- Email: [email protected]
How Well Trained Are Clergy in Care of the Dying Patient and Bereavement Support?
44
Journal of Pain and Symptom Management
Vol. 32 No. 1 July 2006
Original Article
How Well Trained Are Clergy in Care of the Dying Patient and Bereavement Support? Mari Lloyd-Williams, FRCP, FRCGP, MD, MMedSci, ILTM, Mark Cobb, Rev., BA, MPhil, Chris Shiels, BA, MPhil, and Fiona Taylor, BS, MB ChB Academic Palliative and Supportive Care Studies Group (M.L.W., C.S.), Division of Primary Care, and Mersey Primary Care R&D Consortium (C.S.), University of Liverpool, Liverpool; Sheffield Teaching Hospitals NHS Trusts (M.C.), Sheffield; and University of Leicester Hospitals (F.T.), Leicester, United Kingdom
Abstract Although comparatively few people have regular contact with a church or spiritual leader, during times of terminal illness or bereavement, clergy are expected to be available and able to provide support. This study was carried out to determine the perceptions of clergy on the training they had received in supporting the dying patient and the bereaved. A sample of clergy working in the diocese of Sheffield was sent a questionnaire to assess what skills and knowledge clergy believed they had in this area, together with areas where they would wish for further training. The questionnaire was developed with input from hospital, hospice, and academic chaplains, and palliative care consultants. A subsidiary questionnaire was sent to clergy training colleges to evaluate the teaching offered. There was a trend across all denominations that those who had trained more recently were more likely to have received relevant training. Most clergy believed that they possessed adequate liturgical skills, but 13% felt they possessed none or little skill in pastoral care of the dying. Seventy-one percent indicated that they would like further training in pastoral care of the dying and 66.3% desired training in care of the bereaved. Of the 50% of training colleges that responded, the number of hours of training on pastoral care of the dying ranged from 6 to 36 hours (median 23 hours and mean 25 hours) and only 26% believed that their training in pastoral support skills was comprehensive. This study suggests that care of the dying and the bereaved is identified by clergy as an area in need of further training by the majority of clergy and should be part of the core curriculum within clergy training colleges and late training programs. J Pain Symptom Manage 2006;32:44--51. Ó 2006 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Clergy, palliative care, pastoral care, care of the dying, bereavement, training
Address reprint requests to: Mari Lloyd Williams, MD, Academic Palliative and Supportive Care Studies Group, Division of Primary Care, University of Liverpool, Liverpool L69 3GB, United Kingdom. E-mail: [email protected]
Introduction
Accepted for publication: January 18, 2006.
As religious observance has decreased,1,2 many people have no regular contact with a church or spiritual leader. Yet, the terminal phase of illness may be a time for spiritual searching, growth, and renewal.3 Paradoxically,
Ó 2006 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved.
0885-3924/06/$--see front matter doi:10.1016/j.jpainsymman.2006.01.010
Vol. 32 No. 1 July 2006
Dying Patient and Bereavement Support
the journey into death is sometimes considered to be the ultimate vehicle for spiritual discovery.4 The need for spiritual support must not be confused with religious affiliation5dspiritual support is sought and required by those of all faiths and none. The confidence of health professionals to enter the spiritual domain of patients appears to be waning,6 and even among chaplains, there seems to be a lack of clarity about their role,7 a factor underlined by Orchard8,9 in her study of chaplaincy within the United Kingdom. At major life events, e.g., birth, marriage, and death, society has an expectation that support from a religious leader will be available.10 For clergy, these contacts can be extremely rewarding, when relationships are deepened and there is a time of reaffirmation and renewal of faith for the families involved.11,12 It can, however, be difficult to initiate and develop a relationship at such times of great emotional distress, when the terminally ill patient or bereaved relatives are not known. The pressure on clergy of all faiths is enormous. Lack of resources means that they are responsible for many more aspects of parish life than ever before and often have a large number of places of worship within their remit. During bereavement, families again often express dissatisfaction that support from the church or clergy has not been available. Health care professionals (including chaplains) who work with patients who are dying and the bereaved receive training, which frequently involves communication skills teaching, information about the dying process, and the process of normal and abnormal bereavement. It is acknowledged that working with the dying and the bereaved can be stressful and health professionals also have access to formal support during which they can reflect on their experiences. Society expects members of the clergy to be able to offer support, but does not always consider the clergy’s own needs for support. A search of the literature revealed many papers that have looked at the spiritual support of patients who are dying within hospices, hospitals, or nursing homes by chaplains, but little work on the role of the ‘‘community’’ clergy in providing this care and the teaching given to clergy on this aspect of their work. There is
45
also no literature on whether clergy are offered training in this aspect of their work. This study was carried out to determine the training given to clergy on supporting the dying patient and the bereaved, both during initial preordination training and the provision of ongoing professional development.
Methods A questionnaire was developed with input from hospital, hospice, and academic chaplains and palliative care consultants. A sample of clergy (which included Roman Catholic, Methodist, and Anglican clergy all working in the diocese of Sheffield) was sent the questionnaire to assess what skills and knowledge clergy believed they had in this area, together with areas where they would wish for further training. Specific areas covered in the questionnaire included denomination of cleric; year ministerial training was completed; any previous training in three key areas (pastoral care of the dying, conduct of funerals, pastoral care of the bereaved); hours of training received in each area; composition of any training in key areas (medical, sociological, psychological, theological, or legal components); the current level of rated ability in each of the three areas (rated as none/little/medium/a lot/comprehensive); any desired additional training in the key areas; any past placements in a hospice, hospital, nursing home, or visits with funeral directors; and number of funerals conducted, dying supported, and bereaved counseled, in previous 12 months. A subsidiary questionnaire aimed to evaluate the teaching offered was sent to all training institutions for clergy, which included Roman Catholic, Anglican, Baptists, Methodist, and Ecumenical colleges. The content of this short questionnaire corresponded to that used in the survey of individual clerics.
Statistical Analysis None of the continuous variables in the survey of clergy approximated normal distribution, and were thus analyzed using nonparametric statistical techniques. For investigating differences between subgroups of clerics in relation to skewed data and ordinal
46
Lloyd-Williams et al.
variables, the Mann-Whitney U test (MW-U) was used. For investigating significance of association between categorical variables, the Chisquared (c2) test was deemed appropriate (with a continuity correction for 2 2 tables). In addition to univariate analysis, three logistic regression models were constructed to test for independent effects of cleric characteristics, previous experience/training, and perceived ability on each of three outcome variables: a reported desire for more training in pastoral care of the dying, conduct of funerals, and care of the bereaved. For both univariate and multivariate analyses, a standard a of 0.05 was assumed to indicate statistical significance. For the survey of training colleges, because of the relatively small number involved, only basic descriptive statistics were calculated and are presented. Data were analyzed using the statistical software, SPSS for Windows V10. For both sets of data, based upon individual clergy or training institution, there were varying levels of missing data across variables. Hence, denominators used in the reported analyses were not always similar.
Results Profile of Respondents Of the 312 members of clergy working within the diocese of Sheffield who were sent questionnaires, 125 (39.4%) responded. Of these, 55 (44%) were Anglican, 60 (48%) were Methodist, and 10 (8%) were Roman Catholic. The median duration of time since completion of clerical training was 13 years. In terms of the content of previous training, 76% of responding clerics reported some degree of training in pastoral care of the dying (median hours of training ¼ 11), 82.4% reported some training in conducting funerals (median ¼ 10 hours), and 73.6% stated that they had received training in pastoral care of the bereaved (median ¼ 10 hours). Over 71% indicated that they would like further training in pastoral care of the dying, 41.8% in conducting funerals, and 66.3% in care of the bereaved. Information about components of theoretical knowledge and practical skill included in previous training was requested in the survey.
Vol. 32 No. 1 July 2006
For those with previous training in pastoral care of the dying, 86.3% reported ‘‘pastoral support skills’’ as an important (‘‘more than a little’’) factor in training, while only 37.8% indicated that ‘‘medical knowledge’’ had a similar degree of content. In terms of conduct of funeral training, over 83% reported that teaching of ‘‘pastoral support’’ skills was a major component in this arm of training. Those clerics reporting some previous training in pastoral care of the bereaved also cited ‘‘pastoral support skills’’ (79.1%) as a significant component, but also reported that sociological (68.5%) and psychological (73.1%) elements were ‘‘more than a little’’ involved in training. Clerics were also surveyed about how they rated their current level of ability in each of the three general areas. The 5-point ordinal response scale ranged from ‘‘none’’ (0) to ‘‘comprehensive’’ (4). In terms of pastoral care of the dying, 53.6% rated themselves as having ‘‘a lot’’ or ‘‘comprehensive’’ ability in this area. Corresponding figures for conduct of funerals and pastoral care of the bereaved were 88.8% and 75%, respectively. Respondents also provided information about visits to and placements at hospices, hospitals, nursing homes, and funeral directors that were deemed part of their clerical training. While 32.8% stated that they had visited a hospice during training, only 18.5% reported a formal placement in a hospice. Equivalent figures for hospitals were 26.4% and 37.6%, nursing homes 27.2% and 5.6%, and funeral directors 43.2% and 1.6%. In relation to recent practice, respondents reported they had officiated at a median number of 25 funerals conducted in the previous 12 months (range 0--150). Within the group of clerics, a median of four dying people (range 0--70) and 15 bereaved relatives (range 0--600) were reportedly counseled or supported in the same period.
Desire for Further Training, Cleric Characteristics, and Previous Experience/Training Table 1 presents data relating to associations between reported desire for further training in the three main areas (pastoral care of the dying, conduct of funerals, and care of the bereaved), denomination of cleric, and aspects of
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Dying Patient and Bereavement Support
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Table 1 Reported Desire for Further Training in Pastoral Care of the Dying, Conduct of Funerals, and Care of the Bereaved: Association with Cleric Denomination and Previous Training/Experience Clerics Reporting Desire for Further Training in: Pastoral Care of Dying % Denomination Anglican (n ¼ 55) Roman Catholic (n ¼ 10) Methodist (n ¼ 60)
71.1 55.6 74.1
P (c )
Conduct of Funerals %
0.41
63.4 60.0 69.8
2
P (c )
Pastoral Care of Bereaved %
P (c2)
0.73
2
0.55
33.3 42.9 47.9
Previous training in pastoral care of the dying No (n ¼ 61) 72.9 Yes (n ¼ 64) 69.8
0.90
44.4 39.1
0.76
68.8 64.3
0.63
Previous training in conducting funerals No (n ¼ 45) 70.6 Yes (n ¼ 80) 71.6
0.91
45.5 39.7
0.75
70.6 64.3
0.67
Previous training in pastoral care of bereaved No (n ¼ 47) 69.4 Yes (n ¼ 78) 72.3
0.94
47.1 38.6
0.57
66.7 66.2
0.96
Previous placement in hospice No (n ¼ 101) Yes (n ¼ 23)
72.8 63.2
0.58
45.2 29.4
0.24
69.4 50.0
0.11
Previous placement in hospital No (n ¼ 78) Yes (n ¼ 47)
69.2 75.0
0.70
41.4 42.4
0.92
66.7 65.8
0.93
previous training. No statistically significant associations were found. However, some nonsignificant trends are worthy of noting. Of the three denominations, a higher proportion of Methodists consistently reported a desire for training in the three areas, 74.1% for pastoral care of the dying, 47.9% for conducting funerals, and 69.8% relating to pastoral care of the bereaved. The lack of a previous placement in a hospice was also associated with higher proportions desiring further training. Nearly 73%, 45.2%, and 69.4% of those with no previous hospice placement desired more training in the three areas, respectively. The duration of clerical experience was significantly associated with a reported wish for further training in one of the pastoral areas. Those clerics expressing a wish for more training in pastoral care of the dying tended to be less experienced than those who did not (median of 12 years compared to 14 years since completion of clerical training; MW-U: P ¼ 0.04). When considering training/experience received in the past, clerics reporting previous training in pastoral care of the bereaved were significantly more likely to be those who had
received their general ministerial training in the more recent past (median years since completion of training ¼ 11), compared to 18 for those with no training experience (MW-U; P ¼ 0.001). A similar significant association was found between number of years since completion of general training and any reported previous training in conducting funerals. Those having no previous training had a median of 17 years since general clerical training was completed, compared to only 12 for those who reported such specialized training (MWU; P ¼ 0.01). No significant differences were found between those groups of clerics reporting and not reporting previous training in pastoral care of the dying, or previous placements in a hospice or hospital, in terms of period since completion of ministerial training. For one of the pastoral areas, care of the dying, there was a significant denominational difference in rates of previous training experience (Roman Catholic 70%, Anglican 60%, Methodist 40%; c2 ¼ 6.1, df ¼ 2, P ¼ 0.04). However, rates of previous placement in a hospice or hospital did not significantly vary across the three denominational groups.
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Lloyd-Williams et al.
Table 2 Association Between Perceived Ability to Perform a Service and Previous Training in That Area Reported Previous Training in Pastoral Care of Dying No (n ¼ 61) Yes (n ¼ 64) P (MW-U) Perceived ability to perform pastoral care of dying (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’
2
3
42.7
67.2
0.003
Reported Previous Training in Conduct of Funerals
Vol. 32 No. 1 July 2006
rated their ability on the uppermost points of the rating scale (a lot/comprehensive), 67.2% of those who had received previous training in pastoral care of the dying rated their ability at these levels, compared with only 42.7% of those with no training in this area. For pastoral care of the bereaved, corresponding figures were 84.6% and 57.1%, respectively. Table 3 reports results of analyses investigating how clerics’ rating of their ability was associated with their reported requirement for further training in each of the three procedural areas. Results follow the pattern of the previous analysis associating perceived ability with past training. Those clerics who expressed
No (n ¼ 45) Yes (n ¼ 80) P (MW-U) Perceived ability to conduct funerals (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’ Reported Previous Training in Pastoral Care of Bereaved
3
3
90.0
93.6
0.16
Table 3 Association Between Reported Desire for Further Training and Perceived Ability to Perform a Service Reported Desire for Further Training in Pastoral Care of Dying No (n ¼ 29) Yes (n ¼ 72) P (MW-U)
No (n ¼ 47) Yes (n ¼ 78) P (MW-U) Perceived ability to perform pastoral care of bereaved (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’
3
3
57.1
84.6
0.04
Perceived ability to perform pastoral care of dying, conduct funerals, and to care for bereaved: 5-point rating scale, 0 ¼ no ability / 4 ¼ comprehensive.
Perceived ability to perform pastoral care of dying (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’
3
2
67.9
44.4
0.04
Reported Desire for Further Training in Conduct of Funerals No (n ¼ 53) Yes (n ¼ 38) P (MW-U)
Perceived Levels of Ability in the Three Pastoral Areas, Cleric Characteristics, Previous Experience, and Desire for Further Training No statistically significant associations were found between how clerics rated their current ability in the three areas, and either denomination or years of experience. Table 2 reports association between how clerics rated their current ability and any reported previous training in pastoral care of the dying, bereaved, and conducting funerals. For two areas, pastoral care of the dying and of the bereaved, there were significant differences in rated ability between those who had and those who had not received previous training in the relevant area. When considering only clerics who had
Perceived ability to conduct funerals (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’
4
3
90.2
94.6
0.13
Reported Desire for Further Training in Pastoral Care of Bereaved No (n ¼ 35) Yes (n ¼ 69) P (MW-U) Perceived ability to perform pastoral care of bereaved (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’
3
3
84.8
67.6
0.04
Perceived ability to perform pastoral care of dying, conduct funerals, and to care for bereaved: 5-point rating scale, 0 ¼ no ability / 4 ¼ comprehensive.
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Dying Patient and Bereavement Support
a wish for further training in care of either the dying or the bereaved had significantly lower ratings of their ability in these areas. In terms of supporting the dying, 44.4% of those with a desire for future training rated their ability as ‘‘a lot’’ or ‘‘comprehensive,’’ compared to 67.9% who expressed no requirement for training. For pastoral care of the bereaved, the figures were 67.6% and 84.8%.
Multivariate Analysis In addition to the univariate analysis reported above, three logistic regression models were also constructed to estimate effects of a range of potential explanatory variables upon specific outcome measures. Binary outcome variables in the models related to any expressed desire for further training in pastoral care of the dying, conduct of funerals, or care of the bereaved. The explanatory covariates in each model included clerics’ denomination, years of clerical experience, previous placements in hospital or hospital, reported previous training, and perceived ability in the given area. However, when each of the three models was run, no statistically significant associations were found between any of the independent covariates and the risk of positive outcome.
Survey of Training Colleges Forty-two training colleges were identified and 21 (50%) responded. The colleges included Anglican, Baptist, Moravian, Methodist, United Reformed, Baptist, and Roman Catholic denominations and the degrees/qualifications offered included diploma and certificate courses, Bachelor and Masters degrees in theology, and opportunities for study toward a higher degree. The numbers of students ranged from 20 to 102. Colleges were asked to indicate how much training they provided in three general areas: pastoral care of the dying, conduct of funerals, and care of the bereaved. In particular, the survey requested information about theoretical knowledge and practical skill content in the training programs offered. In terms of training aimed at enhancing skills in pastoral care of the dying, 23% of colleges reported that such training had some medical content. Psychological knowledge (58%), sociological knowledge (47%),
49
theological knowledge (100%), pastoral support skills (68%), and liturgical skills (79%) were all aspects of training well reported by colleges as making significant contributions to training in this area (‘‘a lot or comprehensive content’’). The number of hours dedicated to this area of training ranged across colleges from 6 to 36 hours (median 25 hours). Duration of training in conduct of funerals reported by the training institutions ranged from 4 to 243 hours (median 12 hours). Only 47% reported that such training included a ‘‘lot or comprehensive’’ inclusion of legal content. Equivalent figures for other components were 63% for sociological knowledge, 100% for theological knowledge, 80% for pastoral support skills, and 95% for liturgical support skills. In the third training area, pastoral care of the bereaved, a ‘‘lot or comprehensive’’ content in training was reported for psychological knowledge (80% of institutions), sociological knowledge (50%), theological knowledge (79%), pastoral support skills (75%), and liturgical support skills (68%). The range of training hours allocated to this pastoral area was 6--34 (median 25). Colleges were asked to indicate whether students were able to visit a hospice, hospital, or nursing home, and whether placements were available. Over 47% of colleges said there were opportunities to visit a hospice and 90% said there were opportunities for a placement at a hospicedthe length of placement ranged from half a day to 4 weeks. A similar number of colleges stated that students could visit a hospital (48%) and had opportunities for placement within a hospital (90%), with the duration ranging from a half-day visit to three months. Nearly 43% stated students had opportunities to visit a nursing home and 38% reported opportunities for placement at a nursingdthese ranged in time from half a day to 200 hours. Eighty-five percent of colleges gave clergy an opportunity to visit a funeral director as part of their training and 19% said placements were available, which ranged from an hour to 35 hours.
Discussion A number of interesting points emerge from this study that require further discussion and
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Lloyd-Williams et al.
merit further research. The less experienced clergy, i.e., those with shorter time since completion of ministerial training, were more likely to desire further training in pastoral care of the dying. Previous training in pastoral care of the bereaved and in the conducting of funerals was more likely in those who received ministerial training in the more recent past (i.e., less experienced). It also emerged that the more experienced and possibly older clerics were less likely to have received formal training, but were still unlikely to indicate a desire for any training in the future. We can compare this to areas such as communication skills training for medical and nursing staff within palliative care. Such training is now offered routinely, but the take-up by experienced staff is lowdsuch staff believe that they will already have acquired such skills during their long service within post and do not recognize that they may need such training. In a wide-ranging analysis of spiritual care at the end of life, Cobb13 calls for more training, more consistency, and a more integrated approach to spiritual caregivingda finding echoed by this study. However, in the multivariate analysis, the significance of association with desire for further training found at the univariate level was negated in the logistic regression models and there were no significant independent effects upon outcome. In the survey of training colleges, only a quarter of respondents believed their training to be comprehensive in pastoral support skills. When considering the total number of hours of clergy training, the mean of 25 hours devoted to pastoral care of the dying and bereaved appears quite low when one considers that these are core and key duties of a clergy role.14 There is no uniform syllabus for clergy training. Although the emphasis is on scholarly instruction and knowledge, we would argue that pastoral care and bereavement support should be key components and have greater time than the findings of this survey suggest.15 To feel comfortable working within a particular area or environment, it is essential that staff feel appropriately trained and supported. It was outside the remit of this study to look specifically at stress within clergy, but working in an environment where society expects clergy to have a great knowledge and empathy for
Vol. 32 No. 1 July 2006
both pastoral and bereavement care and to feel underskilled in this area would be stressful. Although some denominations, e.g. Church of England, are starting to address the issues of clergy support by nominating a diocese clergy support officer (often a senior clergyman from within a diocese), there is very little in the way of formal support for clergy in general and the key areas of care of self and seeking external support, e.g., after a particularly traumatic bereavement, is still something that few clergy access.16 An introduction to this area and equipping clergy with the skills and resources to debrief is surely as essential as in any other professional group. A weakness of this study is that it only included clergy of Christian faithsdit would be interesting to carry out the same study among other faith group leaders.
Conclusions Pastoral care of the dying and the bereaved is a core activity for all parish clergy. This study has suggested that the majority of clergy perceived the need for further training in this area. Clergy training colleges, although offering placements to clergy within pastoral care settings, were constrained by the amount of time given to this area during clergy training. We suggest that training in care of the dying and the bereaved (including communication skills) should be part of the core curriculum within clergy training colleges and regularly revisited by all those who provide continual ministerial training for clergy.
Acknowledgments The authors wish to thank all those who helped in the development and piloting of this study and to all the clergy for not only taking part but for their interest and enthusiasm. Thank you also to colleagues from the Academic Palliative and Supportive Care Studies Group at the University of Liverpool for their comments on earlier drafts of this paper and to our reviewers for their comments.
References 1. Davie G. Religion in Britain since 1945. London: Blackwell, 1994.
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2. Brierley P. Religious trends. London, UK: Marshall Pickering, 1999. 3. Milson M, Dudley J. The importance of spirituality in hospice work: a study of hospice professionals. Hosp J 1990;6:63--78. 4. Singh KD. The grace in dying: How we are transformed spiritually as we die. Dublin: Newleaf, 1999. 5. Dyson J, Cobb M, Forman D. The meaning of spirituality: a literature review. J Adv Nurs 1997;26: 1183--1188. 6. Highfield MF, Cason C. The spiritual needs of cancer patients: are they recognised? Cancer Nurs 1983;6:187--192. 7. Wright M. Chaplaincy within hospice and hospital: findings from a survey in England and Wales. Palliat Med 2001;15:229--242. 8. Orchard H. Spiritual care in God’s waiting room: a review of the questions. Prog Palliat Care 2001;9:131--135. 9. Orchard H. Hospital chaplaincy: modern, dependable? In: Percy M, Orchard H, eds. Lincoln Theological Institute research reports No 1. London, UK: University of Sheffield, Sheffield Academic Press, 2000.
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10. Swift J. The chaplain’s role in care for the dying: toward a new understanding. Can Med Assoc J 1976;115:181--184. 11. Cobb M, Robshaw V. The spiritual challenge of health care. London, UK: Churchill Livingstone, 1998. 12. Wright M. Spirituality: a developing concept within palliative care? Prog Palliat Care 2001;9: 143--148. 13. Cobb M. The dying soul: Spiritual care at the end of life. Buckingham: Open University Press, 2001. 14. Broccolo GT, VandeCreek L. How are health care chaplains helpful to bereaved family members? Telephone survey results. J Pastoral Care Counsel 2004;58(1--2):31--39. 15. Walter T. The ideology and organization of spiritual care: three approaches. Palliat Med 1997;11: 21--30. 16. Lloyd-Williams M, Cobb M, Wright M, Sheils C. A prospective study of the roles, responsibilities and stresses of chaplains working within a hospice. Palliat Med 2004;18(7):638--645.
Journal of Pain and Symptom Management
Vol. 32 No. 1 July 2006
Original Article
How Well Trained Are Clergy in Care of the Dying Patient and Bereavement Support? Mari Lloyd-Williams, FRCP, FRCGP, MD, MMedSci, ILTM, Mark Cobb, Rev., BA, MPhil, Chris Shiels, BA, MPhil, and Fiona Taylor, BS, MB ChB Academic Palliative and Supportive Care Studies Group (M.L.W., C.S.), Division of Primary Care, and Mersey Primary Care R&D Consortium (C.S.), University of Liverpool, Liverpool; Sheffield Teaching Hospitals NHS Trusts (M.C.), Sheffield; and University of Leicester Hospitals (F.T.), Leicester, United Kingdom
Abstract Although comparatively few people have regular contact with a church or spiritual leader, during times of terminal illness or bereavement, clergy are expected to be available and able to provide support. This study was carried out to determine the perceptions of clergy on the training they had received in supporting the dying patient and the bereaved. A sample of clergy working in the diocese of Sheffield was sent a questionnaire to assess what skills and knowledge clergy believed they had in this area, together with areas where they would wish for further training. The questionnaire was developed with input from hospital, hospice, and academic chaplains, and palliative care consultants. A subsidiary questionnaire was sent to clergy training colleges to evaluate the teaching offered. There was a trend across all denominations that those who had trained more recently were more likely to have received relevant training. Most clergy believed that they possessed adequate liturgical skills, but 13% felt they possessed none or little skill in pastoral care of the dying. Seventy-one percent indicated that they would like further training in pastoral care of the dying and 66.3% desired training in care of the bereaved. Of the 50% of training colleges that responded, the number of hours of training on pastoral care of the dying ranged from 6 to 36 hours (median 23 hours and mean 25 hours) and only 26% believed that their training in pastoral support skills was comprehensive. This study suggests that care of the dying and the bereaved is identified by clergy as an area in need of further training by the majority of clergy and should be part of the core curriculum within clergy training colleges and late training programs. J Pain Symptom Manage 2006;32:44--51. Ó 2006 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Clergy, palliative care, pastoral care, care of the dying, bereavement, training
Address reprint requests to: Mari Lloyd Williams, MD, Academic Palliative and Supportive Care Studies Group, Division of Primary Care, University of Liverpool, Liverpool L69 3GB, United Kingdom. E-mail: [email protected]
Introduction
Accepted for publication: January 18, 2006.
As religious observance has decreased,1,2 many people have no regular contact with a church or spiritual leader. Yet, the terminal phase of illness may be a time for spiritual searching, growth, and renewal.3 Paradoxically,
Ó 2006 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved.
0885-3924/06/$--see front matter doi:10.1016/j.jpainsymman.2006.01.010
Vol. 32 No. 1 July 2006
Dying Patient and Bereavement Support
the journey into death is sometimes considered to be the ultimate vehicle for spiritual discovery.4 The need for spiritual support must not be confused with religious affiliation5dspiritual support is sought and required by those of all faiths and none. The confidence of health professionals to enter the spiritual domain of patients appears to be waning,6 and even among chaplains, there seems to be a lack of clarity about their role,7 a factor underlined by Orchard8,9 in her study of chaplaincy within the United Kingdom. At major life events, e.g., birth, marriage, and death, society has an expectation that support from a religious leader will be available.10 For clergy, these contacts can be extremely rewarding, when relationships are deepened and there is a time of reaffirmation and renewal of faith for the families involved.11,12 It can, however, be difficult to initiate and develop a relationship at such times of great emotional distress, when the terminally ill patient or bereaved relatives are not known. The pressure on clergy of all faiths is enormous. Lack of resources means that they are responsible for many more aspects of parish life than ever before and often have a large number of places of worship within their remit. During bereavement, families again often express dissatisfaction that support from the church or clergy has not been available. Health care professionals (including chaplains) who work with patients who are dying and the bereaved receive training, which frequently involves communication skills teaching, information about the dying process, and the process of normal and abnormal bereavement. It is acknowledged that working with the dying and the bereaved can be stressful and health professionals also have access to formal support during which they can reflect on their experiences. Society expects members of the clergy to be able to offer support, but does not always consider the clergy’s own needs for support. A search of the literature revealed many papers that have looked at the spiritual support of patients who are dying within hospices, hospitals, or nursing homes by chaplains, but little work on the role of the ‘‘community’’ clergy in providing this care and the teaching given to clergy on this aspect of their work. There is
45
also no literature on whether clergy are offered training in this aspect of their work. This study was carried out to determine the training given to clergy on supporting the dying patient and the bereaved, both during initial preordination training and the provision of ongoing professional development.
Methods A questionnaire was developed with input from hospital, hospice, and academic chaplains and palliative care consultants. A sample of clergy (which included Roman Catholic, Methodist, and Anglican clergy all working in the diocese of Sheffield) was sent the questionnaire to assess what skills and knowledge clergy believed they had in this area, together with areas where they would wish for further training. Specific areas covered in the questionnaire included denomination of cleric; year ministerial training was completed; any previous training in three key areas (pastoral care of the dying, conduct of funerals, pastoral care of the bereaved); hours of training received in each area; composition of any training in key areas (medical, sociological, psychological, theological, or legal components); the current level of rated ability in each of the three areas (rated as none/little/medium/a lot/comprehensive); any desired additional training in the key areas; any past placements in a hospice, hospital, nursing home, or visits with funeral directors; and number of funerals conducted, dying supported, and bereaved counseled, in previous 12 months. A subsidiary questionnaire aimed to evaluate the teaching offered was sent to all training institutions for clergy, which included Roman Catholic, Anglican, Baptists, Methodist, and Ecumenical colleges. The content of this short questionnaire corresponded to that used in the survey of individual clerics.
Statistical Analysis None of the continuous variables in the survey of clergy approximated normal distribution, and were thus analyzed using nonparametric statistical techniques. For investigating differences between subgroups of clerics in relation to skewed data and ordinal
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variables, the Mann-Whitney U test (MW-U) was used. For investigating significance of association between categorical variables, the Chisquared (c2) test was deemed appropriate (with a continuity correction for 2 2 tables). In addition to univariate analysis, three logistic regression models were constructed to test for independent effects of cleric characteristics, previous experience/training, and perceived ability on each of three outcome variables: a reported desire for more training in pastoral care of the dying, conduct of funerals, and care of the bereaved. For both univariate and multivariate analyses, a standard a of 0.05 was assumed to indicate statistical significance. For the survey of training colleges, because of the relatively small number involved, only basic descriptive statistics were calculated and are presented. Data were analyzed using the statistical software, SPSS for Windows V10. For both sets of data, based upon individual clergy or training institution, there were varying levels of missing data across variables. Hence, denominators used in the reported analyses were not always similar.
Results Profile of Respondents Of the 312 members of clergy working within the diocese of Sheffield who were sent questionnaires, 125 (39.4%) responded. Of these, 55 (44%) were Anglican, 60 (48%) were Methodist, and 10 (8%) were Roman Catholic. The median duration of time since completion of clerical training was 13 years. In terms of the content of previous training, 76% of responding clerics reported some degree of training in pastoral care of the dying (median hours of training ¼ 11), 82.4% reported some training in conducting funerals (median ¼ 10 hours), and 73.6% stated that they had received training in pastoral care of the bereaved (median ¼ 10 hours). Over 71% indicated that they would like further training in pastoral care of the dying, 41.8% in conducting funerals, and 66.3% in care of the bereaved. Information about components of theoretical knowledge and practical skill included in previous training was requested in the survey.
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For those with previous training in pastoral care of the dying, 86.3% reported ‘‘pastoral support skills’’ as an important (‘‘more than a little’’) factor in training, while only 37.8% indicated that ‘‘medical knowledge’’ had a similar degree of content. In terms of conduct of funeral training, over 83% reported that teaching of ‘‘pastoral support’’ skills was a major component in this arm of training. Those clerics reporting some previous training in pastoral care of the bereaved also cited ‘‘pastoral support skills’’ (79.1%) as a significant component, but also reported that sociological (68.5%) and psychological (73.1%) elements were ‘‘more than a little’’ involved in training. Clerics were also surveyed about how they rated their current level of ability in each of the three general areas. The 5-point ordinal response scale ranged from ‘‘none’’ (0) to ‘‘comprehensive’’ (4). In terms of pastoral care of the dying, 53.6% rated themselves as having ‘‘a lot’’ or ‘‘comprehensive’’ ability in this area. Corresponding figures for conduct of funerals and pastoral care of the bereaved were 88.8% and 75%, respectively. Respondents also provided information about visits to and placements at hospices, hospitals, nursing homes, and funeral directors that were deemed part of their clerical training. While 32.8% stated that they had visited a hospice during training, only 18.5% reported a formal placement in a hospice. Equivalent figures for hospitals were 26.4% and 37.6%, nursing homes 27.2% and 5.6%, and funeral directors 43.2% and 1.6%. In relation to recent practice, respondents reported they had officiated at a median number of 25 funerals conducted in the previous 12 months (range 0--150). Within the group of clerics, a median of four dying people (range 0--70) and 15 bereaved relatives (range 0--600) were reportedly counseled or supported in the same period.
Desire for Further Training, Cleric Characteristics, and Previous Experience/Training Table 1 presents data relating to associations between reported desire for further training in the three main areas (pastoral care of the dying, conduct of funerals, and care of the bereaved), denomination of cleric, and aspects of
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Table 1 Reported Desire for Further Training in Pastoral Care of the Dying, Conduct of Funerals, and Care of the Bereaved: Association with Cleric Denomination and Previous Training/Experience Clerics Reporting Desire for Further Training in: Pastoral Care of Dying % Denomination Anglican (n ¼ 55) Roman Catholic (n ¼ 10) Methodist (n ¼ 60)
71.1 55.6 74.1
P (c )
Conduct of Funerals %
0.41
63.4 60.0 69.8
2
P (c )
Pastoral Care of Bereaved %
P (c2)
0.73
2
0.55
33.3 42.9 47.9
Previous training in pastoral care of the dying No (n ¼ 61) 72.9 Yes (n ¼ 64) 69.8
0.90
44.4 39.1
0.76
68.8 64.3
0.63
Previous training in conducting funerals No (n ¼ 45) 70.6 Yes (n ¼ 80) 71.6
0.91
45.5 39.7
0.75
70.6 64.3
0.67
Previous training in pastoral care of bereaved No (n ¼ 47) 69.4 Yes (n ¼ 78) 72.3
0.94
47.1 38.6
0.57
66.7 66.2
0.96
Previous placement in hospice No (n ¼ 101) Yes (n ¼ 23)
72.8 63.2
0.58
45.2 29.4
0.24
69.4 50.0
0.11
Previous placement in hospital No (n ¼ 78) Yes (n ¼ 47)
69.2 75.0
0.70
41.4 42.4
0.92
66.7 65.8
0.93
previous training. No statistically significant associations were found. However, some nonsignificant trends are worthy of noting. Of the three denominations, a higher proportion of Methodists consistently reported a desire for training in the three areas, 74.1% for pastoral care of the dying, 47.9% for conducting funerals, and 69.8% relating to pastoral care of the bereaved. The lack of a previous placement in a hospice was also associated with higher proportions desiring further training. Nearly 73%, 45.2%, and 69.4% of those with no previous hospice placement desired more training in the three areas, respectively. The duration of clerical experience was significantly associated with a reported wish for further training in one of the pastoral areas. Those clerics expressing a wish for more training in pastoral care of the dying tended to be less experienced than those who did not (median of 12 years compared to 14 years since completion of clerical training; MW-U: P ¼ 0.04). When considering training/experience received in the past, clerics reporting previous training in pastoral care of the bereaved were significantly more likely to be those who had
received their general ministerial training in the more recent past (median years since completion of training ¼ 11), compared to 18 for those with no training experience (MW-U; P ¼ 0.001). A similar significant association was found between number of years since completion of general training and any reported previous training in conducting funerals. Those having no previous training had a median of 17 years since general clerical training was completed, compared to only 12 for those who reported such specialized training (MWU; P ¼ 0.01). No significant differences were found between those groups of clerics reporting and not reporting previous training in pastoral care of the dying, or previous placements in a hospice or hospital, in terms of period since completion of ministerial training. For one of the pastoral areas, care of the dying, there was a significant denominational difference in rates of previous training experience (Roman Catholic 70%, Anglican 60%, Methodist 40%; c2 ¼ 6.1, df ¼ 2, P ¼ 0.04). However, rates of previous placement in a hospice or hospital did not significantly vary across the three denominational groups.
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Table 2 Association Between Perceived Ability to Perform a Service and Previous Training in That Area Reported Previous Training in Pastoral Care of Dying No (n ¼ 61) Yes (n ¼ 64) P (MW-U) Perceived ability to perform pastoral care of dying (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’
2
3
42.7
67.2
0.003
Reported Previous Training in Conduct of Funerals
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rated their ability on the uppermost points of the rating scale (a lot/comprehensive), 67.2% of those who had received previous training in pastoral care of the dying rated their ability at these levels, compared with only 42.7% of those with no training in this area. For pastoral care of the bereaved, corresponding figures were 84.6% and 57.1%, respectively. Table 3 reports results of analyses investigating how clerics’ rating of their ability was associated with their reported requirement for further training in each of the three procedural areas. Results follow the pattern of the previous analysis associating perceived ability with past training. Those clerics who expressed
No (n ¼ 45) Yes (n ¼ 80) P (MW-U) Perceived ability to conduct funerals (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’ Reported Previous Training in Pastoral Care of Bereaved
3
3
90.0
93.6
0.16
Table 3 Association Between Reported Desire for Further Training and Perceived Ability to Perform a Service Reported Desire for Further Training in Pastoral Care of Dying No (n ¼ 29) Yes (n ¼ 72) P (MW-U)
No (n ¼ 47) Yes (n ¼ 78) P (MW-U) Perceived ability to perform pastoral care of bereaved (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’
3
3
57.1
84.6
0.04
Perceived ability to perform pastoral care of dying, conduct funerals, and to care for bereaved: 5-point rating scale, 0 ¼ no ability / 4 ¼ comprehensive.
Perceived ability to perform pastoral care of dying (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’
3
2
67.9
44.4
0.04
Reported Desire for Further Training in Conduct of Funerals No (n ¼ 53) Yes (n ¼ 38) P (MW-U)
Perceived Levels of Ability in the Three Pastoral Areas, Cleric Characteristics, Previous Experience, and Desire for Further Training No statistically significant associations were found between how clerics rated their current ability in the three areas, and either denomination or years of experience. Table 2 reports association between how clerics rated their current ability and any reported previous training in pastoral care of the dying, bereaved, and conducting funerals. For two areas, pastoral care of the dying and of the bereaved, there were significant differences in rated ability between those who had and those who had not received previous training in the relevant area. When considering only clerics who had
Perceived ability to conduct funerals (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’
4
3
90.2
94.6
0.13
Reported Desire for Further Training in Pastoral Care of Bereaved No (n ¼ 35) Yes (n ¼ 69) P (MW-U) Perceived ability to perform pastoral care of bereaved (median rating) % rating ability as ‘‘a lot’’ or ‘‘comprehensive’’
3
3
84.8
67.6
0.04
Perceived ability to perform pastoral care of dying, conduct funerals, and to care for bereaved: 5-point rating scale, 0 ¼ no ability / 4 ¼ comprehensive.
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a wish for further training in care of either the dying or the bereaved had significantly lower ratings of their ability in these areas. In terms of supporting the dying, 44.4% of those with a desire for future training rated their ability as ‘‘a lot’’ or ‘‘comprehensive,’’ compared to 67.9% who expressed no requirement for training. For pastoral care of the bereaved, the figures were 67.6% and 84.8%.
Multivariate Analysis In addition to the univariate analysis reported above, three logistic regression models were also constructed to estimate effects of a range of potential explanatory variables upon specific outcome measures. Binary outcome variables in the models related to any expressed desire for further training in pastoral care of the dying, conduct of funerals, or care of the bereaved. The explanatory covariates in each model included clerics’ denomination, years of clerical experience, previous placements in hospital or hospital, reported previous training, and perceived ability in the given area. However, when each of the three models was run, no statistically significant associations were found between any of the independent covariates and the risk of positive outcome.
Survey of Training Colleges Forty-two training colleges were identified and 21 (50%) responded. The colleges included Anglican, Baptist, Moravian, Methodist, United Reformed, Baptist, and Roman Catholic denominations and the degrees/qualifications offered included diploma and certificate courses, Bachelor and Masters degrees in theology, and opportunities for study toward a higher degree. The numbers of students ranged from 20 to 102. Colleges were asked to indicate how much training they provided in three general areas: pastoral care of the dying, conduct of funerals, and care of the bereaved. In particular, the survey requested information about theoretical knowledge and practical skill content in the training programs offered. In terms of training aimed at enhancing skills in pastoral care of the dying, 23% of colleges reported that such training had some medical content. Psychological knowledge (58%), sociological knowledge (47%),
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theological knowledge (100%), pastoral support skills (68%), and liturgical skills (79%) were all aspects of training well reported by colleges as making significant contributions to training in this area (‘‘a lot or comprehensive content’’). The number of hours dedicated to this area of training ranged across colleges from 6 to 36 hours (median 25 hours). Duration of training in conduct of funerals reported by the training institutions ranged from 4 to 243 hours (median 12 hours). Only 47% reported that such training included a ‘‘lot or comprehensive’’ inclusion of legal content. Equivalent figures for other components were 63% for sociological knowledge, 100% for theological knowledge, 80% for pastoral support skills, and 95% for liturgical support skills. In the third training area, pastoral care of the bereaved, a ‘‘lot or comprehensive’’ content in training was reported for psychological knowledge (80% of institutions), sociological knowledge (50%), theological knowledge (79%), pastoral support skills (75%), and liturgical support skills (68%). The range of training hours allocated to this pastoral area was 6--34 (median 25). Colleges were asked to indicate whether students were able to visit a hospice, hospital, or nursing home, and whether placements were available. Over 47% of colleges said there were opportunities to visit a hospice and 90% said there were opportunities for a placement at a hospicedthe length of placement ranged from half a day to 4 weeks. A similar number of colleges stated that students could visit a hospital (48%) and had opportunities for placement within a hospital (90%), with the duration ranging from a half-day visit to three months. Nearly 43% stated students had opportunities to visit a nursing home and 38% reported opportunities for placement at a nursingdthese ranged in time from half a day to 200 hours. Eighty-five percent of colleges gave clergy an opportunity to visit a funeral director as part of their training and 19% said placements were available, which ranged from an hour to 35 hours.
Discussion A number of interesting points emerge from this study that require further discussion and
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merit further research. The less experienced clergy, i.e., those with shorter time since completion of ministerial training, were more likely to desire further training in pastoral care of the dying. Previous training in pastoral care of the bereaved and in the conducting of funerals was more likely in those who received ministerial training in the more recent past (i.e., less experienced). It also emerged that the more experienced and possibly older clerics were less likely to have received formal training, but were still unlikely to indicate a desire for any training in the future. We can compare this to areas such as communication skills training for medical and nursing staff within palliative care. Such training is now offered routinely, but the take-up by experienced staff is lowdsuch staff believe that they will already have acquired such skills during their long service within post and do not recognize that they may need such training. In a wide-ranging analysis of spiritual care at the end of life, Cobb13 calls for more training, more consistency, and a more integrated approach to spiritual caregivingda finding echoed by this study. However, in the multivariate analysis, the significance of association with desire for further training found at the univariate level was negated in the logistic regression models and there were no significant independent effects upon outcome. In the survey of training colleges, only a quarter of respondents believed their training to be comprehensive in pastoral support skills. When considering the total number of hours of clergy training, the mean of 25 hours devoted to pastoral care of the dying and bereaved appears quite low when one considers that these are core and key duties of a clergy role.14 There is no uniform syllabus for clergy training. Although the emphasis is on scholarly instruction and knowledge, we would argue that pastoral care and bereavement support should be key components and have greater time than the findings of this survey suggest.15 To feel comfortable working within a particular area or environment, it is essential that staff feel appropriately trained and supported. It was outside the remit of this study to look specifically at stress within clergy, but working in an environment where society expects clergy to have a great knowledge and empathy for
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both pastoral and bereavement care and to feel underskilled in this area would be stressful. Although some denominations, e.g. Church of England, are starting to address the issues of clergy support by nominating a diocese clergy support officer (often a senior clergyman from within a diocese), there is very little in the way of formal support for clergy in general and the key areas of care of self and seeking external support, e.g., after a particularly traumatic bereavement, is still something that few clergy access.16 An introduction to this area and equipping clergy with the skills and resources to debrief is surely as essential as in any other professional group. A weakness of this study is that it only included clergy of Christian faithsdit would be interesting to carry out the same study among other faith group leaders.
Conclusions Pastoral care of the dying and the bereaved is a core activity for all parish clergy. This study has suggested that the majority of clergy perceived the need for further training in this area. Clergy training colleges, although offering placements to clergy within pastoral care settings, were constrained by the amount of time given to this area during clergy training. We suggest that training in care of the dying and the bereaved (including communication skills) should be part of the core curriculum within clergy training colleges and regularly revisited by all those who provide continual ministerial training for clergy.
Acknowledgments The authors wish to thank all those who helped in the development and piloting of this study and to all the clergy for not only taking part but for their interest and enthusiasm. Thank you also to colleagues from the Academic Palliative and Supportive Care Studies Group at the University of Liverpool for their comments on earlier drafts of this paper and to our reviewers for their comments.
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2. Brierley P. Religious trends. London, UK: Marshall Pickering, 1999. 3. Milson M, Dudley J. The importance of spirituality in hospice work: a study of hospice professionals. Hosp J 1990;6:63--78. 4. Singh KD. The grace in dying: How we are transformed spiritually as we die. Dublin: Newleaf, 1999. 5. Dyson J, Cobb M, Forman D. The meaning of spirituality: a literature review. J Adv Nurs 1997;26: 1183--1188. 6. Highfield MF, Cason C. The spiritual needs of cancer patients: are they recognised? Cancer Nurs 1983;6:187--192. 7. Wright M. Chaplaincy within hospice and hospital: findings from a survey in England and Wales. Palliat Med 2001;15:229--242. 8. Orchard H. Spiritual care in God’s waiting room: a review of the questions. Prog Palliat Care 2001;9:131--135. 9. Orchard H. Hospital chaplaincy: modern, dependable? In: Percy M, Orchard H, eds. Lincoln Theological Institute research reports No 1. London, UK: University of Sheffield, Sheffield Academic Press, 2000.
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10. Swift J. The chaplain’s role in care for the dying: toward a new understanding. Can Med Assoc J 1976;115:181--184. 11. Cobb M, Robshaw V. The spiritual challenge of health care. London, UK: Churchill Livingstone, 1998. 12. Wright M. Spirituality: a developing concept within palliative care? Prog Palliat Care 2001;9: 143--148. 13. Cobb M. The dying soul: Spiritual care at the end of life. Buckingham: Open University Press, 2001. 14. Broccolo GT, VandeCreek L. How are health care chaplains helpful to bereaved family members? Telephone survey results. J Pastoral Care Counsel 2004;58(1--2):31--39. 15. Walter T. The ideology and organization of spiritual care: three approaches. Palliat Med 1997;11: 21--30. 16. Lloyd-Williams M, Cobb M, Wright M, Sheils C. A prospective study of the roles, responsibilities and stresses of chaplains working within a hospice. Palliat Med 2004;18(7):638--645.