By George Fitchett, DMin, PhD
Chaplains’ acceptance of the importance of evidence-based practice (EBP) is growing. The term “evidence-based pastoral care” first appeared in our literature in a 1998 article by Tom O’Connor and Elizabeth Meakes (Hope in the Midst of Challenge: Evidence-Based Pastoral Care. Journal of Pastoral Care 52(4):359-367). A decade later it was affirmed in the Standards of Practice adopted by the APC.
Among 59 NACC members who completed surveys at the 2012 NACC National Conference, the vast majority (93%) agreed they would like their care to be more evidence-based. Research is part of the current Strategic Plan for the NACC. A research-informed approach to practice has been affirmed by chaplaincy organizations in the United Kingdom and Australia. We should also remember that research played a central role in guiding the ministry that Anton Boisen, a pioneer in the development of modern chaplaincy, provided to the patients under his care. One of the goals of Boisen’s approach to CPE was to teach his students to do research.
While chaplains are embracing EBP, there are misconceptions about what it means. This figure shows the three components of EBP. It is important to recognize that in addition to using the best available evidence, EBP makes use of the expertise of clinicians (e.g., chaplains) to apply that evidence in light of the specific needs, resources, and values of each person for whom we provide care. EBP relies on a well-established hierarchy of evidence to inform clinical practice. In this hierarchy the strongest evidence comes from meta-analyses and systematic reviews of evidence. Clinical trials also provide strong evidence to guide practice. Case studies and expert opinion also provide evidence, albeit a weaker level of evidence, to guide practice. Chaplains Brian Hughes and George Handzo used these levels of evidence to rate the evidence for many common chaplaincy activities. (See the Spiritual Care Handbook on PTSD/TBI (2010) written for chaplains in the U.S. Navy. The handbook is available at healthcarechaplaincy.org/userimages/Spiritual%20Care%20PTSD%20Handbook1.pdf)
In order for chaplains to adopt EBP they will need to be research literate. This idea makes many chaplains anxious, partly because they mistakenly think it means they must do research. In fact, being research literate means that a chaplain has the ability to critically read a simple research study and apply any relevant findings to his or her spiritual care. All chaplains will need to develop a basic level of research literacy in order for our profession to meaningfully adopt EBP. Beyond this, some chaplains will develop advanced levels of research literacy that will enable them to contribute to research projects led by experienced investigators. In addition, a few chaplains will have or will develop the expertise required to design and lead research that helps inform our spiritual care.
In a time when we must be accountable for every healthcare dollar we spend, most chaplains recognize the importance of having evidence for the benefits associated with their care. While this is an important reason for chaplains to embrace EBP, in my mind it is the second reason to do so. The first and most important reason to embrace EBP is to improve our spiritual care. Let me illustrate. In my early work as a chaplain I sometimes met patients who were facing difficult medical conditions and who were feeling angry with God about their illness. While I provided helpful spiritual care for these patients, doing so was no more of a priority for me than visiting any other patients. The results of a study I conducted with my colleagues caused me to rethink my attitude towards patients who were feeling this way. Our study examined religious coping and its effect on treatment outcomes for 96 medical rehabilitation patients (Fitchett et al., 1999. The role of religion in medical rehabilitation outcomes: A longitudinal study. Rehabilitation Psychology, 44(4), 333-353). In the study we found that religious struggle, which includes feeling angry with God as well as feeling abandoned or punished by God, was associated with poorer recovery of functional abilities. Soon other investigators, such as Ken Pargament and Harold Koenig, began to report similar findings. There is now a sizable body of evidence of the harmful effects of religious/spiritual struggle. This evidence points to at least two ways we can improve the quality of our care. First, it suggests we make care for any patients with religious/spiritual struggle a priority. Second, it suggests we educate our healthcare colleagues on ways they can screen for religious/spiritual struggle and make referrals for patients who may be experiencing it. My colleague Jay Risk and I developed one protocol that can be used for such screening (Fitchett & Risk, 2009 Aug 19. Screening for spiritual struggle. Journal of Pastoral Care and Counseling 63, 1,2.).
While chaplains have begun to embrace the need for EBP, becoming an evidence-based profession will be a big and challenging undertaking. We will need to provide continuing education to help practicing chaplains develop basic research literacy. One model for this is the Webinar Research Journal Club that my colleague Pat Murphy and I teach through the APC. (NACC members are welcome to enroll. See www.professionalchaplains.org/content.asp?pl=72&contentid=72). Currently only about 12% of CPE programs provide research education for their CPE residents. Obviously that needs to become 100% if we want to train research literate chaplains who will be prepared to offer evidence-based spiritual care. We will also need research about the religious/spiritual needs and resources of the patients and families for whom we care, and especially research about the impact of the care we provide for them. Few chaplains will have the training or resources to conduct such studies, but many chaplains may develop advanced research literacy and help experienced investigators at their institutions thoughtfully include spiritual care in their research. This is the model that is being used in the important HealthCare Chaplaincy/Templeton Foundation project described in the accompanying article. While developing evidence-based chaplaincy is a big job, embracing EBP is the first and most important step.
George Fitchett is associate professor and director of research in the Department of Religion, Health and Human Values at Rush University Medical Center in Chicago, IL.
