February 28, 2018
Standardized Methods of Education within Clinical Training for Chaplaincy
The Need for Evidence-Based Education
In recent years, professional chaplaincy has begun seeking to base itself on evidence-based practice in order to align with other health care disciplines and the current health care environment. According to Masic's definition, "Evidence-Based Medicine (EBM) represents integration of clinical expertise, patient’s values and best available evidence in process of decision making related to patients health care”.[i] Evidence-Based Practice (EBP), according to Satterfield “incorporates each discipline's most important advances and attempts to address remaining deficiencies”.[ii] In a study by Weng and colleagues on the implementation of evidence-based practice across medical, nursing, pharmacological and allied health professionals, they stated:
Evidence-based practice (EBP) is clinical practice consistent with the current best evidence. Implementation of EBP mainly involves four sequential steps first, framing a clear question based on a clinical problem; second, searching for relevant evidence in the literature; third, critically appraising the validity of contemporary research; and fourth, applying the findings to clinical decision-making. There are increasing examples illustrating that EBP can help healthcare professionals improve care quality. Implementing EBP by all health professionals is thus needed.”[iii]
One of the challenges of both evidence-based knowledge and evidence-based practice is teaching how to achieve the application of those skills in clinical care.[iv][v][vi] However, many health care disciplines including medicine, nursing, social work, nursing assistants[vii], and others are integrating evidence-based knowledge and practice into their standardized curriculums.
Evidence-based knowledge and practice are not new concepts for professional chaplaincy, but rather one that was first introduced in 1998: “Evidence from research needs to inform our pastoral care. To remove the evidence from pastoral care can create a ministry that is ineffective or possibly even harmful”.[viii] O’Connor defined evidence-based spiritual care as “the use of scientific evidence on spirituality to inform the decisions and interventions in the spiritual care of persons”[ix] and argued that chaplaincy and science are not opposed. A great deal of research has been done in the past twenty years to explore the practice and outcomes of chaplaincy to determine outcomes that have become the basis of evidence-based practice.
The Need for Standardized Training and Curriculum
However, what has been missing is the same focus to link evidence-based best practices to a standardized curriculum in the clinical and educational training of chaplains. In other words, while the profession is working to be evidence-based in its practice of chaplaincy, relying on reputable research to determine the best choices of care for persons, it has failed to apply the same process to the education and training of chaplains. This is despite 60 years of calls by chaplain educators, practitioners, leaders, and researchers across the profession to engage in dialogue regarding the standardization of education and training processes in preparation for certification and practice.
In the education world, there are specific definitions applied to the concept of knowledge.[x] Content knowledge is the body of knowledge and information that teachers teach and that students are expected to learn in a given content area; it includes the facts, concepts, theories, and principles that are taught and learned in specific academic courses rather than to related skills which are also learned in order to put content knowledge into practice.[xi] In all professions, particularly health care, there is a tension between content or theoretical knowledge (“know that”) and practice knowledge (“know-how”) [xii] in the quest to prepare students to provide effective, value-added, and quality care to patients and families. Health care disciplines, with the exception of chaplaincy, have integrated the two by not only acknowledging the tension but incorporating both kinds of knowledge into their education and credentialing processes.
Chaplaincy has very little research regarding its education processes. There has been no investigation or study of how many units of clinical training or what academic degrees have produced the best combination of content/theoretical and practice knowledge to make a competent chaplain. The efficacy or impact of religious endorsement, required by some chaplaincy certification associations, has not been examined. The elements of curriculum content taught in clinical training have not been investigated or examined to determine what topics are needed to provide competent chaplaincy care nor have efforts been made to standardize that curriculum. Meanwhile, other health care disciplines including medicine, nursing, social work, physical therapy, and others,[xiii] [xiv] [xv] [xvi] [xvii] have embraced standardized education, including evidence-based knowledge and practice
History of Chaplaincy Training and Education
For decades, chaplaincy training, or Clinical Pastoral Training (CPE) has relied primarily upon practice knowledge that focuses on the person of the chaplain, how he or she develops their “inner self”, and in turn how that self-growth impacts the ways in which chaplaincy care is provided. Content or theoretical knowledge - the facts, concepts, theories, and principles that are necessary to effective practice and patient benefit - have not been standardized or made consistent within the field and so cannot be standardized in chaplaincy training. [xviii]
The earliest call to “better measure the effectiveness of clinical pastoral training so we have more objective standards”[xix] came from Thomas in 1958. At that time the focus of CPE was in partnership with theological schools to train Christian ministers how to be more effective in parish ministry. Even then, “there were very different views of how and where clinical training should contribute to theological education and how the movement should be organized” according to Jernigan.[xx] In the early 1970s, Meiburg addressed the need for “greater precision in relating educational structures to instructional objectives.”[xxi] Aist continued to ask this question as he asked numerous questions:
“Do we emphasize the self-development of the student for general ministry? Or do we focus on the acquisition of specific competencies for ministry that might be utilized in specialized settings? Should our educational programs themselves have built-in closure points, or do the various types of certification offered by cognate groups offer a sufficient closing process? And what about the thorny issue of curriculum content? Not only how we teach, but what we teach.”
“Our subjective intuitions have by and large served us well in certification, but there is growing recognition of the need to make the process more objective and to more clearly specify the levels of knowledge and skill that the candidate must acquire.”[xxii]
In the eighties, as the effort to include CPE as an integral part of theological education diminished, the focus increased on training chaplains, supervisors, and lay leaders.[xxiii] As clinical pastoral education faced this shift in its historical purpose, supervisory educators such as Hilsman addressed the questions that were being asked.
“Supervisors and department directors are asking, ‘What competencies will need to be taught to both established and aspiring chaplains, and how will current training methods be altered to help them assimilate the new learning?’
“Two reasonable first steps in the process of preparing chaplains for integrated system spiritual care work will be 1) to acknowledge the need for new learnings, and (2) to identify competencies that promise to be useful in emerging health care structures.”[xxiv]
Fitchett and Gray found in 1994 that “CPE assessment focuses on curricular objectives, student learning outcomes, and individualized contracts for learning as the basis for training and evaluation. Traditionally CPE outcomes are evaluated qualitatively, using the personal testimony or subjective interpretation by CPE supervisors and students.”[xxv] This was confirmed by a study done by VandeCreek, Hover, and Gleason in 2001, in which they found that quantitative CPE outcomes relied predominantly on self-reported instruments.[xxvi]
By 2000, clinical training education had formally moved to discussions between the Association for Clinical Pastoral Education with other organizations concerned with professional chaplaincies, particularly the Association of Professional Chaplains and the National Association of Catholic Chaplains.[xxvii] This created a renewed dialogue regarding CPE as professional training and the implications for its education processes.
Ford and Tartaglia (2006) spoke to the development of standards for spiritual assessment, specific training in interdisciplinary care, and the emerging need for research education.[xxviii] By doing so, they clearly challenged the historical paradigm that focused solely on personal development in chaplaincy education to include and emphasize content knowledge in order to prepare chaplains to provide effective and quality care to patients and families.
Little[xxix] continued to question whether clinical training (CPE) was professional training for chaplaincy, with a profession being defined as “requiring specialized knowledge and often long and intensive academic preparation' and professionalism as 'the conduct, aims or qualities that characterize or mark a profession or professional person'” as described by Cornett.[xxx] To describe the two types of knowledge needed for competent practice and for these definitions, Little turned to Eraut, and while the terms differ from “practice and content/theoretical knowledge” used by Wintz, the descriptions are the same:
“There are two types of esoteric knowledge essential for competent professional practice. Eraut describes the first type as propositional knowledge that is the knowledge which underpins or enables professional action and belongs to the academic forum where the discourse is about facts, ideas, and theories. The second type is the practical knowledge, which is the practical know-how inherent in the action itself and cannot be separated from it, for example, knowing to play a musical instrument. This practical knowledge is more difficult to codify and assess than propositional knowledge because of its more 'intuitive' nature. However, Eraut believes that both types of knowledge are essentially the same, claiming that knowing how to use a theory or fact is the result of observing the outcome of its use. Furthermore, these two sets of knowledge are not completely exclusive of each other as students acquire practical knowledge during propositional learning and propositional knowledge during practical training.”[xxxi]
Little summarized the outcome of professional education as “a person who has competently mastered the necessary propositional and practical knowledge has formed a professional identity including the integration of the values of public service and autonomy and can be trusted to practice with integrity.”[xxxii] In relation to traditional clinical training (CPE), Little stated several issues which he believed needed to be addressed:
“The action/reflection method is excellent for understanding the pastoral interaction but does not necessarily facilitate the further development of the propositional knowledge base.”
“Trainees' presentations for supervision broadly determine the content of the CPE program curriculum rather than the curriculum determining the program content. This can mean that some areas of pastoral care do not present themselves in the actual course. This limitation of the action/reflection methodology restricts the ability to provide a well-rounded professional education curriculum.”
“CPE tends to leave trainees to gather this knowledge unsystematically through their experiences with patients and from other sources that can be erroneous. This is inadequate for professional education.”
“For a valid assessment, the certifying organization [and church authorities] need to define as unambiguously as possible the range of experience and the professional (propositional and practical) knowledge they require at the conclusion of training and set those requirements out as standards for achievement. In addition, standard methods of assessing those standards need elucidation.”
“Lacking standardization, there is no professionally acceptable common standard of competence.”
“Assessment of professional competence requires a system of grading.”[xxxiii]
Other professional clinical educators continued to raise the issue of historical clinical training as objective and lacking standardization. Jackson-Jordon and Moore (2010) suggested that BCCI (the certifying affiliate of the Association of Professional Chaplains) competencies be used as the basis for a CPE-based curriculum intentionally focused on the preparation for professional chaplaincy.[xxxiv] In 2012, sociologist Wendy Cadge[xxxv] suggested that future chaplaincy training not be organized on what were the existing platforms but rather learn from methods used by other professionals that demonstrate professional competency, propositional knowledge, and objective outcome-oriented clinical practice in order to standardize the quality of care that is provided.
In an article describing the use of standardized patients in order to enhance objectivity in the measurement of behavioral communication styles of students, Tartaglia and Dodd-McCue found that it was a valid method. In addition, their study emphasized “the merits of systematically evaluating interview behaviors by categories and sub-categories. The checklist evaluation allows for identification of major response categories as well as student utilization of sub-categories in the interview process. Reliance on self-report by CPE students, historically emphasized in pastoral training, is enhanced by an observer's relatively more objective assessments (and quantification) using the checklist categories.”[xxxvi]
Massey[xxxvii], in observing the need for transformation in chaplaincy training, stated in 2014 that “The process of training chaplains has changed little over several decades. More recently, some involved in healthcare chaplaincy have perceived that new models are needed in forming, training, and evaluating chaplains.” Describing the historical provision of spiritual care, he called for chaplaincy to “study itself to learn what measurable outcomes of its work can be found.” While acknowledging the importance of CPE in the early formation of persons for ministry, Massey suggested: “it may be ill-designed to deliver the techniques, skills, and advanced competencies needed to work in professional chaplaincy.” In addition, he pointed out that:
“As it is, the structure of CPE itself only delivers the same territory over and over again—and importantly, that territory is centered on personal formation, not on professional competence.”
“The standards governing what constitutes a unit of CPE are written intentionally broadly to leave plenty of room for differences of style and pedagogical philosophy.” “While the standards are helpfully broad, they do present in their simplicity a dichotomy of educational activity and clinical practice that is itself an unhelpful concept.” “No standards exist for what should constitute a residency, how many units of CPE it should include, or what measurable outcomes should accompany successful completion of a residency.”
“What is missing is specific training on techniques and procedures in the delivery of healthcare chaplaincy and the exploration of how specific techniques and practice patterns can deliver improved patient outcomes.” “A re-designed curriculum would surface the full inventory of chaplain-associated knowledge that would be imparted through a variety of pedagogical techniques. The successful student would master the body of propositional knowledge and be able to capably demonstrate this mastery. One could envision a healthcare chaplain competencies test through which a chaplain candidate would demonstrate mastery of this propositional knowledge of chaplaincy intended effects.”
Fitchett, Tartaglia, Massey and colleagues also questioned the relationship of clinical education training models to fulfilling the need to train towards professional competencies. A disconnect between clinical training and the competencies needed by professional chaplains was revealed by two 2015 studies of ACPE accredited residency program. In the first, less than half of recently accredited or re-accredited CPE residency programs specifically addressed the twenty-nine professional competencies assessed for certification as a board certified chaplain (BCC) by the Association of Professional Chaplains, one of several certifying professional associations. “At a time of growing recognition of the important role of chaplains in the care of patients and families, there are no consensus guidelines for how healthcare chaplains should be trained and no organization exercising oversight for the development of such guidelines.”[xxxviii]
In the second, it was found that only “only nineteen percent of those centers use an electronic medical record pastoral care documentation tool grounded in a published theoretical model. Combined with the apparent lack of consensus among the pastoral care organizations, these findings contribute to the current environment where chaplains often sit on the periphery of the dialogue between spirituality and healthcare.”[xxxix]
Tartaglia encouraged the exploration of a learning/training model for the education of health care chaplains. “As with any educational model, we would begin with the expected outcomes. What knowledge and skills need to be learned? What methods should be employed in imparting those learning outcomes? Then we would ask what structures would need to be put in place to maximize the opportunity for such learning.” “Adding another level of accreditation to [ACPE] programs that wish to train healthcare chaplains will require compromises in order to establish a standardized curriculum through joint effort among groups” (those that educate and those that certify).[xl]
While the concerns chaplaincy educators and practitioners have raised since 1958 have been framed in in different ways, the central issue has remained the same. Curriculum, training, and testing needs to be standardized in order to remove inconsistencies in the education and certification of professional chaplains. The lesson is clear from all other health care disciplines that when candidates are tested to measure a person’s comprehension of evidence-based content or theoretical knowledge of their field, pass objective observations of their ability to demonstrate it through practice knowledge, the person has met the requirements needed to practice in their field and will reliably provide quality care.[xli]
Attempts at Change throughout the Decades
The history [xlii][xliii][xliv][xlv][xlvi][xlvii] of educating, training, and certifying chaplains has a long and complicated history, which is too complex for this article, however it began as part of the education provided through Protestant Christian seminaries to white male students in the mid-1920s. In his history, Thorton [xlviii] described clinical pastoral education as providing practical training to complement the theological knowledge seminarians received in order to prepare them as pastors in ministry. Freeman elaborated by describing clinical pastoral education as developing “psychological education for professional functioning”. Several groups were established to provide educational training, each with their own style and curriculum. Four of those groups, after much debate, joined together to form the Association of Clinical Pastoral Education in 1967. However, other groups have continued to emerge to establish and provide training with various focuses on what was taught as well as methods, which has often resulted in discord, conflict, splits, and even lawsuits. Today there are dozens of organizations offering clinical pastoral education training. As a result, there is no one curriculum or educational process that is standardized across the profession.
The Current Development of Standardized Evidence-Based Chaplaincy Education and Training
After nearly sixty years of questioning and calls for dialogue by researchers, educators, and leaders between numerous chaplaincy education and certification bodies to resolve these issues which proved unsuccessful, the HealthCare Chaplaincy Network (HCCN) and its affiliate, the Spiritual Care Association (SCA) which was created in 2016, stepped up to integrate evidence-based best practice into the education and training of chaplains in more explicit ways. By exploring the research successful models of health care education across disciplines, the SCA patterned much of its structure to incorporate elements of the training of competent physicians, nurses, physician assistants, nurse practitioners, social workers, physical therapists, and other professional clinicians. In doing so, the historical appeals by leaders, researchers, and educators within professional chaplaincy that have spanned decades are finally being heard and responded to with evidence-based chaplaincy training and education.
HCCN, who has provided accredited clinical pastoral education (CPE) since 1972, has incorporated standardized curriculum into its education process. This addresses the need for chaplaincy to follow the example of other health care professions by creating a process that mirrors their more objective process to assure that a person has both the knowledge and clinical skills to delivery evidence-based quality process, structure, and outcomes for spiritual care.
The Spiritual Care Association (SCA), which certifies chaplains and provides ongoing education opportunities, developed a standardized clinical knowledge-based test as is required within other health care disciplines. The SCA Standardized Clinical Knowledge Test was developed, following the example of other health care professions, by using international subject matter experts, evidence-based knowledge gained through research, the input of senior chaplain leaders, and the most rigorous standards. The scoring is completely objective. The test has now been determined to have a high degree of reliability. The knowledge that is tested is outlined for the candidate ahead of time and is publicly available, thus allowing educators and candidates to fully prepare without any uncertainty about the content of the Standardized Clinical Knowledge Test. For example, questions in the test include health care ethics, basics of world religious/spiritual systems, and spiritual assessment models, grief concepts and processes, and effective communication skills in working with patients, families, and interdisciplinary team members.[xlviii] The test is easily altered so it can be updated regularly in order to integrate new knowledge and research as it is developed.
As part of the SCA certification and credentialing processes, the Clinical Knowledge test is coupled with a Simulated Patient Encounter. These encounters are scored against a list of objective observable behaviors also derived from evidence that are shared with the candidate in advance so he or she is aware of the professional elements being assessed. Simulated patients (SP) are extensively used in medical, nursing, pharmacy, other health discipline education and increasingly in CPE programs to allow students to practice and improve their clinical and conversational skills for an actual patient encounter.[xlix][l][li]
Presently, HCCN and SCA are the only chaplaincy organizations to develop, publically announce and make available a standardized curriculum that incorporates evidence-based knowledge and practice. They are also the only known organizations who have publically and personally invite other chaplaincy education and certification associations to participate in dialogue and collaboration around the work of developing a comprehensive standardized evidence-based method of chaplaincy training and education that will be used across all organizations. While many groups have joined into the discussion and are both implementing and contributing to the integration of the curriculum, there remain several groups that have refused to participate, and the lack of collaboration and communication continues to the detriment of providing consistent quality-based, value-added care to patients and families as well as health care staff.
For six decades, chaplaincy leaders, educators, and researchers have called for the examination of the profession’s process of education and training in preparation for certification within the profession including the incorporation of evidence-based knowledge and practice. While research into evidence-based outcomes for chaplaincy care began to occur, there was little effort to apply the same process to the training, education, and eventual certification of chaplains. In 2016, the Spiritual Care Association, which is founded on the call for evidence-based best practice throughout all elements of spiritual and chaplaincy care, patterned its structure and system to develop curriculum, clinical training, and a certification process which reflects that integration. Several chaplaincy education and certification association groups have joined the process, yet many have declined invitations to participate in the dialogue. The questions that have permeated the field of professional chaplaincy education and practice for six decades of how to standardize curriculum, as well as how to focus efforts of all to embrace collaboration rather than noncooperation and competition continues.
1. What educational themes throughout the sixty-year call to standardization within the training of professional chaplaincy are consistent? Which are not? Which are applicable to today’s health care environment?
2. What has been your experience of standardized curriculum throughout your own chaplaincy education?
3. What has been your experience of standardized curriculum education when you compare your knowledge and skills with those of chaplaincy colleagues?
4. Evidence-based knowledge and practice are integrated through all other health care disciplines. Why should it be integrated into professional chaplaincy? Why not?
5. In what ways do you practice evidence-based knowledge and practice in your chaplaincy work?
6. What specific steps would you take to encourage the chaplaincy community, including the various education, certification, and membership groups, to work collaboratively to establish standardized education for the chaplaincy profession?
Rev. Sue Wintz, BCC, is Director, Professional and Community Education at HealthCare Chaplaincy Network where she oversees the development, design, writing, and instruction of HCCN’s professional continuing education offerings. Sue has over 35 years of clinical, administrative, consulting, educational design, development and teaching experience in the provision of professional chaplaincy and spiritual care in health care and congregational settings including community hospitals, hospice, and academic medical centers. She has contributed to national multidisciplinary health care initiatives through participation on committees, as a consultant, a subject matter expert, and author. She is board certified by the Spiritual Care Association and the Association of Professional Chaplains. Sue is a past president of the Association of Professional Chaplains, and in 2013 was given APC’s highest honor – the Anton Boisen Professional Service Award.
Rev. Brian Hughes, BCC, is a chaplain advocate and consultant with HealthCare Chaplaincy Network (HCCN). He has worked clinically in New York, Texas, Arizona, and Pennsylvania, and served in leadership positions within the Association of Professional Chaplains. He has contributed to the writing of recent HCCN White Papers including Spiritual Care and Nursing: A Nurse's Contribution and Practice and Spiritual Care: What it Means, Why it Matters in Health Care. Brian also coordinates and presents the annual "Best Chaplaincy Papers" webinar each spring. He lives in Dallas, Texas, with his wife and two elementary-school-aged children.
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