Chaplain Rounds: A Chance for Medical Students to Reflect on Spirituality in Patient-Centered Care

Abstract

Objective

This study assesses the perceived impact of a required half-day with a hospital chaplain for first-year medical students, using qualitative analysis of their written reflections.

Methods

Students shadowed chaplains at the UCLA hospital with the stated goal of increasing their awareness and understanding of the spiritual aspects of health care and the role of the chaplain in patient care. Participation in the rounds and a short written reflection on their experience with the chaplain were required as part of the first-year doctoring course.

Results

Qualitative analysis of reflections from 166 students using grounded theory yielded four themes: 1) importance of spiritual care; 2) chaplain’s role in the clinical setting; 3) personal introspection; 4) doctors and compassion.

Conclusions

Going on hospital rounds with a chaplain helps medical students understand the importance of spirituality in medicine and positively influences student perceptions of chaplains and their work.

Recent decisions of major health care organizations have underscored the importance of addressing spirituality as a part of patient-centered health care. The Joint Commission on Accreditation of Healthcare Organizations recommends that a spiritual assessment be part of the admission process for patients in acute care hospital settings [1]. The Institute of Medicine and the National Hospice and Palliative Care Organization have also recommended that spiritual care is a key component for dying patients and their families [2]. At the same time, there has been a growing literature on the relationship between spirituality and health [3].

A recent 3-year initiative developed consensus recommendations for spiritual care competencies for family medicine residents [4]. These include the following:

• Knowledge of the terms of spirituality and religion, a conceptual framework of spirituality in patient care, the diversity and influence of beliefs, the roles of specialty resources, ethical considerations, and the empirical literature.

• Assessment skills, including recognizing indications for spiritual assessment, collecting relevant information, listening attentively, and synthesizing and communicating the findings.

• Therapeutic skills, including compassionate presence, supporting patient self-care, formulating a whole-person care plan, given spiritually integrated care, and negotiating differences in belief.

• Attitudes, including respect, spiritual self-awareness, spiritual self-care, and spiritual centeredness.

Addressing spirituality in medical school is challenging. Medical students already have a large amount of material to learn and digest, and the study of “spirituality” can seem like an unnecessary addition to the curriculum. As seen in the competencies outlined above, students may not understand how spirituality fits into the whole-person care they are learning. They may equate religion and spirituality, or equate culture and religion, and feel that the topic is addressed by the demographic information which has been collected.

It is also very likely that they do not understand the role of chaplains in health care. Physicians are familiar with addressing spirituality in the context of life-threatening illness [5] or end-of-life care [6]. A recent study found that physicians tend to see chaplains as primarily performing rituals and supporting patients and families dealing with death. Chaplains see their role as broader, however, relating more to “wholeness, presence and healing” [7]. Medical students also feel that they do not know very much about spiritualty and health [8]. There have been some successful medical school courses in spirituality and health, but most of these have been electives [9].

This study combined what has been learned about teaching spirituality and health and the spiritual competencies with recent work on use of reflective writing [10] to better understand what students gleaned from the experience of shadowing a chaplain.

METHOD

For the past 15 years, first-year students at the David Geffen School of Medicine at UCLA have been required to attend 3 hours of chaplain rounds as part of their year-long doctoring curriculum in the behavioral and social sciences. This is one of the planned experiences designed to help medical students understand the types of care settings and professionals involved with health care, including homecare of a chronically ill child, elderly residents of a skilled nursing facility, and Alcoholics Anonymous meetings. The afternoon starts with approximately 20 minutes with the director of spiritual care, who provides an introduction to the experience, discusses the objectives, and introduces the students to the chaplains who participate in the program. Students are assigned individually to a chaplain and shadow that chaplain as they make their visits to their patients. Typically the students visit three to four hospitalized patients with the chaplain. Chaplains visit patients from a variety of services, including, but not limited to, medical, surgical, oncology, intensive care, heart and lung transplant, liver and kidney transplant, pediatrics, and psychiatry. Most of the patients are quite ill, and many have been in the hospital for an extended time. The students have some time during the afternoon to ask the chaplains about their roles and to debrief after the visits. The majority of the time, however, is spent watching the chaplain with patients.

Each of the chaplains attends the orientation to the program and participates in a faculty development session on the expectations and objectives of the program. After the rounds, students are asked to write a one-page personal reflection about their experience and submit these to their tutors. The instructions are as follows: “Your reflection should focus on your thoughts, reactions, feelings, or what stood out to you the most and why. First person writing is appropriate for this type of assignment. This is not a formal/analytical essay, but an honest, straightforward reaction.”

For this study, 166 student-written reflections were de-identified and analyzed, as we looked for common themes using the grounded theory method [10]. Written reflections were reviewed by two of the authors (MF and MS), with UCLA IRB approval. As reflections were reviewed, certain repeating ideas were identified and used to develop a set of themes. Once the themes were “saturated” (meaning no more different themes were emerging), all of the reflections were categorized by their predominate themes. Themes clustered into four categories: 1) the importance of spiritual care; 2) the chaplain’s role in the clinical setting; 3) personal introspection; and 4) doctors and compassion.

RESULTS

The most common theme was the importance of spiritual care. The majority of the students (63%) wrote that spiritual care needed to be addressed to fully treat the patient. As one student put it, “Medicine is the art of healing, and this healing is incomplete without spiritual and emotional well-being.” Many students (43%) observed that meeting spiritual needs was therapeutic for the patient, and a third of them stated that doctors should make spiritual care available to all of their patients. One student wrote, “[the chaplain] offered more healing to this patient than any doctor could have.” Some of the students particularly underscored the importance of spirituality for patients at the end of life. Others noted examples of patient’s willingness to disclose personal information to someone willing to listen.

The importance of involving family in spiritual care was noted by a third of the students. Students wrote about how patients’ families often needed spiritual care more than the patients themselves. Students commented that a patient’s family could be a great spiritual and emotional support during the patient’s illness.

Most students reported a broader understanding of what chaplains did after chaplain rounds. Students often reported surprise that chaplains offered more services than the student had previously thought. One student wrote, “In all, my misconception that chaplains are only necessary during end of life issues was totally debunked.” Another student stated, “Chaplains provide a lot more than performing last rites, baptisms, and other religious ceremonies. They really offer valuable counseling services to all patients regardless of faith (or absence of faith).” Students also noted an increased willingness to refer patients to a chaplain due to the experience. One student noted, “I definitely plan to utilize chaplains and their services when providing my patients with whole person care.” Some students had not previously realized that the chaplains were also available to doctors and nurses.

The majority of students commented on observing chaplains pray with patients or their families. Often students noted that patients looked relieved following prayer. One student wrote that during and following a prayer, “a woman who seemed so despondent throughout our entire encounter suddenly appeared to have gotten happier and stronger in a matter of minutes.” Students often remarked that patients were happy to see/receive chaplains and were sometimes surprised that chaplains were welcomed even when the patient had not requested a chaplain visit. A few students commented on the philosophy of the chaplain service to seek to relieve spiritual distress and not to create new distress by pressing certain religious beliefs.

Many of the students (41%) specifically addressed their own emotional responses to patients in their reflections. Some expressed anger at the absence of compassion in the way some patients were treated by physicians, whereas others expressed deep sadness at seeing people in very difficult situations. Students also reported feeling guilty for bothering patients and were concerned about imposing their beliefs on others. One described a wish to “empathize without self-identifying.”

A sizeable number of students (21%) wrote that the visits served to support and re-emphasize their determination to give compassionate care as a physician. A smaller number of students (7%) reported difficulty in addressing spiritual needs for various reasons, including not being spiritual themselves and their lack of knowledge of different religions.

A smaller group of students reflected more generally rather than personally on the need for doctors to have compassion. One student quoted a chaplain as saying, “The best doctors she has seen are those who see their patients as humans, not merely diseases to be treated.” Students commented on the need for doctors to take time, listen to, and comfort patients and to have good communication with their patients. One student wrote: “[The patient] said some physicians come in and out, say a few words, and leave. The point of any interaction, he explained, is that once the conversation is over, one should gain something from that interaction.”

Discussion

The reflections suggest that the chaplain rounds were successful in helping the students to better understand the role of the chaplain and the value of spiritual care. In addition, students appeared to reflect on the importance of compassionate care of patients by physicians. The majority of students indicated that they had found the chaplain rounds to be a positive experience. As one student put it, “Overall, my experience with the chaplain was a very inspiring and unforgettable one.” Several students wrote specifically that they would offer chaplain services to future patients, and from the reflections it appeared that most of the students would.

A strength of this study is that the chaplain visits and written reflections were required activities for all first-year students and that all of the reflections were included in the analysis. The experience was standardized as much as possible in terms of providing an orientation to review goals and obtaining feedback from the chaplains. The written reflections were designed to make the students pause, contemplate their experience, and learn from it. If it also served to renew a commitment to compassionate care, it has been successful indeed as a formative intervention, regardless of the value to research.

There are limitations to the generalizability of the findings. Because the students knew that their reflections would be read by a faculty member for the course (though anonymous in the study), they may have been more inclined to be positive in their description of the experience. Although the large number of chaplains at UCLA meant that students could be in very small groups, this also meant that not all students had the same type of experience in terms of the religious background of the chaplain. The patients were also extremely variable in age, illness, culture, and religious background. Further, the fact that two of the authors did the qualitative analysis may have introduced some unintended bias.

The qualitative nature of the study makes it impossible to quantify specifically how much knowledge was gained about the role of spiritual care. Although the students reported changes in knowledge and attitudes, we have no measures of what they knew or believed before the chaplain rounds. This qualitative study can serve as a foundation for a more structured, quantitative study, examining knowledge and perspective before and after the chaplain rounds experience.

Chaplain rounds appear to be successful in helping students gain a better understanding of the role of chaplains and an appreciation for the importance of having spiritual care available to patients. In addition, many of the students reported that the chaplain provided them with a chance to reflect on their emotional responses to patients and their own spirituality. The task thus achieved its goals, and the time appears to be well spent.