This study will investigate the positive effects of intercessory prayer on health care outcomes and propose an underlying construct of "Consciousness."  In 1988, a report appeared by cardiologist Randolph Byrd, M.D. of a controlled double blind study of 200 persons (from a sample of 400 patients) who while receiving otherwise standard care for cardiac surgery at San Francisco General Hospital also received systematic intercessory prayer by community volunteers.  A positive effect attributed to the prayer was measured by means of an accepted methodology and statistical treatment at p < .01 for the experimental group.  Because of its methodological design  this proposed study will replicate and enhance the Byrd study in order to:

(1)  Determine if intercessory prayer effects as demonstrated by Byrd can be detected by replication using this experimental protocol,
(2) assess whether chaplains (as a group) will present statistically higher scores on measures of consciousness than patients (as a group), assess whether patients and chaplains can be grouped by measures which operationally define attributes of "Focused" or "Expanded"  Consciousness"  that can be related to measures of health status and outcomes,
(3)  Assess whether chaplains can be found to be grouped as measured by the operational definitions of  focused or expanded Consciousness and other demographic factors,
(4)  Given detection of the Byrd effect, whether significantly greater effect will be found in patients prayed for by clusters of chaplains representing expanded  Consciousness, and
(5) Given the presence of intercessory effects from the chaplains' intercessory prayer, what impact on reduction of the health care costs can be detected.

(1) recommend specific chaplain training interventions to enhance the standard of effectiveness for the entire chaplaincy;
(2)  identify means to improve the nomenclature, taxonomy  and descriptive indicators  of "Consciousness" and other signature characteristics; and
(3) propose an ongoing cluster of studies.

 Introduction:

     This proposal presents a plan to further study the contributions of intercessory prayer as a component of the clinical support of chaplains and other pastoral care providers in serving a patient's religious and spiritual needs.  Intercessory support for these needs is expected to be associated with positive health care outcomes and reduced cost  of care.  This is a process in which chaplains are critically important catalysts.  First the study will replicate Byrd (1988) to determine whether the positive effects are detectable in a complex health care setting.. Then by using a "Consciousness" paradigm (Harmon, 1992;  Hameroff, et al. 1996;  Chalmers, 1996a,b) the study will determine whether chaplains and patients can be clustered into groups by operational measures of  that construct.  Finally, if the effect can be detected, the study will document  whether there is a modified relationship when  chaplains are grouped sharing common traits on the scale of Consciousness compared to the general effect.  This study further intends to document the potential cost savings created by such chaplain intercessions in providing spiritual support for a patient's recovery.  Collectively, such effects can have a significant salutary impact on reducing the cost of health care for such patients and inhibiting recidivism. In response to a goal of the RFA, this proposal promotes interdisciplinary collaboration in the alternative area of mind-body medicine. In addition to chaplains, diverse contributors to this proposal and subsequent project development will include physicians, psychologists, and research methodologists working in religion, engineering, social science, and health care fields. At  time of submission of this proposal, 17 VA Medical Centers (VAMCs) providing  cardiac inpatient surgery with a combined potential sample of 1543 inpatient episodes during the proposed window of study, and 125 chaplain intercessors, have officially committed to support this project.
     The Byrd (1988) study, the foundation for this proposal, was a controlled double blind study of 200 cardiac patients (from a sample of 400 patients) who while receiving otherwise standard care for cardiac surgery at San Francisco General Hospital, also received systematic intercessory prayer by community volunteers.  The outcome demonstrated a positive effect attributed to the prayer as measured by means of an accepted methodology and statistical treatment.  Byrd found a positive impact of prayer (at p < .01) on the recovery and wellness of the experimental group.   The six variables most contributing to the overall  positive effect are cost intensive and were absent or minimal for the prayed for group. These included:  (1) congestive heart failure, (2)  cardiopulmonary arrest, (3) pneumonia, (4) need for antibiotics,  (5) intubation or ventilation, and (6) diuretics.  Byrd did not control for characteristics of praying agent, prayer style, or patient characteristics which this study will do.
     The Bryd study did not occur as an isolated phenomenon or anomaly, but in the context of several independent bodies of research over the past decade that relate in some way to phenomenon underlying the effects demonstrated by Byrd.  These other areas include, (1) a consistent positive relationship of a variety of measures of "religiosity" and "spirituality" to patient health status and outcomes of medical interventions, (2)  effects of human intentionality to promote accelerated and more effective recovery from various wounds and other physical dysfunction, (3) studies of the ability of human intentionality to affect the behavior of a variety of microorganisms and other life forms,  (4) studies showing the responsiveness of subtle energy emanations from the human body to human intentionality yielding a positive correlation with the subject's physiological measures, (5) the capacity of human intentionality to alter the otherwise random outcome of electromechanical Random Event Generators (REGs) at statistically significant levels, and (6) documented evidence acquired under rigorous scientific controls of the capacity of ordinary people to accurately experience at statistically significant levels, anomalous perceptions of target information from remote target sites.

 1. Specific Aims

A. The aims of the proposed study by the Department of Veterans Affairs (VA) intends to address the following research questions:

 1. Aim #1: Can the positive effects of chaplain intercessory prayer for cardiac patients be detected in VA Medical Centers (VAMCs)?  Intercessory prayer will be associated with improved clinical outcome in cardiology patients as measured by the physiological measures used in the Byrd study.   Within the complexity of the VA's large national health care system, the proposed study will replicate the basic protocol of Bryd (1988), but with the following enhancements: (1) use of professional chaplains, (2)  more explicit definitions and controls for prayer protocols and measures of types of prayer, (3) defined praying agent and patient characteristics, and  (4)  with the chaplains  widely dispersed across the VA's complex national health care system and while otherwise continuing their normal operational duties.

 2. Aim #2:  Can chaplains be grouped  by measures which operationally define a spiritual, religious, psychological and practice pattern profile so as to define discrete typologies of  chaplains?  Can patients be likewise clustered on related traits?   A pattern of standard survey  measures of religious, spiritual, and psychological variables will collectively define a construct called "Consciousness"  having the characteristics of being "Expanded (EX)" or "Focused (FO)."  At the outset of the study multivariate analysis will process the scores on the variety of  instruments and other data  to determine whether chaplains can be identified as members of groups sharing common characteristics or patterns of scores on these standard instruments and other demographic data.   If found, a factor analyzed short form of these measures will be tested to subsequently assess patients.  Patient clinical outcomes will be used to control for the intercessory effects of chaplain prayer.  Patients demonstrating expanded Consciousness are expected to do better in recovery than patients showing focused Consciousness independent of intercessory prayer.   Membership of a chaplain or patient in their respective statistically defined cluster or group will be referred to as a "signature" which is representative of some quality of "EX Consciousness" compared to FO Consciousness as operationally defined by the pattern of scores on the measurement data.

 3. Aim #3:  Can the variance of the experimental effect of intercessory prayer be associated with discrete chaplains clusters, i.e., with shared or common signature characteristics associated with Consciousness?  Chaplains are expected to score higher as a group on Expanded Consciousness than patients as a group.   Then a  question will be posed to compare chaplains with "Focused" Consciousness"  with Chaplains with "Expanded"  Consciousness in order to detect the presence of any significant variance in their intercessory effects on patients.

 4. Aim #4: Special Report & Recommendations for Rapid Implementation of Project Findings:  The VA Chaplaincy has made a major commitment to this self-examination as key clinical providers in support of our veteran patients' healing and wellness.  This project has implemented an innovative approach to project design and management called a "Holistic Experiment"  (Mitroff & Blankenship, 1973 & Van Gigch, 1978.)  An interdisciplinary "Science Court" in conjunction with VA chaplains will collaboratively interpret the significance of the findings for "rapid turn-around" proactive and healing interventions to apply the findings and enhance Chaplain effectiveness in interventions with patients.  Report recommendations will::   (1)  enhance the chaplaincy through continuing education interventions for the professional services of the Chaplaincy,    (2)  recommend means to integrate the construct of Consciousness  to more effectively assess the implications of such profiles for chaplain intercessors and participating patients, (3)  facilitate recognition of future research alternatives, and   (4)  develop a near and long term research planning horizon for the chaplaincy and pastoral counseling; i.e. to  assess contributions of current intervention procedures and further define and design improved intervention protocols for chaplains.

 2. Background and Significance

A.  Effects of religiosity and spirituality related to health:    The following literature provides a context for the relationship of religiosity and related surrogates for human "Consciousness" as contributory to health.

 Larson and Larson (1992) have presented extensive conclusions based on a  systematic review of literature with those findings applicable to religion and spirituality as independent constructs affecting health.  They have concluded that religion and spirituality are profoundly important forces in wellness and recovery, but have suffered from inappropriate adverse neglect and prejudice.  Larson et al  (1986.) stated that only one percent of 2,348 studies included one or more religious variables, and only one study included a multidimensional religious commitment questionnaire that had been tested for its statistical accuracy.  They carefully document the variety of ways that competent research has shown the efficacy of spiritual forces as factors in wellness and recovery.  The following studies are reported by the Larson and Larson (1992) reference:

 Mental Health:  The authors cite a number of studies that document a consistent negative, discounting and even hostile attitudes among segments of the scientific community.    They note that a Gallup poll (1985) demonstrated that about 72% of the US population state that their "whole approach to life is based upon religion."  However only 33% of psychologists, 39 % of psychiatrists,  46 % of social workers and 62 % of family therapists were religious according to Bergin and Jensen (1990).  This discrepancy between the general population can be expected to appear within the VAMC community and affect the capacities of treatment teams that include mostly psychologists, psychiatrists, and social workers.  While competent chaplains build their own credibility over time even with resistant clinicians, some chaplains are sometimes excluded from meaningful involvement on treatment teams, and when they are included sometimes experience discounting and rejection.  Even support for the role of chaplains and pastoral counselors from psychiatry (Waldfogel & Wolpe, 1993) does not acknowledge or affirm chaplains as devoted and effective agents of spiritual intercession.  Pastoral counselors are useful in treatment teams not as literal agents of healing but as "culture brokers" to mediate (as though they were separate) medical treatment with the religious structure and experience of the patient.

 Depression:  Among elderly female patients subject to the severe trauma of hip replacement surgery, recovery as measured by effort and success at walking was positively correlated with religious beliefs (Pressman, Lyons, Larson & Strain, 1990).   Four other studies are documented whose results are consistent with these effects.    Re-Stress and Well-Being:  Williams et al, (1991) found that both direct and symptomatic expressions of stress measures correlated with religion with the effect that stronger religious involvement produced better coping and less systems in the presence of induced stress.  Similar results were obtained in epidemiological studies by Lindenthall, et. al. (1970) and Stark (1971.)

  Physical Health (Longevity, Blood Pressure, Cardiac Disease):  Zukerman, Kasl and Ostfeld (1984) reported in an epidemiological study in the New Haven area that mortality levels after hospitalization were less when patients were involved with religion, and that the discrepancy doubled after two years.  The effect was sustained when race, gender, age, health measures and prior hospitalizations were controlled.  Likewise, after controlling for other variables House, Robbins and Metzner (1984) found that in an 8 to 10 year follow up of 2,700 persons, of women only, increased church attendance was found to be protective of mortality.
 In another 1988 study, Koenig, Kvale and Ferrel found that religious attitudes, activities and commitment tended to affect measures of health, while sociodemographic factors such as church attendance, group support and financial aspects, tended to more directly affect coping, morale and well being.  The authors conclude in support of the role of chaplains, that:

 "The pastoral counselor often with considerable training in both psychological and religious methods, may play a vital role in fulfilling the expanding need for mental health care... a moderately strong association between religion and morale in a sample of community-dwelling elderly has been demonstrated in this present study, and suggested that religious behaviors and attitudes are involved in the complex interacting of health and sociodemographic factors affecting well being."  (Page 27)

B.  Effects of prayer and mind-body intercession

     A recent study by ÓLaoire (1993) investigated the relationship of intercessory prayer to measures of self- esteem, trait anxiety, and  state anxiety, and permitted the subjects to self-enroll into either the "praying" called  "agent" groups or as subjects who were  "prayed for" or "recipient" groups.  He, then randomized the subjects into an experimental (prayed for) group and control group (not prayed for.)  He  found higher initial scores on objective profiles for the agent group over the subject group both before and after, and found strong positive effects for both the prayed for and control group (p < .02-10-6) on all measures.  What then, is the mediating factor accounting for the effect of prayer?  Effects through a mediating  mental state may be more subject to influence than the physical state as stated by Braud, Schlitz & Schmidt, 1989, and Braud, Bain and Schweers, (1992),  both cited in ÓLaoire, (1993).   Poloma (1993) found that religiosity and four types of prayer (colloquial, petitionary, ritual and meditative) were positively correlated with responses to questions on indexes of negative affect, existential well-being and happiness.  Effects were: meditative prayer associates with existential well being, colloquial prayer with happiness, meditative prayer with existential well being and religious satisfaction, and ritual prayer with negative affect.   Chaplains and patients will complete a measuring instrument built upon Poloma's factors of prayer style.
 Interactive effects with Ayurvedic natural compounds have shown consistent positive results in the following areas: Cancer, cardiovascular disease, blood pressure, cholesterol, stress reaction, cognitive functioning, retardation and aging, immune functioning, reduction of the pathogenic effect of free radicals.  In his review of the above research, Bodeker (1992) states:   "Specific reductions have been observed in cancer, organ pathology associated with high fat diets, and in blood clotting. Generalized effects on immune functioning and central nervous recovery and functioning have also been observed." (p 17)

 According to Braud and Schlitz (1991):

"Findings from the areas of hypnosis, autogenic training, biofeedback training, psycho physiological training, placebo, meditation, and imagery research indicate that mental processes, especially intentionality, can have dramatic somatic effects."

"A significant relationship was found between the calming or activating imagery of one person and the electrocardial activity of another person who was isolated at a distance (overall Z = 4.08, p = .000023, mean effect size = 0.29). Potential artifacts which might account for the results are considered and discounted.  The findings demonstrate reliable and relatively robust anomalous interactions between living systems at a distance."

C. Effects of  Remote Influence in Small Animals

 Effects have been found for electrodermal activity, blood pressure, muscular activity, spatial orientation of fish, locomotor activity of small animals, and rate of hemolysis of red blood cells.  These findings have accumulated in over 13 year of experiments and the possibility of anomalous effects are accounted for. The effects are not due to subtle cues, recording errors, expectancy or suggestion, artificial responses to external stimuli, confounding internal rhythms, and chance or coincidence.  These conclusions are reported in Braud and Schlitz (1983.)

 Braud and Schlitz (1991) have considered the psychological variables which can facilitate or impede direct mental influence effects. The recipient of influence can facilitate the effect by their "felt need" to be influenced (p 37).  There may be personality variables which affecting the intercessor.  They conclude: "A `successful' session may depend upon the presence of certain psychological conditions in the influencer, the influencee, and perhaps even in the experimenter, and these critical psychological ingredients may not always be reproducible."   They consider that confidence, expectation, absent resistance can be positive while boredom, non spontaneity, poor mood and rapport, defensiveness and excessive egocentric striving may inhibit success.

 O'Reagan (1987) and Seigel (1986, 1989) have commented on the growing evidence for subtle mental influences affecting the remission of illness.  Most importantly for the intent to build a Spiritual Paradigm, Braud and Schlitz conclude from more than 13 years of investigation into subtle energy phenomenon that:

 "Regardless of how the effect is mediated, its very occupance presupposes a profound interconnectedness between the influencer and the influences in these experiments.  The mental processes of the influencer are able to have non-local effects.  This in turn suggests that the mental processes themselves may be non-local, rather than restricted to a particular spatiotemporal locus within the brain of the influencer. ...The successful outcomes of these experiments suggest that, in principle, judiciously selected directional mental influences could be focussed upon particular organs, tissues, or cells of specific persons in ways that could be medically relevant."  (p- 42, emphasis added)

 Hawthorn and placebo effects:   Both effects have given constant clues over the years as to the importance of the observer (healer, experimenter) in determining the power of their minds to influence the outcome of complex human processes.  The following observations and quotes are found in Schwartz (1992) in regard to the placebo effect:

 "What is even more startling than the conscious biofeedback technologies is the unconscious self- regulation demonstrated by the placebo effect.  The placebo concept, so well established in the medical protocols that it is a given, has another side rarely considered.  As Harvard researcher Henry Beecher noted in a 1955 JAMA article,

 'The constancy of the placebo effect... in a fairly wide variety of conditions...suggests that a fundamental mechanism is operating in these several cases, one that surely deserves further study... Many effective Drugs have power only a little greater.' [Beecher, 1955]

 The full implications of this remarkable phenomenon have received remarkably little attention.  It took a non-medical person, Norman Cousins to frame the idea:

`The placebo has a role to play in transforming the will to live from a poetical conception to a physical reality and a governing force... it leads us through the uncharted passageways of (the) mind." [Cousins, 1977]

  `This remarkable efficacy should not be discarded or ridiculed.  After all, unlike most other forms of therapy, the placebo effect has withstood the test of time and continues to be safe and inexpensive.'" [Benson & McCallie, 1979]  (pp 7-8)

D. Effects of human intentionality on mechanical processes

 Another area in which the evidence for human intentionality affecting the behavior of other systems has been documented and tracked is useful to this study because the effects can be observed in ultra-stable electro- mechanical systems which are not confounded by the interaction effects of complex human biology.  The Princeton University Engineering Anomalies Research (PEAR) laboratories have reported on a complex series of ongoing experiments beginning in 1979 (Jahn & Dunne, 1987.)   Dunne, (1991) reports that:

 "The results of some 840,000 trials per intention ( a total of more than 504,000,000 binary samples) generated on this REG [Random Event Generator] by 91 different individuals over a twelve year period, show statistically significant correlation between operator intentions and the mean counts of 200 sample trials.  Although the observed effects are quite small (the mean of the high efforts is 100.026 and the low efforts 99.984), given the magnitude of the data base, the likelihood of this large a separation occurring by chance is less than 5 x 10-5."

 (1) Intentionality of operators produce effects statistically greater than chance; there is a consistently greater effect for high perturbations from chance than for low; (2) Individual operators can be recognized by consistent "signatures" appearing in the data patterns they generate, results from diode and shift- register base devices are statistically indistinguishable (within some conditions); (3) distance of the operator from the device (up to several thousand miles) produce no statistical difference in effect; (4) Variations in operator protocols (run length, mode of assignment, control of trial initiation) are important for some individual operators but not for the fully concatenated data base; (5) There appears  to be a consistent pattern of enhanced effect in the first series of runs, with decline in the next two series, and recovery thereafter to approach the initial effect; and (6) Feedback showing the results of their effort tentatively appears to be marginal and conditional upon the interaction of  feedback.

 "...what is of overarching interest here is the possibility that the Consciousness of the operator, using that capacity for which it is most extraordinarily equipped--the processing of information--has in these interactions entered proactively into the affairs of the physical world, rearranging not only a portion of the information array, but thereby accessing its energy, and thence, by inference, its very substance.  Extrapolating to more general implications, this model would thus suggest that the third side of the mass- energy-information triangle of physical currencies can provide a natural entry for human Consciousness to participate in the construction of tangible reality..." (Jahn, Dobyns, & Dunne, 1991).

 "These extensive databases constitute strong evidence for the correlation of marginal but highly significant shifts of the output distribution means, relative to the theoretical expectations and to unattended calibrations, with human operators pre-recorded intentions. ...Further insights follow from transcribing various quantum mechanical principles such as Exclusion, Correspondence, Indistinguishability, Uncertainty, and Complimentarity into more explicit Consciousness terms and applying them to specific experimental situations." (Abstract)

E. Literature  Contributing to the Study's Survey Instruments Supporting  the Major Thesis of  the Study

    What defines an underlying construct of "Consciousness?"  The following body of literature suggests that "Consciousness" can be assessed as the collective set of factors defining expanded or heightened awareness of "self" in the context of the larger order of perception and experience, or focused or narrowed with respect to that realm of potential experience. Goalder (1990) found that advanced spiritual maturity links heightened Consciousness with various measures of life adjustment, e.g., with reference to scores on Beck (1961).
    Likewise, "Consciousness" can also translate into the findings reported by Koenig (1988) in his use of the Springfield religiosity measures to assess health correlation among elderly and depressed  patients.  There is a consistent pattern of  linkage among the following fields of inquiry that can be the underlying fabric of an integrating construct of Consciousness.   Such studies include:

(1) Schroeder et al's (1978) continuum of concrete (focused-limited)- abstract (expanded flexible)  human information processing styles which are also consistent with
(2) Adorno, et al's (1950) construct of "authoritarianism personality",
(3)  Rotter's (1966) constructs of external-internal control),
(4) Deci (1975), intrinsic-extrinsic motivation,
(5) Hoge's (1961) intrinsic-extrinsic religiosity (scale used in this study),
(6) Goalder's (1990) application of Spilka et al's (1977) Intrinsic- Extrinsic religiosity (scale used in this study),
(7)  Kohlberg's (1967) stages of moral development (accounted for in the 16PF scales to be used) which demonstrates a person's moral-ethical behavior the progression of "Consciousness" from wholly ego centered agendas through the highest human expressions of agapic love and service to others,
(8) in the "personal growth" subscale of the Quality of Life Questionnaire (Evans & Cope, 1989),
(9) in Achterberg and Lawlis' constructs in their Health Attributes Test (used in this study), and
(10) Cattel's (1989,1992) personality factor traits yielding the PF16 multivariate measures also used in this study.

(A) warm-cool,
(B) Concrete-Abstract Intelligence,
(C) Instability-ego strength,
(E)  control-deference,
(F) Exuberant-somber,
(G) Moral strength, low/high super-ego,
(H) Bold-timid temperament,
(I) the Jungian construct of feeling vs thinking (also measured by Myers-Briggs),
(L) alienated-identification in social orientation,
(M) Intuiting-sensing (also Myers Briggs),
(N) self-presentation, as artless-shrewd,
(O) Guilt, untroubled-troubled; and three undergirding derived constructs,
(Q1) Change Orientation,
(Q2) Self-sufficiency- dependence, (
Q3) High self sentiment (discipline)-Low self-sentiment, and
(Q4)  Tense-relaxed temperament.

 Based upon the operational definition of "Consciousness" presented in Table 1, following are the complete set of research hypothesis for this exploratory study:

1. Intercessory prayer effects will be associated with improved clinical  outcomes on physiological measures used  by Byrd.

2. Chaplains and patients can be identified by measures which operationally define an underlying construct called "Consciousness"  that can be related to more positive measures of  health status when Consciousness is expanded or less positive outcomes when Consciousness is focused.

3. Chaplain as a group will present statistically higher scores defining Expanded Consciousness than patients as a group.

4. Patients defined by Expanded Consciousness will show greater improvement in clinical outcomes than patients with Focused Consciousness.

5. Chaplain can be found to be grouped on measures of common characteristics defined by the operational measures of  Expanded/Focused Consciousness.

6. Given detection of the Byrd effect, significantly greater effect will be found in patients prayed for by groups of chaplains representing Expanded Consciousness.

  The concept of Consciousness is an appropriate mediating mechanism for the effects of non-local influences defining "Era III" medicine (Dossey, 1989.)   Saudia et al (1991) have shown the relationship of health locus of control to the effectiveness of prayer.
    What then is the personal and professional impact on chaplains who may demonstrate patterns of disability identified with expanded or focused Consciousness?  Is there a measurable difference compared to chaplains who show strength in association with the construct?   Is there a correlation with intercessory potency of chaplain intercessor if the effect can be detected?  Do clues to designing a loving, compassionate (i.e. spiritually grounded) remediation become accessible if the patterns are revealed?      In the context of the above pattern of reports,  the spiritual health of chaplains, and the profiles of patients on the above measures ought correlate with the extent and scale of potency of intercessory prayer and its benefits if the effects can be detected.  The Myers-Briggs (1987) as interpreted by Keirsey & Bates (1987) will also be used to assess chaplains and provide confirmation using this instrument as a widely validated context on the basis of their four factor continuum.

F.   Cost benefit studies related to the contributions of Chaplains

     Costs are mediated by positive clinical effects. Patients who recover more quickly than others consume less resources and are discharged from various types of Intensive Care Units (ICU) and the VAMC sooner.  Although costs associated with the impact of intercessory prayer have not been systematically integrated and studied until now, the potential health effects of intercessory prayer are only one of the beneficial impacts created by chaplains in their support of a patient's spiritual needs.   Cost-benefit studies already suggest the important role of chaplain intercessors simply as members of the treatment process.  McSherry et al (1987) has concluded that the spiritual resources generated in elderly men have not been adequately nourished by their health care community in order to develop their own intrinsically strong spiritual resources, thereby creating a condition that makes the spiritual contributions of the Chaplain during the hospitalization of such patients all the more important.
     Cuillia et al (1988) has found that the capacity for chaplain mediated meaningful religious and spiritual involvement of patients reduces the need for a variety of health services with direct implications for cost containment and reduction. McSherry, et al (1988) have found that the dualistic values between mental health professionals (materialistic science) and clergy (spirituality and religion) can confound the thoroughness of mental health services to needy clients (a cost amplifying condition) who may approach either group unilaterally. (See also Larson et al, 1988) The findings suggests the need for greater integration of chaplains into the functions of treatment teams, a trend that can be facilitated by improved chaplain credibility with clinical providers and administrators in documentation of chaplain effects on patient outcomes and wellness, and the attendant cost benefits of such effects.  Likewise, chaplain contributions to systemic change in Medical Center practices can also be enhanced by the "value added" involvement of chaplains in Total Quality Improvement activities, provided they submit to the discipline of documentation.  (McSherry, et al, 1992, See Appendix 3.)
     Other findings show the translation into economic savings when the elderly (a significant number of VA inpatient episodes of care) requires less intense or prolonged health care as a result of a heightened spirituality that Chaplains can nourish in their VA veteran patients (McSherry, 1991.)

G. Limitations and Conditions

  The purpose of this study is to determine if the effects of prayer can be detected in both patient outcomes and cost reduction when applied across a large complex health care system in the face of a number of factors than can mitigate or confound detecting the intercessory effect.   The study does not need to "prove" that prayer works, or that chaplains are equal to or better than the intercessory agents used by Byrd or others.   The above cited literature gives ample evidence of the intercessory or volitional power of human intentionality, and there is also a growing literature as represented above, e.g., McSherry & Nelson (1993) that independently affirms that chaplains are effective agents in reducing the cost of care for some patients.   The possibly limiting factors that confront this study are:

(1) prayer external to the study: Byrd addressed the confounding effect of external prayer in behalf of some patients, but a large number of patients in the study can randomly distribute the possibility of this effect;
(2)  patient placebo or Hawthorne Effect:ÓLaoire (1993) has shown that simply knowing that one is in a prayer study, whether assigned to control or experimental groups within the study, can produce significant effects in the control group. Hence because of informed consent, the entire participating patient population can show gains that can not then be differentially detected in the absence of a large retrospective database,
(3) chaplain Hawthorne effect:  A reading of the above literature on human intentionality suggests that the intercessory effect is subtle and subject to confounding by emotional states of the agent.  Byrd had the advantage of a low profile study using prayer agents who were acting normally and simply included Byrd's patients in their ongoing prayer circles or groups.  This  study required notification and permissions of large numbers of VA staff thus forcing the study to prematurely become high profile among the chaplains.  Their acting as prayer agents for the experimental sample will be in addition to their regular duties, and the novelty and "pressure to succeed" may itself confound effects that might otherwise be present.   Further chaplains who attend to the patients as part of their normal duties, but who are not the study's assigned prayer agents for a particular patient can inadvertently if not deliberately give additional prayer attention to their patients and thus confound any differential effects, and
(4) systemic Confounding:  This could arise from the complex logistical task of orchestrating for the first time,  more than 1000 chaplains and their patients using an untested protocol such that  unforeseeable interactions may act to confound the intercessory effects.
 Therefore, if effects can be detected in the face of this challenging array of possibly confounding factors, such an outcome will be a finding of major proportions and worthy of serious attention in the subsequent studies which will follow. This effort, then, must be accepted as an "exploratory" study in the truest sense of the term.
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The Study's  Larger Context:

Observers have stated that if the Byrd effect had been caused by a drug, it would have been called a miracle drug.   If intercessory prayer effects can be detected under the conditions of this study, then there are implications for an emergent holistic paradigm.  Studies by the PEAR (Princeton Engineering Anomolies Laboratory)  and elsewhere have demonstrated that human intentionality, volition, or intercessory prayer and other non-local effects are not subject to the normal electromagnetic laws of wave propagation.   Intercessory prayer effects must then be seen as either commanding some other kind of concentration or focusing of the human energy  and/or intelligence fields by participating with some kind "master field" of intelligence, energy or information.   What is now an "ill- defined" or  inadequately labeled medium forces the use of inadequate descriptors, e.g., God's presence,  mediating field of God, field of God intelligence, etc..   Likewise there are no constructs to adequately capture the linking mechanism such that a human intercessor must be inadequately described as serving as a "conduit" or "lens" for focusing this master energy-intelligence-force on a target patient.  Until now, such linkages have been dismissed by orthodox science as anomalies or superstition.
     The possibility for an emergent holistic paradigm is highly consistent with a body of established scientific literature (e.g., Bohm,  1980) and defined by General Systems Theory (GST)  initiated by Bertalanffy, (1968).  In the massive taxonomy of GST and its exhaustive research defense offered by Miller (1978) his "high confidence" hypothesis (#5.4.3-6,  page 109) states: "The more decentralized a system's deciding is, the more likely there is to be discordant information in various echelons or components of the decider." e.g., in the controlling elements of the human body, specifically the immune system.   This hypothesis can be interpreted as a systems definition of illness in which the dynamics of prayer is to provide some kind of reintegrating force, energy, information and/or intelligence to restore the holistic capacity of a pathogenic human physiology.
     The capacities of an intercessor to act within, through, or by involvement with a "God field" induces or produces healing.  This hierarchy of the holistic integration of systems is consistent with Pearce's (1981, 1988) and others assertions that all lower echelons of living intelligence are embedded in and must surrender to and accept direction by the higher systems of which they are a part.  Pearce (1981) illustrates the emergence of the controlling elements of the maturing human is progressively served by higher functions of  the echelons of  three human brains;  from infancy (control dominated by medulla/brain stem) to childhood (control surrendered to the cerebrum) and finally adulthood (control surrounded to the cerebellum.)   In this model, to what medium does the mature holistic  human surrender?  If Expanded Consciousness as operationally defined in this protocol  can be shown to positively correlate with intercessory effects produced by prayer, a major plank will have been added to the emergent platform supporting a 21st Century practice of holistic medicine and science.

 4. Research Design and Methods

The complete sequence of project activity, including selection of variables, project methodology, statistical treatments and functions of project staff are all accounted for in the following sequence of steps:

A.  Data Collection

1. As of June 4, 1993,  17 VA Medical Centers (VAMCs) have committed to support this project by providing cardiac patients and managing the research protocol for those patients.  125 chaplains from the 171 VAMC's have committed to support the project as praying chaplains.  Letters of commitment from each participating facility are on file at the VA Chaplain Center in Hampton.  Because of the constraints in obtaining commitment under short notice, the numbers are expected to increase, perhaps significantly, by the time the study is initiated.   Based on VA figures for the a six months window in 1992 which approximates the anticipated stud, cardiac inpatient enrollment from February through August of 1994 was assessed.  The 43 VAMCs conducting cardiac surgery have an approximate collective volume of  3,640 inpatient cardiac care episodes.   Only 400 episodes are required to replicate Byrd.  The number of chaplains committed as praying agents required to serve the number of approximately 200 experimental patients in the Byrd study is 40  if each patient is to have an average of five intercessors.  Byrd used from three to seven intercessors.   At time of submission of this proposal,  a total of 18 cardiac VAMCs had officially committed to provide a potential sample of  approximately 1,543 cardiac patients.   Chaplains committed to be intercessory agents are 125 on June 4.  This number permits an experimental sample of from  625 (with 5 intercessors per patient ) up to 1000 patients having 8 intercessors per patient.    At onset of the project, the largest number of available patients and chaplains will be used that can properly be managed by the Center project team.

 The following defines the roles of coordinating chaplains (one at each VAMC):
 All  VAMC Coordinators will: (1) Maintain regular contact with the national chaplain database files and E-Mail system as required for project coordination, (2)  participate in regular telephone conference calls intended to relate progress, guidance, quality control  and to facilitate Q&A activities.  The role will require participation in one regional or national training meeting in the fall of 1993; (3)   supervise and insure the correct compliance of participating chaplains at her/his facility in regard to their completing surveys and accurately and faithfully following such protocols as may define their participation.  This will include insuring that the means for conducting patient "intakes," and correctly acquiring such spiritual and other assessments in a manner faithful to the protocols provided. This supervision applies to intercessor chaplains, clinical or research support staff, VAMC community volunteers, or others involved in the project; and (4)  conduct regular liaison with other VAMC staff  coordinators.   This chaplain will also coordinate with the COS, ACOS for Research, and Chief of IRM  or their designees to involve other non chaplain professional and support staff.  Activities can include enrolling patient participation in the study, and arranging for the technical staff to cull selected clinical variables from the local DHCP (Decentralized Hospital Computer Program).  This is a database whose core patient data structure  is essentially identical for every VAMC. The DHCP contains identical data fields for tracking participating patients, and has technical provisions for "batching" the selected aggregate patient data to the National Chaplain Center database at Hampton.  Other than acquiring the patient survey inventory data at intake, chaplains will not become directly involved in gathering or managing the patient's clinical data.

2.  Selection of Participating Patients: Cardiac patients at intake to the VAMC,  except those specifically for PTCA (or for non primary cardiac diagnoses), will be entered into a prospective randomized protocol to assess the effects of intercessory prayer.  At patient intake, before entry into the study  informed consent will be obtained and the patient assessment completed.    Patients will alternately be assigned to "experimental" or "control" conditions in the order in with they are admitted to the VAMC by use of a computer-generated daily list managed at the Hampton Center either to receive or not to receive intercessory prayer.  Each experimental patient will have  from 4 to 8 chaplains in their prayer group depending on the number of participating chaplains.
      In order to permit chaplains to continue to serve the patients in their hospital in the normal manner without distorting the study, patients will not be assigned to chaplain intercessors at the hospital in which they are patients.   The patients, the staff and doctors in the unit, and local chaplain coordinators at each VAMC will remain "blinded" throughout the study.  At the cardiac surgery medical centers, neither chaplains, physicians, nurses or the patients will know which patients are in the study.  After intake data has been entered into the laptop by the patient and/or interviewing chaplain, as an additional precaution against biasing the study, the patients will not be further contacted by the interviewing chaplain.  It is assumed that some of the patients in both groups will be prayed for by themselves, by relatives, and by people not associated with the study.  However such external prayer should be randomly distributed across both the experimental and control groups.  Depending upon the volume of patients system wide, the outcome measures of a second control group of patients not involved in the study at all can be examined.
 

     Minority Racial and Gender Mix:  The VA constituency provides a patient population which includes a disproportionate large number of economically stressed, aging,  and ethnic minority patients, especially black and Hispanic  [current data to be provided??].  While enrollment of females is necessarily minimal, the study protocol is such that its protocol  can be easily replicated in health care environments with a large female population.   Further, the construct of "Expanded/Focused Consciousness" is expected to be independent of race or gender.

3. Patient and Chaplain Assessment Instruments:
   Patients will be given the surveys described above in a single session not to exceed 30 minutes.  See Appendix 4  for the implementation protocol to be used by chaplains both for self assessment and for patient assessment.

4.  Intercoder Reliability--Instruct Chaplains in Administering Assessment forms
 As part of acquisition of a variety chaplain data for management and staff development purposes, telephone conferences and computer linked communications (via the National Database E-Mail system) will prepare all staff chaplains to self administer their own surveys and enter them into the national database.  The Annual Chief's Conference which occurs in December 1993 will provide time to arrange for instructing the Coordinating Chaplains in standard protocols for interviewing patients or directing then to self administer their own surveys when appropriate, and for entering the patient data in the computer.  This step is intended to insure uniform and standardized interview and data processing protocols and intercoder reliability in the contributions of participating Chaplains.  A workshop at the conference will instruct attending chiefs and coordinating chaplains in the following procedures of the study:

Protocol 1:   To validate that all prior self administered Chaplain measurement instruments were correctly administered and the code sheets correctly entered into the Hampton data base.
Protocol 2:  To explain the reasons for the patient measurement instruments and instruct how to interview patients and enter their data in the code sheets, and then into the Hampton data base
Protocol 3:   Standardization of prayer patterns for chaplain intercession prayer groups, delivered to patients in accordance with the identical protocol to be used at all participating medical centers.  The chaplain will be shown how to use the log book and enter its data to unsure the integrity of the study.  In Phase 1 of the study, patients will be randomly assigned to chaplain prayer groups usually located at medical centers other than VAMCs where the patient is enrolled.  In Phase 2 patients will be randomly assigned to chaplain groups who will be scattered across different stations.
Protocol 4:  Logging of prayer activities by intercessor chaplains throughout the study to permit tracking.

5. Administration of the Instruments to Chaplains:  At the onset of the study, as the first order of business, the coordinating chaplain at sites where there are intercessor chaplains will hold a briefing session for those chaplains.   Coordinating chaplains will already have received training in using the Hampton Center database.   They will be given specific instructions in how to enter the project's survey data into the data base.  Where  laptops computers are to be used at the cites for enrolling patient data,  the chaplains will be trained in their use for recording the survey data, and insuring it is properly  transported to the Hampton database by what ever defines the local protocol determined by the IRM staff. (See Appendix 6)  The chaplains will be given each survey to be completed on paper in the following order:  (1) Prayer Style, (2) BDI, (3) Religiosity Scales (Goalder), (4) QL scale, (5) Religiosity Scale (Koenig), (6) Myers-Briggs,  (7) Health Attributes Test, and (7) the Cattell 16PF.
    A "session" is defined by completing one or more surveys and entering the data into the Hampton computer.  Each intercessor chaplain will be given those surveys to be taken at one session and will self administer each survey and then enter the data  for that survey directly into the Hampton database.   If time and comfort permit, a chaplain can complete more than one survey at any one session.   One week will be allowed for entry of all seven surveys into the Hampton data base.

6.  Administration of Instruments to Patients
  Using standardized protocols, (see Appendix 4), after obtaining  informed consent,  the following instruments will be administered to patients in the following order: (1)  Prayer style Survey, (2) BDI, (3) QL Survey "Personal Growth" subscale, (4) The Health Attributes Test, and (5) the Religiosity Survey (Koenig short form of the Springfield assessment.)  On the day of enrollment during patient intake, the Chaplains will first administer an informed consent form, and when the patient volunteers to participate, the interviewing chaplain will enroll each patient by name and special identifier and begin entering the data into a form or into a laptop. The name of the patient and their data will remain confidential, but capability will exist to link and track the subsequent entry of both survey and clinical entry and outcome variables for each patient.  When these data leave the VAMC for the Hampton Center, all means of linking the data to a particular patient will be lost.
    Administration of all patient related assessments will be managed by either

(1) entry first onto paper forms and then directly transferred  by the chaplain into the Hampton database, or
(2) entry first directly into a laptop computer using a modified  protocol as developed and tested by Chaplain Gary Berg (1992, See Appendix  6.)

7.  Patient Clinical Data
The following data replicates the Byrd Study: Age (mean +/- SD); Sex (Female/Male); Time (in hours) in Intensive Care Unit (ICU) or Medical Intensive Care Unit ( MICU) and in the Medical Center (days and quarter days).   See Appendix 3 for additional alternative possibilities currently under development.
________________
 
 

                    *  NS = P > .05;   VT/VF = ventricular tachycardia/ventricular fibrillation; COPD = chronic obstructive pulmonary disease.
_________________

 Course of Illness Standards: The hospital course after surgery will be graded good, intermediate, or bad based on criteria used by Byrd:
      Good: Only one of the following: left heart catheterization, mild unstable angina pectoris of  less than six hours duration; self-limiting ventricular tachycardia within the first 72 hours of myocardial infarction; supraventricular tachyarrythmia; uncomplicated third degree heart block requiring temporary pacemaker; mild congestive heart failure without pulmonary edema; or no complications at all.
     Intermediate:  Moderate to severe unstable angina pectoris without infarction, congestive heart failure with pulmonary edema, non-cardiac surgery, third-degree  heart block requiring permanent pacemaker, pneumonia without congestive heart failure, combination of any two events from the "good" category
     Bad: Nonelective cardiac surgery, readmission to CCU or MICU after a myocardial infarction with unstable angina, extension of initial infarction, Cerebrovascular accident, cardiopulmonary arrest, need for artificial ventilator, severe congestive heart failure with pulmonary edema and pneumonia, hydrodynamic shock due to sepsis or left ventricle failure, or death.

8. Patient Cost Analyses:
The following dimensions of costs will be assessed:   Use of all intermediate products and services will be tracked during the study window, including: Lab tests, x-rays, nursing ward days, EKG, cardiac cath, respiratory therapy/MD consults.  This will be "bottom-up" or actual counted costs and not averaged generalizations.

 - Length of Stay for admission, and for all sub-units (e.g. CCU, ICU, and/or MICU).
 - DRG variables analysis

1. Mechanics of Data Transport, Storage and Processing:
  At time of patient intake, chaplains will directly enter patient survey data  by a patient identifier number directly into the Hampton database.  Patients will be identified by a coded number which permits survey and clinical data to be merged for that patient, but which looses the patient's name and social security number.  In that manner, no identifiable patient records will leave the VAMC.  At patient discharge from the participating VAMC, the local IRM or medical administration staff will conduct "search and sort" routines on participating patient data in the DHCP using Fileman protocols, thus acquiring all relevant clinical data required by the study.  The data  for all patients discharged during that window of analysis will be "packaged" by another  Fileman protocol and uploaded into the IDCU/VADATS network and transmitted to Hampton as a batch file.  The file will be received at the Hampton Center Fileserver, interpreted and  unpackaged as an ASCI standard file where it will be merged with the chaplain collected survey data by patient identifier number and then  transformed into an Excel spreadsheet and concatenated to the complete existing matrix of patient data.  This data matrix will then be subject to analysis.  Under the direction of Dr. Kashner, all statistical analysis will be managed from the Dallas Health System Research and Development Office and VA Fileman data that has been transformed into a spreadsheet for statistical analysis at Hampton will be manipulated from  the Dallas VAMC using either SAS (Statistical Analysis System) and/or PC Stat and SysStat.  Large corporate files are accessible at the Austin  data center.

2.A. Experimental Hypothesis--Phase 1:  Based on the current chaplain enrollment (120??) and 11 ?? committed cardiac hospitals who will provide a collective number of 612 experimental patients, each patient will on the average receive prayers from six chaplains, and each chaplain will on the average pray  for six patients. Following are the experimental hypothesis for the first phase of the study:

(1) Typologies defining discrete profiles of "Expanded to Focused Consciousness" will be found for both chaplains and patients.
(2) Patient's who are prayed for by Chaplains will indicate greater positive effects on physiological measures compared to the control group, and in quality of life indicators will reveal higher scores regardless of spiritual, religious and psychological profiles
(3)  Patients who represent groups showing elevated scores for expanded  Consciousness will show a significantly greater improvement than focused Consciousness patients.
(4) Unique chaplains will emerge as to define relatively expanded-focused spiritual, religious and psychological "signatures" as determined from initial assessment survey data.
(5) Chaplains as a group will show significantly higher scores defining Expanded Consciousness than will the patients as a group

2.B. Analysis of Phase 1 Hypothesis:  Analysis for the presence of the above effects will be run to detect the presence of statistically different patterns in clinical risk and severity data between the experimental and control groups at admission.  After admission, all patients will receive follow-up for the remainder of the hospitalization.  New problems, new diagnoses, and new therapeutic interventions will be recorded and summarized by existing VAMC protocols in the data base.
(1) ANOVA will be used to detect the presence of clinically significant differences between the control group and the experimental group in physiological indicators of health care outcomes
(2) Survey data collected pre-and post intervention can be analyzed as an ANCOVA in which the experimental vs control is the grouping variable and the pre- assessment is the covariant.  The variables that are outcomes only (e.g., length of hospital stay) can be analyzed using MANOVA hierarchical regression models in which the intervention (experimental versus control dummy variable) is entered last.
(3) Multiple regression and cluster analysis will be applied to identify of patients and chaplains as defined as Focused or Expanded Consciousness  by their common  responses to the assessment measures.
(4) Because of the multiple hypothesis, alpha tests of significance will be adjusted for the number of independent tests we engage using the Bonferonni correction.   With respect to the above N patients and chaplains  who are subject to treatment, a power analysis will be conducted to affirm that sufficient subjects have been tested to confirm the hypothesis.   Using alpha = .05 and a power of .80, the proposed sample size is sufficient to detect even relatively small effect sizes (.20) on the proposed outcome measures.  Thus the proposed study does not offer substantial risk of failing to detect important effects of intercessory prayer.

3. Begin Phase 2 Revised Patient Assignment Protocol
  Procedural Methodology  (Modifications to Phase 1):  Patient enrollment will continue as in Phase 1, but with assignment of  patients to  chaplain clusters as Treatment (Prayer)  Groups:  Chaplains who share membership in Expanded (EX) vs Focused (FO)  Consciousness typologies as revealed from Phase 1 analysis will be grouped to serve particular patients.  In Phase 2, specific patients will be randomly assigned, but only to chaplains who are representatives of a "Focused" or  "Expanded" Consciousness regardless of the VAMC at which they are resident, but excluding the patient's VAMC.  The Fileman database permits the file structure to be used in a manner to track chaplain types and match patient assignment to chaplains who are of the intended level (EX vs FO) Consciousness.  A crossed design will permit EX chaplains to be compared to FO chaplains re the intercessory effect of  type of Consciousness upon their randomly assigned patients.

4.A. Phase 2 Hypothesis

(1) Chaplain defining EX Consciousness will demonstrate greater intercessory effect than chaplain representing FO Consciousness.

(2) Patient representing EX Consciousness will benefit more than patients representing  FO Consciousness.

4.B. Phase 2 Analysis
(1)  Multivariate regression, factor (orthogonal and oblique) analysis will be run to detect chaplain and patient clusters on measures of EX to FO  Consciousness, but including other study variables (e.g. patient clinical data and chaplain demographic and practice pattern data).
(2)  Each patient enrolled into the study during Phase 2 will  be treated by means of  the protocols of  Phase 1, except they will be randomly assigned to chaplain clusters (by chaplain Consciousness characteristics.)

5. Methodology
  The following analysis will be used
(1) ANOVA or MANOVA will continue as in Phase 1

(2) Multivariate Orthogonal and  Oblique Factor analysis an cluster analysis  of chaplain Consciousness measures with patient variables will be considered.   Logistic or hierarchical regression will be evaluated based on data patterns after initial analysis.   Because of the multiple hypothesis, alpha tests of significance will be adjusted for the number of independent tests we engage using the Bonferonni correction.   With respect to the above N who are subject to treatment, a power analysis (as defined under 2-B-4 above) will again be conducted to detect the effects of the study.

6. Phase 3--Conduct Cost benefit Analysis of Phase 1 and Phase 2 Data:
In this phase the cost differential for the prayed for and control groups will be assessed.  Cost Factors: Experimental  Hypothesis:

(1) There will be a statistically significant cost differential between prayed for and control groups in favor of the prayed for group.
(2) Prayed for patients will require less treatment costs than patients clustered by classical DRG assignments

7. Methodology--Phase 3, Cost-Effectiveness Analysis:
     By  costs we mean expenditures or depletion from the US treasury to purchase the resources used to produce health care services.   Costs are measured to include direct professional and staff salaries, fringe benefits, and supplies.  Indirect costs  include administrative support, building management, and maintenance including  building and equipment  depreciation.  In addition to cost and utilization data participating local VAMCs,  access to IBM  mainframes at the VA's Austin centralized data processing facility permit project access to all system wide aggregated cost utilization data..
     The costs of resources used by surviving patients in each of the two study groups (control and intervention) will be compared.  The total cost of the resources used by the patients who die in each of the 2 groups will also be compared between the two groups and compared to the costs of the survivor-groups.  Significant differences in Length of Stay of the surviving set of patients occurs, the statistical difference if present, between control and study groups will be reported.  Resource use of patients stratified by those with good outcomes and those with intermediate outcomes will be compared between the study and control groups.  Finally, overall costs or resources used to acquire comparable numbers of good or intermediate outcomes in both the study and control group will be evaluated and compared intra groups.  These analyses will assist us assess the costs of similarly effective outcomes between the 2 groups.  The probability of less good outcomes and thus greater hospital costs for intermediate outcomes and greater familial/societal costs for "bad" outcomes of death or risk of death can also be estimated.  The difference in costs between caring for study and for the control patients with their greater amounts of ventilator support, antibiotics and diuretics (Table 2) will also be determined.  This determines overall the cost-effectiveness of specifically applied intercessory prayer in Cardiac MICU patient populations.
     The VA has supported a seven year study to develop VAMC resource costing and management systems at the product level.  Thus comprehensive resource automated resource tracking systems exist which are comparable to private sector "billing" systems, in the VA.  Additionally these systems use Standard Costs (developed annually from "real costing" the VAMC's individual products).  The B/W DMMS even has "bottom-up" real costs for all its array of resources, so these costs figures can be used for all VAMCs as a single standard of costs for each intermediate product.  The 172 VAMCs also have nationally standard intermediate product identification in their automated product collection systems so a lab test at one VAMC is comparable to that at another.  A sensitivity range can be applied which uses first B/W VAMCs DMMS "bottom-up", "real", standard costs at the low side, and a comparable Boston private sector teaching hospital's charges per product, for the high side.
     Thus the difference between study group resource use and the control group's use can be expressed in terms of "real" standard cost dollars for resources or as difference in comparable area's charges (and thus more costly cases would represent a "negative revenue stream").  This permits the VA Cost-Effectiveness findings of this study to be generalized to the health care sector, in general.  The Boston Deaconess Hospital (HMS Affiliated) will be used to assess high levels of differences based on gross charge differences.

 The final report will contain the following:

A. Traditional statement regarding the theory, methodology, and findings of the study.
B. Assess the significance of identified chaplain Consciousness typologies to pastoral counseling, Clinical Pastoral Education and other practices in chaplain service to veteran patients
C. Recommend immediate chaplain training interventions to begin enhancement and further development of chaplain skills in their professional roles
C. Asses the utility of the Consciousness  construct for profiling both the spiritual, religious, and psychological instrumentation used and recommend changes of usage for subsequent studies.
D. Recommend subsequent research to pursue and benefit from study insufficiencies, to develop the practical findings of the study, and to advance the development of a Consciousness paradigm.

Research collaborators contributing to this proposal available on request.

Current Draft status updated on July 10, 2005