Despite recognition of the centrality of professional board-certified chaplains (BCC) in palliative care, the discipline has little research to guide its practices. To help address this limitation, HealthCare Chaplaincy Network funded six proposals in which BCCs worked collaboratively with established researchers. Recognizing the importance of interdisciplinary collaboration in the development of a new field, this paper reports on an exploratory study of project members’ reflections over time on the benefits and challenges of conducting inter-disciplinary spiritual care research.
Data collection occurred in two stages. Stage 1 entailed two independent, self-reflective focus groups, organized by professional discipline, mid-way through the site projects. Stage 2 entailed end-of-project site reports and a conference questionnaire.
Eighteen professionals participated in the group discussions. Stage 1: researchers perceived chaplains as eager workers passionately committed to their patients and to research, and identified challenges faced by chaplains in learning to conduct research. Chaplains perceived researchers as passionate about their work, were concerned research might uncover negative findings for their profession, and sensed they used a dissimilar paradigm from their research colleagues regarding the ‘ways of relating’ to knowledge and understanding.
Stage 2: researchers and chaplains noted important changes they ascribed to the interdisciplinary collaboration that were classified into six domains of cultural and philosophical understanding: respect; learning; discovery; creativity; fruitful partnerships; and learning needs.
Chaplains and researchers initially expressed divergent perspectives on the research collaborations. During the projects’ lifespans, these differences were acknowledged and addressed. Mutual appreciation for each discipline’s strengths and contributions to inter-professional dialogue emerged.
Spiritual care is recognized as an essential component of quality palliative care [1-3]. In the USA, spiritual care needs are often addressed by professional, board-certified chaplains (BCCs); however, few rigorous studies exist describing or evaluating chaplaincy services in the palliative care setting [4,5]. Chaplaincy research has only recently begun to employ methodologically rigorous study designs , develop a body of outcomes data and other knowledge to inform practice , and focus on nurturing a community of chaplain-researchers.
To address some of these limitations, in 2011 HealthCare Chaplaincy Network (HCCN) started work to foster a sustainable, critical mass of chaplain-researchers by engaging them in research that addressed substantive spiritual care questions. HCCN sought proposals in which BCCs worked collaboratively with established biomedical or behavioral science researchers and funded six projects (see Table 1) that collectively, along with the faculty-advisors to the projects, formed the founding membership of the Chaplaincy Research Collaborative (CRC).
Collaboration across – as well as within – disciplines can be problematic. Distinct cultural values, norms, processes, paradigms, communication methods and organizational barriers can result in inter-disciplinary discord, and ‘tribal’ alliances that negatively impact the patient experience [8,9]. Social science has long accepted that before they can deliver high quality results, such team-based collaborations go through a phased development process. The classic articulation of these functioning growth stages was by Tuckman in 1965 following his analysis of team dynamics, and entailed: Forming (the initial, pre-project preparatory phase) – Storming (the phase of initial team collaboration often characterized by individual competition for status and ideas’ acceptance, with conflict that is addressed by learning how to solve problems together) – Norming (when the team begins to work more effectively) and – Performing (when the team is functioning at a very high level, with a focus on reaching goals as a group) . In this model, all four stages are necessary and inevitable to develop, address challenges, tackle problems, find solutions, plan work, and deliver results. Contributing to a nascent field in which inter-professional collaboration will be critical to its success, this paper reports on an exploratory study of CRC team members’ reflections over time on the benefits and challenges of inter-disciplinary spiritual care research.
Respondents included all CRC members, both biomedical or behavioral science researchers and BCCs, participating in and advising the six funded projects. Written informed consent to participate in the study was obtained from all participants. Given the exploratory and preliminary nature of this project in a very new field, all participants were offered the opportunity to also contribute to the writing of the report.
This occurred over two stages. Stage 1: two independent, self-reflective focus groups, separated by professional discipline (i.e., BCCs and biomedical/behavioral science researchers), and conducted at a CRC symposium mid-way through site projects (June 2013). Participants completed a brief form providing socio-demographic and research experience data and responded to three questions:
“What has your experience been working with chaplains/researchers in your team?”
“What do you think could make things work better?”
“What are some of the professional characteristics that compare and contrast between chaplaincy and researcher cultures?”
Discussions were facilitated by an experienced chaplain (GH) and palliative care researcher (LE), who were also the co-principal investigators for the project. Identified themes were recorded on flipcharts.
Stage 2: CRC members were asked to reflect on two questions in end-of-project reports (January 2014):
“What do you consider the benefits and potential drawbacks of working collaboratively in support of the aims of this project?”
“Share with us the thoughts of your research team on how those interested in this area of research, and the inclusion of chaplains in those projects, might continue to work together collaboratively to attain these aims?”
CRC members were asked to provide additional feedback in response to a brief questionnaire at the end-of-project conference (March 2014).
In Stage 1, profiling socio-demographic and profession data were entered into an Excel spreadsheet for descriptive analysis and presented as simple frequencies. In view of the near-verbatim nature of the data recorded directly onto the flipcharts, the authors decided against formal qualitative analysis, instead reviewing and categorizing the topics into thematic groups. Agreement with the final categories, and their validation, was obtained from all participants. Given the number of participants was small, the authors presented the data by professional group and site only, rather than by any other potentially contextualizing factor (e.g., gender, age), with the quotes cited as summarizing group perspectives rather than attributable to individuals.
In Stage 2, CRC members’ statements were collated and emergent themes recorded by two authors (LE and GH), with disagreements – which were minimal in nature – resolved by consensus discussion.
The study was deemed exempt locally from institutional board review by the Children's Mercy Hospital, Missouri.
Participants’ profiles from Stage 1 are outlined in Table 2.
(i) Characteristics of participants
Eighteen professionals participated in the group discussions.
There were slightly more non-chaplains (10 versus 8) – with researchers representing sociology, psychiatry, nursing, psychology, medicine, psycho-oncology and palliative care – and more women (10 versus 8). Non-chaplains had been involved in research generally for significantly longer than BCCs (18 versus 6.5 years).
(ii) Perceptions of professional characteristics and experiences
Researchers perceived chaplains as easy to work with, seeing them as eager workers passionately committed to their patients and research. When asked to think of words describing chaplains, they used numerous highly complementary terms – e.g., thoughtful; enthusiastic; reflective; hard working; deep, as well as systematic thinkers.
The researchers identified challenges chaplains faced in participating effectively in a research team. These included technological and logistical issues (e.g., dealing with information technology, databases, and audio recordings). Additionally, researchers perceived that chaplains were generally untrained in research.
Researchers also perceived that some chaplains experienced research as a threat to their profession, e.g., feeling they were being judged. Other researchers noted some chaplains’ concerns about the potential impact of being observed on the effectiveness of their chaplaincy practice.
Another common theme noted by researchers was some chaplains’ apparent deep-rooted questioning of the appropriateness and effectiveness of research in studying issues previously considered by some as elusive, unquantifiable or sacred, exemplified by researchers following perceptions:
“You can’t measure the divine”;
“Don’t unpack the ‘special”, and;
“Sacred means don’t probe”.
Chaplains perceived researchers as “passionate about what they do.” They also expressed a “fear of being exposed”; specifically, that research studies might uncover negative findings, e.g., demonstrating that pastoral interventions are ineffective and thereby harming chaplaincy as a profession.
Chaplains reported feeling their research skill sets were inadequate. They felt basic training should be a prerequisite for effective research participation. However, they also reported experiencing unrealistic expectations from their research colleagues regarding their level of research training and education.
Chaplains suggested they used a dissimilar paradigm from their research colleagues in terms of their “ways of relating” to knowledge and understanding. As one commented:
“Chaplains and researchers talk differently. A researcher may ask, ‘How do you know that?’ ‘What’s your data?’ Whereas a chaplain may say, ‘I know that by my experience …’ and … chaplains perceive [that] as the disconnect between art and science”.
(iii) Improving collaboration
In addition to understanding chaplains’ concerns regarding research collaboration, researchers acknowledged the need to identify chaplains as “the experts” in the spiritual domain, and to convey their appreciation of that fact. Additionally, creating learning opportunities – e.g., “How database people and chaplains (work) together” – was important, as was fostering an inclusive inter-disciplinary team atmosphere by having such events as a “Series of ‘lunch and learns’”.
Chaplains wanted researchers to have a more realistic appreciation of their existing research abilities (e.g., evaluating ability with a project management checklist). Additionally, it was considered critical that directors of chaplaincy care services are fully supportive of the chaplains’ participation in research – including an accurate appreciation of its time commitments – with transparency regarding the multiple work accountabilities involved.
Lastly, there was an emphasis accorded to collaboration as a way forward, by ‘Keep(ing) making an intentional effort to stay together” in a supportive, equitable partnership: “Established as mutuality – two-way learning”.
Primary findings from end-of-project reports are presented thematically (see Table 3). Two main challenges emerged: researchers perceived chaplains lacked knowledge of basic research principles, rendering it difficult for chaplains to be optimal collaborators. To help address this challenge, researchers suggested that “Future projects need to include a supplemental research training component and/or time funded for mentorship” (SD)a. Second, there was a general BCC reflection regarding “the (severity of the) learning curve associated with the deepening of the professional relationships” (MA).
Six primary themes were identified in the collaborative process: respect; learning; discovery; creativity; fruitful partnerships; and learning needs. While participants provided positive overall evaluation of their collaborations, they also identified an important need to clarify the critical terms and definitions of the lexicon that underpinned the new collaborations – including regarding ostensibly basic terminology.
At the end-of-project conference, feedback from the group indicated:
All researchers but one felt they had achieved career advancement from their participation, while just under half the chaplains felt they had.
All groups reported a substantial number of projects and presentations made and proposed emanating from their work, reflecting feasible career possibilities.
Researchers planned more project proposals and publications than chaplains (range 2–5 for researchers versus 2–3 for chaplains, 5–8 versus 2- > 5, respectively) but a similar numbers of presentations (5–7 for researchers versus 4–10 for chaplains).
Discussion and conclusions
This exploratory study has limitations, as it was conducted among a convenience sample of researchers and BCCs in a fledgling learning partnership aiming to identify some of the pertinent issues involved in inter-disciplinary spiritual care research. Consequently, the conclusions derived are circumspect.
However, it has highlighted a number of interesting provisional findings. Chaplains and researchers initially expressed varying ways of seeing the world. Chaplains’ concerns about the appropriateness and effects of researching the spiritual domain appeared to reflect both their personal beliefs and their relative unfamiliarity with the culture of research. Researchers also expressed concerns regarding chaplains’ relative research inexperience – part of the raison d’ être for this project.
However, and acknowledging the potential impact of different data collection methodologies used in Stages 1 and 2, generally participants appeared to experience positive changes over time in inter-disciplinary cultural and philosophical understanding derived from the collaborations across multiple domains. While the overall benefit from collaboration was experienced among both professional groups, chaplains appeared to be reflecting further on how to build research into their career pathways.
During the projects’ lifespans, initial differences were not only acknowledged but aimed to be addressed with appropriate interventions (e.g., research training for chaplains team members). Moreover, the teams expressed a growing appreciation of each discipline’s strengths and contributions to inter-professional dialogue and functioning. These positive reflections are indicative, along with the list of proposed conference presentations and publications completed and planned from each site, of the ‘performing’ phase of Tuckman’s group dynamics.
The findings underscore that future chaplain-researcher collaboration will require mutual respect, patience, and willingness to reconsider assumptions in both disciplines. For instance, chaplains’ concerns about the applicability of research to the spiritual domain must be respected, not dismissed. Only with increased research experiences will chaplains – and the field of chaplaincy generally – grow more comfortable and confident as professionals who not only provide personalized spiritual care to patients and families, but also conduct research on this care.
Researchers will need to adapt their learning and communications styles to maximize the contributions professional chaplains can make to research, as part of a reciprocal process of accommodation and knowledge acquisition that values professional diversity and is sensitive to the dynamics inherent to professional cultures’ interactions .
As for future research arising from this study: this remains a nascent field of enquiry, with limited funding opportunities to conduct larger, more representative studies using a critical mass of chaplain-researchers and established biomedical or behavioral science researchers. However, it is important – and more pragmatic – that existing and future research networks explore further the inter-disciplinary issues identified in this study to help identify lessons learnt and best practices to support a growing body of understanding.
aSources attributed to cited quotations in Stage 2 data are constructed by the initial of the site principal investigator’s surname and the first letter of the lead organization (e.g., ‘Evans’ and ‘Yale University’ would be ‘EY’).
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The authors acknowledge the contribution of the following to the development of this paper:George H. Grant, Shoshanna Sofaer, Kenneth I. Pargament and Dylan M. Smith. The authors also thank Mary Ellen Hudson, at Children’s Mercy Hospital, Kansas City, Missouri, and Carolyn Sebron at HealthCare Chaplaincy Network, New York, for their invaluable support with this study. Financial support for this initiative was provided by the John Templeton Foundation (grant reference number 22399). The funder played no role in the design, collection, analysis, and interpretation of data, or in the writing of the manuscript and the decision to submit the manuscript for publication.
The authors declare that they have no competing interests.
RAP conceived the study and, with LE and GH (who led on data acquisition and analysis), participated in its design and helped draft the manuscript. All authors contributed to the analysis and interpretation of data, and read, contributed to, and approved the final manuscript.
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Powell, R.A., Emanuel, L., Handzo, G. et al. Transcending differences to study the transcendent: an exploratory study of researchers’ and chaplains’ reflections on interdisciplinary spiritual care research collaboration. BMC Palliat Care 14, 12 (2015). https://doi.org/10.1186/s12904-015-0004-4