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The Utility of the WHO ICD-10-AM
Pastoral Intervention Codings Within
Religious, Pastoral and Spiritual Care
Research

Lindsay B. Carey & Jeffrey Cohen

Journal of Religion and Health

ISSN 0022-4197

J Relig Health
DOI 10.1007/s10943-014-9938-8

1 23
J Relig Health
DOI 10.1007/s10943-014-9938-8

ORIGINAL PAPER

The Utility of the WHO ICD-10-AM Pastoral

Intervention Codings Within Religious, Pastoral
and Spiritual Care Research

Lindsay B. Carey • Jeffrey Cohen

Ó Springer Science+Business Media New York 2014

Abstract The World Health Organization (WHO) ‘Pastoral Intervention Codings’ were
first released in 2002 as part of the ‘International Statistical Classification of Diseases and
Related Health Problems’ (WHO 2002). The purpose of the WHO pastoral intervention
codings (colloquially abbreviated as ‘WHO-PICs’) was to record and account for the
religious, pastoral and/or spiritual interventions of chaplains and volunteers providing care
to patients and other clients experiencing religious and/or spiritual health and well-being
issues. The intent of such WHO codings was to provide information in five areas: statis-
tical, research, clinical, education and policy. The purpose of this paper predominantly
accounts for research although it does intersect and relate to other WHO priorities. Over
the past 10 years, research by the current and associated authors to test the efficacy of the
WHO-PICs has been implemented in a number of different health and welfare contexts that
have engaged chaplaincy personnel. In summary, while the WHO-PICs are yet to be more
widely utilized internationally, the codings have largely proven to be valuable indices
appropriate to a variety of contexts. Research utilizing the WHO-PICs, however, has also
revealed the necessity for a number of changes and inclusions to be implemented. Rec-
ommendations concerning the future utilisation of the WHO-PICs are made, as are rec-
ommendations for these codings to be further developed and promoted by the WHO, so as
to more accurately record religious, pastoral and spiritual interventions.

Keywords Chaplaincy
World Health Organization
Pastoral care
Spiritual care

L. B. Carey (&)
Palliative Care Unit, School of Public Health, La Trobe University (City Campus), 215 Franklin St.,
Melbourne, VIC, Australia
e-mail: lindsay.carey@latrobe.edu.au

L. B. Carey
Staff Chaplain Research, DCHAP-AC, Chaplaincy Branch, Royal Australian Air Force, Canberra,
Australia

J. Cohen
University of New South Wales Medicine, Sydney, NSW, Australia

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Introduction

The World Health Organization (WHO) is the directing and coordinating authority for
health within the United Nations structure. WHO is responsible for providing leadership on
global health matters, shaping the health research agenda, setting norms and standards,
articulating evidence-based policy options, providing technical support to countries and
monitoring and assessing health trends. The International Classification of Diseases (ICD)
is the WHO’s standard diagnostic tool for epidemiology, health management and clinical
purposes (WHO 2012).
It is not possible within this brief paper to provide a detailed history of the development
of the WHO ICD, suffice to say that the ICD was endorsed by the 43rd World Health
Assembly in May 1990 and came into use among WHO member states as from 1994. The
ICD is used to monitor and analyse the incidence and prevalence of diseases and other
health-related issues occurring within a population, but also, in conjunction with the
‘International Classification of Health Interventions’ (ICHI), it assists health care service
providers, administrators and researchers to utilize common terminology and have a cor-
porate mechanism for reporting and analysing the distribution and evolution of health
interventions in order to undertake a comparison of data between services and countries
which in turn assists with policy and planning (WHO 2012). The ICD-10-Australian
Modification was originally developed by the (Australian) National Centre for Classifi-
cation of Health (NCCH) based on the WHO ICD-10. Since 2007, the NCCH has been
leading the development of the International Classification of Health Interventions (ICHI),
providing updated information for the development of the ICD-10. A network of WHO
Collaborating Centres has promoted a list of health interventions for international use,
based on the Australian Modification (AM) of the ICD-10th revision (ICD-10-AM) (WHO
2012).

Pastoral Intervention Codings 2002

In July 2002, four major ‘pastoral intervention’ codings (WHO-PICs) were incorporated
and made available as part of the ICD-10-AM, which could be used by chaplains (or other
pastoral and spiritual care workers) to record their interventions with patients and other
clients (e.g. family and staff) (refer WHO-PICs Table 1 Column 2). It is important to note
that at the time of formulating the WHO-PICs the term ‘chaplain’, due to a generally
accepted custom originating almost a 1,000 years ago, was used to broadly refer to all the
various types of religious, spiritual and pastoral care workers irrespective of their
employment status (e.g. volunteers or employed) or regardless of their religious beliefs
(e.g. Aboriginal, Jewish, Christian, Buddhist, Hindu or Moslem). The development of
WHO-PICs largely originated in response to the production of the Australian Health and
Welfare Chaplaincy Association Health Care Chaplaincy Standards (AHWCA 1998;
Cross et al. 20041), which was a modified version of the Health Care Chaplaincy Stan-
dards (1997) collaboratively produced by various national chaplaincy organizations in the
UK.

1
The Australian Health and Welfare Chaplain Association (AHWCA) Health Care Chaplaincy Standards
(1998) were later to be revised as the ‘AHWCA Health Care Chaplaincy Guidelines’ (Cross et al. 2004).
The successor organisation to AHWCA, ‘Spiritual Care Australia’ approved its ‘Standards of Practice’
(SCA 2013) which adapted and expanded the original AHWCA Health Care Chaplaincy Standards.

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Table 1 Comparison of Health Care Chaplaincy Standards key roles and the WHO-PICs
Column 1 Column 2
Health Care Chaplaincy Standards/Guidelines WHO ICD-10-AM
Chaplaincy key roles (1998/2004) Pastoral intervention codings (2002)

Identify and assess needs for chaplaincy provision Pastoral assessment

[Health Care Chaplaincy Standard A.1–A.2] (ICD code 96186-00) [Major heading: 1824]
Manage and develop a chaplaincy servicea [No equivalent]
[Health Care Chaplaincy Standard B.1–B.2]
Provide opportunities for pastoral worship and religious expression Pastoral ritual and worship
[Health Care Chaplaincy Standard C.1–C.2] (ICD code 96109-01) [Major heading: 1873]
Provide pastoral careb Pastoral ministry
[Health Care Chaplaincy Standard D.1–D.2] (ICD code 96187-00) [Major heading: 1915]
Provide pastoral counselling and spiritual directionb Pastoral counselling or education
[Health Care Chaplaincy Standard D.1–D.2] (ICD code 96087-00) [Major heading: 1869]
Provide an informed resource on ethical, theological and pastoral mattersa [No equivalent—but achievable under ‘pastoral counselling or education’]
[Health Care Chaplaincy Standard E.1–E.2]
a
The Health Care Chaplaincy Standards/Guidelines have two key roles relating to chaplaincy departmental requirements not directly reflected within the WHO-PICs
b
The complete Health Care Chaplaincy Standard Key Role is: ‘Provide pastoral care, counselling and spiritual direction’ [Key Role D]. Within this table, the Health Care
Chaplaincy Standard Key Role D is divided to demonstrate the similarities with the WHO-PICs

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A comparative review of both Health Care Chaplaincy Standards and the subsequently
developed WHO-PICs (Carey 2002) revealed that while the different documents varied in
focus and therefore diverse in specific codings, there was, nevertheless, substantial con-
sistency between the two nomenclatures in terms of terminology (refer Table 1 Colum 1 cf
Column 2)—which might be expected, given that both taxonomies utilized the pastoral
care discipline as the sole frame of reference (Carey 2002). Nevertheless, as will be noted
later, some valuable detail was forfeited with the development of the WHO-PICs.
The predominant concern, however, was that while the Health Care Chaplaincy Stan-
dards and subsequent guidelines (AHWCA 1998; Cross et al. 2004) served as a useful
operational reference for categorizing the functions of pastoral care departments, these
were vastly too complex and did not actually note the types of interventions undertaken by
chaplains when caring for patients (or their families and staff) and, further, some of the
detailed elements of the standards were largely not relevant to the welfare context (Carey
2002). Hence, the need for common codings that could broadly account for actual inter-
ventions relating to religious, pastoral or spiritual care that might be applied within both
health and welfare milieus (refer Table 2).

Historic Development

The development and release of the WHO-PICs (WHO 2002) with the support of the
Australian Health and Welfare Chaplains Association (AHWCA)2 created a great deal of
interest, simply because for the very first time it was considered possible to utilize common
terminology and a corporate tool (both nationally and internationally) for reporting and
analysing the implementation and evolution of interventions undertaken by chaplains or
other pastoral and spiritual care workers, irrespective of their own or the client’s cultural,
religious, spiritual or denominational affiliation.
While a number of global reviews regarding chaplaincy have been written (e.g. Swift et al.
2012; Orton 2008), the majority have thus far failed to draw upon the historic development of
the WHO-PICs that inherently sought to refocus chaplaincy to be ‘evidenced based’, ‘out-
come orientated’ and ‘research focused’ in order to achieve ‘quality improvement’ without
sacrificing the sacredness of chaplaincy ministry. The other perceived benefit of the WHO-
PICs providing common coding terminology was the potential of international collaboration
that might improve global outcomes for professional chaplaincy.
The key question however was whether the WHO-PICs degree of utility was/is sufficient,
given the considerable diverse environments in which chaplains have and do minister (e.g.
acute care, aged care, mental health, welfare, military, court and prison chaplains) and whether
the WHO-PICs were applicable given the substantial diversity of religious and spiritual beliefs.

Research

Aims

Over the past decade, a number of research projects have been undertaken by the current
and associated authors that have utilized the WHO-PICs to gather data about the work of

2
The Australian Health and Welfare Chaplains Association (AHWCA) was reconstituted as ‘Spiritual Care
Australia Incorporated: A professional association for practitioners in chaplaincy, pastoral care and spiritual
services’.

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Table 2 Description of ‘Pastoral Intervention Codings’—World Health Organization (ICD-10-AM)

Pastoral assessment (ICD code 96186-00) [Major heading: 1824]
Description: An appraisal of the spiritual wellbeing, needs and resources of a person within the context of a pastoral encounter
Pastoral ministry (ICD code 96187-00) [Major heading: 1915]
Description: The provision of the primary expression of the service, which may Include:—establishing of relationship/engagement with another, hearing the story, and the
enabling of pastoral conversation in which spiritual wellbeing and healing may be nurtured, supported and companioning persons confronted with profound human issues
of death and dying, loss, meaning and aloneness. Predominantly a ‘ministry of presence and support’
Pastoral counselling or education (ICD code 96087-00) [Major heading: 1869]
Description: An expression of pastoral care that includes personal or familial counsel, ethical consultation, a facilitative review of one’s spiritual journey and support in
matters of religious belief or practice. The intervention expresses a level of service that may include counseling and catechesis for example, and the following elements
may be identified:—‘‘emotional/spiritual counsel’’, ‘‘ethical consultation’’, ‘‘religious counsel/catechesis’’, ‘‘spiritual review’’, ‘‘death and dying’’
Pastoral ritual/worship (ICD code 96109-01) [Major heading: 1873]
Description: This intervention contains the pastoral expressions of informal prayer and ritual for individuals or small groups, and the public and more formal expressions of
worship, including Eucharist and other services, for faith communities and others. Elements of this intervention may include:—
(a) ‘‘private prayer and devotion’’, bedside ‘‘Communion’’ and ‘‘Anointing’’ services, ‘‘Blessing and Naming’’ services for the stillborn and miscarried, and other
‘‘sacrament’’ and ritual expressions;
(b) ‘‘public ministry’’—’’Eucharist/Ministry of the Word’’, funerals, memorials, seasonal and occasional services

Some interventions and related terms are not profession specific to pastoral care and are therefore given generic code numbers with the WHO ICD. The interventions of
‘‘Bereavement care/counsel’’ and ‘‘Crisis care/debriefing’’ terms, for example, may be used by pastoral care personnel, but coders may record such activity within the relevant
generic codes

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chaplains. The collation of these and any other research publications was sought out to
formulate the literature review. This enabled a secondary aim of considering whether the
WHO-PICs did in fact cover sufficiently the breadth of ministry undertaken by religious,
pastoral and spiritual carers working within health and welfare contexts. Subsequently, it
was hoped that such information would aid chaplaincy organizations and ultimately the
WHO to consider the lessons learned from these various research projects and implement
necessary changes (if any) to the WHO-PICs. This challenge was made more urgent with
the future introduction of ICD-11 pending in 2015.

Method

A review of published research was undertaken utilizing the medical and allied health
databases (e.g. Medline, CINAHL and PsychLit.) and various ‘grey literature’ sourced
via internet searches (e.g. Google Scholar, CareSearch.) that referenced the use of the
WHO ICD-10-AM and the keywords ‘clergy’, ‘chaplains’, ‘pastoral/spiritual/religious
carer/worker/assistant/practitioner’. A total of 17 publications were identified and one
conference presentation (n = 18). Approximately 77 % (n = 14/18:77.8 %) related to
research conducted within Australia—which was not surprising given that the WHO-
PICs were part of the Australian Modification (AM) to the WHO ICD codings.
Approximately 22 % of publications related to research conducted overseas (n = 4/
18:22.2 %) namely in England and New Zealand (refer Table 3). Similarly, just over
three quarters of the literature related to health care (n = 14/18:77.8 %) while just less
than a quarter related to welfare contexts all of which were undertaken in Australia
(n = 4/18:22.2 %). As noted earlier, the research projects identified had been under-
taken independently of the WHO by the current and/or associated authors and were
partly supported by the AHWCA and more recently by the Palliative Care Unit of La
Trobe University. Nevertheless, for a number of reasons noted later, there was a
conspicuous lack of published research regarding the WHO-PICs (refer research
limitations).
Depending upon the context of the research, either a quantitative or qualitative meth-
odology (or sometimes a combination of methods) had been utilized within the various
literature. It is important to note however that one of the difficulties of implementing and
reviewing any form of research involving health and welfare chaplains, clergy or other
spiritual carers, is simply the lack of previous research—for while such professions have
been in existence post the time of Constantine (Fourth Century), nevertheless, empirically
based evidence has not accompanied their professional progression; indeed, conducting
empirical research has sometimes been considered a complete anathema by those involved
in religious occupations. Thus, most of the research conducted and noted within this report
is exploratory research that has analytically considered religious, pastoral and spiritual care
using the WHO-PICs for the very first time.

Results

While any number of classification strategies could have been used to group the various
research articles, the simplest was to divide the literature into two types—those spe-
cifically relating to health care and those relating more broadly to welfare (refer
Table 3).

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Table 3 Research utilizing the WHO ‘Pastoral Intervention Codings’

Context Location Research References

Health Care
Hospital chaplaincy Ringwood Private—Melbourne QN/QL Carey et al. (2004)
Hospital chaplaincy Royal Adelaide—Adelaide QN McFarlin and Carey (2004)
Hospital chaplaincy Royal Women’s—Melbourne QN/QL Carey and Meece (2005)
Hospital chaplaincy Northern General—Sheffield QN Carey et al. (2005a, b)
Hospital and aged care chaplaincy National Study—New Zealand QL Carey (2012, 2013)
Mental health care chaplaincy National Study—New Zealand QL Carey and Del Medico (2013a)
Hospital and aged care chaplaincy National Study—Australia QL Carey et al. (2006a, b); Carey and Newell (2007a, b, c, 2008);
(Carey and Cohen 2008); Carey et al. (2009); Carey et al. (2011)
Welfare
Military chaplaincy RAAF—Australia QN Carey and Willis (2010)
Prison chaplaincy Salvation Army—Sydney QL Carey and Del Medico (2013b)
Court chaplaincy Salvation Army—Sydney QL Carey (2014)
Community service chaplaincy Salvation Army—Melbourne QL Carey and Rumbold (2014)

QN quantitative research, QL qualitative research

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The Health Care Context

Providing Support and Guidance

Amidst the literature relating to health care chaplaincy, the WHO-PICs were used for both
quantitative and qualitative data. One of the first pilot studies to utilize the WHO-PICs was
that of the Ringwood chaplaincy evaluation programme among their clinical staff (Carey
et al. 2004) which involved pre- and post-pilot surveys that defined the meaning of each
WHO-PIC, so that respondents knew clearly the chaplaincy roles they were considering
and assessing. The only category about which some respondents indicated a sense of
confusion (via comments on the survey) was the rather generic term ‘pastoral ministry’
preferring instead to describe the role more as providing ‘support’.
Similar comments were also entered on a number of Royal Women’s Hospital (RWH,
Melbourne) ‘Pastoral Care and Spirituality’ surveys undertaken by clinical staff who noted
the provision of ‘support’ to patients and family as an important chaplaincy intervention
(Carey and Meese 2005). Subsequently, at the AHWCA Annual General meeting (2007), it
was agreed in principle that the term ‘ministry’ should be replaced with ‘support’ and more
clearly defined. Another term utilized within the RHW survey was that of ‘guidance’ as the
term ‘counselling’ had additional formal connotations and processes, if not legal impli-
cations, that were not always warranted for chaplaincy personnel in their engagement with
patients/clients or their families.

Data Inclusion

Another issue identified within the research literature was whether chaplaincy statistical
data were coded or not coded at all. The Sheffield Hospitals (i.e. Northern General and
Royal Hallamshire Hospitals, UK) utilized a ‘Pastoral Contact’ coding system; however,
when compared with the WHO-PICs, it was clearly evident that the chaplains working
within the Sheffield hospitals were not coding chaplaincy data that involved ‘counselling
and education’ and only partially coded ‘assessment’. Thus, a great deal of chaplaincy
work was under-reported. It was interesting to note however that the Sheffield Pastoral
Contact Codings, though somewhat incomplete, did include ‘pastoral support’ (an issue
noted earlier) and at least included statistics relating to the care of staff and not just patients
(Carey et al. 2005a, b). Nevertheless, with respect to chaplaincy interventions, the WHO-
PICs proved to be a valuable tool for providing an important check on the integrity of
another coding system.
Another consideration arising from the research reviewed was the inclusion of data
that was of a specialist nature. The Royal Adelaide Hospital pilot study, which
researched chaplaincy activity over a 2-year period (McFarlin and Carey 2004), sub-
divided ‘counselling and education’ to specifically identify any encounters, which were
related purely to bereavement and grief. Other major WHO-PIC categories were also
allocated sub-categories or sub-elements to specifically identify and codify specialist
chaplaincy roles that addressed particular patient/client needs. The formation of sub-
elements as divisions within the major categories specific to particular client/patient
needs proved beyond doubt the flexibility of the WHO-PICs, namely that the major
WHO-PIC categories were specific enough to identify the core activity, yet broad and
flexible enough to incorporate a range of sub-elements relevant to ministry.

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Qualitative Data

Another potential form of data to test the utility of the WHO-PICs involved the inclusion of
qualitative data. In-depth interviews with over one hundred health care chaplains from
across Australia (n = 100) (Carey et al. 2006a, b) and New Zealand (n = 30) (Carey 2012)
were coded according to the WHO-PICs concerning chaplaincy involvement in bioethical
issues such as abortion, withdrawal of life support and resuscitation (Carey and Newell
2007a, b, c), plus in vitro fertilization (Carey and Newell 2008), euthanasia (Carey et al.
2009), organ transplantation (Carey et al. 2011) and pain management (Carey et al. 2006a;
2013).
Focus group research was also undertaken with those serving in mental care and
forensic facilities (Carey and Del Medico 2013a). A particular issue raised by this research
was the advocacy work undertaken by chaplains on behalf of clients and/or their families
as a direct administrative intervention with clinical staff due to government policies
inhibiting and sometimes preventing adequate spiritual and cultural care of patients/clients
(Carey and Del Medico 2013a). Another administrative task was that of providing ‘reli-
gious and spiritual resources’—particularly if these were provided directly to a patient/
cleint (e.g. Holy Bible, Quran, supportive literature, video and other technology.), which
can constitute a direct intervention that may affect a patient/cleint’s well-being (Carey and
Del Medico 2013a, b). Hence, it seemed appropriate that there should be an additional core
category that included administrative care and provision of resources as a form of inter-
vention by chaplains to benefit patients/clients. The inclusion of an additional coding for
this type of intervention is noted again later (refer WHO-ICF Codings).
In overall terms, it was found that the WHO-PICs proved a useful framework within the
health care context by which to collate and codify a considerable amount and variety of
data that allowed an efficient and effective means of comparison and analysis of religious,
pastoral and spiritual interventions. The WHO-PICs also provided a method by which
research findings could be summarized and categorized for the purposes of continuing
education about chaplaincy involvement in health care treatment issues (Carey and Cohen
2008) (Table 3).

The Welfare Context

Military Chaplaincy

Within a welfare context, the Royal Australian Air Force Chaplaincy Branch was the first
military organization to utilize the WHO-PICs on a trial basis purely for the quantitative
measurement of intervention issues, the number of people involved and the time allocated
(Carey and Willis 2010). Thus, far these have been utilized nationally on a spasmodic basis
over the last 4 years while undergoing further testing and development. Fundamentally,
similar to health care contexts, the main WHO-PICs have worked well within the military
context—however, there was the need to develop specific sub-elements to cater for particular
interventions and tasks that are specialist to the military environment. The Royal Australian
Navy and the Australian Army have also been exploring the utility of the WHO-PICs, and it
would seem that all three services, despite their traditional idiosyncrasies, will hopefully
avoid reinventing the wheel and uniformly utilize the WHO major heading categories—
particularly as each military service can develop their own unique sub-elements if they so
wish. The military context clearly highlighted one of the advantages of the WHO-PICs,
namely that the major categories were again found to be specific enough to identify the core

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activity, yet broad and flexible enough to incorporate a range of sub-elements relevant to air,
sea and land units. Another advantage of military chaplaincy collaboratively using the WHO
codings, particularly given increasing global military intervention, is the additional associ-
ated links with the WHO and subsequently the United Nations.

Prison, Court and Community Chaplaincy

Most of the literature, however, that can be classified as ‘welfare chaplaincy’ utilized the
WHO-PICs, not for quantitative research, but as a template for qualitative data—more
specifically for focus group coding. Irrespective of whether the research involved prison
chaplaincy, court chaplaincy or community chaplaincy, the WHO-PICs proved (similar
to health care research) to be sufficiently broad enough, yet adequately flexible to enable
the coding of chaplaincy roles and duties arising from within each of these welfare
contexts.
Some prison and court chaplains however believed that roles such as ‘inter-religious
facilitation’, ‘institutional liaison’, ‘community relations’ and ‘facilities coordination’ were
not adequately covered under the existing WHO-PIC description of ‘Ministry’ (Carey and
Del Medico 2013b; Carey 2014). While it can be argued that such administrative roles are
not really direct interventions but rather a type of administrative referral and thus could be
sub-categorized as form of ‘ministry’ (i.e. ‘support’), nevertheless, such administrative
roles were, and are, a form of intervention that can, eventually, affect the patient/client
directly—particularly, if not done properly or not done at all. In the future the inclusion of
an administrative and resourcing category seems appropriate.

WHO-ICF Codings

It is also worth considering the WHO’s International Classification of Functioning, Dis-

ability and Health (WHO 2001). This system has four categories recognizing the role of
religion and spirituality (refer Table 4). Threats (2013) noted that the WHO is advocating
for combining the ‘ICF’ classification system with the ‘ICD’ to produce a unified and
multifactorial classification system to better define health (Threats 2013, p. 58). The

Table 4 Summary of the WHO-ICF (WHO 2001) codings relating to religion and spirituality
Religion and spirituality
Products and technology
Social norms, practices and
ideologies
Association and
organizational services
ICF Section D: activities and participation
Chapter 9 community, social and civic life;
d930—Religion and spirituality
ICF Section E: environmental factors:
Chapter 1 products and technology;
e145—Products and technology for religion and spirituality
ICF Section E; environmental factors
Chapter 4 attitudes: e465—Social norms, practices and ideologies; oral and
religious behaviour or etiquette, religious doctrine, resulting norms and
practices; norms governing rituals or social gatherings
ICF Section E; environmental factors
Chapter 5 services and policies;
e555/e5550—Association/organization/groups of people in the pursuit of
common noncommercial interests (e.g. cultural, religious services)

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findings arising from this review support at least two inclusions from the WHO-ICF into
the WHO-PICs.
Firstly, is the inclusion of ‘products and technology’ recognizing a form of intervention
to clients that occurs when religious resources, artefacts and other symbolic representations
are organized and provided directly to clients to assist them spiritually—this intervention
could be combined along with administrative care (noted earlier). Secondly, the more
prominent use of the terms ‘religion’ and ‘spirituality’ should likewise be incorporated
within the WHO-PICs for a number of reasons. The term ‘spirituality’ was an accepted and
inclusive term within both UK and Australian Health Care Chaplaincy Standard elements,
but was largely omitted in the development of the WHO-PICs. Over time, it has become
obvious that many of the WHO-PICs were Christological in focus and based on a tradi-
tional pastoral theology with a strong liturgical/sacramental emphasis. This represented the
interest and needs, at the time, of particular theological persuasions when developing the
WHO-PICs.
However, as noted by Koenig et al. (2012), a continuum can be utilized to consider the
breadth of those with/without spiritual religious beliefs. Firstly, there are those individuals
who are religious and spiritual (religious/spiritual); secondly, there are those who are not
religious but for whom religion may be part of their lives (religious but not spiritual); and
thirdly, there are those who are not religious nor spiritual but see themselves as humanistic
or secular. One could also add a fourth criterion based upon an increasing number within
contemporary Western societies, who would not regard themselves as ‘religious’, but still
regard themselves as ‘spiritual’ (spiritual but not religious) (Tacey 2003).
It is of course important to recognize that within most Western countries religious, pastoral
and spiritual care has been expanding holistically to provide interfaith and multifaith care to
all as required (Carey et al. 2009). Plus it is also important to acknowledge the influence that
various religious, pastoral and spiritual carers can have upon health care treatment decisions
(Carey and Cohen 2008) and the communication of public health issues (Miller and Rubin
2011). Thus, the authors are aware that any future iteration of the WHO-PICs will need to be
expanded to become more inclusive of both the range of people who provide care and the
range of those that are treated in any health care system. Originally, the Health Care Chap-
laincy standards coded ‘pastoral, spiritual and religious needs’ (AHWCA 1998, A1.2), and
similar to the WHO-ICF codings, it is recommended that the major WHO-PIC categories be
expanded to also include ‘religious’ and ‘spiritual’ to formulate revised categories utilizing
the terms ‘religious, pastoral and spiritual’ to allow for a broad continuum of people’s beliefs
and the appropriate coding of interventions.

Discussion

Based on a decade of utilization, changes to the initial WHO-PICs are necessary to

improve the existing codings, but also to take into account changes that have occurred over
the last 10 years. A number of recommendations derived from this review are summarized
within Table 5. A revised version of the WHO-PICs incorporating these recommendations
is presented as the WHO-Religious, Pastoral and Spiritual Intervention codings (WHO-
REPSICs) at Table 6. In addition to these recommendations, it is also worth reflecting on
the fact that there is now a growing range of material published in the general medical
literature and allied health literature about religion/spirituality and health, as well as the
emergence of various informal and formal measurement tools for screening and assessing
religious and spiritual well-being of patients/clients—the coding of which is another

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Table 5 Summary of recommended changes to the current WHO-PICs (2002)
Recommendations

1. The inclusion of ‘Religious, Pastoral and Spiritual’ to all of the WHO-PIC categories (e.g., ‘Pastoral Assessment’ to become ‘Religious, Pastoral and Spiritual Assessment’;
‘Pastoral Ritual and Worship’ to become, ‘Religious, Pastoral and Spiritual Ritual and Worship’, etc.) so as to be more inclusive of the different emphases of care
2. The change of ‘Pastoral Ministry’ to ‘Religious, Pastoral and Spiritual Support’ so as to reflect more accurately the intervention undertaken and its associated activities
3. The change and division of ‘Pastoral Counselling and Education’ to (a) ‘Religious, Pastoral and Spiritual Counselling and Guidance’ so as to include the more generic term
guidance and (b) ‘Religious, Pastoral and Spiritual Education’ as a new and separate category so as to distinguish the educational intervention that chaplains so often
provide to patients/clients and their families
4. The addition of a new category ‘Religious, Pastoral and Spiritual Administration, Products and Technology’ to incorporate administrative interventions such as
intercollegiate contacts and referrals, plus the preparation and distribution of resources and products which will incorporate both administrative care and the ICF recognition
of products and technology as a form of direct intervention to patients/clients and their families
5. The wider promotion and distribution of the revised WHO-PICs (‘WHO-REPSICs’) to encourage global utilisation and measurable outcomes that will encourage an
evidenced informed profession
6. The provision of funding for further research and development of the revised WHO-PICs (‘WHO-REPSICs’) to ensure ongoing evaluation and to improve the efficacy of
religious, pastoral and/or spiritual care to patients, family caregivers and to assist staff
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 Table 6 Recommended/revised WHO-REPSICs: ‘Religious, Pastoral and Spiritual Intervention Codings’
Religious, pastoral and spiritual assessment
(ICD code 96186-00) [Major heading: 1824]
Description: Initial and subsequent appraisals of the religious, pastoral and spiritual wellbeing issues, needs and resources of a person. Elements of this intervention may include:—(a) an
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‘informal’ exploratory dialogue to screen for immediate religious, pastoral, spiritual well-being issues and needs (b) a ‘formal’ instrument or assessment tool (e.g., completion of religious/
pastoral/spiritual history assessment or scale, etc.) to ascertain deeper religious, pastoral, spiritual and well-being concerns. This intervention may subsequently lead to other interventions (e.g.,
support, counselling, education or ritual and worship interventions).
Religious, pastoral and spiritual support
(ICD code 96187-00) [Major heading: 1915]
Description: The provision of support to individuals which may include:—establishing of relationship/engagement with another, fully hearing the person’s narrative and the enabling of
conversation in which spiritual wellbeing and healing may be nurtured, plus (where possible) practically supported and/or advocated and subsequently may involve the companioning of
individuals or groups confronted with profound human issues of death and dying, loss, meaning and aloneness, etc.; predominantly a ministry of presence and pragmatic support
Religious, pastoral and spiritual counselling and guidance:
(ICD code 96087-00) [Major heading: 1869]
Description: An expression of religious, pastoral and/or spiritual care that includes a facilitative/in-depth review of a person’s life journey, personal or familial counsel, ethical consultation, and
guidance in matters of religious belief or spiritual practice. This intervention expresses a level of service that may include, for example, ‘‘emotional/spiritual counsel’’, ‘‘ethical consultation’’,
‘‘religious counsel’’, ‘‘spiritual review’’, ‘‘death, dying and bereavement counselling’’, ‘‘mental health’’ issues
Religious, pastoral and spiritual education
(ICD code: TBA) [Major heading: TBA]
Description: An expression of religious, pastoral and/or spiritual care that involves educating (either formally or informally) those requesting or seeking greater knowledge about religious,
pastoral and/or spiritual issues having sacred or significant meaning, including issues relating to life and death, ethical issues, etc. This intervention is appropriate at multiple levels; (a) with
individuals, (b) families, (c) unit personal and (d) public forums/education seminars.
Religious, pastoral and spiritual ritual and worship
(ICD code 96109-01) [Major heading: 1873]
Description: This expression includes informal ritual and worship activities for individuals or small groups, plus more formal expressions of public worship. Elements of this intervention may
include (a) ‘‘private prayer and devotion’’, personal/family ‘‘anointing’’ services, ‘‘blessing and naming’’ services, dedications and other sacramental/ritual expressions; and (b) ‘‘public
ministry’’—public worship services, weddings, funerals, memorial services, dedications, seasonal and occasional services
Religious, pastoral and spiritual administration, products and technology
(ICD code: TBA) [Major heading: TBA]
Description: Products and technology, uniquely designed or mass produced, that are given or take on a symbolic meaning for the administration, education and practice of religious or spiritual
activities, customs or practices. The distribution of such products and technology can directly intervene in the emotional, attitudinal and behavioural practice of individuals and groups to aid
their pastoral, religious and/or spiritual response, for example, to relationship crises, bereavement, grief and mourning. Such products may include the provision of religious literature (e.g.,
Bible, Quran, Tanakh, Tao Te Ching) or artefacts (e.g., cross, prayer beads, prayer shawl/tallit, prayer beads) or audio-visual material (e.g., videos, electronic programs, etc.), it might also
include food which meets religious requirements such as vegan, halal and kosher foods

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justification for ensuring the WHO-PICs are current and revised to the more contemporary
WHO-REPSICs.

Limitations

The findings in this review are based on various exploratory research projects conducted
over a 10-year period that have trialled the WHO-PICs either in Australia, New Zealand
and/or England but were limited to particular health and welfare contexts; future research
needs to consider in greater depth other specialty areas (e.g. palliative care, aboriginal
care). While it is known that some institutions and organizations (e.g. Spiritual Health
Victoria, Melbourne) have also been trialling the WHO-PICs, no other results/findings
have yet been published in peer reviewed journals. Any such additional work would also
need to be assessed and considered once accessible. It should also be noted that as a
number of countries are not current with the WHO ICD-10 codings, and given that some
chaplaincy organizations/associations are still ‘attempting to reinvent the coding wheel’,
this naturally limits collaborative international involvement and hence restricts the breadth
of research and findings.
Further, and as noted earlier, one of the major limitations noted by this review has been
the lack of previous research to provide any guidance with exploring and utilizing the
WHO-PICs—which is surprising given that the codings have been available since 2002.
However (in general terms), there has usually been a lack of research into the coding of
chaplains and other pastoral/spiritual carers ministry with regard to religious, pastoral and
spiritual care. In the future, adequate research funding needs to be allocated to more
extensively assess and develop these codings.

Epilogue

This review will partly help to address the international need for action regarding the
professional development of chaplains and other religious/spiritual carers by further
developing, implementing and documenting religious, pastoral and spiritual interventions
(Handzo et al. 2014). More particularly, it is hoped that this review will aid the progression
of the ICD-11(and possibly versions beyond) to have a well-developed taxonomy spe-
cifically related to the religious, pastoral and spiritual needs of patients/clients, their family
caregivers and staff.

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