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


Davidson, J. E., Boyer, M. L., Casey, D., Matzel, S. C. and Walden, D. "Gap analysis of cultural and religious needs of hospitalized patients." Critical Care Nursing Quarterly 31, no. 2 (April-June 2008): 119-126.


SUMMARY and COMMENT: This qualitative study grew out of concerns about cultural awareness at a community hospital in California, and it is valuable not only for its very practical findings but also as a research model for exploring issues of religious and cultural diversity in a hospital setting. When the case of a Jewish patient requesting circumcision for a newborn highlighted a lack of understanding on the part of staff, a Social Worker gathered a team to address the question: "If we do not know this about something so common as a Jewish circumcision, what else do we not know?" That team decided to engage the question with original research. The lead author, Judy E. Davidson, is also the lead author of last year's notable article, "Clinical practice guidelines for support of the family in the patient-centered intensive care unit…," [--see Related Items of Interest, below], and David Waldron is a chaplain with experience in hospital, prison, and community settings.

Data were collected from 22 semi-structured interviews, 6 lectures, and 2 panel discussions, targeting groups of special interest to the hospital, including Muslim, Baha'i, Catholic, Protestant, Jewish, Buddhist, Mormon, Jehovah's Witness, Latino, Filipino, Chinese, and African American participants. The authors point out that hospital demographic information proved to be an inadequate guide to group identification, because many issues pertained to groups subsumed under the category of "other" in hospital records (--a point that suggests how research using hospital records must be cautious of data pigeonholing within hospital record systems). The project focused pragmatically on the needs of health care consumers, especially regarding the contexts of birth and death but also relating to the needs of hospital patients in general. The results are presented in sections on religious items, dietary needs, modesty, blood, birth and death (the largest section, including some transcribed dialogue), visiting, and feedback about the design of new hospital buildings.

Excerpts from the Religious Items section illustrate the character of the findings:

Despite the preliminary nature of this study, it became apparent that the consumers recommended many items the hospital did not have available. …Specific items not currently found in the hospital and advised by the participants included bibles or prayer books for more than just the Christian religion, bookcases for the chapel, inspirational texts, texts on grief and coping, and Spanish language bibles. It was requested that the hospital gift shop carry more prayer-related items including inspirational texts, cards, and prayer cards. Participants of the Catholic faith requested availability of rosaries, crucifixes, and holy water. Muslim participants requested prayer rugs and prayer compasses. ...Reformed Jewish participants stated that a Sabbath kit would be helpful with possibly a video of a Sabbath prayer service, kippot, and electric candles. [p. 121]

Various findings regarding Muslim patients stood out for this reader: a potential for hospital staff to become confused by the fact that Muslims may chose the Kosher food selection on the hospital menu, an inadequacy of some hospital gowns to cover patients' knees for kneeling in prayer, a concern about a perception that a Muslim patient who does not stop praying when a staff member enters the room is simply rudely ignoring the staff member, and staff ignorance of the custom of whispering a profession of faith in the ear of a child at birth or of the importance of a verbal profession at the time of death.

The authors make a special note of three "unexpected themes": 1) a lack of respect by staff for clergy not in clerical dress, 2) tension between hospital rules and "rule orientation" within some minority groups, and 3) the importance of calling in clergy early in the process of supporting patients [--see p. 125]. They also describe receiving negative feedback about several ideas put forward as enhancements to patient care: for instance, "ringing a soft bell at the time of a death to let staff know that a death had occurred" --"No group accepted the idea. Most even cringed visibly at the thought" [p. 123]. Such suggests the subtle difficulty of working with cultural/religious diversity issues and illustrates how a research approach that draws insights directly from target groups may be more useful than even very well-meaning ideas of health care providers who are not representative of those groups.

A number of limits to the generalizability of the findings are addressed on p. 121, but the authors observe that the study brought about "immediate purchases and changes in practice," and, "The process of interviewing consumers about their cultural and religious needs was fruitful and yielded many items, services, and considerations previously not addressed by this community hospital" [p. 126]. Moreover:

The findings provide fuel for further investigation. In the future, each subgroup could be studied across generations to explore the relationship between assimilation and needs. Interviewing greater numbers from each group would further validate findings. Additional religious and cultural groups could be studied. [p. 126]
The article cites only 11 references.


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

This is an easily read article, well suited for students at any stage of CPE. It could be discussed in terms of research or purely as a practical exposé on religious and cultural diversity in health care. Regarding research, newer students might think about the straightforward and effective method of the PICO Question: "…a form of research question, which includes the population of interest, the intervention, comparison group, and outcome" [p. 120]. More advanced students will likely want to discuss the study's Limitations or Obstacles [p. 121], especially the idea of what it may take to saturate data of the present kind. The article looks to be a natural discussion-starter about diversity issues, and the major headings by which the findings are reported provide a menu of thought-provoking points. The piece may even generate interest in performing a "gap analysis" of diversity issues at the CPE center. Discussion could also turn to the importance of hearing others' needs, rather than postulating what they could be --an idea that has implications for the chaplain's role as a listener.


Related Items of Interest:

I. Judy E. Davidson, the lead author of this month's article, co-authored the following report of the American College of Critical Care Medicine Task Force 2004-2005, for which she was also the chair.

Davidson, J. E., Powers, K., Hedayat, K. M., Tieszen, M., Kon, A. A., Shepard, E., Spuhler, V., Todres, I. D., Levy, M., Barr, J., Ghandi, R., Hirsch, G. and Armstrong, D., for the American College of Critical Care Medicine Task Force 2004-2005, Society of Critical Care Medicine. "Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005." Critical Care Medicine 35, no. 2 (February 2007): 605-622. [This report covers broadly the topic of support of the family in the ICU, but see especially the sections on Cultural Support of the Family and Religious and Spiritual Support (pp. 610-612).]

II. For a variety of articles on religious/cultural diversity, click HERE for a bibliography (PDF) of recent article series in health care publications. Such articles are not reports of research, but they are often quite insightful, especially those written by representatives of cultural/religious groups. This resource is available through the Department of Pastoral Care of the Hospital of the University of Pennsylvania. See also Religious Diversity: Practical Points for Health Care Providers, by Chaplain John Ehman.

III. For more on Muslim issues in particular, see the June 2003 Article-of-the-Month page.


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