Original Article

American Journal of Hospice

& Palliative Medicine®
What Do Chaplains Do: The Views of Palliative 2019, Vol. 36(5) 396-401
ª The Author(s) 2018
Article reuse guidelines:
Care Physicians, Nurses, and Social Workers sagepub.com/journals-permissions
DOI: 10.1177/1049909118807123
journals.sagepub.com/home/ajh

Annelieke Damen, MA1 , Dirk Labuschagne, MDiv, MPH2,

Laura Fosler, RN, MS, FNP-BC, ACHPN3, Sean O’Mahony, MB, BCh, BAO4,
Stacie Levine, MD, FAAHPM5, and George Fitchett, DMin, PhD, BCC6

Abstract
It is well accepted that attention to spiritual concerns is a core dimension of palliative care. It is similarly well accepted that
chaplains are the spiritual care specialists who should address such concerns. However, what chaplains do when they provide care
for patients and families is often poorly understood by their palliative care colleagues. Having a clear understanding of what
chaplains do is important because it contributes to improved utilization of the spiritual care and other resources of the palliative
care team and thereby to better care for patients and families. The aim of this study was to describe what palliative care physicians,
nurses, and social workers understand about what chaplains do. Brief surveys were distributed to participants at 2 workshops for
palliative care professionals in 2016. The survey was completed by 110 participants. The majority reported that they understood
what chaplains do moderately well or very well. Thirty-three percent of the written comments about what chaplains do were very
general; 25% were more specific. Only a small proportion of the participants were aware that chaplains provide care for the team,
are involved in facilitating treatment decision-making, perform spiritual assessments, and bridge communication between the
patient/family/team/community. Based on our survey, palliative care colleagues appear to have a broad understanding of what
chaplains do but many may be unfamiliar with important contributions of chaplains to care for patients, families, and teams. These
findings point to the need for ongoing education of palliative teams about what chaplains do in palliative care.

Keywords
palliative care, spiritual care, chaplain, chaplaincy, spirituality

Introduction palliative care teams do not have a chaplain and this further
limits physicians, nurses, and social workers from learning
It is well accepted that attention to spiritual concerns is a core
about their contribution.18,20
dimension of palliative care.1,2 Research suggests that reli-
Some existing research on the understanding of what cha-
gion and spirituality are important to palliative patients3-6 and
plains do among pediatric physicians in large academic hospi-
integral to their coping with illness.7-9 Failure to meet spiri-
tals21 and physicians in pediatric palliative care programs22,23
tual needs is associated with patients reporting lower ratings
suggests that physicians see chaplains as part of the interdisci-
of quality and satisfaction with care,10 poor quality of life,4
plinary team, providing emotional and spiritual support to
and end-of-life despair.11 Support of spiritual needs on the
patients and families (especially around death), performing
other hand is associated with higher quality of life, greater
hospice utilization, less aggressive care, and lower costs at the
end of life.12,13
1
It is similarly well accepted that chaplains are the spiritual Care Ethics, University of Humanistic Studies, Utrecht, The Netherlands
2
care specialists on palliative care teams who should address School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
3
such concerns, based on a generalist-specialist model of care College of Nursing, Section of Palliative Medicine, Rush University Medical
Center, Chicago, IL, USA
in which nonchaplain clinicians provide general spiritual 4
Palliative Care, Rush University Medical Center, Chicago, IL, USA
care and refer to a chaplain for more extensive spiritual 5
University of Chicago Medicine, Chicago, IL, USA
support.14,15 Yet what exactly chaplains do when they provide 6
Religion, Health and Human Values, Rush University Medical Center, Chicago,
care for patients and families is often poorly understood by IL, USA
their palliative care colleagues.16 This is not surprising given
Corresponding Author:
the limited content that addresses spiritual concerns in under- Annelieke Damen, MA, University of Humanistic Studies, Kromme Nieuwe-
graduate and graduate-level medical and nursing curricula gracht 29, 3512 HD Utrecht, the Netherlands.
and even in palliative care specialty training. 17-19 Many Email: [email protected]
Damen et al 397

rituals, improving family–team communication about goals of Table 1. Sample Description.

care, and supporting team members. Although some of these
Current employment (N ¼ 110, n %)
physicians had positive assessments of chaplains’ contribu- Physician 46 41.8
tions, they also expressed concern about chaplains’ ability to Advanced practice nurse 21 19.1
provide care for people from diverse religious traditions, indi- Registered nurse 27 24.6
cating possible unfamiliarity with chaplains’ experience in pro- Social worker 16 14.6
viding interfaith care.21 Years worked in the profession (N ¼ 110, mean, SD) 20.0 11.8
Two studies point to differences in vocabulary between Years worked in palliative care (N ¼ 108, median,a IQR) 4 1.5-9.5
physicians and chaplains when describing what chaplains Survey distributed in meeting (N ¼ 110, n, %)
American Academy of Hospice and Palliative 58 52.7
do.21,23 Physicians describe the outcomes of chaplaincy care, Medicine preconference workshop
whereas chaplains emphasize the process of their care using Coleman Palliative Medicine Training Program 52 47.3
broad terms such as wholeness, presence, and healing. These
a
different vocabularies may compromise chaplains’ efforts to Years worked in palliative had a skewed distribution.
educate their professional colleagues about their role in caring
for palliative care patients and their families. Palliative Medicine Training Program26). The survey had 3
One study by Kim and colleagues reports intensive care unit parts. The first part asked participants to rank the questions
nurses’ perceptions of what chaplains do.24 This includes lis- “How well do you understand chaplains’ training and scope
tening, providing physical touch (hand-holding, hugging), of practice” and “How well do you feel you understand what
praying, counseling, and performing religious rituals. Nurses
chaplains do” on a scale of 1 to 4 (1 ¼ “I understand very well,”
also indicate that:
4 ¼ “I have no understanding”). The second part asked parti-
cipants to “Write down one, two, or three things that chaplains
. . . chaplains were particularly able to fulfill these supportive roles
because, paradoxically, while chaplains are ‘‘insiders’’ in that they
contribute in palliative care.” The third part asked several ques-
are members of the medical team, they are also viewed as tions about the participant’s background.
“outsiders” because of their unique position in the hospital. They For questions about understanding of chaplains’ training
are not responsible for making clinical decisions or dealing with and work, we report percentages and means for the sample as
the daily minutiae of caring for a patient. This allows them to serve a whole and within professional subgroups. To discern if scores
as a familiar, yet somewhat removed, source of comfort for between the professions differed significantly, we used the
patients and their families.24(p43) Kruskal-Wallis test.27 For the correlation between “How well
do you understand chaplains’ training and scope of practice”
Nurses expressed a wish for a better understanding of the and “How well do you feel you understand what chaplains do,”
chaplains’ role to eliminate barriers to requesting chaplaincy as well as the correlation between years in the profession and
services for patients, families, and the team.24 No study was years in palliative care, we used Spearman r.28
found that focused exclusively on social workers’ perceptions of For the qualitative analysis of the descriptions of what cha-
chaplains. Social workers were included in one small study of plains do, we began with a sample of comments from 40 parti-
the palliative care teams’ understanding of what chaplains do.25 cipants (20 physicians and 20 nurses). Two authors (A.D. and
The team members named support with spiritual/religious cop- G.F.) examined these comments and developed an initial code-
ing, holistic care, addressing spiritual needs, assisting in advance book for the major themes in the comments. Four authors
care planning, support for families and leading family meetings, (A.D., G.F., L.F., and S.O’M.) subsequently coded the com-
and support for the team as main activities of the chaplain. ments from this subsample and proposed changes and additions
Having a clear understanding of what chaplains do is impor- to the initial codebook. Two authors (A.D. and D.L.) used the
tant because it contributes to improved utilization of resources revised thematic codebook to code the comments of all the
of the palliative care team and thereby better care, including participants; they consulted GF in case of disagreement.
spiritual care, for palliative care patients and their loved ones.
The aim of this study was therefore to describe what palliative
care physicians, nurses, and social workers understand about
what chaplains do. Results
The survey was completed by 120 participants. For 6 of the
participants, profession was missing and 4 participants came
Method from other professions (one each), so we decided to exclude
Brief surveys were distributed to participants at 2 workshops these 10 questionnaires from the sample, leaving a sample of
for palliative care professionals in 2016 (a preconference work- 110 participants. The characteristics of the participants are
shop about addressing spiritual issues in palliative care at the shown in Table 1. The sample consisted of almost equal pro-
annual meeting of the American Association for Hospice and portions of physicians (42%) and nurses (44%, with approxi-
Palliative Medicine and a session on spiritual care at a 2-day mately half of those now practicing as advanced practice
multiprofessional conference that was part of the Coleman nurses) as well as some social workers (15%). Many had been
398 American Journal of Hospice & Palliative Medicine® 36(5)

Table 2. Participants’ Self-Rating of Understanding Chaplains’ Training and Work.

Understanding of Chaplains’ Training and Scope of

Practice (%)a Understanding of What Chaplains Do (%)b

1¼ 2¼ 1¼ 2¼
Very Moderately 3 ¼ 4 ¼ No Very Moderately 3 ¼ 4 ¼ No
Professional group Mean, SD Well Well Slightly Understanding Mean, SD Well Well Slightly Understanding

Physician 2.20, 0.81 21.7 39.1 37.0 2.2 2.02, 0.65 17.4 65.2 15.2 2.2
Nurse practitioner/ 2.19, 0.75 19.1 42.9 38.1 0 1.86, 0.57 23.8 66.7 9.5 0
advanced nurse
practitioner
Registered nurse 2.07, 0.68 18.5 55.7 25.9 0 1.85, 0.46 18.5 77.8 3.7 0
Social worker 1.88, 0.72 31.3 50.0 18.8 0 1.69, 0.60 37.5 56.3 6.3 0
Total 2.12, 0.75 21.8 45.6 31.8 0.9 1.90, 0.59 21.8 67.3 10.0 0.9
a
The Kruskal-Wallis test for differences for understanding of training between the professions was nonsignificant, w2 ¼ 2.48, df ¼ 3; P > .05.
b
The Kruskal-Wallis test for differences for understanding of work between the professions was nonsignificant, w2 ¼ 3.99, df ¼ 3; P > .05.

Table 3. Association of the Understanding of Chaplains’ Training and Work to Years in the Profession and in Palliative Care.

Understanding of Chaplains’ Training Understanding of What

Survey question and Scope of Practice, Spearman r; P Chaplains Do, Spearman r; P

Understanding what chaplains do 0.76; <.001

Years in the profession 0.20; <.05 0.26; <.05
Years in palliative care 0.37; <.001 0.39; <.001

Table 4. Types of Comments: Total and by Professional Group.

Total MD APN RN SW
Type of Comment (N ¼ 110) (n ¼ 46) (n ¼ 21) (n ¼ 27) (n ¼ 16)

General support, listening, provide space 33% 32% 32% 34% 38%
Support for specific concern 25% 27% 29% 18% 24%
Team focused: support, renewal, educate 12% 14% 13% 10% 7%
Involvement in decision-making, family meetings, ACP þ AD 9% 4% 13% 8% 16%
Spiritual assessment and spiritual history taking 8% 9% 9% 7% 5%
Provide rituals, prayer 7% 6% 1% 16% 7%
Bridge communication and conflict between patient/family þ team 4% 7% 0% 4% 0%
Bridge communication between team/hospital þ patient/family local religious leaders/ 2% 1% 1% 4% 3%
community

in their respective professions for 2 decades but had only as well as comments about chaplains’ performing spiritual
worked in palliative care for less than 5 years. assessments (8%). Nine percent of the comments described
The majority of the participants reported that they under- chaplains’ involvement in goals of care and advance care
stood what chaplains do moderately well or very well; their planning conversations (private conversations about these
self-rated understanding of chaplains’ training and scope of topics with patients and families as well as conversation that
practice was slightly lower overall (see Table 2). The 2 ratings were part of team meetings with families). Some comments
were strongly correlated (r ¼ 0.76; P < .001). There were slight noted chaplains’ assistance in facilitating communication
differences in the self-rated understanding of chaplains by pro- when there was conflict between patients and families and
fessional group, but these were not statistically significant. the team (4%). Although an important part of chaplain care
Years in one’s profession, and especially years in palliative includes offering prayer and leading other religious rituals, we
care, were associated with greater self-reported understanding found it interesting that only a small proportion of the com-
of chaplains (see Table 3). ments mentioned these stereotypical activities (7%). These
It was somewhat difficult to evaluate the participants’ grasp comments notwithstanding, the largest proportion of the com-
of what chaplains do from their written descriptions. There ments (33%) were very general statements about chaplains
were many comments about specific ways in which chaplains listening or providing support to palliative care patients, fam-
provide support for palliative care patients and families (25%), ilies, or team members. Table 4 shows the major categories
Damen et al 399

Table 5. Examples of Participants’ Descriptions of Chaplain Activities.

Type of Comment Exemplary Quotation

General support, listening, provide space Provide spiritual support to patients, families and staff
Support for specific concern Addressing meaning/purpose/existential suffering
Team focused: support, renewal, educate Discussions with staff about spiritual distress and staff support
Involvement in decision-making, family meetings, ACP þ AD Provide a reflective supportive healthy space to support difficult medical decision
Spiritual assessment and spiritual history taking Robust spiritual assessments using a language consistent with patients’ needs
Bridge communication and conflict between They are often an immediate consult for our miracle thinking families and are
patient/family þ team able to be supportive and explore deeper the miracle context of their beliefs
and inform the health-care team
Bridge communication between team/hospital þ patient/ Liaison between patients and the health-care team (help translate “doctor
family local religious leaders/community speak”)

for participants’ descriptions of what chaplains do. Table 5 participating in trans- or interdisciplinary palliative care curri-
has examples of participants’ descriptions of chaplain culums, 35,36 by pairing medical residents with chaplain
activities. interns37 or inviting medical residents to shadow chaplains,25,38
by quality documentation of patient encounters in the patient’s
record, and through daily presence in team meetings.25 Sharing
Discussion case studies of chaplain care can also be effective.32,39-41
The majority of the palliative care physicians, nurses, and Furthermore, chaplains need to be more articulate about the
social workers in this study report understanding of what work that they do. An important step in this direction is the
chaplains do moderately well or very well, with slightly lower recent development of a taxonomy of chaplain activities in
self-rated understanding of chaplains’ training and scope of palliative care.33 The taxonomy was the result of a multistage
practice. Years in the profession and especially years in pallia- research process that included a literature review, chart
tive care are associated with greater understanding. At the same reviews, focus groups, concept mapping, and reliability testing.
time, one-third of the participants’ comments are very general The resulting list offers the possibility of a standardized
statements of what chaplains do. They vary from very short to description of chaplain activities, an important new develop-
longer unspecified answers about chaplains listening or provid- ment for the profession.
ing support to palliative care patients, families, or team mem- This study has a number of limitations. The sample is a
bers. For example, a short comment was “Counseling,” a convenience sample of workshop participants and therefore
longer comment was “Providing spiritual care at all phases of unrepresentative of palliative care teams in general. Moreover,
life.” Comments that include more detail named specific ways the brief survey did not include demographic information about
in which chaplains support palliative care patients and families the participants (gender, race, age), their place of work, their
(eg, “Help patients/families find meaning at the end of life”) education about spiritual issues in palliative care, and experi-
report that chaplains perform spiritual assessments, are ence of working with a chaplain. Future research should there-
involved in goals of care and advance care planning conversa- fore focus on a more rigorous study of what proportion of
tions, offer prayer and lead religious rituals, and assist in facil- palliative care professionals have an effective understanding
itating communication when there is conflict between patients of what chaplains do and the factors that contribute to that
and families and the team. understanding. It is widely recognized that spiritual care is an
Key activities described by our participants are broadly important component of palliative care. Chaplains are making
similar to the findings of prior studies,21-25 as well as to a important contributions addressing the spiritual needs of pal-
small body of evidence of key chaplain activities in palliative liative care patients and their loved ones. Our findings suggest
care29-32 and to chaplain care in general.33 Based on this broad palliative care colleagues appear to broadly understand what
similarity, the participants’ self-rating of understanding what chaplains do, but continued education will enhance their under-
chaplains do moderately well or very well seems appropriate. standing of and collaboration with the spiritual care specialists
However, as we have seen, a substantial proportion of the on their team.
comments missed some important chaplain activities in their
descriptions. Respondents seem to be less aware of chaplain
Declaration of Conflicting Interests
activities as for example conflict resolution29 or facilitating
The authors declared no potential conflicts of interest with respect to
goals of care conversations.30,34 Further education of palliative
the research, authorship, and/or publication of this article.
care teams about chaplain care appears warranted. Chaplains
also need to accept that an integral part of their job is educating
their health-care colleagues about what they do and how they Funding
contribute to good outcomes for patients, families, and the The authors received no financial support for the research, authorship,
team. Effective ways to educate colleagues include and/or publication of this article.
400 American Journal of Hospice & Palliative Medicine® 36(5)

ORCID iD 15. Puchalski CM, Vitillo R, Hull SK, Reller N. Improving the
Annelieke Damen https://orcid.org/0000-0001-6626-2116 spiritual dimension of whole person care: reaching national and
international consensus. J Palliat Med. 2014;17(6):642-656.
16. Cunningham C, Panda M, Lambert J, Daniel G, DeMars K.
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