January 2017 Article of the Month
This month's article selection is highlighted by John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Kim, K., Bauck, A., Monroe, A., Mallory, M. and Aslakson, R. "Critical care nurses' perceptions of and experiences with chaplains: implications for nurses' role in providing spiritual care." Journal of Hospice and Palliative Nursing 19, no. 1 (February 2017): 41-48.
SUMMARY and COMMENT: Understanding how other disciplines experience and think about chaplaincy has been a valuable line of spirituality & health research, supporting chaplains' integration into care teams. The present qualitative study sought to explore specifically ICU nurses' "(a) experiences with providing spiritual care to critically ill patients and their families, (b) perceptions about chaplains and the duties best performed by chaplains, and (c) suggestions regarding ways to better integrate nursing and chaplaincy practices to meet the spiritual needs of critically ill patients, their families, and the ICU staff" [p. 42]. While written by nurses, for nurses, the article should be useful to chaplains in the building of high-functioning multidisciplinary relationships.
Data from 19 individual interviews and 2 focus groups, involving a total of 31 critical care nurses from a tertiary-care, inner-city academic medical center were analyzed using a grounded theory approach. (The methodology is briefly but well outlined [p. 42].) Statements by the participants fell out into four categories. Among the findings were:
Related to this last section of findings were further examples of nurses' perceptions of chaplains:
- 1) When Nurses Encounter Patients and Their Families Who Need Spiritual Care --
- "[M]ost nurses felt unprepared to meet the spiritual needs of critically ill patients and their families" [p. 43]. Also, "nurses were not used to proactively collect relevant cues" to patients' spiritual needs but were more "reactive" to perceived indications of need, especially in situations of "patients' end-of-life situations, organ donations, and patients and families with strong religious beliefs" [p. 43].
- 2) What Nurses Consider Caring for Patients and Their Families Who Require Spiritual Support --
- "Participants who were aware of the spiritual care department were more likely to invite spiritual care providers and vice versa," with one nurse pointing out that there had been no "formal introduction to pastoral care" [p. 43]. Also, "Nurses who valued the importance of religion and/or spiritual beliefs in their personal life noted that they also frequently invited spiritual care providers for patients and their caregivers" [p. 43]. Highlighting this finding: "Conversely, others who were ambivalent about spirituality in their own life noted not frequently requesting or keeping them from offering spiritual care services for their patients" [p. 43].
- 3) How Nurses Perceive the Role of Chaplains --
- "Nurses' perceived role of the spiritual care providers included listening, providing physical touch (hand-holding, hugging), praying, counseling, and performing religious rituals, [and they]...acknowledged that the role of the spiritual care providers overlap[s] what nurses could offer as part of holistic care" [p. 43]. "Participants felt chaplains were particularly able to fulfill...supportive roles because, paradoxically, while chaplains are 'insiders' in that they are members of the medical team, they are also viewed as 'outsiders' because of their unique position in the hospital" [pp. 43-44]: i.e., "they are not responsible for making clinical decisions or dealing with the daily minutiae of caring for a patient, [which]...allows them to serve as a familiar, yet somewhat removed, source of comfort for patients and their families" [p. 44].
- 4) What Nurses Recommend for Improving Spiritual Care in the ICU --
- "Nurses felt that their own spiritual needs should be met in order to offer spiritually based nursing care among patients and their families" [p. 44]. "Participants repeatedly reported that their personal debriefing sessions with the spiritual care providers helped them deal with unpleasant clinical events in the ICU...[but]…they noted that these sessions are not regularly offered" [p. 44]. Participants also emphasized a need to make referrals to pastoral care a more convenient process and to "build better preexisting connections and relationships between nurses and chaplains" [pp. 45-46]. Nurses also "expressed a desire for routine chaplain support to address spiritual needs early on for all patients, particularly as some nurses worried that abruptly introducing chaplains to critically ill patients and their families might be perceived as a forerunner of death" [p. 45].
Most participants perceived spiritual care services as being helpful for patients and their families. Some felt that the most helpful support from the best chaplains was difficult to describe, a quality that went above and beyond concrete activity (such as offering a blessing) to a more ethereal connection (such as intuitive social support). Some nurses were unable to explain this. They described chaplains possessing this quality as someone who was able to "just tell what people need." Others tried to describe characteristics of these chaplains as people who "bend over backwards" to develop relationships with patients and families and address their spiritual needs. However, although rarely addressed, nurses acknowledged that spiritual care services might not be beneficial in some cases. For example, nurses noted concern about if or when a patient's and/or family's religion did not match that of the spiritual care provider.... [p. 44]
The findings are well-illustrated by quotations.
The authors address the study's limits, including limits of the sample, and go on the offer a number of helpful suggestions for further research, including the need to...
For this reader, the most striking takeaway from the study is the reported recognition, by nurses, of the importance of familiarity with the role of the chaplain, whether by formal orientation or the regular presence of chaplains on patient care units. It may be that solutions to many problems regarding patient assessment, communication and teamwork, as well as staff self-care, could flow simply from such practical familiarity. As chaplains seek to understand others on the multidisciplinary team, it seems key to comprehend those others' understanding of chaplains.
- "…explore how and whether regular spiritual support of critically ill patients, their family members, and/or the ICU staff could impact outcomes such as patient or family psychological distress, posttraumatic stress disorder, or spiritual distress and/or ICU staff spiritual or moral distress and/or job satisfaction"
- "...explore the differences of spiritual support provided by community-based spiritual care experts and/or members of the patient's home faith community as opposed to that provided by hospital-based chaplains"
- "...test our proposed conceptual model. Practice implications include medical centers considering an orientation session on spirituality and spiritual care with chaplain participation for all new nurses and new hires across all health care disciplines as well as periodically inviting chaplains to educational sessions throughout the institution's educational programs. Intensive care units could also consider chaplain involvement in routine unit debriefings following patients' deaths or traumatic codes and invite chaplains to regular patient care conferences to promote better communication between ICU providers and chaplains such
that the ICU can truly provide interdisciplinary care with best practices for both the physical and spiritual care of ICU patients and their family members." [p. 46]
Suggestions for Use of the Article for Student Discussion:
This article should be useful at any level of CPE and would give an opportunity to invite nurses to be part of a student discussion, which in turn may open up more dialogue between the chaplains and nurses and inspire plans for better collegial interaction on patient care units. How do nurses at your institution become familiar with the role of the chaplain? The article notes areas of overlap between the practice of nursing (as a holistic profession) and chaplaincy, so the group might explore how this could be advantageous to teamwork and not a source of confusion about professional "turf." What do students think of the comments regarding "How Nurses Perceive the Role of the Chaplain" (--see pp. 43-44 and Table 3 on p. 45). What else would students say to describe their own role? What do they make specifically of the characterization of chaplains as both "insiders" and "outsiders" [p. 43]. In addition, what are students' thoughts about the statement: "Some [nurses] felt that the most helpful support from the best chaplains was difficult to describe…" [p. 44]. Moreover, what is their reaction to reservation by some nurses [--see p. 44] about a mismatch between the religion of a patient/family and that of a spiritual care provider? Turning to the topic of research itself, the group could review the concise outline of methodology [p. 42] and, for those newer to research, discuss especially the idea of "an iterative process of refinement based on ongoing data collection throughout the study" [--note that the word iterative is used three times in the section, including once in relation to the term saturation].
Related Items of Interest:
I. Regarding the relationship between nurses and chaplains generally, Network members should recall the Ministry Special Project carried out by CPE residents at Saint Luke's Hospital, Kansas City, MO: "Nurses' perception of the role of chaplain," which was highlighted in our Fall 2013 Newsletter and a report of which is available online. That project found that "there is a positive correlation between nurses' familiarity with the role of chaplain and their likelihood to work collaboratively with chaplains" [--from the abstract].
Also, readers may be interested in the following study out of New York Presbyterian Hospital and Stony Brook University:
Gallison, B. S., Xu, Y., Jurgens, C. Y. and Boyle, S. M.
"Acute care nurses' spiritual care practices." Journal of Holistic Nursing 31, no. 2 (June 2013): 95-103. [(Abstract:) The purpose of this study was to identify barriers in providing spiritual care to hospitalized patients. A convenience sample (N = 271) was recruited at an academic medical center in New York City for an exploratory, descriptive questionnaire. The Spiritual Care Practice (SCP) questionnaire assesses spiritual care practices and perceived barriers to spiritual care. The SCP determines the percentage that provides spiritual support and perceived barriers inhibiting spiritual care. The participation rate was 44.3% (N = 120). Most (61%) scored less than the ideal mean on the SCP. Although 96% (N = 114) believe addressing patients spiritual needs are within their role, nearly half (48%) report rarely participating in spiritual practices. The greatest perceived barriers were belief that patient's spirituality is private, insufficient time, difficulty distinguishing proselytizing from spiritual care, and difficulty meeting needs when spiritual beliefs were different from their own. Although nurses identify themselves as spiritual, results indicate spirituality assessments are inadequate. Addressing barriers will provide nurses opportunities to address spirituality. Education is warranted to improve nurses' awareness of the diversity of our society to better meet the spiritual needs of patients. Understanding these needs provide the nurse with opportunities to address spirituality and connect desires with actions to strengthen communication and the nurse-patient relationship.]
II. This month's article may be profitably paired with our March 2007 Article-of-the-Month: 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.
III. Regarding the iterative process used in this qualitative study, and its relationship to the idea of saturation in grounded theory methodology, the Robert Wood Johnson Foundation offers a concise, very readable guide to qualitative research in their online Qualitative Research Guidelines Project, including a brief explanation of Iterative Sampling as part of the explanation of Grounded Theory.
Chaplains should be aware of the excellent introduction to qualitative methodology by Chaplain Daniel Grossoehme: "Overview of qualitative research" [Journal of Health Care Chaplaincy 20, no. 3 (2014): 109-122], which was featured as our August 2014 Article-of-the-Month. (The author mentions "iterative design" on p. 114, as well as the RWJF Qualitative Research Guidelines Project on p. 110.)
In addition, the National Center for Research Methods in the UK has produced an interesting review paper pertaining to the related idea of saturation: Baker, S. E. and Edwards, R., "How many qualitative interviews is enough? Expert voices and early career reflections on sampling and cases in qualitative research" (2012): 42pp. (--available online from the NCRM website.)
IV. Our authors cite the American Nurses Association Code of Ethics for Nurses [p. 47]. It might be an interesting exercise for chaplains to read this document with an eye for how the ethics of nursing support aspects of role overlap with chaplains. It is available online from the ANA website.