Benchmarking for Spiritual Care Services: Building a Case

Alexander Tartaglia, DMin, Professor Emeritus

Patient Counseling, College of Health Professions,

Virginia Commonwealth University, Richmond, Virginia

Not long ago the director of spiritual care at a large academic medical center contacted Transforming Chaplaincy (TC) at Rush University. Planning to embark on a departmental strategic plan, the director was seeking benchmarking data on staffing for spiritual care at comparable institutions. The response was pretty much what the director had also discovered, the cupboard is pretty bare.

Spiritual care directors and managers across the board have on more than one occasion raised similar questions. How many chaplains should my department have?  If my administrator asked the same question, what data could I bring to the table to provide a well-documented response? Multiple students and colleagues have posed those questions to me over the years. My response has been both simple and elusive, “it depends.”

Spiritual care departments typically have a defined scope of service.  Departmental scopes of service outline specific responsibilities/expectations of chaplains defined by the organizations they serve as well as the tasks and responsibilities the department has committed itself to deliver. Hospitals also vary by patient census as well as acuity and spiritual care departments may mirror that variation.

A response to chaplain staffing might begin with answering some foundational questions. How large and complex is the organization and population it serves? Are chaplains expected to be integrated members of the health care team assigned to service lines or is the focus primarily on crisis care? What tasks and responsibilities does the organization expect from spiritual care? For example, are chaplains expected to respond to every code or death or play a key role in the facilitating the completion of advance directives? Are there parameters around those expectations? For example, are they to be met during typical business hours alone, extended hours, or 24/7? To what extend are those responsibilities met by professional staff vs. learners vs. volunteers?

Attempts to standardize spiritual care services are not new. COMISS Standards (n.d.) detail a wide range of expectations for spiritual care including chaplain integration into the structure of the organization, 24/7 availability of chaplains services, and most relevant here – sufficient personnel to meet the goals and scope of service for the department. VandeCreek and Burton (2001) edited “Professional chaplaincy: Its role and importance in healthcare” (aka, The White Paper). The paper highlighted an extensive range of chaplain services and noted the need to benchmark staff for roles performed by spiritual care departments. Subsequent attempts to establish standards of practice for chaplain activities were developed by the Association of Professional Chaplains (APC, 2015; King et al., 2009) and the Catholic Health Association of the United States (CHA, 2019). Despite these efforts, considerable variation exists among spiritual care departments and no standard evidence-based benchmarks are consistently practiced. Cadge (2012) reported this disparity among spiritual care departments in a study of 17 leading hospitals in the U.S. suggesting a lack of consensus in the profession regarding chaplains’ core responsibilities.

Already contemplating a next step study to benchmark chaplain functions and staffing, TC embarked on supporting a study using a comparable subset of U. S. hospitals, in this case, the U. S. News and World Report Top 20 from the year 2020-2021. Data for the study were gathered via Zoom/telephone employing a 76-item structured survey instrument with the directors/managers with oversight for spiritual care at the organizations’ flagship hospitals. The findings of the study have resulted in the completion of a recently online published article in the Journal of Health Care Chaplaincy (Tartaglia, et. al., 2022). A second manuscript focused on a subset of questions related to chaplain involvement in staff care is currently under review. The preliminary study findings were also presented during the 2021 Spiritual Care Week and are available on the TC YouTube Channel. Here are just a few highlights from the study.

Figure A

Selected 24/7 Chaplain Functions by Protocol vs. Request

Figure A provides detail of selected chaplain functions provided by protocol (hospital policy or department scope of practice) on a 24/7 basis vs. by request only. A few other study findings stand out for me. Five (25%) of the hospitals have a chaplain in-house and awake 24/7, 13 (65%) departments provide some routine outpatient care, seven (35%) offer routine, pre-op care, and four (20%) departments are involved in assisting with the completion of advance directives by policy with half indicating that chaplains “never” are involved. Eleven (55%) departments expect that chaplains will attend health team rounds on their assigned units at least a few times per week. Finally, other than annual/semi-annual memorial services for families follow-up bereavement support by chaplains is limited, with only one of the departments providing a more comprehensive service that also included notes/cards, support groups, and memory boxes.

Figure B

Staff support activities by request, routine, or protocol expectation

Most spiritual care departments consider staff support an essential function. All twenty managers confirmed that their department identified staff support as very important, with 17 noting that their administration saw this as a very important chaplain priority. The range of staff support services in considerable and is detailed in Figure B.

Thirteen (65%) managers reported that staff chaplains spend between 10-30% of time on staff support with another 5 (25%) spending >30%. The wide majority of staff support results from personal relationships, working end-of-life situations with staff, and referrals from staff managers.
 
The study examined staffing levels according to both bed size and number of chaplains per 100 patient average daily census.

Also, fourteen departments (70%) were supported by one administrative FTE. Five (25%) were supported by more than one administrative FTE and one (5%) by a shared FTE.

Two previous key studies have examined chaplain staffing by patient census. The first was the 2001 seminal study by VandeCreek et al. and the second a 2004 study by Flannelly et al. What did our TC study find and what if anything has changed in two decades or so? VandeCreek et al. (2001) found that, for 36 university hospitals, there was a range of 0 to 3.33 FTEs per 100 patients with a mean of 1.50 FTEs per 100 patients. This compares to a range of 0.4 to 4.3 FTEs per 100 patients in the TC study with a mean of 2.5 FTEs per 100 patients. Flannelly (2004) reported staffing for a variety of hospital types including general, not-for-profit, and non-religiously affiliated with a 1.8 mean FTEs per 100 patients for each group. Again, our study found a mean of 2.5 FTEs per 100 patients. One consistent finding across all studies, including the current one, is that the number of chaplains increased with patient census, but at an inconsistent rate. The chaplain-to-patient ratio decreased with size.

Your thoughts? Consider that this disproportionate change in both total department FTEs and clinical FTEs may in part be explained by limited staff responsible for administration, CPE education, after-hours coverage, worship services, and/or committee representation. More precise explanation requires further investigation.

A few other findings related to staffing stand out in comparison to prior studies. The first is the limited use of volunteers. While nearly all the spiritual care departments in our study utilized volunteers, they were limited to request only faith-specific rather than core services. This compares to the finding of VandeCreek et al. (2001) that reported considerable variation in the use of volunteers for core spiritual care services at university hospitals with a range of 0-100% and a mean of 20%. The second notable finding is the percentage of board-certified chaplains. Flannelly reported that for hospitals with a census > 400, the mean certification rate was 71.4%. Our study specifically asked about eligibility for certification and found that as a composite, approximately 90% of staff chaplains met that threshold.

So what are some of the takeaways from the TC study?  First, findings support the notion that staffing is at some level a factor of chaplain integration into an organization and the functions the organizations expect chaplains to fulfill. Second, data collection that includes tracking chaplain activities and trends for chaplain services are critical to making a case for staffing. Third, as leaders play an important role in setting direction and strategic goals for organizations, communication and collaboration between spiritual care leaders and hospital administrators to define those functions is essential.

References

Association of Professional Chaplains, Inc. (2015). Standards of Practice for Professional Chaplains. Retrieved January 17, 2022, from https://www.professionalchaplains.org/content.asp?pl=200&sl=198&contentid=514  

Association of Professional Chaplains, Inc. (2017). Common Qualifications and Competencies for Professional Chaplains. Retrieved February 22, 2022, from https://www.professionalchaplains.org/files/2017%20Common%20Qualifications%20and%20Competencies%20for%20Professional%20Chaplains.pdf

Cadge, W. (2012) Paging God: Religion in the halls of medicine. University of Chicago Press.

Catholic Health Association of the United States. (2019) Pastoral care standard work and staffing tool. https://www.chausa.org/pastoralcare/private—pastoral-care-standard-work-and-staffing

COMISS Network (n.d.) CCAPS Standards. Retrieved January 17, 2022, from https://www.comissnetwork.org/wp-content/uploads/2021/02/CCAPS-Standards-2021.pdf

Flannelly, K. J., Handzo, G. F., Weaver, A. J. (2004). Factors affecting healthcare chaplaincy and the provision of pastoral care in the United States. J Past Care Counsel, 58(1-2), 127-130. https://doi.org/10.1077/154230500405800119

King, S., Overvold, J., Fitchett, G., Grossoehme, D., Handzo, G., Jacobs, M., Johnson, D., Kidd, B., LaRocco-Pitts, M., Lindquist, T., Mather, J., Murman, K., O’Bryan, F., Patterson, D., Peery, B., Wintz, S. (2009). Standards of practice for professional chaplains in acute care: Second draft of the consensus document November 1, 2009. Chap Today, 25(2), 2-16. https://doi.org/10.1080/10999183.2009.10767377

Tartaglia, A., Corson, C., White, K. B., Charlescraft, Al, Jackson-Jordan, E., Johnson, T. & Fitchett, G. (2022): Chaplain staffing and scope of service: benchmarking spiritual care departments. J Health Care Chap, https://doi.org/10.1080/08854726.2022.2121579  

VandeCreek, L. & Burton, L. (eds.) (2001). Professional chaplaincy: Its role and importance in healthcare. J Past Care, 55(1), 81-97. https://doi.org/10.1177/002234090105500109

VandeCreek, L., Siegel, K., Gorey, E., Brown, S., Toperzer, R. (2001). How many chaplains per 100 inpatients? Benchmarks of health care chaplaincy departments. J Past Care, 55(3), 289-301. https://doi.org/10.1077/0022340990105500307