Introduction

Hospital-based chaplaincy originated in the 1920s and focuses on the provision of spiritual care to inpatients (Ford & Tartaglia, 2006). This service improves patients’ and families’ satisfaction with their clinical care, increases patients’ perceived quality of life (Kirchoff et al., 2021), and improves mental and physical health outcomes (Berning et al., 2016). Chaplaincy visits also have the capacity to improve primary care patients’ overall well-being (Kevern & Hill, 2015), and chaplains may be uniquely equipped to support patients and families, provide assistance to medical staff, help with complex end-of-life scenarios (Timmons & Pujol, 2018), and advocate for the upholding of ethical standards (Carey & Medico, 2013).

Furthermore, it has been demonstrated that 83% of patients surveyed were interested in discussing religion and spirituality (McCord et al., 2004) and believe that adequate attention to their spiritual needs improves the patients’ experiences in the hospital. Yet, today, chaplains increasingly face pressure to define their roles and demonstrate their value in hospital settings (VandeCreek, 2010). It is imperative to identify which patients are most interested in and likely to benefit from chaplain visits in order to allocate limited chaplaincy resources effectively. The first step toward this aim is to understand which patient characteristics are associated with chaplain visits. Overall, there may be greater demand for the spiritual care services of chaplains in an inpatient rather than an outpatient setting (Rajaee & Patel, 2022); therefore, the current study focuses on patients’ primary reasons to be admitted to the hospital and their associations with chaplain visits, in addition to the characteristics of patients’ demographics that are associated with chaplain visits.

Previous studies revealed that a patient’s demographic background is likely to affect chaplain visits. One such factor is biological sex. Studies indicate that women are more likely to receive spiritual care (White et al., 2021) and that there may be greater chaplaincy utilization among women than men, although the latter finding was derived from small groups of patients (Stang, 2017). Another study based on 30,995 chaplain visits from 1994 to 1996 indicated that patients’ religious affiliation was also related to their chaplaincy visits (Handzo et al., 2008). Although a study suggested that a patient’s age seems to influence the number of spiritual concerns a cancer patient may possess (Winkelman et al., 2011), little is known about the relationships between a patient’s age and chaplain visits.

In addition to factors in their demographic background, patients are especially inclined to seek chaplaincy services during serious illness, during major decisions, and when searching for “personal strength and resilience” (Rajaee & Patel, 2022). Furthermore, medical status, such as pre-operative, end stage, and dying, was more likely to elicit religious/spiritual interventions, whereas rehabilitation or check-up were less likely to lead religious/spiritual interventions (Handzo et al., 2008).

A large survey of 1413 patients found that many respondents believed that information about their spiritual beliefs might alter both the treatment they received (62%) and the medical advice their physicians offered (66%). This belief is shared by medical professionals, as well, with 79% of ICU attendings and 89% of ICU nurses surveyed, affirming that they should address patients’ religious/spiritual needs. Despite this, 86% of attendings and 74% of nurses surveyed did not regularly cover these topics with patients (Choi et al., 2019). Another study of 136 physicians and nurses reports similar results and indicates that there is a high desire for increased education in spiritual care (82.4%) and a strong belief in the importance of spiritual care (70.6%) though most lacked training in the subject (64.7%), further indicating that while both patients and providers agree on the importance of spiritual care, physicians and nurses feel unable to meet the spiritual needs of patients (Farahani et. al, 2019). These findings suggest the need for physicians to collaborate with chaplains on patient care issues, a task most chaplains view as their duty according to a 2009 Australian study (Carey & Cohen 2009).

When chaplaincy visits do occur, a high proportion begin through nurse-initiated chaplain referrals (Handzo et al., 2008 and Galek et al., 2009), which may be attributable to nurses’ potential discomfort and/or unfamiliarity with addressing spiritual concerns directly (Connolly & Timmins, 2022). Thus, patients’ primary reasons to be admitted to the hospital (e.g., emergency), as well as reasons for chaplaincy visit (e.g., referral, self-harm support), should be taken into account. In sum, both patients’ demographics and their situational factors or primary reasons to be admitted to a hospital seem to affect chaplain visits and care. More studies that can provide empirical evidence of the relationships between patients’ characteristics and chaplain visits are expected to help spiritual care staff to identify “best practices” in their field (De Vries et al., 2008), especially as hospital structures are increasingly complex and driven by evidence-based data (Farahani et al., 2019).

This is a critical step because the effectiveness of spiritual care provided by chaplains is related to its potential to improve patient outcomes, including spiritual, mental, emotional, and physical health. In order to provide this care, however, chaplains must more carefully organize, structure, and document their activities, which not only allows for communication within the health-care team, but provides objective data for future quality improvement projects (Stewart et al., 2022). Given that most hospitals do not employ enough chaplains, limited resources make it challenging to provide services to all patients in need, and to respond to expectations established by physicians, nurses, and families. In order to identify the greatest areas of need, it is critical to evaluate patient records, ideally from a large hospital, to understand the specific factors influencing chaplaincy encounters with hospitalized patients.

The aim of this research is to investigate the associations between the demographic background of patients and chaplain visits as well as the primary reasons for patients to be admitted to the hospital and the number of chaplain visits by providing empirical evidence that would help healthcare professionals to improve spiritual care outreach and further understand which patients received inpatient spiritual care, why those visits occurred, and the characteristics of those visits. The current study first focuses on demographic factors such as patient age, gender, race, ethnicity, and religion. Second, we examine patients’ additional background information, such as type of admission, length of hospital stay, discharge location, and context of chaplaincy visit (e.g., bedside). Third, we investigate the reasons for chaplaincy visits (e.g., referral, self-harm support), and how those reasons are associated with the number of chaplain visits. The current study aims to provide a comprehensive picture of patients’ characteristics and chaplain visits.

Methods

A retrospective chart review of the spiritual care section of the electronic medical record (EMR) used at a large, Midwest suburban teaching hospital in the United States was conducted. Institutional Review Board (IRB) approval was obtained before beginning the study. Data from the EMR were provided by the study site’s information technology staff in a Microsoft Excel spreadsheet. Author KH scrubbed and formatted the data and assigned initial codes. The research team’s biostatistician then completed statistical analysis in the SAS statistical software suite. No manual chart review was performed.

Any patient aged 18 or older who was seen by a member of the hospital’s spiritual care team, including staff chaplains and Clinical Pastoral Education (CPE) residents, between March 2021 and May 2021, was eligible for inclusion in the study. Given that the purpose of the current study is to analyze the associations between patients’ characteristics and chaplain visits, other clinical services that are conducted by chaplains (e.g., family support, or paying a visit to patients who were unable to engage with chaplains) were not included in the current study. For example, even if a patient was present for the chaplain visit but unresponsive, near death, comatose, etc., their records were excluded from the current study because the patient was not considered to be “engaged” and was unable to interact with the chaplain. It is important to note that the study criteria did not exclude any group of patients based on diagnosis alone (e.g., patients with dementia or a stroke). Instead, patients were excluded on the basis of not being able to receive spiritual care for reasons such as being comatose, sleeping, or being unable to interact with the care being provided.

Data regarding patient demographics, background information, and the factors that are associated with chaplaincy visits were obtained from the EMR, de-identified, and analyzed with SAS analytics software. In order to avoid mixing different criteria or taxonomic codes that different hospitals may utilize and to protect data integrity, the current study was performed as a single-site study at a location in which all chaplains were systematically trained under standardized conditions in protocols related to charting spiritual care visit information. All chaplains at the study site received training regarding data input into the spiritual care template of the EMR using the same categories, a consistent conceptual schema for the spiritual care template, and other related topics through a standardized training curriculum.

During the study period, the study site spiritual care team was composed of 11 members, including 7 full/part-time staff chaplains, 3 CPE residents, and 1 contingent (PRN) chaplain. The 3 CPE residents completed 28.75% of all chaplaincy encounters. Some sacramental visits were provided by volunteer chaplains, who provided communion or other sacramental support at the hospital. The volunteers had their encounters recorded in the medical record by one of the staff chaplains.

Results

Out of 10,127 total patients, 1315 unique patients (12.99%) received chaplain visits between March 1, 2021 and May 31, 2021, totaling 2373 chaplain visits. In fact, chaplains attempted a grand total of 4141 total visits. Of this total, 2373 patients engaged. The remaining 1329 attempted visits were unsuccessful for various reasons, such as patients choosing not to engage, being asleep or unavailable, or due to a clinical presentation that made a chaplain visit not possible; thus, these were eliminated from the following analyses. In addition, 439 visits were also excluded because they were family-only visits, with no spiritual care provided to patients themselves (Fig. 1).

Fig. 1
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Patients seen by chaplains from March 2021–May 2021

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As shown in Table 1, the demographic characteristics of the patients who were seen by the spiritual care department largely mirror the characteristics of the overall patient population admitted to an Inpatient or Psychiatric patient class during the study period.

Table 1 Comparisons of the demographics of patients
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Overall, patients who were seen by chaplains were older than the general hospital patient population. Contrary to the studies suggesting the gender differences in usage of chaplain visits, the gender ratio did not vary between those who received chaplain visits and the broader hospital population. Regarding religious affiliation, 20.8% of the entire hospital population (n = 2057) reported that they are Catholic, whereas 28.4% of those who were seen by chaplains (n = 374) reported that they are Catholic. Similarly, 33.8% of the entire hospital population (n = 3336) reported that they are Christian, whereas 36.9% of those who were seen by chaplains (n = 485) reported that they are Christian. This discrepancy was mainly due to the larger ratio of patients who identified “None” as a religious preference, which accounted for 28.5% of all hospital admissions (n = 2810), whereas only 18.9% of those who were seen by chaplains reported “None” for their religious affiliation (Table 1, Fig. 2).

Fig. 2
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Religious affiliations of patients seen by chaplains

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Next, the total chaplain visits that occurred between March 1, 2021 and May 31, 2021 (n = 2373) were analyzed in relation to the patients’ background information. As shown in Table 2, patients seen by chaplains had an average length of stay of 10.19 days. This duration was longer, compared to the overall admitted inpatient population, who had an average length of stay of 5.0 days and median of 3 days. Approximately 70% of chaplain visits were emergent, followed by trauma and urgent. Regarding the discharge location, most went home, and then to a Skilled Nursing Facility (n = 175 or 7.4%). While Intensive Care only accounted for 6.0% of chaplain visits, the encounter rate of patients discharged from the ICU was one of the highest, as the chaplains encountered 35% of all patients discharged from one of the five adult ICU units (Table 2).

Table 2 Characteristics of chaplain encounters
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Although not included in the tables, 74.2% of the visits involved only patients, 16% involved one other support person present. There were a total of 196 encounters (8.1%) in which patients were accompanied by 2 or more support persons.

Characteristics of the chaplain visit and primary reasons (e.g., referral) for the visits were analyzed (Fig. 3). As seen in Table 3, the majority of visits were conducted at the patient’s bedside. Regarding the reasons for visit, the total frequencies exceeded the number of visits, as chaplains were able to select multiple reasons for their encounter. Table 3 shows that spiritual care consults were the most commonly reported reason for visit. In reality, the number of patient and family requests might have been higher than what is presented in Table 3. This is most likely because chaplain visits were coded as either a consult or referral, even though they may have begun as a patient and family request that was communicated as a consult or referral.

Fig. 3
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Spiritual care consults by reason for visit. “Other” includes daily visit, trauma, trauma follow-up, chaplain initiated, group, patient/family request, and advanced directive assistance

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Table 3 Context of chaplaincy visit, length of visit, and reason for visit (n = 2,373)
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Finally, the number of chaplain visits and its associations with admission type (emergent vs. non-emergent, and urgent vs. non-urgent) as well as two of the visiting reasons (self-harm support and referral) were tested using Chi-square statistics. As shown in Table 4, among the 1,315 unique patients who received chaplain visits, 937 (71%) received one chaplain visit, 185 (14%) patients received two chaplain visits, 61 (5%) received three visits, 39 (3%) received four visits and the remaining 93 (7%) received five or more visits. A Chi-square test indicated there were significant relationships between type of admission as emergent vs. non-emergent and number of visits (p = 0.0003). Specifically, as the number of visits increased, the ratio of visits provided to patients whose admission type was classified as emergent also increased (Table 4).

Table 4 Chaplain visit associations
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A similar trend was also observed for urgent admissions (p < 0.0001) (Table 4). As shown in Table 2, 70.6% of chaplain visits were associated with patients whose type of admission was “Emergent,” whereas only 7.7% of visits were associated with whose type of admission was “urgent.” Admission Type (ex. Emergent, urgent, trauma, elective, etc.) was determined by one of any of the following hospital departments: Registration, Transfer Center, Bed Management, or the Emergency Center. All patients that arrive through the Emergency Center or presenting with an acute illness are classified as emergent admissions. Direct admissions from a physician’s office are generally classified as urgent. Patients arriving with bodily injuries through the Emergency Center are given a Trauma admission type. The Chi-square results suggest that the more one of the chaplains visited the same patients, the more likely that they were admitted to the hospital as either emergent or urgent (Table 4).

Furthermore, a Chi-square test indicated that self-harm support encounters also showed a significant relationship with the number of visits (p < 0.0001). Of the 1,315 patients who received chaplain visits, 13.61% (n = 179) were due to self-harm support. As shown in Table 4, among 179 patients visited for self-harm support, 33 (18.43%) received 5 or more visits, as opposed to only 60 out of 1136 patients (5.28%) who received chaplain visits due to “other reasons,” such as “referral.” Chaplain visits as a result of a referral from the medical team showed a significant relationship with the number of visits (p < 0.0001) (Table 4).

Discussion

The current study provides empirical data about the associations between patient demographics and chaplain visits. Like most spiritual care departments, the current study site’s spiritual care department follows a triage protocol that prioritizes emergent needs such as arriving traumas, ICU transfers, CPR codes, and patient deaths. This study focused on encounters in which the patient was able to engage with the chaplain in order to identify the characteristics of patients’ demographics and background that are associated with chaplain visits. One potential area worth investigating is the chaplains’ workflow and referral process, and ways in which this contact efficiency might be improved. Additionally, this may highlight the need for increased communication within the patient’s entire care team. Some patients may not be receiving chaplaincy services simply because they are away for a medical test or procedure or were approached by a chaplain when they were being seen by their attending physician or other health-care professionals. As many spiritual care departments operate with limited staffing, it is imperative that chaplains are focusing on patients who are not only available, willing, and interested to receive chaplaincy support, but also focusing on patients with the greatest spiritual needs.

As stated above, 74.2% of the chaplain visits involved only patients, with the rest of the visits involving a family member or other individuals. That is, most of the spiritual care visits provided by the chaplaincy team included a patient only, perhaps due to patient choice or other factors such as COVID-19 visitor restrictions. In fact, it is important to note that the study period (March 2021–May 2021) was at the height of the COVID-19 pandemic, and therefore, hospital-enforced visitor restrictions are suspected to have adversely impacted availability of family presence, as such restrictions have been noted to be prevalent throughout the pandemic (Moss et al., 2021).

Unlike other studies suggesting that more female patients were visited by chaplains than male patients (White et al. 2021; Choi et al., 2015), the current study did not show robust gender differences between those who received chaplain visits and the overall hospital population. Those who received chaplain visits were largely Christian, white, and skewed toward an older age group (Tables 1 and 2). As the majority of patients encountered in this study would be considered to be part of the “Baby Boomer” generation (born 1946–1964) ("Pew Research Center, May 12, (2015), “America’s Changing Religious Landscape”), further education and attention to this cohort’s unique life-cycle emotional, spiritual, and relational needs is warranted. On the other hand, spiritual care teams may also desire to better understand and extend services to more diverse types of patients in order to meet the varied and multifaceted needs of a hospital’s entire patient population.

Current data indicated that most patients (71%) received a single chaplain visit during their hospitalization; however, those with emergent and urgent admissions received more visits over the course of their hospitalization. Future studies should investigate how qualities of spiritual care services evolve from a single visit to multiple visits and analyze the differences between an initial visit and subsequent follow-ups. Additionally, more research is needed to consider the potential impacts of various ways of organizing chaplaincy departments and determining which patients should be seen by inpatient spiritual care staff. Although various methods exist (e.g., rounding in particular units or floors, seeing patients based on referrals, or creating “priority” lists), each hospital will have to determine how to best allocate limited resources in light of their unique patient demographics (Morrison & Alvarez, 2019).

Overall, a wide variety of reasons brought chaplains to encounter patients. As presented in Table 3, many patient requests are communicated via consults and referrals, with referrals associated with the overall number of chaplain visits. Future studies should investigate the reasons underlying chaplaincy referrals with the intent of improving targeted chaplaincy efforts. Understanding which patients desire and/or are more likely to respond to chaplaincy visits may increase the effective and efficient delivery of chaplaincy services.

One area that the current study site’s spiritual care department has been engaged in its “Self-Harm Support” protocol, which accounts for the fourth most common reason for chaplain visits (14.6%, n = 347) (Table 3). This protocol is a department priority in which the chaplains identify all patients who have a positive suicide risk assessment or have otherwise been identified as having an elevated risk of suicidality or self-harm. The department surveys the hospital census through automated reports and proactively assigns a chaplain to approach each patient and offer to co-create a spiritual care plan. Chaplains and patients then work together to decide an appropriate schedule for any desired follow-up over the course of the patient’s hospitalization based on the patient’s psycho-spiritual needs.

Overall, our data reveal that patients with self-harm risks were visited more frequently (Table 4). The motivation and rationale for this protocol is the department’s recognition that patients with an elevated risk of suicidality often also experience debilitating spiritual distress, particularly in the domains of hope, meaning, purpose, and social connection (Kopacz, 2014; Spencer et al., 2012; Trevino et al., 2014; Van Orden et al., 2010). This finding is significant, especially since chaplains may be uniquely positioned to address patients’ psychosocial needs, either in a manner different from that of physicians, or in a way that addresses potential shortages of mental health professionals (Klitzman et. al., 2022). Other research, such as a paper published by Carey & Medico, indicates that further research into the role of chaplaincy care in mental health treatment may ultimately improve outcomes in this area of medicine (2013).

The Self-Harm Support Program (SHSP) has been a foundational pillar of the spiritual care department’s mission for the past several years, and the CPE program has developed a 6 h curriculum on suicidality and suicide intervention that is provided to each CPE cohort. The SHSP curriculum consists of 4 modules. The first module functions as the core module that covers the epidemiology of suicidality, notable theoretical frameworks of suicide, reviews contemporary evidenced-based treatments and therapeutic approaches and interventions, and surveys historical, religious, and cultural understandings of mental illness and suicidality. This introductory module in the SHSP curriculum utilizes several resource from the ‘Faith.Hope.Life’ campaign of the National Action Alliance for Suicide Prevention (https://theactionalliance.org/faith-hope-life) as well as several resources from the Substance Abuse and Mental Health Services Administration (https://www.samhsa.gov). The second module centers on small-group discussion and presents students with a variety of practical therapeutic strategies gleaned from the literature and leading scholar-clinicians for engaging persons living with suicidality. The third module rotates a feature documentary of either ‘The S Word’ (Klein, 2017), ‘The Wisdom of Trauma’ (Benazzo et al., 2021) or Medicating Normal’ (Cunningham et al., 2020), followed by a film debrief. The fourth module rotates between topics between cohorts, and previous topics have focused on adolescents and young adults, dual-diagnosis, trauma-informed care, and suicide bereavement, to name a few. Additionally, 3 of the chaplains and 1 CPE resident have completed the LivingWorks Applied Suicide Intervention Skills Training (ASIST©) program (https://www.livingworks.net/asist). Due to this strategic emphasis, the percentage of patients with psychiatric class admission and those receiving care in a mental health unit are likely idiosyncratic to the study site and may not be a common representation of other spiritual care departments at other institutions.

Future research should investigate the quality of chaplaincy visits (e.g., contents of services provided), in addition to examining correlates between encounter contexts and encounter content, such as elements of assessment, interventions, and outcomes. One such approach may include conducting focus groups with chaplains about their experience of conducting and documenting their spiritual care. It is also important to study how other healthcare team members refer to chaplaincy services, engage with chaplains and then, read and understand the chaplains’ spiritual assessments and care plans. Additionally, qualitative analysis of notes narrated by chaplains after visiting patients would be helpful to further understand the nature of patients’ spiritual needs that may not be captured by predetermined categories.

Further research is needed to empower the interdisciplinary healthcare team to better understand which patients are receiving benefits of spiritual care, why those visits are occurring, and what is occurring at those visits. With more data, chaplains, healthcare professionals, and institution administrators will be able to predict more accurately the spiritual needs and goals of various patient populations in order to align their interventions—both medical and spiritual—with patients’ holistic needs and goals. If empirical data about inpatient chaplaincy encounters, just like the one that was presented here, are accumulated and shared in a constructive way, then all members in the team can better understand and collaborate toward the common goals.

Limitations

There are a number of important limitations in interpreting the current results. First, this study was conducted at a single site Midwest USA, with a single cohort of chaplains, so the results may not be broadly generalizable and contain variance due to individual differences in chaplain practice, although these errors are likely reduced when compared to studies that involve multiple institutions with potentially inconsistent methods of providing care, triaging patients, and other idiosyncratic factors. Nevertheless, these results are inevitably affected by being drawn from a single site.

Notably, as mentioned earlier, the Self-Harm Support program is, for instance, a unique function of the study site’s spiritual care department and that particular sub-population may be overrepresented compared to the general population that receives spiritual care since those patients are intentionally visited by chaplains according to department protocols. This, however, instead of skewing the results, should be considered as a form of a desirable and effective protocol aimed at improving patients' spiritual well-being. More hospitals and departments should consider developing the protocols and programs that are specifically tailored to their patients’ needs, and local context, rather than attempting to increase generalizability. The current study focused on the associations between patients’ characteristics and chaplain visits to provide a comprehensive picture of the context of spiritual care; thus, details of the spiritual assessment, interventions, outcomes, and patient goals were outside the scope of this project.

Conclusion

Providing and assessing quality spiritual care is a challenging but vitally important task in today’s healthcare environment. This study sought to provide an empirically descriptive account of patients’ characteristics and chaplain visits that have not yet been comprehensively reported in the literature. Ultimately, as part of what may potentially give rise to a multi-step investigation, this study aimed to lay the foundation for future research by providing a comprehensive picture of patient characteristics and chaplain visits at a large suburban teaching hospital in the Midwest. Providing basic demographic information about the types of patients seen and the types of visits conducted, and evaluating which patients are more likely to receive more than one chaplaincy visit, sets the stage for additional inquiry which has not yet been conducted in the field of inpatient spiritual care. In the future, we aspire to not only evaluate what types of chaplaincy activities are occurring, but furthermore hope to draw conclusions about potential correlation and/or causation between specific chaplaincy interventions and patient outcomes (spiritual and/or medical). This work is much beyond the current scope of this analysis, but nevertheless, it is our hope that this study will help to inspire and generate new research that will advance the field of hospital spiritual care by providing crucial data for the development of evidence-based chaplaincy “treatment pathways” (Peery, 2021).