March 2023 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
Tartaglia, A., White, K. B., Corson, T., Charlescraft, A., Johnson, T., Jackson-Jordan, E. and Fitchett, G. "Supporting staff: the role of health care chaplains." Journal of Health Care Chaplaincy (2022): online ahead of print, 12/15/22. 14pp.
[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. References are to manuscript [MS] page numbers.]
SUMMARY and COMMENT: "Chaplain support for the staff with whom they work in the care of patients/families is increasingly reported in the literature" [MS p. 10], but "[d]espite this developing body of research on chaplain care for staff colleagues, there remains limited knowledge, understanding, and utilization of chaplain care for team members" [MS p. 3]. "This study aimed to benchmark hospital chaplains' staff support activities in a subset of U.S. hospitals" [MS p. 2], and it "...expands the literature on the importance of staff care and captures the extent to which it occurs in...highly successful organizations" [MS p. 10]. Such benchmarking studies give clinical chaplains perspective on their profession, help chaplaincy managers to position their departments' work within and across institutions, and set a practical ground for further research.
This article is a companion piece to the authors' publication of "Chaplain staffing and scope of service: benchmarking spiritual care departments," online ahead of print in September 2022 in the same journal. See our October 2022 Article-of-the-Month for details about the earlier article, but it is worth reiterating here that the study sample consisted of the 20 Honor Roll hospitals listed by U.S. News & World Report for 2020-2021 and, while chaplaincy managers were interviewed between April-June 2021, they were "asked to describe the services their departments provided in January/February 2020 (prior to the [COVID-19] pandemic)" [MS p. 4]. A listing of the particular institutions is noted conveniently in our Related Items of Interest [§V, below]. That information does not appear in the article, though a table of Hospital & Workforce Characteristics is provided [MS p. 5] along with some description in the text.
Among the results:
- "Seventeen directors/managers indicated that their organization/administration considered staff care by chaplains to be a 'very important' role with three indicating it to be 'somewhat important.'" [MS pp. 5-6]
- "Six departments reported chaplain representation on organization-level committees related to employee wellness/well-being/mental health." [MS p. 6]
- "Departments with at least 10 FTE (n=12) chaplains reported spending more time on staff care; eight of the 12 departments spent 10-30% of their time on staff care and four reported even more time [31-50%] on staff care." [MS p. 6, including Table 2]
- "As for religiously focused activities specifically targeting staff, all twenty departments routinely provided blessings for occasions such as Nurses' Week and sacraments/rituals upon request. Three departments held periodic worship experiences designed specifically for staff. Three departments held annual remembrance services for deceased staff both routinely and upon request. Fourteen provided memorial services upon request only, while three did not hold any memorial services for staff members." [MS p. 6]
- "Fifteen departments offered 'Tea for the Soul' carts to support staff either routinely or in response to critical events in the hospital. Nine departments provided alternative healing modalities specifically for staff. These included: mindfulness (n=3); Reiki (n=4); aromatherapy (n=3); hand massage (n=1); meditation (n=3); guided imagery (n=2); and pet therapy (n=1)." [MS p. 6]
- "Chaplains at nine (45%) hospitals participated in 'code lavender' or 'Support of Staff (SOS)' protocols to provide immediate support for staff in distress following a traumatic or stressful event. In addition, half (n=10) of the departments expect that a working or on-call chaplain will respond to all requests for staff care during non-business hours. Fifteen (75%) of the chaplain departments participated in critical incident stress debriefings/management interventions upon request. However, there was varying demand for such support with departments called on once per week (n=4, 20%); a few times per month (n=4, 20%); once per month (n=4, 20%); and a few times per year (n=3, 15%)." [MS p. 7]
- "Eight departments collect data on staff support including numbers and types of individual care and group activities. Only two regularly reported these data to administration." [MS p. 7]
In their Discussion, the authors comment on spiritual care managers' insight into the referral contexts of staff care [--see Figure 2, MS p. 8]. "Findings from this study suggest that staff care emerges organically from familiarity with chaplains (personal relationships) that contrasts with other studies...that suggested nursing staff rarely turn to chaplains for personal support" [MS p. 9]. They conjecture that it "might be that chaplain visibility does matter" [MS p. 9].
Future studies may focus on the development of standardized referral protocols and enhanced understanding of the impact of nurse-chaplain collaboration on the work environment. Understanding this staff relationship may inform the development of standard referral protocols that support earlier chaplain involvement in crisis situations as well as care of critically ill patients and their families. [MS pp. 9-10]
Other areas of further investigation include a more systematic look at how much time chaplains spend on staff support, the long-term impact of those focused activities, the "possible association between chaplain availability and support for staff at critical events (e.g., traumas, codes, and deaths) and patient satisfaction" [MS p. 9], and the state of chaplains' support of staff post-pandemic.
Though the study sample was chosen in part for its prestigious selectivity, the authors also recognize this as a limitation and suggest that future research could involve larger and varied samples. Another limitation is said to be the self-report of data from managers, which not only may rely on how data for a department is reported to those managers from their staff but also brings into play the potential for social expectation bias. Moreover, the data is based in managers' recollections of the state of their departments before the pandemic, so there is also a risk of recall bias. Finally, the categories for gauging the amount of time staff spend on staff support may have been too broad.
This article is a valuable contribution to the benchmarking literature, and it was surely wise of the authors to communicate their findings about staff support in a distinct article rather than fold it into their previous report on staffing and scope of service. The results are illuminating, but the findings leave this reader with a question particularly in mind: How do chaplains experience tension between the need/desire to provide staff support with the need/desire to provide patient and family support, given that the care they offer is a limited resource? Concomitantly, do such tensions affect managerial decisions about the amount and nature of chaplaincy support to direct to staff, and how have managers found that staff support efforts can get out of balance in relation to other department activities and require either reigning in or urging on periodically?
The bibliography of 52 references is quite thorough and current, including four from 2022 and seven from 2021.
Suggestions for Use of the Article for Student Discussion:
This month's article could stand well on its own or be read together with the authors' 2022 report of "Chaplain staffing and scope of service: benchmarking spiritual care departments." It should be easily readable and relatable for almost any chaplaincy group, though more experienced groups would be able to bring greater perspective from personal experience with staff. Discussion could begin with an around-the-room question of, "What do you do specifically to support staff, and what does it feel like to support staff as opposed to patients or families?" (This may well bring up authority issues.) Do the students participate in any systematic, departmental program to support staff, and does that "push" them into such activities or provide a convenient structure for offering care? What referral contexts are typical, and how might there be improvements for referrals? Has the article spurred any new thinking about ways to support staff? Are there any risks that come with staff support? How does the group feel about documenting or otherwise collecting data about their staff support? Another topic for discussion may come out of our authors' comment that chaplains could have an impact on how staff (and institutions) may see work as a "calling" [MS p. 10]. Do the students believe they exhibit a sense of "calling" that may affect non-chaplains around them? Lastly, in light of the finding that "[a]ll 20 managers indicated that chaplain support for staff was standard when responding to a patient death, is this true for the group, and are there other common events that generally lead to staff support activity?
Related Items of Interest:
I. In addition to reading this month's article alongside its companion report -- Tartaglia, A., Corson, T., White, K. B., Charlescraft, A., Jackson-Jordan, E., Johnson, T. and Fitchett, G., "Chaplain staffing and scope of service: benchmarking spiritual care departments," Journal of Health Care Chaplaincy (2022): online ahead of print, 9/14/22 [which was our October 2022 Article-of-the-Month] -- the following Article-of-the-Month features should be of particular interest:
Klitzman, R., Al-Hashimi, J., Di Sapia Natarelli, G., Garbuzova, E. and Sinnappan, S. "How hospital chaplains develop and use rituals to address medical staff distress." SSM -- Qualitative Research in Health 328, no. 2 (December 2022): 2:100087 [electronic journal article designation]. [This was our September 2022 Article-of-the-Month.]
Muehlhausen, B. L. "Spirituality and vicarious trauma among trauma clinicians: a qualitative study." Journal of Trauma Nursing 28, no. 6 (November-December 2021): 367-377. [This was our November 2021 Article-of-the-Month.]
Liberman, T., Kozikowski, A., Carney, M., Kline, M., Axelrud, A., Ofer, A., Rossetti, M. and Pekmezaris, R. "Knowledge, attitudes, and interactions with chaplains and nursing staff outcomes: a survey study." Journal of Religion and Health 59, no. 5 (October 2020): 2308-2322. [This was our June 2020 Article-of-the-Month.]
Copeland, D. and Liska, H. "Implementation of a Post-Code Pause: extending post-event debriefing to include silence." Journal of Trauma Nursing 23, no. 2 (March-April 2016): 58-64. [This was our May 2016 Article-of-the-Month.]
II. In our study, "Fifteen departments offered 'Tea for the Soul' carts to support staff either routinely or in response to critical events in the hospital. Nine departments provided alternative healing modalities specifically for staff" [MS p. 6]. For more on Tea for the Soul, see:
Callis, A., Cacciata, M., Wickman, M. and Choi, J.
"An effective in-hospital chaplaincy-led care program for nurses: Tea for the Soul, a qualitative investigation." Journal of Health Care Chaplaincy 28, no. 4 (October-December 2022): 526-539. [(Abstract:) Tea for the Soul (TFS) is an understudied care model, addressing bereavement and other emotional needs of nurses related to impactful patient care experiences. Nurses are at high risk for compassion fatigue, moral distress, and burnout. Facilitated by a Chaplain, the TFS program provides participants a venue to express their feelings and explore ways of adapting effectively with the death of a patient, and other traumatic workplace experiences. In this qualitative grounded theory study, hospital nurses (N = 7) who participated in TFS were interviewed. IRB approval was obtained. Questions were constructed within the context of the medical center research council and asked if TFS: (a) was personally beneficial, (b) helped nurses feel better about their work, and (c) affected job satisfaction. Four core themes emerged: (a) Nurses' Self-Care, (b) Professional Practice, (c) Community, and (d) Improved Patient Care Outcomes. The Roy Adaptation Model, Group Identity Mode was applied to the content analysis. Overarching themes were Compassionate Service, Ministry of Presence, Reflective Practice, and Sacred Encounters. Nurses reported that TFS facilitated a spiritual respite and a sense of enhanced community and was a source of strength and coping, thus may aid in the promotion of nurse well-being and the amelioration of moral distress, compassion fatigue, and burnout.]
Walsh, E., Greider, H. and Ridling, D.
"Tea for the Soul: an intervention to support nurse resilience." Nursing Management 53, no. 12 (December 1, 2022): 37-45. [This article describes an investigation into a Tea for the Soul activity conducted by chaplains at a large pediatric hospital. A staff survey revealed that 82% of participants liked the activity "a great deal" or "extremely." In an optional comments section of the survey, 133 of 164 comments were classified as positive, and 13 classified negative, with 18 were classified as mixed. Five themes were identified in the data: Benefits, Endorse, Gratitude, Logistics, and Structure --and their description constitutes the core of the article's findings. Co-author Heidi Greider is Manager of Spiritual Care at Seattle Children's Hospital (Washington).]
III. The February 24, 2023 Providence Nursing Research Conference included two presentation and a poster about chaplains' support to health care staff.
Bock, D., Timmerman, R., Mendelson, S., Leavitt, R., Gaines, A. and Rangel, T. "Nurse professional quality of life and chaplain interactions." This presentation reports a study conducted February-April 2022 that analyzed surveys from 741 nurses. Among the results: 63% reported interaction with a chaplain in the last 12 months regarding patient-related stress, 38% for work-related stress, and 26% for personal stress. Nurses with higher levels of burnout more frequently interacted with chaplains, and there was a positive relationship shown for nurses between higher levels of secondary traumatic stress and more frequent interactions with chaplains. However, there was no relationship found between compassion satisfaction and reported frequency of contact with chaplains. This is another example of a study using REDCap for data collection [--see Related Items of Interest, §IV, below]. Co-authors Robert Leavitt and Adam Gaines are chaplains.
Doucette, S. and West, A. "Exploring the frequency of hospital-based chaplain and nursing interactions." This presentation reports an analysis of surveys from 767 nurses from 31 hospitals across five states, conducted from February-April 2022. Among the findings: the most frequent interactions with chaplains were for patient-related issues, with interactions for patient stress at least once per month associated with perceived higher degree of chaplaincy support and importance. Nurses who reported a high-volume of interactions with chaplains were more likely to work in day shift in the emergency or critical care settings, and there was strong agreement that COVID-19 increased interactions with chaplains.
Rangel, T., Powell, A., Sumner, S., Vaitla, K and Colorafi, K. "Chaplains and hospital staff stressors: a qualitative framework." This conference poster presents an analysis of online interviews with 33 hospital staff from five states, exploring the appropriateness of the Lazarus & Folkman Transactional Model of Stress and Coping (TMSC), which conceptualizes stress as contextual, changing over time, and based on individual coping mechanisms/personal appraisal of the situation. The researchers recognize that chaplains facilitate meaning-focused coping: drawing on one's values and beliefs to take positive actions and ascribe positive meaning to stressful events. The authors conclude that participant descriptions of interactions with chaplains supported the conceptual model and that the model is useful in explaining how chaplain interactions relieve stress.
IV. Our featured authors used REDCap (Research Electronic Data Capture) for their survey, and they cite the article below in connection. For more on REDCap, see www.project-redcap.org.
Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzales, N. and Conde, J. G. "A metadata-driven methodology and work flow process for providing translational research informatics support." Journal of Biomedical Informatics 42, no 2 (April 2009), 377-381. [(Abstract:) Research electronic data capture (REDCap) is a novel workflow methodology and software solution designed for rapid development and deployment of electronic data capture tools to support clinical and translational research. We present: (1) a brief description of the REDCap metadata-driven software toolset; (2) detail concerning the capture and use of study-related metadata from scientific research teams; (3) measures of impact for REDCap; (4) details concerning a consortium network of domestic and international institutions collaborating on the project; and (5) strengths and limitations of the REDCap system. REDCap is currently supporting 286 translational research projects in a growing collaborative network including 27 active partner institutions.]
Other recent examples of research with chaplain co-authors using REDCap are:
Bandini, J. I., Courtwright, A., Zollfrank, A. A., Robinson, E. M. and Cadge, W. "The role of religious beliefs in ethics committee consultations for conflict over life-sustaining treatment." Journal of Medical Ethics 43, no. 6 (June 2017): 353-358.
Dolan, J. G., Hill, Douglas L., Faerber, J. A., Palmer, L. E., Barakat, L. P. and Feudtner, C. "Association of psychological distress and religious coping tendencies in parents of children recently diagnosed with cancer: A cross-sectional study." Pediatric Blood and Cancer 68, no. 7 (July 2021): e28991 [electronic journal article designation].
Gourley, M., Starkweather, S., Roberson, K., Katz, C. L., Marin, D. B., Costello, Z. and DePierro, J.
"Supporting faith-based communities through and beyond the pandemic." Journal of Community Health (2023): online ahead of print, 2/15/23.
Grossoehme, D. H., Friebert, S., Baker, J. N., Tweddle, M., Needle, J., Chrastek, J., Thompkins, J., Wang, J., Cheng, Y. I., and Lyon, M. E. "Association of religious and spiritual factors with patient-reported outcomes of anxiety, depressive symptoms, fatigue, and pain interference among adolescents and young adults with cancer." JAMA Network Open 3, no. 6 (June 5, 2020): e206696 [electronic journal article designation].
Lewis, A. and Kitamura, E. "The intersection of neurology and religion: a survey of hospital chaplains on death by neurologic criteria." Neurocritical Care 35, no. 2 (October 2021): 322-334. [This was our July 2021 Article-of-the-Month.]
Livingston, J., Cheng, Y. I., Wang, J., Tweddle, M., Friebert, S., Baker, J. N., Thompkins, J. and Lyon, M. E.
"Shared spiritual beliefs between adolescents with cancer and their families." Pediatric Blood and Cancer 67, no. 12 (December 2020): e28696 [electronic journal article designation].
Szilagyi, C., Tartaglia, A., Palmer, P. K., Fleenor, D. W., Jackson-Jordan, E., Knoll Sweeney, S. and Slaven, J. E. "Delivering Clinical Pastoral Education (CPE) remotely: educators' views and perspectives during the COVID-19 pandemic and beyond." Journal of Pastoral Care & Counseling 76, no. 3 (September 2022): 189-209.
Torke, A. M., Maiko, S., Watson, B. N., Ivy, S. S., Burke, E. S., Montz, K., Rush, S. A., Slaven, J. E., Kozinski, K., Axel-Adams, R. and Cottingham, A. "The Chaplain Family Project: development, feasibility, and acceptability of an intervention to improve spiritual care of family surrogates." Journal of Health Care Chaplaincy 25, no. 4 (October-December 2019): 147-170. [This was our June 2019 Article-of-the-Month.]
V. The article does not specify the hospitals comprising the US News & World Report "Honor Roll" for 2020-2021, and the link given in the References goes to the magazine's general web page for its rankings, which provides only the information for the current year. However, the listing for 2020-2021 is a matter of public record (--see, for instance, Becker's Hospital Review, which also links to an extensive description of the methodology employed by US News & World Report at that time) and is as follows:
1) Mayo Clinic (Rochester, Minn.)
2) Cleveland Clinic
3) Johns Hopkins Hospital (Baltimore)
4) NewYork-Presbyterian Hospital-Columbia and Cornell (New York City) --TIE
4) UCLA Medical Center (Los Angeles) --TIE
6) Massachusetts General Hospital (Boston)
7) Cedars-Sinai Medical Center (Los Angeles)
8) UCSF Medical Center (San Francisco)
9) NYU Langone Hospitals (New York City)
10) Northwestern Memorial Hospital (Chicago)
11) University of Michigan Hospitals-Michigan Medicine (Ann Arbor)
12) Brigham and Women's Hospital (Boston)
13) Stanford Health Care-Stanford Hospital (Palo Alto, Calif.)
14) Mount Sinai Hospital (New York City)
15) Hospitals of the University of Pennsylvania-Penn Presbyterian (Philadelphia)
16) Mayo Clinic-Phoenix
17) Rush University Medical Center (Chicago)
18) Barnes-Jewish Hospital (Saint Louis) --TIE
18) Keck Medical Center of USC (Los Angeles) --TIE
20) Houston Methodist Hospital