ISPEC November 2022 Application Form

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Thank you for your interest in the Interprofessional Spiritual Care Education Curriculum (ISPEC) Course scheduled for November 15 & 16, 2022 [VIRTUAL]. At GWish, we envision a world where ALL patients and families have access to spiritual care during a serious or chronic illness. ISPEC is your opportunity to join the movement, leading the way to more compassionate health care systems for everyone.

Application Instructions

Please read the instructions provided throughout the application carefully and address all required information. Use the checklist provided to make sure that all required information is included in your application.

Note: The ISPEC program is designed to be taken as clinician-chaplain pairs, where clinicians partner with a chaplain or spiritual care provider to learn how to collaboratively teach colleagues to integrate spiritual care into their clinical practice and develop goals to integrate spiritual care into their institution. Each organization’s team will ideally include one clinician and one chaplain. We recognize there are situations that do not allow for team participation. If you are unable to attend ISPEC as a clinician-chaplain pair but would like to apply as an individual, please contact Cherron Gardner-Thomas at gwish@gwu.edu.

As you complete the application, please keep in mind:

Each team member must submit a separate application. Have your team member’s email address and phone number available for inclusion on this form.
When completing the institutional information section, please provide information about the organization at which you and your partner will work together as a team to integrate the ISPEC training.
As part of the application, we ask that each clinician-chaplain pair submit three integration goals. Please develop these goals jointly as a team for inclusion on each team member’s application. Please ensure both team members are submitting the SAME goals on each application.

Please ensure all sections are completed. Incomplete applications will not be considered.

You can save your application to complete at another time. Do not start multiple applications – use your return code to continue working on your original application. To save your application to complete later, select “Save and Return Later” at the bottom of the application. DO NOT HIT SUBMIT.

You will be presented with a code – make a note of this code. A box will appear, and you will be asked to enter your email address. A link to the application will be sent to this email. To continue working on your application, click on the link and enter your return code.

Participation in the ISPEC course includes completion of a series of brief evaluation surveys, each of which will take between 5 - 15 minutes. The surveys are part of the evaluation that we are conducting to better understand the experiences of participants in the Interprofessional Spiritual Care Education Curriculum (ISPEC) Course. Your responses will be kept confidential. When we write about the study, you will not be identified, and your name will not be used in presentations or publications. In completing the course application and surveys, you confirm your interest in participating in this research study. Please see additional information at the end of this application.

APPLICATION DEADLINE: All applications are due October 25, 2022. Acceptance notices will be sent out on a rolling basis beginning October 1, 2022. For questions regarding the ISPEC course or assistance in completing the application, please contact Cherron Gardner-Thomas at gwish@gwu.edu.

Thank you! We look forward to reviewing your application.

Application Checklist

General Applicant Information
Institutional Information (One per team - indicate the organization at which you will partner as a team)
Three Goals (One set per team – developed jointly; please ensure both team members are submitting the SAME goals on their individual applications)
One Letter of Support from Supervisor/Administrator

What is today's date?

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D-M-Y

Prefix

First Name

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Middle Initial

Last Name

* must provide value

Suffix

Current Title/Position

* must provide value

Are you an international participant?

* must provide value

Yes

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Address

* must provide value

Address 2

City/Town

* must provide value

State/Province

* must provide value

Zip Code

Post Code (International)

Country

* must provide value

Phone Number

* must provide value

Phone Number (International)

Are you applying with a team member?

* must provide value

Yes

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Team Member Name

Team Member Email

Team Member Phone Number

What is your profession? (Select all that apply)

* must provide value

Advanced Practice Nurse / Nurse Practitioner

Chaplain/Spiritual Care Provider

Counselor/Therapist

Nurse

Nursing Assistant

Occupational Therapist

Physical Therapist

Physician

Physician Assistant

Psychologist

Social Worker

Other

If other, please specify

What is your degree? (Select all that apply)

* must provide value

AA/AAS/ADN

BA/BS/BSN/BSW

DMin

DNP

DPhil

EdD

EdM

MD/DO/MBBS

MDiv

MPH

MSW

PharmD

PhD

ThD

Other

If other, please specify

If you are faculty at an academic institution, what is your rank?

N/A - Not Faculty

Instructor

Assistant Professor

Associate Professor

Professor

Other

If other, please specify

How would you describe your gender?
(Both cisgender and transgender individuals should feel free to use the term with which they identify)

Female

Male

Non-binary/third gender

Prefer to self-describe

Prefer not to say

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If prefer to self-describe, please use the space provided.

Please indicate your ethnicity

Hispanic or Latino

Not Hispanic or Latino

Prefer not to specify

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Please indicate your race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Paciﬁc Islander

White

More than one race

Prefer not to specify

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FOR CLINICIANS: Have you had any previous training in Spiritual Care or Spirituality and Health?

Yes

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Please describe.

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Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

I am a spiritual person.

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I am a religious person.

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How would you describe your religious or spiritual background?

Buddhist

Catholic

Hindu

Humanist

Jewish

Muslim

Native American

Other Christian

Other Eastern Religion/Spirituality

Orthodox Christian (Russian, Greek, Eastern)

Protestant

Spiritual, not religious

Neither religious nor spiritual

Other, prefer to self-describe

Prefer not to answer

If prefer to self-describe, please use the space provided.

Please describe in the space provided why you are interested in participating in the Interprofessional Spiritual Care Education Curriculum (ISPEC) and how you will apply the information in your institution.

* must provide value

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Please describe your previous efforts, including any successes or challenges, at integrating spiritual care or other patient care improvement project(s) at your institution.

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Employing Institute/Program

* must provide value

Address

* must provide value

Address 2

City/Town

* must provide value

State/Province

* must provide value

Zip Code

* must provide value

Zip Code (International)

Country

* must provide value

Phone Number

Work Setting (Select all that apply)

* must provide value

Assisted Living or Independent Living Center

Cancer Center

Long-term Care Setting or Nursing Home or Memory Unit

Home Care Setting

Hospice

Hospital

Outpatient Clinic

Other

If other, please specify

In general, for whom do you provide care?

* must provide value

Adults

Children

Both Adults and Children

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The purpose of this course is to educate clinician/chaplain pairs from the same health setting to:

- Utilize the ISPEC curriculum and resource manual to teach colleagues
- Apply interactive educational methods that lead to results-oriented teaching
- Implement goals in their healthcare setting

FOR CLINICIANS: Learn skills to integrate spiritual care into your clinical practice and teach concepts to others in the organization.

FOR CHAPLAINS: Create the opportunity to partner and teach with a clinician to achieve a broader, more systemic reach across the institution.

The program emphasizes leadership skills, institutional culture change, and team goal development. As a participant, you will be part of a one-year ISPEC© 2022 community. In this community, we will share stories and best practices as you implement your goals and gain experience teaching ISPEC© concepts to others in your organization.

Preparation for completing this objective begins with the development of SMART goals which are:

Specific (simple, sensible, significant)
Measurable (meaningful, motivating)
Achievable (agree, attainable)
Relevant (reasonable, realistic and resourced, results-based)
Time-bound (time-based, time/cost-limited, timely, time-sensitive)

As part of the application, we ask that you submit three goals that will positively impact spiritual care at your institution. Please submit your goals (as a team) related to the institution where you typically work together and plan to integrate the ISPEC course concepts. During the course you will have time to discuss, refine—even change—your goals, but we encourage you to start thinking about them here.

Sample Goals:

Train 10 colleagues in doing a spiritual screening or history by month, year.
Include a flier in all new patient packets explaining our chaplaincy services by month, year. Implement in one unit by month, year.

Goal 1:

* must provide value

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Goal 2:

* must provide value

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Goal 3:

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Letter of Support from the Institution's Administrator/Supervisor (Required)

The successful implementation of the curriculum will depend on the support and commitment from your institution. Therefore, one letter of support must be included in your application. The letter of support should demonstrate your organization's commitment to foster change in clinical care and facilitate the implementation of ISPEC training programs, following completion of the course. An administrator/supervisor from your institution must provide one letter on company letterhead indicating his or her support and commitment to your attendance at the ISPEC Course and efforts to extend spiritual care skills training in your clinical setting. Team members are welcome to submit the same letter from an Administrator or Supervisor from the institution where they will work together as a team to integrate the ISPEC training.

Administrator/Supervisor Name:
Administrator/Supervisor Email:
Administrator/Supervisor Phone:

Attachment:ISPEC LOS Template.docx

Thank you for completing the letter of support. Please upload.

* must provide value

Upload file

Informed Consent for Participation in a Research Study

Title of Study: Advancing Spiritual Care – Interprofessional Spiritual Care Education Curriculum (ISPEC) Train-the-Trainer Program
IRB#: NCR224112

Principal Investigator Name: Christina Puchalski, MD
Version Date: November 15 & 16, 2022

You are invited to participate in a research study under the direction of Dr. Christina Puchalski of the Department of the School of Medicine and Health Sciences, George Washington University (GWU), and paid for by The John Templeton Foundation.

The purpose of this study is to better understand the experiences of participants in the Interprofessional Spiritual Care Education Curriculum (ISPEC) Course. Your participation in this evaluation study will provide ongoing assessment of participant satisfaction and program effectiveness, facilitating ongoing innovation in curriculum development, participant mentorship, and goal implementation. Data from this study will further allow for sharing of best practices and recommendations for spiritual care education. Further information regarding this study may be obtained by contacting Dr. Christina Puchalski, Principal Investigator, at telephone number +1.202.994.6220

This course is being offered as part of a generous grant from The John Templeton Foundation. As part of your participation in this 2-day course and one-year post-course mentorship, you will be required to complete eight ISPEC evaluation surveys.

The total amount of time you will spend in connection with this study is approximately 100 minutes. Participants may be contacted by email/phone for retention purposes and to improve survey response rates. We will be collecting your survey responses. By agreeing to be in this research, you are consenting to the researcher's use of your survey responses for research purposes, which is voluntary. In addition to two daily course evaluations, as a part of this research study you will be asked to provide information at five points in time including the course application and pre-course surveys, and four post-course online evaluations at the following intervals: Course completion, 3 months, 6 months, and 12 months.

At each of these points of time, we estimate it will take:

Application and pre-course surveys - 25 minutes
Daily Evaluations - 5 minutes each
Post-course survey - 10 minutes
3-month evaluation - 10-15 minutes
6-month evaluation - 15-20 minutes
12-month evaluation - 15-20 minutes

As in most behavioral research studies, possible risks or discomforts you could experience during this study include the potential for emotional and/or psychological risk. However, such risk is low, since the evaluations primarily involve participants’ satisfaction with educational programming and successes at implementing related goals in spiritual care at their home institutions. Since some aspects of the evaluation process involve linked data, there is a possible loss of confidentiality prior to data being deidentified for evaluation purposes.

Every effort will be made to keep your information confidential, however, this cannot be guaranteed. We will link participants’ pre- and post- survey responses, but subject names will not be used for linking the data. The personally identifiable information collected will be coded using a unique ID# or fake name (pseudonym). The coded lists are only accessible to the research team. The information that has your personally identifiable information will be kept separately from the rest of your data for data analysis. De-identified data may be used for future ISPEC-related research. If results of this research study are reported in journals or at scientific meetings, the people who participated in this study will not be named or identified.

You will not benefit directly from your participation in the study. Indirect benefits of participation include personal growth and increased self-knowledge. The benefits to science and humankind that might result from this study include support of our ongoing efforts to promote curricular improvement and advance the field of interprofessional spiritual care in health settings.

The Office of Human Research of George Washington University, at telephone number (202) 994-2715, can provide further information about your rights as a research participant.

By agreeing to be in this research, you are consenting to the researcher’s use of your survey responses for research purposes, which is voluntary. Your willingness to participate in this research study is implied through your application submission.

*Please keep a copy of this document in case you want to read it again.

Attachment:ISPEC2022_Informed Consent.pdf

Are you Demonstration Project?

Yes

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Are you Faller teams?

Yes

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