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February 2015 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Marin, D. B., Sharma, V., Sosunov, E., Egorova, N., Goldstein, R. and Handzo, G. F. "Relationship between chaplain visits and patient satisfaction." Journal of Health Care Chaplaincy 21, No. 1 (2015): 14-24.


SUMMARY and COMMENT: Patient satisfaction is an important metric for hospitals and one that pastoral care departments may affect. This month's feature is the "first study demonstrating that patients who are seen by chaplains are more satisfied with their hospital stay, as measured by HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems] and Press Ganey surveys" [p. 20] --the former impacting Medicaid/Medicare incentives under the Value Based Purchasing Program [--see Items of Related Interest, §I, below], and the latter a popular and long-standing measure. This research also collected useful data on referral sources for chaplains.

The authors "hypothesized that patients who were visited by chaplains would be more satisfied with their overall hospital experience and would endorse that their spiritual and emotional needs were met on the HCAHPS and Press Ganey surveys, respectively" [p. 20]. The study was conducted at Mount Sinai Hospital, a 1,171-bed tertiary-care teaching hospital in New York City, between December 14, 2011 and May 1, 2013.

Within the study period, there were 67,952 hospitalizations, representing 48,734 adult patients. Patients had chaplain visits in 5,173 of these hospitalizations. Responses to the surveys were received from 8,978 patients who had been hospitalized and responded to the survey only once. Among respondents, we identified 498 (5.6%) hospitalizations during which patients were visited by chaplains. During these 498 hospitalizations, chaplains conducted 738 visits, ranging from 1 to 10 visits per hospitalization, with a median of 1 visit per hospitalization (first quartile = 1, fourth quartile = 2). The number of referrals for chaplain visits varied from 1 to 5 per hospitalization, with a median of 1 (first quartile=1, fourth quartile=1). [p. 15]
Six items were chosen from the HCAHPS and Press Ganey surveys to test the central hypothesis.
  • Overall rating of care given at hospital  [--from Press Ganey]
  • What number would you use to rate this hospital during your stay?  [--from HCAHPS]
  • Likelihood of your recommending this hospital to others  [--from Press Ganey]
  • Would you recommend this hospital to your friends and family?  [--from HCAHPS]
  • Degree to which hospital staff addressed your spiritual needs  [--from Press Ganey]
  • Degree to which hospital staff addressed your emotional needs  [--from Press Ganey]
Before controlling for patient characteristics (i.e., age, gender, race, ethnicity, language, education, faith, general health status, and medical conditions), analysis showed that patients visited by a chaplain scored significantly higher on the two HCAHPS items: "What number would you use to rate this hospital during your stay?" and "Would you recommend this hospital to your friends and family?"; and two of the Press Ganey items: "Overall rating of care given at hospital" and "Degree to which hospital staff addressed your spiritual needs" However, after controlling for patient characteristics, all six survey items were significantly affected by chaplains' visits. [--See pp. 19-20, including data presented in two tables.]

The study also revealed information about referral sources for the chaplains:

Most referrals originated from chaplain rounds (74.7%), while nurses were the next most frequent source of referrals (8.7%). Self-referrals from patients were more frequent (3.4%) than referrals from social workers (1.6%) and doctors (1.1%). [p. 19]
The authors note that "referrals to chaplains accounted for the minority of chaplain visits" [p. 20], and they go on to advocate for greater integration of chaplains into the healthcare team [--see pp. 20-21].

While this research does not establish causal connections between chaplains' visits and patient satisfaction, it does present remarkable associations worthy of recognition in health care and, of course, further research. The findings may even speak to the perennial issue of how chaplains may affect hospital revenue:

Historically, chaplaincy is not viewed as revenue generating. Our findings suggest that meeting patientsí spiritual needs increases patient satisfaction and may also have positive fiscal consequences, given the advent of the [HCAHPS-connected] Value Based Purchasing Program. [p. 22]
Two final comments: First, the study does not address the concern of some pastoral care departments that patient satisfaction surveys may be returned more by patients with short-term stays while chaplains may spend more time with long-term patients or with patients who die. This could be a fruitful topic for both research and ethical discussion. Second, this reader noticed an apparent inaccuracy in the introductory paragraph: the authors state, "The Joint Commission requires a spiritual assessment for each patient, to determine any religious affiliation and spiritual practices or beliefs which may impact patient care" [p. 15], citing a 2005 Joint Commission publication. Though the Joint Commission does support the idea of spiritual assessment as a general hospital practice in such documents as its 2010 "Roadmap for Hospitals" and in the practical emphases of individual site surveys, the actual standards by which hospitals are accredited still only explicitly require a spiritual assessment in the acute care setting for patients receiving end-of-life care or treatment for behavioral health and substance abuse issues, and in the context of an assessment of factors affecting patient education. [See a summary listing.] This point does not in any way impact the validity of study's data or analysis.

This prospective research substantiates the important connection between chaplains' work and satisfaction scores at a time when those scores may have practical implications for hospital finances, as well as being indicators of the quality of patient experiences.


Suggestions for the Use of the Article for Student Discussion: 

Discussion could begin with a general consideration of possible connections between chaplains' visits and patient satisfaction and then focus on the six survey items used in the study. Can students think of chaplaincy interventions that might boost patient satisfaction? The two Press Ganey items about spiritual and emotional needs may be fairly straightforward, but what about the two broad items on the increasingly important HCAHPS survey? Also, how much should a concern for patient satisfaction guide or shape a chaplain's practice? A few of hypothetical scenarios could be discussed. Might a patientís expression of poor satisfaction during a hospitalization be an automatic trigger for staff to refer a chaplain? In order to increase your hospitalís satisfaction scores, would you be willing to pay special attention to satisfaction issues in your pastoral visits? How might satisfaction issues be indicators of spiritual concerns, and vice-versa? What is the nature of satisfaction to begin with? [See Related Items of Interest, §III, below.] What does it really mean for a patient to be "satisfied" with a chaplainís visit? Finally, more along the lines of referrals, students could discuss the authors' speculation about referral patterns [pp. 20-21], and the need for chaplains to become more integrated into the health care team. The authors note that referrals tend to be more likely from nursing than from other disciplines. What other disciplines or departments in a hospital might chaplains want especially to cultivate referral-generating relationships?


Related Items of Interest:

I. For more on HCAHPS, see, especially the actual survey questions. And for more on the role of HCAHPS in the Value Based Purchasing Program, also see the Centers for Medicaid and Medicare Services ( site, noting: "The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148) includes HCAHPS among the measures to be used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program, beginning with discharges in October 2012" [--from the website].

Information about the Press Ganey survey may be found at


II. The Research Network has highlighted research on satisfaction several times before. See especially the Article-of-the-Month pages for September 2014, August 2011 and, much earlier, October 2004. Note that the September 2014 study deals with the satisfaction of family members of patients who have died in the hospital.


III. To think more about the very idea of satisfaction, especially in relation to expectations, the following articles may be helpful, even though they focus on other fields in health care.

Newsome, P. R. and Wright, G. H. "A review of patient satisfaction: 1. Concepts of satisfaction." British Dental Journal 186, no. 4 (February 27, 1999): 161-165. [(Abstract:) Against a background of growing consumerism, satisfying patients has become a key task for all healthcare providers. This paper reviews current conceptual models of consumer satisfaction, including the one most dominant in the marketing literature--disconfirmation theory.]

Thompson, A. G and Sunol, R. "Expectations as determinants of patient satisfaction: concepts, theory and evidence." International Journal for Quality in Health Care 7, no. 2 (June 1995): 127-141. [(Abstract:) The apparent lack of conceptual agreement and the inconsistency in the approach to understanding expectations prompted this analysis of the literature in the field of patient satisfaction. A review of 18 journals over the last few years, as well as a number of relevant books, provided the evidence for the state of the current theory. An attempt has been made to distill the main definitions in use, to illustrate practical models of the relationship between expectations and satisfaction, to identify the influential personal and social variables, and to consider the special nature of health care. Some of the empirical methods and findings are then presented, with conclusions made about how the theory of expectations may be developed to assist in understanding patient satisfaction.]



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