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March 2008 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Piderman, K. M., Marek, D. V., Jenkins, S. M., Johnson, M. E., Buryska, J. F. and Mueller, P. S. "Patients' expectations of hospital chaplains." Mayo Clinic Proceedings 83, no. 1 (January 2008): 58-65.


SUMMARY and COMMENT: The authors of this month's article--four of whom are from the Department of Chaplaincy Services at the Mayo Clinic--state in the introduction: "Research is needed to determine what patients expect of hospital chaplains in the current climate, so that those who serve in this way can use their time and commitment well" [p. 59]. Their study both indicates the high value that patients place on pastoral visitation and reveals specific priorities for pastoral services.

The findings are based upon 535 questionnaires, returned from 1,500 mailed to consecutive (eligible) patients within 3 weeks of their discharge from two large tertiary care hospitals in Rochester, MN, in 2006. The patients were "18 years or older [and] had been hospitalized in medical or surgical units, intensive care units, or rehabilitation units for more than 24 hours" [p. 59]. The survey included questions about actual religious contacts during hospitalization, as well as about expectations for contacts. It also asked participants to rate on a 5-point Likert scale the importance of seven possible reasons for wanting to see a chaplain (--this list having been developed from chaplains' experience and other research):

  • Listen to me
  • Remind me of God's care and presence
  • Be with me at times of particular anxiety or uncertainty
  • Counsel me regarding moral/ethical concerns or decisions
  • Pray and/or read scripture or sacred texts
  • Administer religious ritual or sacrament
  • Offer support to family or friends
The survey also provided an opportunity to write in comments (--summarized in a table on p. 63).

Among the findings: "36.0% expected that a chaplain would visit them without having to request a visit, and 33.0% expected follow-up visits" [p. 60]; and "16.1% of respondents stated that they would have liked daily visits from a chaplain, 46.2% would have appreciated a chaplain visit every few days, and 17.4% would have preferred weekly visits" [p. 61]. "More than half (52.9%) of respondents reported being visited by a chaplain," (which was especially the case if they had been in the hospital for at least a week), and "[a]mong those who were visited, 50.4% reported that this visit was very important to them" [p. 61]. In this sample, Catholic patients were more likely than those of other groups to want daily visits from a chaplain and to rate visits as "very important." Eight patients (1.5%) "indicated that they would have preferred not to be visited without their request" [p. 63].

As for preferences regarding the 7 reasons for wanting to see a chaplain, the one rated highest was "to be reminded of God's care and presence," with 62.5% indicating that it was "very important," and another 21.3% noting that this was "somewhat important" [p. 61]. Also, "[m]ore than three-quarters (76.2%) of respondents reported that 'at times of particular anxiety or uncertainty,' seeing a chaplain would be 'very important' (46.3%) or 'somewhat important' (29.9%) to them," and "[m]ost also indicated that a 'very important' (39.8%) or 'somewhat important' (34.3%) reason for desiring a visit by a chaplain would be "to offer support to my family or friends" [p. 61]. "Most endorsed a chaplain's listening as 'very important' (34.5%) or 'somewhat important' (30.7%) to them" [p. 61]. The lowest rated reason was to "counsel me regarding moral/ethical concerns or decisions," with only 19.1% saying that it was "very important" and 27.6% saying that it was "somewhat important." This reader found it unfortunate that the item, "pray and/or read scripture or sacred texts" did not allow for a distinction between prayer and reading, but that (compound) item was rated as "very important" or "somewhat important" by 42.3% and 27.5% of the respondents, respectively.

The hospitals at which the study was conducted are said to have "21.5 FTEs in the inpatient setting, providing a chaplain-to-patient ratio of approximately 2 to 100, depending on the inpatient census" --quite a reasonable institutional presence. Yet, 45% of the study participants "were unsure of how to contact a chaplain" [p. 64]. The authors speculate that while contact information might have been given to patients, "it is possible that the stresses and complexity associated with illness and hospitalization impeded retention" [p. 64]. They emphasize the importance of patient-initiated requests for pastoral visitation, in addition to the value of staff referrals.

This research was limited by a lack of diversity in its sample, which was predominantly older and Christian, represented strongly by Catholics and Lutherans. Also, it did not capture information about patients' severity of illness or their reasons for hospitalization, and the questionnaire presented only a short list of reasons for requesting a chaplain. These limits are appropriately addressed on pp. 64-65, and the authors suggest a number of ideas for future study. Since patients' expectations of a chaplain may affect the very substance of a pastoral interaction, that may be yet another direction for continuing research.

This work points up the importance of pastoral visitation to hospitalized patients, and the findings may be informative for the deployment of pastoral resources. The researchers have taken a very practical approach that should appeal to most career chaplains (and perhaps hospital administrators), in an attempt to "explore and discover creative ways to meet the spiritual needs and expectations of patients within the current reality of the limited duration and importance of hospital stays" [p. 65].


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

CPE students should find this a highly interesting article, though it may be best to discuss it only after students have accrued a bit of personal experience with patients. Supervisors could have students themselves prioritize the study's 7 reasons for requesting a chaplain, before they read the article, so that there can be a comparison between their views or assumptions and the data from the research. Table 2 [p. 62] gives a wealth of easily understandable data about patients' preferences for pastoral services. The article could lead into a broader discussion about the role of patient expectations in pastoral interaction. The fact that patients assigned a relatively low priority to counseling and high priorities to more pastoral functions (e.g., "listen to me," "be with me") may help students think and talk about differences between pastoral care and pastoral counseling.


Related Items of Interest:

I. The following are a handful of recent reports of research regarding chaplains' activities and functions:

Flannelly, K. J., Galek, K., Bucchino, J., Handzo, G. F. and Tannenbaum, H. P. "Department directors' perceptions of the roles and functions of hospital chaplains: a national survey." Hospital Topics 83, no. 4 (2005): 19-27. [The article reports the results from 1,159 surveys from medical, nursing, social service, and pastoral care directors across the US (from a total sample of 5000). Questionnaires asked directors to rate on a 6-point Likert scale the importance of 19 chaplaincy activities or roles which were subsequently grouped into 7 categories: grief and death, emotional support, community liaison, advance directives and organ/tissue donations, religious services and worship, consultation and advocacy, and prayer. Among the findings: "directors in all four disciplines rated three of the seven chaplain roles (grief and death, prayer, and emotional support) to be 'very' to 'extremely' important," "physicians rated the importance of most chaplains' roles lower than did other disciplines," and " there was a tendency for directors in smaller hospitals, especially those with fewer than 100 patients, to place less importance on most of the chaplain roles investigated here" (--from the abstract, p. 19).]

Flannelly, K. J., Handzo, G. F., Weaver, A. J. and Smith W. J. "A national survey of healthcare administrators' views on the importance of various chaplain roles." Journal of Pastoral Care & Counseling 59, nos. 1–2 (2005): 87–96. [This national survey asked hospital administrators about the importance of 11 roles and functions of chaplains. Among the findings, administrators tended to rate all roles/functions as relatively important, though those at hospitals without a pastoral care department tended to give lower ratings. "Meeting the emotional needs of patients and relatives were seen as chaplains' most important roles, whereas performing religious rituals and conducting religious services were seen as least important.... In all but a few instances, the level of importance that administrators assigned to the various roles were positively related to their ratings of their own religiousness and spirituality...." (--from the abstract, p. 87).]

Flannelly, K. J., Weaver, A. J. and Handzo, G. F. [The HealthCare Chaplaincy, 307 E. 60 St., New York, NY 10022-1505;]. "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. [This article was featured as the 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.]

[ADDED 10/14/08]: 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." Journal of Health Care Chaplaincy 14, no. 1 (2008): 39-56. [Abstract: The current study analyzes data from 30,995 chaplain visits with patients and families that were part of the New York Chaplaincy Study. The data were collected at 13 healthcare institutions in the Greater New York City area from 1994-1996. Seventeen chaplain interventions were recorded: nine that were religious or spiritual in nature, and eight that were more general or not specifically religious. Chaplains used religious/spiritual interventions, alone or in conjunction with general interventions, in the vast majority of their visits with patients and families. The types of interventions used varied by the patient's medical status to some degree, but the pattern of interventions used was similar across faith group and medical status. The results document the unique role of the chaplain as a member of the healthcare care team and suggest there is desire among a broad range of patients, including those who claim no religion, to receive the kind of care chaplains provide.] 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., Murphy, K. M., Bauman, J. P., Oettinger, M., Goodell, E., Hasan, Y. H., Barrie, D. P. and Jacobs, M. R., "What do chaplains really do? I. Visitation in the New York Chaplaincy Study" (pp. 20-38) 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, see the Fall 2008 Newsletter (§7).

For more articles, see the May 2004 Article of the Month.

II. At the 2006 ACPE conference in Honolulu, HI, Network member Gordon J. Hilsman (CPE Supervisor in the Franciscan Health System of Tacoma, WA) made a poster presentation of research done through his center which sought to pair patient-identified needs with chaplains' functions. While his study did not focus explicitly on patients' expectations, connections can obviously be made to the subject of our Article-of-the-Month. A summary of his presentation is available here as a PDF. See also our Winter 2006 Newsletter (§1) for more information on the poster presentation.

III. Other recent spirituality & health research articles co-authored by our featured article's lead author:

Johnson, M. E., Piderman, K. M., Sloan, J. A., Huschka, M., Atherton, P. J., Hanson, J. M., Brown, P. D., Rummans, T. A., Clark, M. M. and Frost, M. H. [Department of Chaplain Services, Mayo Clinic, Rochester, MN]. "Measuring spiritual quality of life in patients with cancer." The Journal of Supportive Oncology 5, no. 9 (October 2007): 437-442. [(Abstract:) There is no one established approach to the measurement of spiritual quality of life (QOL). Available instruments are based on various theoretical components. We used a multi-instrument approach to measure the spiritual domain of QOL that adds to our understanding of a participant self-definition of spiritual QOL. In total, 103 participants with advanced cancer receiving radiation therapy were enrolled in this study. Most were Caucasian, male, and had advanced lung, head and neck, or gastrointestinal cancer. Two instruments, the Spiritual Well-Being Linear Analogue Self Assessment (SWB LASA) and the 12-item Functional Assessment of Chronic Illness Therapy-Spiritual (FACIT-Sp-12), were used to measure spiritual QOL at enrollment and 4, 8, and 27 weeks after enrollment. Analyses included descriptive statistics, Spearman correlations, stepwise multiple regression, and repeated measures analysis of variance. There was a strong association between SWB LASA and FACIT-Sp-12 total scores. However, FACIT-Sp-12 items defining SWB LASA scores varied over time. Two to three of the FACIT-Sp-12 items explained approximately two thirds of the variance in the SWB LASA scores at each time point with the exception of 4 weeks after enrollment. SWB scores were strongly associated with all QOL domains. In research and clinical care, SWB must be treated as a complex concept that has the potential to change over time. Although a single-item measure of SWB provides valuable information and is strongly associated with the multiple item FACIT-Sp-12, our more detailed inquiry using the FACIT-Sp-12 provides additional guidance for the design and timing of spiritual support interventions.]

Piderman, K. M., Schneekloth, T. D., Pankratz, V. S., Maloney, S. D. and Altchuler, S. I. [Department of Chaplain Services, Mayo Clinic, Rochester, MN]. "Spirituality in alcoholics during treatment." American Journal on Addictions 16, no. 3 (May-June 2007): 232-237. [(Abstract:) The purpose of this study was to measure spiritual well-being (SWB), private religious practices (PRP), positive religious coping, abstinence self-efficacy (AASE), affiliation with AA (AAA), and their associations with alcoholics in treatment. Seventy-four adults in a three-week outpatient addiction treatment program were assessed at admission and discharge. Wilcoxon signed rank and t tests demonstrated significant increases in all variables. Spearman correlation coefficients detected significant associations between the spiritual variables, SWB and AASE, as well as PRP and AAA. Findings suggest that spiritual variables can change during treatment and that there may be connections between spiritual variables and variables associated with longer-term recovery.]


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