Screening for spiritual distress in the oncology inpatient: a quality improvement pilot project between nurses and chaplains

Measuring the impact of a pastoral care intervention to increase referrals and improve the quality of chaplain documentation in patient records

The complexity of patient care demands that health care teams collaborate effectively. This means that when pastoral care staff engage with patients, they need to communicate their findings to other members of the multidisciplinary team to maximize patient benefits. In 2016, an Australian hospital found that pastoral care staff were able to visit only 30% of admitted patients, and that documentation of pastoral care visits was minimal. This paper describes and measures the impact of a quality improvement education program for pastoral care workers by auditing patient medical records pre- and post-intervention. The intervention did not significantly increase the number of pastoral care visits or referrals. Documentation of pastoral care visits was significantly improved in terms of the detail provided. More work is required to standardize indications for pastoral care referral and templates for pastoral documentation in patient medical records.

Testing items to screen for religious or spiritual distress in adult outpatient cancer care

PURPOSE

The experience of cancer diagnosis and treatment is associated with significant stress. While religion and spirituality (R/S) can provide crucial support, many patients also experience R/S distress. Screening for distress has gained recognition, with tools evolving to address spiritual needs; however, existing screening measures have limitations. This study aims to validate screening items for R/S distress among cancer patients undergoing treatment, using a standardized chaplain assessment as a reference standard.

METHODS

The study involved adult cancer patients undergoing outpatient treatment at Rush Cancer Center. Procedures included researcher-administered screening questions and the ONC-5 spiritual assessment interview with a board-certified chaplain. Data included demographics, illness variables, and R/S measures. Eight single-item and two multi-item screening measures were evaluated against the ONC-5. Analysis entailed descriptive statistics and sensitivity/specificity determination.

RESULTS

Study participants (N = 71) were predominantly female (53.5%) with common cancers (breast, colon/rectum, and lung). R/S distress was evident in 19.7%. Single-item screeners exhibited sensitivities from 14 to 71% and specificities from 72 to 98%. The King 2-question combination showed 71% sensitivity and 63% specificity. The Rush protocol demonstrated 36% sensitivity and 88% specificity. Post hoc analyses of two-item combinations did not enhance sensitivity.

CONCLUSION

This study evaluated R/S distress screening items among outpatient cancer patients. The single-item screener asking whether participants' R/S provided all the strength and comfort needed now performed best with a sensitivity and specificity of 71% and 83%, respectively. Despite limitations, our findings underscore the importance of refining R/S distress screening tools in oncology care.

Translation of Evidence-Based Interventions Into Oncology Care Settings: An Integrative Review

BACKGROUND

Adoption of evidence remains slow, leading to variations in practices and quality of care. Examining evidence-based interventions implemented within oncology settings can guide knowledge translation efforts.

OBJECTIVE

This integrative review aimed to (1) identify topics implemented for oncology-related evidence-based practice (EBP) change; (2) describe frameworks, guidelines, and implementation strategies used to guide change; and (3) evaluate project quality.

METHODS

PubMed and CINAHL were searched to identify published practice change projects. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. Fifty articles met the inclusion criteria. Data were extracted; content analysis was conducted. The Quality Improvement Minimum Quality Criteria Set guided quality assessment.

RESULTS

Topics included infection control/prevention (n = 18), pain/palliative care (n = 13), psychosocial assessment (n = 11), and medication adherence (n = 8). Among the projects, Plan, Do, Study, Act (n = 8) and Lean Six Sigma (n = 6) frameworks were used most. Thirty-six projects identified guidelines that directed interventions. Multiple implementation strategies were reported in all articles with planning, education, and restructuring the most common. Reach, sustainability, and ability to be replicated were identified as quality gaps across projects.

CONCLUSION

The EBP topics that emerged are consistent with the oncology nursing priorities, including facilitating integration of EBP into practice. The studies identified used national guidelines and implementation strategies to move evidence into practice. Heterogeneity in measurement made synthesis of findings difficult across studies, although individual studies showed improvement in patient outcomes.

IMPLICATIONS FOR PRACTICE

Development of an interprofessional oncology consortium could facilitate a standardized approach to implementation of high-priority topics that target improved patient outcomes, harmonize measures, and accelerate translation of evidence into practice.

Using patient-reported religious/spiritual concerns to identify patients who accept chaplain interventions in an outpatient oncology setting

PURPOSE

The goals of this study were to (1) describe the prevalence and correlates of patient-reported religious/spiritual (R/S) needs in outpatient oncology patients and (2) estimate the associations of R/S concerns with acceptance of an R/S intervention offered by phone.

METHODS

This was a retrospective analysis of data collected from distress screenings and spiritual care interventions at an outpatient cancer center from March 1, 2017 to May 9, 2017. Patients (n = 1249) used a tablet to self-report the following R/S concerns: spiritual or religious concern, isolation, struggle to find hope/meaning in life, concern for family, fear of death, shame/guilt, and doubts about faith. Patients were also screened for anxiety, depression, and distress. A chaplain contacted patients that reported one or more R/S concerns to offer R/S interventions via telephone or in person.

RESULTS

Approximately one third (29.9%) of surveyed patients indicated at least one R/S need. Younger age, female gender, anxiety, depression, and distress were associated with indication of specific R/S concerns. Fear of death (OR 1.64 [1.02, 2.66], p = 0.043), struggle to find meaning/hope in life (OR 2.47 [1.39, 4.39], p = 0.002), and anxiety (p = 1.003) were associated with increased odds of intervention acceptance.

CONCLUSION

Effective screening practices are needed for chaplains to prioritize patients most in need. This exploratory study suggests that screening for struggle to find meaning/hope in life, fear of death, and anxiety will help chaplains identify patients who have R/S concerns and will likely accept R/S interventions. Developing effective telehealth practices like this is an important direction for the field.

Recent Progress in Chaplaincy-Related Research

In light of the continued growth of chaplaincy-related research this paper presents an overview of important findings. The review summarizes research in six broad areas: what chaplains do; the importance of religion and spiritual care to patients and families; the impact of chaplains' spiritual care on the patient experience; the impact of chaplain care on other patient outcomes; spiritual needs and chaplain care in palliative and end of life care; and chaplain care for staff colleagues. It concludes with a description of several innovative and important new studies of chaplain care and notes areas for future investigation.

Spiritual Well-Being in Hispanic and Non-Hispanic Survivors of Allogeneic Hematopoietic Stem Cell Transplantation

Research suggests that spiritual well-being positively contributes to quality of life during and following cancer treatment. This relationship has not been well-described in ethnically diverse survivors of allogeneic transplantation.  This study compares spiritual well-being and quality of life of Hispanic (n = 69) and non-Hispanic (n = 102) survivors. Hispanic participants were significantly younger and reported significantly greater spiritual well-being than non-Hispanic survivors. Survivors with higher spiritual well-being had significantly better quality of life. Meaning and Peace significantly predicted quality of life. Although Hispanic survivors report greater spiritual well-being, Meaning and Peace, irrespective of ethnicity, have a salutary effect on quality of life.

Spirituality and religion in oncology

Despite the difficulty in clearly defining and measuring spirituality, a growing literature describes its importance in oncology and survivorship. Religious/spiritual beliefs influence patients' decision-making with respect to both complementary therapies and aggressive care at the end of life. Measures of spirituality and spiritual well-being correlate with quality of life in cancer patients, cancer survivors, and caregivers. Spiritual needs, reflective of existential concerns in several domains, are a source of significant distress, and care for these needs has been correlated with better psychological and spiritual adjustment as well as with less aggressive care at the end of life. Studies show that while clinicians such as nurses and physicians regard some spiritual care as an appropriate aspect of their role, patients report that they provide it infrequently. Many clinicians report that their religious/spiritual beliefs influence their practice, and practices such as mindfulness have been shown to enhance clinician self-care and equanimity. Challenges remain in the areas of conceptualizing and measuring spirituality, developing and implementing training for spiritual care, and coordinating and partnering with chaplains and religious communities.

Testing the Validity of a Protocol to Screen for Spiritual Struggle among Parents of Children with Cystic Fibrosis

Spirituality is important to many Americans and is used to cope with adverse events. Some forms of spiritual coping are maladaptive or troubling, and are known as negative spiritual coping or spiritual struggle. These forms of spirituality are often associated with poorer physical and mental health outcomes. Thus, in clinical contexts there is a need to identify persons who may be experiencing spiritual struggle and, if indicated, offer spiritual care that may address that struggle. Twenty-two parents of children with cystic fibrosis (CF) completed semi-structured interviews and questionnaires exploring spirituality's role in their child's illness. Interviews included oral administration of a protocol to screen for spiritual struggle. The parents also completed the negative religious coping subscale of the Brief RCOPE, a commonly used measure of spiritual struggle. Descriptive statistics were obtained. The screening protocol identified 18% of the parents as potentially having spiritual struggle. Thirty-two percent had negative religious coping scores suggestive of spiritual struggle. Comparison of results with both measures found the screening protocol had good specificity (87%) but relatively low sensitivity (29%). Using either measure, indications of spiritual struggle were associated with higher levels of depressive symptoms. The screener's administration was acceptable and feasible. The low sensitivity may be due in part to differences between the focus of the screener and that of the negative religious coping subscale, which focuses on struggle with the Divine. Further work is needed to establish the best approach to screening for spiritual struggle.