May 2021 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
Muehlhausen, B. L., Foster, T., Smith, A. H. and Fitchett, G. "Patients' and loved ones' expectations of chaplain services." Journal of Health Care Chaplaincy (2021): online ahead of print, 4/15/21.
[Note: This article is accessible freely online from the publisher. 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: This month's featured study, out of Ascension St. Vincent Indiana, began from the "desire by the hospital board to explore the specific expectations and level of satisfaction of persons receiving chaplain services." There is a good deal of spirituality & health literature around satisfaction -- in fact, co-author George Fitchett has observed elsewhere that "[m]ore research has examined the relationship between chaplain care and patient/family satisfaction than any other outcome" [see Fitchett (2017):166 in Related Items of Interest, §III, below] -- however, "This study was unique in seeking feedback from loved ones as well as patients" [MS p. 1, abstract]. It speaks to the importance of the care of patients' loved ones and highlights areas of expectations that may be useful to chaplains and chaplaincy departments in considering the foci of their attention.
Data were analyzed from 452 adult patients or loved ones across 16 hospitals in a traditionally Catholic healthcare system in central and southern Indiana. Survey-based interviews were conducted in-person by trained research assistants from February 7th to May 15th, 2017. The participation rate was 81% of the pool of 561 people approached. Among the demographics of participants: 65% were women, 59% were married, 80% were non-Hispanic whites, and 84% were Christian. Among those identifying as Christian, a total of 11.1% were Catholic or Orthodox, 14.4% were Mainline Protestant, 26.1% were Evangelical Protestant, and 32.3% said they were unaffiliated. At the time of the interview, 39.9% of the cases had involved hospital stays of three days of less, and 35% had involved stays of over six days. Full demographic information is given in Table 1 [MS p. 6]. "Compared to the patients who answered the survey themselves, the patients whose loved one answered the survey were less likely to have had an expected admission and more likely to have had a longer length of stay at the time of the interview" [MS p. 5].
The survey instrument itself is an adaptation of one developed at the Mayo Clinic by Katherine M. Piderman, et al. [see Related Items of Interest, §I, below], and included asking participants to rate on a five-point Likert scale eight possible reasons for wanting a chaplain to visit: "(1) to listen to me, (2) to remind me of God's care and presence, (3) to be with me at times of particular anxiety or uncertainty, (4) to counsel me regarding moral/ethical concerns or decisions, (5) to pray and/or read scripture or sacred texts with me, (6) for a religious ritual or sacrament, (7) to offer support to my family or friends [and] (8) to assist me with understanding advance directives paperwork" [MS p. 4]. The latter item about advance directives was an addition to the original form of the instrument, taking the place of Other. The present survey also asked about "awareness of the availability of chaplains, ...the expectation of who should initiate the chaplain visit, ...[and] desire for the frequency of follow-up visits" [MS p. 4].
Among the findings:
- "Most respondents (n=415; 92%) were aware of chaplain services. However, the number of all participants who knew how to contact a chaplain was much lower (n=250; 55%)." [MS p. 5]
- "An overwhelming majority of participants wanted a chaplain to visit at least once (n=416; 93%). Of note, 83% of participants with no religious preference (n=54) reported wanting a chaplain to also visit at least once." [MS p. 5]
- "Approximately two-thirds (65.6%) of respondents expected a chaplain to visit without having to request it. Two-thirds of respondents (66.3%) expected repeat visits with a chaplain at least weekly." [MS p. 5]
- "Approximately three-fourths of respondents endorsed emotional support (listen to me, be with me in anxiety, support a loved one) as most important for seeing a chaplain. Similar proportions of respondents valued the spiritual services provided by chaplains (reminding of God's presence, praying, reading sacred texts), while a plurality (40%) valued chaplain assistance with rituals and sacraments. Approximately half of respondents valued the input of chaplains on advance directives or ethical decision-making." [MS p. 7]
- There were no significant differences between patients and loved ones regarding chaplain services, with the exception of "to offer support to family and friends," which was significantly more valued by loved ones than by patients (i.e., 67.7% of patients rated this item as important and 14.9% as unimportant, while 81.4% of loved ones rated this item as important and only 6.4% as unimportant). [See table 3, MS p. 8.]
- "Of those who had been visited by a chaplain [59.3% at the time of the interview], an overwhelming majority of respondents (88%) reported that the visit was either very or somewhat important to them. There were no significant differences regarding expectations of chaplain services between patients and loved ones." [MS p. 5]
- "Overall, chaplains performed 992 services for 230 respondents, resulting in an average rate of 4.3 services per chaplain visit. Across all services, respondents gave the chaplain the highest satisfaction score 868 times (88%)." [MS p. 9]
- Given the opportunity to comment freely about chaplain services or anything else they wanted to share, 69% of patients and 76% of loved ones took advantage of the offer. The strongest themes in this qualitative data were around the value of the availability of chaplain services and the idea that chaplains provided a calming presence and reminded some of the presence of God. [See Table 5, MS p. 11, for themes and exemplary quotes.]
The authors discuss standout findings, including the "surprisingly high portion (93%) of the respondents [who] said they wanted at least one visit from a chaplain, with two-thirds of those respondents expecting a visit without having to request one" [MS p. 10]. They acknowledge that this very statistic may suggest some bias in the study, and they speculate on possible contributing factors (e.g., "...the study was conducted in a Catholic healthcare system with crucifixes in every room and throughout the hospital reminding participants of the value of spiritual care" [MS p. 10]). Nevertheless, when chaplains visited, they were apparently very much appreciated by both patients and loved ones.
Also of special note in the Discussion section:
...[O]ur study shows that the most important, most commonly performed, and highest rated services performed by chaplains involved emotional support in some fashion, whether that was listening, offering support, or being with them in times of anxiety or uncertainty. This demonstrates that patients and loved ones highly value the many skills chaplains have to offer, [e]specially in an era where the number of patients and families who are not members of a church community are rapidly increasing.
And, while assisting patients with advance directives might not be common for all chaplains, it turned up as the third most important category of services in the findings. [See MS p. 12.]
Spiritual and religious support was the next group of items of most importance to patients and loved ones. Qualitative data again corroborated the quantitative data with patients and loved ones citing prayers offered, reminders of God's presence, and sacraments given as having a very positive impact on their emotional and mental well-being. Patients and loved ones noted the chaplain's work in alleviating spiritual distress, which allowed patients to better cope with their health conditions. [MS p. 12]
The authors offer thoughts on the implications of their findings for spiritual care in general [MS pp. 12-13], including the indication that "people assume that spiritual care services are like other hospital services, meaning they do not need to ask for a chaplain visit" [MS p. 12], and they propose that "it would be helpful to post signs in family waiting areas with instructions on how to contact a chaplain as well as a description of services provided by chaplains" [MS p. 13]. All of this, of course, should be taken as fodder for continued research, "with larger samples across multiple states, and a variety of faith based and secular hospitals...," [MS p. 13] and with more non-white and non-Christian samples.
Muehlhausen and colleagues comment particularly about the inclusion of loved ones in the study population, here broadly defined as "visitors/friends, family members, and significant others" [MS p. 2]. "Including loved ones in the sample allowed a more thorough examination of attitudes about and opportunities for chaplaincy services, especially when considering the important role they play as members of a patient's care team" [MS p. 12]. They go on to recommend: "In settings where chaplains are spread thin and need to triage who needs to be seen first, strong consideration needs to be given to the needs of loved ones as well as patients" [MS p. 14]. They point up the fact that "while chaplains regularly care for loved ones, research has tended to be almost exclusively patient-centered" [MS p. 12] and urge that "[m]ore research needs to be done specifically on the needs of loved ones, possibly exploring factors that lead to a spiritual care referral for loved ones" [MS p. 14]. Moreover, they say, "Nurses and spiritual care volunteers need training to include an emphasis on screening loved ones for spiritual distress" [MS p. 13].
One final observation about this research and its methodology: the finding that "emotional support" was the theme of the services that came out on top of the eight choices implicitly raises the question of whether this would have been the result by another methodology that didn't explicitly name those particular services. A set list of options, no matter how intentionally inclusive, is necessarily limiting and leading to some degree. The items in the original survey instrument by Piderman, et al., was based on "the clinical experience of chaplains and previous research suggesting that hospital ministry involves both a religious and more generally supportive dimension" [Piderman, et al. (2008):59 --see Related Items of Interest, §I, below]. Now, most readers will likely view the list as presently adapted to be quite comprehensive, and the wisdom of the current research is that it also included a qualitative portion, and this mixed methods approach combines an ease of basic quantification with the richness of qualitative data --each complementing the other and providing some check-and-balance. Still, if chaplains were to construct their own list of services from which patients might choose of offer an opinion, what might that list look like? After all, Muehlhausen and colleagues added an item about advance directives, which became a major theme in the study findings. And, how might that list be used in research: as was done here, with each item paired with a Likert rating, or as a ranked choice process with people choosing their top three or more, or as a full ranking of all items? The possibilities are as varied as they are fascinating for their psychometrics.
Suggestions for Use of the Article for Student Discussion:
Discussion could begin with how much students are aware of patients' or loved ones' expectations when they approach a clinical encounter. How are expectations believed to change according to various types of clinical situations (e.g., an end-of-life gathering at bedside, a pre-surgical patient visit, a call to an anxious family, a random encounter while rounding, etc.)? How do students feel about others' expectations of them (e.g., causing resistance in them for being constraining or stereotyping, or evoking a response of acceptance or even welcome for how expectations may provide guidance for what to do)? Do the chaplains go into encounters with their own expectations of patients or family members? What is the practical relationship between expectations and satisfaction? Have people had successful visits where patients or loved ones were satisfied because of some service that was not expected? What might be the significance of this? In light of all these personal experiences, what do the students think about the ranking of the services in the survey results? How might the students rate their own competence in providing each of the services listed? Which ones might indicate areas for professional growth? What does the group make of the finding that 65.6% of respondents expected a chaplain to visit without having to request it? One of the findings was that patients and loved ones wanted "more visibility/promotion of services" [MS p. 10], and the authors specifically suggest "post[ing] signs in family waiting areas with instructions on how to contact a chaplain as well as a description of services provided by chaplains" [MS p. 13]. Would there be interest at your institution to increase visibility and promote services, and if so then what might be some practical means to do so? How much do the students think of contact with loved ones as a priority? Finally, the article does a good job at walking the reader through the issues of doing research, including such things as the confidentiality of materials generated along the way, the idea of capitalizing on an already-established survey instrument, and the logistics of data collection. Do the students have any questions about the research process?
Related Items of Interest:
I. This month's article cites a 2010 study by Katherine M. Piderman and colleagues at the Mayo Clinic, adapted for the present use. The instrument first appeared in an article from 2008 article and subsequently in one from 2013.
Piderman, K. M., Jenkins, S. M., Hsu, J. S. and Kindred, A. S. "Hospitalized young adults' expectations of pastoral interventions." Journal of Pastoral Care and Counseling 67, no. 1 (March 2013): 7 [electronic journal article designation]. [(Abstract:) The objective of this analysis of 4500 inpatients was to identify the experience and expectations of 18-35 year olds regarding chaplain visitation and to compare results with data from older adults. 71% of young adults reported wanting to be visited by a chaplain; 45.5% were visited; 68% indicated that this was important. Young adults value chaplains' role as a sign of God's care and presence (77.4%), in providing support for family (73.6%), being present during times of anxiety (66.0%), and praying/reading scripture with them (62.3%). Results were similar to older respondents, but young adults were more likely to value ethical counsel from chaplains (58.5% vs. 38.2%). This study provides clinically relevant information and suggestions for further research.]
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. [(Abstract:) OBJECTIVE: To evaluate patients' expectations of hospital chaplains. PATIENTS AND METHODS: From April 6, 2006, through April 25, 2006, we surveyed by mail 1500 consecutive medical and surgical patients within 3 weeks of their discharge from the hospital. The survey included questions related to demographics, duration and area of hospitalization, awareness of chaplain availability, expectations regarding chaplain visits, and reasons for wanting to see a chaplain. Measured characteristics were summarized by calculating means and SDs for continuous variables and proportions for categorical variables. Proportions were statistically compared via Fisher exact tests or Monte Carlo estimates. RESULTS: Surveys were returned by 535 of the 1500 patients to whom they were sent. Most of those who returned surveys had been hospitalized for less than 1 week (398/514 [77.4%]) and were male (265/510 [52.0%]), married (396/528 [75.0%]), 56 years or older (382/532 [71.8%]), or affiliated with either the Lutheran (177 [33.3%]) or Catholic (133 [25.0%]) churches. Most (78.9%) were aware of the availability of chaplains, and 62.3% would have appreciated chaplain visitation at least every few days. More than half (52.9%) reported that they were visited, and 86.4% reported that this visit was important to them. The primary reason selected for wanting to see a chaplain was "to be reminded of God's care and presence." Items related to ritual, prayer, and pastoral support were also highly endorsed. Some results were dependent on sex, age, religious affiliation, or duration of stay. CONCLUSION: Hospitalized patients value visitation by chaplains and appreciate both religious and supportive interventions. Opportunities for patient care, education, and research are apparent.]
Piderman, K. M., Marek, D. V., Jenkins, S. M., Johnson, M. E., Buryska, J. F., Shanafelt, T. D., O'Bryan, F. G., Hansen, P. D., Howick, P. H., Durland, H. L., Lackore, K. A., Lovejoy, L. A. and Mueller, P. S. "Predicting patients' expectations of hospital chaplains: a multisite survey." Mayo Clinic Proceedings 85, no. 11 (November 2010): 1002-1010. [(Abstract:) OBJECTIVE: To identify patient expectations regarding chaplain visitation, characteristics of patients who want to be visited by a chaplain, and what patients deem important when a chaplain visits. PARTICIPANTS AND METHODS: Three weeks after discharge, 4500 eligible medical and surgical patients from hospitals in Minnesota, Arizona, and Florida were surveyed by mail to collect demographic information and expectations regarding chaplain visitation. The survey was conducted during the following time periods: Minnesota participants, April 6 until April 25, 2006; Arizona participants, October 16, 2008, until January 13, 2009; Florida participants, October 16, 2008, until January 20, 2009. Categorical variables were summarized with frequencies or percentages. Associations between responses and site were examined using chi(2) tests. Multivariate logistic regression was used to assess the likelihood of wanting chaplain visitation on the basis of patient demographics and perceived importance of reasons for chaplain visitation. RESULTS: About one-third of those surveyed responded from each site. Most were male, married, aged 56 years or older, and Protestant or Catholic. Of the respondents, nearly 70% reported wanting chaplain visitation, 43% were visited, and 81% indicated that visitation was important. The strongest predictor of wanting chaplain visitation was denomination vs no indicated religious affiliation (Catholic: odds ratio [OR], 8.11; 95% confidence interval [CI], 4.49-14.64; P<.001; evangelical Protestant: OR, 4.95; 95% CI, 2.74-8.91; P<.001; mainline Protestant: OR, 4.34; 95% CI, 2.58-7.29; P<.001). Being female was a weak predictor (OR, 1.48; 95% CI, 1.05-2.09; P=.03), as was site. Among the reasons given by respondents for wanting chaplain visitation, the most important were that chaplains served as reminders of God's care and presence (OR, 4.37; 95% CI, 2.58-7.40; P<.001) and that they provided prayer or scripture reading (OR, 2.54; 95% CI, 1.53-4.20; P<.001). CONCLUSION: The results of this study suggest the importance medical and surgical patients place on being visited by a chaplain while they are hospitalized. Those who valued chaplains because they reminded them of God's care and presence and/or because they prayed or read scripture with them were more likely to desire a visit. Our results also suggest that being religiously affiliated is a very strong predictor of wanting chaplain visitation.]
II. An interesting take on patient expectations may be found through the phenomenon of stereotyping. The following study, which was featured as our January 2018 Article-of-the-Month, considers what might be said to be chaplains' expectations of patients' expectations along those lines.
"Handling stereotypes of religious professionals: strategies hospice chaplains use when interacting with patients and families." Journal of Pastoral Care and Counseling 71, no. 4 (December 2017): 284-290. [(Abstract:) Stereotypes of religious professionals can create barriers for those who provide spiritual/pastoral care. Through interviews and journal entries, hospice chaplains (n = 45) identified the following stereotypes that affected their work: chaplains as people whom others try to impress, who only talk about spiritual and religious topics, who are male, and who try to convert others. Participants reported using a variety of communication strategies to counteract stereotypes and make meaningful connections with the people they serve.]
III. For more on chaplains and patient satisfaction, see the following recent articles. However, for earlier research, see our February 2015 Article-of-the-Month.
Damen, A., Murphy, P., Fullam, F., Mylod, D., Shah, R. C. and Fitchett, G. "Examining the association between chaplain care and patient experience." Journal of Patient Experience 7, no. 6 (December 2020): 1174-1180. [(Abstract:) A developing body of evidence indicates that chaplain care is associated with higher levels of patient/family satisfaction with their hospital care. We examined the association between chaplain care and patient experience among patients at Rush University Medical Center in Chicago who responded to Hospital Consumer Assessment of Healthcare Providers and Systems and Press Ganey survey items between 2011 and 2017. Information about chaplain care was taken from the inpatients' electronic medical record. Our analyses included 11,741 patients, 26.5% of whom had received any chaplain care. Patients with lower self-rated health were more likely to have received chaplain care (P < .001). In bivariate analyses, chaplain care was associated with lower likelihood of reporting the highest score for 4 patient experience items (P < .001). In multi-variable models that adjusted for patient self-rated health and other factors, the association between chaplain care and the 4 patient experience items was nonsignificant. There was no effect modification for patient religious affiliation, self-rated health, or other demographic factors. The chaplain care-patient experience association may be more complex than has initially appeared, and further research is needed to help us better understand it.]
Donohue, P. K., Norvell, M., Boss, R. D., Shepard, J., Frank, K., Patron, C. and Crowe, T.Y. 2nd. "Hospital chaplains: through the eyes of parents of hospitalized children." Journal of Palliative Medicine 20, no. 12 (2017): 1352-1358. [(Abstract:) BACKGROUND: Chaplain services are available in 68% of hospitals, but hospital chaplains are not yet incorporated into routine patient care. OBJECTIVES: To describe how families of hospitalized children view and utilize hospital chaplains. DESIGN: Telephone survey with 40 questions: Likert, yes/no, and short-answer responses. SUBJECTS: Parents visited by a hospital chaplain during their child's hospitalization in a tertiary care center. MEASUREMENTS: Descriptive statistics were used to characterize the sample. Nonparametrics were used to compare religious versus nonreligious parents. Regression was used to identify independent predictors of a chaplain visit positively influencing satisfaction with hospital care. RESULTS: Seventy-four parents were interviewed; most were 25-50 years old, and 75% felt their child was very sick. Children ranged from newborn to adolescence. Forty-two percent of parents requested a chaplain visit; of the 58% with an unsolicited visit, 11% would have preferred giving prior approval. Parents felt that chaplains provided religious and secular services, including family support and comfort, help with decision making, medical terminology, and advocacy. Chaplains helped most parents maintain hope and reduce stress. Seventy-five percent of parents viewed chaplains as a member of the healthcare team; 38% reported that chaplains helped medical personnel understand their preferences for care and communication. Most parents (66%) felt that hospital chaplaincy increased their satisfaction with hospital care. CONCLUSION: Families play a fundamental role in the recovery of hospitalized children. Parents view hospital chaplains as members of the healthcare team and report that they play an important role in the well-being of the family during childhood hospitalization. Chaplains positively influence satisfaction with hospital care.]
Fitchett, G. "Recent progress in chaplaincy-related research." Journal of Pastoral Care and Counseling 71, no. 3 (September 2017): 163-175. [See especially pp. 4-5 regarding satisfaction. (Abstract:) In light of the continued growth of chaplaincy-related research this paper presents an overview of important findings. The review summarizes research in six broad areas: what chaplains do; the importance of religion and spiritual care to patients and families; the impact of chaplains' spiritual care on the patient experience; the impact of chaplain care on other patient outcomes; spiritual needs and chaplain care in palliative and end of life care; and chaplain care for staff colleagues. It concludes with a description of several innovative and important new studies of chaplain care and notes areas for future investigation.]
Kirchoff, R. W., Tata, B., McHugh, J., Kingsley, T., Burton, M. C., Manning, D., Lapid, M. and Chaudhary, R. "Spiritual care of inpatients focusing on outcomes and the role of chaplaincy services: a systematic review." Journal of Religion and Health 60, no. 2 (April 2021): 1406-1422. [(Abstract:) OBJECTIVE: To identify demographic trends associated with patient utilization and healthcare provider request for spiritual care services and to describe the impact of spiritual care on the quality of life (QoL), spiritual well-being (SWB) and level of satisfaction (SAT) of hospitalized patients. PATIENTS AND METHODS: A systematic search of Ovid MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, was combined with review of relevant bibliographies. A total of 464 titles and abstracts were reviewed. Data were independently extracted by reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data on the effects of spiritual interventions on QoL, SWB and SAT were extracted, along with demographic data reflecting chaplain services. The results of the studies are presented narratively and in a qualitative manner. RESULTS: Observational or experimental studies investigating chaplain utilization demographics (n = 12), patient satisfaction (n = 9) and QoL/SWB (n = 3) were included. Perceived severity of illness, average length of stay and older age were consistently found to be predictors of higher need for spiritual care. Receipt of spiritual care was correlated with increased patient and family satisfaction, independent of clinical outcome. Chaplain interventions were associated with improvement in perceived QoL and SWB. In spite of this, healthcare workers rarely attempt to explore the patient's or family's need for spiritual care, with the majority of chaplaincy consults occurring in the final day of the patient's life, potentially leading to a failure to meet the spiritual needs of non-terminal patients who have spiritual trauma related to their resolving illnesses. CONCLUSION: Attention to the spiritual needs of hospitalized patients is an essential yet often overlooked aspect of patient care. Chaplains serve as spiritual care specialists whose services can enhance the hospital experience, improve patient satisfaction and help to bridge potential gaps between the patient and medical providers.]
Purvis, T. E., Crowe, T. Y., Wright, S. M. and Teague, P. "Patient appreciation of student chaplain visits during their hospitalization." Journal of Religion and Health 57, no. 1 (February 2018): 240-248. ["The most interesting finding from this study may be that the overwhelming majority of patients believed that the student chaplains' visits positively influenced their rating of the hospital care" [p. 445]. (Abstract:) Spiritual care is associated with improved health outcomes and higher patient satisfaction. However, chaplains often cover many hospital units and thus may not be able to serve all patients. Involving student chaplains in patient spiritual care may allow for more patients to experience the support of spiritual care. In this study, we surveyed 93 patients hospitalized on general medical units at a tertiary care center who were visited by nine student chaplain summer interns. The results indicated that the majority of patients appreciated student chaplain visits and these encounters may have positively influenced their overall hospital experience. Thus, student chaplains could be a way to extend valuable spiritual care in settings where chaplaincy staff shortages preclude access.
IV. The methodological task of constructing closed-ended survey items -- as opposed to open-ended questions -- is addressed in the following article by Neal Krause, an experienced Spirituality & Health researcher. While this particular article is focused on constructing survey items for a specific demographic group, his description of the method should be a useful guide for chaplain researchers in general. It is available freely online through NIH Public Access.
Krause, N. "A comprehensive strategy for developing closed-ended survey items for use in studies of older adults." Journals of Gerontology Series B-Psychological Sciences & Social Sciences 57, no. 5 September 2002): S263-274. [(Abstract:) OBJECTIVE: The purpose of this study is to describe the development and implementation of a nine-step strategy for devising closed-ended survey questions that assess religion in late life. The intent was to illustrate one way in which qualitative and quantitative methods could be combined in the same study. METHODS: The following methods and procedures were developed to create closed-ended questions: Focus groups, in-depth interviews, input from ongoing quantitative studies, input from an expert panel, cognitive interviews, a quantitative pretest, a nationwide random probability sample of elderly people, and rigorous empirical psychometric testing. Three hundred ninety-nine older people took part in the first seven steps, and 1,500 elders participated in the nationwide survey. RESULTS: Approximately 175 closed-ended survey items were developed assessing 14 different major dimensions of religion. In the process, practical solutions to a number of problems encountered in implementing the nine-step strategy are discussed. DISCUSSION: The item development strategy may serve as a template that can be used to improve the quality of closed-ended survey items that assess a wide range of topics in social gerontology.]