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George Handzo, a leader in pastoral care and chaplaincy, often writes on his blog about areas in which chaplaincy as a profession can work towards higher professionalism.  I plan on featuring some of his posts in looking at chaplaincy. In the meantime, this first piece, while not the first conversation on improvement in chaplaincy care, focuses in on a fundamental need for quality improvement.  It is not enough for chaplains to just “show up (though it certainly can be an important element in spiritual care).”  Rather, chaplains need to have a plan like other health care disciplines.  Yet, I would question the notion of measurability of outcomes for spiritual care in the following sense.  I think it can be measured through qualitative research that provides quantitative data.  It has to be measured through descriptive care.  It can’t be merely a numbers game of, for example, reducing spiritual anguish from a level 10 to 3 on a visit, like we would rank physical pain.  I think that gets awkward for the people being serviced.  Now, you could argue that people will adapt, but I think the number system overmedicalizes the care.

Quality Improvement in Chaplaincy: Where to Start?

I am a totally unapologetic champion of continuous quality improvement for chaplaincy.  I believe there is a theological imperative to improve our conduct in all aspects of our life- especially in the service to others. I know that we as professional chaplains are woefully deficient in being able to define and measure the outcomes that help improve the spiritual dimension of patient care. I am convinced that if we don’t get on this bandwagon, chaplaincy jobs will be lost and, worse, many patients will not have their spiritual care needs addressed during their illness and suffering.

We have to give up one of chaplaincy’s articles of faith- that what we do cannot and maybe even should not be measured. We have to banish from our collective professional vocabulary the premise that “chaplains don’t have an agenda”.  If we don’t have any agenda, then we are saying that we have no intention of helping patients in any way. In that case, why should we be included on the care team?

However, even if one buys all of the above, where do we start?  It is very easy to look around and get paralyzed by the options.  Many want to start with the question “What is best practice?”. Christina Puchalski and Betty Ferrell lay out a whole system for integrating spiritual care in Making Health Care Whole. Since the answer to the question is a moving target, it is easy to do nothing while we wait for “best” to emerge.

I would propose that we need to pick a measurable outcome that is easy to integrate into the health care process as it is now structured. In other words, we want to avoid any proposition that requires significant change in how the systems now operate.

I would propose starting with the premise that professional health care chaplaincy needs to focus on those with a need for spiritual care as opposed to a desire for a chaplaincy visit.  This premise would immediately eliminate, “Do you want to see a chaplain?” as a screening question because, as George Fitchett pointed out years ago, those with spiritual need are least likely to ask for a chaplain. The next premise is that this need for spiritual care is best (at the moment) captured by the concept of spiritual struggle or spiritual distress. I would leave aside for the moment whether “struggle” and “distress” are the same or different and assume that for clinical purposes, any distinction if it exists, is not important. And the third premise is that at least some significant portion of spiritual struggle in any given patient population can be discovered with a couple simple screening questions administered as part of standard screening protocols by those in the system who do the overall screening- usually nursing. Thus, chaplains do not need to visit every patient.

As to which screening questions to use, what is now being called the Rush Religious Struggle Screening Protocol designed by George Fitchett is the best known and has several studies to back it up[i]. However, it still needs to be tested in different populations and alternatives may emerge.  If someone in a given institution has energy behind other questions, I would try them rather than hold up the whole enterprise over insisting on the Rush questions.

Accepting these conditions sets us up to:

1.   Engage the health care team- especially those doing the screening- in the spiritual care process.

2.   Begin identifying the number of patients in our institution who exhibit spiritual struggle which demonstrates from a quality perspective that there is need for chaplaincy.

3.    Begin to measure, even in very simple ways, how chaplains help patients. The measure could be as simple as how often does the patient report reduced spiritual struggle after a chaplain’s visit?

4.    Begin discovering some of the correlates of patients with spiritual struggle. Do they have lower patient satisfaction scores? Do they have longer stays? Do they as Tracy Balboni and her colleagues have suggested use more aggressive care and less hospice care at the end of life?

I would try to avoid becoming hung up in issues that, while maybe not unimportant, are not important enough to derail this whole process. Those would include the issue of struggle vs. distress and exactly what questions to use in the screen.

The most common obstacle I encounter in this process is the legitimate concern from those doing the screening (normally nursing) that every clinical department in the institution wants to add questions to the screening process and to accept all of them will make the screening too time consuming and unwieldy.  The counter to this is (1) to compile and present the growing evidence for the undesirable consequences of spiritual struggle and (2) to point out that if the institution and the team want to live out what most claim to be their goal of caring for the whole person, they must attend to the person’s spiritual domain. The next obstacle is that often those doing the screening will need training to become comfortable asking questions in this domain.

I understand that I have made this way forward sound simple. I understand that is true in concept but often far from true in execution.  This change requires commitment, focus, and building alliances over time.  And it is not the way forward that will be the most appropriate for all institutions. I offer this plan simply as a way forward that seems to appeal in a lot of settings, will help spiritual care become more integrated into whole person care, and doesn’t require significant change to the prevailing culture of most health care institutions.


[i] King S., Fitchett G, Berry D. (2012) Screening for religious/spiritual struggle in blood and marrow transplant patients. Support Care Cancer. Published online 11 October 2012.