Chaplains’ Perspectives on Standardizing Spiritual Assessments

Abstract

Chaplains are an integral part of mental health treatment within the Veterans Health Administration (VHA) and over the past decade, efforts have been made to integrate chaplain services into behavioral health treatment. One unique duty of chaplains is to conduct spiritual assessments, which are characterized as collaborative discussions with Veterans to understand their overall religious and belief system, identify spiritual injuries, and how to integrate one’s spiritual values into medical care. Although spiritual assessments in Veterans Affairs Medical Centers (VAMCs) have evolved throughout the years to adopt a more structured approach, spiritual assessments can vary depending on site, clinical setting, and medical center. The current study sought to examine chaplains’ perspectives on standardizing spiritual assessments and incorporating empirically validated measures into the assessments. Thematic analysis was conducted on two focus groups of chaplains from a large VHA medical center. Overall, chaplains appeared interested in standardizing spiritual assessments, with an expressed desire to maintain their current conversational format.

Chaplains have been identified as an integral part of mental health treatment and in 2010, the Veterans Health Administration (VHA) and Department of Defense (DoD) developed the Integrated Mental Health Strategy to focus on integrating chaplains into Veterans’ mental health treatment (DoD and VHA, 2010). Chaplains have been described as a “front-line” service provider for mental health concerns of Veterans (Bonner et al., 2013) and can be a less stigmatizing resource for military personnel (Morgan, Hourani, Lane, & Tueller, 2016). Additionally, a study of post-9/11 conflict Veterans highlighted how pastoral and mental health care services complement each other and successful collaboration enhances favorable Veteran treatment outcomes (Nieuwsma, Fortune-Greeley, Jackson, Meador, Beckham, & Elbogen, 2014).

Integrating mental health treatment between chaplaincy and behavioral health disciplines within the VHA may be key to effectively and comprehensively addressing certain Veteran mental health concerns. Spiritual assessments are a unique service provided by VHA chaplains (Vance & Kopacz, 2016). Spiritual assessments are defined in VHA as an “ongoing evaluation administered by a chaplain, with voluntary participation from the Veteran, that uses standardized questions to gather information and define the Veteran’s desires, needs, hopes, spiritual resources and spiritual injuries for the purposes of care planning” (VHA Directive 1111, 2021). Spiritual assessments inquire about the Veteran’s belief system, spiritual or religious practices, spiritual needs, support needed, spiritual coping measures, spiritual issues that may impact medical care, and spiritual injuries. Incorporating religious or spiritual values within psychotherapies supports such favorable outcomes as reduced psychological distress and increased spiritual well-being (Captari, Hook, Hoyt, Davis, McElroy-Heltzel, & Worthington, 2018).

In recent years, a body of literature has examined the benefits of supporting Veterans impacted by moral injury through integrated spiritual support provided by chaplains and clinical mental health care. Moral injury occurs when an individual either engages in or witnesses events that challenge deeply held values or spiritual beliefs (Litz et al., 2009; Jinkerson, 2016). Although not a formal diagnosis within the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), researchers and clinicians have proposed that moral injury is a syndrome characterized by intractable and irrational guilt or anger, self-loathing, loss of faith or loss of meaning/purpose in life, and is associated with suicidal ideation and attempts, depression, substance use, withdrawal from social relationships, and difficulty with occupational and family role functions (Bryan et al., 2014; Harris et al., 2012; Maguen et al., 2012; Jinkerson, 2016; Kopacz et al., 2016; Gray et al., 2012).

Current research on the treatment of moral injury has brought forth promising concepts, many of which incorporate behavioral health with chaplain services (Capone et al., 2021; Harris et al., 2011; Litz, Lebowitz, Gray, & Nash, 2016; Maguen & Burkman, 2013). Treatment of moral injury tends to differ from treatment of Posttraumatic Stress Disorder by targeting guilt, shame, and emphasizing moral repair. Despite the psychological impact of moral injury, Veterans are sometimes reticent to discuss inherently spiritual concerns with mental health providers (Harris et al., 2015; Kopacz et al., 2016; Tanelian et al., 2008). For this reason, enhancing spiritual assessments with psychometric evidence - effectively having such assessments double as validated psychological measures – could help foster interdisciplinary collaboration and benefit treatment outcomes for Veterans. The goal of this study was to learn chaplains’ perspectives on if integrating standardized assessment into spiritual assessments would be acceptable to chaplains, appropriate for chaplaincy practice, and consistent with organizational culture.

Spiritual assessments in VAMCs have evolved throughout the years to adopt a more structured approach in which Chaplains are required to inquire about certain domains. The concepts of spiritual assessments have also developed throughout the years and tend to focus on the spiritual needs and resources within the context of clinical healthcare (Cadge & Bandini, 2015). Although these assessments have become more structured in which Chaplains have topics to inquire about, VHA spiritual assessments continue to lack empirically validated measures and standardized questions that are universal across VHAs. Further, the structure and format of VHA spiritual assessments can vary depending on site, clinical setting, and medical center. Implementation of a standardized semi-structured interview across a nation-wide service such as the VHA can be difficult and may take time. Accordingly, discussions with stakeholders, such as chaplains, are crucial to continue to develop a collaborative effort to address the needs of Veterans. The current study was a preliminary effort to expand the literature by empirically investigating how chaplains conduct spiritual assessments, their perspectives on standardized spiritual assessments, and their opinions on future integration of empirically validated measures.

Methods

Participants

The project was reviewed by the IRB and deemed exempt due to the minimal risk involved and because interviews were deidentified. All VHA chaplains at a large, southeastern VHA facility (N = 17) were invited via e-mail to participate in the focus groups. The chaplaincy department at the recruitment site provides services to all care-lines at the medical center and see an estimated 70 Veterans each month from mental health care-lines. The primary investigator worked with the Chief of Chaplaincy at the site to ensure the chaplains were supported and provided time to participate in the study. The Chief of Chaplaincy was the on-site investigator for the study. To avoid putting undue influence on the potential chaplain participants, the primary investigator, who worked at a different VA facility, e-mailed all chaplains inviting them to participate in the study. Two recruitment emails were sent out by the primary investigator requesting interviews, describing the focus of the study, and the approximate time commitment. The e-mail also informed potential participants that there were no penalties for deciding not to participate. Chaplains were invited to participate if they had at least two years of experience in the VHA chaplaincy setting. There were no other exclusion criteria. Those interested were invited to contact the study coordinator for further information. Interested chaplains who called the study coordinator were asked about their experiences working with moral injury prior to being enrolled in the study.

In total, there were seven chaplains who participated across two focus groups. One chaplain who was scheduled to participate in the focus group was sick the day it took place. Three of the chaplains who took part in the study were themselves Veterans and also had experience addressing moral injury within military personnel. Participants primarily worked in standard inpatient chaplaincy settings; however, participants were also recruited from outpatient chronic pain, rehabilitation, and palliative care clinics. All chaplains who participated in the focus groups had Masters of Divinity degrees and two had Doctor of Ministry degrees. Participants’ time spent working within the VHA chaplaincy settings ranged from 2 – 11 years, with an average of 6.88 years. Chaplains involved in the focus groups were primarily from conservative, non-Catholic Christian dominations. Participant demographics can be found in Table 1.

Table 1:

Participant Demographics

N = 7	mean (SD)
Age
Mean (SD)	48.10 (15.94)
Sex
Male	57.14%
Female	28.57%
Race
White	28.57%
African American	71.42%
Years of Experience	6.88 (2.95)
Faith Identification
African Methodist Episcopal	14.29%
American Baptist	14.29%
Independent Evangelical	14.29%
Pentecostal	14.29%
Presbyterian	14.29%
Southern Baptist	14.29%
Primary Setting
Outpatient Chronic Pain Rehabilitation	14.29%
Palliative Care	14.29%
Domiciliary	14.29%
Standard Inpatient Chaplaincy Practice	57.14%

Focus Group Protocol

Data were part of a larger qualitative study (Boska, Dunlap, Kopacz, Bishop, & Harris 2021; Kopacz et al., 2022) and involved two 90-minute focus groups that were audio-recorded and transcribed. The focus groups began with introductions from the research staff and the chaplains. Chaplains then shared their length of experience working with Veterans who had moral injury, a specific type of spiritual injury. Finally, the researchers described the goal of the research, how focus groups functioned, and allowed for the chaplains to ask questions before beginning.

The questions were derived by an interdisciplinary research team comprising senior-level chaplains, psychologists, and physicians, based on Proctor and colleagues’(2011) model of implementation for new procedures in organizational settings. The model proposed by Proctor suggests three distinct but interrelated types of outcomes: implementation, service, and client. The authors indicated that improvements at the population-level (or within large providing systems such as the VHA) are first examined within implementation research (Proctor et al., 2011). Proctor and colleagues (2011) suggest that prior to instituting of new protocols at the population-level, implementation research examining acceptability from the perspective of stakeholders, including providers, is necessary.

Dimensions of Proctor’s (2011) model that were assessed in this interview included acceptability, appropriateness, and organizational openness to change. The chaplains were asked to describe their experiences conducting spiritual assessments and their recommendations related to a) perceived difficulties they identified with implementing a new spiritual assessment template, b) preferences for using a spiritual assessment template, c) openness to including empirically validated instruments as part of the spiritual assessment, d) the chaplain’s perspectives on incorporating validated measures to current spiritual assessment procedures or creating a new instrument for spiritual assessments, and e) perceived difficulties of using a standardized spiritual assessment. The goal of these questions was to understand dimensions of acceptability, appropriateness, and organizational openness to change of standardizing spiritual assessments.

Data Analysis

The de-identified transcriptions were analyzed using the Hamilton Rapid Turnaround technique utilizing a narrative and “in vivo” coding approach (Hamilton & Finley, 2019). Codes were derived inductively in which codes came from the data and not a priori. As recommended, a multidisciplinary team of experienced qualitative investigators organized the data into templates based on the questions asked, and subsequently derived themes (Beebe, 2005). There were seven individuals on the coding team. Within the coding team there were five Ph.D. level psychologists, one Doctor of Ministry, and one anthropologist. All coders were employed within the VHA system and had familiarity with Veteran culture. The coders also had different perspectives and areas of research associated with Veteran mental health including trauma, homelessness, spiritual concerns, and sleep. Furthermore, the coders were at different stages in their career ranging from early career to senior researchers. Coders were given the transcripts to read beforehand to identify codes and “in vivo” data prior to meeting. Coders then met as a team and read through the transcripts to confirm codes and themes into the template provided. Stanza divisions, or chunking, was used during the coding team meeting in which the narrative was broken in to sections and coders identified the themes they identified within each section. The themes were iteratively reviewed by the full research team to derive consensus. The first and second author organized the themes for the current manuscript (see Tables 2 and 3).

Table 2:

Chaplains’ Current Practices with Spiritual Assessments

Questions Asked	Themes	Quotes
What are the basic elements of a spiritual assessment	• Identifying the spiritual injury • Individual’s current faith (i.e., spiritual orientation, basic tenets of their faith and beliefs, spiritual strength, rituals) • Spiritual history • Engagement (e.g., faith community and how faith intersects with life choices)	• Part of it is identifying what the injury is, what the spiritual injury is. Whether and what feelings are associated with that injury. • I think there is a template that student chaplains go through. How is their faith? Do they have a faith community? How do they work in their community around issues of faith or spirituality? I try to find out if there’s some hopelessness going on. What is the underlying feeling around what the Veteran is dealing with and is a part of that moral injury? • Our focus has largely been to listen to where the Veteran is in their present state, and then be able to channel our questions in such a way that it helps us to understand what their moral injury disposition is, you know, beyond the basic tenets of their faith and their beliefs. How does that interaction of faith, belief, and life choice intersect, and how it is able to create some profound moral injury dispositions? So our spiritual assessments will often wind up becoming more questions than providing answers, certainly, so that way we’re able to focus in on having the Veteran’s assurance that we’re there listening, especially initially, the initial conversations, to understand where they are on their walk on spirituality • I think that spiritual assessments are looking for spiritual orientation.
How are elements identified	• Interviews with Chaplains • “Conversation” rather than interviews	• I primarily have been taught and have often utilized the availability of the Veteran’s response in constant questions and trying to find specifically what he’s talking about and where his injury lies. • We refined the questions until we finally could get him to funnel out specifically what his needs, his requests. That’s what we believe the spiritual assessment tells us to do is to funnel our questions continually until they give us the patient’s desired outcome.
When do chaplains offer Veterans a spiritual assessment	• Depends on the environment	• 1111 directives have specifics about each type of patient. Some within that 24 to 72 hours. In the community living center it’s like every 28 days. Some are every 14, 15 days. So if you’re dealing with inpatients, I think that it outlines that specifically. I’m not sure if there are resources for outpatients. • [The local VA] wants us to have it done within 24 to 48 hours in the inpatient environment at the hospital. That’s from the time that they are admitted in like MICU or extended care, or certainly the palliative care unit. But in other areas of the hospital, the time frame is a little different because they’ve been there for a while, particularly in CLC. I think in mental health, inpatient mental health is also within 24 to 48 hours, and then it’s every 14 days following that. • We have a requirement to do spiritual assessments. Sometimes we think of it in these terms as spiritual assessments within certain areas. You have to have a, we do a spiritual assessment within 24 hours for folks that are in intensive care units those in psych, and those in palliative care.
What steps precede a spiritual assessment	• Chart review • Review denomination or faith group • Rapport building with the Veteran	• I would check the chart. I would look for other interdisciplinary notes to see if it would give me some idea of, particularly mental health patients, what their diagnosis is and how chaplaincy or spiritual care might be of assistance in that, whatever that diagnosis is. But if I’m just going to meet with a patient I would not review the chart prior to, because I don’t want to have an agenda going in. • When I work with mental health patients, Veterans, I try to look at what’s going on with them, so I have a little bit of an idea. Do they have someone in their community that they are connected to for spiritual care? I’ll even look at what denomination they are or what faith group they are part of so that I could channel my care based on who they are as a person. I wouldn’t approach a Muslim the same way I approach an Episcopalian. • So we know for sure when we’re doing our assessment that we will find out that they’re going to call on some deity, if you will, in the midst of them going through life, and sometimes that for them may just be in the order of an AA group or some other parachurch, organization. And it’s just very helpful to allow ourselves to kind of get an advanced understanding of their profile without profiling them. • A couple things happen. Initially there’s some rapport building. Identification of who I am and why I’m there. Also asking for permission to engage the spiritual assessment. • So I go in and try to build a relationship first, get to know the Veteran a little bit. Get to know about them. Get to know maybe why they are, if it’s in the hospital, why they’re admitted to the hospital. If it’s in the outpatient setting, I try to get to know maybe why they were referred to me or what it is, what outcome are they seeking, before I would go into a spiritual assessment. So I like to know the story, basically, of the Veteran first.
What types of Veterans might or might not “qualify” for a spiritual assessment?	• Severe pain	• Initially, those who are in pain, severe pain. Those who simply ask if we can come back later. I would simply um talk with them and ask how they’re doing when I walk in the room. Is this a good time? • And if immediately they’re saying, you know, can you come back later? I’m in too much pain. I’m undergoing, just undergone chemotherapy or some type of treatment. That’s lot of the time that you want to give them an opportunity to allow medications to adjust, treatments to take place, and then to normalize as much as possible. Those are the times when we certainly will not try to administer a spiritual assessment.
How is information from a spiritual assessment different from that derived from a typical chaplaincy consultation?	• More historical • “Checking a box” • More formal • More questions asked with spiritual assessments	• In a spiritual assessment, we’re asking for some specifics relative to that person’s religious, if you will, historical scenario. We want to know, of course, that person’s, patient’s, [religious history] if you will. • Their religious collaborations, attachments, associations relative to their history, and also how that alignment really shapes who they are today. Those ties bind, but they also factor into decisions that they often make, and those are reflections of character. And their religious associations, and what their beliefs are, are often [important] in that religious association. • Spiritual assessments were checking a box. I think in a regular spiritual care visit, it’s less formal. • In the spiritual assessment visit, there are certain things you have to find out from the patient in order to complete the assessment. But in a typical spiritual care consultation, you’re listening for what the Veteran has. You may not ask as many questions. You may let them free flow information from their life and what brings them to the hospital or brings them to the outpatient clinic, or what is it that is causing you to come talk to the chaplain today? And we listen.
Describe how chaplains use the results of a spiritual assessment.	• Not for chaplains – more for interdisciplinary team • Spiritual care plan for the Veteran (frequency of meeting with the Veteran)	• Once I get the information, I work on a plan, a care plan for the patient, and a spiritual care plan, to be more specific. Many times, that plan is discussed in rounds in inpatient. They have rounds. That plan may be discussed in meetings, with team meetings in the outpatient setting. Providers want to know what we are doing to support the patient spiritually. So once I get the information, that lets me know what they need. How frequently they need visits. What resources they need. Whether it’s reading literature, something to listen to. Sometimes they need prayer and things like that. So whatever those are needs are. So usually I take the information, develop a plan, develop a frequency of how often I need to visit or meet with that patient. • So our spiritual assessments are electronically [entered into EHR]. We just complete it within our CPRS charting system. So that’s where it’s documented. Beyond that, after the assessment, what is the plan? What is the is the pastoral plan? Whether that’s connecting or collaborating with other disciplines, addressing issues that were uncovered, or coming up with a plan to address guilt or shame or whatever the issues are there connecting that person with their community or their other spiritual care resources. So it’s documented in the CPRS electronic system, but then what’s done with it is that we come up with that hopefully addresses the goals of care and the needs of the Veteran. • Basically what takes place following the assessment is that sometimes we will discuss again in an interdisciplinary team the findings of the assessment. Then again develop the spiritual care plan with the Veteran. Then also again document it in the CPRS so that other chaplains and other providers can track what was said and what was taking place during that spiritual assessment as well, because the chaplain who performed the spiritual assessment may not do the follow-up visit.
How does a spiritual assessment inform practice, referrals, or other support options?	• Listening for suicidal ideation and inquire further about plans  • Bridge the gap between different interdisciplinary teams  • Used to inform medical decisions that may conflict with spiritual beliefs  • Assessments can drive the creation of a spiritual care plan	• I think it’s important that in the interdisciplinary team, that we’re all working toward the same goal for the Veteran, even with holistic health. So I would think that if there are some key phrases and words that the Veteran uses, for instance, I’m tired. I don’t want to do this anymore. I don’t know if I can take this anymore. That would be a red flag for me to start questioning are you not, are you thinking about ending your life? Are you thinking about, and do you have a plan? You know, it would move me down a different avenue, and I would contact and even ask another mental health professional to cosign the note. • The impact I think is certainly one which requires us to not only listen, but to be able to make the necessary decision based upon where the Veteran is. And so that spiritual assessment, once they’re administered, they will literally help persons within our team structure to become not only fundamentally aware of what our role is as chaplains for Vets, but also how congruent or how juxtaposed the issues that the Veteran faces and if there are any alignments that they seek, because all of us have a different lens. So I think clinically together, the difference can be assessed as a result of these assessments which holds true across the connection. • Those assessments, again, make all the difference in the world of bridging the gap between the different professional teams that are part of that person’s whole health care.
Do spiritual assessments include empirically validated measures?	• Some models – FACT, FICA, HOPE, and SPIRIT • Experimental and standard approaches • No	• We aren’t restricted to any one spiritual assessment. There are a lot of options. [There is] model that’s called FACT. There are some called HOPE and SPIRIT. There are a lot of different spiritual assessments that will help to get the same information using different questions. • We do utilize the VHA Directive 1111, if you’re familiar with appendix A. They have a series of spiritual screening and assessment questions. Those particular questions are at the heart of our training as chaplains conducting a spiritual assessment. • From my experience no. Not often. If we’re talking about, maybe the patient has told me, their pain is 9 out of 10 or something, or some other particular language that I’ve heard from social workers, psychologists, and what you’re mentioning, that that was part of the discussion. That’s connected with the interdisciplinary discussion that I want to make reference to, but from my experience, no. • I don’t recall using particular tool or instrument. In my training we had didactics and teaching where there were tools and examples of spiritual assessment that were used. Then we also have the template in the note, CPRS, that we use for spiritual assessment.
How might empirically validated measures prove useful for chaplaincy services?	• It appears as though chaplains prefer broad themes rather than empirically validated measures • Good premise to have these tools – some benefit • Helpful to introduce the tool at the student/intern level	• There’s a whole long list of questions that we could use in interrogation, but we try to make it a conversational obtaining of information rather than just going through the list of questions. • As we continue to grow in our work, uh, and how we communicate, not only within ourselves in chaplaincy, but also being integrated within a team, I think there’s some value, most definitely some value in having those particular tools, and if we can adapt them [to be] universal throughout the spiritual care system. • I think that has good promise and would have good benefit. I think that’s something that in chaplaincy, chaplains would need to be a part in helping continue to develop those tools or use tools that are already in the industry. • I think that if we had a tool, that would be helpful if it was introduced even at the student level with the interns and residents and fellows. I think it would be helpful to introduce a tool then, and even for our staff chaplains, whether they’re inpatient or outpatient. It would be a great resource, so I definitely think that’s a good idea, as long as long as chaplains are involved in creating that tool, because I think the staff chaplains who have been doing this for a few years now would maybe know what would be helpful within that tool.

Table 3:

Chaplain Perspectives of Changes to Spiritual Assessments

Questions Asked	Themes	Quotes
Describe perceived difficulties for spiritual assessment templates.	• Too structured • Less flexibility • No set definition of moral injury across disciplines	• I don’t know if I would be comfortable going down a list of questions, because I think that chaplains, the difference between the chaplaincy and other mental health providers is like our service, what we provide, is more relational. It’s a pastoral relationship. • Perhaps those type of questions would be in addition to, so there’s something that’s sort of noticed. • So I see a useful part of that as a secondary way of making that connection to make sure that that Veteran’s needs are met in those areas.
Describe preferences for spiritual assessment templates.	• Chaplain’s involvement in development • Interdisciplinary • Taught early in chaplain’s careers	• It’s a learning process. I think over time that’s most definitely something that could be integrated. Again, I’m concerned about boundaries and making sure we’re attending to the spiritual care and existential needs of the Veteran. I do like that if there is some type of way to trigger involving others. • We could perhaps do both. I think there needs to be some conversation or some exploration that this goal is to end up in this final place of these agreed upon questions. But until we get to that place you know of being able to have those questions and start with those question with additional training but alongside of the process is to have ongoing conversations about coming up with new questions, maybe tweaking certain questions that will fit well within the assessment. • If we had a tool, that would be helpful if it was introduced, even at the student level with the interns and residents and fellows. I think it would be helpful to introduce a tool then for our staff chaplains, whether they’re inpatient or outpatient. it would be a great resource, so I definitely think that’s a good idea, as long as chaplains are involved in creating that tool because I think the staff chaplains who have been doing this for a few years now would maybe know what would be helpful within that tool. • There’s something that’s revealed and that becomes an additional set of questions to ask that would trigger involvement with other disciplines outside of making the various calls and copying folks on notes. • I do think also that that would be a great training tool with our student chaplains. I think it would be great to introduce that as a tool when they train, so they will know how to better perform spiritual assessments. • Somewhere in that template where we could have an area for consults to other providers if needed. Also, if we could have a list of interventions. I think that would be helpful also if there was a list in the template, so you could select on maybe some interventions and also select what the spiritual injury might be. • There are plenty of tools for assessing spiritual needs or templates for doing an assessment and how that information is sort of put together. But as far as drilling down on this particular injury or scoring system or evaluation system. That would be, I think, helpful. • I’m wondering if there are some ways, for whatever the issue, something in the note that triggers other discipline involvement if I mark this or if there’s a number. We talked about maybe having more numerical ways or ways to identify things. I would like to see something that if there’s an issue, instead of being so many other steps involved, it would automatically trigger involvement by other disciplines.
How open would chaplains be to include empirically validated instruments?	• Very open • Do not want to be locked in though • Do not want to go down a list of questions	• I often try, even with the spiritual assessment template, I try not to go down a list of questions. I try to find the information I need through conversation. So if there is a list of questions, I would probably get them answered through a narrative approach rather than off a list. • I think there’s some value in having those particular tools and if we can adapt them universally throughout the spiritual care system. I think that has good promise and would have good benefit. I think that’s something that in chaplaincy, chaplains would need to be a part in, in helping continue to develop those tools that are already in the industry. I do see benefit in that. • If I can enhance my spiritual assessment tool now and then just incorporate a few more questions or something in addition that doesn’t take away from my goal or my aim or my desire to be personable and authentic right there in the moment, right? it’s sort of a non-diagnosis, nonjudgmental, you know, experience. • There’s a whole long list of questions that we could use in interrogation, but we try to make it a conversational, obtaining of information, rather than just going through the list of questions.
Would it be better to add validated measures to existing spiritual assessment templates or to create a whole new battery of instruments or toolkit for chaplains?	• Difficult to implement • Create questions that facilitate conversation and narrative approaches • Both add to current measures and create new ones • Good to add some questions without taking away from the goal or aims	• Does this begin to feel like I’m not attending to the spiritual care of the Veteran? Or am I sort of being led or asked to operate in another domain. Now, that can be overcome with additional training and education. • Now you can go to these set of questions instead of sort of always being sort of a mandated part of the assessment that I think will get away from sort of the relationship and the openness and the exploration. • I think that it would be helpful to see the existing tools in order to come up with a tool that would be more specific to chaplaincy. that would help us to better assess our Veterans and know what kind of spiritual intervention to provide. • Not just checking the box, because all the questions serve value in sort of exploring and making sure the needs of the patient are met. so I do like this whole idea of this sort of adjunct to the spiritual assessment. So when those areas come up, whether it’s some type of moral injury or suicide or whatever it is
What difficulties might chaplains face in using a standardized spiritual assessment tool?	• Fear of new assessments • Need some additional training	• I think we also need some additional training. We meet with people from various faith traditions or no faith traditions at all with moral injuries. • how do we take this information? You know, can we sort of condense this information so it’s usable or readily identifiable, usable information for other disciplines? • Fear of the unknown. Fear of something new. Fear of being forced to grow where I don’t want to grow.

Note: Words such as “um” and “like” were deleted from qualitative data for clarity. Words deleted did not impact the meaning of the quotes.

Malterud and colleagues (2015) indicated that sample sizes necessary for qualitative studies can vary depending on their concept of information power. Information power proposes that rather than a specific sample size to achieve saturation of results, the proposed sample size should take into account the (1) the aim of the study, (2) sample specificity, (3) use of established theory, (4) quality dialogue, and (5) analysis strategy. The current study used a specific interview structure based on Proctor and colleagues’ (2011) implementation theory with questions that were designed to assess acceptability, appropriateness, and organizational openness to new types of assessment form moral injury that could be used by chaplains. The participants within our sample were specific in which they had experience within the VHA, engaged in spiritual assessments, and treated moral injury. The interviews were also conducted by experienced licensed Ph.D. level psychologists who have had experiences with qualitative interviewing and building dialogue. Given the dynamic nature of factors associated with information power sample size, the current scope of work is appropriate for a smaller sample size (Materud et al., 2015). We acknowledge the smaller sample size as a limitation. Given the dearth of research on chaplain preferences for spiritual assessments and the potential to enhance the quality of VHA supportive services to Veterans, it was thought the findings presented here stand to make a real contribution to the growing body of research.

With qualitative analyses, potential biases from the research team must be discussed. Although the coding team was an interdisciplinary team who had different research foci and were at different stages of their careers, the study sought to examine the chaplains’ perspectives on how spiritual assessments could be standardized. We ensured that the questions were open to allow the chaplains to bring forth their opinions and had an interdisciplinary approach to question development. Despite our efforts to minimize any bias during qualitative coding, the authors recognize that there are implicit biases that are involved with qualitative coding.

The chaplains were asked a series of questions to help the research team understand chaplains’ perspectives on (1) how spiritual assessments are conducted (see Table 2) and (2) their perspectives on modifying spiritual assessments and the utility of incorporating behavioral health questionnaires in the chaplaincy setting (see Table 3). Quotes from both focus groups were incorporated into the results section to highlight the themes identified through coding. Each heading in the results section were the questions posed to the focus groups.

Results

Current spiritual assessment logistics

In order to understand the role that spiritual assessments play in chaplaincy settings, participants were first asked about the current practices of assessments and how to conduct them (see Table 2 for themes and quotes). The chaplains clarified how spiritual assessments are different than routine chaplain consultation by indicating that spiritual assessments tend to be more formal, historical, and involve more questions than chaplaincy consultations. The basic elements of spiritual assessments that were identified by chaplains reflected many of the core components of spiritual assessments outlined in VHA Directive 1111; however, the chaplains within our study did not directly discuss how they inquired about spiritual issues that may impact medical care. Instead, the chaplains within our study emphasized the qualities such as identifying current faith practices, spiritual history, how engaged the Veteran is in their faith community, and, especially, identifying the spiritual injury.

The chaplains within the study were also asked to identify how and with whom spiritual assessments are conducted. The chaplains acknowledged that when spiritual assessments are done tends to depend heavily on the work setting, with outpatient visits having different regulations than encounters on inpatient units or at community living centers. They also emphasized that prior to performing an assessment, the chaplain’s focus is often on building rapport with the Veteran. This ideology is also exemplified through the chaplains’ insistence that spiritual assessments would be enhanced if they were more conversational rather than focused on a set of questions. This desire to have a fluid conversation was a theme that was common throughout the interviews and across focus groups.

The next set of questions involved discussing the logistics of spiritual assessments and focused on how they are utilized in patient care. The chaplains within our study reported that the data from spiritual assessments can often inform clinical care. For example, chaplains indicated that spiritual assessments can bridge the gap between interdisciplinary teams and can assist to inform the Veteran’s treatment planning. One chaplain in our study suggested that electronic medical records should be programmed such that, when completing a spiritual assessment, key words would trigger notification to other specialties. For example, words or phrases that are associated with suicide (e.g., “I can’t do this anymore”) should send a notification to behavioral health. Similar procedures may be useful if there are any spiritual concerns that interfere with medical treatment. Chaplains also highlighted that medical concerns can impact spiritual assessments, for example, Veterans who are in severe pain would not be able to tolerate activity long spiritual assessments. The chaplains within our study also reported that spiritual assessments can also be used as an opportunity for additional suicide risk assessment in which they inquire and listen for suicidal ideation and probe about additional thoughts and plans.

Perceptions on standardization of assessments and incorporating empirically valid measures

The chaplains in our study described discomfort in using standardized templates as primary tools, but appeared open to having a more standardized secondary questionnaire if the chaplain chooses. If the more standardized approach were to be taken, the chaplains within our focus groups emphasized the need to have an interdisciplinary approach to developing the tools and to have chaplaincy involvement with the development. There was also mention that a standardized tool may be beneficial for trainees who are learning spiritual assessments.

Chaplains in our focus groups described themselves as having a distinct relationship with Veterans that is unlike the typical relationship Veterans have with other mental health providers. As one chaplain described, “the difference between the chaplaincy and other mental health providers is our service, what we provide, is more relational. It’s a pastoral relationship.” While some of chaplains in our focus group did reflect on the different models of spiritual assessments that can help shape the formulation of questions and background information, other chaplains endorsed using the templated electronic medical record note.

Overarching theme

Throughout each of the questions, there was a common theme produced by the chaplains. Namely, in conducting spiritual assessments, there should be openness of structure while maintaining flexibility of questions. Multiple chaplains cautioned that having an overly rigid template may inhibit exploration into a specific Veteran’s spiritual issues during spiritual assessments and miss the conversational aspect of spiritual assessments. In fact, one chaplain stated that the process can be done so discretely that, “the Veteran may not even realize that they are participating in a spiritual assessment.”

Chaplains in the focus groups expressed concerns about completely changing the current spiritual assessment. Chaplains highlighted that their main priority was to continue to attend to the spiritual needs of the Veteran and that they are focused on addressing issues within the spiritual domain. Chaplains within our study expressed a need for openness and flexible exploration during the spiritual assessment rather than just a list of questions. They indicated that these tools would be helpful, especially if they were able to easily integrate other disciplines if/when necessary for supporting the needs of the Veteran.

Discussion

The current study examined chaplains’ perspectives on how spiritual assessments are conducted and how open they would be to integrating standardization (e.g., across VAMCs) and empirically validated measures. This study also provided preliminary data for understanding how spiritual assessments are used within chaplain services. Chaplains within our study were open and engaged with the research team, expressing both positive and negative opinions regarding increased standardization of spiritual assessments.

Spiritual assessments are a core component of VHA chaplaincy and can provide unique insight to the spiritual injuries that Veterans face. Over time, spiritual assessments have developed to address the realities of chaplaincy practice as well as the needs of Veterans. Chaplains are trusted confidants of Veterans and service members and there is less stigma or fear of repercussions when visiting chaplain services unlike behavioral health (Kim, Britt, Klocko, Riviere, & Adler, 2011; Kim, Thomas, Wilk, Castro, & Hodge, 2010). Previous research on in the integration of chaplaincy and mental health has highlighted how more effectively using spiritual assessments could help better address Veterans’ mental health needs (Nieuwsma, Rhodes, Jackson, Cantrell, & Lane, 2013).

Currently, spiritual assessments have a structure; however, it is not always followed nor conducted in a systematic way. We posit that this may be due to the shift in the language of spiritual assessments. VHA Directive 1111, which outlines spiritual care, has undergone considerable edits and evaluations in the recent years. The current VHA directive indicates that spiritual assessments are “standardized questions”; however, previous iterations of the directive emphasize a conversational approach to spiritual assessments. In fact, the 2019 directive highlights both “standardized questions” and “conversational approach”. The continuous changing of terms and nuanced language may be problematic with implementation of changes in a nation-wide healthcare system.

Chaplains indicated an acceptance of integrated spiritual assessment as long as they would continue to have flexibility allowing them to engage with Veterans in a conversational way. Chaplains also emphasized the need to be involved in the development spiritual assessment templates. Collaboration between chaplaincy and behavioral health is crucial for optimally treating spiritual injuries, such as moral injury. Spiritual assessments, individual therapy, and group therapy are viable means for facilitating such interdisciplinary collaboration (Boska et al., 2021; Griffin et al., 2015; Harris et al., 2018). This is an organic and important collaboration given that chaplains have been described as crucial for the treatment of moral injury (Koenig & Zaben, 2021).

An interesting concept that one of the chaplains in our study suggested is to have the spiritual assessments alert other associated disciplines, like behavioral health, signaling a need for collaborative care. The Chaplain posited that if there were empirically validated measures embedded into the assessment, a certain score may trigger the necessary treatment teams. Future research may expand upon this concept for implementation.

Chaplains are crucial for the care of spiritual injuries that can result in long-lasting psychological and physical distress. The results of the current study highlighted the lack of standardized and integrated spiritual assessments for chaplains. Multiple chaplains in our focus groups stated that it would be helpful to have a standardized spiritual assessment so they would know what type of spiritual injury the Veteran is presenting with. Similarly, there was some apprehension about how to best help or treat these Veterans. To assist in creating spiritual assessments that can assist in mental health treatment of Veterans, future research could examine the feasibility, acceptability, and implementation of a standardized spiritual assessment with empirically validated instruments.

The findings presented here should be interpreted in the context of several limitations. Specifically, the chaplains who were involved in the focus groups were primarily from conservative non-Catholic Christian denominations. Although these faith demographics reflected the VHA facility from which the sample was drawn, the results cannot be generalized to chaplains from other faith denominations. Although the Malterud (2015) framework indicated that a comparatively small sample would be appropriate for this study, the sample size was smaller than the goal sample size, signaling a need for additional research with larger sample sizes. The current transcription methods and focus group format also limited our ability to identify demographic differences with speakers or identify themes from specific chaplains. Furthermore, the use of rapid turnaround qualitative analysis was required to complete the larger project in which the present analysis was embedded. Future research should conduct interviews with a larger set of chaplains from a variety of religions and use more in-depth qualitative analyses to draw a richer understanding of chaplains’ perspectives on moral injury.

Despite these limitations, our focus groups of stakeholders were VHA chaplains and therefore, extremely well positioned to address questions about the assessment of moral injury in Veterans and the potential for doing so within a spiritual assessment in a VHA chaplaincy setting (Koenig & Zaben, 2021). The current investigation identified facilitators and barriers that chaplains perceived for the possibility of using standardized spiritual assessments. It is important to note that the chaplains in our study expressed a desire to have chaplains provide input on the development of new spiritual assessment protocols, an important focus of the larger study.

Future research should continue to utilize a collaborative approach between behavioral health and chaplaincy to increase spiritual assessment resources. Additional research into the implementation of standardized spiritual assessments is warranted. The current study indicated general acceptability among this sample of VHA chaplains for the idea of creating a standardized spiritual assessment tool that would include questions to assess spiritual injury while maintaining a flexible approach.

Impact Statement:

The current study identified themes from chaplains about using templated spiritual assessments and incorporating validated measures. The overarching theme was that chaplains were open to incorporating new empirically tested measures into spiritual assessments; however, would like to maintain the flexibility of current spiritual assessments.