  2014.  Reflective Practice: Formation and Supervision in Ministry. 34. 144-152.

[38] Fitchett G, Tartaglia A, Massey K, Jackson-Jordon B, Derrickson P.  2015. Education for Professional Chaplains: Should Certification Competencies Shape Curriculum? J HealthCare Chaplaincy. 21:4

[39] Tartaglia A, Dodd-McCue D, Ford T, Demm C, and Hassel A. Education for Professional Chaplains: Should Certification Competencies Shape Curriculum? 2015.  J HealthCare Chaplaincy.  22:2.

[40] Tartaglia AF.  Reflections on the Development and Future of Chaplaincy Education.  2015.  Reflective Formation and Supervision in Ministry. 35. 116-133.

[41] Wintz S. 2017.

[42] Johnson P.  1968.  Fifty Years of Clinical Pastoral Education. The Journal of Pastoral Care.  22(4). 223-231.

[43] Hall C.  Head and Heart:  The Story of the Clinical Pastoral Education Movement. 1992. Journal of Pastoral Care Publications. Decatur, GA.  Review: Thomas J.  The Journal of Pastoral Care. 1992.  46(4).  405-407.

[44] Maguire M, et al.  1988.  The Association of Clinical Pastoral Education.  The Journal of Pastoral Care.  42(3).  203-208.

[45] Beverly U. Clinical Pastoral Education:  Exile or Exodus.  1995. Journal of Pastoral Care. 49(4). 353-357.

[46] Jerrigan H. Clinical Pastoral Education:  Reflections on the Past and Future of a Movement. 2002.  The Journal of Pastoral Care and Counseling.  56(4).  377-392.

[47] Snorton T, Lawrence R, et al.  ACPE and CPSP Statement.  2010. The Journal of Pastoral Care and Counseling.  64(4).

[48] Requirements for Board Certification. Spiritual Care Association.  https://spiritualcareassociation.org/requirements-for-board-certification.html

[49] Simulation-based assessments in health professional education: a systematic review.  2016.  Ryall, et al.  J Mutlidiscip Healthc.  9.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4768888/

[50] Improving Pharmacy Student Communication Outcomes Using Standardized Patients. 2017.  Gillette, et al.  Am J Pharm Educ 81(6). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607720/

[51] Impact of standardized patients on the training of medical students to manage emergencies.  2017. Herbstreit, et al. Medicine (Baltimore). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5293440/


 [SW1]http://healthcarechaplaincy.org/docs/about/nurses_spiritual_care_white_paper_3_3_2017.pdf

 [SW2]https://healthcarechaplaincy.org/docs/about/spirituality.pdf

Thursday
Dec282017

Thank you, Jimmie Holland. We Will Miss You. 

One of the many things I marvel at in my professional life is how often I have been placed in the way, seemingly by chance, of people of extraordinary wisdom and talent who have more than freely shared that wisdom and knowledge with me and thus enabled me to make whatever contributions I have made.  In health care chaplaincy, there are still a lot of my colleagues who see physicians as mostly impediments to the integration of spiritual care. Indeed those physicians exist, but I have found it true much more often that physicians are glad to have me around and to share with me wisdom I never was exposed to in seminary or even my own clinical training.

When I arrived at Memorial-Sloan Kettering Cancer Center as a very new chaplain in 1978, there were chaplains but no chaplaincy service or department and chaplaincy was not integrated at all. I soon met Dr. Jimmie Holland who had arrived the year before as an already well-established psychiatrist in oncology. Over the next 30 years or so, Jimmie built, not only a premier mental health service and training and research program in a cancer center but founded and built the international discipline of psycho-oncology itself.

During those decades, she always had the time to share with this increasingly not so young chaplain not just how to do what we now call palliative care and how to be a contributing member of an interdisciplinary team, but how to actually build a profession for the long term. She always welcomed chaplains into her projects- not as something exceptional but as something that was the right thing to do for patients. She was a consistent, outspoken and unrelenting supporter of chaplaincy and spiritual care including at times and in places where that defense was not very popular among her medical peers. She was founding chair of the pastoral care advisory committee at MSKCC and held that position for many years. She was a recipient of HCCN’s Wholeness of Life Award, and the APC’s 2007 Distinguished Service Award which is the highest award given to a non-chaplain.  She included chaplains in every major conference and publication she did and I cannot remember a favor we ever asked of her that she didn't enthusiastically accept. Any attempts at expressing gratitude were almost always met with the same response. "But George, this is really important". Jimmie eventually retired from her administrative positions but never stopped running groups, seeing patients, and doing research.

Dr. Jimmie Holland died on December 24th at the age of 89. I last talked to her on November 17th as part of the annual conference call of the National Comprehensive Cancer Network's Distress Management Guidelines Panel that she advocated for many years ago and chaired ever since. As usual, she had lots of energy, an encyclopedic grasp of the latest research, and lots of ideas for moving the work of the panel ahead including some long-needed, major rework on the chaplaincy section of the guidelines that she asked me to lead. For Jimmie, it was always about making life better and reducing suffering for people with cancer and their caregivers. Another lesson that became a mantra in my own career.

Jimmie Holland's death is certainly a major loss for me personally but it is also a huge loss for everyone involved in psychosocial-spiritual care. Fortunately, I am far from the only practitioner who learned their lessons well under Jimmie's tutelage.  We are literally all over the world in psychiatry, psychology, social work, nursing, oncology, palliative care and even a few chaplains. As the excerpt from the MSK press release below says, Jimmie Holland changed the field of cancer care. Thanks Jimmie.

From the MSKCC Press release.

  For more than 40 years, Jimmie made an essential question — "How do people withcancer feel?" — the center of her work. During her years at MSK, she created the nation's largest training and research program in psycho-oncology. In 1984, she produced for MSK the first-ever syllabus on psycho-oncology and, in 1989, was senior editor of the first textbook on the subject.

  Throughout her career, Jimmie conducted important research about how battles with cancer affect the mind. She helped establish important insights on the best way to treat depression during cancer treatment and to treat anxiety in those who have survived.

  Jimmie also shared her knowledge with the world. She co-founded the International Psycho-Oncology Society in 1984, and she founded the American Psychosocial Oncology Society in 1986. She is credited with putting psychosocial and behavioral research on the agenda of the American Cancer Society (ACS) in          the early 1980s. She was also a co-editor-in-chief of the journal Psycho-Oncology.

  The ACS awarded her its Medal of Honor for Clinical Research in 1994. She was elected a Fellow of the Institute of Medicine in 1995, and received the Presidential Commendation from the American Psychiatric Association in 2000, among many other awards.

Through her visionary work, Jimmie changed the field of cancer care by shining a light on the inner lives of patients. She will be dearly missed.

 

Thursday
Nov232017

Knowledge and Professional Chaplaincy Practice

This article originally appeared in the November 22, 2017 issue of PlainViews®, the online journal published by HealthCare Chaplaincy Network and is published here with permission.

 Board certified chaplains are uniquely trained to be the spiritual care specialists within health care….As integral members of the interprofessional team, chaplains uniquely contribute to the well-being and overall health of patients, their families, and health care professionals.[1]

In the education world, there are specific definitions applied to the concept of knowledge.  Content knowledge is the body of knowledge and information that teachers teach and that students are expected to learn in a given content area; it includes the facts, concepts, theories, and principles that are taught and learned in specific academic courses rather than to related skills which are also learned in order to put content knowledge into practice.[2]   In all professions, particularly health care, there is a tension between content or theoretical knowledge (“know that”) and practice knowledge (“know-how”) [3] in the quest to prepare students to provide effective and quality care to patients and families.   Health care disciplines, with the exception of chaplaincy, have integrated the two by not only acknowledging the tension, but incorporating both kinds of knowledge into their education and credentialing processes.

All other health care professions also require a knowledge-based test as a required step in obtaining licensing or certification.  A list for reference is at the end of the article. Note that the list is not comprehensive for every health care professional, but covers most that are part of the multidisciplinary care team with whom the chaplain works.

For decades, chaplaincy training has relied primarily upon practice knowledge that focuses on the person of the chaplain, how he or she develops their “inner self”, and in turn how that self-growth impacts the ways in which chaplaincy care is provided. Content or theoretical knowledge – the facts, concepts, theories, and principles that are necessary to effective practice and patient benefit, have not been standardized or made consistent within the field and so cannot be standardized in chaplaincy training.  Thus the ways in which this knowledge is imparted cannot be standardized or measured for their ability to produce effective chaplaincy practice. What one may learn through a didactic or workshop in one training setting is often not the same as what a different chaplain learns in another training setting and can even be completely different.  For example, while one chaplain may be taught a thorough background of and process of spiritual assessment based on research and evidence, another’s training center may place no emphasis on spiritual assessment at all and the candidate does not learn how to incorporate best practices.

Curriculum and testing that is standardized, while still leaving room for the inclusion of other areas of study, removes those inconsistencies.   The lesson is clear from all other health care disciplines that when candidates are tested to measure a person’s comprehension of evidence-based content or theoretical knowledge of their field, pass objective observations of their ability to demonstrate it through practice knowledge, the person has met the requirements needed to practice in their field and will reliably provide quality care.  In addition, these professionals are shown to have the same knowledge and skills in the topics essential to their profession. (See the information linked in the list at the end of this article.)  As a result, consumers of the care provided by these professionals can expect and trust what their provider will know about and that they will know how to behave in certain ways and do certain things within their defined scope of practice.

To apply this educational theory to chaplaincy, the traditional processes for education and certification do not align with those of other health care professionals, which should be a major concern for all chaplains.  While there have been changes in health care and other disciplines such as psychology that have led all other related professions to change their education, licensing, and certification processes, chaplaincy has not.  Rather, chaplaincy has continued to hold on to its subjective processes for evaluating a candidate’s readiness and certifying them for professional practice.  In many of the chaplaincy certifying organizations, candidates still choose and write the materials they submit, including verbatims of a patient encounter as they remember it and a theory paper.   A gathered committee of peer volunteers – some of whom are trained in certification processes, some who are not - then reviews those documents, meet with the candidate, determine his or her readiness, and recommend whether she or he should receive certification.[4] [5] [6]  Neither component – the written material by the candidate nor the committee’s process to determine the candidate’s readiness for certification, are objective; in fact they are often not consistent from one candidate or committee to another. Indeed, they cannot be consistent because there is no agreed upon reference point of a body of knowledge that every certification process is to evaluate among these certifying organizations. Add to this variance, the fact that there are about a dozen different professional associations certifying health care chaplains in the US, none operating with exactly the same culture or process, means that employers and patients alike cannot know what to expect when a "certified" chaplain walks into their room or team meeting. All of this variance inevitably results in certified chaplains who are often unqualified to provide reliably high quality care to patients, families, and staff

What has been missing in health care chaplaincy certification processes is any attempt to come to a consensus among the various groups of what that knowledge should be or the testing of content or theoretical knowledge. How, then, does the profession know that it is reliably educating and certifying persons to be high quality professional chaplains without a way of objectively measuring their knowledge and ability to apply it through their skills?

In other words, when health care regulatory agencies or health care administrators ask, as they increasingly do, how chaplains are tested to ensure they hold a common set of facts, knowledge and skills as do other disciplines, what can be the response of the chaplaincy profession?   There isn’t one, just as there is no agreed upon evidence-based answer to the increasingly common question of what value to certified chaplains bring

It is no longer enough to have a chaplaincy process that is subjective, varied, and not knowledge, content, or evidence-based nor should it be if chaplaincy wants to provide the best spiritual care possible and be fully integrated as members of the multidisciplinary health care team.

One important goal of the Spiritual Care Association (SCA) when it was created over a year and a half ago, was to address the need for chaplaincy to follow the example of other health care professions by creating a process that would mirror their more objective process to determine if a person has the knowledge and clinical skills to delivery evidence-based quality process, structure, and outcomes for spiritual care.  One essential element of this effort was to develop a standardized clinical knowledge-based test as is required within other health care disciplines.

The SCA Standardized Clinical Knowledge Test was developed, following the example of other health care professions, by using international subject matter experts, evidence-based knowledge gained through research, the input of senior chaplain leaders, and the most rigorous standards. The scoring is totally objective. The test has now been determined to have a high degree of reliability. The knowledge that is tested is outlined for the candidate ahead of time and is publicly available, thus allowing educators and candidates to fully prepare without any uncertainty about the content of the Standardized Clinical Knowledge Test.  For example, questions in the test include health care ethics, basics of world religious/spiritual systems, and spiritual assessment models, grief concepts and processes, and effective communication skills in working with patients, families, and interdisciplinary team members.[7] The test is easily altered so it can be updated regularly in order to integrate new knowledge and research as it is developed.

As part of the SCA certification and credentialing processes the Clinical Knowledge test is coupled with a Simulated Patient Encounter. These encounters are scored against a list of objective observable behaviors also derived from evidence that are shared with the candidate in advance so he or she is aware of the professional elements being assessed. Simulated patients (SP) are extensively used in medical, nursing, pharmacy, other health discipline education and increasingly in CPE programs to allow students to practice and improve their clinical and conversational skills for an actual patient encounter.[8] [9] [10] Yet they have not been a part of chaplaincy certification until the formation of the SCA. 

Importantly, in discussions with regulatory agencies and administrators, the ability to describe a process that is in alignment with other health care disciplines in the demonstration of an objective testing of both content or theoretical knowledge and practice knowledge has raised the understanding, acceptance, and incorporation of chaplains who have demonstrated their ability in a manner that mirrors other health care disciplines.

Neither the online knowledge test nor the SP are proprietary. SCA has repeatedly made clear that it is very open to sharing these methods and having dialogue about how to improve them with other certifying bodies that could easily replicate what SCA has done. Indeed we are in discussions with several associations on these topics.  However despite numerous invitations to the Association of Professional Chaplains (APC), the National Association of Catholic Chaplains (NACC), and the National Association of Jewish Chaplains (NAJC), their leadership has refused to engage in dialogue, thus ignoring the need before the profession to review and improve their certification processes to mirror those of other health care disciplines, beginning with standardizing the chaplain’s scope of practice and core knowledge  Doing so minimizes not only a sense of collaboration within the profession, but the ability to equip their members for success in the continually changing environment and demands of all health care settings.  More importantly, it impacts the ability of chaplains to reach the ultimate outcome of their work, which is providing consistent and quality patient, client, family, and staff care.

As chaplaincy moves into the future, it ignores the standards applied to other disciplines to measure knowledge and skills together at its own peril and to the detriment of the people it serves.  This will require a change in perception of how many chaplains, and indeed the profession itself, has understood itself in order to acknowledge the importance of moving the integration of spiritual and chaplaincy care forward into the future.  The SCA continues to be dedicated to helping set and test the highest possible standards for health care chaplaincy and welcomes any and all who wish to partner with it in this effort.

 Health Professional Testing Requirements

  • ·       Physicians must pass the U.S. Medical Licensing Examination (USMLE).  The USMLE has three steps:  1) measuring basic science knowledge; 2) assessing one’s ability to apply medical knowledge, skills (including those that are patient-centered), and understanding of clinical science to provide patient care; and 3) a case simulation.[11]  More information on the test content can be found here.[SW1] 
  • ·       The National Commission on Certification (NCCPA) of physician assistants requires successful completion of the Physician Assistant National Certifying Exam (PANCE)[12] which is organized in two dimensions:  1) organ systems, diseases, disorders, and medical assessments; and 2) knowledge and skills.  Content of the exam can be found here.[SW2]  
  • ·       The American Academy of Nurse Practitioners Certification Board requires examinations tailored to the area of expertise that the nurse practitioner desires to concentrate in, such as family, adult-gerontology, or emergency.[13]  Exams cover clinical knowledge across the life span and application in assessment, diagnosis, plan, and evaluation.  Example of content can be found here[SW3] .
  • ·       Licensing for nurses requires an exam overseen by the National Council of State Boards of Nursing (NCSBN).  The content of the test is organized into four major client needs categories, with two of the four divided into subcategories.  They include:  1) safe and effective care environment; 2) health promotion and maintenance; 3) psychosocial integrity and 4) physiological integrity.[14]   A description of the test content can be found here.[SW4] 
  • ·       Social workers’ licensing requires the successful completion of the Association of Social Work Boards (ASWB) examination.[15]  The exam covers 1) content areas that are broad areas of knowledge including human development, diversity, and behavior; 2) assessment and intervention planning; 3) direct and indirect practice; and 4) professional relationships, values, and ethics.  A list of the content can be found here[SW5] .
  • ·       The National Physical Therapy Exam (NPTE), overseen by the Federation of State Boards of Physical Therapy (FSBPT)[16] is required for licensure of physical therapists.  The test content is divided into three areas to measure knowledge, clinical application, and awareness of current best evidence from research:  1) physical therapy examination including the various systems of the body; 2) foundations for evaluation, differential diagnosis, and prognosis; and 3) interventions.   More information on the exam content can be found here.[SW6] 
  • ·       Speech therapists, according to the American Speech-Language-Hearing-Association[17]  must complete the Praxis Examination in Speech Language Pathology[SW7] .   Occupational therapists, part of the American Occupational Therapy Association[18], must pass the NBCOT® Certification Examination.[SW8]   Respiratory therapists undergo examinations depending on their chosen specialty[19] through the National Board for Respiratory Care[SW9] . 

 

Rev. Sue Wintz, BCC, is Director, Professional and Community Education at HealthCare Chaplaincy Network and the managing editor of its publication PlainViews®, the preeminent online professional journal for chaplains and other spiritual care providers. She has a major role in the development, design, writing and instruction of HCCN’s professional continuing education offerings. Sue has over 35 years of clinical, administrative, educational design, development and teaching experience in the provision of professional chaplaincy and spiritual care in health care and congregational settings. She is board certified by the Spiritual Care Association and the Association of Professional Chaplains.  Sue is a past president of the Association of Professional Chaplains, and in 2013 was given APC’s highest honor – the Anton Boisen Professional Service Award.


[1] Spiritual Care:  What it Means, Why it Matters in Health Care.  2016.  HealthCare Chaplaincy Network. https://healthcarechaplaincy.org/docs/about/spirituality.pdf

[2] The Glossary of Education Reform.  http://edglossary.org/content-knowledge/

[3] Defining Nursing Knowledge.  Nursing Times.  2005.  https://www.nursingtimes.net/roles/nurse-educators/defining-nursing-knowledge/203491.article

[4] Certification Frequently Asked Questions.  Board of Chaplaincy Certification Inc.  http://bcci.professionalchaplains.org/content.asp?pl=25&sl=26&contentid=26

[5] Certification Competencies & Procedures.  National Association of Catholic Chaplains. https://www.nacc.org/certification/nacc-certification-competencies-and-procedures/

[6] Neshama:  Association of Jewish Chaplains.  http://www.najc.org/join/requirements

[7] Requirements for Board Certification. Spiritual Care Association.  https://spiritualcareassociation.org/requirements-for-board-certification.html

[8] Simulation-based assessments in health professional education: a systematic review.  2016.  Ryall, et al.  J Mutlidiscip Healthc.  9.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4768888/

[9] Improving Pharmacy Student Communication Outcomes Using Standardized Patients. 2017.  Gillette, et al.  Am J Pharm Educ 81(6). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607720/

[10] Impact of standardized patients on the training of medical students to manage emergencies.  2017. Herbstreit, et al. Medicine (Baltimore). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5293440/

[11] USMILE.  United States Licensing Examination®.  http://www.usmle.org/practice-materials/index.html

[12] The National Commission on Certification. http://www.nccpa.net/become-certified

[13] American Academy of Nurse Practitioners Certification Board. https://www.aanpcert.org/certifications , s

[14] NCSBN. National Council of State Boards of Nursing. https://www.ncsbn.org/testplans.htm

[15] ASWB.  Association of Social Work Boards.  https://www.aswb.org/exam-candidates/about-the-exams/exam-content-outlines/

[16] FSBPT. The Federation of State Boards of Physical Therapy.  https://www.fsbpt.org/ExamCandidates/NationalExam(NPTE)/PrepareforExam/NPTEContent.aspx

[17] American Speech-Language-Hearing-Association. https://www.asha.org/Certification/Speech-Language-Pathology-Pathway-To-Certification/

[18] The American Occupational Therapy Association.   https://www.aota.org/Advocacy-Policy/State-Policy/Licensure/How-To.aspx

[19] National Board of Respiratory Care. https://www.nbrc.org/examinations/

Wintz S.  Knowledge and Professional Chaplaincy Practice.  PlainViews. Vol 14. No. 11.  November 22, 2017. HealthCare Chaplaincy Network. Web:  http://www.plainviews.org.


 [SW1]http://www.usmle.org/practice-materials/index.html

 [SW2]http://www.nccpa.net/ExamsContentBPTasks

 [SW3]http://www.aanpcert.org/certs/fnp

 [SW4]https://www.ncsbn.org/PN_Det_Test_Plan_2017.pdf

 [SW5]https://www.aswb.org/wp-content/uploads/2014/02/MastersKSAs.pdf

 [SW6]https://www.fsbpt.org/Portals/0/documents/free-resources/ContentOutline_2013PTT_201212.pdf

 [SW7]https://www.asha.org/Certification/praxis/Speech-Language-Pathology-Exam-5331-Content/

 [SW8]https://www.nbcot.org/

 [SW9]https://www.nbrc.org/examinations/

Saturday
Aug192017

What Should Chaplains Do About Bigotry and Hate?

Like many of us I trust, I have been wondering how to react to the recent events in our country which show hate and bigotry in a virulent way that many of us at least hoped had vanished permanently into some dark corner if not been extinguished altogether. I did my stint registering African- American voters in the rural south in the mid 60's and I guess I imagined that those days were gone in our country. In that sense, the words and actions (and inactions) of our President have done us a favor. Rationalizing that this kind of hatred is restricted to a small fringe group in our country that we really don't have to be concerned about just got much harder.

These events call on all of us to examine how we might be contributing to this state in our country and how we might grow in our contribution to its solution.   There are of course, the public stances we can take. For Christians, one I hope is easy for each of us is to say loudly and repeatedly that doing violence of any kind to others or justifying hatred or bigotry by proof texting Christian Scripture or using the name of Christ is simply wrong. It is not debatable or negotiable. It is simply wrong. What may be harder for some of us is to just as loudly and repeatedly support our Muslim friends and colleagues when they proclaim that those who carry out violence or hatred in the name of Allah or using citations from the Qu'ran are equally wrong and are not Muslims.

Then, how do we as chaplains who say we value respect and acceptance for everyone most aggressively live that out in our work lives?   Our professional lives as health care chaplain affords us some particular opportunities and particular challenges. We are fortunate I believe to work in a profession and generally in professional settings where the values, culture and regulatory mandates require us to treat all of those we serve with dignity and respect irrespective of their race, gender, culture or belief system. Thus, there is pretty much no question that we have to afford the bigot and unapologetic racist the same respect and treatment we offer those the racist abuses.

However, as usual, this policy is sometimes much hard to live out than it is to espouse. What happens in your institution when a client refuses treatment from a member of your staff because of that staff member's race, culture or faith system? Is there policy? Is that policy made clear to staff and clients? Do the chaplains have a voice in forming and administering that policy? Do the chaplains get involved when a staff member is disrespected or worse because of their race, religion or culture? How are the needs, values and beliefs of the client and the staff member reconciled when they clash? Not easy issues.

What distresses me is that I continue to hear stories from colleagues involving disrespect, bias and down right abuse from chaplain colleagues. Generally, these stories seem to emerge within the context of our certification or our educational processes but stories of disrespect or outright lack of acceptance clearly occur in other contexts as well. The normative story line seems to involve colleagues from the liberal Christian traditions which dominate our profession telling colleagues not of those traditions that their presumed values or faith systems make it impossible for them to be "good" chaplains simply on the basis of the faith group they claim membership in. For me this crosses the line from respectful dialogue and disagreement among colleagues that professional chaplaincy highly values to bias and disrespect based on a presumed characterization of a certain group and masquerading under the banner of "speaking our truth".

While it is entirely appropriate for our profession to express its total opposition to the hatred and bias we see in our country, that message is not complete unless we also communicate to our own colleagues that kind of behavior, even in much milder forms, constitutes a serious violation of our professional code of ethics and will be treated as such. We need to make it clearer than we have that we encourage reporting of this kind of behavior and will protect those who do so. We need to spend at least as much outrage on reforming ourselves as we do on reforming the world around us. To date, we have not done that.

 

Sunday
May142017

It Is About the Money

I have devoted a lot of time and energy over the past several years to the development of the "evidence" for spiritual care and chaplaincy. That means mainly guidelines and studies with numbers. We have made some major gains over that time. The 3rd edition of the NCP guidelines[i] and the research of Tracy Balboni[ii] and colleagues and Deborah Marin and colleagues[iii] are major examples. The case for the inclusion of spiritual care and chaplaincy is much more compelling today than it was ten or even five years ago. And yet, despite the fact that spiritual care is named as a required service in virtually every model for palliative care, study after study continues to show that chaplaincy (and to a lesser degree, social work) lag behind and are the most often omitted members of palliative care teams[iv].  

In an interview discussing this study, Dr. Sean Morrison said:

We've seen really a tremendous growth in the number of advance practice nurses that are in the field. We've also seen a growth, you know, an accompanying growth in terms in of the number of physicians. But where we, as you said, we still have a lot of room for improvement is both in social work and in chaplaincy. And it's perhaps not surprising that those are the two disciplines where they can't bill for their services. And I think a large part of the lack of growth in those two areas is because of finances[v].

Recently I reviewed and submitted comments on two documents outlining guidelines for community palliative care.  In both, spiritual care was included. In one case, the document stated that spiritual care should be provided "when reasonable". In the other case, "availability" was all that was required. Further investigation convinced me that at least a part of the issue in each case was the presumed costs of chaplaincy. This will certainly amuse or anger many chaplains who know how little money most institutions invest in spiritual care and how cheap it is. While we should continue to develop "evidence" in all forms, we need to go after the money issue directly and aggressively.

Why is this happening? What is missing?

There is no silver bullet here of course but at least in part, I think we have not focused on making the business and financial case justifying the value of what we do. Years ago, the values of health care, the reimbursement structures and the lack of spiritual care research would have made that task impossible in a convincing way. I and others now believe that the situation has changed dramatically. It is now entirely possible and essential to the survival and growth of spiritual care that the case be made both in general terms and in terms that are customized to each institution.

What needs to happen for that case to be made in a convincing and widespread way?

1. We need to get over the attitude many chaplains still have that letting money drive our ministry is somehow beneath us or even unnecessary or something we can never build a case around.

2. We need to make common cause with social work. Neither chaplaincy nor social work can any longer afford to be engaged in turf wars over who does what in psychosocial-spiritual care. We need to get it straight, agree, and support each other. This will mean some swallowing of egos but it will benefit patients. Otherwise the game too often played by administrators of divide and conquer will continue.

3. Each of us needs to educate ourselves on the evidence for the cost effectiveness of spiritual care and chaplaincy at this time in health care. A paper recently produced by HealthCare Chaplaincy Network is a good place to start and a resource that can be passed on to administrators[vi].

4. Each of us needs to educate ourselves on what our individual institution is focused on in terms of cost savings and revenue generation, especially in light of the latest federal quality reporting options that have serious financial implications. Is it patient satisfaction? Is it care in the last month or 6 months of a patient's life? Is it increasing the percentage of patients with advance care plans? Whatever that is in our institution, we need to work at figuring out how chaplaincy can contribute and demonstrate that contribution in dollars made or saved.

5. We need to be pressuring our professional associations and certifying bodies to be involved both in resource development and direct advocacy. What resources and educational opportunities have your professional association offered membership on this topic? What direct advocacy are they doing both at the federal and state level? What support are they offering you directly to deal effectively with challenges in your institution? There are a dozen or so associations in the US that certify health care chaplains. How has your body collaborated with the other eleven in this cause?  (Hint: It is not true that all these bodies refuse to talk to each other.) Are we teaching aspiring chaplains the skills and knowledge they need to produce value added outcomes in health care chaplaincy and do our certification processes focus on making sure those skills and that knowledge are demonstrated- how to build a spiritual care service and do quality improvement for instance?

Again, this is not the time for turf wars or "we are the best" talk. We want to see all our associations grow and thrive.  What we should be caring about is how we are supporting each other in making a difference, not for our association, but for the patients we serve.

 

 

 


[i] The National Consensus Project for Quality Palliative Care Clinical Practice Guidelines for Quality Palliative Care 3rd edition 2013.

[ii] Balboni, T. A., Paulk, M. E., Balboni, M. J., Phelps, A. C., Loggers, E. T., Wright, A. A., ... & Prigerson, H. G. (2010). Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death. Journal of Clinical Oncology, 28(3), 445-452.

 [iii] Marin DB, Sharma V, Sosunov E, Egorova N, Goldstein R, Handzo G. 2015. The relationship between chaplain visits and patient satisfaction. Journal of Health Care Chaplaincy. 21 (1):14-24.

[iv] How We Work: Trends and Insights in Hospital Palliative Care http://bit.ly/2qd3zHU

[v] "Sean Morrison and the Current State of Palliative Care",  GeriPal: Geriatrics and Palliative Care Blog, April 19, 2017.

[vi] Spiritual Care: What It Means, Why It Matters in Health Care. http://bit.ly/2dtxiHA.