Journal of Health Care Chaplaincy, 21:60–75, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 0885-4726 print/1528-6916 online DOI: 10.1080/08854726.2015.1016317

A Qualitative Study of Patient and Family Perceptions of Chaplain Presence During Post-Trauma Care STEVEN C. MCCORMICK AND ALICE A. HILDEBRAND Neuroscience Institute, Maine Medical Center, Portland, Maine, USA

Improving the provision of spiritual care to hospitalized patients requires understanding what patients look for from a hospital chaplain, and why. This qualitative study uses grounded theory methodology to analyze data from 25 interviews with adult patients and/or adult family members who received spiritual care in a large tertiary care hospital. Analysis reveals three key themes in chaplaincy care: the attributes valued in the chaplain’s presence, the elements necessary to form relationship with the chaplain, and the role of the chaplain in helping patients to discover and express meaning in their experiences. The authors weave these three themes together into a grounded theory and propose an assessment model that incorporates psychological theory about human motivation, faith development, and the development of autonomy. An understanding of the proposed assessment model can guide chaplain interventions and benefit all members of the clinical care team. KEYWORDS assessment, chaplain, grounded theory, spiritual care, trauma Spiritual care practices in acute care inpatient hospital settings are often based upon the self-understanding of the chaplains. However, there is a growing consensus in the field of spiritual care that chaplains need to understand their work not on this anecdotal, personalized basis, but on the same kind of clinical, evidential base as the other disciplines whose members make up the patient care teams of twenty-first century health care institutions Address correspondence to Steven C. McCormick, EdD, Neuroscience Institute, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA. E-mail: [email protected] 60

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(Fitchett, 2011). The standards of practice for professional chaplains in acute care settings state, “The chaplain practices evidence-based care including ongoing evaluation of new practices and . . . contributes to or conducts research,” (Association of Professional Chaplains, 2009, p. 1). A recent review of studies of the clinical practice of chaplains concludes that the current research body does not adequately define chaplain interventions nor provide sufficient evidence of the effectiveness of these practices, thus limiting the ability of chaplains to practice evidence-based care. More research is needed to describe the unique contributions of chaplains to spiritual care, to identify best chaplaincy practices to optimize patient and family health outcomes, and to test the efficacy of chaplaincy care (Fitchett, 2011; Jankowski, Handzo, & Flannelly, 2011; Marin et al., 2015). Future research will be most helpful if it is grounded in a better understanding of what chaplains actually do when they visit patients, and how patients perceive and experience various chaplain traits and practices. There is much evidence that patients’ thoughts, attitudes, and emotions play a central role in health outcomes (Benedetti, 2013). Spiritual care focuses on these elements of patient care. Studies have shown that spiritual care increases trust in a medical team and overall satisfaction with care (Lichter, 2013; Marin et al., 2015). Actions such as ritual and prayer are important to many individuals when facing physical illness and distress (Jankowski et al., 2011). Such evidence has contributed to the Standards of the Joint Commission on Accreditation of Healthcare Organization’s statement that “‘Psychosocial, spiritual, and cultural values affect how [patients] respond to their care’ and [the Joint Commission] has addressed spirituality and emotional well-being as aspects of patient care,” (Clark, Drain, & Malone, 2003, p. 659). Defining optimal spiritual care interventions for trauma patients presents additional challenges to evidence-based practice. To date, there is limited research on the impact of traumatic stress on spirituality or spiritual care needs (Hughes & Handzo, 2010). Life-threatening accidents and illnesses can overwhelm normal coping abilities and lead to mental, emotional, and spiritual distress along with physiological distress. Such suffering threatens the patient socially and psychologically as well as physically (Cassel, 1982). Unless this distress is treated through interventions of spiritual caregiving/chaplaincy, it may impede healing (Pargament, 1997) and negatively impact patient satisfaction and willingness to take responsibility for self-care after discharge. Hospital chaplains address psychosocial and spiritual distress of patients and their significant others throughout patient admission. Understanding the nature and impact of such chaplaincy care from the perspective of the patient or family member is the clinical issue addressed in this study. Prior to the design of this research, the authors reviewed the literature relevant to the provision of spiritual care and any aspect of the intersection

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between physiological and psychological trauma and the spiritual care of those patients in particular. No research hypothesis was developed, in keeping with a qualitative approach based upon grounded theory methodology (Grossoehme, 2014). However, the authors’ previous theoretical work analyzing spiritual care encounters with patients documented in process notes, verbatim accounts, and case study guided the research design and data analysis. It is a matter of debate among grounded theory researchers whether it is possible to conduct qualitative research without the influence of previous relevant research as well as researcher personal bias (Kennedy & Lingard, 2006). Some researchers maintain that previous research has an inevitable impact and therefore should be used as an advantage and acknowledged as such (Strauss & Corbin, 1990), a position endorsed by the authors of this study. As a result of their prior work, the authors believe that it is vitally important to assess the developmental level at which a patient is functioning in three key areas: motivation, belief system, and attachment/autonomy (Fowler, 1981; Maslow, 1943; Westerhoff, 1976; Winnicott, 1958). They joined Maslow’s theory of human motivation with the work of Fowler and Westerhoff on faith and belief system development, and with Winnicott’s theories on individuation through the development of attachment/autonomy. This theoretical adaptation provided them with a way to understand the nature of patients’ needs in the moment of chaplain encounter, the nature of their religious or philosophical coping or distress, and the nature of patients’ degree of felt and expressed autonomy and self-agency. The following considerations influenced the design of the semistructured, open-ended interviews. What motivational factors can be observed in a patient or family member at any given moment during an encounter? What beliefs are expressed regarding their experience, and how do these experiences fit into participants’ pre-trauma faith or belief systems? Is the patient or family member currently able to maintain an autonomous adult level of psychological function? Can they sustain previous attachments and form new ones? These considerations also influenced the initial coding of the study data.

METHODS This study was designed to collect data in the form of self-reported narratives from a purposeful sampling of 25 patients, and in some cases loved ones and family members, who received hospital chaplain visits during post-trauma care at a 637 bed Level One Trauma Center. Semi-structured interviews were conducted by the Principal Investigator (PI), focused on patient and family member perceptions of chaplain traits and practices. Responses were audio recorded on a small handheld device placed between the participant and the

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interviewer. The interview recordings were professionally transcribed by a confidential third party transcriptionist in a manner that protected participant anonymity. Interview transcripts were coded and analyzed based upon established guidelines for qualitative study employing grounded theory methodology (Grossoehme, 2014). A total of nearly 10 hours of recordings was collected. Individual interviews ranged from 8 to 48 minutes in length. Patients at this institution receive chaplain visits in a variety of ways. Faith tradition-specific chaplains, funded by external religious bodies, attempt to visit all the patients in their religious tradition. Hospital-funded interfaith chaplains and Clinical Pastoral Education (CPE) Residents receive consult requests and referrals from medical staff. They also respond by protocol as members of the Code Blue team and Trauma team, and they self-refer to patients by rounding on assigned floors. The authors were attentive to the influences that their individual backgrounds might bring to an interpretation of the study data, including their approaches to chaplaincy and the inherent theories and expectations in their practices. The PI is a male former Protestant, now Roman Catholic, trained in educational research and technology, employed as an advanced level CPE Resident at the research study site and as a Catholic chaplain in another hospital. The Co-Investigator (CI) is a female United Church of Christ ordained minister, Board Certified Chaplain and employed as a full-time staff chaplain by the study site hospital. These differences and any potential biases were addressed by discussion and agreement (Charmaz, 1996, 2008; Corbin & Strauss, 1990; Grossoehme, 2014; Miles, Huberman, & Saldana, 2014). All aspects of the design and implementation of this research study were approved by the Institutional Review Board (IRB #4321).

Data Collection Twenty-five adult patients and/or adult family members of patients were enrolled during the time frame of January-April, 2014. During that period, all of the chaplains were invited to refer candidates who had experienced physical and/or psychological trauma. The PI’s goal was to build a study sample varied in age, gender, race, religion, role, and type of trauma or illness, and he accepted participants in accordance with this. Criteria for selection were fluency in English, the capacity to comprehend and respond to interview questions near the time of patient discharge, and a record of visits from one or more hospital chaplains during the hospital stay. Participation in this study had no bearing on the availability of ongoing chaplaincy care for any patient, nor on the patient’s right to discontinue chaplain visits at any time. One candidate declined participation in the study based upon her preference for maintaining privacy regarding her conversations with the chaplain who visited her. Signed consent was obtained from all participants

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before they were interviewed. For those patients who chose to participate in this study a frequency of visits was established based upon the wishes of the patient. No referred candidates that met inclusion criteria were declined by the PI, and no further participants were enrolled once the study target of 25 was reached. The study data came from participant accounts of experiences with a variety of chaplains. The chaplaincy care provided was no different from the care offered to other patients and their family members and friends, with the exception of the interview. In addition to conducting all 25 of the onetime study interviews, the PI made chaplaincy care visits to six participants in his role as a Level II CPE Resident. The dual role of chaplain and interviewer in those six instances may mean that factors of social desirability and acquiescence affected the data, in addition to the general potential for self-report bias in chaplaincy interviews (Dodd-McCue & Tartaglia, 2010). The PI was aware the interviews themselves could be experienced as spiritual care by participants (Grossoehme, 2011), and that the potential existed for participants to experience re-traumatization in the retelling of their stories (Grossoehme, 2014). He was mindful of the power differential inherent in his role as researcher and chaplain, and that of the participants. All of these factors were discussed frequently with the CI. Together they decided when follow-up spiritual care was needed from the PI or another chaplain after an interview. The only participant data recorded was age, gender, religious preference, and patient diagnosis. The demographic profile of the 25 participants is as follows: age range (18–82), female (14), male (11), Protestant (9), Roman Catholic (7), no religious preference (6), Greek Orthodox (1), Episcopal (1), Jewish (1), stroke (7), traumatic brain injury (5), cancer (3), multiple fractures (3), fetal demise (2), and infant heart disease (2). Three participants had other trauma-related clinical diagnoses. All of the participants were Caucasian. Each participant was assigned a unique code for recording data. No records of visits were kept other than the customary chaplaincy care charting in the patient’s electronic record. All study data were kept in a locked cabinet inside a secured office in the hospital. Electronic copies were password protected on a secured server behind firewalls inside the private hospital network.

Interviews A semi-structured interview was designed to elicit self-reported data on participant experiences of chaplain visits. As the results of the study were intended to be found in the voices of the patients, careful planning was given to ensure that the interview would focus on the areas of interest to the study while also ensuring the authenticity of participant responses (Speziale & Carpenter, 2007).

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Each interview started with this invitation to the participant by the PI: “Talk about the experience you went through that resulted in you being here and what that was like for you.” Follow up and clarifying questions included: 1. Describe in your own words one or more of the visits you had with a chaplain during your stay. What was helpful to you? What was not? 2. Describe the challenges you faced during your stay and how the chaplain visits helped you with those challenges. How could those chaplain visits have been more helpful to you? 3. Based upon your experience, what personal traits do you think are most important for a chaplain to demonstrate during visits with patients? What should the chaplain avoid? 4. Were there any particular spiritual or religious practices that were helpful to you during this stay? If so, what were they and how were they helpful to you? 5. Based upon your experiences during this visit, would you recommend to other patients that they spend time with the hospital chaplains? If so, why? If not, why not? 6. To what degree do you believe that the chaplain care that you have received during your stay has contributed to your well-being and overall satisfaction with the care you have received?

Data Analysis The PI reviewed the transcribed text for accuracy against the interview recordings. The CI then coded the first eight interviews and noted any statements regarding the characteristics of the chaplain, the nature of the interactions with the chaplain, and the impact of those interactions on the hospital experience of the participants. Together, the PI and CI created a table of codes from these statements to be used in the subsequent coding of interviews nine through twenty-five. During the coding of interviews nine through thirteen by the CI several themes began to emerge: traits of the chaplain that patients sought in the presence of the chaplain, traits in the chaplain that described what patients required for relationship with the chaplain, and traits in the chaplain that contributed to patients’ efforts to find meaning in their experiences. These concepts, presence, relationship, and meaning, formed the axes for further coding. After coding the sixteenth interview, the PI and CI were satisfied that a saturation of themes had been reached. Remaining transcripts were examined for further instances of recurring or new codes, by theme. Additional codes discovered were grouped by the PI and CI working together into the identified axial codes. Ultimately all individual codes were successfully grouped into the three axial codes, which formed a structure for summarizing the data and building the basis of a grounded theory.

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Validation Study findings were validated in several ways, including the collaborative approach described above. Several participants were revisited and given the opportunity to read their transcripts and comment on coding results. Eight trauma nurses who were aware of the study and three nontrauma nurses who were unfamiliar with the study were asked for feedback on study findings. The nurses agreed that the themes and codes found in the data were consistent with their own perspectives and observations of patient needs for, and patient responses to, spiritual care. Three hospital staff members representing other cultures (Somali Muslim, Latino, and Nigerian Christian) who were not involved in the study were also shown study results and asked for feedback. All three stated that the kind of spiritual care described in the themes of this study would be relevant to their cultural community.

RESULTS As previously noted, three themes emerged from the data: presence, relationship, and meaning. Participants described presence in short phrases and single words, essentially listing traits of character they desired in a chaplain. They expanded upon these traits by describing certain chaplain qualities and actions necessary to the formation of a relationship with the chaplain. Many also spoke about what chaplains said or did that contributed positively to their own efforts to find meaning in their experiences. All but two participants stated that they valued the chaplain visits and experienced these visits as an important part of their recovery.

Presence Participants reported that chaplain presence starts with simply being available to the patient; to be willing to just unobtrusively “show up.” Sometimes, that is all a participant wanted in a particular moment. Just knowing that the chaplain came by, that he cared. (wife of 53-yearold Catholic male with head and neck trauma and respiratory distress from a motor vehicle accident [MVA])

Sensitivity to how much interaction is desired by the participant at any particular moment is an important quality for a chaplain. Sensing how much to say or not to say and how long to visit is important from the very start. I think early on I was so inundated with doctors and nurses and just the shock of what was happening that I could only handle so many people.

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I think that [a chaplain] approaching a family in crisis and just giving them the option is nice, just being like, “Hey, we’re here for you if you need us.” And if they’re a family that really needs that, then they know that’s there. If they’re a family that maybe needs a couple days, hey you’re gone. (38-year-old “no religious preference” [NRP] mother of 18-yearold child with traumatic brain injury [TBI])

Participants expressed that they wanted the chaplain to be positive and hopeful. If a chaplain is there with positive talk, sometimes it makes you feel like you’re not in such a tragic moment, you know. (39-year-old Christian mother of 17-year-old child with multiple fractures from a MVA) A chaplain should listen and have some good things to say to try to cheer the person up; to have good feedback and just interact. (55-yearold Catholic male with a self-inflicted gunshot wound)

Yet, being positive and hopeful without regard to participant suffering in a particular moment was not helpful and could even alienate participants by seeming unrealistic or trite. I knew that she was just trying to make me feel better. But I didn’t want to feel better because I just wanted to get it figured out. (31-year-old Catholic mother of a 2-year-old with leukemia) And there’s no saying that I’m doing good. I’m not doing good, okay? I will be better, you know, but I have to pay attention to what I’m doing to get better. (65-year-old Protestant female, ischemic stroke) It’s funny how people say “God is not ready for you.” Many say, “Oh, you survived because God didn’t want you yet.” You know, what is that? I’m still here because I’m a bad shot. (55-year-old Catholic male with a self-inflicted gunshot wound)

The desired chaplain demeanor was one that is consistently calm, gentle, and respectful. I guess it’s just the way that they come in and they come across. They’re so mellow and caring, you know. (77-year-old Catholic male, acute renal failure) I was comfortable and she saw that I was comfortable and she moved on. She didn’t press anything on me. (58-year-old Catholic father of 29-year-old with severed spine from a MVA)

Being respectful also meant not being too talkative or assertive, but rather to listen and follow the participant’s lead.

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I would not like chaplains forcing themselves on you when you just need some time alone. Someone who is a real “chatty Kathy” and talking a lot and not really listening to what the person wants to talk about or not talk about. (43-year-old NRP mother of multiple premature births with one fetal demise)

All the while chaplains must demonstrate compassion and empathy without any indication of judgment of the patient or family member. A chaplain should not be judgmental. Not listen to hearsay. Positive, non-judgmental, open views, just caring. (39-year-old Christian mother of 17-year-old child with multiple fractures from a MVA)

The kind of chaplain presence patients spoke of most favorably required an evolving balance of qualities dictated by the changing needs of the participants in each encounter.

Relationship Participants described the process by which an initial encounter became a spiritual care relationship, stating in individual ways that the basis of forming this relationship is good listening on the part of the chaplain. I think he [patient] doesn’t like anybody telling him what to do, but the chaplain listens, I think he likes that. (39-year-old Christian mother of a 17-year-old child with multiple fractures from a MVA) She came in and she sat with me and talked, just let me, hear me talk. That’s all it was. She let me talk, let me vent. (28-year-old Baptist mother of premature baby with an inoperable heart defect) Just listen. And when they are all done, just give them a blessing. (77-year-old Catholic male, acute renal failure)

Once trust was established, encounters were more likely to include emotional expressions of personal spiritual experiences. Our second meeting was more spiritual and I started to ask some of the questions that I was a little scared to ask her at first, you know, “Do you think God forgives me? Do you think God would understand?” And, some of those harder questions. I needed the chaplain to reaffirm to me, “No, God does not hate you.” (30-year-old Catholic mother who underwent termination of pregnancy for fetal anomalies incompatible with life) Some people come in and you can tell by the way they act they’re almost afraid of you. And others come in and they touch your hand, they feel you, the conversation is easy. And they are willing to stay, and just talk. (64-year-old Protestant male with a brain tumor)

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It helps you so you can open up more. So if you do have, like, you know, you really want to cry, you feel comfortable crying, and just sobbing your heart out to that one person because you’ve built that relationship up. So I think that’s a good thing. (28-year-old Baptist mother of a premature baby with an inoperable heart defect)

The frequency of chaplain visits and interactions with patients and family members outside of a visit to the room was also important. He saw me in the waiting area and he stopped and talked. And then I saw him down in the cafeteria and he did the same thing there. To me, it doesn’t make you feel alone. (53-year-old Catholic male with head and neck trauma and respiratory distress from a MVA)

Familiarity grew as a result of frequent visits and that contributed to participants forming relationships with the chaplain. There was something there more than just somebody coming in to say, “I’m so and so and I’m a chaplain, or whatever.” But it was the way she treated my family, too. It really got me. Like an old pair of shoes. (69-year-old NRP female with terminal cancer) She knew a bit about me, my personal life. And that might add to that sense of compassion. I just sensed that there was more of a depth of understanding there than if she didn’t know me at all. (78-year-old Christian male with a subarachnoid hemorrhage [SAH])

How prayer was used was a critical element in the formation of spiritual care relationships. It could help or hurt, depending upon the particular patient or family member and how prayer was approached by the chaplain. She did ask if I would like to have her pray for me, or pray for my situation. And my wife was with me at that time and I said, “Yes, I wish you would.” And she did. It was a very quiet, a very appropriate prayer. Not the intent to try to encourage me or tunnel me into some system of belief. (78-year-old Christian male with a SAH)

For some, not offering prayer was a detriment. Prayer is the first priority. Something that makes you feel lighter, and you can express emotions and everything. (55-year-old Greek Orthodox mother of 17-year-old child with arteriovenous malformation rupture)

For others, prayer could be distancing. I’m not a kneel-by-the-bedside type of prayer person. I just say, “Hey, dear God, Mother Nature, and the Powers That Be walking down the

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street.” I find that if I’m really upset, prayer and that group effort and that talk about stuff, it almost makes me more upset personally. (38-year-old NRP mother of 18-year-old child with a TBI) If the chaplain had prayed, it probably would have felt awkward because I don’t pray with people. I usually pray alone, or in my head, or whatever. (39-year-old Christian mother of a 17-year-old child with multiple fractures from a MVA)

Forming relationships with patients and family members required an ongoing assessment by the chaplain of participant needs in each encounter and responding with the most appropriate interventions in the moment. By staying with the patient throughout these various moments and encounters, familiarity grew and the opportunity for meaning-making between participant and chaplain was enhanced.

Meaning Participants talked readily and openly to the PI about the events that brought them into the hospital. For many, sharing this personal story was lengthy and tearfully emotional. The opportunity to tell the story appeared to be a key element in creating a relaxed and open attitude during the interview. Many were very articulate in characterizing their traumatic experiences. It was obvious that they had thought about those experiences extensively in an effort to make sense of them. Often participants reported that they had already discussed these thoughts with a chaplain, and they shared a sense of new perspective as a result. The initial trauma event or news was universally upsetting to study participants. “You know that term ‘the dark night of the soul?’ I think it was crisis mode. I went to worse-case scenario. And it was like, you know, you don’t sleep. You just lay there and worry, unsure,” (31 year old Catholic mother of a 2 year old with leukemia). This mother went on to talk about the manner in which the chaplain shared her own faith and used scripture as well as her pastoral authority to help her make meaning of the experience. And I said to [the chaplain], I was like, “So basically, we’ve brought this upon ourselves, because of, you know, the way you create your own life through your thoughts or whatever.” And [the chaplain] said to me, she’s like, “I don’t think you have that kind of power.” And then I thought about it, I was like, “You’re right. I don’t have that power.” And then I remembered a part of me always knew that only God has that power. And I don’t know the reason that this happened. But [the chaplain] reminded me that we can’t know the reason. And maybe we don’t need to know right now.

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Assessing and appropriately responding to the need for the religious practices of particular patients helped provide meaning. Right after I got here, anxiety started setting in. I was thinking I was going to die, so I was real worried about where my soul was going. [The chaplain] was the first one to come down and see me and she prayed with me. She read to me out of my Bible. And it was a big help. After I talked with her I was a lot less anxious. I slept better. (62-year-old Protestant male with a hemorrhagic stroke)

A preconception of the role of the chaplain could be an obstacle. I thought that chaplains were only brought in when people were dying. (40-year-old Protestant wife of 53-year-old Catholic male with head and neck trauma and respiratory distress from a MVA)

But for that participant’s husband, the patient, the first sight of the chaplain brought this reaction, “Seeing him come in gave me a good feeling that everything was going to be alright.” For many Catholic participants, the presence of a priest along with church sacraments and rites was received positively. I asked for a priest to come bless her, which he did. He brought in a rosary. She was overjoyed with the rosary. (82-year-old Protestant husband of a 75-year-old Catholic woman with a SAH)

Another participant commented on the Sacrament of the Sick in particular. The priest came and gave him the Sacrament of the Sick. There was a tear that was coming down his [patient’s] eye when Father was praying with him. (58-year-old Catholic father of a 29-year-old male with a broken spine)

Another spoke of the Catholic sacraments in general. I always feel uplifted when they leave because you’ve received the sacraments and it gives you that nice feeling; very soothing, soothing to the soul. And that’s good when you’re in a place like this. (77-year-old Catholic male with acute renal failure)

Metaphors were often used as part of the effort to make new meaning. I feel like this journey is a long walk and along that walk are several bridges. And it’s like traveling along and then, “Uh, we’ve got this bridge. Do we pay the trolls, do we try to run across it, do we do this, do we do that?” Then you cross that bridge and you’re like, “Whew” and you just

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kind of walk for a while and then you stumble, you fall, you get up, you cross another bridge. (38-year-old NRP mother of a teenager with a TBI)

For this mother, “Just having the chaplain come around to talk was helpful, but prayer probably would have made me mad.” It was clear that her effort to make meaning of the trauma was leading her to think about faith. And I think putting your faith into an unknown, I think this experience has kind of not forced me, but allowed me to do that. I think I understand why people say you have to have faith to get going. I guess I get that concept a little bit more. That’s changed. I don’t know if that makes sense. You can’t control the situation. I can’t control the situation. So I have no other option but to take a deep breath and have faith that good outcome will come out of this.

The exploration of meaning with the chaplain happened in a manner unique to each participant. One participant put it this way: I believe that the chaplain or minister, or priest or whatever, should be responsive to the needs of the individual and not responsive to their own needs of being a religious person. (78-year-old Christian male with a SAH)

Another said: I think we all have to share our brokenness. No matter where our relationship goes, or how our relationship is; to be there on behalf of the greater power. Then from there you allow your life to flow through theirs. And that’s one thing that does make a difference. (79-year-old Baptist male with multiple fractures from a MVA)

DISCUSSION Participants in this study clearly described the traits they sought in a chaplain, which they experienced not in a static form, but in the active process of relationship building. In some cases, this dynamic process occurred over a series of visits. In other cases, the process could be seen in the course of one visit, which was often the PI’s experience with the study interviews. The needs for spiritual care are in some manner expressed by the participants; the assessment and intervention are the responsibility of the chaplain. The previously cited work by Maslow (1943), Fowler (1981), Westerhoff (1976), and Winnicott (1958), integrated with the study data, provides a basis for assessing the state of mind of the patient or family member and choosing what intervention to offer (Table 1).

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TABLE 1 Holistic spiritual care assessment model Assessment Presence

Maslow Primary Motivation

Fowler, Westerhoff Faith Development

Winnicott Primary Attachment

Given faith

Caregiver

Relationship

Physiological needs, safety needs Love needs, esteem needs

Affiliative faith

Transitional object

Meaning

Self-actualization

Doubting faith, owned faith

Transitional phenomena

Note. Maslow (1943); Fowler (1981); Westerhoff (1976); Winnicott (1958).

Individuals who are in the shock of a trauma or who are struggling with bad news are likely to be located on the basic presence level of the table. Their motivation may be dominated by physical needs such as critical medical care and safety. Patients or family members may ask very simple faith related questions, reflecting basic understandings often explored in childhood. “Why did this happen to me? Where is God?” In the context of this level of distress, the individual may seek a temporary strong attachment to a particular trusted caregiver. As physical trauma stabilizes, human motivation may shift toward a need for a sense of belonging and community, and the mutuality possible in a relationship. As the chaplain demonstrates trustworthy and consistent attention, he or she can represent a transitional presence between the helplessness initially experienced and the new autonomy that may lie ahead. The successful formation of a healthy relationship can support the patient in exploring new meaning in a different and challenging context. At the meaning level of the assessment model, the patient or family member is motivated to re-establish a sense of self, now in a new context. The same challenging questions that were asked at the previous levels may still be explored, but with a greater depth of understanding and acceptance. The patient or family member seeks to take ownership of their experiences, to revisit their interests, affiliations and beliefs, and to reclaim autonomy, even if in a new form. Patients and family members often vacillate in their progress through these levels. Chaplains must reflectively assess patient progress and choose appropriate interventions in response. They must seek to understand the changing patient needs of each moment, to join patients where they are and then move with them, sometimes as guide and sometimes as follower. To do so, the chaplain demonstrates the necessary qualities of presence and remains as a witness through the darkest hours of patient suffering, that period of time that Rambo (2010) describes as “a world in which the parameters of life and death no longer seem to hold—to provide meaning” (p. 3). The goal is to help patients free themselves from the spiritual distress that can restrict healing (Pargament, 1997). As healing occurs, it is followed by the new challenges of integration into a meaningful life within a changed context.

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This assessment model and the grounded theory behind it can contribute to evidence-based spiritual care practice. Future quantitative research should advance these findings, with the goal of developing and validating an assessment instrument to guide chaplain interventions, improving patient outcomes that drive key hospital performance metrics. Such research evidence is critical to ensuring and enhancing the role of spiritual care on the care team.

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