Enhancing the integration of chaplains within the healthcare team A qualitative analysis of a survey study among healthcare chaplains

Abstract

Background

Spiritual well-being is considered an important component of health and is increasingly integrated at all levels of healthcare. Delivering good integrated spiritual care requires coordination between different colleagues in which interprofessional collaboration is crucial. However, this interprofessional collaboration is not always self-evident. What spiritual care entails, is often poorly understood by their healthcare colleagues. Developing a shared professional identity is a crucial component of the shift towards professionalisation in chaplaincy.

Objectives

We aim to answer the following research question: how do healthcare chaplains in the Netherlands describe their work and their professional identity in relation to other healthcare professionals?

Design and subjects

Analysis of open-ended questions of a survey among healthcare chaplains regarding professional self-understanding in the Netherlands.

Results

107 Dutch chaplains working in a healthcare setting completed the five open-ended questions in the survey. The field of healthcare chaplaincy is changing from an exclusive focus at patients, towards more activities at staff and organisational level such as educating other healthcare professionals and, being involved in ethics and policy making.

Conclusions

Our research shows that the professional self-understanding of chaplains entails many leads to foster interprofessional collaboration. At the same time, there are concerns about the professional identity of the chaplain which is not always clear to every healthcare professional. Healthcare teams can benefit from an extensive integration of chaplains in the healthcare team, by including the non-patient-related activities of chaplains, such as staff training, moral deliberation and policy advice.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Spiritual well-being is considered an important component of health and is increasingly integrated at all levels of healthcare.

• Delivering good integrated spiritual care requires coordination between different colleagues in which interprofessional collaboration is crucial.

• What spiritual care entails, and thus what chaplains do, is often poorly understood by their healthcare colleagues.

WHAT THIS STUDY ADDS

• The lack of a clear professional profile and the (financially) dependent, vulnerable and not always self-evident position was experienced by chaplains as an obstacle in their collaboration with other healthcare professionals.

• The wider range of activities chaplains deplore at organisational level, including contributing to the competence development of healthcare professionals, were described as opportunities for interprofessional collaboration.

• ‘Seeing the whole person’ and ‘adopting a critical view of the organisation’ were described as somewhat ambivalent positions towards integrated care.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The professional self-understanding of healthcare chaplains entails many leads to foster interprofessional collaboration.

• Healthcare teams may benefit from an extensive integration of chaplains in the healthcare team, by including the non-patient-related activities of chaplains, such as staff training, moral deliberation and policy advice.

• Identified barriers within interprofessional collaboration will need to be explored so that they can be addressed.

• This will be of the benefit of the patient, family members and healthcare staff.

Background

Spiritual well-being is considered an important component of health and is increasingly integrated at all levels of healthcare,^1–5 according to underlying notions such as the bio-psycho-social-spiritual model⁶ and the concept of positive health.⁷ There is solid evidence that attention to the spiritual needs of patients and their relatives is essential to their perceived quality of life, quality of care and spiritual well-being.^8–11 Delivering good integrated spiritual care requires coordination between different colleagues in which interprofessional collaboration is crucial. Studies show higher patient and family satisfaction with care when chaplains are integrated into the healthcare team.^{12 13} When chaplains are more involved in healthcare teams, they are more likely to address goals of care, facilitate communication between patients, family and the healthcare team, address family conflicts and discuss advanced directives.¹⁴ However, this interprofessional collaboration is not always self-evident. What spiritual care entails, and thus what chaplains do, is often poorly understood by their healthcare colleagues.^{15 16} A survey study of Damen et al ¹⁷ shows that only few colleagues were aware that chaplains provide care for the team, are involved in facilitating treatment decision making, perform spiritual assessments and foster communication between the patient, family, team and/or community.¹⁷ Developing a shared professional identity is a crucial component of the shift towards professionalisation in chaplaincy.^18–22

Professional identity is at the core of each profession and a vital aspect to interdisciplinary collaboration. An inability to articulate a distinct professional identity may result in confusion, conflicts or ineffective interprofessional collaboration.^{23 24} While the profession of hospital chaplains and other healthcare professionals may differ, they are united by the shared goal to do what is best for the patient, hence their reason for existence.²⁵ To achieve this goal it requires a self-understanding of one’s role and, therefore, one’s professional identity.^25–27 Kelchtermans²⁸ defines professional self-understanding as a combination of the professional’s views and representations of oneself in a continuous dialogue with the context in which one finds oneself. He distinguishes five components: self-image (descriptive component); self-esteem (evaluative); task perception (normative); professional motivation (conative component) and future prospects.

Self-understanding may shift in relation to developments within the chaplaincy profession itself, in the broader field of healthcare and in society as a whole. The developments in healthcare towards a greater focus on evidence-based care, protocols and accountability also influence the way in which multidisciplinary collaboration takes shape. In addition, the development of chaplaincy being a more worldview tradition bound profession towards a profession that focuses more on general spiritual care,²² may influence how chaplaincy is perceived by other professionals. In the Netherlands, healthcare chaplains are deployed by the hospital and often operate in a multireligious spiritual care team. Hospitals strive for a broad spiritual care team, in terms of ideological backgrounds, because of the religious and cultural diversity of Dutch society.²⁹

The recent developments, and the known barriers harming the integration of spiritual care within healthcare, prompt us to look at the way hospital chaplains describe their self-understanding in relation to other healthcare professionals. Therefore, we aim to answer the following research question: how do healthcare chaplains in the Netherlands describe their work and their professional identity in relation to other healthcare professionals?

Methods

The data used in this study were collected in September and October 2019 by means of an online questionnaire in Survey Monkey. A total of 830 members of the Dutch Association for Spiritual Caregivers (VGVZ) were invited by email to participate in the survey. 433 chaplains working in different areas of healthcare completed the questionnaire, completely or partially, leading to a 52% response rate. The original research question was: what does the professional identity development of chaplaincy look like in 2019, and how can this be explained? The results of the mixed-methods analysis of these data are reported in a separate article.³⁰ For the purpose of this article, only respondents working in a hospital setting who completed at least one of the open questions in the questionnaire were selected (n=107). The survey consisted of 38 questions total, including demographic, current work situation, self-presentation and interdenominational chaplaincy questions, and 5 open questions about the chaplain’s professional identity. For the purpose of this study, the authors analysed the answers to the five open questions (qualitative), as well as background characteristics and the answers to two close-ended questions (quantitative): (1) the frequency of chaplains’ professional activities; (2) how positively or negatively chaplains rated the future of chaplaincy. Atlas.ti V.9.0 was used (Atlas.ti, Berlin, Germany) to code the qualitative data, while the quantitative data was analysed in IBM SPSS Statistics V.27. The data for the qualitative analysis were derived from the answers to five open questions based on Kelchtermans’ model²⁸ of professional self-understanding. The questions in the survey were formulated as follows:

1. What motivates you to practice the profession of chaplain? What are your main drivers?

2. What do you see as your responsibilities as a chaplain?

3. How do you feel about yourself in the performance of your profession, what do you think of yourself as a chaplain? Do others agree? Is that consistent with how you would like to see yourself?

4. To what extent do you feel that you are doing your work well as a chaplain? What do you consider your strengths and your weaknesses?

5. How do you see the future of the profession of chaplaincy?

Data from 107 respondents were imported to Atlas.ti. The authors applied an inductive approach to data analysis, applying the different phases as described by Braun and Clarke.³¹ All four researchers independently coded the answers of about 25 respondents each. The obtained codes were discussed by the research team and this resulted in a preliminary thematic coding scheme. Themes were iteratively developed from the coding.

Results

Sample descriptive

The majority of respondents (62.6%) were female and the largest group were in the age category of 51–60 years, 46.2% (see table 1). On average, respondents had 14.1 years of work experience in chaplaincy (SD=9.3) and worked as a chaplain for 28.7 hours a week (SD=6.2).

Table 1.

Sociodemographic characteristics of participants

	n	%
Gender
Female	67	62.6
Age
≤40 years	20	18.7
41–50 years	20	18.7
51–60 years	49	45.8
≥61 years	18	16.8
Type of care
Inpatient only	78	74.3
Inpatient and outpatient	27	25.7
Denomination
Protestant	44	41.5
Catholic	18	17
Humanist	17	16
Muslim	3	2.8
Non-denominational affiliation	14	13.2
Other	8	7.5
Affiliation pending	2	1.9

n=107 for the age and gender variables, n=106 for denomination and n=105 for type of care. Participants had on average 14.1 years (SD=9.3, n=102) of work experience in spiritual counselling and worked as a chaplain/spiritual counsellor for an average of 28.7 hours (SD=6.2, n=102) a week.

When looking at the frequency of chaplains’ professional activities, individual counselling is clearly the main activity of the healthcare chaplains (see table 2). 96.1% of the respondents indicated that they do this (very) often.

Table 2.

Frequency of chaplains’ professional activities

	(Almost) never		Sometimes		Regularly		(very) often
	%	n	%	n	%	n	%	n
Individual counselling	–		–		3.9	4	96.1	98
Worship services/gatherings	13.7	14	20.6	21	34.3	35	31.3	32
Ritual care	6.9	7	38.2	39	37.3	38	17.6	18
Group counselling	17.6	18	47.1	48	31.4	32	3.9	4
Staff training	2.0	2	27.5	28	47.1	48	23.5	24
Policy development	10.8	11	32.4	33	36.3	37	20.5	21

n=102.

At the question ’How positively or negatively do you rate the future of chaplaincy?’ 96 chaplains responded, 21 were missing. The response scale ranged from 0 (very negative) to 100 (very positive). The mean was 70.75 (SD=21.0).

Struggling with the lack of a clear professional profile

At the organisational level, the importance and the lack of a clear professional profile is mentioned several times. Here, the respondents mostly express their frustration over the fact that others, such as patients, coworkers or policy makers, do not have an adequate image of what a chaplain is. Frequently mentioned is the image of clergy which many of the respondents feel does not apply to them. Other false images include someone ‘who is not professional’ or ‘some kind of psychologist’. The unclear and false images of the healthcare chaplain are experienced as a burden to their daily practice. Furthermore, being embedded as a healthcare chaplain in the organisation is considered important.

Within my organization we have built up a good profile (…) and we receive adequate referrals. Even though the image of pastor/death is persistent, we are regarded as a good interlocutor in all kinds of situations, not only for the patient but also for healthcare in general. We pick up themes that are at stake and subsequently provide a training or symposium. We also have deliberately appointed an ethicist in our department who is active at precisely this meta/meso level. So, we are involved in all kinds of places and layers in the organization and that is starting to bear fruit. It is appreciated that we are putting the culture of humane care on the agenda, and we increasingly notice more collaboration with other healthcare providers and the Board of Directors. (D104)

In line with this, the respondents mention profiling and networking as part of their job description. ‘In addition to the main task, another task has become important. To emphasise and draw attention to the specifics of spiritual care and the chaplain as an expert in that field, at all appropriate times and ways within the organisation and towards the healthcare staff.’ (D76) Furthermore, some respondents mention collaborating with other healthcare professionals and contributing to new organisation policies. Some chaplains reported being embedded in the hospital, others pointed out their challenges in collaborating. ‘I find it difficult to consult with doctors. I often feel insecure towards them and find it difficult to speak their language.’(D48)

Contributing to competence development of healthcare professionals

The respondents mentioned the counselling of other professionals and volunteers. Educating their colleagues and making them sensitive to existential questions and needs patients may have, was mentioned as an important part of their work. ‘The hospital setting requires coordination and collaboration with other disciplines and focus on vision and policy (…) Part of our work is to contribute to training, especially for nurses and doctors in training.’ (D75) Another task refers to ethics, and encompasses a whole range of activities such as moral deliberation, multidisciplinary consultation and addressing ethical issues within the organisation.

Several respondents expressed hope that in the future, chaplains will become less focused on individual counselling and more involved in other tasks such as ethical decision making and staff training. The latter involves training health professionals to recognise spiritual needs in patients and loved ones, and to make referrals to spiritual care professionals when needed. Sometimes these new activities were described as challenging when the chaplain did not feel competent enough; sometimes these developments are embraced as new and exciting. ‘I am doing more palliative support within patient care. There is also more participation in patient discussions with nurses and other disciplines than a few years ago. In addition, more other activities have been added: training and ethics have become more extensive. I like that very much because it makes the work more varied.’(D89)

Shifting towards more general spiritual care

A shift that is currently taking place is that of a mainly worldview-oriented profession towards more general spiritual care. ‘Initially I started this work with a clear Christian identity. This has shifted towards more general meaning making and being concerned with existential issues.’ (D2) Especially chaplains who have more work experience are describing this shift. ‘I do see that my profession is evolving from a (hospital) pastor (first 10 years) via spiritual counsellor (last 15 years) in the direction of a meaning-making coach for care employees.' (D86) Some chaplains describe the fear that letting go of the direct link with a religious tradition will result in an erosion of the profession, others applaud this shift as it ‘fits well with the current time’.

Adopting a critical view of the organisation

On the other hand, ‘critical organisational view’ and ‘seeing the whole person opposed to the medical view’ were more critical notions that were mentioned when asked about job description. ‘In addition, I see it as my task to continuously point out the human side of the organisation and to stand up for it, if I believe this is at stake.’ Other chaplains pointed out that their job description also includes being there for patients who are not always visible in the organisation. And some define their role in the organisation as: ‘represent the other perspective in care; stimulate care-ethical thinking’.(D71)

Vulnerable and dependent position of chaplains

Despite the fact that the respondents rated the future of chaplaincy overall positively, the qualitative analyses of the data showed also worry about the future of the profession. Those who express their concerns are mentioning the vulnerable and dependent position of chaplains within the setting of a healthcare institution. ‘The type of interventions we perform are not always transparent. There isn't much research. (….) This also means that you are too much dependent on that one chaplaincy minded manager, physician or nurse.' (D38)‘Our added value is difficult or impossible to express in numbers. Although the hospital does ask for evidence.’(D43) The guarantee of financing is also mentioned as a vital element, heavily dependent on national politics. The dependent position of chaplains is also reflected in the needs that are articulated, such as the need of interprofessional collaboration, professionalisation, specialisation and more research to enhance the transparency of what it exactly is that chaplains do.

Discussion

Main findings

We discovered both opportunities and challenges arising from self-understanding of hospital chaplains’ professional identity and their position towards interprofessional collaboration within healthcare. First of all, there are barriers within the profession of chaplaincy itself when it comes to a clear profile of the profession. Chaplains reported not being very good at profiling themselves and their work which hampers their collaboration with other healthcare professionals. These collaborations are important to chaplains as many of them receive referrals from nurses or physicians to see patients. Respondents formulated their dependent position as ‘a burden’, mostly due to the fact that others have to be ‘sensitive to spiritual needs of patients’ to understand the added value of chaplaincy. Hospital chaplains feel that also the financial position of chaplaincy is dependent on the ’spiritual mindedness' of the Board of Directors. Opposed to barriers that can harm interprofessional collaboration, the respondents also cite opportunities and examples of integrated care provision. The shift from chaplaincy being a mainly worldview-oriented profession towards more general spiritual care provides several opportunities to collaboration between professions. Also the wider range of activities chaplains deplore at organisational level by contributing to competence development of healthcare professionals where described as opportunities for further collaboration. We discovered also some ambivalent positions of healthcare chaplains that may challenge the interprofessional collaboration. The respondents mentioned several times ‘seeing the whole person’ in contrast with the some more protocol driven field of medicine. In addition, some respondents mention adopting a critical view of the organisation.

Discussion

As the results show, being embedded as a healthcare chaplain in the organisation is considered important, but also challenging. Some consider it an integral part of chaplains’ job to educate their healthcare colleagues about what they do and how they contribute to good outcomes for patients.³² Telling this story also means speaking each other’s language, translating it into the language of outcomes is considered to help chaplains improve healthcare colleagues’ understanding of chaplains’ contributions to care.³³ However, there is a challenge in providing more evidence for chaplains’ work as the core of their activities may not lend itself philosophically to measurement.³⁴ It is suggested that outcome studies within chaplaincy should use mixed-methods designs to accommodate the variance in chaplaincy practices, and should focus more explicitly on characteristic chaplaincy outcomes.³⁵

In terms of competence development of healthcare professionals, chaplains seem to be more involved in this than they used to be, also in other countries there is a tendency that chaplains become more involved with training and supporting healthcare staff.³⁶ This is in line with a wider movement of seeing the provision of spiritual care as a task for every healthcare professionals.^{32 36} In training healthcare professionals, there is also the opportunity to become partners in working on certain shared values in providing holistic care, such as ‘seeing the whole person’. Studies indicated that nurses are the most frequent clinicians to initiate a chaplain referral,^{33 37} because nurses are often the most intimately aware of and present for patients in their suffering and are driven to provide holistic care; including providing spiritual care.³⁸

In addition, some chaplains formulated being critical towards the organisation in terms of making others aware of ethical issues. As a consequence of the position of healthcare chaplains—not being embedded in the medical staff—it provides them with the opportunity to take a stand on ethical issues when they believe they are at stake. This position is obviously not the best way to integrate into healthcare teams. However, it can also be an opportunity to collaborate with other ethicist within the hospital or to develop leadership on ethical issues.³⁹

Strengths and limitations of the study

For this study, we relied on chaplains’ self-reports in our analysis of the survey outcomes, which is a limitation. Future studies should examine if these outcomes correspond with documentations, patients’ medical records and the experience of involved healthcare staff. Furthermore, our study was conducted prior to the COVID-19 pandemic, therefore, the latest developments of chaplaincy are not included in this study. A recent study from the Netherlands, however, indicates that the developments we describe in our study are even more emphasised due to the pandemic.⁴⁰ That applies in particular when it comes to the positive impact of chaplains providing staff support in this high-stress context.⁴¹ Future research may focus on the identified opportunities, barriers and ambivalent position of healthcare chaplains towards interprofessional collaboration to address critical issues and seize the opportunities that arise. Furthermore, the need for more evidence-based research on outcomes of spiritual care should be taken seriously and future research should focus on this in order to improve spiritual care and make it self-evident to every professional.

What this study adds

There is an evident need to make explicit what chaplains do and contribute to interdisciplinary healthcare teams.^42–44 Our research shows that the professional self-understanding of chaplains entails many leads to foster interprofessional collaboration. At the same time, there are concerns about the professional identity of the chaplain which is not always clear to every healthcare professional. Other studies also emphasise that providing good care is most effectively delivered by an interdisciplinary team, in which all healthcare professionals, including chaplains, interact with each other to develop and implement the spiritual care plan for the patient in a fully collaborative model.^{45 46} Our study underlines this need for effective interdisciplinary collaboration, which is in the interest of patients, their family members and the hospital staff themselves. Healthcare teams can benefit from an extensive integration of chaplains in the healthcare team, by including the non-patient-related activities of chaplains, such as staff training, moral deliberation and policy advice.

Data availability statement

Data may be obtained from a third party and are not publicly available.

Ethics statements

Patient consent for publication

Not applicable.