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BY: DAVID A. LICHTER, D.MIN.

Research is an essential mark of any clinical profession, and the quality of research denotes the discipline's development. Research on chaplaincy services spans nearly a half century, and it is growing and improving. Clinical health care researchers are strengthening the chaplaincy profession by providing evidence that spiritual issues need to be addressed or health outcomes falter.

In this Health Progress issue, the Mayo Clinic Department of Chaplaincy Services has contributed its research on the spiritual needs of hospitalized Catholics. (See page 58.) The chaplaincy profession has benefitted from two previous studies of patient needs conducted by the Mayo Clinic chaplaincy group.1 These studies, along with Mayo's productivity data on chaplaincy activity, have informed the Mayo Clinic's decisions for the spiritual care department's staffing and services. Their research allowed them to confidently link patient needs to adequate staffing, as well as to demonstrate increased patient satisfaction when spiritual care needs are being met.

This article is intended to situate the Mayo research within the broad and growing arena of research on the chaplaincy profession, patients' spiritual needs and how meeting or not meeting their religious or spiritual needs affect patient perception of the quality of care — and their health outcomes.

George Fitchett, professor and director of research at Rush University Medical Center in Chicago, offered three reasons for integrating research into professional chaplaincy. The first is the most important: to strengthen one's professional practice in order to improve service to patients and families. Secondly, publishing the results of this research will increase awareness of what and how chaplains contribute to the health care team. And finally, such research will promote and strengthen interdisciplinary relations.²

Other researchers have agreed with Fitchett.³ As one report states, "In addition to improving care, making chaplaincy a research-informed profession will promote the constructive dialogue about the roles of religion, spirituality, and professional chaplains in healthcare settings."⁴

METHODOLOGY AND SCHOLARLY REVIEWS
In 1990, John Gartner and colleagues reviewed the quantity and quality of quantitative research of articles published in four pastoral counseling journals between 1975-1984.⁵ In 2003, The Journal of Pastoral Care and Counseling provided another review, "An Evaluation of the Quantity and Quality of Empirical Research in Three Pastoral Care and Counseling Journals, 1990-1993: Has Anything Changed?"⁶ The latter noted improvements in compliance with some of the criteria used for internal validity but reported no improvement in the sophistication of statistical analysis and research design.

Research on chaplaincy continued to develop. In 2011, the Journal of Health Care Chaplaincy again published a review of chaplaincy research, "A Methodological Analysis of Chaplaincy Research: 2000-2009."⁷ This article aimed to assess the sophistication of the research studies compared to studies before 2000, and it found improvements in reporting of response rates and use of inferential statistics and statistical controls and increases in sample sizes.

Yet, the article noted that few discussed validity and reliability of measures, and still too many relied on cross-sectional survey of convenience samples versus experimental or quasi-experimental studies which allow for making greater generalizations. They urged more research that employed hypothesis testing, but acknowledged that such hypothesis models need to be based on theories about chaplaincy service, which are lacking in the field.

Although these critiques might have significance only to a seasoned researcher, they signal the seriousness with which the profession takes its goal to improve clinical research and the clarity of the critique and direction it provides to its fellow researchers.

The review also was helpful in classifying the areas of research being examined: attitudes about the roles of chaplains, the nature of chaplain visits and interventions, referrals to chaplains, instrument development, patient and family satisfaction with chaplains, intervention studies, other studies with patient populations, chaplaincy staffing, chaplain attitudes and perceptions, chaplain well-being and chaplain education.

In England, Dr. Harriet Mowat published the 2008 milestone work The Potential for Efficacy of Healthcare Chaplaincy and Spiritual Care Provision in the NHS (UK): A Scoping Review of Recent Research.⁸ It was commissioned in 2006 as part of the Caring for the Spirit National Health Service (NHS) Project initiated by NHS Yorkshire and the Humber. Since NHS required all health service treatment to be evidenced-based, so it was for chaplaincy. Mowat entitled one of her subpoints in the section on context of chaplaincy as "movement from an assumption of chaplaincy to a case for chaplaincy."

Her study included review of research in the United Kingdom and beyond. It was groundbreaking in scope and depth and provided a framework and a bar of excellence for future research reviews and mandates. A caveat she offered remains a valuable caution for the field of research and those who work with professional chaplains: "healthcare chaplaincy has a very limited evidence base for a number of reasons." She cautioned that "a lack of evidence of efficacy does not mean that the work of the hospital chaplain and spiritual care giver is not efficacious." Put succinctly, she said, "Absences of evidence does not mean evidence of absence." Research continues this quest for evidence.

In 2011, the Journal of Health Care Chaplaincy provided one of the most useful reviews of chaplaincy research in the article "Testing the Efficacy of Chaplaincy Care," by Katherine R. B. Jankowski, et al.⁹ Work for the article was funded by the John Templeton Foundation, which also is funding the major research project "Growing the Field of Chaplaincy Research in Palliative Care."¹⁰

In their article, Jankowski and her colleagues noted, "Research into chaplaincy outcomes falls roughly into two general categories: studies of patient satisfaction with chaplaincy care and studies of actual chaplaincy interventions and their relationship to health outcomes. The patient satisfaction studies are generally stronger methodologically than the intervention studies and tend to show the chaplain visits have a positive effect on overall patient satisfaction … The outcome studies are very few in number and most have serious methodological shortcomings." They asserted that these studies needed "targeted and enhanced replication."

The article is most useful in identifying what is known about chaplaincy and spiritual care's effectiveness and the gaps that need to be addressed through further research. The major ones include: religious and spiritual needs and resources; who chaplains are, what chaplains do and the desired outcomes of chaplain interventions; the efficacy of chaplains (where, when, how are they helpful?); and research methodology.

Although helpful lists of research on chaplaincy service exist, the profession has a way to go. However, the chaplaincy profession is grateful that HealthCare Chaplaincy, a New York-based nonprofit that serves as a hub for professional chaplaincy education, research and practice, in 2011 was awarded a three-year, $3 million grant to advance scientific research on professional chaplaincy's contributions to health and health care, particularly palliative care. HealthCare Chaplaincy has awarded $1.5 million to six project grants to advance the field of research on chaplaincy in palliative care. All proposals for these grants required professional clinical researchers and an interdisciplinary team, including a board-certified chaplain, as part of the research team. We look forward to the research results.

RESEARCH BY OTHER HEALTH CARE PROFESSIONALS
The Mayo Clinic's 2010 research (see page 58) explores another very important area, the religious or spiritual needs of patients. Clinical researchers, sometimes with the help of professional chaplains, have examined the connections between identifying and addressing religious or spiritual needs and patients' perception of and satisfaction with care. This type of research not only augments, but strengthens the evidence-based foundations of the importance of health care clinicians being trained to screen for such needs and refer to the professional chaplain when indicated, and of spiritual care professionals being trained to address these needs.

A team of medical researchers from the University of Chicago-Pritzker School of Medicine showed the relationship of addressing religious or spiritual needs and satisfaction with care, in findings published in 2011 in the Journal of General Internal Medicine. The research provided evidence that addressing a patient's spiritual concerns increases trust in the medical team and overall satisfaction with care.11 Part of the strength of this study is its sample, over 3,000 medical patients treated at the University of Chicago who represented a broad racial and ethnic mix, as well as a mix of religious and non-religious people.

Another example is research published in the Journal of Clinical Oncology by a medical team at St. Vincent's Comprehensive Cancer Center in New York City.¹² The study of very diverse patients with cancer examined the relationship between patients' spiritual needs and perceptions of quality and satisfaction with care. The research showed that most patients (73 percent) had spiritual needs; a majority (58 percent) thought it was appropriate for physicians to ask about these needs, and 18 percent reported that their spiritual needs were not being met. A significant finding, however, was that those 18 percent gave lower ratings to their quality of care and satisfaction with their care.

Other research has examined the relationship between religious or spiritual needs and physical and mental health. Several studies have shown the positive associations between religion and health and well-being.¹³ However, over the past decade there also has been a significant amount of empirical research on religious and spiritual struggle.¹⁴ This growing body of research indicates that if spiritual struggle, or distress caused by something in one's belief, practice or experience, is not identified and addressed, it will have an adverse effect on one's health. Such distress could show itself as a single primary emotion (guilt, anger), or as a person's internal struggle to reconcile their experience with their beliefs. Well-known researcher Kenneth I. Pargament categorized religious or spiritual struggle or distress as divine (anger with God), intrapersonal (trying to forgive oneself for something), or interpersonal (being betrayed by a religious leader).¹⁵ When these types of distress are not recognized and addressed, they can have an adverse effect on health outcomes.

A study by Crystal Park, a professor of psychology at the University of Connecticut, bears this out. Her research published in the Journal of Behavioral Medicine reports that among congestive heart failure patients, higher levels of religious struggle are associated with poorer physical functioning and increased hospitalization.¹⁶ The study's longitudinal method permits a somewhat stronger inference that religious struggle contributed to these poorer outcomes. "Religious struggle predicted higher number of nights subsequently hospitalized, higher depression, marginally lower life satisfaction … Religious struggle appears to have a potentially negative impact on well-being in advanced [congestive heart failure]; therefore, helping patients address issues of struggle may meaningfully lessen the personal and societal costs of [congestive heart failure]."

A team of Pittsburgh researchers published an excellent study in the Journal of Palliative Medicine exploring the relationship between religious coping and well-being in women with breast cancer. This was another longitudinal study in which results indicated "negative religious coping predicted worse overall mental health, depressive symptoms, and lower life satisfaction."¹⁷ Such results signal to health care professionals the importance of screening for signs of spiritual distress signs, taking them seriously and referring them to professional chaplains as appropriate.

CONCLUSION
The chaplaincy profession presses ahead to undertake research that supports evidence-based practice. The Association of Clinical Pastoral Education, the Association of Professional Chaplains, the National Association of Jewish Chaplains and the National Association of Catholic Chaplains all have research initiatives to strengthen the research literacy of their members, as well as to collaborate on research initiatives for evidence-based practice.18 Most importantly, these associations urge their members to become engaged in research projects at their health care places of employment, making a case that integrating spiritual care into health outcomes research is not an add-on but integral to sound research.

Indeed, Standard 12 of the "Standards of Practice for Professional Chaplains in Acute Care Settings" is on research: "The chaplain practices evidence-based care including ongoing evaluation of new practices and, when appropriate, contributes to or conducts research."19

Clinical health care researchers — other than chaplains — are providing the evidence that spiritual issues need to be addressed or health outcomes falter. The chaplaincy profession is ready to partner in addressing those needs.

DAVID A. LICHTER is executive director of the National Association of Catholic Chaplains, Milwaukee.

NOTES

1. Katherine M. Piderman et al., "Patients' Expectations of Hospital Chaplains," Mayo Clinic Proceedings 83, no.1 (2008): 58-65, and Katherine M. Piderman et al., "Predicting Patients' Expectations of Hospital Chaplains: A Multisite Survey," Mayo Clinic Proceedings 85, no. 11 (2010): 1,002-1,010.
2. George Fitchett, "Health Care Chaplaincy as a Research-Informed Profession: How We Get There," Journal of Health Care Chaplaincy 12 (2002): 67-72.
3. Larry L. VandeCreek, "Chaplains Yes: Should Clinical Pastoral Education and Professional Chaplaincy Become More Scientific in Response to Health Care Reform?" Journal of Health Care Chaplaincy 12 (2002): XXI-XXII; and Thomas O'Connor and Elizabeth Meakes, "Hope in the Midst of Challenge: Evidence-Based Pastoral Care," Journal of Pastoral Care 52, no. 4 (1998): 359-367.
4. Literature Review – Testing the Efficacy of Chaplaincy Care, part of the proposal to the John Templeton Foundation, "Growing the Field of Chaplaincy Research in Palliative Care." Available at www.healthcarechaplaincy.org/templeton-research-project/literature-review.html.
5. John Gartner et al., "A Systematic Review of the Quantity and Quality of Empirical Research Published in Four Pastoral Care Journals: 1975-1984," Journal of Pastoral Care 44, no. 2 (1990): 115-123.
6. Kevin, J. Fannelly et al., "An Evaluation of the Quantity and Quality of Empirical Research in Three Pastoral Care and Counseling Journals, 1990-1999: Has Anything Changed?" Journal of Pastoral Care and Counseling 57, no. 2 (2003): 167-178.
7. Kathleen Galek et al., "A Methodological Analysis of Chaplaincy Research: 2000-2009," Journal of Health Care Chaplaincy 17 (2011): 126-145.
8. Harriet Mowat, The Potential for Efficacy of Healthcare Chaplaincy and Spiritual Care Provision in the NHS (UK): A Scoping Review of Recent Research (Aberdeen, Scotland: Mowat Research Ltd., 2008) Available online at www.nhs-chaplaincy-collaboratives.com/efficacy0801.pdf.
9. Katherine R. B. Jankowski et al, "Testing the Efficacy of Chaplaincy Care," Journal of Health Care Chaplaincy 17, no. 3-4 (2011): 100-125.
10. Literature Review – Testing the Efficacy of Chaplaincy Care.
11. Joshua Williams et al., "Attention to Inpatients' Religious and Spiritual Concerns: Predictors and Association with Patient Satisfaction," Journal of General Internal Medicine 26, no. 11 (2011): 1,265-1,271.
12. Alan B. Astrow et al., "Is Failure to Meet Spiritual Needs Associated with Cancer Patients' Perception of Quality of Care and Their Satisfaction with Care?" Journal of Clinical Oncology 25, no. 36 (2007): 5,753-5,757.
13. Harold G. Koenig, Kenneth I. Pargament and Julie Nielsen, "Religious Coping and Health Status in Medically Ill Hospitalized Older Adults," Journal of Nervous and Mental Disease 186, no. 9 (1998): 513-521; also see Harold G. Koenig, "Religion, Spirituality, and Medicine: Research Findings and Implications for Clinical Practice," Southern Medical Association 97, no. 12 (2004): 1,194-1,200.
14. Julie J. Exline, "Religious and Spiritual Struggles," in APA Handbook of Psychology, Religion, and Spirituality Vol. 1, eds. Kenneth I. Pargament, Julie J. Exline and James W. Jones (Washington D.C.: American Psychological Association Press, 2013), 459-475.
15. Kenneth I. Pargament, Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred (New York: Guilford, 2007).
16. Crystal L. Park et al., "Religious Struggle as a Predictor of Subsequent Mental and Physical Well-Being in Advanced Heart Failure Patients," The Journal of Behavioral Medicine 34, no. 6 (2009): 426-436.
17. Randy Hebert et al., "Positive and Negative Religious Coping and Well-Being in Women with Breast Cancer, Journal of Palliative Medicine 12, no. 6 (2009): 537-545.
18. The Association for Clinical Pastoral Education (www.acpe.edu), the Association of Professional Chaplains (www.professionalchaplains.org), the National Association of Catholic Chaplains (www.nacc.org), the National Association of Jewish Chaplains (www.najc.org), the Canadian Association of Spiritual Care (www.spiritualcare.ca) and the American Association of Pastoral Counselors (www.aapc.org) were the six professional associations that developed and adopted the Common Standards for Professional Chaplaincy. Chaplains must show they meet these standards of professional knowledge and skills to become certified by the Board of Chaplaincy. See http://professionalchaplains.org/.
19. The Standards of Practice for Professional Chaplains in Acute Care Settings were adopted in 2010 by the associations noted above. Available at http://professionalchaplains.org/content.asp?admin=Y&pl=198&sl=198&contentid=200.