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Journal of Health Care Chaplaincy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/whcc20
Outcomes for Professional Health Care Chaplaincy: An International Call to Action a
b
c
d
George F. Handzo , Mark Cobb , Cheryl Holmes , Ewan Kelly & Shane Sinclair
e
a
Director of Health Services Research & Quality, HealthCare Chaplaincy , President, Handzo Consulting , USA b
Sr. Chaplain and Clinical Director, Sheffield Teaching Hospitals, NHS Foundation Trust , United Kingdom
Click for updates
c
CEO, Healthcare Chaplaincy Council of Victoria , Australia
d
Programme Director for Spiritual Care and Healthcare Chaplaincy, NHS Education for Scotland, Senior Lecturer in Pastoral Theology, University of Edinburgh, Research Fellow, University of Glasgow , Scotland e
Assistant Professor, Cancer Care Research Professorship, Faculty of Nursing, University of Calgary , Canada Published online: 02 May 2014.
To cite this article: George F. Handzo , Mark Cobb , Cheryl Holmes , Ewan Kelly & Shane Sinclair (2014) Outcomes for Professional Health Care Chaplaincy: An International Call to Action, Journal of Health Care Chaplaincy, 20:2, 43-53, DOI: 10.1080/08854726.2014.902713 To link to this article: http://dx.doi.org/10.1080/08854726.2014.902713
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Journal of Health Care Chaplaincy, 20:43–53, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 0885-4726 print=1528-6916 online DOI: 10.1080/08854726.2014.902713
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Guest Editorial Outcomes for Professional Health Care Chaplaincy: An International Call to Action
THE CURRENT STATE Health care in industrialized countries is increasingly focused on outcomes (Department of Health, 2013). The reasons for this focus are complex and contextualized but adopting this new currency is a central driver in each of the health care systems in the countries we represent (Australia, Canada, England, Scotland, and the United States). Primary to this focus is the recognition that the cost of health care as currently provided is unsustainable. The funding of interventions and care providers is increasingly evaluated against the data for the efficacy of the intervention; that is, does it serve one or more valued outcomes? Valued outcomes are generally those that reduce costs, improve the quality of care and patient experience often measured by patient satisfaction, and=or enhance health outcomes often measured by cure rates, reduced lengths of stay, or reduced use of health care resources (Berwick, Nolan, & Wittington, 2008). There is increasing evidence that patient experience contributes along with patient safety and clinical effectiveness in influencing outcomes (Doyle, Lennox, & Bell, 2013). Whereas chaplains have generally been exempt from this economic focus, increasingly the value of chaplaincy care is being evaluated on these criteria. A common conceptualization resulting from this shift is ‘‘volume to value’’ (Porter & Teisburg, 2006). Thus, outcome measures that can be determined to contribute value are preferred over the number of patient contacts. The issue is how much value a health care individual or an intervention adds to the system. Michael Porter at Harvard Business School has defined value as quality divided by cost (Porter & Teisberg). Concurrently, there has been increased focus on moving the person to the center of care and thereby differentiating between clinical and personal outcomes. Clinical outcomes are what a clinician wants for the patient often through a medical lens as opposed to personal outcomes which are what a person wants=desires for themselves in terms of function= way of being following a health care intervention. Such a person-centered approach focuses on the assets, capacity and resilience of individuals and takes into consideration their natural support systems, including community based resources. It involves working toward co-production of well-being rather than 43
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focusing on fixing or repairing deficits (Miller, Whoriskey, & Cook, 2008). Porter helpfully explains that, ‘‘Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system’’ (Porter, 2010, p. 2477). These outcomes not only have to be achieved effectively, but their value is enhanced if they can be achieved efficiently and predictably. Increasingly in the United States, interventions with similar targets are evaluated against one another, with the lesser effective treatment no longer being reimbursed. Determining predictable outcomes typically involves standardization of practice, increased accountability of health care providers (HCP), and decreased decision-making ability on the part of clinicians in order to mitigate variance in practice. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) provides evidence-based guidance regarding treatments, procedures, medicines, and technologies that aim to not only deliver the best quality care, but the most value for the money. While the process for evaluating outcomes in some areas of care such as the relative value of two medicines for a given condition is well understood, that process in non-pharmacologic interventions for mental health issues for instance is much more difficult (Bohmer, 2009).1 Over several decades chaplains in health care in our countries have moved from being emissaries of local religious communities to integrated members of the health care team (Puchalski & Ferrell, 2010; Sinclair & Chochinov, 2012).2 In the former state, chaplains were commissioned and employed by their faith communities to provide religious care to their members. Increasingly, chaplains (increasingly referred to as pastoral or spiritual care practitioners, or specialist spiritual care professionals) are paid from the budgets of the health organizations in which they serve and are considered health care providers (Cadge, 2012). The emergence of the profession and the integration of the spiritual domain into contemporary conceptualizations of health is a positive development as it reflects the recognition of and increased attention to the role of spiritual and religious needs in health care—something patients and families desire and which likely impacts clinical and personal outcomes as well as cost (Balboni et al., 2011; Puchalski & Ferrell). In the United States, an example of this shift is evident in the standards of The Joint Commission which accredits the majority of hospitals and now requires a chaplain on the palliative care team as criteria for advanced certification in palliative care (The Joint Commission, 2013). In the United Kingdom, spiritual and religious support is included in the NICE quality standard for end of life care and in clinical guidance on supportive and palliative care. In Australia, published guidelines and standards for palliative care and aged care point to the responsibility to provide spiritual support (Australian Government, Department of Health & Aging, 2006). Increasingly, chaplains in Scotland are working to promote a well-being
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agenda rather than one of crisis intervention and moving toward working in community settings not just in acute or palliative institutions. This shift aligns with the movement of the National Health Service in Scotland on both the wellness and the community practice agendas (Scottish Government, 2012). The emergence of chaplains as HCPs, employed by and accountable to a health care system, has subjected chaplains to the same expectations around outcomes and reporting as other disciplines. Failure to meet these outcomes has many implications including a reduction in service and funding levels. An example from Australia is the introduction of Activity Based Funding in line with the National Health Reform Agreement. The emphasis is on the ability to demonstrate outcomes and there is increasing pressure for those involved in spiritual care to fit within this model alongside other HCPs.3 However, funding is not the only driver of change in how chaplains are integrated. For instance, in Canada, much of the conversation about utility of chaplaincy as a profession centers on the development of professional colleges—a distinguishing mark of regulated health care professions versus unregulated health care professions. In the province of Alberta, professional chaplains fall into the latter category as ‘‘giving information and providing advice for the intent of enhancing personal development, providing emotional support or promoting spiritual growth of individuals, couples and groups’’ is not considered to be a ‘‘restricted activity’’ (i.e., activities that can cause harm) within the province’s Health Professions Act (Government of Alberta, 2000). This has resulted in increased effort to demonstrate that chaplains do need to be considered a regulated health care profession on the basis that they are involved in activities that could cause harm and, as such, require specific professional competence to be performed safely. While the primary driver is concern for public safety and holding chaplains accountable for activities that are judged to be potentially harmful, such legislation is a determinant of value with nonregulated health care professionals often being considered nonessential and expendable. In order to address these concerns chaplains within the province of Ontario are actively seeking status as a regulated health care profession within the proposed College of Registered Psychotherapists and Registered Mental Health Therapists. In the United Kingdom, chaplains have formed a self-regulating Board of Healthcare Chaplaincy and are exploring accreditation by the Professional Standards Authority for organizations that hold a voluntary register for health and social care occupations. While this focus on producing predictable outcomes that add value is being demanded of all professions, there are some unique challenges for chaplains: 1. Health care chaplains historically operated with a great deal of autonomy within health care. As no one knew precisely what chaplains did, quality
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based outcomes were rarely used to evaluate the profession, and chaplains were rarely held accountable for value based outcomes by their faith communities or the health care organizations although faith communities often had their own metrics like number of sacraments administered. 2. Health care chaplains have traditionally been trained to avoid an agenda in their encounters with patients and rather to respond to any presenting issue, thus making the notion of outcomes challenging, and even contradictory to this explicit purpose. 3. The professional activities of chaplains were considered by many, inside and outside of chaplaincy, by their very nature, to be unmeasurable. Certainly, replicable outcomes (with the possible exception of patient satisfaction) are antithetical to the way many chaplains are taught to practice. In other words, chaplains have always claimed to be a process centered rather than an outcome centered profession. This stance is a formerly useful adaptation that set contemporary chaplains apart from many of their predecessors who saw their role as preaching, guiding, and converting. Ironically this nonprescriptive stance is an agenda targeted at outcomes such as healing, alleviating suffering, and helping the other to feel more peace. The failure to acknowledge these outcomes keeps chaplains from explicitly integrating them in their care and measuring them. 4. The particular outcomes the system now values, especially cost reduction, are also considered by many chaplains as antithetical to how the profession has seen itself, because they violate what chaplains perceive as their focus on the human spirit as opposed to any alignment with health care being perceived as business-related. Even chaplains who are amenable to making chaplaincy an evidenceinformed and outcome driven profession face several challenges: 1. There has been little consensus within the profession about what constitutes relevant chaplaincy outcomes despite the fact that some evidence is beginning to emerge on what patients want or expect from chaplains and the impact of chaplain interventions on patient outcomes (Piderman et al., 2008; Snowden,Telfer, Kelly, Bunniss, & Mowat, 2013). The discussion that has taken place has happened sporadically in pockets rather than across the profession. In Victoria, Australia, consultation across pastoral practitioners resulted in the development of the Pastoral Care Information System to collect data on spiritual assessment, intervention and outcomes. In the United Kingdom, there has been some work to analyze activity data and map it onto a simple coding system and healthcare chaplains use a mixture of ‘‘home-grown’’ databases and proprietary software systems for recording case notes, planning follow-ups, and reporting activity (Carey, Cobb, & Equeall, 2005). Although a couple of studies are now underway in the United States, chaplains lack a well-accepted taxonomy
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of what they do, much less what they should be doing. Thus, chaplains are challenged to articulate the quality they add to the value equation by virtue of the fact that they do not agree on shared indicators. 2. The role of spirituality in health care and how spiritual needs could be met are decidedly under-researched. The field lacks a robust literature on research methods and measures and even the definition of terms as basic as spirituality itself lack consensus ( Jankowski, Handzo, & Flannelly, 2011; Mowat, 2008). 3. Although these issues are not unique to chaplains, as care becomes more team-based, it becomes increasingly difficult to tease out the scope and influence of any one member of the team or any one discipline. 4. Most chaplains lack even basic training in research and are not research literate, let alone capable of doing this kind of research themselves. Chaplains often lack the resources and networks seen in other professions to support research, although they often work in organizations that have a research infrastructure and expertise. Finally, as there is little substantive evidence that anything involving chaplaincy is of value, there is the rarely spoken of fear among us, namely, ‘‘What if in conducting the research we find that we do not contribute any value at all?’’ For chaplains, this result would not just be evidence that we need new interventions. It would signal that the part of our identity as persons who make a significant contribution to healing, which many of us highly value and view as central to who we are would be called into question. At the end of the day, our profession faces a dilemma that places us at a crossroad. We want to be valued, included, and integrated and we want patients’, caregivers’, and staff’s spiritual=religious needs attended to, but we struggle to identify and claim outcomes. Significantly, we often hold that becoming outcome driven is a violation of some basic tenets of our profession.
OUR THESIS We as chaplains have to propose, test, develop, and demonstrate the contributions and value of our profession to patients, family=carers, staff, and the organizations that employ us. These outcomes should allow us to continually improve the care we deliver, and be consistent with our values and our vision for spiritual care. If we do not develop, implement, and document these outcomes, there is a real danger that the profession may become redundant; outcomes may be imposed on us which could be inconsistent with our professional values; and=or we will be increasingly marginalized or eliminated as members of the health care team. Ultimately, the result would be that patients and their caregivers would largely have their spiritual needs unmet and would not receive the support to draw upon their spiritual
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and religious beliefs and practices—valuable resources in coping with suffering and in the promotion of well-being. There are several premises supporting our thesis. 1. The primary goal of setting outcomes and developing the evidence of how they add value is to improve the spiritual care chaplains provide to patients, family caregivers, and staff. Part of this goal is to improve the efficacy of spiritual care by eliminating practices that are not helpful, not beneficial or just ‘‘old wineskins’’ and identifying optimal practices that contribute to health and wellness. We regard this focus on improving our care as a moral and ethical imperative consistent with our belief in being good stewards of our time and talents and of the limited resources within the health care system, and being people called to a ministry of healing. 2. The results of this work can and should also be used to demonstrate the ‘‘value-added’’ of spiritual care including chaplaincy care to the health care systems that include and fund chaplaincy positions. Chaplains need to accept the reality that this kind of engagement and willingness to work within the health care system as it is constituted is a natural consequence of the integration of spiritual care. That said, as part of the engagement with the health systems, we as chaplains can work to redefine the conversation to place it in the context of patient experience and person centered care as the evidence mounts that meeting spiritual needs also serves the aims of improving clinical and personal outcomes and cost containment (Balboni et al., 2011; Bunniss, Mowat, & Snowden, 2013). However, this goal, while critical and necessary to achieve the primary goal of improving spiritual care, is a secondary outcome (Mowat, Bunniss, & Kelly, 2012; Mowat, Bunniss, Snowden, & Wright, 2013).4 3. Given the primary goal of improving spiritual care, the development of these outcomes needs to be strongly influenced by chaplains. Researchers and others can and should be enlisted to support the effort, but chaplains themselves must play a leadership role because we are best positioned to understand spiritual needs and how to meet them. The recent experience of HealthCare Chaplaincy Network in New York City demonstrates that many researchers are eager to partner with us in this area of research.5 4. As has been true in other disciplines, while we propose an ‘‘evidenceinformed’’ profession with replicable and predictable outcomes, this should not be interpreted to mean that the patient’s values and expectations and the chaplain’s professional expertise, ways of relating, and professional wisdom rooted in rigorous formation and nurtured by ongoing reflective practice are no longer of value. Health care and research granting agencies increasing focus on patient oriented research indicate that the health issues at the heart of our profession also lie at the heart of clinical health care and research (Canadian Institutes of Health Research, 2013). Researchdeveloped evidence needs to be included as a driver of better care but only
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as a driver along with others, not as the driver (American Psychological Association Presidential Task Force on Evidence-Based Practice, 2006). 5. The fact that spirituality in health care and spiritual care has been difficult to research does not mean it cannot be researched. Furthermore, ‘‘research’’ needs to be broadly defined to include demonstration projects and the use of qualitative research methods including case studies (Bunniss, Mowat, & Snowden, 2013; Cooper, 2011; Kelly, 2013) In general, beginning with practice-based evidence would be helpful here as this is a much needed first-step for chaplaincy, values chaplains’ tacit knowledge and grows the evidence base from the ground up (Glombicki & Jeuland, 2014). 6. The evidence for chaplaincy outcomes can be developed without compromising the sacredness of the chaplain-patient relationship. Anyone who has been present with a patient at the moment of their death knows the sacredness of that moment. That sacredness is not diminished by the fact that we now understand the processes by which most people die. 7. Coming to some understanding of what outcomes contribute to value will allow professional chaplaincy to enumerate the skill sets we should possess in order to deliver these outcomes and thus to design educational and training programs which address these competencies.
A CALL TO ACTION We believe that the following steps should be taken to support the development of evidence-based outcomes that allow professional chaplains to demonstrate how we meet the expressed spiritual needs of patients, family care-givers, and staff. This development will increase both the quality and quantity of spiritual care in health care and enable those who commission and procure health services to understand and have confidence that chaplains add value to health care. 1. We call upon all professional health care chaplains to support and contribute to an outcome oriented approach to chaplaincy care. 2. We call upon all professional health care chaplaincy membership associations and those associations which support spiritual care in health care to issue policy statements supporting an outcome oriented approach to chaplaincy care that promotes continual improvement of the care chaplains deliver, and are consistent with the values and vision for caring for the human spirit. 3. We call upon all programs that educate and train health care chaplains to base the training on an outcome orientation and include significant training in research literacy and quality improvement. 4. We call upon all organizations that certify chaplains to require research literacy as a requirement for certification.
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5. We call upon research funders to support research which investigates the intersection of spiritual care and health and how spiritual care can produce outcomes related to health and healing, reduce suffering, and promote well being in individuals and communities.6 6. We call for the convening of an international consensus conference of individuals committed to transformational change in chaplaincy training and conduct to write a consensus statement on chaplaincy outcomes and the values that undergird them.
ACKNOWLEDGEMENTS The inspiration for this article arose out of the International Consensus Conference on Improving the Spiritual Dimension of Whole Person Care held in Geneva, Switzerland in January, 2013. The authors would like to thank the George Washington Institute for Spirituality and Health and Caritas Internationalis which sponsored this conference and the Fetzer Institute which provided the funding. George F. Handzo Director of Health Services Research & Quality HealthCare Chaplaincy Network President, Handzo Consulting USA Mark Cobb Sr. Chaplain and Clinical Director Sheffield Teaching Hospitals, NHS Foundation Trust United Kingdom Cheryl Holmes CEO Healthcare Chaplaincy Council of Victoria Australia Ewan Kelly Programme Director for Spiritual Care and Healthcare Chaplaincy NHS Education for Scotland Senior Lecturer in Pastoral Theology, University of Edinburgh Research Fellow, University of Glasgow Scotland Shane Sinclair Assistant Professor, Cancer Care Research Professorship Faculty of Nursing, University of Calgary Canada
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NOTES 1. Richard Bohmer argues that health care consists of two types of processes: sequential and iterative; the former applies to well-structured problems to which we can apply a known solution described in a (linear) protocol; the latter applies to uncertain problems that require exploratory approaches, tacit knowledge, and learning cycles. He relates the care process to the development stage of knowledge in the condition which we could apply to spiritual care: ‘‘The greater the knowledge, the easier it is to make a prediction about outcome and thus describe the approach to problem solutions as a discrete set of steps’’ (p. 80). 2. For the purposes of this article, but also increasingly in line with current practice, we will differentiate spiritual care and chaplaincy care according to the model developed by Puchalski and Ferrell (2010) along with others. In this model spiritual care is a domain of care in which all HCPs have a role, just as they all have a role in emotional care. All HCPs are spiritual care generalists. Chaplains are the spiritual care specialists on the health care team. 3. Activity Based Funding (ABF) is a model based on outputs agreed by national bodies, that is, how many appendectomies should be completed by a particular health service at what cost. The health service is then free to decide for itself what the inputs are that it needs to deliver to achieve the agreed outputs. In this context, chaplaincy must be able to demonstrate the contribution it makes so that it continues to be funded as one of the inputs. 4. The establishment of Community Chaplaincy Listening services in family doctor surgeries in Scotland has enabled patients to gain confidence in the self-management, normalized patient experience of loss and transition, and to potentially reduce the time family doctors have to spend with these patients (thus, reducing expenditure). 5. In 2011, HealthCare Chaplaincy received a $3 million grant from the John Templeton Foundation to (1) begin the process of developing a cadre of chaplain-researchers and building a community interested in research in the efficacy of spiritual care and (2) to provide grant support and supervision to six research groups that would conduct research in this area. The six research projects, all of which include a certified chaplain on the research team, will finish their work and report out in the spring of 2014. 6. We do recognize that there are funders who have already stepped forward to be involved in this effort. We note especially the Archstone Foundation, the Fetzer Institute, and the John Templeton Foundation in this regard.
REFERENCES American Psychological Association Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271–285. Australian Government, Department of Health & Aging. (2006). Guidelines for a palliative approach in residential aged care. Retrieved from www.health.gov.au Balboni, T., Balboni, M., Paulk, E., Phelps, A., Wright, A., Peteet, J., . . . Prigerson, H. (2011). Support of cancer patients’ spiritual needs and associations with medical care costs at the end of life. Cancer. Dec 1, 117(23), 5383–5391. doi:10.1002= cncr.26221 Berwick, D., Nolan, T., & Wittington, J. (2008). The triple aim: Care, health and costs. Health Affairs, 27(3), 759–769. Bohmer, R. (2009). Designing care: Aligning the nature and management of health care. Boston, MA: Harvard Business Press, p. 80. Bunniss, S., Mowat, H., & Snowden, A. (2013). Community chaplaincy listening: Practical theology in action. The Scottish Journal of Healthcare Chaplaincy, 16(special), 42–51. Cadge, W. (2012). Paging God: Religion in the halls of medicine. Chicago, IL: University of Chicago Press.
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Canadian Institutes of Health Research. (2013). Strategy for patient-oriented research. Retrieved from http://www.cihr-irsc.gc.ca/e/41204.html Carey, L., Cobb, M., & Equeall, D. (2005). From ‘‘pastoral contacts’’ to ‘‘pastoral interventions.’’ Scottish Journal of Healthcare Chaplaincy, 8, 14–20. Cooper, R. (2011). Case study of a chaplain’s spiritual care for a patient with advanced metastatic breast cancer. Journal of Health Care Chaplaincy, 17, 19–37. Department of Health. The NHS Outcomes Framework 2014=15. London: Author. Retrieved from https://www.gov.uk/government/publications/nhs-outcomesframework-2014-to-2015 Doyle, C., Lennox, L., & Bell, D. (2013). A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open Jan 3, 3(1), pii: e001570. doi:10.1136=bmjopen-2012-001570 Glombicki, J. S., & Jeuland, J. (2014). Exploring the importance of chaplain visits in a palliative care clinic for patients and companions. Journal of Palliative Medicine, 17(2), 1–2. doi:10.1089=jpm.2013.0523 Government of Alberta. (2000). Government Organization Act. (Alberta Queen’s Printer). Edmonton, AB: Author. Jankowski, K., Handzo, G., & Flannelly, K. (2011). Testing the efficacy of chaplaincy care. Journal of Health Care Chaplaincy, 17(3–4), 100–125. The Joint Commission. (2013). Advanced certification for palliative care program. Palliative Care Certification Manual. Oak Terrace, IL: The Joint Commission. Kelly, E. (2013). Translating theological reflective practice into values based reflection: A report from Scotland. Reflective Practice- Formation and Supervision in Ministry, 33, 245–256. Miller, E., Whoriskey, M., & Cook, A. (2008). Outcomes for users and carers in the context of health and social care partnership working: From research to practice. Journal of Integrated Care, 16(2), 21–28. Mowat, H. (2008). The potential for efficacy of healthcare chaplaincy and spiritual care provision in the NHS (UK): A scoping review of recent research. Aberdeen, Scotland: Mowat Research Limited. Retrieved from www.nhs-chaplaincycollaboratives.com/efficacy0801.pdf Mowat, H., Bunniss, S., & Kelly, E. (2012). Community chaplaincy listening: Working with general practitioner’s to support patient wellbeing. Scottish Journal of Healthcare Chaplaincy 15(1), 21–26. Mowat, H., Bunniss, S., Snowden, A., & Wright, L. (2013). Community chaplaincy listening. Scottish Journal of Healthcare Chaplaincy 16(special), 33–52. Piderman, K., Marek, D., Jenkins, S., Johnson, M., Buryska, J., & Mueller, P. (2008). Patients’ expectations of hospital chaplains. Mayo Clinic Proceedings, 83(1), 58–65. Porter, M. E. (2010). What is value in health care? New England Journal of Medicine, 363, 2477–2481. Porter, M. E., & Teisberg, E. O. (2006). Redefining health care: Creating value-based competition on results. Boston, MA: Harvard Business School Publishing. Puchalski, C., & Ferrell, B. (2010). Making healthcare whole: Integrating spirituality into patient care. West Conshohocken, PA: Templeton Press. Scottish Government. (2012). 2020 Vision for health and social care. Edinburgh: Author.
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Sinclair, S., & Chochinov, H. M. (2012). The role of chaplains within interdisciplinary oncology teams. Current Opinion in Supportive and Palliative Care, 6(2), 259–268. Snowden, A., Telfer, I., Kelly, E., Bunniss, S., & Mowat, H. (2013). Spiritual care as person centered care: A thematic analysis of interventions. Scottish Journal of Healthcare Chaplains, 16, 3–32.
Journal of Health Care Chaplaincy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/whcc20
Outcomes for Professional Health Care Chaplaincy: An International Call to Action a
b
c
d
George F. Handzo , Mark Cobb , Cheryl Holmes , Ewan Kelly & Shane Sinclair
e
a
Director of Health Services Research & Quality, HealthCare Chaplaincy , President, Handzo Consulting , USA b
Sr. Chaplain and Clinical Director, Sheffield Teaching Hospitals, NHS Foundation Trust , United Kingdom
Click for updates
c
CEO, Healthcare Chaplaincy Council of Victoria , Australia
d
Programme Director for Spiritual Care and Healthcare Chaplaincy, NHS Education for Scotland, Senior Lecturer in Pastoral Theology, University of Edinburgh, Research Fellow, University of Glasgow , Scotland e
Assistant Professor, Cancer Care Research Professorship, Faculty of Nursing, University of Calgary , Canada Published online: 02 May 2014.
To cite this article: George F. Handzo , Mark Cobb , Cheryl Holmes , Ewan Kelly & Shane Sinclair (2014) Outcomes for Professional Health Care Chaplaincy: An International Call to Action, Journal of Health Care Chaplaincy, 20:2, 43-53, DOI: 10.1080/08854726.2014.902713 To link to this article: http://dx.doi.org/10.1080/08854726.2014.902713
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
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This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Health Care Chaplaincy, 20:43–53, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 0885-4726 print=1528-6916 online DOI: 10.1080/08854726.2014.902713
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Guest Editorial Outcomes for Professional Health Care Chaplaincy: An International Call to Action
THE CURRENT STATE Health care in industrialized countries is increasingly focused on outcomes (Department of Health, 2013). The reasons for this focus are complex and contextualized but adopting this new currency is a central driver in each of the health care systems in the countries we represent (Australia, Canada, England, Scotland, and the United States). Primary to this focus is the recognition that the cost of health care as currently provided is unsustainable. The funding of interventions and care providers is increasingly evaluated against the data for the efficacy of the intervention; that is, does it serve one or more valued outcomes? Valued outcomes are generally those that reduce costs, improve the quality of care and patient experience often measured by patient satisfaction, and=or enhance health outcomes often measured by cure rates, reduced lengths of stay, or reduced use of health care resources (Berwick, Nolan, & Wittington, 2008). There is increasing evidence that patient experience contributes along with patient safety and clinical effectiveness in influencing outcomes (Doyle, Lennox, & Bell, 2013). Whereas chaplains have generally been exempt from this economic focus, increasingly the value of chaplaincy care is being evaluated on these criteria. A common conceptualization resulting from this shift is ‘‘volume to value’’ (Porter & Teisburg, 2006). Thus, outcome measures that can be determined to contribute value are preferred over the number of patient contacts. The issue is how much value a health care individual or an intervention adds to the system. Michael Porter at Harvard Business School has defined value as quality divided by cost (Porter & Teisberg). Concurrently, there has been increased focus on moving the person to the center of care and thereby differentiating between clinical and personal outcomes. Clinical outcomes are what a clinician wants for the patient often through a medical lens as opposed to personal outcomes which are what a person wants=desires for themselves in terms of function= way of being following a health care intervention. Such a person-centered approach focuses on the assets, capacity and resilience of individuals and takes into consideration their natural support systems, including community based resources. It involves working toward co-production of well-being rather than 43
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focusing on fixing or repairing deficits (Miller, Whoriskey, & Cook, 2008). Porter helpfully explains that, ‘‘Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system’’ (Porter, 2010, p. 2477). These outcomes not only have to be achieved effectively, but their value is enhanced if they can be achieved efficiently and predictably. Increasingly in the United States, interventions with similar targets are evaluated against one another, with the lesser effective treatment no longer being reimbursed. Determining predictable outcomes typically involves standardization of practice, increased accountability of health care providers (HCP), and decreased decision-making ability on the part of clinicians in order to mitigate variance in practice. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) provides evidence-based guidance regarding treatments, procedures, medicines, and technologies that aim to not only deliver the best quality care, but the most value for the money. While the process for evaluating outcomes in some areas of care such as the relative value of two medicines for a given condition is well understood, that process in non-pharmacologic interventions for mental health issues for instance is much more difficult (Bohmer, 2009).1 Over several decades chaplains in health care in our countries have moved from being emissaries of local religious communities to integrated members of the health care team (Puchalski & Ferrell, 2010; Sinclair & Chochinov, 2012).2 In the former state, chaplains were commissioned and employed by their faith communities to provide religious care to their members. Increasingly, chaplains (increasingly referred to as pastoral or spiritual care practitioners, or specialist spiritual care professionals) are paid from the budgets of the health organizations in which they serve and are considered health care providers (Cadge, 2012). The emergence of the profession and the integration of the spiritual domain into contemporary conceptualizations of health is a positive development as it reflects the recognition of and increased attention to the role of spiritual and religious needs in health care—something patients and families desire and which likely impacts clinical and personal outcomes as well as cost (Balboni et al., 2011; Puchalski & Ferrell). In the United States, an example of this shift is evident in the standards of The Joint Commission which accredits the majority of hospitals and now requires a chaplain on the palliative care team as criteria for advanced certification in palliative care (The Joint Commission, 2013). In the United Kingdom, spiritual and religious support is included in the NICE quality standard for end of life care and in clinical guidance on supportive and palliative care. In Australia, published guidelines and standards for palliative care and aged care point to the responsibility to provide spiritual support (Australian Government, Department of Health & Aging, 2006). Increasingly, chaplains in Scotland are working to promote a well-being
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agenda rather than one of crisis intervention and moving toward working in community settings not just in acute or palliative institutions. This shift aligns with the movement of the National Health Service in Scotland on both the wellness and the community practice agendas (Scottish Government, 2012). The emergence of chaplains as HCPs, employed by and accountable to a health care system, has subjected chaplains to the same expectations around outcomes and reporting as other disciplines. Failure to meet these outcomes has many implications including a reduction in service and funding levels. An example from Australia is the introduction of Activity Based Funding in line with the National Health Reform Agreement. The emphasis is on the ability to demonstrate outcomes and there is increasing pressure for those involved in spiritual care to fit within this model alongside other HCPs.3 However, funding is not the only driver of change in how chaplains are integrated. For instance, in Canada, much of the conversation about utility of chaplaincy as a profession centers on the development of professional colleges—a distinguishing mark of regulated health care professions versus unregulated health care professions. In the province of Alberta, professional chaplains fall into the latter category as ‘‘giving information and providing advice for the intent of enhancing personal development, providing emotional support or promoting spiritual growth of individuals, couples and groups’’ is not considered to be a ‘‘restricted activity’’ (i.e., activities that can cause harm) within the province’s Health Professions Act (Government of Alberta, 2000). This has resulted in increased effort to demonstrate that chaplains do need to be considered a regulated health care profession on the basis that they are involved in activities that could cause harm and, as such, require specific professional competence to be performed safely. While the primary driver is concern for public safety and holding chaplains accountable for activities that are judged to be potentially harmful, such legislation is a determinant of value with nonregulated health care professionals often being considered nonessential and expendable. In order to address these concerns chaplains within the province of Ontario are actively seeking status as a regulated health care profession within the proposed College of Registered Psychotherapists and Registered Mental Health Therapists. In the United Kingdom, chaplains have formed a self-regulating Board of Healthcare Chaplaincy and are exploring accreditation by the Professional Standards Authority for organizations that hold a voluntary register for health and social care occupations. While this focus on producing predictable outcomes that add value is being demanded of all professions, there are some unique challenges for chaplains: 1. Health care chaplains historically operated with a great deal of autonomy within health care. As no one knew precisely what chaplains did, quality
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based outcomes were rarely used to evaluate the profession, and chaplains were rarely held accountable for value based outcomes by their faith communities or the health care organizations although faith communities often had their own metrics like number of sacraments administered. 2. Health care chaplains have traditionally been trained to avoid an agenda in their encounters with patients and rather to respond to any presenting issue, thus making the notion of outcomes challenging, and even contradictory to this explicit purpose. 3. The professional activities of chaplains were considered by many, inside and outside of chaplaincy, by their very nature, to be unmeasurable. Certainly, replicable outcomes (with the possible exception of patient satisfaction) are antithetical to the way many chaplains are taught to practice. In other words, chaplains have always claimed to be a process centered rather than an outcome centered profession. This stance is a formerly useful adaptation that set contemporary chaplains apart from many of their predecessors who saw their role as preaching, guiding, and converting. Ironically this nonprescriptive stance is an agenda targeted at outcomes such as healing, alleviating suffering, and helping the other to feel more peace. The failure to acknowledge these outcomes keeps chaplains from explicitly integrating them in their care and measuring them. 4. The particular outcomes the system now values, especially cost reduction, are also considered by many chaplains as antithetical to how the profession has seen itself, because they violate what chaplains perceive as their focus on the human spirit as opposed to any alignment with health care being perceived as business-related. Even chaplains who are amenable to making chaplaincy an evidenceinformed and outcome driven profession face several challenges: 1. There has been little consensus within the profession about what constitutes relevant chaplaincy outcomes despite the fact that some evidence is beginning to emerge on what patients want or expect from chaplains and the impact of chaplain interventions on patient outcomes (Piderman et al., 2008; Snowden,Telfer, Kelly, Bunniss, & Mowat, 2013). The discussion that has taken place has happened sporadically in pockets rather than across the profession. In Victoria, Australia, consultation across pastoral practitioners resulted in the development of the Pastoral Care Information System to collect data on spiritual assessment, intervention and outcomes. In the United Kingdom, there has been some work to analyze activity data and map it onto a simple coding system and healthcare chaplains use a mixture of ‘‘home-grown’’ databases and proprietary software systems for recording case notes, planning follow-ups, and reporting activity (Carey, Cobb, & Equeall, 2005). Although a couple of studies are now underway in the United States, chaplains lack a well-accepted taxonomy
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of what they do, much less what they should be doing. Thus, chaplains are challenged to articulate the quality they add to the value equation by virtue of the fact that they do not agree on shared indicators. 2. The role of spirituality in health care and how spiritual needs could be met are decidedly under-researched. The field lacks a robust literature on research methods and measures and even the definition of terms as basic as spirituality itself lack consensus ( Jankowski, Handzo, & Flannelly, 2011; Mowat, 2008). 3. Although these issues are not unique to chaplains, as care becomes more team-based, it becomes increasingly difficult to tease out the scope and influence of any one member of the team or any one discipline. 4. Most chaplains lack even basic training in research and are not research literate, let alone capable of doing this kind of research themselves. Chaplains often lack the resources and networks seen in other professions to support research, although they often work in organizations that have a research infrastructure and expertise. Finally, as there is little substantive evidence that anything involving chaplaincy is of value, there is the rarely spoken of fear among us, namely, ‘‘What if in conducting the research we find that we do not contribute any value at all?’’ For chaplains, this result would not just be evidence that we need new interventions. It would signal that the part of our identity as persons who make a significant contribution to healing, which many of us highly value and view as central to who we are would be called into question. At the end of the day, our profession faces a dilemma that places us at a crossroad. We want to be valued, included, and integrated and we want patients’, caregivers’, and staff’s spiritual=religious needs attended to, but we struggle to identify and claim outcomes. Significantly, we often hold that becoming outcome driven is a violation of some basic tenets of our profession.
OUR THESIS We as chaplains have to propose, test, develop, and demonstrate the contributions and value of our profession to patients, family=carers, staff, and the organizations that employ us. These outcomes should allow us to continually improve the care we deliver, and be consistent with our values and our vision for spiritual care. If we do not develop, implement, and document these outcomes, there is a real danger that the profession may become redundant; outcomes may be imposed on us which could be inconsistent with our professional values; and=or we will be increasingly marginalized or eliminated as members of the health care team. Ultimately, the result would be that patients and their caregivers would largely have their spiritual needs unmet and would not receive the support to draw upon their spiritual
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and religious beliefs and practices—valuable resources in coping with suffering and in the promotion of well-being. There are several premises supporting our thesis. 1. The primary goal of setting outcomes and developing the evidence of how they add value is to improve the spiritual care chaplains provide to patients, family caregivers, and staff. Part of this goal is to improve the efficacy of spiritual care by eliminating practices that are not helpful, not beneficial or just ‘‘old wineskins’’ and identifying optimal practices that contribute to health and wellness. We regard this focus on improving our care as a moral and ethical imperative consistent with our belief in being good stewards of our time and talents and of the limited resources within the health care system, and being people called to a ministry of healing. 2. The results of this work can and should also be used to demonstrate the ‘‘value-added’’ of spiritual care including chaplaincy care to the health care systems that include and fund chaplaincy positions. Chaplains need to accept the reality that this kind of engagement and willingness to work within the health care system as it is constituted is a natural consequence of the integration of spiritual care. That said, as part of the engagement with the health systems, we as chaplains can work to redefine the conversation to place it in the context of patient experience and person centered care as the evidence mounts that meeting spiritual needs also serves the aims of improving clinical and personal outcomes and cost containment (Balboni et al., 2011; Bunniss, Mowat, & Snowden, 2013). However, this goal, while critical and necessary to achieve the primary goal of improving spiritual care, is a secondary outcome (Mowat, Bunniss, & Kelly, 2012; Mowat, Bunniss, Snowden, & Wright, 2013).4 3. Given the primary goal of improving spiritual care, the development of these outcomes needs to be strongly influenced by chaplains. Researchers and others can and should be enlisted to support the effort, but chaplains themselves must play a leadership role because we are best positioned to understand spiritual needs and how to meet them. The recent experience of HealthCare Chaplaincy Network in New York City demonstrates that many researchers are eager to partner with us in this area of research.5 4. As has been true in other disciplines, while we propose an ‘‘evidenceinformed’’ profession with replicable and predictable outcomes, this should not be interpreted to mean that the patient’s values and expectations and the chaplain’s professional expertise, ways of relating, and professional wisdom rooted in rigorous formation and nurtured by ongoing reflective practice are no longer of value. Health care and research granting agencies increasing focus on patient oriented research indicate that the health issues at the heart of our profession also lie at the heart of clinical health care and research (Canadian Institutes of Health Research, 2013). Researchdeveloped evidence needs to be included as a driver of better care but only
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as a driver along with others, not as the driver (American Psychological Association Presidential Task Force on Evidence-Based Practice, 2006). 5. The fact that spirituality in health care and spiritual care has been difficult to research does not mean it cannot be researched. Furthermore, ‘‘research’’ needs to be broadly defined to include demonstration projects and the use of qualitative research methods including case studies (Bunniss, Mowat, & Snowden, 2013; Cooper, 2011; Kelly, 2013) In general, beginning with practice-based evidence would be helpful here as this is a much needed first-step for chaplaincy, values chaplains’ tacit knowledge and grows the evidence base from the ground up (Glombicki & Jeuland, 2014). 6. The evidence for chaplaincy outcomes can be developed without compromising the sacredness of the chaplain-patient relationship. Anyone who has been present with a patient at the moment of their death knows the sacredness of that moment. That sacredness is not diminished by the fact that we now understand the processes by which most people die. 7. Coming to some understanding of what outcomes contribute to value will allow professional chaplaincy to enumerate the skill sets we should possess in order to deliver these outcomes and thus to design educational and training programs which address these competencies.
A CALL TO ACTION We believe that the following steps should be taken to support the development of evidence-based outcomes that allow professional chaplains to demonstrate how we meet the expressed spiritual needs of patients, family care-givers, and staff. This development will increase both the quality and quantity of spiritual care in health care and enable those who commission and procure health services to understand and have confidence that chaplains add value to health care. 1. We call upon all professional health care chaplains to support and contribute to an outcome oriented approach to chaplaincy care. 2. We call upon all professional health care chaplaincy membership associations and those associations which support spiritual care in health care to issue policy statements supporting an outcome oriented approach to chaplaincy care that promotes continual improvement of the care chaplains deliver, and are consistent with the values and vision for caring for the human spirit. 3. We call upon all programs that educate and train health care chaplains to base the training on an outcome orientation and include significant training in research literacy and quality improvement. 4. We call upon all organizations that certify chaplains to require research literacy as a requirement for certification.
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5. We call upon research funders to support research which investigates the intersection of spiritual care and health and how spiritual care can produce outcomes related to health and healing, reduce suffering, and promote well being in individuals and communities.6 6. We call for the convening of an international consensus conference of individuals committed to transformational change in chaplaincy training and conduct to write a consensus statement on chaplaincy outcomes and the values that undergird them.
ACKNOWLEDGEMENTS The inspiration for this article arose out of the International Consensus Conference on Improving the Spiritual Dimension of Whole Person Care held in Geneva, Switzerland in January, 2013. The authors would like to thank the George Washington Institute for Spirituality and Health and Caritas Internationalis which sponsored this conference and the Fetzer Institute which provided the funding. George F. Handzo Director of Health Services Research & Quality HealthCare Chaplaincy Network President, Handzo Consulting USA Mark Cobb Sr. Chaplain and Clinical Director Sheffield Teaching Hospitals, NHS Foundation Trust United Kingdom Cheryl Holmes CEO Healthcare Chaplaincy Council of Victoria Australia Ewan Kelly Programme Director for Spiritual Care and Healthcare Chaplaincy NHS Education for Scotland Senior Lecturer in Pastoral Theology, University of Edinburgh Research Fellow, University of Glasgow Scotland Shane Sinclair Assistant Professor, Cancer Care Research Professorship Faculty of Nursing, University of Calgary Canada
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NOTES 1. Richard Bohmer argues that health care consists of two types of processes: sequential and iterative; the former applies to well-structured problems to which we can apply a known solution described in a (linear) protocol; the latter applies to uncertain problems that require exploratory approaches, tacit knowledge, and learning cycles. He relates the care process to the development stage of knowledge in the condition which we could apply to spiritual care: ‘‘The greater the knowledge, the easier it is to make a prediction about outcome and thus describe the approach to problem solutions as a discrete set of steps’’ (p. 80). 2. For the purposes of this article, but also increasingly in line with current practice, we will differentiate spiritual care and chaplaincy care according to the model developed by Puchalski and Ferrell (2010) along with others. In this model spiritual care is a domain of care in which all HCPs have a role, just as they all have a role in emotional care. All HCPs are spiritual care generalists. Chaplains are the spiritual care specialists on the health care team. 3. Activity Based Funding (ABF) is a model based on outputs agreed by national bodies, that is, how many appendectomies should be completed by a particular health service at what cost. The health service is then free to decide for itself what the inputs are that it needs to deliver to achieve the agreed outputs. In this context, chaplaincy must be able to demonstrate the contribution it makes so that it continues to be funded as one of the inputs. 4. The establishment of Community Chaplaincy Listening services in family doctor surgeries in Scotland has enabled patients to gain confidence in the self-management, normalized patient experience of loss and transition, and to potentially reduce the time family doctors have to spend with these patients (thus, reducing expenditure). 5. In 2011, HealthCare Chaplaincy received a $3 million grant from the John Templeton Foundation to (1) begin the process of developing a cadre of chaplain-researchers and building a community interested in research in the efficacy of spiritual care and (2) to provide grant support and supervision to six research groups that would conduct research in this area. The six research projects, all of which include a certified chaplain on the research team, will finish their work and report out in the spring of 2014. 6. We do recognize that there are funders who have already stepped forward to be involved in this effort. We note especially the Archstone Foundation, the Fetzer Institute, and the John Templeton Foundation in this regard.
REFERENCES American Psychological Association Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271–285. Australian Government, Department of Health & Aging. (2006). Guidelines for a palliative approach in residential aged care. Retrieved from www.health.gov.au Balboni, T., Balboni, M., Paulk, E., Phelps, A., Wright, A., Peteet, J., . . . Prigerson, H. (2011). Support of cancer patients’ spiritual needs and associations with medical care costs at the end of life. Cancer. Dec 1, 117(23), 5383–5391. doi:10.1002= cncr.26221 Berwick, D., Nolan, T., & Wittington, J. (2008). The triple aim: Care, health and costs. Health Affairs, 27(3), 759–769. Bohmer, R. (2009). Designing care: Aligning the nature and management of health care. Boston, MA: Harvard Business Press, p. 80. Bunniss, S., Mowat, H., & Snowden, A. (2013). Community chaplaincy listening: Practical theology in action. The Scottish Journal of Healthcare Chaplaincy, 16(special), 42–51. Cadge, W. (2012). Paging God: Religion in the halls of medicine. Chicago, IL: University of Chicago Press.
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Canadian Institutes of Health Research. (2013). Strategy for patient-oriented research. Retrieved from http://www.cihr-irsc.gc.ca/e/41204.html Carey, L., Cobb, M., & Equeall, D. (2005). From ‘‘pastoral contacts’’ to ‘‘pastoral interventions.’’ Scottish Journal of Healthcare Chaplaincy, 8, 14–20. Cooper, R. (2011). Case study of a chaplain’s spiritual care for a patient with advanced metastatic breast cancer. Journal of Health Care Chaplaincy, 17, 19–37. Department of Health. The NHS Outcomes Framework 2014=15. London: Author. Retrieved from https://www.gov.uk/government/publications/nhs-outcomesframework-2014-to-2015 Doyle, C., Lennox, L., & Bell, D. (2013). A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open Jan 3, 3(1), pii: e001570. doi:10.1136=bmjopen-2012-001570 Glombicki, J. S., & Jeuland, J. (2014). Exploring the importance of chaplain visits in a palliative care clinic for patients and companions. Journal of Palliative Medicine, 17(2), 1–2. doi:10.1089=jpm.2013.0523 Government of Alberta. (2000). Government Organization Act. (Alberta Queen’s Printer). Edmonton, AB: Author. Jankowski, K., Handzo, G., & Flannelly, K. (2011). Testing the efficacy of chaplaincy care. Journal of Health Care Chaplaincy, 17(3–4), 100–125. The Joint Commission. (2013). Advanced certification for palliative care program. Palliative Care Certification Manual. Oak Terrace, IL: The Joint Commission. Kelly, E. (2013). Translating theological reflective practice into values based reflection: A report from Scotland. Reflective Practice- Formation and Supervision in Ministry, 33, 245–256. Miller, E., Whoriskey, M., & Cook, A. (2008). Outcomes for users and carers in the context of health and social care partnership working: From research to practice. Journal of Integrated Care, 16(2), 21–28. Mowat, H. (2008). The potential for efficacy of healthcare chaplaincy and spiritual care provision in the NHS (UK): A scoping review of recent research. Aberdeen, Scotland: Mowat Research Limited. Retrieved from www.nhs-chaplaincycollaboratives.com/efficacy0801.pdf Mowat, H., Bunniss, S., & Kelly, E. (2012). Community chaplaincy listening: Working with general practitioner’s to support patient wellbeing. Scottish Journal of Healthcare Chaplaincy 15(1), 21–26. Mowat, H., Bunniss, S., Snowden, A., & Wright, L. (2013). Community chaplaincy listening. Scottish Journal of Healthcare Chaplaincy 16(special), 33–52. Piderman, K., Marek, D., Jenkins, S., Johnson, M., Buryska, J., & Mueller, P. (2008). Patients’ expectations of hospital chaplains. Mayo Clinic Proceedings, 83(1), 58–65. Porter, M. E. (2010). What is value in health care? New England Journal of Medicine, 363, 2477–2481. Porter, M. E., & Teisberg, E. O. (2006). Redefining health care: Creating value-based competition on results. Boston, MA: Harvard Business School Publishing. Puchalski, C., & Ferrell, B. (2010). Making healthcare whole: Integrating spirituality into patient care. West Conshohocken, PA: Templeton Press. Scottish Government. (2012). 2020 Vision for health and social care. Edinburgh: Author.
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Sinclair, S., & Chochinov, H. M. (2012). The role of chaplains within interdisciplinary oncology teams. Current Opinion in Supportive and Palliative Care, 6(2), 259–268. Snowden, A., Telfer, I., Kelly, E., Bunniss, S., & Mowat, H. (2013). Spiritual care as person centered care: A thematic analysis of interventions. Scottish Journal of Healthcare Chaplains, 16, 3–32.
