The following is intended as an overview for persons preparing for the Standardized Clinical Knowledge Test as required for Advanced Practice Board Certification (APBCC), Board Certification (BCC) or Credentialing (CC) by the Spiritual Care Association. This guide can assist you in multiple ways, by providing you with:

• An outline of the topics within the Quality Indicators and Scope of Practice developed in 2016 by international, interdisciplinary panels of experts. These two documents served as the foundation of the evidence-based Standardized Clinical Knowledge Test
• A list of the learning objectives that generate the questions included in the Standardized Clinical Knowledge Test
• A description of areas to be knowledgeable about in preparation for the Standardized Clinical Knowledge Test
• Sample questions to become familiar with the format of the Standardized Clinical Knowledge Test (Note: these are not actual questions from the test) • A list of articles and resources to assist in preparation for the Standardized Clinical Knowledge Test

OVERALL PERSPECTIVE

For many years, chaplains have been allowed and even sometimes encouraged to develop their own style or process. Part of this came from the fact that there was no evidence for best practice in the field. That situation has fortunately changed. SCA and this test are focused, not on what you or I or your institution do or think, but on what the published guidelines, research and expert opinion in the field generally say should be done. This change brings us into alignment with other health care disciplines. As an example, while your institution for very good reasons may emphasize readmission rates their as primary quality metric, that metric is not considered a major driver of health care value and quality nationally. A review of the literature would support that. Likewise, some choices to some questions are close in content. However, all of them are clearly differentiated in the literature. The material in this document gives some direction on literature you should be familiar with before you take the test.

TEST PREPARATION COURSE

The Spiritual Care Association Learning Center has a full course available, Preparation for Standardized Clinical Knowledge Test, which provides more in-depth preparation, articles and resources to assist candidates in preparing for the Standardized Clinical Knowledge Test.

By the end of the course, the learner will be able to:

• Name the learning objectives used in the Standardized Clinical Knowledge Test
• Define evidence-based competency in chaplaincy practice, and provide examples
• Describe each of the Quality Indicators and the knowledge required to demonstrate an understanding of each
• Distinguish the competencies identified in the Scope of Practice, and articulate methods by which to integrate them into one’s professional practice
• Identify additional book and article resources and ways in which to locate them to increase one’s knowledge in preparation for the Standardized Clinical Knowledge Test

FOUNDATIONAL TEXTS

While many books can be useful as part of a chaplain’s education, the following are considered to be essential foundational texts that every chaplain should read, have in his or her library, and be able to discuss and integrate into his or her practice. For those desiring to complete the Standardized Clinical Knowledge Test for Board Certification or Credentialing, the texts below are invaluable:

• Making Health Care Whole. Puchalski C and Ferrell B. 2010. Templeton Press. ISBN-10: 159947350X
• Professional Spiritual & Pastoral Care: A Practical Clergy and Chaplain’s Handbook. Roberts, S. Ed. 2012. Skylight Paths Publishing. ISBN-10: 1594733120
• National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care, 4th Edition. Richmond, VA, National Coalition for Hospice and Palliative Care, 2018. https://www.nationalcoalitionpc.org/ncp. (Note: This is a free download)
• Hall, E., Hughes, B., Handzo, G. (2016) Spiritual Care: Why It Matters in Health Care. HealthCare Chaplaincy Network, New York, NY.
• Fitchett, G., White, K., Lyndes, K. (Eds). (2018) Evidence-Based Healthcare Chaplaincy: A Research Reader. Jessica Kingsley Publishers.

STANDARDIZED CLINICAL KNOWLEDGE TEST LEARNING OBJECTIVES

The questions in the Standardized Clinical Knowledge Test are developed from the following learning objectives. A test candidate may wish to focus specifically on those topics for which he or she wants to refresh his or her knowledge base or read more about unfamiliar concepts. (We have marked in red those learning objectives that apply only to Advanced Practice Board Certification – not BCC or CC.)

1. Articulate the role of spiritual, religious or existential support, practices, and cultural norms in coping, dying, grief, bereavement, and after death care of the body
2. Competently assist other people in correctly completing health care advance directives
3. Define and describe effective nonverbal communication practices and skills
4. Define and describe effective verbal communication practices and skills
5. Define and differentiate the following concepts: grief, mourning, bereavement, anticipatory grief, complicated grief, and disenfranchised grief
6. Define appropriate supportive responses to traumatic events so that patients, families and staff can manage the situation and respond appropriately
7. Demonstrate an understanding of the discipline’s scope of practice, the competencies required of his or her role and the discipline’s scope of practice
8. Demonstrate knowledge and understanding of the differences and methodologies of spiritual screening, spiritual history, and spiritual assessment
9. Demonstrate knowledge with one accepted model of spiritual assessment, and apply the model appropriately with patients and families within the required time frame of the setting
10. Demonstrate proficient knowledge of the different kinds of health care advance directives and the specific contexts in which each is applicable
11. Demonstrate sensitivities to the varied losses persons may experience, such as the loss of a parent, spouse/partner, child or sibling, as well as losses that may be disenfranchised by the larger community
12. Demonstrate the capacity for creating strategies for the Health Insurance Portability and Accountability Act (HIPAA) compliance for chaplains & Spiritual/Pastoral Care Departments (Advanced Practice Board Certified Chaplains Only)
13. Demonstrate an understanding of grief and bereavement theories and their application, including anticipatory, acute and traumatic grief
14. Demonstrate an understanding of the importance of documentation and the requirements of organizational and regulatory guidelines (Advanced Practice Board Certified Chaplains Only)
15. Describe the components of multidisciplinary teamwork and the contributions of chaplains
16. Describe the current best practices for integrating spiritual care, including the goals of spiritual care, current implementation models, and how they integrate with treatment plans (Advanced Practice Board Certified Chaplains Only)
17. Describe the role of the chaplain when ethical situations arise, including assessment, interventions, seeking consults, chaplain’s role on the ethics team, and documentation
18. Describe the steps in writing an implementation plan and obtaining buy in from the institutional administration (Advanced Practice Board Certified Chaplains Only)
19. Describe the theory, concepts and barriers to continuous quality improvement (CQI) in chaplaincy care, and why CQI is both a necessity and an imperative (Advanced Practice Board Certified Chaplains Only)
20. Describe why cultivating leadership is important
21. Distinguish between the importance of conducting conversations about health care values and wishes and the completion of health care advance directives
22. Effectively articulate the spiritual, religious, cultural, existential, emotional and social needs, resources, and risk factors assessed, as well as identify any needed referrals
23. Engage in self-awareness of and the ability to articulate one’s own cultural values, beliefs, assumptions and biases, and be able to set those aside in order to assess for persons’ beliefs and values, and provide interventions to patients and families
24. Gain basic knowledge of different cultural groups and common beliefs and practices
25. Gain basic knowledge of different religious traditions and common beliefs and practices
26. Gain understanding about interventions to respect and demonstrate the ability to create care plans that accurately incorporate the patient’s or surrogate’s stated beliefs, values, culture and preferences without inserting one’s own beliefs
27. Identify chaplaincy services that facilitate cultural, religious and spiritual observance by clients, families and staff
28. Identify how to secure information on faith tradition directives regarding medical interventions, such as termination of pregnancy; use of certain medications or ingredients; and provision, withholding or withdrawing of life-sustaining treatments
29. Identify methods to obtain and employ knowledge on unfamiliar cultures, religious/spiritual beliefs, or existential norms
30. Identify methods to provide a calm and calming presence to the interdisciplinary health care team in the midst of crisis and stress
31. Identify the issues of emotional and spiritual distress that are experienced by patients facing the end of life, articulate appropriate interventions, and demonstrate their application
32. Identify ways in which HIPAA is applied to protect patient privacy
33. Recognize and understand the physiological changes that occur during the dying process
34. Summarize steps involved in communication to enhance goal clarification
35. Understand and articulate the different spiritual, religious and existential beliefs about dying and death, and articulate the appropriate interventions
36. Understand and describe the concept and competencies of negotiation when working with patients, families and staff
37. Understand effective listening habits and skills, and a systematic method of listening behavior
38. Understand the legalities and applications of HIPAA for health care participants/patients
39. Understand the ways that grieving is experienced and expressed at varied points within the life cycle
40. Understand ways to assess and include in a care plan appropriate spiritual/religious interventions for cross-cultural situations, and include them in documentation in the medical record

LITERATURE

To locate articles, many health care settings have libraries available to staff that might include the journals that include these articles, and/or have resources that can locate sources for them. In addition, there are websites to become familiar with in order to do your own literature search for either a specific article or topic. Typing in the name of the article or topic into a web search engine will typically give you several options to find the full article or an abstract.

The following sites may also be helpful to test candidates:

• PubMed Central^® (PMC) is a free full-text archive of biomedical and life sciences journal literature at the U.S. National Institutes of Health’s National Library of Medicine (NIH/NLM). To access and save articles, free registration is required
• Medscape is the leading online global destination for physicians and health care professionals worldwide, offering the latest medical news and expert perspectives; essential point-of-care drug and disease information; and relevant professional education. To access articles, free registration is required
• Trip (Turning Research into Practice) searches across multiple internet sites for evidence-based content. It covers key medical journals, Cochrane Systematic reviews, clinical guidelines, and other highly relevant websites to help health professionals find high-quality clinical evidence for clinical practice. As well as research evidence, Trip allows clinicians to search across other content types, including images, videos, patient information, leaflets, educational courses, and news
• The Cochrane Library contains high-quality, independent evidence to inform health care decision-making. It includes reliable evidence from Cochrane systematic reviews and a registry of published clinical trials. The methodology used to create the Cochrane reviews is recognized as the gold standard for developing systematic reviews
• Research Gate was founded in 2008 by two physicians and a computer scientist to facilitate the sharing of articles and information, and engaging in collaboration among professionals. To access articles, free registration is required
• Open Access Online Journals are available from some publishers, including BMJ Open, PLOS Medicine, and Google Scholar

IN-DEPTH COURSES

Further preparation for the Standardized Clinical Knowledge Test may also be undertaken by finding courses and in-services with topics that the candidate may not be familiar and desires more study on. Universities offer both in-person and online courses for credit and to audit. In addition, webinars, conferences, and other educational events through health care-related professional associations or other providers may address topics of interest. Full courses are available at the Spiritual Care Association Learning Center for those who may wish to study more in-depth in certain competencies covered by the Standardized Clinical Knowledge Test. Click on each course title listed on the website for a more in-depth description of the course. Each course description in the Learning Center identifies each Quality Indicator foundational to the test that is addressed in the course.

I. Evidence-Based Practice in Health Care

It is essential for test candidates to have basic knowledge of what evidence-based health care is in order to understand the rationale behind evidence-based competency and the standardized clinical knowledge testing process as well as to improve their own chaplaincy practice.

Evidence-based practice (EBP) improves health care quality, reliability, and patient outcomes as well as reduces variations in care and costs. (Melnyk, et al. 2014). The most common definition of EBP is from Dr. David Sackett. EBP is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett D, 1996). It includes the conscientious, explicit and judicious use of current best evidence in making decisions regarding the care of individual patients. (Kang. 2016).

It is the professional responsibility of chaplains to apply the best scientific evidence for designing and implementing spiritual care assessments, interventions and outcomes into the spiritual components of care plans, and integrate the accessible research evidence into their decision making. (Duke University Medical Center Library. 2014).

The evidence-based process which leads to practices decisions is defined by its founders as a process that involves “the integration of best research evidence with clinical expertise and patient values” (Sackett et al. 2000). The evidence, by itself, does not make the decision, but it can help support the patient care process. The EBP process acknowledges the importance of both clinical expertise and client characteristics/values, along with the consideration of the best available evidence when making practice decisions. (Ruben and Parrish. 2011).

• Resource: Understanding Evidence-based Healthcare: A Foundation for Action. U.S. Cochrane Center. This module is designed for the consumer; however, it has a wealth of information that can serve as an introduction to aspects of the EBP process when an individual is a novice.

II. Evidence-Based Practice in Chaplaincy

Evidence-based practice (EBP) has been discussed at various times throughout the history of professional chaplaincy and has occasionally appeared in articles (O’Connor and Meakes. 1998; O’Connor 2002) and documents released by professional chaplaincy organizations (Association of Professional Chaplains. 2009.) However, there was little information about, resources for, or testing to establish how chaplains understood EBP and outcomes into their practice. Some studies indicated that some chaplains were uncertain about how EPB would enhance their practice (O’Connor. 2005), while others were simply resistant to learning about it and/or incorporating it. (Lewis. 2002).

In 2014, Chaplain Researcher George Fitchett and his colleagues undertook a study to examine chaplains’ attitudes and practices with respect to evidence-based chaplaincy care. The study data came from surveys of health care chaplains working in the Department of Veteran Affairs, the Department of Defense, and civilian settings. Chaplains from all three settings strongly endorsed an evidence-based approach to chaplaincy, although, interestingly, “a larger proportion of civilian chaplains were skeptical that chaplaincy care and chaplaincy outcomes could be measured.” Four moderate to major barriers were identified:

• Problems measuring outcomes relevant to chaplaincy
• Problems measuring chaplain care
• No existing evidence-based practice
• Individuality or uniqueness of patients

Fitchett and his colleagues identified several conclusions in their study, the most important of which was that all chaplains, in order to apply EBP “will be required to develop research literacy so they have the ability to critically examine and integrate the results of research into their professional practice” (Fitchett and Grossoehme. 2012). They also concluded that the findings of the study have implications for chaplain training and continuing education.

Reading: Evidence-Based Chaplaincy Care: Attitudes and Practices in Diverse Healthcare Chaplain Samples. Fitchett, Nieuwsma, et.al. 2014.

In 1998, Chaplain John Gleason argued that health care chaplaincy was entering a new paradigm as a “response to individual need” in light of changes in health care, including intentional models for spiritual assessment and attention to outcomes and research. Pay-for-performance (P4P) entered the U.S. health care payment system in 2005, providing financial incentives to hospitals, physicians, and other providers to improve the quality, efficiency, and overall value of care in order to achieve optimal outcomes for patients. Gleason identified strong implications for chaplains, including the need to identify more evidence-based practices. (Gleason. 2012).

In 2005, Gleason initiated An Ideal Intervention Paper project to consolidate the learnings of clinical pastoral education students, which were then collected over a period of seven years. (Gleason. 2013). The goal was to create a knowledge base for effectiveness research in order to identify replicated effective interventions to designate evidence-based best practices in spiritual care, and a pilot effectiveness study of samples was undertaken.

Reading: The Ideal Intervention Project Explained. Sharing Spiritual Care Knowledge for the Good of All. Gleason JJ. 2011. National Association of Catholic Chaplains Conference.

Numerous other chaplains have written articles contributing to the call for evidence-based chaplaincy practice. A test candidate can utilize the literature search information described earlier to find articles to add to one’s knowledge. Examples include:

• Outcomes for Professional Health Care Chaplaincy: An International Call to Action. Handzo G, Cobb M, Sinclair S, et al. 2014. Journal of Health Care Chaplaincy. 20:2. 43-53. DOI:10.1080/08854726.2014.902713
• Health Care Chaplaincy: A Scoping Review of the Evidence 2009–2014. Pesut B, Sinclair S, et al. 2016. Journal of Health Care Chaplaincy. 22(67-84). DOI: 10.1080/08854726.2015.1133185.

III. Quality Indicators and Scope of Practice

In developing the Standardized Clinical Knowledge Test, the foundational documents were the Quality Indicators and Scope of Practice published in 2016, which relate to the most comprehensive evidence-based information that demonstrates the quality and practice of spiritual care. The Quality Indicators and Scope of Practice were developed by two international, multidisciplinary panels of experts in the field that were convened by HealthCare Chaplaincy Network.

Numerous evidence-based professional articles from a variety of disciplines were utilized. This model allows for updates to the standardized knowledge testing, curriculum made available through the Spiritual Care Association Learning Center, and ultimately the Scope of Practice as research continues to identify best practices and evidence for the provision of expert spiritual care to individuals, families and staff.

Test candidates will want to download and become familiar with these three documents.

• What Is Quality Spiritual Care and How Do You Measure It?
• Guidance on Quality Indicators
• Scope of Practice

What Is Quality Spiritual Care in Health Care and How Do You Measure It? provides:

• Indicators of high-quality spiritual care
• The metrics that can measure those indicators
• Suggested evidence-based tools that can reliably qualify those metrics

The Scope of Practice document articulates the scope of practice that chaplains need to effectively and reliably produce quality spiritual care. It follows on the work of the evidence-based Quality Indicators document, establishing what chaplains or spiritual care professionals need to be doing to meet those indicators and establish evidence-based quality care.

The competencies within the Scope of Practice provide specific examples of what a professional chaplain’s knowledge base should be in order to provide the most effective care to meet the Quality Indicators.

IV. Structural Quality Indicators

Structural Indicators refer to the ways in which a health care organization and chaplaincy department ensure a framework is in place and followed in order to provide and promote quality spiritual care for patients/clients, families and staff.

Structural Indicator 1.A.

1.A. Quality Indicator: Certified or credentialed spiritual care professional(s) are provided proportionate to the size and complexity of the unit served and officially recognized as integrated/embedded members of the clinical staff. (Handzo G and Koenig. 2004; Wintz and Handzo 2005)

1.A. Metric: Institutional policy recognizes chaplains as official members of the clinical team.

1.A. Suggested Tool: Policy review

1.A. Competencies (from Scope of Practice. HCCN.2016)

1. The chaplain supports and advocates for the growth and integration of spiritual care within the organization to make spiritual care more accessible to clients, families and staff.
2. The chaplain performs an audit of spiritual care needs in the organization and produces a strategic plan to support the inclusion of spiritual care professionals.

• The chaplain is aware of and has a working knowledge of relevant health care policies (national and local), delivery plans, key drivers and levers for change, and understands why this is important for chaplaincy.

1. The chaplain is aware of the difference between management and leadership, and why cultivating leadership is significant.
2. The chaplain articulates his or her unique professional role as the spiritual care leader to other members of the team.
3. The chaplain articulates an understanding of the goals of spiritual care, current models to achieve them, and how they integrate with the treatment plans of the intradisciplinary team.

• The chaplain demonstrates an understanding of the competencies required of his or her role and the discipline’s scope of practice.
• The chaplain utilizes common medical, social and chaplaincy terminology
in order to communicate with other members of the team.

1. The chaplain utilizes a working knowledge of the key physical, psychological and social issues/principles in spiritual care sufficient to effectively communicate with other team members in a particular clinical setting.

Structural Indicator 1.A. What Do I Need to Know?

Test candidates need to be familiar with the best-practice knowledge and skills needed to advocate within a health care setting. This includes a wide range of issues as indicated in the competencies. A major mistake that many chaplains and their departments make is to plan their department’s program in isolation from other stakeholders within their organizational setting; however, the issues of planning, policies and procedures, regulatory guidelines, being a leader and advocate for spiritual care within the organization, how to work with both management and other members of the intradisiciplinary team, being able to articulate the goals of chaplaincy/spiritual care and how they integrate into treatment plans are essential whether one is a staff chaplain or a department director.

Reading: Intradisciplinary Spiritual Care for Seriously Ill and Dying Patients: A Collaborative Model. (Puchalski C, et. al. 2006)

Structural Indicator 1.A Sample Question

According to Puchalski’s 2006 model for intradisciplinary spiritual care, all professionals on the health care team participate in providing care to the patient. What two critical elements does she include in this model?

1. Communication and documentation
2. Intrinsic and extrinsic dimensions
3. Confidentiality regarding patient concerns and sensitivity to privacy
4. Prayer and sharing of the intradisciplinary member’s own beliefs

Correct answer: b. Source: Intradisciplinary Spiritual Care for Seriously Ill and Dying Patients: A Collaborative Model. (Puchalski C, et. al. 2006)

Structural Indicator 1.B.

1.B. Quality Indicator: Dedicated sacred space is available for meditation reflection and ritual. (The National Consensus Project for Quality Palliative Care. 2013)

1.B. Metric: Yes/No

1.B. Suggested Tools: N/A

Structural Indicator 1.B. Competency

The chaplain advocates effectively for the allocation and equipping of dedicated space for meditation, reflection and ritual, taking into account the particular cultural, ethnic and religious needs of the community.

Reading: Sacred Spaces in Public Places: Religious and Spiritual Plurality in Health Care. (Reimer-Kirkham, et al. 2012).

Structural Indicator 1.B. What Do I Need to Know?

Test candidates should understand the important elements to be taken into consideration when designing sacred space within their institutional setting, including steps to be taken to capture the demographics of the patient population cache to ensure representation of cultural, ethnic, religious, spiritual and existential beliefs and values.

Structural Indicator 1.B Sample Question

Sacred spaces within health care institutions need to:

1. Reflect the beliefs and values of the organization

1. Be open at all times for use by patients, families and staff
2. Reflect the religious, spiritual and existential beliefs of the patient population cache and staff
3. Provide religious literature for encouragement to those who use the space

Correct answer: c. Source: Sacred Spaces in Public Places: Religious and Spiritual Plurality in Health Care. (Reimer-Kirkham, et al. 2012).

Structural Indicator 1.C.

1 C. Quality Indicator: Information is provided about the availability of spiritual care services. (National Quality Forum. 2006).

1 C. Metric: Percentage of patients who said they were informed that spiritual care was available.

1 C. Suggested Tool: Client satisfaction survey

Structural Indicator 1.C. Competencies

1. The chaplain makes information on the range of spiritual care services in the organization available to staff, clients and families, and educates them on how to access those services.
2. The chaplain maintains links to local faith communities and belief groups, and makes this information available to staff, clients and families as requested.

• The chaplain identifies and makes available information and resources explaining spiritual needs and services to clients new to the organization.

1. The chaplain is able to provide information to clients and families about resources for communicating their care preferences to the medical team and assists in their completion as appropriate.

Structural Indicator 1.C. What Do I Need to Know?

Test candidates will need to have the knowledge required to communicate the availability and description of chaplaincy/spiritual care services within a health care setting, including what elements are important to be aware of and include in planning, execution and evaluation.

Reading: Relationship Between Chaplain Visits and Patient Satisfaction. (Marin D, et al. 2015).

Structural Indicator 1.C. Sample Question

One reason the availability of chaplaincy services is an important element for patients and families to be aware of is because studies demonstrate that:

1. Patient outcomes are more positive

1. Staff reports less stress
2. Patient satisfaction surveys can improve
3. Chaplains receive more referrals

Correct answer: c. Source: Relationship Between Chaplain Visits and Patient Satisfaction. (Marin D, et al. 2015).

Structural Indicator 1.D.

1. D. Quality Indicator: Professional education and development programs in spiritual care are developed for all disciplines on the team to improve their provision of generalist spiritual care. (Pulchaski C, Ferrell B, et.al. 2009)
2. D. Metric: All clinical staff receive regular spiritual care training appropriate to their scope of practice and to improve their practice
3. D. Suggested Tools: Lists of programs, number of attendees, and feedback forms

Structural Indicator 1.D. Competencies

1. The chaplain, in collaboration with educators from other professions, provides education in the practices and processes involved in spiritual care as provided by each member of the interprofessional team (e.g., for health care: physician, nurse, social worker, physical therapist, pharmacist, quality improvement) and introduces spiritual care. practices/processes into training for the other team professionals.
2. The chaplain participates with the interprofessional members of the health care team to modify, innovate and implement practices and processes for the provision, collaboration, communication, education, and quality improvement of spiritual care.

Structural Indicator 1.D. What Do I Need to Know?

Test candidates should have a knowledge of intradisciplinary teams, particularly the importance of the presence and functions of both generalist and specialist spiritual care providers. In addition, candidates should have knowledge of how chaplaincy fits into the intradisiciplinary team structure, communication within teams, and how to articulate the contributions of the chaplain as the spiritual care specialist.

Reading: Collaborating with Chaplains to Meet Spiritual Needs. (Grossoehme D and Jacobson A. 2006).

Structural Indicator 1.D. Sample Question

A key component of an intradisciplinary infrastructure to address patient spiritual needs is for spiritual care generalists to know:

1. When and how to refer to the chaplain as the spiritual care specialist

1. What hours a chaplain is available
2. The patient’s religious affiliation
3. Whether the patient wants to see a chaplain

Correct answer: a. Source: Collaborating with Chaplains to Meet Spiritual Needs. (Grossoehme D and Jacobson A. 2006).

Structural Indicator 1.E.

1.E. Quality Indicator: Spiritual care quality measures are reported regularly as part of the organization’s overall quality program and are used to improve practice. (Arthur J. 2011).

1.E. Metric: List of spiritual care quality measures reported

1.E. Suggested Tools: Audit of organizational quality data and improvement initiatives

Structural Indicator 1.E. Competencies

1. The chaplain integrates with any organizational quality team and supports the inclusion of relevant spiritual care outcome measures in organizational quality reports.
2. The chaplain identifies quality improvement processes, objectives and outcomes in spiritual care.

• The chaplain uses quality improvement data to refine spiritual care programs and services.

1. The chaplain is familiar with research processes and practice within spiritual care.
2. The chaplain accesses spiritual care journals and other expert sources of research data and best practices to apply to his or her work.
3. The chaplain engages in the discussion of research findings with other chaplaincy colleagues and the interdisciplinary team.

Structural Indicator 1.E. What Do I Need to Know?

Test candidates should possess the fundamental knowledge, processes and practices associated with quality improvement projects and the process for conducting research within and about professional chaplaincy.

Reading: An Invitation to Chaplaincy Research: Entering the Process. (HealthCare Chaplaincy Network. 2014.)

Structural Indicator 1.E. Sample Question

“Satisfaction with overall care” is an example of what component in research methodology?

1. Independent variable

1. Dependent variable
2. Control variable
3. Staff variable

Correct answer: b. Source: An Invitation to Chaplaincy Research: Entering the Process. (HealthCare Chaplaincy Network. 2014.)

V. Process Quality Indicators

Process indicators refer to actions undertaken by chaplains and the chaplaincy department as the second part of a framework consistently followed to provide and promote quality spiritual care for patients/clients, families and staff.

Process Indicator 2.A.

2. A. Quality Indicator: Specialist spiritual care is made available within a time frame appropriate to the nature of the referral. (Pulchaski C, Ferrell B, et.al. 2009.)
3. A. Metric: 1) Percentage of staff who made referrals to spiritual care and report that the referral was responded to in a timely manner, and 2) Percentage of referrals responded to within chaplaincy services guidelines.
4. A. Suggested Tools: 1) Survey of staff, and 2) Chaplaincy data reports

Process Indicator 2. A. Competency

The chaplain integrates effective and responsive spiritual care into the organization through policies and procedures, use of evidence-based assessment and documentation processes, and education of the interdisciplinary team about spiritual care.

Process Indicator 2. A. What Do I Need to Know?

Test candidates should have knowledge of the theories and evidence that provide effective foundational policies, procedures and processes to establish and integrate chaplaincy care throughout a health care organization.

Reading: Handzo G. The Process of Spiritual/Pastoral Care: A General Theory for Providing Spiritual/Pastoral Care Using Palliative Care as a Paradigm. In Roberts S (Ed). Professional Spiritual & Pastoral Care: A Practical Clergy and Chaplains Handbook. 2012.

Process Indicator 2. A. Sample Question

Chaplaincy protocols are based on:

1. Judgment by the chaplain on who needs to be seen

1. The level of spiritual distress identified in a spiritual screening
2. Specific medical orders or predetermined diagnoses, procedures or transitions
3. Availability due to staffing levels of the chaplaincy department

Correct answer: c. Source: Handzo G. The Process of Spiritual/Pastoral Care: A General Theory for Providing Spiritual/Pastoral Care Using Palliative Care as a Paradigm. In Roberts S (Ed). Professional Spiritual & Pastoral Care: A Practical Clergy and Chaplains Handbook. 2012.

Process Indicator 2.B.

2.B. Quality Indicator: All clients are offered the opportunity to have a discussion of religious/spiritual concerns. (Williams J, Meltzer D, et al. 2011.)

2.B. Metric: Percentage of clients who say they were offered a discussion of religious/spiritual concerns

2.B. Suggested Tool: Client survey

Process Indicator 2.B. Competencies

1. The chaplain supports and advocates for the establishment of timely and documented spiritual screening to discover and refer clients for discussion of religious/spiritual concerns.
2. The chaplain provides timely response to all referrals and facilitates discussions of religious/spiritual concerns.

Process Indicator 2.B. What Do I Need to Know?

Test candidates should have knowledge of the theories and evidence that provide effective foundational policies, procedures and processes to establish and integrate chaplaincy care throughout a health care organization.

Reading: Do You Want to See the Chaplain? Ensuring a Patient’s Right to Pastoral Care and Spiritual Services. (Carlson, J. 2002.)

Process Indicator 2.B Sample Question

Spiritual screening should NOT include the question:

1. Are you active in a faith community?

1. Do you want to see a chaplain?
2. Have you experienced a high level of stress regarding your current medical condition?
3. Do you have religious, spiritual or cultural practices that we can support you in during your stay?

Correct answer: c. Source: Carlson, J. Do You Want to See the Chaplain? Ensuring a Patient’s Right to Pastoral Care and Spiritual Services. 2002. Vision 12(5).

Process Indicator 2.C.

2. C. Quality Indicator: An assessment of religious, spiritual and existential concerns using a structured instrument is developed and documented, and the information obtained from the assessment is integrated into the overall care plan. (The National Consensus Project for Quality Palliative Care. 2018; Puchalski C, Ferrell B, et.al. 2009.)

2.C. Metric: Percentage of clients assessed using established tools such as FICA (Puchalski C and Romer A. 2000) Hope (Anadarajah G and Hight E. 2001), 7X7 (Fitchett G. 1993), or Outcome Oriented (VandeCreek L and Lucas A. 2001) models with a spiritual care plan as part of the overall plan of care

2.C. Suggested Tool: Chart review

Process Indicator 2.C. Competencies

1. The chaplain implements a process to define and give structure to goals of care, interventions, and care plans that can be articulated clearly according to the situation and applied appropriately and is able to modify them based on changes in the status of the client or situation.
2. The chaplain demonstrates a working knowledge of the methodologies of spiritual screening, spiritual history, and spiritual assessment that takes into account the diversity of the population served.

• The chaplain uses several published models for spiritual assessment, appropriately choosing and applying the model suitable for each specific situation, client and family.

1. The chaplain evaluates and executes new models of spiritual assessment that have been tested for effectiveness.
2. The chaplain respects and advocates for the development of plans of care that accurately incorporate the client’s or surrogate’s stated beliefs, values, culture and preferences without inserting the chaplain’s own beliefs.
3. The chaplain develops clear, concise and personalized spiritual care plans for clients and families based upon the assessment of spiritual, religious, existential and cultural beliefs, values, needs and practices, and integrates them into the client’s overall care plan.

• The chaplain collaborates effectively with clinicians from other disciplines to create and implement an interdisciplinary treatment plan.
• The chaplain makes follow-up visits to clients as indicated and informs the team of his or her findings.

1. The chaplain incorporates spiritual assessment and documentation into the discharge planning/continuity of care plan.
2. The chaplain integrates knowledge of specific community-based resources, such as hospice, home health, long-term care, counseling, and grief and bereavement services into discharge and continuity of care plans.
3. The chaplain understands the importance of documentation and the requirements of organizational and regulatory guidelines.

• The chaplain implements best practices for chaplaincy documentation, including documenting the spiritual, religious, cultural, existential, emotional and social needs, resources, and risk factors of clients and any needed referrals.

Process Indicator 2.C. What Do I Need to Know?

Test candidates should have not only a broad knowledge of chaplaincy practices as described in the competencies but also be able to demonstrate an understanding of the theory, evidence, and best practices that are central to every component of the provision of chaplaincy/spiritual care.

Reading: Improving the Quality of Spiritual Care as a Dimension of Palliative Care: the Report of the Consensus Conference. (Puchalski C, et al. 2009.)

Process Indicator 2.C. Sample Question

Which of the following is NOT true of spiritual screening?

1. It provides a quick determination of whether a person is experiencing a serious spiritual crisis.
2. It can be used by health professionals from any and all disciplines who are trained in its use.
3. It should be completed on every patient.
4. It is the primary tool to be used by a professional chaplain.

Correct answer: d. Source: Puchalski C, et al. Improving the Quality of Spiritual Care as a Dimension of Palliative Care: The Report of the Consensus Conference. 2009. Journal of Palliative Medicine.

Process Indicator 2.D.

2.D. Quality Indicator: Spiritual, religious and cultural practices are facilitated for clients, the people important to them, and staff. (The National Consensus Project for Quality Palliative Care. 2018).

2.D. Metric: Referrals for spiritual practice

2.D. Suggested Tool: Referral logs, including disposition of referrals

Process Indicator 2.D. Competencies

1. The chaplain understands the concepts of cultural competency and inclusion.
2. The chaplain can articulate his or her own cultural values, beliefs, assumptions and biases, and has the self-awareness to set those aside in order to provide spiritual care to clients and families from diverse backgrounds.

• The chaplain facilitates, provides and accommodates religious, spiritual and cultural events, rituals, celebrations and opportunities appropriate to the population served.

1. The chaplain provides client-centered, family-focused spiritual care that understands and respects diversity in all its dimensions and takes into account cultural and linguistic needs.
2. The chaplain integrates into his or her provision of care a basic knowledge of different religious and cultural groups, including common beliefs and practices related to health care.
3. The chaplain acquires knowledge of unfamiliar cultures, religious/spiritual beliefs, or existential norms as needed to provide appropriate care.

• The chaplain assesses, documents and includes in care plans appropriate spiritual/religious interventions for cross-cultural situations.
• The chaplain identifies and integrates into care the unique spiritual/religious/cultural beliefs within vulnerable client populations.

1. The chaplain creates partnerships with community religious and cultural leaders to enhance the cultural understanding of the care team and ensure effective support to the client/family.
2. The chaplain works collaboratively with the care team as a culture broker in identifying, recommending and integrating appropriate diversity concepts, needs and interventions into client/family care plans and organizational programs and policies.

Process Indicator 2.D. What Do I Need to Know?

Test candidates should have knowledge in cultural competence, inclusion, and vulnerable populations; the importance of diverse spiritual, religious, existential and cultural beliefs; assessment tools that explore, respond to, accommodate and document beliefs, values and practices; and the best practices to communicate their importance to other members of the interdisciplinary team.

Reading: Creating and Implementing a Spiritual/Pastoral Care Plan. Roberts S, et. al. In Roberts S (Ed). Professional Spiritual & Pastoral Care: A Practical Clergy and Chaplains Handbook. 2012.

Process Indicator 2.D Sample Question

The most important place for chaplains to include identified issues regarding religious, spiritual and existential practices is:

1. The chaplaincy department log book

1. A documented spiritual assessment
2. Their report to the bedside nurse
3. Intradisciplinary team meetings

Correct answer: b. Source: Creating and Implementing a Spiritual/Pastoral Care Plan. Roberts S, et. al. In Roberts S (Ed). Professional Spiritual & Pastoral Care: A Practical Clergy and Chaplains Handbook. 2012.

Process Indicator 2.E.

2.E. Quality Indicator: Families are offered the opportunity to discuss spiritual issues during goals of care conferences. (Ernecoff N, Curlin F, et.al. 2015)

2.E. Metric: Percentage of meeting reports in which it is noted that families are given the opportunity to discuss spiritual issues

2.E. Suggested Tool: Chart audit

Process Indicator 2.E. Competencies

1. Within the discipline’s scope of practice, the chaplain leads, guides or participates in goal clarification with clients, families and team.
2. The chaplain supports and advocates for clients and families in goal clarification and family meetings.

• The chaplain provides and models a leadership role within the spiritual care team when talking with families who identify significant religious, spiritual, existential and/or cultural issues in regard to care decisions.

1. The chaplain has a working knowledge of the ethical and moral challenges that may occur in relation to spiritual care, as well as the ethical principles of respect, justice, non- maleficence and beneficence.
2. Within the discipline’s scope of practice, the chaplain participates effectively in the process of ethical decision making, including with the ethics committee as appropriate to the setting, in such a way that theological, spiritual and cultural values are supported.
3. The chaplain secures and disseminates to the team information on faith tradition directives regarding the provision, withholding or withdrawing of medical treatments.

• The chaplain understands the benefits and burdens of specific medical interventions in clients with advanced illness, including nutrition and hydration, and the issues involved in physician-assisted death and terminal sedation.
• The chaplain understands the process to determine client decision-making capacity and government regulations regarding those designated to make decisions for the client.

Process Indicator 2.E. What Do I Need to Know?

Test candidates should possess knowledge regarding key spiritual, religious, existential and cultural beliefs, values and practices at the end of life as well as methods by which to identify those components, find resources, provide appropriate interventions, and identify outcomes in collaboration with the patient and family to improve their decision making. In addition, the candidate should have a knowledge of medical ethics, the understanding of various ethical issues from diverse beliefs and values, how ethics committees work in an interdisciplinary manner, and best practices for participating effectively in ethical decision making, family conferences, and interdisciplinary plan of care meetings.

Reading: Health Care Professionals’ Responses to Religious or Spiritual Statements by Surrogate Decision Makers During Goals-of-Care. (Ernecoff N, Curlin F, et.al. 2015).

Process Indicator 2.E Sample Question

Several studies have identified that goals of care conferences typically do not include discussion of religious or spiritual considerations. What major opportunity may health care professionals miss when these discussions are not held?

1. Hearing about patient and family end-of-life beliefs
2. Knowing what topics health care providers should avoid in conversations
3. Understanding how patients and families make medical decisions
4. Having information on what religious practices are important to the family

Correct answer: c. Source: Health Care Professionals’ Responses to Religious or Spiritual Statements by Surrogate Decision Makers During Goals-of-Care. (Ernecoff N, Curlin F, et.al. 2015).

Process Indicator 2.F.

2.F. Quality Indicator: Spiritual care is provided in a culturally and linguistically appropriate manner. (The National Consensus Project for Quality Palliative Care. 2013) Clients’ values and beliefs are integrated into plans of care. (Joint Commission Resources. 2010)

2.F. Metric: 1) Percentage of clients who say that they were provided care in a culturally and linguistically appropriate manner, and 2) Percentage of documented plans of care that mention client beliefs and values

2.F. Suggested Tools: Client survey, chart audit

Process Indicator 2.F. Competencies

The competencies for this Indicator are the same as the competencies for Indicator 2.D.

Process Indicator 2.F. What Do I Need to Know?

Test candidates should have the knowledge of cultural and linguistically appropriate ways in which to engage persons in discussions of beliefs and values and how to incorporate them into plans of care, including the core knowledge of regulations from government, accrediting and professional organizations that advocate and educate about the importance of these issues.

Reading: Cultural Humility Versus a Critical Distinction in Defining Physician Training Outcomes in Multicultural Education. (Tervalon, et al. 1998).

Process Indicator 2.F. Sample Question

Cultural humility differs from cultural competence in that:

1. Competence requires understanding cultural, nutritional and belief systems of patients and communities

1. Humility requires a life-long commitment
2. Humility includes the development of programs for specific populations
3. Competence requires continual self-evaluation

Correct answer: b. Source: Cultural Humility Versus a Critical Distinction in Defining Physician Training Outcomes in Multicultural Education. (Tervalon, et al. 1998).

Process Indicator 2.G.

2.G. Quality Indicator: End of life and bereavement care is provided as appropriate to the population served

2.G. Metric: Care plans for clients approaching end of life include document attention to end-of-life care. A documented plan for bereavement care after all deaths.

2.G. Suggested Tool: Chart audit

Process Indicator 2.G. Competencies

1. The chaplain identifies and integrates into care appropriate grief interventions for those at end of life and those who are grieving.
2. The chaplain effectively uses culturally appropriate, evidence-based strategies for communicating with clients and families regarding pain and suffering, loss, complicated and anticipatory grief, and life review.

Process Indicator 2.G. What Do I Need to Know?

Test candidates should have the knowledge of current theories of grief and bereavement, including processes and interventions to provide appropriate care to those experiencing it within their own belief and value system.

Reading: Cultural Humility and Compassionate Presence at the End of Life. (Austerlic S. 2009).

Process Indicator 2.G Sample Question

Health care providers, including chaplains, must become knowledgeable of their patients’ and families’ beliefs and values around end of life and bereavement and include them in the plan of care because principles, practices and procedures that are beneficial to one cultural group might be __________ to another.

1. Harmful
2. Unknown
3. Embarrassing
4. Misunderstood

Correct answer: a. Source: Cultural Humility and Compassionate Presence at the End of Life. (Austerlic S. 2009).

VI. Outcomes Quality Indicators

Outcomes are the desired difference that the chaplain’s contribution to the care of the patient/client, family and/or staff may help bring about. They are an observed and witnessed change in the person’s ability to cope and/or adapt; a measurable “turn-around” point or points. (VandeCreek and Lucas. 2001).

Outcome Indicator 3.A.

Quality Indicator: Clients’ spiritual needs are met. (Balboni, et.al. 2007)

Metric: Client-reported spiritual needs documented before and after spiritual care

Suggested Tools: Spiritual Needs Assessment Inventory for Patients (SNAP) (Sharma R, et al. 2012) and Spiritual Needs Questionnaire (SpNQ) (Bussing A, et al. 2010)

Outcome Indicator 3.B.

Quality Indicator: Spiritual care increases client satisfaction. (Marin et al. 2015)

Metric: Client-reported satisfaction documented before and after spiritual care

Suggested Tools: HCAHPS #21 (Giordano L, et al. 2009), and QSC (Daaleman T, et al. 2014)

Outcome Indicator 3.C.

Quality Indicator: Spiritual care reduces spiritual distress. (Snowdon A, et al. 2013)

Metric: Client-reported spiritual distress documented before and after spiritual care

Suggested Tool: “Are you experiencing spiritual pain right now?” (Mako, C et al. 2006)

Outcome Indicator 3.D.

Quality Indicator: Spiritual interventions increase client’’ sense of peace. (Snowdon A, et al. 2013).

Metric: Client-reported peace measure documented before and after spiritual care

Suggested Tools: Facit-SP-Peace Subscale (Peterman A, et al. 2002), and “Are You at Peace?” (Steinhauser K, et al. 2006)

Outcome Indicator 3.E.

Quality Indicator: Spiritual care facilitates meaning-making for clients and family members. (Flannelly K. et al. 2005)

Metric: Client-reported measure of meaning documented before and after spiritual care

Suggested Tools: Facit-SP-Meaning Subscale (Peterman A, et al. 2002,) and RCOPE (Pargament K, et al. 2000)

Outcome Indicator 3.F.

Quality Indicator: Spiritual care increases spiritual well-being. (Rabow M and Knish S. 2014)

Metric: Client-reported spiritual well-being documented before and after spiritual care

Suggested Tool: Facit-SP (Peterman A, et al. 2002)

3.A.-3.F. Outcomes Indicators Competencies

The competencies listed below were determined to apply to all of the outcomes for Indicators 3.A through 3.F, and, therefore, are listed as a group rather than repeating the same list for each competency.

1. The chaplain integrates theories from the behavioral sciences into spiritual care practice.
2. The chaplain integrates spiritual, existential and emotional concepts for clients and families in spiritual care, including faith, hope, forgiveness, meaning and remorse.

• The chaplain integrates a thorough knowledge of chaplaincy practice into interventions to support the client’s identified religious, spiritual, existential or cultural beliefs and values.

1. The chaplain utilizes evidence-based practices in spiritual care and chaplaincy to improve spiritual care service.
2. The chaplain understands and abides by the ethical standards of care giving in general and chaplaincy in particular.
3. The chaplain effectively uses best practice in communication, including listening habits and techniques.

• The chaplain effectively and appropriately uses supportive responses with clients who experience traumatic events so that they can manage the situation and respond appropriately.
• The chaplain utilizes evidence-based practices to help clients and families address their fears, as well as distress (spiritual and otherwise) related to chronic, serious, life-limiting illness, and/or end-of-life care.

Outcomes Indictors 3.A.-3.F. What Do I Need to Know?

Test candidates should have knowledge of the definition of outcomes in chaplaincy care, best practices, and processes by which to consistently demonstrate them in their own practice.

Reading: Spiritual Pain Among Patients with Advanced Cancer in Palliative Care. (Mako C, et al. 2006)

Outcome Indicators 3.A.-3.F. Sample Question

Spiritual distress or “spiritual pain” typically falls into three main categories:

1. Interpersonal, resilience, and relationship with God
2. Intrapsychic, theological and physical
3. Resilience, sense of peace, and meaning-making
4. Intrapsychic, interpersonal, and the divine

Correct answer: d. Source: Spiritual Pain Among Patients with Advanced Cancer in Palliative Care. (Mako C, et al. 2006)

VII. Helpful Additional Texts

Other books that will be helpful in building a test candidate’s knowledge base, and were drawn upon in the development of the standardized clinical knowledge test, include:

• 1001 Solution Focused Questions. Bannink F. 2010. Norton. ISBN-10: 0393706346
• An Invitation to Chaplaincy Research: Entering the Process. HealthCare Chaplaincy Network. 2014. http://bit.ly/29Nuroz
• Assessing Spiritual Needs: A Guide for Caregivers. Fitchett, G. 1993. Augsburg Fortress. ISBN-10: 078809940X
• Being Mortal: Medicine and What Matters in the End. Gawande A. 2014. Metropolitan Books. ISBN-10: 0805095152
• Communicating in Groups: Applications and Skills. Adams KL, Galanes GJ, and Brilhart JK. 2009. McGraw-Hill. ISBN-10: 0073523860
• Crucial Conversations: Tools for Resolving Broken Promises, Violated Expectations, and Bad Behavior. 2nd Edition. Patterson K and Grenny J. 2005. Gramedia Pustaka Utama. ISBN-10: 0071829318
• Dignity Therapy: Final Words for Final Days. Chochinov H. 2012. Oxford University Press. ISBN-10: 0195176219
• Disenfranchised Grief: New Directions, Challenges, and Strategies for Practice. Doka K. 2002. Research Press. ISBN-10: 0878224270
• Essentials of the U.S. Health Care System. 3rd Ed. 2012.Shi L and Singh D. Jones & Bartlett Learning. ISBN-10: 1284100553
• Family Therapy in Clinical Practice. Bowen M. 1985.: Rowman and Littlefield. ISBN-10: 1568210116
• Grief and Bereavement in Contemporary Society: Bridging Research and Practice. Neimeyer R, Harris D, Winokuer H, and Thorton G, Eds. 2011. Taylor and Frances. ISBN-10: 0415884810
• Grief Counseling and Grief Therapy. 4th Ed. Worden J. 2008.Springer. ISBN-10: 0826101208
• Hardwiring Excellence: Purpose Worthwhile Work Making a Difference. Studer Q. 2003. Fire Starter Publishing. ISBN-10: 0974998605
• Lean Six Sigma for Hospitals: Simple Steps to Fast, Affordable, Flawless Healthcare. Arthur, Jay. 2011 McGraw-Hill. ISBN-10: 0071753257
• Meaning Reconstruction and the Meaning of Loss. Neimeyer RA. 2001. American Psychological Association. ISBN-10: 1557987424
• Nonviolent Communication: A Language of Life: Life-Changing Tools for Healthy Relationships. Puddle Dancer Press. ISBN-10: 189200528X
• Oxford Textbook of Spirituality in Healthcare. Puchalski C and Rumbold B. Eds. 2012. Oxford University Press. ISBN-10: 0198717385
• Paging God; Religion in the Halls of Medicine. Cadge W. 2013. University of Chicago Press. ISBN-10: 0226922111
• Principles of Medical Ethics. 7th Edition. Beauchamp T and Childress J. 2008. Oxford University Press. ISBN-10: 0199924589
• Psychological First Aid: Field Operations Guide. 2nd Ed. National Child Traumatic Stress Network & National Center for Post-Traumatic Stress Disorder. http://bit.ly/2e3ESrR
• Rando T. Treatment of Complicated Mourning. 1993. Research Press. ISBN-10: 0878223290
• Stages of Faith: The Psychology of Human Development and the Quest for Meaning. Fowler JW. 1981. Harper and Row. ISBN-10: 0060628669
• The Art of Helping in the 21st Century. Carkhuff. RR. 2000. Human Resource Development. ISBN-10: 0874255309
• The Discipline for Pastoral Care Giving: Foundations for Outcome Oriented Chaplaincy. VandeCreek L and Lucas A, Eds. 2001. Haworth Press. ISBN-10: 0789013460
• The Health Care Handbook. 2nd Ed. Askins E and Moore N. 2014. Washington University. St. Louis, MO. ISBN-10: 0615650937
• The Minister as Diagnostician: Personal Problems in Pastoral Perspective. Pruyser P. 1976. The Westminster Press. ISBN-10: 0664241239
• The Psychology of Religion and Coping: Theory, Research, Practice. Pargament, K. I. 1997. New York: Guilford Press. ISBN-10: 1572306645
• The Structure of Scientific Revolutions: 50th Anniversary Edition. Kuhn, TS. 2012. University of Chicago Press. ISBN-10: 0226458121

VIII. References

This list of references includes not only the articles and books referenced in the full Spiritual Care Association Learning Center course Preparation for Standardized Clinical Knowledge Test, it also includes additional resources that may be helpful to the test candidate. All references have links to where the reference can be found, either available as full text or requested on the website or the candidate’s medical library if available.

1. Anandarajah, G., & Hight, E. (2001). Spirituality and medical practice. American family physician, 63(1), 81-88. PMID:11195773 http://bit.ly/2eSpdxa
2. Arthur J. (2011) Lean Six Sigma- Simple Steps to Fast, Affordable, Flawless Healthcare. New York: McGraw-Hill. ISBN-10: 007175325.
3. Ashley W. Counseling and Interventions. In Roberts S (Ed). Professional Spiritual & Pastoral Care: A Practical Clergy and Chaplains Handbook. 2012. ISBN-10: 1594733120. http://amzn.to/2f2bZgF
4. Askins E and Moore N. The Health Care Handbook. 2nd Ed. 2014. Washington University. St. Louis, MO. ISBN-10: 0615650937. http://amzn.to/2d5LBSe
5. Association of Professional Chaplains (APC). Standards of Practice for Professional Chaplains in Acute Care. 2009. http://bit.ly/1Uvhlff
6. Austerlic S. Cultural Humility and Compassionate Presence at the End of Life. 2009. Santa Clara University. http://bit.ly/2d9O12n
7. Balboni, T. A., Paulk, M. E., Balboni, M. J., Phelps, A. C., Loggers, E. T., Wright, A. A., … & Prigerson, H. G. (2010). Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death. Journal of Clinical Oncology, 28(3), 445-452. DOI: 10.1200/JCO.2009.24.8005. http://bit.ly/2esggt8
8. Balboni, et al. (2007). Religiousness and Spiritual Support Among Advanced Cancer Patients and Associations with End-of-Life Treatment Preferences and Quality of Life. Journal of Clinical Oncology, 25(5), 555-560. DOI: 10.1200/JCO.2006.07.9046. http://jco.ascopubs.org/content/25/5/555.full
9. Berlinger N. Ethics and Care of the Sick. In Roberts S (Ed). Professional Spiritual & Pastoral Care: A Practical Clergy and Chaplains Handbook. 2012. ISBN-10: 1594733120. http://amzn.to/2f2bZgF
10. Bredle J, et al. Spiritual Well-Being as a Component of Health-Related Quality of Life: The Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being Scale (FACIT-Sp). 2010. Religions. 2. 77-99. DOI: 10.3390/rel2010077. http://bit.ly/2esIHao
11. Brophy E. Improving the Patient Experience One Interaction at a Time. 2012. PlainViews. (9).11. HealthCare Chaplaincy Network. http://www.plainviews.org
12. Büssing A (1), Balzat HJ, Heusser P. (2010) Spiritual needs of patients with chronic pain diseases and cancer – validation of the spiritual needs questionnaire. Eur J Med Res. Jun 28;15(6):266-73. DOI: 10.1186/2047-783X-15-6-266. http://bit.ly/2dxBjpA
13. Byrne-Martelli S. Advocacy Tips for Chaplains. 2013. PlainViews.10(6). HealthCare Chaplaincy Network. http://www.plainviews.org
14. Canada A, Murphy P, Fitchett G, et al. A 3-Factor Model for the FACIT-Sp. 2008 Psycho-Oncology. 17. 908-916. DOI:10.1002/pon.1307. http://bit.ly/2e8bAVc
15. Carlson, J. Do You Want to See the Chaplain? Ensuring a Patient’s Right to Pastoral Care and Spiritual Services. 2002. Vision 12(5). http://bit.ly/2es4RXr
16. Center for Practical Bioethics. Resources about Ethics Committees: Their Purpose, Creation, and Operation. 2014. http://bit.ly/2epv798
17. Chi GC. The Role of Hope in Patients with Cancer. Oncol Nurs Forum. 2007;34. 415–424. 10.1188/07.ONF.415-424. http://bit.ly/2ewkLAQ
18. Choi P, Curlin F, Cox C. “The Patient is Dying, Please Call the Chaplain”: The Activities of Chaplains in One Medical Center’s Intensive Care Units.” 2015. J Pain Symptom Manage. 50(4). 501-6. DOI: 10.1016/j.jpainsymman.2015.05.003. http://bit.ly/2etIi4r
19. Psychological First Aid: Field Operations Guide. National Child Traumatic Stress Network & National Center for Post-Traumatic Stress Disorder. 19.Psychological First Aid: Field Operations Guide. http://bit.ly/2eORjJD
20. Clark P, Drain M, Malone M. Addressing Patients’ Emotional and Spiritual Needs. 2003. Jt Comm J Qual Saf. 29(12). 659-70. PMID:14679869. http://bit.ly/2ee4aBw
21. gov. HCAHPS: Patient’s Perspectives of Care Survey. 2014. Centers for Medicare & Medicaid Services. http://go.cms.gov/2cdIRiF
22. Community Tool Box. Chapter 8: Developing a Strategic Plan. 2016. http://bit.ly/2cEtmAS
23. Community Tool Box. Chapter 27: Understanding Culture, Social Organization, and Leadership to Enhance Engagement. Lee K. 2016. http://bit.ly/1KAea50
24. Corman J. Hospitals Revamp Chapels into Interfaith Meditation Rooms. Religion News Service. Huffington Post. 7/21/2010. http://huff.to/2dIJTrr
25. Cramer E and Allen M. Translating Spiritual Care in the Chaplain Profession. 2013. Journal of Pastoral Care and Counseling. 67(1):6. DOI: 10.1177/154230501306700106. http://bit.ly/2dEvj0W
26. Cultural Relevance in End-of-Life Care. Kagawa-Singer & Blackhall’s ABCD Cultural Assessment Model. http://bit.ly/2dRAzMV
27. Daaleman T, Reed D, et al. Development and Preliminary Testing of the Quality of Spiritual Care Scale. 2014. Journal of Pain and Symptom Management. 47(4). 793-800. DOI: http://dx.doi.org/10.1016/j.jpainsymman.2013.06.004. http://bit.ly/2dSbXp6
28. Dasitar J and Odden A. How do I Determine if My Patient has Decision-Making Capacity? 2011. The Hospitalist. August 2011. http://bit.ly/2eAtssh
29. Duke University Medical Center Library and the Health Sciences Library, University of North Carolina at Chapel Hill. Introduction to Evidence-Based Practice. 2014. http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036002
30. Ehman J. Spiritual Distress in Patients: A Guideline for Health Care Providers. 1998. http://bit.ly/2dXSCnG
31. Ernecoff, N, Curlin, F., Buddadhumaruk, P, White, D. Health Care Professionals’ Responses to Religious or Spiritual Statements by Surrogate Decision Makers During Goals-of-Care Discussions. JAMA Intern Med. 2015;175(10):1662-1669. Doi:10.1001/jamainternmed.2015.4124. http://bit.ly/2ecHst1
32. Evidence-Based Behavioral-Practice (EBBP). Introduction to Systematic Reviews and Searching for Evidence. http://bit.ly/2d9zbqX
33. Farokhzadian J, Nayeri ND, Borhani F, Zare MR. Nurse leaders’ Attitudes, Self-Efficacy and training Needs for Implementing Evidence-Based Practice: Is It Time for a Change toward Safe Care? British Journal of Medicine and Medical Research. 2015. 7(8):662-671. Doi:10.9734/BJMMR/2015/16487. http://bit.ly/2etIAIq
34. Fitchett, G. Assessing Spiritual Needs: A Guide for Caregivers. 1993. Augsburg Fortress. ISBN-10: 078809940X. http://amzn.to/2dw4yOj
35. Fitchett G. Wondering if it’s Time to Give Up: A Case Example of the 7×7 Model for Spiritual Assessment. 2009. Rush University Medical Center. Chicago, IL. http://bit.ly/2dWzFQk
36. Fitchett G and Grossoehnme D. Health Care Chaplaincy as a Research-Informed Profession. In Roberts S (Ed) Professional Spiritual and Pastoral Care: A Practical Clergy and Chaplains Handbook. 2012. SkyLight Paths Publishing. Woodstock, VT. ISBN-10: 1594733120. http://amzn.to/2f2bZgF
37. Fitchett G, Nieuwsma J, et al. 2014. Journal of Health Care Chaplaincy. 20 (4). Evidence-Based Chaplaincy Care: Attitudes and Practices in Diverse Healthcare Chaplain Samples. DOI: 10.1080/08854726.2014.949163. http://bit.ly/2d2zAIo
38. Fitchett G and Nolan S (Eds). Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy. 2015. Jessica Kingsley Publishers. ISBN-10: 1849059764. http://amzn.to/2ehUHgJ
39. Fitchett G and Murphy P. Evidence-Based Spiritual Care for Chaplains: Update and Prospects. 2015. http://bit.ly/2dmTUFA
40. Flannelly, K. J., Handzo, G. F., Weaver, A. J., & Smith, W. J. (2005b). A National Survey of Health Care Administrators’ Views on the Importance of Various Chaplain Roles. Journal of Pastoral Care & Counseling, 59(1-2), 87 – 96. PMID:15943148. http://bit.ly/2e9Z8Wh
41. Galek K, Vanderwerker L, et al. Topography of Referrals to Chaplains in the Metropolitan Chaplaincy Study. 2009. J Pastoral Care Counsel. 63(1-2). 6:1-13. PMID:20196354. http://bit.ly/2dcsMrQ
42. Georgetown University Health Center, National Center for Cultural Competence. Bridging the Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker Programs. 2004. http://bit.ly/2e7fS1h
43. Georgetown University Health Center, National Center for Cultural Competence. Sharing a Legacy of Caring Partnerships Between Health Care and Faith-Based Organizations. 2001. http://bit.ly/2eqJw0g
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