January 2022 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA
McManus, K. and Robinson, P. S. "A thematic analysis of the effects of compassion rounds on clinicians and the families of NICU patients." Journal of Health Care Chaplaincy 28, no. 1 (2022): 69-80.
SUMMARY and COMMENT: This qualitative study assesses the experiences of participants in a special rounding practice adapted by a Neonatal Intensive Care Unit at an AdventHealth hospital in Florida. Compassion Rounds "bring physicians, chaplains, and other care team members together with patients and their families in conversations that are dedicated completely to assessing and addressing their emotional, psychological, and spiritual needs...," ..."differ[ing] from routine, daily multidisciplinary Rounds that center on the treatment of medical conditions by focusing solely on how patients and their loved ones are coping with the experience of illness and hospitalization" [p. 71]. They are "an opportunity to not only provide whole-person care to patients but also for physicians and other clinicians to learn from chaplains and to practice psychosocial/psycho-emotional aspects of patient care" [p. 71]. Results suggest its success in this case and further provide proof-of-concept data for a model that might be considered by chaplains in other health care contexts.
Compassion Rounds are intended to provide spiritual care for patients (or in the case of neonates, for their families) by offering them an opportunity to interact with their physician and a chaplain focusing solely on their emotional well-being and spiritual needs. One or two other care providers typically attend as well, and usually, the team spends about 15-20 minutes in a patient's room. [p. 72]
Study participants were drawn from those who had been involved with the Rounds: 15 family members, 8 chaplains, 3 physicians, and 4 other clinicians. The group was topped out at 30, after recorded and transcribed interviews appeared to have collected thematic data to a point of saturation. In addition, "employees who were interviewed were invited to participate in a focus group following the initial data analysis to validate the findings and provide additional input on their emerging experience with Compassion Rounds" [p. 74]. Data collection occurred between October 2018 and June 2019.
Results are presented in terms of three major themes (with several subthemes) that emerged from the data. Among the findings:
THEME ONE: EFFECTS OF CREATING A SPACE FOR PSYCHO-EMOTIONAL NEEDS -- "Interviewees almost unanimously professed that Compassion Rounds were effective in improving their spiritual wellness, even if only temporarily," and their comments signaled "the otherwise unavailability of a space to address patients' psycho-emotional needs" [p. 75].
THEME TWO: RESTORATIVE BENEFITS THAT COUNTERACT BURNOUT AND RETURN MEANING TO THEIR WORK
- FEELING HEARD --
- "Physicians reported feeling dismayed at sometimes being unaware of a NICU mom's distress until they attend[ed] a Compassion Round. NICU families described the exhaustion and stress they often feel, but do not want to reveal to the care team or other family members. Many NICU moms wept during Compassion Rounds and voiced their feelings of relief after releasing those emotions. The physicians' lack of insight and the NICU mom's emotional labor are examples of how Compassion Rounding makes room for communications and understandings that are difficult to execute in the day-to-day NICU routine." [p. 75]
- FEELING CONNECTED --
- "Patients and chaplains commented they felt more connected to the care team as a result of Compassion Rounds, and the care team felt more connected with each other as well as with the patients and families." [p. 76] In relation to this theme and to that of hearing others, one physician participant stated that "listening to the person's story ... and hearing it, helped [physicians] identify and connect with the families at the point of their greatest emotional or spiritual need." [p. 72]
- TRUST --
- "Study participants, caregivers, and recipients confirm...associations between trust and Compassion Rounds." In the words of one chaplain: "I've seen parents change, from having to make decisions or get ready for any big news to feeling supported completely, more trusting of the team, more available to the team, in the sense they're opening up emotionally to the team." [p. 76]
THEME THREE: COLLABORATION WITH CHAPLAINS THAT PHYSICIANS FIND HELPFUL IN PROVIDING SPIRITUAL CARE TO THEIR PATIENTS
- RESILIENCE AND PREVENTION OF BURNOUT --
- "[C]omments of three physician participants illustrate how Compassion Rounds positively influenced their resilience and burnout prevention: ...I've been totally exhausted, physically and emotionally, but I feel refreshed and revitalized after participating in Compassion Rounds." And, "You get instant gratification from the help that you can give, versus when you are in the NICU, you can make changes on the ventilator, or you can start antibiotics, but you don't immediately see someone get better. In Compassion Rounds, we provide comfort immediately to these moms that are struggling." Also, the authors note that the Rounds "may counteract burnout among other members of the care team as well, as illustrated by these comments: 'I've seen when burnout shows up; it is very ugly and very painful ... physicians or chaplains who've lost the ability to be compassionate at the bedside. [However]...[i]t seems they feel more connected, more energized by what we're doing in our workplace, and it just seems like everybody benefits from it.'" [pp. 76-77]
- RESTORED MEANING TO PRACTICING MEDICINE --
- "The observations of chaplain participants also suggest that the Compassion Round experience benefits physicians and other care providers by restoring meaning to their work through the provision of spiritual care: 'During Compassion Rounds, everyone witnesses the interaction and the suffering, but also the meaning behind the work they're providing for a family.'" [p. 77]
"Every physician interviewed professed to feel much more confident about providing spiritual care as a result of their experiences with Compassion Rounds. Their initial apprehensions gave way to increasing comfort with Compassion Rounds and their ability to connect with patients around spiritual care in other contexts. The physician participants pointed to the modeling that chaplains provide during Compassion Rounds as a way to learn and develop their own skills tending to an overlooked aspect of whole-person care. The chaplains affirmed they could see their physician collaborators mirroring their own behavior and becoming surer of themselves as they gained experience." One physician commented that once he saw how the chaplain and behaved, "I felt like, yes, I can do this." [p. 78]
The Rounds had begun at the study institution with a "small group of chaplains and multidisciplinary clinicians" wishing to "more effectively integrate chaplains into care plans" [p. 71], and the authors hold that "the overall findings strongly suggest that greater integration of spiritual care, using methods such as Compassion Rounds, supports models of whole-person care and patient well-being" [p. 78].
Compassion Rounds provide a space to address patients' and families' psycho-emotional needs and contribute to patient-centered care, wherein the patient feels heard and experiences stronger and more trusting connections and improved relationships with the care team. Most notably is the extent to which clini- cians describe the benefits of Compassion Rounds to their own resilience and resistance to burnout. Their testimony suggests that care providers who deliver Compassion Rounds may benefit as much as or even more than the patients and family members who are the intended beneficiaries because of the restorative effects of Compassion Rounding. [p. 78]
They conclude: "This exploratory study of Compassion Rounds affirms the value of providing spiritual care as part of whole-person health and wellness interventions," and they observe that the Rounds "provide a way for physicians to learn from chaplains, develop empathic compassion, and provide an intervention to patients and family members with perceived positive effects that require limited contact time by physicians" [p. 78]. Moreover, "[m]ost [clinicians] agreed Compassion Rounds have the potential to prevent or overcome burnout, restore meaning to the work of clinicians, and create trust not only between caregivers and care recipients but also within a multidisciplinary care team" [p. 79].
While the authors here are focused on one particular iteration of rounding strategy that concentrates on spiritual and psychosocial care, the themes expressed by participants would seem to suggest the value of similar initiatives in other healthcare contexts and the potential for broader research in this area. For example: How might emphatic attention to spirituality and psychosocial dynamics during rounding be alike or different if they are made a part of -- though a distinct part of -- more standard medical rounds? Might the discipline-specific composition and size of the rounding team at the patient's room have an effect? What might be the optimal amount of time for the rounding discussion with the patient (since there is an old and unwritten/unresearched rule in chaplaincy circles that patients tend to share much more deeply at about the 25-minute mark of a visit)? What variations on the strategy might be fruitful, such as having the chaplain speak privately first with the patient and then have the larger care team join them (and the chaplain could leave for the next patient when the care team shifted to technical medical issues)? Might such rounding with patients be compared with the effects of discussing spiritual issues in a team-only "rounding" discussion of patients? The findings from our featured study are promising, but even more they point toward intriguing questions for further investigation, which ultimately is the hallmark of the scientific method.
This chaplain reader would offer a few more thoughts on the article: First, The article's introductory material occupies a greater proportion of the text than most articles and includes references to the study's findings ahead of the formal report of results. This is a bit unusual, but it works well in the narrative presentation. Second, the authors nicely clarify their use of the terms spiritual and religious [--see p. 71], and this plays into their observation that chaplain participants came to envision the "Rounds and other spiritual care interventions to be an integral part of a patient's care plan and history, not a religious opportunity" [p. 73]. Third, the authors draw upon a 2012 article by Barbara Pesut, et al., in stating, "The key role of the chaplain in delivering Compassion Rounds supports the assertion that chaplaincy may be re-emerging as an important concept in modern health care" [p. 71]. The use of the word re-emerging is curious here, as it appears to be in the context of our authors sense of increasing appreciation and integration of chaplaincy in recent years, but Pesut and colleagues were describing the change in the role of the chaplain in the present day compared to that in the 16th century. Fourth, our featured article does not address role differentiations between spiritual care "generalists" versus spiritual care "specialists," though this seems pertinent not only to the process of interdisciplinary collaboration but to the potential for interdisciplinary tension. Fifth, Finally, for a study about integrating the perspective of chaplains, there is no indication that a chaplain had a direct hand in shaping the article itself.
This is an easily read article that provides information useful beyond its limited scope, and it lifts up a model both of chaplains' involvement (and leadership) in patient rounding and of a general carving out of rounding time specifically for the spiritual and relational aspects of the experience of patients and families. The bibliography of 27 citations covers basic sources in the literature.
Suggestions for Use of the Article for Student Discussion:
If chaplain students are in any way participating in care team rounding, then discussion could obviously revolve around how the study relates to their experience; otherwise, the article could open up a departmental discussion of rounding possibilities, and one or two well-placed physicians might be invited to join the discussion session. Conversation could be straightforwardly organized around the themes that came out of the data. Also, our authors note the "collaborative nature" of the Rounds in "pair[ing] chaplains and physicians in ways that enable chaplains to model spiritual care for physicians and physicians to integrate spiritual care into their bedside skills" [p. 72, and see p. 78]. What do the students think about such a "collaborative" relationship and their potential role in educating physicians? Regarding trust, one of the chaplain participants is quoted as saying that "there was a built-in trust factor between the physician and the patient that I, as a chaplain, would have to work months to gain" [p. 76]. Does this ring true to the group, or do the students find that sometimes patients tend to trust chaplains more readily than they do some physicians, perhaps especially when patients are dealing with large teams in teaching hospitals? If the latter, then what might this signal about the particularity of either the study participant or the setting of the research? On the issue of burnout, does the group believe that some form of Compassion Rounds might help them counter their own risks, and why might that be the case? [--See esp. p. 77.] And, as a bit of aside, what does the group make of the cited research that broad "physical and cognitive functional outcomes...have been associated with compassionate behaviors on the part of providers, such as decreasing personal distance, leaning in, direct eye contact, and smiling" [p. 70]. Do the students intentionally use body language like this in their pastoral practice? Finally, in terms of research methodology, there might be some exploration of the "six phases of thematic analysis" listed on p. 74 [--and see Related Items of Interest, §II, below].
Related Items of Interest:
I. This month's article describes a program by which physicians may learn from chaplains. For more on this general tropic, especially in the context of medical education, see our February 2014 Article-of-the-Month on shadowing programs. In addition, see:
Frazier, M., Schnell, K., Baillie, S. and Stuber, M. L.
"Chaplain rounds: a chance for medical students to reflect on spirituality in patient-centered care." Academic Psychiatry 39, no. 3 (June 2015): 320-323. [(Abstract:) OBJECTIVE -- This study assesses the perceived impact of a required half-day with a hospital chaplain for first-year medical students, using qualitative analysis of their written reflections. METHODS -- Students shadowed chaplains at the UCLA hospital with the stated goal of increasing their awareness and understanding of the spiritual aspects of health care and the role of the chaplain in patient care. Participation in the rounds and a short written reflection on their experience with the chaplain were required as part of the first-year doctoring course. RESULTS -- Qualitative analysis of reflections from 166 students using grounded theory yielded four themes: 1) importance of spiritual care; 2) chaplain's role in the clinical setting; 3) personal introspection; 4) doctors and compassion. CONCLUSIONS -- Going on hospital rounds with a chaplain helps medical students understand the importance of spirituality in medicine and positively influences student perceptions of chaplains and their work.] [Note: co-author Karen Schnell is a chaplain.] [This article is available freely online through the National Library of Medicine.]
II. Our authors this month were guided by a six-phase process of thematic analysis: 1) familiarizing with the data, 2) generating initial codes, 3) searching for themes, 4) reviewing themes, 5) defining and naming themes, and 6) producing the report. This approach was put forward by Virginia Braun and Victoria Clarke in 2006:
Braun, V. and Clarke, V. "Using thematic analysis in psychology." Qualitative Research in Psychology 3, no. 2 (2006): 77-101. [(Abstract:) Thematic analysis is a poorly demarcated, rarely acknowledged, yet widely used qualitative analytic method within psychology. In this paper, we argue that it offers an accessible and theoretically flexible approach to analysing qualitative data. We outline what thematic analysis is, locating it in relation to other qualitative analytic methods that search for themes or patterns, and in relation to different epistemological and ontological positions. We then provide clear guidelines to those wanting to start thematic analysis, or conduct it in a more deliberate and rigorous way, and consider potential pitfalls in conducting thematic analysis. Finally, we outline the disadvantages and advantages of thematic analysis. We conclude by advocating thematic analysis as a useful and flexible method for qualitative research in and beyond psychology.]
Chaplain researchers may be interested in a newly published book and its related Sage Publishing web page (which links to online resources):
Braun, V. and Clarke, V. "Thematic Analysis: A Practical Guide." Sage Publications, December 2021. [From the Sage Publishing website: Developed and adapted by the authors of this book, thematic analysis (TA) is one of the most popular qualitative data analytic techniques in psychology and the social and health sciences. Building on the success of Braun & Clarke's 2006 paper first outlining their approach -- which has over 100,000 citations on GoogleScholar -- this book is the definitive guide to TA, covering: Contextualisation of TA, Developing themes, Writing TA reports and Reflexive TA. It addresses the common questions surrounding TA as well as developments in the field, offering a highly accessible and practical discussion of doing TA situated within a clear understanding of the wider terrain of qualitative research. Virginia Braun is a Professor in the School of Psychology at The University of Auckland, Aotearoa New Zealand. Victoria Clarke is an Associate Professor in Qualitative and Critical Psychology in the Department of Social Sciences at the University of the West of England (UWE), Bristol.]
For some background to Braun and Clark's work, see:
Jankowski, G., Braun, V. and Clarke, V. "Reflecting on qualitative research, feminist methodologies and feminist psychology: in conversation with Virginia Braun and Victoria Clarke." Psychology of Women Section Review 19, no. 1 (2017): 43-55. [(Abstract:) Virginia Braun and Victoria Clarke met as PhD students at Loughborough University where their research was supervised by pioneering feminist psychologists Professors Sue Wilkinson and Celia Kitzinger. They began writing collaboratively about qualitative methods in 2006; their first output was a paper on thematic analysis that has proved rather popular (25,000 citations and counting on Google Scholar), and they have subsequently written numerous chapters on thematic analysis and qualitative methods, a prize-winning textbook Successful Qualitative Research (Sage, 2013), they have edited (with Debra Gray) Collecting Qualitative Data (Cambridge University Press, 2017), and have books on thematic analysis and story completion (the latter with Naomi Moller) in progress (both for Sage). They were invited to give a joint keynote address at the 2016 POWS Conference and speak to the conference theme of feminist methodologies. Their talk was entitled "We can do it!" Feminist qualitative research and methodological innovation and ended with everyone in the room flexing their biceps Rosie the Riveter style (you may have seen the pictures on Twitter)! Glen Jankowski met Virginia and Victoria at Victoria's home in Gloucestershire in early November 2016 to discuss and reflect on their POWS keynote and feminist methodologies, qualitative research and feminist psychology more broadly. Glen audio recorded and transcribed the conversation, and all three have edited the transcript for clarity, including adding references where relevant for interested readers.]
The six-step process has been widely used in research over the past 15 years. Below are just a few recent examples from research relating to chaplains:
Butler, A. and Duffy, K.
"Understanding the role of chaplains in supporting patients and healthcare staff." Nursing Standard (2019: published 10/10/19. [(Abstract:) AIM: To investigate attitudes towards chaplaincy in NHS Scotland, including the role of the chaplain in supporting healthcare staff. METHOD: This was a qualitative study that involved semi-structured interviews with four chaplains working throughout NHS Scotland. The research transcripts were analysed, and themes were identified and examined. FINDINGS: Two main themes were identified from the interviews: understanding the role of the chaplain; and understanding the future role of the chaplain. The sub-themes identified were: healthcare staff members' perceptions; chaplains' perceptions; generic chaplaincy services; and becoming an allied healthcare profession. CONCLUSION: The findings of this study suggest that chaplains are increasingly providing support to healthcare staff, alongside their role in providing support to patients. The researchers also identified that chaplains in Scotland are adopting an increasingly educational role and that, in the future, they may adopt reflective practice programmes to assist them in managing increased requests for chaplaincy support from healthcare staff. It was also acknowledged that chaplaincy services may also be required to become an allied healthcare profession in the future, which may require chaplains to provide an increasingly generic and less religious service.]
Pentaris, P. and and Tripathi, K. "Religious/spiritual referrals in hospice and palliative care." Religions 11, no. 10 (2020): 496 [electronic journal article designation]. [(Abstract:) This study examines the religious/spiritual referral patterns in hospice and palliative care. Religion and death are two highly intersected topics and albeit often discussed together in hospice and palliative care, little is known about how professionals respond to religious/spiritual needs of patients/families/friends and in relation to the chaplaincy team. By means of an in-depth interviewing method, this paper reports on data from 15 hospice and palliative care professionals. Participants were recruited from across five hospice and palliative care organisations, and the data was managed and analysed with the use of NVivo. Largely, participants were keen to refer patients/families/friends to the chaplaincy team, unless the former's faith or lack thereof did not match the chaplains, in which case referrals to a religious leader in the community were favoured. This shed light to the tendencies to homogenise religious/spiritual beliefs. The paper concludes with some implications for practice and research.]
Schuhmann, C. M., Wojtkowiak. J., van Lierop. R. and Pitstra, F. "Humanist chaplaincy according to Northwestern European humanist chaplains: towards a framework for understanding chaplaincy in secular societies." Journal of Health Care Chaplaincy 27, no. 4 (October-December 2021): 207-221. [(Abstract:) In this article, views on humanist chaplaincy of Northwestern European humanist chaplains are explored with a view to the question of how to understand chaplaincy in secular societies. Seventeen questionnaires were analyzed, filled in by humanist chaplains from Belgium, the UK, Ireland, and Denmark, who attended an international conference on humanist chaplaincy organized in 2015 in the Netherlands. In the Netherlands, humanist chaplaincy has a history of several decades and is meanwhile firmly integrated in public institutions; a brief overview over this history is presented. Using thematic analysis, respondents' understandings of 'humanist' in humanist chaplaincy were explored, yielding 4 key themes: humanist chaplaincy as a calling, caring for all fellow human beings, belief in (inter)personal potential, and struggling with a non-supportive environment. On the basis of these themes, building blocks are proposed for a future-oriented perspective on chaplaincy that allows for open dialogue between all chaplains and identification of common ground.]
Szilagyi, C., Vandenhoeck, A., Best, M. C., Desjardins, C. M., Drummond, D. A., Fitchett, G., Harrison, S., Haythorn, T., Holmes, C., Muthert, H., Nuzum, D., Verhoef, J. H. A. and Willander, E.
"Chaplain leadership during COVID-19: an international expert panel." Journal of Pastoral Care and Counseling (2021): online ahead of print, 12/21/21. [(Abstract:) Chaplain leadership may have played a pivotal role in shaping chaplains' roles in health care amidst the COVID-19 pandemic. We convened an international expert panel to identify expert perception on key chaplain leadership factors. Six leadership themes of professional confidence, engaging and trust-building with executives, decision-making, innovation and creativity, building integrative and trusting connections with colleagues, and promoting cultural competencies emerged as central to determining chaplains' integration, perceived value, and contributions during the pandemic.]
III. This month's study isn't the only exploration by McManus and Robinson of a rounding model involving chaplains (though to much less of an extent). See:
McManus, K. and Robinson, P. "Evaluation of NICU Healthcare Providers' Experience of Patient Ethics and Communication Excellence (PEACE) Rounds." Advances in Neonatal Care (2020): online ahead of print on 7/7/20. [(Abstract:) BACKGROUND: Neonatal intensive care (NICU) providers may experience distress due to controversial orders or the close relationships they form with neonates' families. A "Patient Ethics and Communications Excellence [PEACE] Rounds" intervention developed at Indiana University proved to significantly relieve distress by facilitating interdisciplinary discussions of clinically and ethically challenging issues associated with pediatric intensive care (PICU) patient care. NICU healthcare providers face similar challenges and will benefit from understanding the potential efficacy of PEACE Rounds in this setting. PURPOSE: This study describes the experiences of NICU healthcare providers who participate in PEACE Rounds and evaluates their perceptions of how it affects their distress levels, contributes to interdisciplinary collaboration, and influences their understanding of ethical decision-making. METHODS: Researchers conducted semi-structured interviews with 24 intervention participants, observed 12 interventions, facilitated a validation focus group, and performed a constructionist thematic analysis and triangulation based on data from transcribed recordings. FINDINGS: PEACE Rounds improved interdisciplinary communication and collaboration and demonstrated restorative value through the benefits of voice and collective support. The intervention may reduce, but not replace, the need for formal ethics consultations. IMPLICATIONS FOR PRACTICE: PEACE Rounds may potentially improve interdisciplinary communications and collaboration, relieve employee distress, and reduce ethics consultations. IMPLICATIONS FOR RESEARCH: Studies of PEACE Rounds undertaken in other clinical settings, and facilitated by a nurse educator, will help assess the potential benefits of greater reach and access and the efficacy of less structured ethics discussions.]