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February 2010 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Weinberger-Litman, S. L., Muncie, M. A., Flannelly, L. T. and Flannelly, K. J. "When do nurses refer patients to professional chaplains?" Holistic Nursing Practice 24, no. 1 (January-February 2010): 44-48.


SUMMARY and COMMENT: While a number of studies in recent years have indicated that nurses are a key source for chaplaincy referrals, it has not been clear "what specific patient and family issues nurses believe should be referred to chaplains" [p. 45]. This month's featured article explores the likelihood of referrals based upon family issues, patient feelings, treatment issues, and circumstances related to discharge from the hospital. What is more, this research employs a questionnaire that could be useful generally to pastoral care departments seeking to understand patterns of referral in their institutions.

A survey of 133 staff members at St. Luke's Hospital in New York City was conducted as part of an inservice presentation "that focused on when and how nurses should contact chaplains for both routine and emergency pastoral care" [p. 45]. Participating were 94 RNs/BSNs, 11 CNAs, 11 unit secretaries, 10 nurse managers, 3 LPNs, 2 student nurses, and 1 care coordinator. The questionnaire gave scenarios to be ranked on a 4-point Likert scale of 1 = not at all likely, 2 = slightly likely, 3 moderately likely, and 4 = very likely. The measure contained the following items (grouped here by categories for analysis --the original form displayed the items mixed):

  • Family issues
    • A patient’s family is meeting to decide whether to remove life support from their mother.
    • A patient has died and the family is grieving the loss uncontrollably.
    • A patient has come to the emergency department after a major life-threatening trauma and the family is arriving with no idea of the severity of the injury.
  • Patient feelings
    • A patient has just received a kidney transplant and it is not yet functioning. The patient seems to be despondent.
    • A palliative-care patient wants to talk to someone about his/her feelings.
  • Treatment issues
    • Patient and family members disagree about whether the patient should have surgery.
    • A patient’s family is arguing among themselves about the patient’s treatment.
    • The patient and doctor disagree over treatment options.
    • A patient refuses to take his/her medicine as he/she cannot see the point in it.
    • A patient has been rude and belligerent to the staff, demanding that he/she is not receiving quality treatment.
    • A patient states that he/she is in pain and the pain is not being addressed despite the physician’s prescriptions and nurses providing prescribed medication.
  • Discharge
    • A patient learns he/she has a change in diagnosis that affects prognosis.
    • A patient is to be discharged from the hospital but is exhibiting behaviors that show he/she desires to remain hospitalized.

[This measure is not given an official name. It was developed by 2 psychologists and 5 chaplains from various healthcare settings, and a version was field tested on 45 nursing staff and revised before the present study. One item (not shown) was excluded from analysis when it was determined that it did not fit well into the major categories.]

Among the findings: referrals seem to be triggered most often for family issues and least frequently for treatment issues. "On average, all nursing staff were between 'moderately likely' and 'very likely' to make referrals to chaplains for all 3 family issues listed [on the questionnaire] [p. 46], and "…the likelihood they would make referrals to chaplains for treatment-related issues were closer to 'slightly likely' than 'moderately likely' [p. 47]. Emotional support regarding patient feelings was the second most frequent reason for referrals, and discharge-related issues was the third most frequent, though "nurses were significantly more likely…to refer patients to chaplains for discharge…than were allied nursing staff…" [p. 47].

The results indicate that nursing staff refer patients and their families to chaplains for a wide range of reasons, but that they are more inclined to make referrals for some kinds of issues than others. Indeed, they are most likely to make referrals for those kinds of issues that have long been regarded as the traditional role of chaplains--to care for patients who are dying and for family members whose loved ones have died or are near death. …[And]…nurses clearly refer patients to chaplains for emotional support. [p. 47]
Since this study was carried out at only one hospital, generalizations should be made with caution, but the results are largely consistent with various findings of other research, though the rating of referrals for treatment issues was "somewhat lower than we expected on the basis of a recent analysis of actual referrals in a number of hospitals in the New York City area" [p. 47, and see: Galek, K., et al., "Topography of referrals to chaplains in the Metropolitan Chaplaincy Study," Journal of Pastoral Care and Counseling 63, nos. 1-2 (2009): 6.1-13 --noted in Related Items of Interest, §I, below].

For this reader, the study's questionnaire offers a convenient model for assessing staff assumptions about how chaplains' might be helpful in clinical situations, and it could be used to guide education about the potential breadth of the chaplain's professional role. Where one type of referral appears to less common, like treatment issues, then educational programs (such as the inservice used at St. Luke's-Roosevelt, which was the setting for this research) could then emphasize scenarios of that type. Referrals may be an especially rich indicator of the state of chaplaincy in an institution, since they would seem follow from staff's attitude towards spiritual care, capacity to recognize a range of pastoral needs, and a willingness to collaborate [--the authors touch briefly on these dynamics in their Discussion section, p. 47]. Formal replication of the study is, of course, always an option and should be quite manageable for most pastoral care departments. That not only would provide a larger cumulative data set but would promote further development of the questionnaire.


Suggestions for the Use of the Article for Discussion in CPE: 

The questionnaire for this study was designed to reflect scenarios for referral that commonly occur in hospitals, so students may want to think about the items [as given above, and listed in Table 1, p. 46] in terms of their experience at their CPE center. For students still new to research, this exercise may lead to a discussion of instrument specificity and the generalizability of results. Do students believe that they receive referrals from nursing in a different pattern from that indicated by this research?

The article briefly accounts milestones in the story of nurse-chaplain collaboration [--see the opening paragraphs, p. 44], and notes various aspects of nursing's relationship to spirituality and chaplains [--see the Discussion section, p, 47]. Students might consider broadly how nurses and chaplains work together. Including one or more nurses in the discussion could prove fruitful. While the article focuses on how nurses think of chaplains, students should be reminded that chaplains' views of nurses--especially as providers of spiritual care--is significant [--see related Items of Interest, §II, below].


Related Items of Interest:

I. The following are among other studies addressing referrals to chaplains.

Flannelly, K. J., Weaver, A. J. and Handzo, G. F. "A three-year study of chaplains' professional activities at Memorial Sloan-Kettering Cancer Center in New York City." Psycho-Oncology 12, no. 8 (December 2003): 760-768. [Among the findings of this analysis of 3570 chaplaincy visits that occurred during three two-week periods--one period each year from 1995 to 1997--at Memorial Sloan-Kettering Cancer Center in New York City: "Nurses made almost one quarter of all referrals and more than three quarters (82.3%) of the total from hospital staff" and "...the proportion of referrals that came from nurses increased significantly from 1995 to 1997" (p. 363). "The most common reason chaplains were referred to patients and their families and friends was a change in diagnosis or prognosis" (p. 763, and table on p. 764).] The article was featured as our Network's May 2004 Article-of-the-Month.

Fogg, S. L., Weaver, A. J., Flannelly, K. J. and Handzo, G. F. "An analysis of referrals to chaplains in a community hospital in New York over a seven year period." Journal of Pastoral Care and Counseling 58, no. 3 (Fall 2004): 225-235. [(Abstract:) The study analyzed the pattern of referrals to chaplains in a suburban hospital over a 7-year period. Nurses made more than half of all the referrals to chaplains, with nursing accounting for 81.74% of referrals from staff members other than pastoral care workers and volunteers. Social workers and physicians made 11.74% and 4.08% of referrals, respectively. The number of referrals from social workers (r= .86, /K.05), nurses (r = .68, /κ. 10) and other staff (r= .69, /κ. 10) increased across years, with the exception of physicians. Three quarters of referrals were requests for chaplains to visit patients and one quarter were requests to visit with family or friends. A significant difference was found in the percentage of referrals made for patients and family/friends by staff members (/K.05), with social workers making a higher percentage of referrals for relatives and friends (34.1%), compared to nurses (26.74%) and physicians (27.27%). The most common pre­ senting problems for which patients were referred to chaplains were anxiety, depression, and pregnancy loss. The rate of referrals for patients over the entire study period was 39.04 per 1000 patient stays.

Galek, K., Vanderwerker, L. C., Flannelly, K. J., Handzo, G. F., Kytle, J., Ross, A, M. and Fogg, S. L. "Topography of referrals to chaplains in the Metropolitan Chaplaincy Study." Journal of Pastoral Care and Counseling 63, nos. 1-2 (2009): 6.1-13. [(Abstract:) Understanding referral patterns to chaplains is essential not only to ensure proper patient treatment, but also to assist chaplains seeking to expand the range of patient situations in which they are called to intervene. Information about more than 58,000 chaplain visits was documented during the first two years (2005-2006) of the Metropolitan Chaplaincy Study. Data from 15,655 of these visits, which were made in response to referrals (26.9% of all visits), were analyzed in the present study. Seventy-eight percent of referral requests were met within the same day, and 94.9% of requests and were met within 2 days. Nurses were the most frequent source of referrals to chaplains (45.0%), followed by self-referrals from patients or requests from their family members (30.3%), with the remainder coming from a variety of hospital disciplines. The most common reason for referrals was that patients requested to see a chaplain. Other relatively common reasons for referrals were problems or issues related to illness or treatment, and end-of-life issues, concerns about death and the death of patients, with reasons for referrals differing by referral source. The most common reason for referrals among professional staff was that patients were feeling bad or in pain, followed by medical issues, and end-of-life issues. Patient and family referrals usually involved positive patient affect, whereas staff referrals usually involved negative patient affect.]

Vanderwerker, L. C., Flannelly, K. J., Galek, K., Harding, S. R., Handzo, G. F., Oettinger, M. and Bauman, J. P. "What do chaplains really do? III. Referrals in the New York Chaplaincy Study." Journal of Health Care Chaplaincy 14, no. 1 (2008): 57-73. [(Abstract:) The current study examines patterns of referrals to chaplains documented in the 1994-1996 New York Chaplaincy Study. The data were collected at thirteen healthcare institutions in the Greater New York City area. Of the 38,600 usable records in the sample, 18.4% were referrals, which form the sample for the current study (N = 7,094). The most common sources of referrals were nurses (27.8%) and patients themselves (22.3%), with relatively few referrals coming from physicians and social workers. The study shows the range of patient issues that are referred to chaplains, including emotional, spiritual, medical, relationship/support, and a change in diagnosis or prognosis. Although the reasons for referral varied by hospital setting and referral source, overall, patients were referred more frequently for emotional (30.0%) than for spiritual issues (19.9%). Results are discussed in relation to the need to clarify the role of the chaplain to the rest of the healthcare team, to recognize when there is a spiritual cause of emotional distress, and to establish effective referral protocols.] NOTE: This is one of three related articles in vol. 14, no. 1 of the Journal of Health Care Chaplaincy --the other two being: Handzo, G. F., Flannelly, K. J., Kudler, T., Fogg, S. L., Harding, S. R., Hasan, Y. H., Ross, A. M. and Taylor B. E., "What do chaplains really do? II. Interventions in the New York Chaplaincy Study," (pp. 39-56) and Vanderwerker, L. C., Flannelly, K. J., Galek, K., Harding, S. R., Handzo, G. F., Oettinger, M. and Bauman, J. P., "What do chaplains really do? III. Referrals in the New York Chaplaincy Study" (pp. 57-73). For abstracts of these latter articles, see our Fall 2008 Newsletter (§7).]

II. On how chaplains may view nurses, see:

Cavendish, R., Edelman, M., Naradovy, L., McPartlan Bajo, M., Perosi, I. and Lanza, M. "Do pastoral care providers recognize nurses as spiritual care providers?" Holistic Nursing Practice 21, no. 2 (March/April 2007): 89-98. [(Abstract:) This descriptive qualitative study was conducted to explicate pastoral care providers' perceptions of nurses as spiritual providers. Spirituality is especially meaningful in contemporary society as a whole with spiritual care an expectation of hospitalized patients. Spiritual care given by nurses is grounded in nursing's history, inherent in its philosophical framework, and supported by research and professional mandates. In hospitals today, the primary responsibility for the spiritual care of patients resides with pastoral care providers. Collaboration between pastoral care providers and nurses may improve patients' spiritual care outcomes. Before collaboration can occur, it is important to learn whether pastoral care providers recognize nurses as spiritual providers. Guided by qualitative research methods, participants were sought until data saturation occurred. This qualitative study consisted of 8 participants who were experienced, full-time pastoral care providers from general and religious-affiliated hospitals. Data were collected through audiotaped open-ended interviews, a demographic data form, and exploratory questions or probes. The analysis included concurrent data collection, constant examination of conceptual interactions, linkages, and the conditions under which they occurred. Themes emerged: quest, conscious response, and essence of caring. Pastoral care providers perceive nurses as spiritual providers. Few felt comfortable initiating collaboration. Study findings are not generalizable.] This study was also featured as our Network's March 2007 Article-of-the-Month.


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