Volume 26 Number 2 • Autumn/Winter 2010
Rozann Allyn Shackleton
Editor's Voice
Linda Brown
Making the Case for Case Study
Research
This article provides a how-to guide for chaplains
interested in conducting case study research, including
research design, data collection/analysis and preparation
of the manuscript.
keywords: methodology, data analysis, evidence-based
practice
Ann Sidney Charlescraft, Alexander
Tartaglia, Diane Dodd-McCue, Sandra B.
Barker
When Caring Hurts . . . A Pilot Study
Supporting Compassion-fatigued
Pediatric Critical Care Nurses
Compassion fatigue is often experienced in health care
institutions. The article describes the vital role that
chaplains may play in addressing self-care as an ethical
and pastoral priority and details an intervention plan
piloted with critical care nurses.
keywords: research, survey, burnout
Mark LaRocca-Pitts
Protocol-based Referrals: A Method for
Selecting Patients in the Electronic Age
Effective patient selection is a perennial concern for
chaplains. Various methods have been proposed,
including case-finding, standard response and referral.
This article discusses protocol-based referrals, a form of
standard response which utilizes electronic medical
records as a tool for selecting patients.
keywords: referral, patient records, triage
Marci Pounders
Essay- Don't Worry, I've Got You
Personal reflection on ministry to a hospice patient.
keywords: pastoral, end-of-life, compassion
George R. Robie, Coordinator
Retired Chaplains' Writing Project
This installment features the reflections of three past presidents of the two organizations which merged
to form the Association of Professional Chaplains.
keywords: collegial, wisdom, history
- Jerry J. Griffin: The Integrity of Authority and Identity
- Ron Ropp: Issues, Concerns and Goals of Chaplain Leadership 1982-83
- Clark S. Aist: Thoughts from the Seventies
Lynn Crager
On Holy Ground- An Accumulation of Grief
Personal reflection on mortality.
keywords: lament, comfort, caring
W. Noel Brown
In the Literature
A survey of current literature related to chaplaincy care culled from an international selection of
professional journals and other media.
Robert W. Duvall
Expression of Faith - pilgrimage
Personal reflection haiku.
keywords: poetry, renewal, inspiration
Mardie Chapman, Media Review Editor
Media Reviews
Courageous Conversations: The Teaching and Learning of Pastoral Supervision • Women Out of Order:
Risking Change and Creating Care in a Multicultural World • Talking with God in Old Age: Meditations
and Psalms • We Do Remember You • Just Conflict: Transformation through Resolution • Coming Out,
Coming Home: Making Room for Gay Spirituality in Therapy • A Sacred Walk: Dispelling the Fear of
Death and Caring for the Dying
©
Chaplaincy Today • Vol. 26 No. 2 • Autumn/Winter 2010
Editor’s Voice
IT’S ALWAYS WITH PLEASURE—and I confess with a certain
amount of relief—that I complete an issue of Chaplaincy Today. This
particular one also comes with an added sense of excitement and
enthusiasm as CT takes another step toward fulfilling the mandate of
APC’s Publications Task Force to expand its focus on research and to
mentor chaplains who are interested in pursuing this area of writing
for publication.
Rozann Allyn Shackleton
MDiv MA BCC
[email protected]
The lead article, authored by Linda Brown, begins with a background
on case study as a research mode and includes recommendations for
designing such research projects. She also offers a step-by-step model
for “writing the case.”
As a follow-up, CT is issuing a call for case study papers to be
published in 2011. The deadline for the first issue (27.1 – Spring/Summer 2011) is January 31.
Guidelines for manuscript submission are posted on the Web site, and queries are welcome.
Also in the research vein, Ann Sidney Charlescraft and her colleagues at Virginia Commonwealth
University discuss the pilot study of their program, “Promoting Self-care among Caregivers,” which
was developed to address compassion fatigue, burnout and stress in pediatric critical care nurses.
She is scheduled to present a professional development intensive on compassion fatigue and selfcare at the APC 2011 Annual Conference.
The profession of chaplaincy is viewed through a multifaceted lens, which looks both to the future
and to the past. Mark LaRocca-Pitts explores the use of electronic medical records as a triage
instrument for setting patient visitation priorities. George Robie again has tapped the expertise of
retired BCCs, through the Retired Chaplains’ Writing Project. Jerry Griffin, Ron Ropp and Clark Aist,
past presidents of the two organizations that merged to form APC, offer their unique views of
chaplaincy as they experienced it.
The next installment of this feature, slated for publication in the Autumn/Winter 2011 issue of CT,
will feature the reflections of female chaplains who joined the profession at a time when men held
the vast majority of leadership roles. See the box on page 40 for information on submissions for
this collaborative article.
Reflective essays and poetry by Marcie Pounders, Lynn Crager and Robert Duvall along with
literature and media reviews round out the issue. I am grateful to all who contributed to this
eclectic collection, and I invite you to add your voice to future issues.
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
Two continuing education credits (CE) are available on completion of the reading of this issue. Enter CT-26-2.
1
Making the Case for Case Study Research
Linda Brown BCC
Linda Brown PhD BCC
serves as bereavement
coordinator at Saint
Luke’s Hospice, Kansas
City, MO. She is
endorsed by the
Episcopal Church USA.
[email protected]
methodology.”i
Case study research is an excellent way for health care chaplains to
contribute to a body of knowledge pertaining to the evidence-based practice
of pastoral and spiritual care in hospitals and health care institutions. This
type of research strengthens our practice, connects it to theory and theology,
facilitates the development of models and paradigms, and demonstrates that
what we do is effective and that it makes a difference. This article provides a
how-to guide for chaplains interested in learning to conduct case study
research, including research design, data collection/analysis and preparation
of the manuscript.
CASE STUDY IS THE REDHEADED STEPCHILD OF RESEARCH. It
is criticized routinely for non-generalizable results and lack of methodological
precision and rigor when, in fact, it is “a necessary and sufficient method for
certain important research tasks in the social sciences … [and] holds up well
when compared to other methods in the gamut of social science research
Case study is commonly used in chaplaincy. Indeed, one of the pioneers of chaplaincy, Anton
Boisen, based his practice on case research, examining the relationship between mental illness and
religious experiences.ii Case study plays a pivotal role for disciplines such as chaplaincy, which are
in the process of establishing their own bodies of research distinct from the research of related
disciplines. Although chaplains owe a debt of thanks to our peers in psychology, sociology,
anthropology and ethnography, we have our own identity and a professional responsibility to
establish that what we do has value and is unique to our discipline.
Thomas Kuhn, noted for his landmark work on the nature of scientific revolution, identifies wellexecuted case studies as a crucial developmental task for emerging and maturing disciplines, as
they amass the paradigms necessary to reflect upon their practice.iii Researcher George Fitchett, a
chaplain himself, argues that case studies are a logical and productive choice for chaplaincy
research at this stage in the profession’s development: “We need good case studies of our work. …
[We] need to link the spiritual care described in them with theories about our work.”iv
Fitchett is a fierce and persistent advocate for health care chaplaincy as a research-informed
profession and for chaplains as competent purveyors of research.v “Chaplains need to demonstrate
that there are solid theories that support the care they provide.”vi This will “strengthen our practice
of ministry; increase awareness of what we contribute; and promote interdisciplinary
relationships.”vii Case studies are particularly important in this effort: “[In] order to effectively tell
our story to our health care colleagues, in order to make the case that we are productive members
of the health care team, we have to provide evidence for the difference that we make.”viii
An in-depth case study offers distinct benefits in looking at the complex real-life issues and
circumstances that are the focus of chaplains’ daily ministry. It is useful for investigating trends
and specific situations and has the advantage both of immediacy and of flexibility. For a chaplain,
trends of importance might include an increase in spiritual care consult requests from outpatient
units, extended length of stay for patients in intensive care units (ICU), high turnover of nurses in
the Neonatal ICU or the readmission rate of patients with intractable pain. In all of these instances,
a chaplain might seek an explanation or propose an intervention in order to address the issue from
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the distinct perspective of spiritual health and with the unique skills of the professional chaplain.
Case studies “can be useful in capturing the emergent and immanent properties of life … and the
ebb and flow of organizational activity, especially where it is changing very fast.”ix
Case studies, as a rule, are more interesting and engaging personally than experimental research
or statistical analyses and therefore may have a strong impact. Unlike experimental and
quantitative research, which is typically concerned with measuring what happens, case study
research is more likely to be concerned with how and why things happen. Case study is useful for
discovery and interpretation, for looking at processes and meanings, and for testing models or
interventions in real-world situations.
For instance, a chaplain may develop an intervention to ease spiritual distress at the end of life.
The intervention is theologically sound. It is based upon accepted theory of pastoral care. But does
it actually ease the distress of dying patients? More important, how does it ease that distress?
What is the process? Why does it work? How might it work with patients who are not imminently
dying but are experiencing multiple losses related to chronic illness? Case study is an accessible
methodology for a chaplain to use in answering those questions, at the same time improving her
practice and adding to the body of knowledge. Palliative Care: A Case-Based Guide,x offered
entirely as a compendium of case studies, is a prime example in the medical literature.
Although it is fair to say that case study is less concerned with objective measurement and
statistical procedures than experimental research, it is not fair to say that case study lacks
methodological standards. There are clear-cut methods for conducting case study research and,
when multiple cases are examined, the possibility of generalization and even replication becomes
feasible.
Every method of research has limitations, and case study is no exception. Cases are, by definition,
embedded into a particular context, making it more difficult to replicate a case study than an
experimental study. Case studies are especially vulnerable to the so-called “ex post facto fallacy,”
which refers to a tendency to observe co-related events or variables and assume a causal
connection in the absence of an actual demonstration of that causality. These weaknesses are not
unique to case study research, but it is easy in narrative interpretation to weave a story that
moves beyond the conclusions that the observations permit.
Case studies are generally constructed socially or relationally, with an emphasis upon describing an
observed pattern and examining the meaning of that pattern and the meanings that people place
upon their experiences. Chaplains daily probe the meaning-making processes and the inter- and
intra-personal relationships of patients, family, and staff. Case study is uniquely suited to mine this
rich data pool, enabling professional chaplains to reflect empirically upon the practice of pastoral
and spiritual care.
Chaplains are encouraged to master this methodology. Chaplain residents are taught the rudiments
of case study in their CPE programs and, at a workshop on evidenced-based spiritual care
presented at Spiritual Care Summit ’09, George Fitchett proposed that a detailed case study be
required for APC board certification (BCC) and included in every 5-year BCC peer review.xi
This article will assist chaplains in formalizing their spiritual assessments and analyzing their
interventions through the case study method. Information is given about ways to design and carry
out case study research and to draw implications from case findings in order to contribute to the
evidence-based practice of chaplaincy.
So, what is a case?
In case study methodology, the “case” generally refers to a person (a patient, a family member, a
staff member) or sometimes to an entity (the palliative care program, the curriculum for in-service
education, the new crisis intervention procedures, the code blue policy). A case study may be used
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to determine not only if a particular intervention is successful (Does dignity therapy offer positive
results for patients living with chronic illness?), but also why and how it works (What changes are
noted in spiritual assessment during the course of dignity therapy?). A single case study will
provide evidence that the intervention was successful in that particular instance; multiple studies
using the same technique provide deeper insight into the process and stronger, more generalizable
evidence of the outcomes. Case methodology also may be used to determine if implementation of
new policies and procedures has been successful, e.g., has the new policy regarding parental
presence during invasive procedures been effective in reducing children’s anxiety and improving
outcomes, have we learned something about the process that may be applied to other situations?
A case study may highlight a single case or it may be a collective study, bringing together multiple
cases with a common thread, e.g., five families who observed CPR performed on loved ones in the
Emergency Department, three hospitals’ code blue policies, all staff members who participated in a
perinatal bereavement seminar. Single cases may be analyzed in greater depth; multiple cases
allow a broader range of occurrences, settings and results to be considered. Generalization is not
the Holy Grail of case study research, though. “The real business of case study is particularization,
not generalization. We take a particular case and come to know it well, not primarily as to how it is
different from others but what it is, what it does. There is emphasis on uniqueness, and that
implies knowledge of others that the case is different from, but the first emphasis is on
understanding the case itself.”xii
How does one identify a critical case? There are some rules of thumb, but no overall standards
exist to guide chaplains in selecting cases. The “typical or average case is often not the richest in
information. Atypical or extreme cases often reveal more information because they activate more
actors and more basic mechanisms in the situation studied.”xiii Random selection of cases is helpful
when the goal is to describe something or to determine its frequency. However, the strategic
selection of cases is a better method if the goal is to examine causes and consequences or to
analyze what is occurring at a deeper level than simple description. “[Identifying critical cases]
requires experience, and no universal … principles exist …. The only general advice that can be
given is that … it is a good idea to look for either ‘most likely’ or ‘least likely’ cases, that is, cases
likely to either clearly confirm or irrefutably falsify propositions and hypotheses.”xiv
That said, “it is not unusual for the choice of a case to be no ‘choice’ at all. Sometimes we are
given, even obligated to take it as the object to study.”xv Robert Stake takes a pragmatic
approach: “[Our] time and access . . . are almost always limited. If we can, we need to pick cases
which are easy to get to and hospitable to our inquiry, perhaps for which a prospective informant
can be identified and with actors (the people studied) willing to [participate].” xvi
Designing case study research
The first step in designing a case study is to establish the area of interest and its relevance to
practitioners or researchers. What do we want to know or learn? What is the research question?
Why is it important? The purpose of a case study is not to survey a broad area but to focus on a
small, discrete area of interest: a single person, a population of people with something in common,
a policy or procedure applied in a particular context, a problem to be understood.
It is important to decide how to address the case in order to ensure collection of the right kinds of
data. “[Case] studies should provide detailed information about three things we need to
understand …: 1) descriptions of the patient (or family) to whom we provided care, 2) descriptions
of the spiritual care that was provided and 3) descriptions of the changes that occurred as a result
of that spiritual care.”xvii
Focus on a limited number of topics or questions, no more than four or five points at the most.
Write those points down and at every juncture during the study ensure that data being collected
are related to one or more of the key points and provide answers to one or more of the research
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questions. These questions or points are the boundaries around the study. They define what we are
doing and keep us from straying into other interesting pastures.
It is important to remember that “Initial research questions may be modified or even replaced in
mid-study by the case researcher.”xviii One of the hallmarks of case study research is that it is
responsive to the needs of the situation. A case study researcher is first and foremost an observer,
more so than a manipulator of the situation, but as chaplains, we are also meaning makers. We
observe the moving parts of the case, but we also examine the meaning of what we observe and
redirect our attention when new meanings emerge.
Particularly in descriptive and explanatory case study research, we are witnesses more than actors,
monitoring and observing the situation; in exploratory case studies, we may be both actors and
witnesses, introducing an intervention and observing its impact.
The researcher, deliberately or intuitively, makes role choices, including the following:
•
How much to participate in the activity of the case.
•
How much to pose as expert, how much comprehension to reveal.
•
Whether to be neutral observer or evaluative, critical analyst.
•
How much to try to serve the needs of anticipated readers.
•
How much to provide interpretations about the case.
•
How much to advocate a position.
•
Whether or not to tell it as a story.xix
For this reason, notes need to be thorough, accurate, methodical, well organized and always
referenced to the key points of the study. Many case study researchers create a spreadsheet or
database in order to organize the data as they become available; this allows efficient and fluid
manipulation of data during and at the end of the study. The case study researcher will classify,
sort, store and retrieve data for analysis and interpretation. Cross-referencing information is
important in order to sort and re-sort data as the study progresses.
For instance, in observing interactions or in analyzing interviews, a chaplain might be interested in
affective descriptors or spiritual terminology used by patients to describe their spiritual needs or
their state of spiritual well-being. Potentially, this could be hundreds of words, some virtually
identical, others similar but with important nuanced differences. How to record and later sort or
analyze such a large and amorphous list? One way is to record the words or phrases on a
spreadsheet, which may be sorted periodically according to different criteria or may be evaluated
by multiple observers. Given the emergent nature of case methodology, the spreadsheet could also
be subjected to the constant comparison method to identify salient entry differences and eliminate
trivial ones. xx
Case study methodology does not demand a particular type of data or evidence. A distinction is
made between quantitative and qualitative research, and case study methodology is often placed
into the latter category. In fact, case studies utilize both qualitative and quantitative data, singly or
in concert with each other, which is a considerable strength.
Robert Yin, an authority on case study research,
notes the importance of distinctions among type of evidence, data collection method,
and research strategy … in defining case studies …: (1) The different types of case
studies that are possible (exploratory, descriptive, and explanatory), (2) The types of
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research questions best addressed by case studies as opposed to other research
strategies (explanations rather than incidence questions); and (3) The types of case
study designs (all must cope with the essential problem that, because the context is
part of the study, there will always be too many “variables” for the number of
observations to be made ….xxi
Case study questions, which usually begin with how or why, are answered in a variety of ways:
spiritual assessment, interviews, journals, observations, self-report tools, tests, questionnaires,
transcripts of video or audio tapes, medical charts. Some data collection techniques, such as
observation or analysis of medical charts, journals or other artifacts, require trained
observers/recorders. Further, researchers need to document that the observation/recording system
is sufficiently uniform that any observer would record essentially the same data in the same
circumstance. Other techniques require development of a tool, such as questionnaires, interview
protocols or test items. Rating scales, interview protocols, and tools of this type may be accessed
in the professional literature, purchased commercially, or developed by a researcher for a specific
purpose.
Address ethical considerations
There are unique ethical considerations in case study research, in part because of the distinctive
trust relationship between researcher and subject and in part because of the emergent nature of
this methodology.
Helen Simons explores issues of trust, confidentiality, and accessibility, as well as dilemmas posed
by cultural differences, with straightforward examples from her own case study research. “Ethics is
a situated practice inextricably connected with … many factors …. This is not always a
straightforward process.” xxii
She goes on to write that in case studies,
people and their experiences are closely described and interpreted …. [Having]
developed a relationship of trust over time, participants often speak quite openly
about their experience, and may inadvertently reveal something they did not intend.
You need to be sure you do not unintentionally misuse this information and exploit a
person’s openness or vulnerability…. Participants should not feel let down, ‘at risk,’
or disempowered when they see in written text experiences closely shared with you
in the field.xxiii
This kind of research is emergent in nature: It changes.
We emphasize placing an interpreter in the field to observe the workings of the case,
one who records objectively what is happening but simultaneously examines its
meaning and redirects observation to refine or substantiate those meanings. …If
early questions are not working, if new issues become apparent, the design is
changed.xxiv
Reflecting on this phenomenon, Simons notes that “ethics in the field” is as important as the ethical
consideration given to the design of the research.xxv She talks of the need for such things as
ongoing informed consent, giving participants a voice in research issues, negotiating what becomes
public, and being in dialogue with stakeholders.xxvi
Simons says she asks herself questions such as these:
•
Are my questions in interview sensitive, not too intrusive?
•
When observing, am I invading participants’ privacy? Or attributing motivations?
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•
When taking photographs or filming, do I have informed consent? What will be the likely
reaction when participants see the photographs or video?
•
Have I recorded participants’ perspectives accurately?
•
Am I documenting participants’ stories or confirming my previous theories?
•
Am I honoring participants’ requests to keep information confidential?
•
Have my biases led to unfair selection of data or interpretation?
•
Have I portrayed participants fairly in reporting?xxvii
As chaplains we are committed ethically to confidentiality and are further guided by HIPAA, which
also takes on unique qualities in case study research because of the intimate role that participants
play, and the inherent risks of exploiting or misrepresenting them and their experiences. There are
also practical considerations: Anonymity and confidentiality are not the same thing. It is common
in case studies to use initials or pseudonyms, or to identify people by role rather than by name.
Although these techniques reduce the likelihood that individual people will be identified, they do
not guarantee anonymity, let alone confidentiality.xxviii
Institutional Review Boards (IRBs) have not traditionally been concerned with case studies, but this
is changing as the ethical challenges are better understood. Be in communication with your
institution’s IRB early in the process to ensure compliance in extending full ethical safeguards to
your subjects.
Identify data to be collected
The researcher may choose to gather a single kind of data, e.g., something extracted from archival
material, an interview, a questionnaire. Alternatively, one may gather multiple kinds of data,
combining data extracted during chart review with observational field notes, information gleaned
from interviews and the results of a questionnaire. Weaving together multiple sources of
information with multiple perspectives (such as those of patients and family, chaplains,
interdisciplinary colleagues, perhaps independent observers) enhances and deepens the case
analysis and also may reflect upon the validity and reliability of the data. “[From] both an
understanding-oriented and an action-oriented perspective, it is often more important to clarify the
deeper causes behind a given problem and its consequences than to describe the symptoms of the
problem and how frequently they occur. Random samples emphasizing representativeness will
seldom be able to produce this kind of insight; it is more appropriate to select some few cases
chosen for their validity.”xxix
If, for instance, one is studying the impact upon families of observing cardiopulmonary
resuscitation (CPR) performed on loved ones in the Emergency Department, in particular the
meaning individual family members make of this experience, then there are several kinds of data
that potentially may be collected. The behavior of family members in the ED may be observed and
recorded. Family members may be interviewed at one or more intervals following the event.
Spiritual assessment may be part of one or more of those interviews. A satisfaction survey may be
mailed to their home. Staff may be interviewed or questionaired. The patient’s chart may be
reviewed to determine the nature of the code, e.g., duration, outcome. These and other data are
all available to the researcher, but they may not all be pertinent to the focus questions. Choose
those that are pertinent and do not be seduced by the Siren voice of those that are attractive but
irrelevant.
Choose data collection methods
Choose data collection methods and tools that serve the purpose of the research question,
recognizing that the tools employed in the case study will shape the findings to some extent.
Deciding to interview family members in the first hour following the code will shape the study in a
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particular way. If families are interviewed at one hour, one week and one month post event, then
the case will take on a different shape. If the interview is constructed as a spiritual assessment
rather than as a phenomenological tool, a different dimension is highlighted. If data are limited to
staff reports and observations in situ, then the study will have still a different shape. It is critical to
note the ways in which decisions about data collection impact the results of a study and particularly
the perception of the event, person or process being chronicled in the case.
Assemble data collection tools
In preparation for data collection, identify the information needed, the most efficient collection
method and the manner in which data will be stored once they are received. Then build or acquire
the necessary tools, e.g., questionnaires, interview protocols, letters of introduction or explanation,
and train any people who will conduct interviews, review charts or observe situations. The chaplain
researcher may be performing all of these tasks or may have colleagues to provide assistance.
In this preparatory phase, anticipate problems that might arise and plan to avoid or cope with
them. Establish guidelines for confidentiality. Be sensitive to ethical considerations. As noted
earlier, the use of unobtrusive methods of data collection, such as observation or chart review,
raises particular ethical concerns around subjects’ right to informed consent and the use of
sensitive data contained in such records. In order to obtain approval from the Institutional Review
Board (IRB), researchers must demonstrate the necessity for such techniques and provide
safeguards that protect the rights of the participants.
Let’s say, for instance, that you are a chaplain at a children’s hospital. Your institution has large
numbers of children with chronic illnesses who eventually transition to a hospital that treats adult
patients. You believe that the children with cardiac conditions transition more successfully to the
adult setting than the children with sickle cell disease, cystic fibrosis or renal conditions. They
appear to be more in-tune with the impact of the disease process on their lives, more able to
create a sense of meaning about wellness/illness and the value of life in the midst of illness, better
prepared to assume responsibility for participating in treatment decisions and for following the
prescribed and agreed-upon treatment. They also appear to have better outcomes, and this is your
goal for all of your patients as they mature and age out of your hospital’s care.
Why do the cardiac patients do so much better? How might the experience of the cardiac patients
be replicated for the sickle cell, cystic fibrosis and renal patients? This is the perfect situation for a
case study. What variables might be important: age at diagnosis, co-morbidities, patient education,
parent participation, unit staff, policies and procedures on the cardiac service? What does existing
research tell you about this phenomenon? Has it been reported elsewhere? What kinds of data may
help to understand what’s going on?
This example also provides the opportunity to understand how case studies may be built into a
body of research. The first case study, or set of studies, might be undertaken to confirm the
chaplain’s anecdotal perception that one set of patients makes a better transition than another set
of patients. The chaplain may then proceed to the how and why questions: In what ways do some
of the patients make better transitions and why is this so? With these suppositions in hand, the
chaplain may create an educational program for parents (or staff or patients), or organize a
covenant group among patient peers, or create a parent support group, or engage patients in a
particular kind of spiritual discernment with the goal of helping other pediatric patients make a
better transition to the adult care setting. Case study may be used not only to confirm that the new
program or new set of interventions is effective, but also how and why it promotes a better
outcome for these young patients moving into maturity and the adult health care system.
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Analyzing results and drawing implications from case findings
In experimental research, data are analyzed statistically. Case data, though, often comprise words,
images, descriptions or exemplars collected through observation, interviews and similar methods.
These data typically are analyzed narratively, although statistical analyses also may be utilized.
Case studies often contain a substantial element of narrative. Good narratives
typically approach the complexities and contradictions of real life. Accordingly, such
narratives may be difficult or impossible to summarize into neat scientific formulae.
… This tends to be seen by critics of the case study as a drawback. To the case study
researcher, however, a particularly ‘thick’ and hard-to-summarize narrative is not a
problem. Rather, it is often a sign that the study has uncovered a particularly rich
problematic. The question, therefore, is whether the summarizing and generalization,
which the critics see as an ideal, is always desirable.xxx
Raw data—transcripts of interviews, field notes from observation sessions or chart review,
responses to interviews and questionnaires, spiritual assessments, journals or art produced by case
subjects—are examined for connections, relationships and links to each other as well as to the focal
points of the research, to pertinent theology or theory and to the outcomes. It is apparent from the
earlier discussion of affect descriptors that this demands efficient and fluid storage of the data so
that they may be sorted and analyzed in several different ways and at different times in the course
of the case study.
Organize data
A database or matrix of variables is an efficient way to organize information. Simple frequency
tabulation in the form of tables, bar graphs or pie charts may be helpful. More than likely, an array
of tools and templates such as the following will be used to organize and analyze nonnumerical
data:
flow charts
process maps
event cycles
time charts
fact/opinion charts
Potter Boxes
cause-effect diagrams
affinity diagrams
concept mapping
biography diagrams
story maps
data flow diagrams
spiritual assessments
5W diagrams (who-where-what-when-why)
family systems communications maps or genograms
SWOT analyses (strengths-weaknesses-opportunities-threats)
graphic organizers (such as stars, spiders, fishbones, and trees)
These are techniques familiar to any chaplain who has participated in ethics consultation, quality
improvement initiatives, or Lean Six Sigma projects in their institutions.xxxi
Drawing tools, such as Visio (Windows), SmartDraw (Windows), Canvas (Apple/Mac) and
ConceptDraw (Mac), help to create and analyze these symbolic representations of the data. Betty
Jung, Andrew Moore and Nancy Tague walk readers through the use of these and other tools for
interpretation and analysis of narrative data.xxxii
To interpret the data collected, begin with the key points identified as the focus of the case and
with the research questions, the how and the why. Categorize the data and arrange them around
appropriate categories. Having multiple sources of information from different perspectives is a
strength of the case study method, so combine observations and then separate them to get the
advantage of multiple observers’ perspectives. Called “data source triangulation,” this technique
offers the opportunity to confirm observations, to give credence to interpretation or to identify
commonalities of assertions—or not.xxxiii In the earlier example of the pediatric chaplain’s
interventions, the use of multiple perspectives may be illustrated well. Who are the people looking
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at these children cope with their chronic illness, mature and move into an adult health care setting?
Obviously, the children themselves have a perspective. So, perhaps, do their parents and siblings
and friends. Certainly, staff have a unique angle and it may even be illuminating to look at different
staff perspectives, e.g., nurses, child life specialists, and especially differences between the sending
and receiving staff. Who shares similar perceptions and who sees things differently? How are the
perceptions different or similar and why? Shifting data, combining them in a new way and/or
tabulating different components may reveal or give rise to new insights.
Construct narratives
As the data are sorted into manageable form, begin to construct narratives around them. Is there
one story or are there multiple stories? In order to maintain focus, be meticulous about referring to
key points and research questions when the images and exemplars that comprise the data pool are
collated. If multiple cases are being analyzed, treat each case as a separate instance and then,
after the data are analyzed for each case independently, look for cross-case trends.
Keep an open mind. Look for insights into the observed relationships. Don’t jump to premature
conclusions. Re-sorting and rearranging data may provide new insights and different perspectives.
Cross-check data. Look for holes or discrepancies. It may be necessary to conduct follow-up
interviews, to do more observation and/or to gather additional data in order to address the
research questions as fully as possible. “Good case study is patient, reflective, willing to see
another view.”xxxiv
Keeping an open mind also means looking not just for congruencies, but also for conflicts in the
data that may weaken the findings or even completely refute expectations, assumptions and
hypotheses. Conflicts are an impetus to probe more deeply.
There are some excellent resources to help case study researchers. Yin’s book, Case Study
Resources, now in its fourth edition, is the gold standard.xxxv It is comprehensive and does assume
some research knowledge on the part of the reader. Case Study Research in Practice, authored by
Simons, is more accessible.xxxvi Stake’s The Art of Case Study Research, while older, is very
pragmatic and easy to use.xxxvii This author would be remiss if she also did not remind chaplains
that the Association of Professional Chaplains (APC) offers many excellent educational
opportunities, including the 5-session “Introduction to Chaplaincy Research” webinar series
directed by George Fitchett and Patricia Murphy, which began in September 2010.xxxviii HealthCare
Chaplaincy is another rich resource for chaplains, offering extensive on-line resources.xxxix
Writing the case
Case study methodology transforms a complex issue into one that may be understood by readers
and practitioners. Data are presented in an accessible manner that allows individuals to incorporate
the case’s conclusions and understandings into their own life experiences and professional
chaplaincy practices.
A case has value when it stands alone, but it begins to take on broader meaning when it is shared
as part of the corpus of knowledge available to other professionals. Typically, this is done in written
format, although a case also may be presented orally. The presentation needs to convey clearly the
parameters of the case and needs to attend to conflicting propositions. Most researchers ask
colleagues and other knowledgeable individuals to review a draft of an article and to offer
comments and suggestions that will guide its revision before submission for publication or
presentation.
One of the strengths of case study research is that people are interesting and their stories are
interesting, so write with the curiosity and fascination that prompted your own interest in the case;
this will appeal to readers and pique their interest and curiosity. Writing research findings does not
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mean the language needs to be pretentious or unnatural. Rather, it should be direct,
uncomplicated and clear.
A case is organized into sections for presentation. Although each report will differ slightly, a case
report will have most of these sections:
•
Executive summary or abstract.
•
Introduction.
•
Review of the literature.
•
Description of the research design.
•
Summary/analysis of the results.
•
Interpretation/recommendations.
A list of the cited references will conclude the case report. In addition, appendices may be provided
to illuminate the case.
Executive Summary
An optional but important component of a case study is the executive summary, or perhaps an
abstract, which introduces the case and brings together its major components.
Abstracts and executive summaries are similar documents in that both encapsulate the research,
but they vary in length (the abstract is shorter) and in detail (the executive summary is more
faceted). An abstract presents enough information about the research to let the reader know if the
article fits his/her needs and warrants a complete reading. An executive summary is a stand-alone
document and has sufficient detail so that the reader can understand the contents of the longer
document without necessarily reading it in its entirety. Because case studies are filled with rich and
plentiful variables, and because the methodology is often an emergent one, an abstract usually will
not suffice.
As a rule of thumb, the executive summary is short and snappy, 500 words or less. It is concise in
stating the purpose of the case, its scope and methods, the results and any conclusions or
implications drawn. The executive summary also is a teaser, enticing the reader to journey with the
author through the case.
Introduction
This section educates the reader: What is the problem being studied? How is this case related to
other cases? Who will be interested in this case? The introduction clearly states what is being
studied and provides a meaningful framework for this work.
Review of the literature
The introduction flows naturally into a review of the pertinent literature, setting the case into the
larger context of the body of knowledge out of which the study has emerged and inviting the
reader into this ongoing conversation. The literature review also serves as a point of reference for
later sections evaluating results and drawing implications from the case.
Research design
The research design is simply a plan that states the problem or question, proposes an intervention
or a solution, offers a theory or premise to explain what might happen and delineates a plan for
collecting and analyzing information. What kinds of data will be gathered, how will data collection
instruments be used or created and how will the information gathered be organized and analyzed?
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Again, keep in mind the emergent nature of case study research: If the questions change then the
plan for data collection may need to change accordingly.
In most chaplaincy research, the research design will:
•
describe the focus of the case study – the subject or population,
•
tell what was done – the intervention,
•
describe what changed, what happened, what was learned – the outcome.
The subject is usually a patient, family member or staff, and the description will address the
contextual, demographic or social information that will be critical to the analysis. This may include
age, gender, racial or ethnic background, faith tradition, diagnostic/treatment descriptors or other
variables pertinent to the research question. In the earlier example of child patients transitioning
from a children’s hospital to an adult care setting, such things as age at diagnosis and general
intellectual functioning may be deemed important variables to include, or some measure of the
intactness of the family, or a description of educational or emotional support previously
provided/declined.
It’s also important to describe how the subjects were sampled: Was it random selection, did the
subjects self-select or did researchers select an individual who met a particular criterion or a group
of individuals who shared a particular experience or aspect? If the decision was to look at random
cases, then state the rationale for that. If a strategic selection process was employed, then
describe the strategy and the selection criteria and explain the reasons for choosing these
particular kinds of cases. What was the rationale for choosing patients with breast cancer, or
nurses who had been assaulted by patients or chaplains from a particular faith tradition? Perhaps
you simply chose the patients who were available and willing to participate.xl
Describing the intervention means telling what was done and why it was done. Any particulars that
distinguish this intervention from other interventions need to be stated and a strong case made for
choosing this intervention over others available. The description will not only include what and why,
but also who, where, when and how. Sufficient description should be offered so that someone else
could repeat what was done based upon the information given.
Describing the outcome means first defining the data that were collected and how they were
collected, e.g., through observation, by personal interviews or online questionnaires, as part of a
review of charts or other documents, or a combination of methods. The rationale is important. Why
were charts reviewed rather than people interviewed? Why is that important to this case?
Acknowledge any weaknesses in the research design, and point out any strengths that the design
offers.
Analysis
The analysis of the case compares the findings of this study with benchmarks established in the
review of literature and offered at the beginning of the case report. The analysis also should be
theory-driven: How is the type of pastoral or spiritual care offered linked to theological and
theoretical understandings about the work that chaplains do? How does this case fit into the body
of case material already available?
Case study is concerned with the distinctiveness and complexity of a single instance and so there is
interest both in the uniqueness of the case and the commonality between this case and other
cases. Therefore, one may name similarities and differences, may recognize and classify
agreements and contradictions, or may propose or hypothesize explanations for the identified
relationships or interactions. A case study may yield unexpected results and lead to new practices
or to research taking a new direction. Remember, too, that case study methodology is designed to
stir debate. The issues of case study are not generally ones for which there is an empirically
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established right or wrong answer. For example, case studies may be used as the basis for arguing
a particular position regarding issues as varied as the risks and benefits of genetically modified
crops, the value of e-participation in political debate, or the benefits and burdens of artificial
nutrition and hydration at the end of life.
What’s more, case studies are “presented with some sense of advocacy” that invites readers into a
lively, reasoned and ongoing conversation.xli
Summary
The summary is the place to tie up loose ends, to recapitulate findings and, if possible, to draw
inferences from the results. The summary is the “so what” section of the report, where the
researcher offers careful conjecture and deductions based upon solid reasoning and informed
interpretation of reported results.
Recommendations
Following a summary of the results, researchers typically make recommendations based upon their
findings, e.g., for further research, for institutional or procedural changes, for expanding or
discontinuing particular pastoral interventions. Whatever recommendations are offered should flow
directly from the analysis of the case and the way it affirms or refutes the existing corpus of
research. Is the body of case research sufficiently large and sufficiently congruent to warrant
conclusions about the effects of similar interventions offered in relatively similar circumstances? If
so, the profession might begin to consider studying whether the intervention analyzed in this case
study is now appropriate for so-called “clinical trials” in order to determine if it is better than no
intervention at all or better than some other intervention commonly employed. As Fitchett writes,
“It will be a big job to build a body of case studies, link them to theories, and later test the
interventions described in them. And we will have to do this over and over for different types of
patients and different chaplain interventions. … When we have a sufficient body of theoreticallyilluminated case material then we will be in a position to design preliminary trial [studies].”xlii
Conclusion
Because only single cases, or a small number of focal cases, are analyzed in case study research,
the power of the methodology is a product of the number of elements that can be detailed and the
relational connections and frames of reference that are possible. Confounding this, though, is Yin’s
reminder that “there will always be too many ‘variables’” in a case study.xliii Case study research
does not take place in the vacuum of a laboratory but is carried out in the midst of people’s lives. It
is, by definition, rich and messy. The researcher’s ability to provide a vibrant and stimulating
profile of a case, highlighting examples and linking them to broader issues and theoretical or
theological understandings, is critical.
For researchers, the closeness of the case study to real-life situations and its multiple
wealth of details are important in two respects. First, it is important for the
development of a nuanced view of reality, including the view that human behavior
cannot be meaningfully understood as simply the rule-governed acts found at the
lowest levels of the learning process and in much theory. Second, cases are
important for researchers’ own learning processes in developing the skills needed to
do good research. If researchers wish to develop their own skills to a high level, then
concrete, context-dependent experience is just as central for them as to
professionals learning any other specific skills.xliv
When journalists were pressing him to understand what he was doing, Albert Einstein is reported to
have told them, “If we knew what it was we were doing, it would not be called research, would it?”
Chaplains, welcome to research!
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i
Bent Flyvbjerg, “Five misunderstandings about case-study research,” Qualitative Inquiry 12, no. 2 (2006): 241.
ii
Anton T. Boisen, Explorations of the Inner World: A Study of Mental Disorder and Religious Experience (New York: Willett,
Clark & Company, 1936).
iii
Thomas S. Kuhn, “What are scientific revolutions?” in The Probabilistic Revolution, eds. Lorenz Kruger, Lorraine J. Daston
and Michael Heidelberger, 7-22 (Cambridge, MA: MIT Press, 1987).
iv
George Fitchett, “Why case studies are the first step toward developing evidence-based spiritual care” (paper presented
for the Oncology Chaplain Case Study Project, Chicago, IL, April 12, 2010). Accessed online at
http://www.professionalchaplains.org/uploadedFiles/pdf/M1.04%20Outline%20Fitchett,%20George.pdf (July 7, 2010)
v
George Fitchett, “Health care chaplaincy as a research-informed profession: How we get there,” Journal of Health Care
Chaplaincy 12, no. 1-2 (2002): 67-72; George Fitchett and Patricia E. Murphy, “Introducing chaplains to research: ‘This
could help me,’” Journal of Health Care Chaplaincy 16, no. 3-4 (2010): 79-94.
vi
Fitchett, “Why case studies are the first step.”
vii
Fitchett, “Health care chaplaincy,” 68.
viii
Fitchett, “Why case studies are the first step.”
ix
Khairul Baharein Mohd Noor, “Case study: A strategic research methodology,” American Journal of Applied Sciences 5, no.
11 (2008): 1602.
x
Jane E. Loitman, Christian T. Sinclair and Michael J. Fisch, eds., Palliative Care: A Case Based Guide (New York: Humana
Press, 2010).
xi
George Fitchett, “Evidence-based spiritual care: How do we get there?” (paper presented at the Spiritual Care Summit ’09,
Walt Disney World, FL, February 3, 2009).
xii
Robert E. Stake, The Art of Case Study Research (Thousand Oaks, CA: SAGE Publications, 1995), 8.
xiii
Flyvbjerg, “Five misunderstandings,” 229.
xiv
Ibid., 230-31.
xv
Stake, The Art of Case Study Research, 3.
xvi
Ibid., 4.
xvii
Fitchett, “Why case studies are the first step.”
xviii
Stake, The Art of Case Study Research, 9.
xix
Ibid., 103.
xx
Robert P. Weber, Basic Content Analysis, 2nd ed. (Newbury Park, CA: SAGE Publications, Inc., 1990).
xxi
Robert K. Yin, “The case study crisis: Some answers,” Administrative Science Quarterly 26, no. 1 (March 1981): 59.
xxii
Helen Simons, “Whose data are they? Ethics in case study research,” in Case Study Research in Practice, 96-111
(London: SAGE Publications Ltd., 2009), 96.
xxiii
Ibid., 97.
xxiv
Stake, The Art of Case Study Research, 9.
xxv
Simons, “Whose data are they.” See tables, Ethical Issues in Research Design, 99, and Ethical Procedures for the
Conduct of Case Study Research, 102-3.
xxvi
Ibid., 103.
xxvii
Ibid., 101.
xxviii
Ibid., 97-100.
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xxix
Flyvbjerg, “Five misunderstandings,” 229.
xxx
Ibid., 237.
xxxi
Many QI and Lean projects are addressing familiar struggles as hospitals and other health care institutions look at what
staff do, not just with an eye toward excellence but also with an eye toward cost. “The same shifts and pressures impacting
clinicians are of concern to chaplains. Just as clinicians are looking at how to standardize what they do, and prove their
value to their belt-tightening organizations by making care delivery as efficient and cost-effective at possible, so too are
chaplains.” This could be done by simple tabulation of number and kinds of tasks completed, but if the goal is “[to] help
chaplains to … gain traction within their organizations, … assessing what chaplains do now, what they should be doing and
how the organizations can help them shift gears,” then case studies may be a powerful and evocative methodology to
achieve the goal. A hospital administrator is quoted as saying that her institution’s chaplains are training medical clinicians
in the hospital and also in outpatient clinics how to be sensitive to patients’ spiritual needs. This is a good case study focus:
how and why is such training done, what is its impact upon patients’ sense of spiritual well-being, how does it affect staff
retention and burn-out issues, how does the process work within the institution. Julia Minda, “Multitasking chaplains put
yardstick to services,” Catholic Health World 26, no.15 (September 1, 2010): Accessed online on 9/3/10 at
http://www.chausa.org/Pages/Publications/Catholic_Health_World/Catholic_Health_World_Archive/2010/September_1/Multi
tasking_chaplains_put_yardstick_to_services/.
xxxii
Betty C. Jung, “Graphing and presenting data,” http://www.bettycjung.net/Graphing.htm (accessed July 22, 2010);
Andrew V. Moore, “A model for self-organizing data visualization using decentralized multiagent systems,” in Advances in
Applied Self-Organizing Systems, ed. Mikhail Prokopenko, 291-324 (London: SpringerLink, 2008); Nancy R. Tague, The
Quality Toolbox, 2nd ed. (Milwaukee, WI: ASQ Quality Press, 2004).
xxxiii
Stake, The Art of Case Study Research, 107-12. See the entire Chapter 7, “Triangulation,” for a very readable
discussion and guidelines on using triangulation for validation, protocols for triangulation and possible targets suitable for
triangulation.
xxxiv
Ibid., 12.
xxxv
Robert K. Yin, Case Study Research, 4th ed. (Thousand Oaks, CA: SAGE Publications, 2009).
xxxvi
Helen Simons, Case Study Research in Practice (London: SAGE Publications Ltd., 2009).
xxxvii
Stake, The Art of Case Study Research.
xxxviii
George Fitchett and Patricia Murphy, “Introduction to chaplaincy research,” Association of Professional Chaplains,
http://www.professionalchaplains.org/uploadedFiles/pdf/FitchettMurphy%202010%20WebinarCoursePromo.pdf.
xxxix
HealthCare Chaplaincy, Spears Research Institute, http://www.healthcarechaplaincy.org/chaplaincy-researchresources.html.
xl
Stake, The Art of Case Study Research, 3.
xli
Ibid., xii.
xlii
Fitchett, “Why case studies are the first step.”
xliii
Yin, “The case study crisis,” 59.
xliv
Flyvbjerg, “Five misunderstandings,” 223.
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When Caring Hurts . . .
A Pilot Study Supporting Compassion-fatigued Pediatric Critical Care Nurses
Ann Sidney Charlescraft BCC • Alexander Tartaglia BCC
Diane Dodd-McCue • Sandra B. Barker
Ann Sidney Charlescraft
DMin BCC is assistant
professor, manager for
bereavement services,
Program in Patient
Counseling, at Virginia
Commonwealth
University (VCU),
Richmond, VA. She is
endorsed by the Alliance
of Baptists.
[email protected]
Alexander Tartaglia DMin
BCC is associate
professor, patient
counseling and associate
dean, School of Allied
Health Professions at
VCU. An ACPE
supervisor, he is
endorsed by the United
Church of Christ.
Diane Dodd-McCue is
associate professor,
Program in Patient
Counseling at VCU. She
holds a doctorate in
business administration
(DBA).
Sandra B. Barker PhD is
professor of psychiatry
and Bill Balaban
endowed chair in humananimal interaction at
VCU.
Compassion fatigue is often experienced in health care institutions yet few
programs exist to identify and address the needs of employees. This article
describes one organization’s limited subject size pilot project to support
health care providers in achieving a healthy balance in work and life, while
offering opportunity for professional and personal maturity. The article
acknowledges the need for collaboration between hospital administration and
its employees in achieving that balance. The article describes the vital role
that chaplains may play in soul care of individuals and institutions when
addressing self-care as an ethical and pastoral priority in health care. Lead
author Ann Sidney Charlescraft will present a professional development
intensive on compassion fatigue and self-care at the Association of
Professional Chaplains’ 2011 Annual Conference in Dallas, TX.
THERE IS A SOUL WEARINESS that comes with caring,
from daily doing business with the handiwork of fear.
Sometimes it lives at the edges of one’s life, brushing against
hope and barely making its presence known. At other times, it
comes crashing in, overtaking one with its vivid images of
another’s terror with its profound demands for attention;
nightmares, strange fears, and generalized hopelessness.1
When caring hurts, the effect may be felt throughout a health care
institution—families devastated, health care providers traumatized,
communities suffering, effectiveness decreasing, professionals feeling as
though they have failed. This is an easily recognized scenario in a level one
trauma center as the staff seeks to offer the very best care of mind, body,
and spirit for patients, families and colleagues. Nursing staffs in particular,
but all health care providers, are vulnerable to secondary traumatic stress
commonly referred to as compassion fatigue. The Virginia Commonwealth
University Medical Center Pediatric Critical Care Unit and the pediatric
chaplain teamed to investigate and intervene on behalf of compassionfatigued critical care nurses.
Literature review
Compassion fatigue
Compassion fatigue, first named by Joinson in 1992, has become an area of
interest in a variety of disciplines within caregiving professions.2 Initially
studied by Charles Figley relative to the psychological trauma associated with
the work of first responders—firefighters, police and emergency medical personnel—the work has
expanded to include the compassion fatigue of second responders.3 The work of Charles Figley and
B. Hudnall Stamm has served as a primary impetus for the work and study of caring for the
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caregiver. Studies in health care and compassion fatigue include critical care nurses in pediatrics
and oncology, physicians, and social workers.4
Compassion fatigue is a natural emotional response to the intense trauma and extensive loss felt
by many health care providers who work with traumatized and dying patients and their families.
Compassion fatigue is the normal response to extreme events, and is a treatable and sometimes
preventable consequence of working in difficult situations that affect the human spirit. Compassion
fatigue can occur suddenly with one event triggering deep sadness and hopelessness as a result of
working with traumatized individuals or it may occur over time as the cumulative effect of working
with victims, traumatic injury, and death.5 Compassion fatigue is a hazard of working in health care
that begs the attention of health care providers and institutions of how to address individually and
collectively this known, natural, prevalent, and preventable condition related to caregiving.
Compassion fatigue affects the efficient and effective work of caregivers as demonstrated through
studies by J. Joy Allen (1999) who investigated posttraumatic stress disorder (PTSD)
symptomatology in critical care nurses. Allen’s study found that 90 percent of dedicated critical
care nurses are likely to experience PTSD symptoms during their career.6 Nurses, as well as other
professional caregivers, appear to be at risk for compassion fatigue by the very nature of their
work.
Compassion fatigue, PTSD and burnout have been linked in the literature.7 Each has its unique
characteristics and qualities. Compassion fatigue is 100 percent treatable whereas PTSD is a
managed health care condition.8 The literature also identifies elements of compassion fatigue
ensuing from emotional and spiritual fatigue as a result of exposure to traumatic events or longterm exposure to death and dying.9 Burnout, however, results from frustration with systems and
the perceived inability to affect change.10 Compassion fatigue may be a precursor to burnout as
providers experience the spiritual and emotional fatigue bumping up against limited and ineffective
resources.
Compassion fatigue symptoms are similar to PTSD as compassion-fatigued individuals may
experience nightmares, depression, heightened startle response, helplessness, anger, irritability,
sleep disruption, fear, anxiety, guilt and grief. The overwhelming experience is one of deep
emotional, psychological and spiritual pain as well as a sense of the loss of self. Individuals
experiencing burnout may exhibit similar symptoms; however, in contrast, the contributing factors
in burnout are insufficient resources, disrespect, lack of pay, lack of security and a perceived lack
of opportunity for increased skill development and promotion.11
While compassion fatigue among health care providers is well documented, interventions to
address this condition among health care professionals typically focus on what the individual
caregiver can offer him or herself.12 Compassion fatigue interventions must extend beyond this
limited focus to include education and support offered by the organization that addresses care of
self, care of others, significant growth in self awareness and spiritual versus religious formation.
Spiritual well-being
Spiritual well-being is described in the literature from a multifaceted approach. While persons may
evaluate their own sense of spiritual well-being, the indices that David Moberg identified for
evaluation include attitudes, beliefs, social activities, feelings, religious activities and identity.13
Spiritual well-being is personal and identifiable by one’s pursuit of wholeness in a lifelong process.
In reviewing holistic health care literature, Lydia Manning determined that spirituality is equated
with a personal philosophy of meaning that includes meaning and purpose in life; transcendence of
self; connection to self, others, and God/Life Force; and a sense of knowing.14 Enhanced spiritual
well-being appears to be beneficial in mitigating the effects of compassion fatigue.
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Self-care
Self-care addresses those elements of life that allow one to be well in a variety of ways—spiritually,
emotionally, physically and mentally—for the purpose of renewal and personal growth.15 Stamm
resisted using the term self-care as she feared people would not understand that self-care is
multilayered and includes personal, professional, collegial and institutional responsibilities.16 Good
self-care requires intentional and disciplined daily activities by the individual to provide the ongoing
rest and renewal needed for mitigating the effects of compassion fatigue. Likewise, institutions
supporting employees through paid time off, adequate health care insurance, preventive health
care resources and reduction of stress through appropriate work schedules, child and adult day
care services, pre-tax payroll deduction for parking fees and other services contribute to the
decrease of compassion fatigue and burnout among health care providers.
Research project
Purpose of study
“Promoting Self-care among Caregivers” was designed to determine if planned educational
interventions would positively affect pediatric critical care nurses’ level of compassion fatigue and
spiritual well-being. The study was based on the empirical research that documents the impact of
compassion fatigue, burnout and stress among caregivers, in particular, pediatric intensive care
unit (PICU) nurses. The aim of the research was two-fold. First, it sought to identify the anticipated
benefits of self-care education and support sessions in the reduction of compassion fatigue levels.
Second, it sought to enhance spiritual well-being among pediatric critical care nurses.
Methodology
The research used a prospective quasi-experimental design with a purposeful sample of pediatric
critical care nurses. All PICU nurses with at least two years of ICU experience were invited to
participate in the study. The sample group was small (n=6). All participants were female with a
range of ICU nursing experience from two to twenty years. Participants completed two
preintervention surveys: the Compassion Satisfaction and Fatigue Test (CSF) developed by Figley
and Stamm (1996), and the Spiritual Well-Being Questionnaire (SWB), designed by Moberg (1984)
and updated by Diane Dodd-McCue (2004).
CSF is a 66-item self-report instrument previously used with caregivers in health services
organizations. The instrument consists of three subscales: compassion satisfaction, burnout and
compassion fatigue with published measurement reliability (Cronback’s alpha, .87, .90, and .87
respectively).17 SWB is an 87-item self-report instrument consisting of thirteen different scales and
indices. The reported measurement reliability of these measures range from .63 (Cronback’s alpha,
personal piety scale) to .86 (Cronback’s alpha, religious well-being scale).18
Each participant also engaged in a confidential individual interview during the first week of the fivesession intervention program. The confidential interview utilized a set of standard open-ended
questions designed by the researcher and the interventionist and conducted by the researcher for
reliability and consistency. At the conclusion of the program, all participants again completed the
CSF and SWB and participated in individual confidential interviews with open-ended questions. Both
quantitative and qualitative data collections were obtained using the stated instruments and
through written field notes of both the research coordinator who conducted the interviews and the
chaplain interventionist who provided the program. In addition, as a pastoral care study, the
chaplain also offered private counseling sessions for participants upon request.
Interventions
This pilot program was designed to maximize education and reflection on self-care as a personal,
professional, collegial and institutional responsibility for health care practitioners. The pilot program
sought to be inclusive of mind/body/spirit dimensions and integration, as well as transformational
in understanding of self and the role of spiritual well-being in wholeness and health. Each session
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addressed elements of mind, body and spirit connections believed beneficial for healing and
recovery of persons experiencing compassion fatigue.
Primary voices affecting self-care philosophy and practice—culture, personality and essence,
theology, and family—were addressed. Sessions were designed for both content and experiential
learning utilizing the “action-reflection” model that is standard in clinical pastoral education (CPE).
Participants were given weekly assignments as incentive to practice the experiential learning
acquired during sessions. The model included various teaching/learning techniques to address the
diversity of learning styles of the participants. Four sessions were designed as 4-hour blocks, and
one session was a full-day retreat away from the work environment. The program was completed
in a three-month timeframe. All participants agreed to attend all five sessions and to complete
homework between sessions.
COMPASSION FATIGUE AND SELF-CARE (SESSION 1) educated participants about compassion fatigue,
compassion satisfaction, burnout, spiritual well-being, spirituality, religion and self-care. The
session was designed to help them define and understand the broader context of self-care, to
reflect on their current level of self-care and to explore three practical methods of self-care—
reflection, hand massage, and centering prayer. Each participant had opportunity to engage in the
practice of self-care. The session included a discussion on self-care as a philosophy and theology of
living well. Each participant left with the assignment of being mindful each day of ways in which
she offered herself care and ways in which she might create changes to provide greater self-care.
CULTURE AND SELF-CARE (SESSION 2) highlighted the cultural expectations of self-care. Too often
caregivers feel selfish when providing themselves with care, and yet not to do so may hinder the
care they seek to offer others. Participants identified cultural expectations of self-care in western
culture, health care and, in particular, the culture of the PICU. They examined the expectations and
identified what would be most beneficial in their nursing unit and in their family lives to enhance
well-being, as well as the elements that hindered good self-care. Participants were taught two new
self-care methodologies: breath prayer and reframing. Subsequently, they participated in
additional work using reflection as a means of self-care. Participants were encouraged to use these
methods daily for the two weeks between sessions. In addition, each participant was provided a
spa gift certificate to experience reflexology as a means of self-care.
PERSONALITY, ESSENCE, AND SELF-CARE (SESSION 3) engaged participants in using the enneagram as a
tool for self-awareness and understanding. Participants completed the enneagram inventory prior
to the session, and through didactic exploration, gained a greater perspective on personality and
essence. This 8-hour, off campus retreat gave participants a greater opportunity to reflect on the
nursing unit’s movement from a blame culture to a problem-solving culture. By this time, nearly six
weeks into the program, participants recognized that their personal growth and reflection on selfcare was beginning to affect the full unit in a positive manner. Homework was essential for the
sustainability of the participants’ growth, and through reflecting and reframing situations at home
and work as well as addressing their feelings about situations, the participants began to
experience recovery and healing from compassion fatigue. In addition, they were able to express
the benefits of breath prayer and reflection as valuable tools for self-care.
THEOLOGICAL ISSUES AND SELF-CARE (Session 4) explored beliefs and values in relation to theology and
self-care. Participants were given information on standard indicators of well-being and discussed
the spiritual aspects. As they acknowledged belief in a higher power, confusion between spirituality
and religion and difficulty with suffering and grace, they recognized their limited opportunity for
spiritual growth and their self-imposed limitations in working with patients and families in the area
of spirituality and cure. Art was utilized as a way for participants to express grief and loss within
the work environment. Participants were especially appreciative of this method of self-care,
expressing surprise at the richness and release of emotions afforded through art.
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FAMILY AND SELF-CARE (SESSION 5) focused on family and self-care as another attempt at selfawareness. How had participants learned self-care habits? What had they modified or enhanced in
the last eight weeks? Working in pairs, they identified characteristics in their families of origin that
were beneficial and non-beneficial in learning good self-care. Each participant created a family
genogram and began a process of reframing and evaluating family relationships. By this session
participants were able to identify patterns of relational engagement in their lives that contributed
to their potential for experiencing compassion fatigue. They identified ways of self-care that had
provided greater renewal and refreshment of spirit that helped to mitigate the effects of
compassion fatigue. The session closed with reflections on grace and blessing in their personal and
professional lives.
Results
Qualitative and quantitative data for the study were collected by the research coordinator and by
the chaplain interventionist through pre and postsurvey instruments on compassion fatigue and
spiritual well-being as well as pre and post individual confidential interviews. In addition, qualitative
data were gathered by the chaplain through the five educational and support sessions and through
conversations with the pediatric critical care staff.
Compassion satisfaction and compassion fatigue intervention instruments provided group scores
that indicated nurses generally exhibit good potential for compassion satisfaction, low risk for
burnout and high risk for compassion fatigue. (See Table 1.)
Spiritual well-being surveys indicated slight changes in mean scores for beliefs, attitudes and social
activities following the intervention program. The group mean change from preintervention beliefs
and attitudes to postintervention beliefs and attitudes suggests a slightly greater optimism among
participants as identified through survey mean scores and behavioral changes. (See Table 2.)
Postintervention interview results revealed enhanced self awareness, acceptance of responsibility
by individual participants in care of self and support of colleagues, improved relationships between
bedside nurses and management, improved sense of community within the unit, improved collegial
trust, greater personal and professional connection for participants and enhanced ability by
participants to reframe workplace issues. Participants demonstrated increased competence in
vocabulary and framework for processing self-care and workplace issues.
Physical compassion fatigue symptoms were no longer prevalent in the postinterview
conversations. Participants’ emotional compassion fatigue symptoms decreased significantly after
having gained skills for problem solving, self affirmation, collegial affirmation and
knowledge/utilization of human resource supports within the institution.
Participants, who had previously reported negative feelings about their professional life, reported a
more hopeful perspective following the interventions. One nurse, who had questioned her decision
to specialize in pediatrics, was able fully to affirm her choice of the pediatric patient population as
congruent with her philosophy of life and work. She remains in the PICU today, five years after this
interventional program.
Postintervention spiritual well-being was reported by participants with greater ease and clarity.
Participants identified greater connection to self, others and a Higher Power. All participants noted
greater integration of spiritual well-being in their lives and the lives of their significant others. They
gained a greater understanding, appreciation and enthusiasm for spiritual well-being as a
necessary dimension of self-care.
Based on postintervention interview results, self-care efforts revealed enhanced sense of self and
self worth through intentional and practical methods of self-care. All participants demonstrated
increased mindfulness about stressors and intentional methods of coping. Intentionality and
mindfulness became key elements in participants’ self-care philosophy and practice.
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Discussion
The basic assumption of the compassion fatigue and self-care pilot program was that enhanced self
awareness, improved spiritual well-being and intentional self-care would positively affect the wellbeing of PICU nurses and thereby reduce the effects of compassion fatigue. The data collection
affirmed self-care education as a positive avenue for supporting this group of nurses. Although the
compassion fatigue risk group norm decreased, the quantitative data gathered at the group level
reflected minimal changes in compassion satisfaction, burnout and compassion fatigue. Group
means on spirituality subscales remained fairly constant with the exception of “Beliefs and
Attitudes,” which indicated a desired change over time. This is noteworthy because of the four
spirituality scales, beliefs and attitudes reflect a starting point for possible changes in self-care.
The quantitative data supplemented by the qualitative data suggest that self-care interventions are
beneficial in reducing and coping with the effects of compassion fatigue. Through education and
support, creative outlets and intentional reflection, the nurses reported an increased ability to
reframe not only work, but also their lives, thus offering greater balance between the two. The
results also suggest an increase in perceived spiritual well-being by the participants. This change is
congruent with the research on intentionality and mindfulness in care of self as a means for
increased well-being.19
The observable and self-reported changes of increased well-being, reframing of workplace issues,
and overall improved coping with the stresses of the work environment appear to support self-care
educational programming for nurses. Participants affirmed self-care education as a valuable
opportunity for all nurses. Specifically, they indicated that it would be beneficial for inexperienced
nurses, believing that education about self-care early in one’s career may make a difference
throughout one’s professional life.
There were several observable and self-reported changes for the nurses in the pilot program,
including decrease in negative physical symptoms, better coping skills, increased collegiality,
greater optimism and increased initiative in problem solving. Participants indicated an increase in
trust among colleagues and a willingness to share professional concerns in a proactive, problemsolving manner.
This study is not without its limitations. First, the authors recognize that the sample is small and
that participants were selected from one critical care nursing unit. These two factors limit the
generalizability of the data. Second, all study participants had a prior relationship with the chaplain
interventionist who conducted the majority of interventions. This factor may enhance the
opportunity for response bias. In particular, self-report bias has its own set of limitations. In this
case, social desirability, tendency to look good, as well as acquiescence and desire to please, may
impact the findings. Third, only five of the six participants elected to use the individual counseling
sessions. This limits the standardization of the interventions as the study cannot factor how these
sessions may have affected the results. Other potential limitations include subjects receiving their
pretest scores prior to conclusion of interventions and the lack of a control group.
Implications of study
The potential implications for pastoral care are multiple. First, it offers an opportunity for pastoral
care departments to analyze and expand their scope of practice. Providing staff support is nothing
new for chaplains and is likely included in the philosophy and practice of most departments.
Chaplains typically are involved in debriefing sessions with staff following difficult situations.
However, structured scheduled interventions designed for defined outcomes—in this case,
mitigating compassion fatigue and reducing staff turnover—are much less common. Nonetheless,
this is consistent with the accepted notion that chaplains have a responsibility to understand the
stressors in which they minister and to provide “soul” care for an institution.
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Second, it offers an opportunity to highlight the cost-effectiveness of pastoral care. Considering the
cost of replacing one critical care nurse, one might suggest that the return on investment is
extraordinary for an institution that employs a chaplain whose primary responsibility is to provide
staff support along the lines of this pilot study.
Third, this study is one that is readily replicated. As such, it offers considerable opportunity for
future study that could be expanded to multiple sites.
Implications of the study for nursing and health care administration are the acknowledgment that
personnel need the support of systems to grow and mature professionally and personally. While
not the sole responsibility of an organization, the advantage for an institution may be the financial
gain in reduction of staff turnover and an evolving institution where individuals help to mature and
grow an institution collectively. The turnover of one ICU nurse in this health system is a loss of
$145,000, a figure that does not include the wisdom and knowledge of experienced personnel. The
empowerment that participants felt and exhibited during the study session provided increased
creativity in problem solving within the PICU. This empowerment was reflected in an improved,
more effective and efficient unit. Nursing retention was a noteworthy benefit of the program with
all participants making intentional decisions to remain in pediatric nursing and identifying self-care
education along with enhanced spiritual well-being as valuable tools for nursing staff retention. The
positive changes with the pilot program group also provided impetus for greater collegiality and
communication among the nursing staff and full interdisciplinary team.
This study appears to indicate that self-care education and enhancement of spiritual well-being is
one method of supporting health care staff who are experiencing day-to-day challenges and facing
the emotional, spiritual and psychological trauma of working with difficult situations. The benefits
of providing such a program include improved individual and nursing unit functioning along with
positively increased personal functioning of individuals. Improved unit function supports the goal
and mission of health care for the benefit of patients and families, while meeting the employees’
need for a safe, trusting and collaborative work environment.
The role of pastoral care is supported in this study as pastoral care providers in health care seek to
support patients, families and staff and to embrace the soul of the institution. Compassion fatigue
risk always will be present in caregiving. However, when organizations understand and respond to
the depth of compassionate pain that health care providers experience, and health care providers
attend to their own physical, mental, emotional and spiritual needs, transformation of institutions
and individuals can and will occur.
Conclusion
Self-care education and enhanced spiritual well-being appear to positively affect the health of the
entire institution and the individual employee. They offer financial gains for the institution with
reduced turnover and increased retention. Most importantly, providing self-care education and
spiritual renewal opportunities for staff provides a healthier environment for nurses, institutions
and communities. Providing opportunities for self-care education and enhancement of spiritual
well-being by chaplains also provides support for sustained professional pastoral care presence in
health care institutions. The benefit of support and education of staff through self-care, self
awareness and spiritual growth, far exceeds the cost of chaplaincy support for health care
institutions. As chaplains we are called to compassionate care and hospitality, and when we provide
a sacred, emotionally safe and educative space for individual and institutional maturation we are
practicing the long history of soul care for individuals and communities.
Author note
For additional information or consultation, please contact Ann Charlescraft, [email protected] or
804.828.4661. Dr. Charlescraft will present a train-the-trainer intensive on compassion fatigue and
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
22
self-care at the Association of Professional Chaplains (APC) conference in Dallas, TX, March 23,
2011. Conference information is available on the APC Web site (www.professionalchaplains.org).
1
B. Hudnall Stamm, Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers and Educators (Lutherville,
MD: Sidran Press, 1999), xix.
2
C. L. Joinson, “Coping with compassion fatigue: Burned out and burned up – Has caring for others made you too tired to
care for yourself?” Nursing 92, no. 4 (1992): 116-21; R. Adams, C. Figley and J. Boscarino, “Compassion fatigue and
psychological distress among social workers: A validation study,” American Journal of Orthopsychiatry 76 (2008): 103-8; D.
DePanfillis, “Compassion fatigue, burnout and compassion satisfaction: Implications for retention of workers,” Child Abuse
and Neglect 30 (2006), 1067-1069; Charles R. Figley, ed., Compassion Fatigue: Coping with Secondary Traumatic Stress
Disorder in Those Who Treat the Traumatized (London, Brunner-Routledge, 1995).
3
Eric Gentry, Anna B. Baranowsky and Kathleen Dunning, “The accelerated recovery program for compassion fatigue, “ in
Treating Compassion Fatigue, ed., Charles R. Figley, 123-38 (New York: Routledge, 2002); Stamm, Secondary Traumatic
Stress, xxi.
4
Adams, “Compassion fatigue and psychological stress,” 103; P. Meadors and A. Lamson, “Compassion fatigue and
secondary traumatization: Provider self-care on intensive care units for children,” Journal of Pediatric Health Care 18, no.4
(2008): 171-79; John-Henry Pfifferling and Kay Gilley, “Overcoming compassion fatigue,” Family Practice Management,
American Academy of Family Physicians (April 2000): 113-20.
5
Charles R. Figley, ed., Treating Compassion Fatigue (New York: Routledge, 2002), 213; Christina Maslach, Burnout: The
Cost of Caring (Englewood Cliffs, New Jersey: Prentice-Hall 1982).
6
J. Joy Allen, “Intensive Care Nurses: Posttraumatic Stress Disorder-like Symptomatology,” PhD dissertation (California,
Loma Linda University 1999), 58.
7
B. Hudnall Stamm, “Measuring compassion satisfaction as well as fatigue. Developmental history of the compassion
satisfaction and fatigue test,” in Treating Compassion Fatigue, ed. Charles R. Figley, 107-22 (New York: Routledge, 2002);
L. A. Pearlman and P. S. MacIan, “Vicarious traumatization: An empirical study of the effects of trauma work on trauma
therapists,” Professional Psychology: Research and Practice 26 (1995): 558-65.
8
Figley, Compassion Fatigue: Coping with, 84.
9
Gentry, “The accelerated recovery,” 123-38; Theresa A. Rando, Grief, Dying and Death: Clinical Interventions for
Caregivers (Champaign, IL: Research Press Company 1984), 437.
10
Jennifer C. Maytum, Mary Bielski Heiman and Ann W. Garwick, “Compassion fatigue and burnout in nurses who work with
children with chronic conditions and their families,” Journal of Pediatric Health Care 18 (2004): 171-79; D. Garrett and A.
McDaniel, “A new look at nurse burnout: The effects of environmental uncertainty and social climate,” Journal of Nursing
Administration, 31 (2001): 91-96; Maslach, “Burnout,” 10.
11
Maslach, “Burnout,” 25; David G. Benner, “Understanding, measuring, and facilitating spiritual well-being: Introduction to
a special issue,” Journal of Psychology and Theology 19, no. 1 (1991): 3-5.
12
Stamm, “Measuring compassion satisfaction,” 107-22.
13
David O. Moberg, “Subjective measures of spiritual well-being,” Review of Religious Research 25 (1984): 351-59.
14
Lydia Manning, “Defining Spirituality from a Student’s Perspective,” American Association of Integrative Medicine, 2003.
15
Teresa E. Snorton, “Self-care for the African American Woman,” in In Her Own Time: Women and Developmental Issues
in Pastoral Care, ed. Jeanne Stevenson-Moessner, 285-94 (Minneapolis: Augsburg Press, 2000).
16
Stamm, Secondary Traumatic Stress, xx.
17
Figley, Treating Compassion Fatigue, 112.
18
Moberg, “Subjective measures,” 351-59; Michael J. Boivin, “Spiritual well-being questionnaire,” in Measures of Religiosity,
ed. Peter C. Hill and Ralph W. Hood, Jr. 375-81 (Birmingham, AL: Religious Education Press, 1999).
19
Snorton, “Self-care,” 289.
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Table 1 – Compassion satisfaction and fatigue test (Figley and Stamm 1996)
Six PICU nurses completed this instrument prior to the start of the educational intervention (December 2004) and at its
conclusion (February 2005). Group results appear in bold italics in two shaded columns on the right. Participants were
provided with both their individual responses and the group results following each survey administration.
SCALE
Compassion
Satisfaction
OBJECTIVE/
INTERPRETATION
Reflects potential for
satisfaction with
compassion in
caregiving
responsibilities
High score
more desirable
Burnout
Reflects risk of
burnout from
caregiving
responsibilities
Low score
more desirable
Compassion
Fatigue
Reflects risk of
compassion fatigue
from caregiving
responsibilities
Low score
more desirable
SCALE OVERVIEW
Scale Range: 0-330
OVERVIEW
OF GROUP
RESPONSES
OVERVIEW
OF GROUP
RESPONSES
PRETEST
POSTTEST
Range: 79-97
Mean = 88
Range: 75-102
Mean = 87
Range: 19-49
Mean = 32
Range: 13-49
Mean = 34
Range: 12-57
Mean = 40
Range: 19-63
Mean = 38
Extremely high ≥ 118
High = 110-117
Good = 82-99
Modest = 64-81
Low ≤ 63
Scale Range: 0-85
Extremely low ≤ 36
Moderate = 37-50
High = 51-75
Extremely high = 76-85
Scale Range: 0-115
Extremely low ≤ 26
Low = 27-30
Moderate = 31-35
High = 36-40
Extremely high ≥ 41
Data collected by Research Coordinator Diane Dodd-McCue
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Table 2 – Spiritual well-being questionnaire (Moberg 1984)
Six PICU nurses completed this instrument prior to the start of the educational intervention (December 2004) and at its
conclusion (February 2005). Group results appear in bold italics in two shaded columns on the right. Participants were
provided with both their individual responses and the group results following each survey administration.
SCALE
Beliefs
and
Attitudes
OBJECTIVE/
INTERPRETATION
Reflects composite of
several different scales
and indices, including
those on faith, spiritual
well-being and religious
cynicism
Low score
more desirable
Social
Activities
Reflects whether active
or passive stance taken
relative to religion,
politics, social issues
Scores show balance
between active and
passive
Feelings
Religious
Activities,
Identity
SCALE OVERVIEW
Scale Range: 76-386
Scale Mean = 155
OVERVIEW OF
GROUP RESPONSE
PRETEST
OVERVIEW OF
GROUP RESPONSE
POSTTEST
Range: 115-180
Mean = 148
Range: 107-191
Mean = 134
Range
Active: 2-10
Passive: 6-14
Range
Active: 8-14
Passive: 2-8
Mean
Active = 7
Passive = 9
Mean
Active = 11
Passive = 5
Quantiles of all
possible scores:
76-154
155-232
233-310
311-386
Scale distribution of 16
points across two categories
(active or passive);
presented as two scores for
simplification
Active/Passive Range: 0-16
Scale Mean = 8
Balanced perspective:
Active = 8
Passive = 8
Three of six
participants had
equal balance:
8 for each scale
Reflects wide range of
emotions
Scale range: 8-56
Scale mean = 28
Range: 15-34
Mean = 23
Range: 14-33
Mean = 24
Low scores more
desirable than high
scores
Quantiles of all
possible scores:
8-20
21-32
33-44
45-56
Scale looks at activities,
identity; this study
limited scores to
activities as identity
categories may not be
relevant to study group
Scale range: 11-60
Scale mean = 36
Range: 14-49
Mean = 38
Range: 23-67
Mean = 45
Low scores reflect more
religious activities
Quantiles of all
possible scores:
11-23
24-35
36-47
48-60
Data collected by Research Coordinator Diane Dodd-McCue
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
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Protocol-based Referrals:
A Method for Selecting Patients in the Electronic Age
Mark LaRocca-Pitts BCC
Effective patient selection is a perennial concern for chaplains. Various
methods have been proposed, including case finding, third-party referral and
standard response. As a form of standard response, protocol-based referrals
provide a rational plan for selecting patients. Protocol-based referrals include
end-of-life, crisis, transition-in-care and procedure-specific situations. A
patient selection system utilizing protocol-based referrals capitalizes on
electronic medical records and provides a solid clinical backbone for hospitalbased chaplaincy.
The Reverend Mark
LaRocca-Pitts PhD BCC
serves as chaplain with
Crossroads Hospice,
Atlanta, GA. He is
endorsed by the United
Methodist Church. This
article draws on
experience gained during
his tenure at Athens (GA)
Regional Medical Center.
[email protected]
IN 1939, RUSSELL DICKS, a chaplain at Presbyterian Hospital in
Chicago, Illinois, delivered a seminal speech at the annual meeting of the
American Protestant Hospital Association.1 Dicks outlined four requirements,
which in a later work were expanded to eight, that he considered essential for
effective work of the chaplain.2 Of these four, the second requirement is of
interest to this paper: the chaplain “shall have a plan whereby he [sic] selects
the patients he is to call upon.” He later modified this requirement with the
adjectival addition of “rational.”3
According to Dicks, “the chaplain can no longer wander from bed to bed, chatting agreeably,
relieving distress occasionally as he discovers it, while down the hall behind a door ….”4 In other
words, without a rational plan for selecting patients, chaplains are left guessing among door
number 1, door number 2 and door number 3. This need for a rational and effective selection plan
remains a perennial concern as echoed some sixty years later in the work of Fitchett, Meyer and
Burton: “How do hospital chaplains and managers of hospital spiritual care departments decide
which patients should receive a visit from a chaplain?”5
Though the heart and soul of chaplaincy remains rooted in relationship, the “net” that chapains
cast to capture spiritual needs must fit well with the modern clinical environment. Door-to-door or
unit-to-unit relational chaplaincy may once have been the best net to capture need. However, the
current reality of ever-decreasing length of stay in acute care settings, ever-increasing demands on
a chaplain’s time and dictates of quality, calls for a more effective and rational net for identifying
patients. This rational net should not replace relational chaplaincy; rather, it should complement it.
This paper presents a protocol-based referral model for patient selection, which combines and
reinterprets previous models as found in the literature. Critical to the implementation of this model
are the new electronic medical records that are becoming standard in most hospitals today.
Following a short review of literature in which the various patient selection models are discussed
and new terms introduced, the author will explore the strengths and limitations of a patient
selection model that uses protocol-based referral as its backbone.
Literature review
Over the years since Dicks challenged chaplains to develop a rational plan for selecting patients
various models have been put forth. Gregory Stoddard distilled these into three categories:
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1. Case finding – chaplain-initiated rounds, e.g., visits to all new admissions or rounding at
nursing stations to inquire after people in need.
2. Referral – chaplain involvement through the referral of third parties.
3. Standard response – chaplain involvement in predetermined situations by administrative
mandate which usually is defined by department or hospital policy, e.g., cardiac arrest calls,
emergency room traumas.6
Case finding
Also called chaplain-initiated rounds, this method is a time-honored model supported by such
pastoral care luminaries as Ernest Bruder and Lawrence Holst.7 Examples may include seeing all
new admits and/or making chaplaincy rounds to nursing stations in order to identify patients in
need of spiritual care. Holst describes this form of pastoral care intervention in the following
manner: “The right of geographical initiative is a valuable vestige of pastoral care’s rich heritage. It
is ‘a custom of the discipline.’ It is essentially the chaplain’s freedom to create and control the
time, place, setting in which, and person to whom, pastoral care is offered.”8
This model certainly speaks to chaplains who see a combination of freedom and control as an
essential part of their particular practice; however, as Stoddard claims, a case-findings model alone
is difficult to justify and to defend in the current cost-conscious environment.9 Also, since it
depends on luck and timing or on nurses’ abilities to recognize spiritual needs and to provide
appropriate referrals, this model falls victim to Dicks’s critique of potentially missing those with
significant spiritual needs. Patient selection may incorporate some case-finding referrals, but this
should not comprise the whole of the model.
Referral
This category also has received support from various quarters within the pastoral care tradition,
including Stoddard himself.10 These referrals often are independent of chaplain-initiated rounds and
generally originate from a third party, such as a member of the hospital staff or a patient/family
member. Stoddard contends that a referral-based model is critical to departmental plans and that
“experiencing a growing number of documented referrals serves as hard evidence of the demand
for chaplaincy.”11 A study conducted by the Catholic Health Association of the United States
supports this statement, concluding that “because of time constraints and greater acuity, fewer and
fewer departments are seeing every patient. Pastoral care will increasingly rely on others to refer
those who find themselves in spiritual distress.”12 In other words, there is a movement away from
case finding to third-party referral.
Such referrals are near the heart of relational chaplaincy. Through making daily rounds, attending
interdisciplinary rounds, and providing in-services, chaplains develop relationships with the staff
and provide education on spiritual care. All of this hopefully results in appropriate referrals.
Referrals that come via these relationships and education will remain key to a chaplain’s overall
selection plan. However, maintaining this level of staff support and education requires considerable
time, which some chaplains may not be able to provide on a consistent basis. This time constraint,
coupled with the availability of electronic medical records as a triage tool for identifying potential
spiritual needs indicates that a rational plan for patient selection should not depend on referrals
alone.
Standard response
Chaplaincy departments that respond to codes, deaths and traumas as directed by administrative
policy use a standard response model. This model may include an acuity-based algorithm through
which chaplains triage their responses to these standard situations based on acuity, again as
defined by administrative policy.
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Though the term “standard response” rarely appears in pastoral care literature, the idea of
chaplains responding to predetermined situations does appear in various forms.
•
DIAGNOSIS: As one example, Dicks speaks of “watching the admission slips … [that] carry an
admission diagnosis. That information is useful to the chaplain to this extent: he is able to
select those who on the basis of their illness are facing serious stress.”13 In other words, as
Dicks continues, ulcerative colitis generally produces a level and kind of stress that differs
from an appendectomy. Based on diagnosis, i.e., a predetermined situation, a chaplain
could triage care, which is a form of standard response.
•
CLINICAL PATHWAY: A second example qualifying as a form of standard response appears in
discussions of clinical and spiritual pathways. George Handzo, in his introduction to a
symposium on clinical pathways published in Chaplaincy Today, notes that two of the
articles “seek to link spiritual issues and pastoral care tasks to distinct points in the
treatment continuum.”14 (emphasis added) Jason Cusick notes that “clinical pathways
provide a map for the general care as well as a place for each service to play a part in the
multidisciplinary treatment of the patient.”15 (emphasis added) This results in making
“pastoral care an official part of the clinical team.”16 Cusick further argues that clinical
pathways result in “the development of pastoral ministry to patients with specific
illnesses.”17 Clinical pathways are sets of illness-specific protocols designed to meet certain
outcomes, which include “distinct points” where pastoral interventions may be more
efficacious than at other points.18 Including referrals to chaplains at these distinct points is
an example of standard response.
•
PROTOCOL-BASED: A third example of a standard response referral system, protocol-based
referral, ”is found in George Handzo’s list of twelve practice areas that “are increasingly
accepted as representing the highest quality in professional pastoral care.”19 Along with
traditional protocols, such as “codes, deaths, organ donation, radical change in prognosis,
execution of advance directives, and disasters,”20 Handzo adds another category. He
connects this additional category with transitions in levels of care for the patient within the
health care system, such as changes “from hospital to hospice, assisted living to long term
care facility, regular medical care to intensive care, or from curative treatment to palliative
care.”21 Handzo recommends a chaplain referral be made at each of these distinct
transitional points in a patient’s clinical experience.
Defining protocols
Three major categories may be isolated from Handzo’s lists of protocols:
1. End-of-life protocols – death, advance directives, organ donation, post-mortem paper work.
2. Crisis protocols – codes, disasters, radical change in prognosis.
3. Transition-in-care protocols – hospital to hospice, curative to palliative, acute care to
intensive care, one facility to a second.
This author suggests a fourth, procedure-specific protocols. This might include all pre-op patients
or those in a specific category, e.g., open heart, valve replacement, amputation. It might also
include procedures such as certain chemotherapies, pacemaker insertion, percutaneous coronary
interventions, e.g., stents, and/or specific treatments related to a clinical area.
These four categories certainly overlap, and some chaplaincy departments already may have
predetermined responses to some of these situations. The issue, according to Handzo, is whether
these predetermined responses have been formalized through departmental policies that have
administrative approval. Such policies would require chaplain referrals for each of these
predetermined situations and would outline a method for triage. Formalizing this step provides an
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opportunity to educate administrators about the spiritual needs of patients and the role of
chaplaincy in a health care setting. It also elicits their explicit buy-in and continued support.
Further, it shows that chaplaincy services are “based on a plan with outcomes,” which is another
practice area Handzo outlines as critical for achieving the highest quality in professional
chaplaincy.22 Justifying such protocols, especially those focused on end of life, may be easier due to
administrators’ expectations that chaplains should have a role in such situations.23
Handzo does not address the question of how these referrals are made or entered into the system.
Who or what generates the chaplain referral? If it remains up to the chaplain to identify situations
to which the protocols apply then protocol-based referrals become a form of case finding and/or
third-party referrals. As noted earlier, referrals meditated in this fashion are subject either to the
chaplain’s detective skills or to the judgment, memory and/or good will of a third party. An
automatic, system-wide, nonsubjective process is needed that both formalizes referrals and
assures that they are made by integrating protocols into the clinical plan of care as true standard
responses. Procedure-specific protocols illustrate this process.
Procedure-specific protocols
Procedure-specific protocols capitalize on electronic medical records by embedding chaplain
referrals within the electronic medical record itself. These protocols connect automatic chaplain
referrals to specific medical orders for predetermined medical procedures. For example, surgeries
are predetermined medical procedures. Some chaplaincy departments see all pre-op patients via
the following, or a similar, method:
•
Acquire a daily list of surgical patients.
•
Visit all or some of them.
•
Document the visits.
Though this appears to be an example of a procedure-specific protocol, as defined in this article, it
is not. These referrals are indirect, added on as it were, to the list of surgical patients. The
chaplain does not receive a list of referrals; instead, the chaplain receives a list of patients to which
referrals are added. In essence, this is no different than Dicks watching the admission slips.
A chaplain referral that is added on after the fact is not an integral part of the clinical pathway.
Instead of the clinical system itself recognizing the need for a chaplain referral through direct and
explicit inclusion, the chaplain “jumps on the band wagon” after the fact. This philosophical or
systemic problem is addressed within traditional clinical pathways wherein referrals to chaplains
are integral; however, this method often requires action by a third party—nurse, chaplain or other
clinician—and thus effectively reverts to the referral mode.
The goal of procedure-specific protocols, and by extension all protocol-based referrals, is to
integrate the chaplain referral into the medical procedure in such a way that it does not require the
mediation of a third party. Electronic medical records make the automatic generation of all
protocol-based referrals possible.
Although this means of obtaining referrals moves chaplaincy away from relying exclusively on its
traditional relationship-based form, the chaplain continues in partnership with staff while at the
same time partnering with the system to meet the spiritual needs of patients. Just as each thirdparty referral may or may not be appropriate, so each automatically generated protocol-based
referral may or may not be appropriate. Every referral, regardless of origin, requires a chaplain’s
spiritual assessment to determine a plan of care. The major difference is that third-party referrals
are subject to the quality of staff education to identify spiritual distress whereas protocol-based
referrals are subject to the quality of the research, which predicts the statistical likelihood of
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spiritual distress for a given clinical situation. Thus, protocol-based chaplaincy is intended to
complement relational third-party and case-finding chaplaincy rather than to replace it.
Using electronic medical records
Electronic medical records are here to stay. Chaplaincy practice may capitalize on these new
systems to enhance as well as to integrate patient selection methods. In electronic medical
records, medical orders are entered individually or as part of an “order set” to which any number of
referrals may be attached automatically. For example, when a surgical order is placed that also
requires orders for various lab tests, nursing preparations, postoperative technical supports and/or
discharge needs, these concomitant orders form the order set attached to the single surgical order.
Entering that single surgical order now generates automatic referrals to the appropriate clinical
disciplines. With proper administrative approval, chaplaincy referrals may be added to any order
set as well.
Along with procedure-specific protocols, those addressing end of life, crisis, transitions in care and
other situations of spiritual risk also may generate automatic referrals via the electronic medical
record, provided an appropriate order is identified to which the referral may be attached. Examples
of such orders are do no resuscitate (DNR), allow natural death (AND), palliative care,
hospice/nursing home placement, certain critical diagnostic tests and advance directives. The key
is to find an appropriate order and to obtain administrative approval to attach a chaplaincy referral
as part of the concomitant order set. Once this is accomplished, the chaplain’s patient selection
practice capitalizes on the advantages of the electronic era.
Using the electronic medical record has distinct advantages. The first is the ease with which clinical
staff may place an order for the chaplain in the electronic system and the ease with which the
chaplain may check for new orders throughout the day. Stat orders still may be placed via pagers.
A second advantage is that the electronic medical record tracks all referrals. As Stoddard noted,
“experiencing a growing number of documented referrals serves as hard evidence of the demand
for chaplaincy.”24 The electronic medical record facilitates both tracking and retrieval of data.
The third advantage may first present as a disadvantage. Whether it is busy or slow, whether the
chaplain is in-house or on vacation, referrals continue to be generated per protocols, which may
result in referrals that are not followed up. This apparent weakness, however, may prove to be a
strength as it establishes unmet need. Few chaplains are able to meet all the pastoral or spiritual
needs of their patient population. Protocol-based, computer-generated, chaplaincy referrals, which
remain unmet after discharge in an electronic medical record, provide documentation of unmet
needs, which may be helpful in justifying requests to administrators for an expanded chaplaincy
presence.
Many hospitals currently are transitioning to electronic medical records. Some systems come
prepackaged with protocols already hardwired into them, including some chaplain referrals. Others
may provide for customization prior to installation. Chaplaincy departments need to be involved
proactively during the planning stages in order to insure that the system provides for appropriate
chaplain referrals. As the institution’s spiritual care specialist, the chaplain continues to provide
education on meeting the spiritual needs of the patients, but the bulk of this education moves to
the beginning of the process instead of being in the day-to-day operations.
Designing a selection plan: getting the right mix
A rational, efficient and effective plan for selecting patients—the right net as it were—is critical to a
chaplain’s professional practice. Designing an intentional selection plan involves identifying the
right mix of case-findings, third-party referral and standard response protocol-based/procedurespecific referrals for one’s particular setting. Though basing chaplaincy involvement on the level of
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staffing rather than on the spiritual needs of the patients may not be considered best practice,
designing a workable selection plan may need to consider the chaplain’s setting within his/her
respective institution.25
For example, a one-person chaplaincy department may find that adding one or two hospital-wide
protocol-based referrals is sufficient given its limited resources. In such a situation, an end-of-life
protocol, e.g., new DNR/AND orders and/or palliative care orders, may be most appropriate. On
the other hand, a multistaff department may have sufficient resources to add a number of hospitalwide protocol-based referrals as well as some that are specific to particular service lines.
Regardless of the size of the department and the number of protocol-based referrals, the more
significant part of a selection plan centers on two factors:
1. The strategic value to the institution.
2. The demonstrated impact of chaplaincy care on the targeted population.26
If an institution’s mission revolves around or highlights a particular service or patient population,
then the chaplaincy department might design appropriate protocol-based referrals that specifically
target these. For example, a pediatric hospital’s chaplaincy department, or a pediatric service line
chaplain, would design protocols for this population. A chaplaincy department connected to a
cancer or heart clinic, or a service-line chaplain in oncology or cardiology, would design protocols
for these populations. A regional medical center which heavily markets its stroke or bariatric
program may use protocol-based chaplaincy referrals to target one of these groups. Such a
selection model strategically aligns the outcomes of chaplaincy with the mission of the institution.
The second factor, the demonstrated impact of chaplaincy care on the targeted population, raises
the issue of quality for a protocol-based approach to chaplaincy mentioned above. Due to higher
morbidity and mortality, some patient populations may experience higher levels of emotional,
spiritual or existential distress. For some of these patient populations, research suggests the
benefits of psychosocial and spiritual care interventions.27 Using this research to argue for the
benefits of an automatic referral to a chaplain, who then conducts a spiritual assessment to
determine actual need, is evidence based and makes for good practice. Thus, a chaplaincy
department could design protocols that specifically target these patient populations.
Once in place, protocols automatically generate referrals on a daily basis. The chaplain also
continues to educate staff, insuring the generation of third-party referrals as well. Responding to
referrals, regardless of the source, also places the chaplain on the floors and thus in position to find
emergent cases. Ultimately, the right mix reflects the particular institution, the needs of the
patients and the “art” of chaplaincy as conceived by the individual chaplain.
Future research
Is a protocol-based referral system better than a third-party referral and/or a case-finding system?
Is one particular combination of the three better than another? Further, does a protocol-based
system lead to better third-party referrals on those units targeted by the protocols? How does one
define “better” in such analyses? Does a patient selection plan that uses protocol-based referrals as
its backbone capture more spiritual needs, or does it just make the chaplain busier? These are
questions to be answered via research projects which might also examine which of the various
protocols leads to better referrals and/or more consistently discovers spiritual needs.
One way to begin answering these questions would be to compare the quality of protocol-based
referrals with the quality of case-finding and third-party referrals. Quality would be based on
whether the chaplain’s subsequent spiritual assessment uncovered spiritual needs and whether
resulting interventions produced measurable outcomes.
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Conclusion
A patient selection plan for chaplaincy practice needs to be rational as well as relational. It also
needs to fit current clinical practices. A selection plan that uses protocol-based referrals as its
backbone meets the criteria Dicks set as rational. It strategically selects patients based on the
institution’s mission and thus aligns chaplaincy with that mission. It selects patients that have been
identified by research as having a statistically higher chance of experiencing spiritual distress. The
chaplain’s spiritual assessment then determines specific needs and formulates appropriate plans of
care.
Protocol-based referrals also are relational in that they foster ongoing involvement with clinical
staff. This high visibility, responsiveness and accountability may lead to additional opportunities to
educate staff and thus garner additional third-party referrals. The chaplain also is available to
respond to emergent situations (case finding). A protocol-based selection plan does not replace
third-party referral and case finding modes; it buttresses them.
A selection plan that uses protocol-based referrals as its backbone is well suited to the modern
clinical environment. Twenty-first century chaplaincy care needs to be on the cutting edge of
technology, and hard-wiring referrals into electronic medical records embeds it in the modern
clinical environment and makes it more effective.
1
Russell L. Dicks, “The work of the chaplain in a general hospital,” The Caregiver Journal 12, no. 1 (1996 reprint, original
1940), 2-5.
2
Russell L. Dicks, “Standards for the work of the chaplain in the general hospital,” Hospitals (Nov 1940).
3
Ibid., 2.
4
Dicks, “Work of the chaplain,” 2.
5
George Fitchitt, Peter M. Meyer and Laurel Arthur Burton, “Spiritual care in the hospital: Who requests it? Who needs it?”
Journal of Pastoral Care 54, no. 2 (Summer 2000), 173.
6
Gregory A. Stoddard, “Chaplaincy by referral: An effective model for evaluating staffing needs,” The Caregiver Journal 10,
no. 1 (1993), 38-39.
7
Ernest E. Bruder, “The role of the chaplain in patient relationships: Initial religious interview,” Journal of Pastoral Care 7,
no.1 (1953), 37-41; see also Donald C. Houts, “Pastoral initiative: Why wait for George/Georgia to do it?” Journal of
Pastoral Care 37, no. 1 (1983), 33-41; Lawrence Holst, “The random initial visit,” in Hospital Ministry: The Role of the
Chaplain Today, ed. Lawrence Holst, 68-78 (New York: Crossroads, 1991).
8
Ibid., 68.
9
Stoddard, “Chaplaincy by referral,” 38.
10
Ibid.; see also Robert A. Preston, “Some indications for referral to the hospital chaplain” Journal of Clinical Pastoral Work
1, no. 1 (1947), 38-41; John Gartner et al., “Supplier-induced demand for pastoral care services in the general hospital: A
natural experiment,” Journal of Pastoral Care 44, no. 3 (1990), 266-70.
11
Stoddard, “Chaplaincy by referral,” The Caregiver Journal 10, no. 1 (1993), 39.
12
The Catholic Health Association of the United States, Chaplaincy: Moving Toward the Next Millennium (St Louis, MO: The
Catholic Health Association of the United States, 1997), 14.
13
Dicks, “The work of the chaplain,” 3.
14
George Handzo, ed., “Symposium – Clinical pathways for pastoral care: Which way are we going,” Chaplaincy Today 14,
no. 2 (1998), 2.
15
Jason Cusick, “‘Paths they have not known’: Ministry to leukemia patients using clinical pathways,” Chaplaincy Today 14,
no. 2 (1998), 22.
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16
Ibid., 23.
17
Ibid.
18
Louis Nieuwenhuizen has developed a method for determining when pastoral interventions may be most effective. See
Louis Nieuwenhuizen, “Spiritual care illustrated: Creating a shared language,” Journal of Pastoral Care & Counseling 61, no.
4 (Winter 2007), 329-41.
19
Handzo, “Best practices,” 663. See also Mark LaRocca-Pitts et al., “A collegial process for developing better practice,”
Chaplaincy Today 24, no. 1 (Spring/Summer 2008), 3-15.
20
Handzo, “Best practices,” 663.
21
Ibid.
22
Ibid.
23
Kevin Flannelly et al., “A national survey of health care administrators’ views on the importance of various chaplain roles,”
Journal of Pastoral Care & Counseling 59, no. 1-2 (2005), 59, 87-96.
24
Stoddard, “Chaplaincy by referral,” 39.
25
George Handzo and Susan Wintz, “Professional chaplaincy: establishing a hospital-based department,” Healthcare
Executive (Jan/Feb 2006), 38-39.
26
Handzo, “Best practices,” 663.
27
As an example for oncology patients, see Tracy A. Balboni et. al., “Provision of spiritual care to patients with advanced
cancer: Associations with medical care and quality of life near death,” Journal of Clinical Oncology 28, no. 3 (Jan 20, 2010),
445-52; for palliative care patients, see C. Puchalski et al., “Improving the quality of spiritual care as a dimension of
palliative care: The report of the consensus conference,” Journal of Palliative Medicine 12, no. 10 (Oct 2009), 885-904; for
cardiac patients suffering an acute myocardial infarction, see C. F. Mendes de Leon et al., “The effect of a psychosocial
intervention and quality of life after acute myocardial infarction: The enhancing recovery in coronary heart disease
(ENRICHD) clinical trial,” Journal of Cardiopulmonary Rehabilitation 26, no. 1 (Jan-Feb 2006), 9-13; for diabetic, congestive
heart failure and oncology patients, see G. Fitchett et al., “Religious struggle: Prevalence, correlates and mental health risks
in diabetic, congestive heart failure and oncology patients,” International Journal of Psychiatry in Medicine 34, no. 2 (2004),
179-96.
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
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ESSAY
Don’t Worry, I’ve Got You
Marci Pounders BCC
THIS MORNING, ONE OF MY PARISHIONERS DIED. He was a
World War II veteran, and a wonderful, caring man. He faithfully attended
church with his wife, offered his home and heart to both his biological and
adopted children, and was a gentle joy to be around. I never heard one angry
or unpleasant word come from his mouth. Until a couple of months ago, he
was still laughing about how funny my husband looked playing Groucho Marx
in the church talent show.
The Reverend Marci
Pounders MDiv BCC
serves as palliative care
chaplain at Baylor
University Medical
Center, Dallas, TX. She is
endorsed by the
Episcopal Church USA.
[email protected]
When I first met him, he was suffering from the effects of congestive heart
failure, but nothing kept him from church. Even when he needed a walker, he
toddled along happily, and insisted on coming to the altar for communion. His
loving family hovered around him like bees to a flower. With one daughter
living next door and another in a nearby city, there was always family around.
The day came when he could no longer make it to church, so we went to him.
Wednesday was my day. I began to look forward to Wednesdays just so I
could see his smile, feel his warm hand in mine and pet his little dogs, who
were never far from his lap.
He showed me his WWII medals, and his father’s WWI medals. We shared a love of WWII history,
so we gabbed on about various battles and victories. I’d bring food and news of the church to share
as well.
We would take communion together, and I would anoint the puppies as well, because if you have
puppies, you know they have to be included in everything. One time I even gave the puppies
communion. It was hard to say no to those wagging tails—heck, humans should be so reverent!—
and to my friend’s smiling face. He got such a kick out of it. I joked that I might be defrocked for
such heresy, but I figured this was an instance where compassion took precedence over liturgical
correctness and that God’s grace would intercede.
This dear man finally went on hospice. He and his wife planned everything, from his memorial to his
disposition. There were no secrets, no denials, just a loving sharing of last days together. They both
knew the truth. He was dying. So they took joy in every moment together. For four months, he
lived happily and securely in his own home, with his puppies in his lap and his family around him.
There were no tubes, wires, PICC lines, shocks or pain.
His daughters came every day, making sure the house was decorated for Thanksgiving, then
Christmas, then St. Patrick’s Day. They all went through old photographs, laughing, talking and
remembering all the faces and family of days gone by.
He began sleeping more. He lost track of time, but it didn’t seem to bother him. He told me he
knew it was Wednesday if I came, and it was Sunday if Father Clif came. It was such a sacred time.
Each visit was an experience of the Holy.
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Then one morning, he got up very agitated and fell, unable to make it the few steps to the
bathroom. His wife was beside him immediately, saying, “Don’t worry, I’ve got you.” She cradled
him in her arms, put a pillow under his head and covered him securely with a blanket. That is how
he died—cradled in loving arms.
Now that my friend is gone, there is a hole in my heart. Yet, can one hope for a better death? What
could be better than being wrapped in loving arms and hearing, “Don’t worry. I’ve got you.” As he
“slipped the surly bonds of earth to touch the face of God,” I know that my friend heard only this
loving Voice, “Don’t worry. I’ve got you.”
In making our transitions to wherever and whatever it may be, may we all hear the Divine Voice
whispering, “Don’t worry. I’ve got you.”
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
35
Retired Chaplains’ Writing Project
Vincent Van Gogh said, "I dream my painting, and then I paint my dream." This installment of the
Retired Chaplains’ Writing Project presents reflections by three former presidents, representing the
College of Chaplains and the Association of Mental Health Clergy, organizations which merged in
1998 to form the Association of Professional Chaplains (APC). These men have spent their careers
dreaming dreams. Then they have gone ahead and symbolically picked up their brushes and turned
those dreams into beautiful murals. These expansive panoramas portray the profession of
chaplaincy on the move, constantly evolving. No still life here. The insights of these retired leaders
encourage us to explore anew the meaning of our roots and from whence comes our authority.
They challenge us to consider the importance of meaningful change—rather than change for its
own sake—and to celebrate the multitude of gifts that come to us as a result of collegiality,
diversity and inclusiveness. The reflections of these retirees compel us to explore what will be
required of individual chaplains and APC as it enlarges its tent and extends its tracks into uncharted
territory. We may become fearful and worry that our assets are, as Clark Aist said, "little more
than a handful of meal and a cruet of oil." We may wonder if we are sufficient or have sufficient
resources to get the job done. At such times, let us remember that the "treasured seed" found
deep within the heart of APC and its chaplains was placed there and is sustained now and into the
future by a power far greater than ourselves.
George R. Robie BCC (retired), Coordinator
The Integrity of Authority and Identity
Jerry J. Griffin BCC
AS I THINK RETROSPECTIVELY of the years of my seminary and
graduate education, clinical pastoral education and early professional career,
I realize that I only thought that I comprehended and understood the power
and integrity of pastoral, personal and professional authority and identity.
During the final decade of my career, the nature of the depth and breadth of
the influence and effect of these vital professional qualities emerged. I
realized that authority and identity are much more than requirements for
graduation, ordination and certification.
Jerry J. Griffin MDiv ThM
BCC (retired) continues
to serve as staff chaplain,
palliative care at
Lancaster (PA) General
Hospital. He is endorsed
by the Christian Church
(Disciples of Christ).
A metaphoric image of train and railroad portray the essentials of the
empowering qualities of professional chaplaincy care. The track on which the
responsibility and effectiveness of our ministry ride represents the
foundational nature of authority and identity. The engines that drive the
vehicle of our profession are the standards and competencies. Both entities
provide the integrity to uphold and sustain excellence.
[email protected]
As I reflected across the span of my career, I discovered that early on, I did
not fully grasp or represent the embodiment of the power and integrity of
who I am and who/what gives me the authority to minister in clinical settings. Nevertheless, the
formational, academic and theological knowledge bases were in place. In the ensuing years, the
practical, experiential and empirical opportunities precipitated the integration of the metaphoric
engines and the track. The awareness of this phenomenon extended the “rail system” into realms
that one can only imagine. I propose that this emergence in later years propelled the effectiveness
of my chaplaincy care far beyond the academic zone.
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36
I have identified some significant contributors to the expansion and enhancement of the power and
integrity of authority and identity of my professional stance and abilities. These influences are the
very essence of chaplaincy care.
One contributor is the awareness that my ministry is not mine alone to claim. By giving honor and
credit to the many mutual encounters with people, events, learning opportunities and experiences,
I am obliged to welcome a “great cloud of witnesses” into the community in which I minister. Each
time I participate in a professional opportunity, I am keenly aware that I am not there alone. This
ministry has far more depth and power than one individual can provide.
Another contributor centers on the intentional effort to constantly question and apprise the reality
of “I” that comes with me into any moment of concern and care. Who I am and to what degree I
influence any given moment of pastoral intervention is critical to the integration of self and
profession. I propose that it is not safe to rest on my laurels, so to speak, about the potential
influence I enact upon the “others” I encounter. The need to check myself brings me to address the
degree to which my practice and competency are in line with my authority and identity. In keeping
with the train metaphor, I need to ascertain that the engines driving my ministry are connected
with the rails of my foundation.
A final contributor collaborates with the preceding ones. Along the way in my career, I began to
realize that the determination of the direction or location of my ministry was not always consistent
with my own agenda or intentions. I have referred to this as being in the wrong place at the right
time. Many opportunities for significant ministry occurred when I literally walked into the wrong
room or down the wrong corridor. What occurred in what I thought was the wrong place became
the right place at the right time! For me, this is giving recognition and will to the power of the
Ultimate Authority in my ministry. The humble reality of these encounters honors the integrity of
true identity and authority.
These reflections in retirement have provided deep satisfaction and appreciation for the influence of
the previous forty-nine years since I entered seminary and throughout my professional career. I
offer them as a stimulus for others to capture moments of opportunity and to continually evaluate
and enhance who we are and in whom or what we anchor our authority. Ultimately, the integrity of
professional chaplaincy care is greatly enhanced and confirmed.
Issues, Concerns and Goals of Chaplain Leadership 1982 – 83
Ron Ropp BCC
MY TERM AS PRESIDENT OF THE COLLEGE OF CHAPLAINS
spanned 1982-83, and over the years, service in a variety of capacities—
council member and chair, secretary, president-elect and past president—
kept me active both in the College and its sponsoring organization, the
American Protestant Hospital Association (APHA).
Ron Ropp RelD BCC
(retired) is a past
president of the College
of Chaplains. An AAPC
fellow, he is endorsed by
the Mennonite Church.
[email protected]
While we faced many issues during the eighties, underlying it all was a
growing movement toward separation from APHA, which had given birth to
the College. As some of the finest administrators in the country had
encouraged and supported our development, and we were represented on
APHA boards and councils, this move to separate created considerable stress
for all concerned.
Many of our members served in systems outside APHA, and even more were
from religious groups outside of the Protestant denominations. Strongest
among those were many Roman Catholic Sisters who were recognized as
peers in the College. This and other factors lead to a surge in opening
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
37
leadership roles to women in the College. During my tenure, I appointed women to the councils as
well as the to the executive committee for the first time.
I was fortunate to be surrounded by outstanding peers and administrative persons, too numerous
to mention, but warmly remembered. The Protestant Health Assembly also provided the College
with a strong tie to many other health professions and denominational leaders; however, that
changed when the College became a separate professional organization.
Although I can’t begin to remember all the issues dealt with or actions taken, some of the goals I
pursued remain concerns for me. As I reread my 1983 President’s address to the College, “Roots,
Ruts and Routes,” the following stand out:
•
Meeting the tremendous challenge of achieving meaningful change that is not merely caught
up in the hysteria of changes within society and health systems.
•
Addressing the image and role of chaplaincy in society and health care through meaningful
Joint Commission (then JCAHO) standards and the role of religion in healing.
•
Developing stronger ties to denominational endorsing groups, which support specialized
ministries and provide ties to local congregations.
•
Encouraging churches to see their potential as centers of health and healing supported by
professionals in the health care system.
•
Continuing to research the effectiveness of pastoral care in health and healing and the
importance of standards for chaplaincy.
•
Continuing to work with all faith groups and other health professionals dedicated to creating
systems for wholistic care for all persons.
I have had the privilege of serving in other roles with the College and APC, including a number of
years on the History Committee, which has given me an even greater appreciation of who we are
and where we have been. With God’s grace and the commitment of so many outstanding members
the possibilities for the future are unlimited.
Thoughts from the Seventies
Clark S. Aist BCC
WHEN I ASSUMED THE PRESIDENCY of the Association of Mental
Clark S. Aist PhD BCC
(retired) is chaplain
emeritus, Saint Elizabeth
Hospital, Washington,
DC. An ACPE supervisor,
he is endorsed by the
United Methodist Church.
[email protected]
Health Clergy (AMHC) in 1978, having already served two years as presidentelect, the second half of the 1970s was rapidly producing a cacophony of
vexing challenges. The promise of the community mental health movement of
an earlier decade was giving way to the often dehumanizing practice of
“deinstitutionalizing” persons with severe mental disorders. On another front,
psychoanalytically oriented interpersonal psychiatry, which had long served
as a compatible hermeneutic for ministries of pastoral care and counseling,
was fast losing ground to what seemed the cold, mechanistic approaches of
biological psychiatry. Indeed a new diagnostic manual reflecting these
changes was already in process.1
It was also a time of hope and opportunity. Having “come of age” as a
national interfaith certifying body in 1969, AMHC was becoming active in a
host of interorganizational collaborations ranging from research to joint
publications. With the establishment of the position of executive director in
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38
1976 and the appointment of George Doebler as its first incumbent, a wave of young, dynamic
chaplains were bringing new vision and innovation to the association’s work.
Since its founding in 1948, a distinguishing mark of the AMHC has been its close affiliation with the
American Psychiatric Association (APA). Annual meetings were held concurrently with those of the
APA. This not only promoted interaction and dialogue among psychiatrists and chaplains, it also
provided access to papers, workshops and continuing education opportunities of unparalleled
richness. Early on, a liaison to the APA had been established to advance collaborative efforts with
the psychiatric community. The continuing question was how to accomplish this?
How indeed could a small organization of mental health chaplains with meager finances gain the
leverage to elevate the profile of spiritual care among the rank and file of American psychiatrists?
How could we enlist APA’s support in strengthening our position on such issues as Joint
Commission (then JCAHO) standards for pastoral services? Given the sheer immensity of the APA
and its endowments, our assets seemed little more than a “handful of meal and a cruet of oil” or
“five loaves and two fish.”
One Sunday afternoon alone in my office, I found myself reflecting on these questions and the
resources the AMHC actually had. By chance, my attention was drawn to Myron C. Madden’s
concept “the power to bless.”2 Could this fundamental pastoral resource be exercised by an
organization, I wondered? A stream of rapid associations followed that amounted to something of
an epiphany. We already were doing this—each year presenting one of our chaplains with the
Anton T. Boisen Award, an honor that conferred an organizational “blessing” of considerable
prestige on an individual who had made distinguished contributions to mental health ministry. Over
the years, as the list of recipients of recognized distinction grew, the award accumulated added
respect and significance. Indeed the Annual Boisen Award Banquet, together with a major address,
had become the highlight of the AMHC annual meeting. What if we were to confer such a blessing
upon a psychiatric leader who had made distinctive contributions to exploring the interface
between religion and psychiatry—someone of the stature of, say an Erik Erikson or Karl Menninger?
The idea was born.
A proposal for an annual award and lectureship in “religion and psychiatry” was discussed at the
fall 1976 meeting of the AMHC executive committee and was approved in principle. Coincidentally,
in a parallel development, APA was actively considering the restoration of its lapsed Religion and
Psychiatry Committee. Dr. Angelo D’Agostino, a prominent Washington, DC, psychiatrist and Jesuit
priest as well as close friend and colleague, was asked to lead this effort. In March 1977, leaders of
AMHC met with APA’s medical director and Dr. D’Agostino to outline the functions and tasks of this
committee.3 During this meeting, we offered our still nascent idea of an annual award and lecture
in religion and psychiatry as a joint effort that could take place alongside other distinguished
lectureships at APA annual meetings. It would anchor the committee to a substantive, ongoing task
and provide a point of liaison between our two organizations. The offer was warmly embraced
without hesitation.
Two years later, an annual award and lectureship co-sponsored by APA and AMHC was formally
approved by both organizations as a key function of the APA’s Committee on Religion and
Psychiatry with full voice and vote by the committee’s AMHC liaison.
Extensive discussions ensued about how to name the award. Ultimately, Oskar Pfister, Reformed
Swiss pastor, lay analyst and close associate of Sigmund Freud, emerged as the unanimous choice.
The spirit, energy and integrity of Pfister’s vibrant 30-year correspondence with Sigmund Freud,
which had been published in Psychoanalysis and Faith, seemed to epitomize the quality of
discourse and exploration that the committee envisioned for the award and its associated lecture.4
In 1983, the Oskar Pfister Award and lecture was inaugurated with Jerome Frank, eminent clinical
and research psychiatrist at The Johns Hopkins University School of Medicine, as its first recipient.
Today the Oskar Pfister Award is deeply embedded in the historical DNA of both associations. Its
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39
twenty-seven recipients to date are among the foremost investigators of the interface between
spirituality and the human psyche.
What insights for our present time and for the future might we glean from these threads of history
from a long ago presidency? Many readers, I am sure, will have keener observations than mine,
but I would suggest three:
1. The most powerful assets we possess as an organization of professional chaplains are to be
found in the resources embedded—perhaps hidden—in our spiritual and religious identities.
Hence we always have something rather than nothing.
2. One of our most useful functions in liaisons with other health care agencies may be to
illumine the dimensions of spiritual depth implicit in their individual discipline identities.
3. A treasured seed, surrendered to the rigorous discipline of planting, can bear fruit beyond
imagination.
1
American Psychiatric Association, Diagnostic and Statistical Manual for Mental Disorders, 3rd ed. (Washington, DC:
American Psychiatric Press, 1980).
2
Myron C. Madden, The Power to Bless (Nashville: Abingdon Press, 1970).
3
George Doebler, executive director; Emanuel Lifschutz, president; and Clark S. Aist, president-elect; represented AMHC.
4
Heinrich Meng and Ernst L. Freud, eds., Psychoanalysis and Faith: The Letters of Sigmund Freud and Oskar Pfister (New
York: Basic Books, Inc., 1963).
Ron Ropp eloquently stated that the influx of Roman Catholic Sisters into the College
of Chaplains, where they were accepted as peers, was one factor that led to a surge
in female membership and a subsequent increase in the number of women in
leadership roles in the College.
These pioneering women came from many denominational and faith backgrounds
and helped shape chaplaincy as we know it today. The Retired Chaplains' Writing
Project invites retired female chaplains to share their reflections and memories about
what it was like to become a chaplain during a time when many denominations were
just beginning to ordain women and most of the chaplains were men.
This collaborative effort will comprise the next installment of the writing project,
slated for publication in Chaplaincy Today 27.2 (Autumn/Winter 2011). To add your
voice, contact George Robie BCC (retired) [email protected]. Further details and
writer's guidelines will be provided.
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
40
ON HOLY GROUND
An Accumulation of Grief
Lynn Crager
MY REACTION SURPRISES ME. At first, I think it’s because today is
my birthday, and I am acutely aware of the transitions of my body—the
graying hair, the aging skin, the loss of fertility—but it’s more than that.
Lynn Crager RN MSN
serves as nurse chaplain
at Norwalk Hospital,
Norwalk, CT. She is an
APC student affiliate
member.
The imposing backyard maple tree that I’ve known since I moved into my
house is in the process of being removed. Limbs are amputated one by one.
Lost body parts fall to the ground. Sections of the trunk give way to the
brute force of the electric saw. It pains me to see the tree’s life end this way,
and I cry.
I spent countless hours under this tree finding refuge from the hot sun. I
remember the baby swing that hung from the strongest bough. Where has
the time gone? My son is an adult now.
[email protected]
The tree specialist points out the inner decay of the trunk that still appears
so sturdy on the outside. “It was time,” he says softly. When he sees my
stricken face, he adds, “Yes, there are emotions attached to trees.”
His sensitivity both startles and comforts me. It’s hard to let go of this tree. I have resisted its
removal despite knowing of its extensive infestation by a parasite. It’s been sick for a long time.
I begin to inspect the pieces of the tree, which are strewn throughout the yard. As I do, memories
of the patients and loved ones that I have known through my chaplaincy work make their way into
my consciousness.
I lay my hands on the bark of the thickest part of the tree. There are bare patches, like patients
with alopecia. “Forgive me,” I lament, like the son of the patient who made the decision to remove
his mother from life support.
I think of the young woman, on her deathbed with metastatic breast cancer, worrying about her
children growing up motherless. I run my hand over the thin, brittle branches from the top of the
tree. The arborist tells me it has been dead for some time, even while the lower portions thrived.
My conversation with the patient with dementia who thought I was someone else returns to me.
“Don’t you remember the time I took you to the country club?” I do now.
It’s hot and humid today. Reaching back into the memories of my high school Spanish, I ask the
tree team if they need anything, “Agua? Hielo?” We are a family now, all awaiting the end.
When the job is complete, I ask to keep some kindling. The stack of fresh firewood holds an
accumulation of grief. Come winter, I will light the fire, using its warmth to find a measure of
comfort.
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
41
In the Literature
W. Noel Brown BCC
Christi Bamford, Kristin H. Lagattuta. “A new look at children’s
understanding of mind and emotion: The case of prayer,” Developmental
Psychology 46, no. 1 (2010): 78-92. • Studies have shown that between
the ages of four and eight years, children consistently exhibit a growing
understanding about the relationship between mind and emotion, including
an awareness that one’s emotional state may influence how one thinks.
Other research has shown that strategies for coping with negative or
uncontrollable events does not develop until children reach age seven or
eight. At this stage, they understand about how people may use their
These summaries of articles
minds to alleviate negative emotions, for instance, by changing the focus
have been selected from the
or the content of their thoughts. In adults, one widely used method of
database of The Orere
handling negative emotions that has a clear mental component is prayer.
Source, a bimonthly
publication of summaries of
However, until this paper, little attention had been given to young
pastoral and other literature
children’s knowledge about the relationship between prayer, which the
of potential value to
authors term “nonsecular activity,” and emotions. This study examines the
chaplains, produced by W.
development of children’s understanding about the relationship between
Noel Brown STM BCC.
mind and emotion in the context of prayer as well as beliefs about prayer
[email protected]
as both cause and effect of a person’s emotional state. The age-related
differences in the responses provide a deeper understanding of the ways
that children begin to pray and why. The methods used are described carefully, and illustrations of
the printed materials that were used in the conversations with both children and adults are
included.
David Bittner. “The old book switcheroo: Or anatomy of a delusion,” Journal of Religion and
Health 49, no. 2 (Jun 2010): 262-73. • An article that provides an immediate view into the inner
world of a person with Aspeger’s Disorder—in Bittner’s case, a mild form of autism with some
schizophrenic features. He describes his personal experiences with some of the “pitfalls of
organized religion” as observed from his perspective as a Jew by birth and a Roman Catholic by
choice.
Tami Borneman, Betty Ferrell, Christina M. Puchalski. “Evaluation of the FICA tool for
spiritual assessment,” Journal of Pain and Symptom Management 40, no. 2 (Aug 2010): 163-73. •
The National Consensus Project for Quality Palliative Care standards, published in 2006, named
spiritual care as one of the eight essential elements of care, describing it in Domain 5: “Spiritual,
Religious and Existential Concerns.” Though completely laudable in itself, the desire to provide
thorough and effective spiritual care that employs a check-list approach will in all probability lose
the very subjectivity and specific human elements that are at the very heart of spirituality. If
spirituality is rationalized and reduced to make it manageable, it loses those ingredients that make
it significant. In 1996, Puchalski and three primary care physicians devised the FICA Spiritual
History Tool as a way for physicians to integrate open-ended questions about religion and
spirituality in the standard medical history. It has been slightly modified since then and is currently
used by some chaplains to obtain an understanding of the presence of faith, belief or meaning in a
person’s life; the importance of spirituality for a person’s life and the influence that beliefs and
values have on health care decisions; the person’s spiritual/religious community; the interventions
to address the person’s spiritual needs. The aim of this study was to evaluate the usability of FICA.
Seventy-six patients with solid tumors provided feedback about this instrument, which is printed in
full in the article. Responses to FICA were placed alongside the responses patients made to a
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
42
second assessment tool, the Functional Assessment of Cancer Therapy Quality of Life (QOL),
developed by Ferrell at the City of Hope Medical Center in 1995. The findings indicate that FICA
does enable the spiritual life of a person to be addressed in a helpful way and lend support to the
belief that spiritual care is an important part of patient care. Responses to the questions revealed
the depth and breadth of spirituality and provided many opportunities for addressing patients’
search for faith, meaning, hope and relationships at the end of life.
Jami Brinton. “Hospital chaplains not required to keep information private,” www.kcrg.com (10
Apr 2010): 3 pp • This is the narrative of a television report concerning a chaplain at a hospital in
Iowa City, Iowa. The chaplain spoke with a mother while her 10-month-old son was receiving
treatment, and she mentioned in passing that she was pregnant. In his required notations in the
medical record, the chaplain included this fact. Subsequently, a different staff member commented
on her pregnant state, the mother became very upset as she considered her conversation with the
chaplain confidential. She wanted the fact of her pregnancy removed from her son’s record, and it
took one week for this to be done. The remainder of the story opens up the topic for comment both
by hospitals and by the public. There are also numerous comments on the station’s Web site about
the subject, many of them very unflattering. Clearly, this is an issue for discussion and education in
chaplaincy circles. The story may be accessed at http://www.kcrg.com/news/local/91000154.html
Herbert Bronstein. “Heart transplants: Three views—the power over life and death,” Chest 136,
no. 5 Supplement (1 Nov 2009): 346-48. • In a commemorative supplement to mark seventy-five
years of publication, Chest includes what its editors still consider three classic essays dealing with
the philosophical and theological questions raised by heart transplants. They were first published in
the October 1968 issue of the journal. The first is this article, authored by a rabbi. While written
from an unabashedly Jewish perspective, it states very clearly the basic questions that need to be
considered by anyone of religious faith involved in some manner with heart transplantation.
Bronstein refers to “historic moral and religious questions,” which he proceeds to spell out. While
the answers to the questions he lifts up—both theological and practical—have been refined over the
past forty years, his words are words of encouragement to push forward into the ever-new
uncertainties that transplant surgery raises today: “[W]e cannot go back. We are barred as by
angels with revolving swords of flame from the paradise of previous innocence.”
James D. Campbell, Dong Phil Yoon, Brick Johnstone. “Determining relationships between
physical health and spiritual experience, religious practices and congregational support in a
heterogeneous medical sample,” Journal of Religion and Health 49, no. 1 (Jan 2010): 3-17. •
Efforts to understand the relationships between physical health and religious practices/spirituality
continue to increase in sophistication. In 1999, the Fetzer Institute and the National Institute on
Aging Workgroup created the Multidimensional Measure of Religiousness and Spirituality (MMRS)
and its brief form, B-MMRS. Subscales were developed to measure distinct aspects of spiritual
experience and religious practices. They were chosen because they held promise for determining
the casual mechanisms that relate religious, spiritual and health variables. Additional work
subsequently has been done to see if using B-MMRS leads to reliable results. One of Johnstone’s
soon to be published studies has found that the B-MMRS may be better understood if it is used to
measure three rather than two domains of religious/spiritual experience including: the emotional
experiences associated with feelings of connectedness with a high power/the universe (termed
spiritual experience); culturally-based activities such as prayer, meditation, reading religious texts,
attending services (termed religious practices); and the support provided by others in one’s
religious/spiritual community (termed congregational support). By conceptualizing B-MMRS in this
way these authors suggest that it may be possible to determine the specific mechanisms by which
religious and spiritual variables impact health, e.g., through emotional experiences, cultural
behaviors and/or social support. It was with this model in mind that they conducted the research
reported in the paper. They studied a convenience sample of 168 patients from an academic health
center and a private group practice, deliberately choosing patients from a number of different
patient groups. The results are limited in that they are cross-sectional in nature, so causal
mechanisms that exist between religion and health cannot be determined. They also are not
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
43
completely generalizable in that the people studied were primarily Christian. With these limitations,
the results indicate that persons with chronic medical conditions do not automatically turn to
religious or spiritual resources following diagnosis. Further, they show physical health as positively
related to frequency of attendance at religious services although this may be related to better
health leading to increased ability to attend religious/spiritual gatherings. Finally, spiritual belief in
a loving, higher power, and a positive worldview are associated with better health, which is
consistent with psychoneuroimmunological (PNI) models of health. The authors suggest that “This
encouragement/practice of spiritual interventions may be promoted by religious leaders, hospital
chaplains and/or health professionals although questions still exist about the best manner … [for
addressing] religious/spiritual matters in their practices. Johnstone also addresses this subject in
an unpublished paper.
Donald Capps. “A spiritual person,” Journal of Religion and Health e-published on the journal’s
Web site. • This is an essay about spirituality, written in Capp’s inimitable accessible style. He
begins with the answer that William James gave when he was asked to describe a spiritual person.
His answer instead was to name one—Phillip Brookes. Capps then uses Brookes to explore
spirituality through a human subject, describing his life, his sermons and, most importantly, “his
ideals and the active imagination.” Capps takes the view that “there is no spirituality in general but
only individual manifestations of it.”
Daniel H. Grossoehme, Judy Ragsdale, Jamie L. Wooldridge, Sian Cotton, Michael Seid.
“We can handle this: Parents’ use of religion in the first year following their child’s diagnosis with
cystic fibrosis,” Journal of Health Care Chaplaincy 16, no. 3/4 (Jul/Dec 2010): 95-108. • The news
that a child of theirs has a life-shortening disease sends many American parents to their religious
beliefs. In this paper, Grossoehme and his colleagues describe how a small sample of parents
(n=15) used their beliefs to cope in the first year following a diagnosis of cystic fibrosis (CF). The
aims of this study were to develop a “grounded theory” of parental use of religion in the first-year
period and to describe whether parents connected their religious beliefs with their at-home,
ongoing treatment of the child. In other words, the authors did not begin with a theory but rather
allowed the model they describe to emerge out of the information they collected, a model that
could then be modified as data were gathered. Of the fifteen parents interviewed, twelve
spontaneously named religion as being an issue during the year following the child’s diagnosis, and
this was explored at greater length. There were four domains within which parental responses
could be grouped; the use of religion to make sense of what was happening to their child was the
central, unifying idea. The results showed that the parents imagined God as “active, benevolent
and interventionist.” Parents also found hope in their beliefs, indicated that they felt supported by
God and related religion to their motivation to stick to the child’s treatment program. The findings
make it clear that having an understanding of the religious beliefs of parents will assist a team
better plan for the care of children with CF and their families.
Jennifer W. Mack, Susan D. Block, Matthew Nilsson, Alexi Wright, Elizabeth Trice, Robert
Friedlander, Elizabeth Paulk, Holly G. Prigerson. “Measuring therapeutic alliance between
oncologists and patients with advanced cancer—The Human Connection Scale,” Cancer 115, no. 14
(15 Jul 2009): 3302-11. • Terminally ill patients are exquisitely sensitive to the relationship and
the human connection they have with their primary physicians. This paper describes the
development and validation process of a measure of the alliance between patients with advanced
cancer and their physicians, in order to evaluate the therapeutic alliance’s effect on end-of-life
experiences and care. The Human Connection Scale is a 16-item questionnaire that has been
tested and found reliable (n=217 patients). The authors plan to use the scale to assess different
aspects of end-of-life care.
Yadollah A. Momtaz, Rahiman Ibrahim, Tengku Aizin Hamid, Nurizan Yahaya. “Mediating
effects of social and personal religiosity on the psychological well being of widowed elderly people,”
Omega (Westport) 61, no. 2 (Mar 2010): 145-62. • The death of a spouse is one of life’s most
stressful events. The authors of this study wanted to learn whether the effects of personal or social
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44
religiosity mediate the psychological impact of a partner’s death. The literature review reflects a
world-wide awareness of this topic. The subjects of the study were 1,367 widowed elderly Muslims
in Malaysia. Three different instruments were used to test psychological and physical health.
Gorsuch and McKenzie’s Internal External Religiosity Scale (1989) also was administered. The
overall finding was that the personal comfort of Muslim religiosity appeared to decrease the
negative effects of widowhood on the psychological well-being of this group. Social religiosity was
not found to have a significant effect.
Robert Mundle. “The hospital chaplain as religious interpreter in bioethical dilemmas,” Scottish
Journal of Health Care Chaplaincy 12, no. 2 (2009): 21-28. • What are the responsibilities of the
hospital chaplain called to assist in a clinical situation that is causing an ethical dilemma, and how
should they be carried out? In order to highlight the difficulties of the task, Mundle describes the
case of a Samuel Golubcheck, whose family insisted that he be continued on life support and
provided with all aggressive care. The case was of such controversy that his attending physician
resigned from the case, as did two intensivists who were then called to provide care in the ICU.
With this case as background, Mundle takes a fresh look at this difficult dilemma, asserting that the
chaplain’s unique and complex role as interpreter of religious beliefs and values requires a full
vision that includes regarding the patient and not the chaplain as the “expert” in the dilemma and
embracing a variety of key images of pastoral care. Further, it suggests a process of dialogical
hermeneutics. Mundle reminds his readers of the importance of Boisen’s belief about understanding
people as living human documents. He quotes Charles Gerkin who in 1984 wrote that to
understand persons in this way means that in pastoral relationships “chaplains require a process of
dialogical hermeneutics that begin with a position of uncertainty and even vulnerability.” Mundle
quotes Gerkin at some length: “To listen to stories with an effort to understand means to listen
first as a stranger who does not yet fully know the language, the nuanced meanings of the other as
his or her story is being told. Needless to say, one of the first lessons of life on the boundary is that
it is important to avoid, at all costs, the temptation to stereotype or take for granted .... It must
thus be understood as a process involving communication across the boundaries of language
worlds.” (C. V. Gerkin (1984) in The Living Human Document: Re-Visioning Pastoral Counseling in
a Hermeneutical Mode.) In addition to deeply listening to patients and families, Mundle believes
there must be an assessment of the validity of certain religious beliefs that may arise in these
situations and he introduces a model for assessing such beliefs. It was described by Gregory Bock
in 2008. (Journal of Medical Ethics 34, no. 6 (2008): 437-40)
Patricia E. Murphy, George Fitchett. “Introducing chaplains to research: ‘This could help me,’”
Journal of Health Care Chaplaincy 16, no. 3-4 (Jul/Dec 2010): 79-94. • Why are a large percentage
of chaplains afraid of research? The findings reported in this article shed light on this important
question. For almost a decade, Fitchett, who is on the staff of Rush University Medical Center in
Chicago, has been working to encourage chaplains to benefit from research. He would like to see
the profession of chaplaincy become an evidence-based profession. In this paper he is joined by his
colleague, Patricia Murphy, in identifying and examining the barriers to making chaplains “research
literate.” In 2002, Fitchett conducted a workshop for chaplains in Australia, which gave him the
opportunity to identify chaplains’ attitudes towards research and barriers to their becoming
involved in research activities. With two Australian colleagues, he published the findings the
following year in a discontinued journal, Ministry, Society and Theology. Fitchett and Murphy have
built on those initial findings and in this article present data from ninety-four chaplains who
attended one of the five subsequent workshops they conducted in the United States between 2004
and 2006. They describe goals and objectives, the process of gathering/analyzing the reactions and
feelings of the participants and analysis of the resulting data. Many chaplains function in the
medical world where the dominant research model is quantitative in nature, so it is hardly
surprising that a large percentage are fearful of research. There are widely-held misconceptions
about what research involves, and the insights in this paper will be of value to those seeking to
effect change in chaplaincy practices. It also may encourage chaplains to take advantage of the
benefits of research as well as to become better “consumers” of research results.
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
45
Jason Q. Purnell, Barbara L. Andersen. “Religious practice and spirituality in the psychological
adjustment of survivors of breast cancer,” Counseling & Values 53, no. 3 (Apr 2009): 165-82. •
The contributions of religious belief and spirituality to patients suffering from cancer and its
aftereffects have been carefully studied. However, research has not adequately separated the two.
That is the significance of this study. The authors looked at the relationships between religious
practice, spirituality, quality-of-life (QOL) and stress in survivors of breast cancer. A total of 130
women were assessed two years after diagnosis. Analysis of the data gathered indicated that
spiritual well-being was significantly associated with QOL and traumatic stress levels, but religious
practice was not. The authors suggest that clinicians should address the individual’s spirituality
when working with breast cancer survivors.
Ann C. Recine, Joan S. Werner, Louis Recine. “Health promotion through forgiveness
intervention,” Journal of Holistic Nursing 27, no. 2 (Jun 2009): 115-23. • Over the past ten years,
the nursing profession in the United States has worked to expand its commitment to patients who
are in need of forgiveness. This paper is authored by a nurse practitioner in private practice who
has specialized in helping her patients find forgiveness, often for health-related matters. She offers
evidence-based forgiveness interventions that she believes will be useful to nurses in both medical
and community settings. She makes the case for helping people find forgiveness, defines
forgiveness, discusses recent research on interventions and describes the theoretical framework
underlying her approaches. She then provides four approaches for forgiveness interventions: giving
patients persuasive information; helping them vicariously to experience forgiveness; helping them
with awareness of, and coping with, their own physiological responses and helping them to
experience “enactive attainment.” Chaplains might add to their pastoral skills by building some of
the material in this paper into their individual theological bases.
Nava R. Silton, Cecille A. Asekoff, Bonita Taylor, Paul B. Silton. “Shema, vidui, yivarechecha:
What to say and how to pray with Jewish patients in chaplaincy,” Journal of Health Care Chaplaincy
16, no. 3/4 (Jul/Dec 2010): 149-60. • This paper describes and analyzes data gathered from the
discussion of a 90-minute focus group about their work as Jewish chaplains. The group comprised
five male and two female professional chaplains from Reform, Conservative and Orthodox
backgrounds. Six questions were introduced by the leader of the focus group, which explains the
wide-ranging information gathered. Is prayer a standard activity during a visit? What are protocols
for acute versus chronic hospitalizations? Protocols for patients who spend 3+ days/week at a
hospital? Which “general” or “spiritual” interventions are typically used? The greatest challenges
facing them? Their best experiences? The key mentoring lessons for a new chaplain? Two
researchers independently read the transcript of the focus-group discussion and identified themes,
which the authors describe and discuss in detail.
Urs Winter-Pfändler, Christoph Morgenthaler. “Are surveys of quality improvement of health
care chaplaincy emotionally distressing for patients? A pilot survey,” Journal of Health Care
Chaplaincy 16, no. 3/4 (Jul/Dec 2010): 140-48. • This paper reports the results of a Swiss study
which sought to clarify whether asking patients to participate in surveys focusing on the services of
chaplains was emotionally distressing, and if so, how much? The lead author is a chaplain. Thirtyseven persons, eight of whom were hospital inpatients, completed a fairly extensive questionnaire
designed to discover if “research on quality improvement in health care chaplaincy is emotionally
distressing for patients in the Swiss context.” (p. 143) The results clearly show that the vast
majority (over 90 percent) of the participants did not find this to be stressful.
William Yang, Ton Staps, Ellen Hijmans. “Existential crisis and the awareness of dying: The
role of meaning and spirituality,” Omega (Westport) 61, no. 1 (Jan 2010): 53-69. • For over thirty
years, the first two authors worked in the field of psychosocial oncology, though in different
hospitals. They met at a center specializing in counseling cancer patients and their relatives. When
they compared notes about their experiences in their respective hospitals as well as at the
counseling center, they found that there was a clear difference in patients’ requests for support. In
the hospitals, requests focused on problems related to the physical impact of their illnesses,
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treatments and the immediate consequences, e.g., managing feelings of fear, decisions concerning
treatment. In contrast, at the counseling center, with their medical treatment ended, their requests
concerned the emotional process of the loss of meaning and the struggle to—hopefully—recover it.
This paper describes the counseling work, which involved responding to what patients experienced
as moments of great emotional distress where they “totally lost all anchorage,” voiced in such
comments as “My world collapsed,” and “I looked into a black hole.” The authors call this loss of
anchorage “existential distress.” Its implications motivated their study of “existential crisis” and the
ways patients deal with it. In their research, they used grounded theory methodology, which they
describe in sufficient detail for the naïve reader to understand. They also detail their data gathering
process, which included interviews of fifteen persons and survey of sixty-eight by questionnaire,
and their use of sensitizing concepts. They note seven characteristics of the existential crisis:
awareness of finitude, dissolving of the future, loss of meaning, fear/anxiety/panic/despair,
loneliness, powerlessness and identity crisis. They analyze the processes that they found occurring
within the existential crisis and include a number of suggestions for those who care for this group
of patients.
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Expression of Faith
pilgrimage
Robert W. Duvall BCC
As hawks soar and kee
a prescribed walk
becomes a pilgrimage.
Kee is the best spelling of the sound that hawks make as they circle high in the sky—
very much like the sound one hears from an eagle. I would often see a pair, probably a
male and female. I did hear this sound as I watched the couple circle one another and
call to each other, and I imagined them exchanging a happy note or greeting. I began
walking in February. Winter segued into spring, and the world seemed to come more
alive with each passing day—as did I.
Robert W. Duvall MDiv BCC is director of
chaplaincy at Gwinnett Medical Center,
Lawrenceville, GA. He is endorsed by the
Cooperative Baptist Fellowship.
[email protected]
©Chaplaincy Today • e-Journal of the Association of Professional Chaplains • Volume 26 Number 2 • Autumn/Winter 2010
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MEDIA REVIEWS
Mardie Chapman BCC
Media Review Editor
Courageous Conversations:
The Teaching and Learning of Pastoral Supervision
William R. DeLong, Editor (Lanham, MD: University Press of
America, 2010, 291 pages, softcover)
Chaplaincy Today publishes
reviews of books and recorded
material that is of interest to
spiritual caregivers, including
chaplains and pastoral
counselors. Address requests
for reviews to Mardie Chapman
MDiv MS BCC
([email protected])
and include a short synopsis.
As William DeLong acknowledges in the preface, “there are few books
that speak to the specialized practice and profession of pastoral
supervision.” This book is a substantial contribution “to fill that gap” by
providing a worthy update to the literature of pastoral supervision.
Pastoral supervisors in all venues and specializations will benefit from this
book, including CPE supervisors and those to whom they report, pastoral
counseling supervisors, field education supervisors and spiritual direction
supervisors. Courageous Conversations is an excellent resource for all
skill and experience levels of pastoral supervisors, from those in training
to those with years in the field. In sixteen diverse chapters, experienced
and knowledgeable clinicians address topics such as the following:
reflecting theologically, power and the supervisory relationship,
supervising in a modern and postmodern age.
The writing in this book is consistently sophisticated and challenging, yet informative and practical.
The chapters bring diverse perspectives on difficult topics while maintaining an underlying
cohesiveness to a worldview that values postmodernism and multiculturalism. I was both intrigued
and challenged by the material. For example, the chapter on sexuality in clinical supervision
challenged me to look more deeply at my own Protestant bias when reflecting on the supervision of
students who are vowed to a life of celibacy. My awareness of the foreign and the unfamiliar was
enhanced. Using this knowledge, I could appreciate and supervise such a student with more
integrity and expertise.
While the writing style varies with each author and topic, the quality of the writing is consistently
high which allows thoughts, ideas and arguments to shine. The end notes for each chapter are
thorough and professional.
Courageous Conversations is challenging to read on several levels. The ideas are complex, holding
the potential to evoke thoughtful reflection and inform professional practice. To hold this potential,
the writing assumes a level of knowledge and a firm grasp of the vocabulary from several fields;
therefore, reading this text is intellectually demanding.
For example, in an intriguing chapter titled “From Object to Subject: Pastoral Supervision as an
Intersubjective Activity,” DeLong explains intersubjective theory as a “psychological and
epistemological framework by which supervisors may utilize their sense of self” in pastoral
supervision. He traces psychoanalytic history and draws on several theologians to inform his
reflections on pastoral supervision.
Overall this fine book serves as a worthy witness to the multifaceted complexity of our unique and
challenging field.
Reviewed by M. Catherine Hasty MDiv ThM BCC, Director, Health Ministry and Pastoral Education, Chaplaincy
Department, Presbyterian Hospital, Charlotte, NC.
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Women Out of Order:
Risking Change and Creating Care in a Multicultural World
Jeanne Stevenson-Moessner and Teresa Snorton, Editors (Minneapolis: Augsburg Fortress
Press, 2009, 434 pages, softcover)
Are words or phrases like interreligious soul care, disembodied spirituality, cultural imperialism,
critical race theory, meritocracy and hegemony, a part of your everyday chaplain’s nomenclature?
Do you desire to increase your working knowledge and competency of behavioral science, theology
and pastoral care with persons of various cultures? Do you sometimes feel you lag behind in
understanding various cultures that you meet on a daily basis in your ministry? If you answered
yes to any of these questions, Women Out of Order, the most recent in a series, provides a wealth
of information to assist in your continuing education efforts.
Clinicians, chaplains and clinical pastoral education (CPE) supervisors will be challenged by this
book. It will enlarge the perspective of the chaplain who may not have had the opportunity to read
the previous volumes in this series and who may have been out of CPE for a while. Pastoral
educators and supervisors will find it a good reference for their trainees who seek to become more
informed about issues facing women outside the dominant culture. The reader’s vocabulary will be
stretched with a whole new language that surrounds multicultural issues.
Clearly, the editors sought extensive racial ethnic representation. While several contributors are
Euro-American, the list also includes representation from Native American, Middle Eastern, Latino,
African American and Asian cultures. Each contributor brings a depth of experience, expertise and
critique of traditional pastoral care understanding and theory. Together, they invite the reader to
explore responses to a woman’s call for pastoral or spiritual care from a different template. Several
of the contributors have served as chaplains, pastors, pastoral counselors and/or pastoral
educators.
The volume is divided into four parts. Part one follows the book’s title: Women Out of Order.
Moving beyond the traditional way of referring and writing about pastoral care for women, these
contributors identify ways that women may be perceived or cared for in stereotypical or harmful
ways. As traditional pastoral care methodologies fall short of the complexity of issues facing
women in crisis, the authors provide new lenses, perspectives, approaches and worldviews that aid
in helping women who may be perceived as being “out of order.” APC readers will recognize
contributors such as Pamela Cooper White and Teresa Snorton, as they have been headliners at
national conferences.
In part two, “Risking Change,” the editors point out that typical pastoral care approaches fail to
involve the woman’s experience. In addressing a “do no harm” ethic of care, the contributors in
this section provide other expansive theoretical constructs and methods to care for women whose
dominant culture is not Euro-American. While most contributors write from a social or liberal
theological perspective, the reader also will discover more centralist theologies, especially from
Korean and Latino perspectives.
Part three addresses the changing world with its emphases on globalism, experiences, models and
case reviews. These assist the reader in developing a vision of what care looks like in a
multicultural—rather than a monocultural—world. Issues faced by African American women and
recent high profile media situations, such as the shooting at Virginia Tech University, are addressed
and analyzed.
While much effort has been given in this volume to inform, educate and expand the reader’s
perspective, the final section, “Challenges Ahead,” concludes with words of “caution and prophetic
vision of the emerging frontier of multicultural care.” (p. 291) Patterns of domination, interreligious
nomenclature and power analysis are addressed as a part of understanding where all of this is
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headed. Questions addressed include the following: Are there limits to multicultural inclusion? Can
we work within a culture rather than without?
With 363 pages of reading material and 40 plus pages of footnotes and reference citations, it will
take a while for the reader to digest. However, helping the reader to become more culturally
competent and sensitive is clearly a strength of this book.
Jeanne Stevenson-Moessner is professor of pastoral care at Perkins School of Theology, Southern
Methodist University, Dallas, TX. Teresa Snorton is executive director of the Association for Clinical
Pastoral Education and adjunct instructor in pastoral care at Chandler School of Theology, Emory
University, Atlanta, GA. Dr. Stevenson-Moessner participated in editing three previous volumes on
pastoral care and women’s issues: Women in Travail and Transition: A New Pastoral Care (2000),
Through the Eyes of Women: Insights for Pastoral Care (1996) and In Her Own Time: Women and
Developmental Issues in Pastoral Care (2000).
Reviewed by Beverly C. Jessup DMin BCC; CPSP Diplomate, Pastoral Supervision; Clinical Director, Pastoral
Care, FirstHealth Moore Regional Hospital, Pinehurst, NC.
Talking with God in Old Age: Meditations and Psalms
Missy Buchanan (Nashville, TN: Upper Room Books, 2010, 96 pages, softcover, large print)
I have one major quarrel with this book: it is not long enough. Missy Buchanan has produced a
wonderful set of meditations based on selected psalm verses. She succinctly and successfully
captures the thoughts of many in their elder years. Whether the subject is concern over limited
financial resources, the difficulties and indignities of rehab, the inability to get a good night’s sleep
or the closeness of God, the author knows her elders and their innermost thoughts.
Talking with God in Old Age may be used as the basis for discussions at long-term care facilities. It
may be part of a creative worship service. Selections woven together would form a wonderful
sermon. It could be part of a handout setting the mood for a meeting of chaplains or used as a way
to complement the agenda of an interdisciplinary team meeting.
Most of the mediations/psalms are only two pages in length. All of them are in large print so that
individuals with limited sight should be able to read them.
Since the author limits her “proof texts” to the Psalter, this work will resonate with readers—and
listeners—within both the Christian and Jewish communities. Here are two examples:
From “Rehab”: I don’t like rehab very much…. / Then you remind me, Lord, that we were not
intended to carry our burdens alone. / Lift up my head so I can see the face of the therapist who
goes beyond kindness…. The poem is followed by Psalm 121:1-2: I lift up my eyes to the hills—
where does my help come from? My help comes from the LORD, the Maker of heaven and earth.
From “Kleenex in My Sleeve”: I have a Kleenex in my sleeve…. / In an odd way, it makes me think
about you, Lord. / About how you are always within reach / whenever I need you…. These words
are then followed by Psalm 34:18 (34:19 Hebrew): The LORD is close to the brokenhearted and
saves those who are crushed in spirit.
The simplicity and felicity of this book is profound. It will lift your spirit and cause you to smile. It is
a work to be bought and shared. It will make a great present for others.
Reviewed by David J. Zucker PhD BCC, Director of Chaplaincy Care, Shalom Park, Aurora, CO.
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We Do Remember You
Steve Butler Illustrated by Grace Mayfield (Charlotte, NC: ENHEART Publishing, 2009, 48 pages,
softcover)
Steve Butler has written We Do Remember You as follow up to his earlier book, A Letter from
Heaven (2008). This book will be helpful to ministers and laypersons as they equip parents with
books and resources that provide coping tools following the death of a baby. Butler’s suggestions
for creating rituals are “good medicine” for grieving parents who also may need to help a grieving,
surviving sibling as Butler shares stories that illustrate ways for parents to establish rituals of
remembrance for both themselves and their other children.
We Do Remember You is full of theology dispensed through both stories and pictures that present a
Christian worldview, especially related to beliefs about afterlife, death, heaven and a remembrance
motif that is associated with the sacraments of the Christian faith. This fact may limit its use by
chaplains.
Butler’s purpose is to address questions a surviving child may ask as to where a deceased sibling
goes after death and even more importantly, how to remember or “talk” to the deceased child. The
question of “how do we remember” is the foundational question. Don’t let the pictures of children
fool you into thinking the book is for children. Instead, this resource provides specific activities and
rituals to help grieving parents and other adults.
In the forward, Butler makes the case that rituals must be established and acted out so that the
living may remember their loved ones—especially infants and babies—in concrete ways. He uses
stories and conversations between children in heaven’s garden to draw parallels to places like
gardens, cemeteries, church nurseries and rooms in the house that help the grieving to create
rituals that allows them to remember and to stay connected.
Butler offers many suggestions for such rituals, e.g., buying and donating a baby rocker to a
church nursery, making a concrete marker that is decorated and placed next to a bush or tree in
memory of one’s baby/child, planting a rose bush and allowing children—especially surviving
siblings—to help with the planting.
Finally, Butler provides a resource list of organizations and their Web sites that help parents and
families cope with the death of a baby. He includes favorite blessings and prayers that he uses for
his own family and his ministry.
Reviewed by George M. Rossi MDiv MA BCC, Clinical Chaplain, Medical University of South Carolina Hospital,
Charleston, SC.
Just Conflict: Transformation through Resolution
Mark Lee Robinson (Rhinebeck, NY: Epigraph Books, 2009, 424 pages, softcover)
This book is a tool for professionals who want to learn first about their own behavioral standing in
dealing with people and creating new maps to approach conflicts—especially chaplains, pastoral
counselors, nurses, counselors, human resources personnel.
As we travel through life, we experience conflicts, and the possibilities to create resolution are
endless. We need to discern, think clearly and decide how to create “maps” to transform our
broken connections. There is not a formula to fix all conflicts. We need to create opportunities to
learn and conditions to interact in this world of relationships.
The author analyzes human behavior from the inside out. We were not born in a vacuum. We are
the human expression of your own physical growth, needs, cultural elements, traditional
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expectations and the ability we have to survive over the years. Everyone has the same rights,
responsibilities and accountabilities in a relationship.
Conflict resolution by no means is an easy task but it is about learning simple steps to increase the
possibility to be successful. The biggest barrier to change is our own set of expectations. However,
it is good to learn that not all conflicts are fixable. Learning and naming our feelings increases our
capacity to interact and comprehend our human core in relationship, first with ourselves and then
with others. The overall purpose is to help us learn to solve conflicts, with a new insight. We may
be very clever at identifying an issue and attaining new tactics to solve the conflict, but the
decision to change our behavior is the key.
Reviewed by Neris Diaz-Cabello MDiv, APC associate chaplain, Manager of Spiritual Care, Sherman Hospital,
Elgin, IL.
Coming Out, Coming Home: Making Room for Gay Spirituality in Therapy
Kenneth A. Burr (New York: Taylor & Francis Group, 2009, 273 pages, softcover)
Kenneth Burr’s Coming Out, Coming Home deserves a place in the national and local discussions of
homosexuality that are taking place in the media, university and seminary classrooms. CPE
supervisors, clergy, therapists and chaplains may enrich their ministries through the insight
received.
This “is a book written to increase the potential for spiritual growth and development in our
society.” Burr illustrates convincingly how “there are members of the GLBTIQ [gay, lesbian,
bisexual, transgendered, intersex, queer] community who have been quite successful in their
spiritual growth and development.” Readers will discover that “setting this book aside because you
are not a sexual minority would be a lost opportunity, because this was designed for anyone who
has had their beliefs and values challenged by the topic of homosexuality.” (p. XV) Burr’s
clarification of his title’s meaning is insightful: “Coming out and coming home are very different
processes; one is a person’s right to be equal and respected for their differences, and the other is a
gift society gives to those who are different by offering a place at the common table.” (p. 15)
In “Thank God for Change!” (Chapter 1), Burr presents a brief history of the social changes for
oppressed minorities that have occurred during the last five decades and acknowledges that social
change for sexual minorities has not advanced at the same pace. Significant changes have taken
place in science, legislation, psychology and religion that have helped to advance a better
understanding of sexual minorities. He observes that changes in institutional policies and civil laws
are examples of the outward change that may alter external behavior; however, transitions are
inward and may alter attitudes and understanding.
“Spiritual Connections,” the focus of Chapter 2, reveals how Burr made his own transitions.
Through his workshops, ministry to AIDS patients and counseling, he began to understand the
deep spirituality of homosexuals; however, he still felt that homosexuality was sinful behavior.
Although his own denomination “believed homosexual orientation was not a sin, it continued to
label homosexual behavior ‘sin,’ which was making less sense to me all the time.” (p. 51) He began
to evaluate his understanding of scripture and to be informed by behavioral science. The close
connections had created strong bonds, and he writes that “once it became personal and I knew
that we were talking about my dear friends and loved ones, it necessitated a change in my
thinking.” (p. 34) His own theology was shifting to being more inclusive.
Burr cited President Obama’s similar transitional experience in relationship to a lesbian who was a
mother, businesswoman and loyal supporter. This experience is documented in Obama’s book, The
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Audacity of Hope (2006). Burr describes the President’s response to a phone message that this
supporter left for him: “As she shared her hurts about his polarizing statements from a previous
public debate, he began to understand life from her perspective. Later when he reflected on his
words, he returned her call and told her he was sorry. Christians who claim to “hate the sin but
love the sinner” are often unknowingly inflicting pain and condemning very good people who are
also made in the image of God.” (p. 54) After admitting his own prejudices and limited
understanding he said: “When I read the Bible, I do so with the belief that it is not a static text but
the living word and that I must be continually open to new revelations—whether they come from a
lesbian friend or a doctor opposed to abortion.” (pp. 54, 55)
After revealing his change of heart, Burr turns to his readers and suggests how they might move
away from some of their “toxic” attitudes. He seeks to engage them in dialogue by asking that they
suspend their stereotypes, be open to guidance from the voice within and learn how that voice
resonates with homosexuals listening for their individual “still small voice.”
Chapter 3, “Development of Sexuality and Spirituality,” and Chapter 4, “Hindrances to Gay
Spirituality,” provide a realistic sequence that coincides with the way sexual minorities experience
their development. Burr helps readers to understand development through the models of Jean
Piaget, Lawrence Kohlberg, James Fowler, Vivienne Cass, Richard Troiden and Eli Coleman.
Insights emerge that may be integrated into the work of therapists, clergy and chaplains.
Chapter 5, “Embracing the Possibility of Gay Spirituality,” reveals the relevance of the theory of
cognitive dissonance. Burr explains that “because our brain wants so much for things to be
resonant, it will override new ideas that challenge former ways of thinking, which explains why it is
so difficult to change our minds once we have taken a position.” (p. 139) In Chapter 6, “Coming
Out Is a Spiritual Experience,” he shares his belief that gays can integrate spirituality into every
aspect of their lives—that they can move beyond self-judgments that promote an unhealthy self
image.
Chapter 7, “The Search for an Inclusive Theology,” encourages individuals to have theological
conversation and evaluations of new knowledge about themselves and sacred text and to discover
hope by encouraging sexual minorities to honor their sexuality and by affirming their place at a
common table.
Reviewed by Michael G. Davis DMin BCC (retired), Hernando, MS.
A Sacred Walk: Dispelling the Fear of Death and Caring for the Dying
Donna M. Authers (Charlottesville, VA: A&A Publishing, 2008, 213 pages, softcover)
Donna Authers shares her personal walk, a journey that took her from being terrified of death to
being fully present to the dying. She is actively involved with Stephen Ministries and presents at
churches and caregiver trainings. A training manual to accompany the book is listed on her Web
site. The perspective is exclusively Christian and clearly stated. While the author cautions
caregivers not to preach or provide answers, she at times ignores her own advice in an attempt to
offer comfort. Biblical quotations are scattered liberally throughout the book.
While the book’s topics are relevant to many chaplains, A Sacred Walk is part guidebook and part
memoir. The vast amount of deeply personal stories requires sifting through this book for generally
applicable insights. Many of the author’s vignettes should have been left for family gatherings or
personal diaries. Paring away the excess, eliminating chattiness and jumbled metaphors would
greatly enhance Authers’ contribution. With that caveat, there are sections in A Sacred Walk that
will be useful in training hospice or spiritual care volunteers.
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Authers gives a personal account of care for the dying and lessons for living. Being called to care
for relatives and friends near the end of life lessened her deep-seated fear of death and this in turn
better equipped her to accompany others on their final journey. Most instructive for this reviewer
was the author’s firsthand account of complicated grief stemming from her early childhood
exposure to numerous deaths, several of them traumatic. Speaking from experience, Authers
makes a strong plea to attend to children’s fears and questions surrounding a death in the family.
Also useful for chaplains is the glimpse into some complex family dynamics. In the case of her
mother’s death there is the added strain of her stepfather’s mental illness and beginning
Alzheimer’s. Where health care providers, maybe even chaplains, see “demanding” relatives, there
may well be a harried family stretched by conflicting loyalties.
The second section includes the concise “seven fears of dying” and practical suggestions for
completing advance directives, which may persuade even those resistant to getting their affairs in
order. In the third and final section, the author narrates the moving “sacred walk” of her mother’s
last days as the family and community pull together and freely share fears, hopes and faith. The
author and her mother make the caregiver-caretaker transitions with grace and in doing so may
light the way for others.
Reviewed by Astuti Bijlefeld MDiv BCC, Staff Chaplain, St. James Mercy Hospital, Hornell, NY.
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