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January 2018 Article of the Month
This month's article selection is highlighted by John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Lindholm, K. "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.


SUMMARY and COMMENT: We have previously featured research describing chaplains' perceived roles and patients' expectations [--see Related Items of Interest, § III, below], but this month's study looks very helpfully at "the challenges that hospice chaplains encounter that stem from patients' and family members' preconceptions about them and the communication strategies chaplains use to handle such challenges" [p. 285]. The findings, while clearly relevant to the hospice context, are put forward as "more broadly applicable to other religious professionals" [p. 289] ..."who have to deal with stereotypes in their own religious and spiritual care venues" [p. 284]. The author, Kristin Lindholm, PhD, is Associate Professor and Chair of the Department of Communication at Trinity International University (Deerfield, IL), a Christian liberal arts institution which includes Trinity Evangelical Divinity School.

In-person or written interviews using standardized, open-ended questions were conducted with 44 current or former hospice chaplains recruited from several sources: "a national organization of professional chaplains, a quarterly meeting of hospice chaplains in a major metropolitan city in the Midwest, and the author's personal networks" [p. 285]. In addition, "[t]wo current hospice chaplains kept journals for two weeks regarding their communication with patients and family members" [p. 285], with one of those chaplains being part of the interviews and one only contributing a journal. Participants were from a variety of denominations but were very largely from Christian faith backgrounds.

Four main stereotypes emerged from the data:

1) Chaplains as religious professionals whom others try to impress
-- "the belief that religious professionals expect the people they interact with to express particular views about God, religion, and spirituality. Thus, chaplains are viewed by patients and their families as people who need to be impressed by spiritual performances." For example, "some patients and their families simply assume that religious professionals like hospice chaplains want to hear particular types of beliefs, such as a serene, unruffled sense of trust in God, and therefore those beliefs are what patients and their family members express, regardless of whether or not such beliefs truly represent their own convictions." [p. 286]

2) Chaplains as people who only talk about spiritual and religious topics
-- "assuming that chaplains only want to engage people in conversations and rituals related to God, religion, or spirituality." Connected to this assumption may be the association of chaplains with organized religions and certain roles within that context, like the administration of end-of-life rites, leading some to "associate the chaplain's presence with imminent death." [p. 286]

3) Chaplains as male
-- with the effect that "female hospice chaplains may not be welcomed by patients or family members who believe that religious authority rightfully belongs only to males." [p. 286]

4) Chaplains as those who try to convert others
-- belief that a "religious professional's goal is to convert people to a particular religion." This may lead some to avoid interaction "for fear of being assaulted by 'Bible thumpers' or other clichés of converters," but may also lead some to show "eagerness to establish their religiosity in the eyes of the chaplain." [p. 287]
"In the face of these challenges from preconceptions about religious professionals, study participants described using a variety of strategies to present themselves and their roles in a manner that could help minimize the resistance of patients and their family members to a chaplain during initial and early meetings." [p. 287] Among the findings:
•   Descriptions of the chaplain role
-- "Many participants described how they introduce themselves in order to proactively shape or respond to people's conceptions of what a chaplain is." For example, one chaplain reported telling patients and families, "The reason I'm here is for us to become acquainted and for you to determine whether or not you want to make use of my services." Some participants sought proactively to check against negative stereotypes: e.g., that the chaplain would "make them feel guilty because they haven't been to church" or that there would be an agenda to "to convert or baptize or any of that stuff." Also, one strategy was to describe the role of the chaplain in terms of spirituality vis-à-vis religion, to emphasize the broad scope of their services. [p. 287]

•   Use of names and titles
-- "Participants often reported using just their first names, although some did use their full names initially and continued to do so if that level of formality seemed appropriate." While some actively encouraged the use of their first names, others let the patient's/family's own tendencies carry the day, realizing that there are people who might "feel awkward if they addressed a religious professional without a title" Foreknowledge of a patient's religious affiliation or non-affiliation was a taken into account by several participants in their plan to use a specific title, "on a case-by-case basis" [pp. 287-288]

•   Choice of clothing and nonverbal expressions of religious/spiritual symbolism
-- Participants "described the clothing choices of hospice chaplains in terms of downplaying or reflecting their religious identities and authority." Some wore casual attire and "[m]ost interviewees reported carefully staying away from wearing or carrying anything with obvious religious and spiritual symbolism." However, one common strategy lay in "[b]ringing religious items but hiding them from plain view" in pockets or purses or having them nearby in their cars, convenient for when the need arose. "Some participants did say they choose to wear a particular piece of jewelry, wear a collar, or carry a religious book," and some reported "using information they already had or what they gathered when they set up an initial meeting to help them decide whether or not to bring something religious with them or wear something in particular." [p. 288]

•   Expressions of affiliation with hospice and the hospice team
-- "Some interviewees reported verbally allying themselves with other members of the hospice team as part of their self-presentation." Strategies included "specifically mention[ing] that they are working with a particular nurse or a part of the team providing the patient's care," and one chaplain "capitalized upon her position as part of the hospice team by traveling with a hospice nurse and initially meeting patients and their families by sitting in on their intake meetings with the nurse, provided the patients gave permission for her to do so." Allying oneself with the team was thought to enhance trust, "particularly if the patients are already having a good experience with other hospice team members." [p. 288]

•   Descriptions of themselves
-- "Participants varied widely in their perspectives on how much information they give about themselves and whether or not they thought their revelations would be helpful." "For some interviewees, providing minimal information was a means of keeping their services relevant to as large a group of people as possible," whereas others "reported sharing their religious background only when they judged that such revelations might help patients and their families." Revealing common religious affiliations, for instance, "could assure patients and their families that their hospice chaplain had a special understanding of their perspectives and concerns." Moreover, "[s]everal participants remarked that they shared information about themselves in an attempt to be reciprocal with patients and families." [p. 289] "Both approaches have their merits in terms of reducing preconceived notions about clergy; the former approach limits the data that could lead to additional stereotyping, and the latter approach stresses authenticity, which can counteract stereotypes." [p. 290]
The author writes: "For religious professionals who wish to make their services relevant to as large an audience as possible, being aware of the communicative strategies available to them to handle people's stereotypes and preconceptions, especially negative ones, may be helpful" [p. 289]. This study, though limited, is a significant contribution to the literature for chaplaincy students and educators, with quite insightful and widely applicable findings being captured by a non-chaplain researcher. Lindholm suggests that further study be conducted with more diverse populations and contexts for ministry, and chaplain researchers would be well-positioned for this. It occurs to this reader that future investigation might also delve deeper into chaplains' feelings about the process of making the "crucial choices" of how to deal with stereotypes and any ethical stress about the "situation-by-situation analysis" required [p. 289]. For instance, might a plan to direct patients proactively away from their natural (preconceived) expectations in some cases be in conflict with a commitment to following the patient's lead in patient-centered pastoral care? What are chaplain's emotional reactions to being the object of stereotyping, and how is that reaction managed?

The bibliography contains only 20 citations, with some from the Internet, but is interesting for its inclusion of some works in sociology and communications by Erving Goffman [The Presentation of Self in Everyday Life, Garden City, NY: Doubleday Anchor, 1959], Clive Seale [Constructing Death, Cambridge, UK: Cambridge University Press, 1998], and Michael E. Roloff & Danette Ifert Johnson ["Reintroducing taboo topics: antecedents and consequences of putting topics back on the table," Communication Studies 52, no. 1 (2001): 37-50].


Suggestions for Use of the Article for Student Discussion: 

This is a very readable article that hits upon some fundamental issues in CPE: a chaplain's professional role and patients'/families' notions of that role. It begins rather provocatively with a listing of negative stereotypes [--see the first paragraph, p. 284] that could work to take the group's "temperature," and the results are laid out clearly, giving a natural structure to discussion. In spite of the hospice context for the study, students in a general hospital setting with even only a little experience should be able to identify with most of the stereotypes and some of the strategies. Each of the categories is worth taking time to discuss individually: the particular findings and what those findings evoke personally for students. Regarding the five categories of strategies, how intentional are members of the group in the ways they manage stereotypes, and does this process ever get in the way of their practice of pastoral care or is it simply part of their pastoral care? What additional stereotypes have students experienced, and what other strategies have they employed? The author mentions the dynamics of institutional support [p. 284] and work-related constraints [e.g., p. 288 regarding displays of religious symbolism]. Are these points pertinent to the group? Finally, for those interested in research methodology, the three-phase process for category identification is outlined very briefly [p. 286] but warrants attention.


Related Items of Interest:

I.  Our featured article is rooted in a larger research project by the author, with data from the same sample of current and former hospice chaplains. Its findings, too, may resonate with chaplains beyond the hospice context. This would be a most appropriate article to carry further one's thinking stirred by its predecessor.

Lindholm, K. "Handling challenges inherent in the hospice chaplain role." Journal of Health Care Chaplaincy (October 25, 2017): 20pp., published online ahead of print. [(Abstract:) With an increasing number of terminal patients in the United States dying in the context of hospice, the role that hospice chaplains play in providing spiritual care for patients and their families is important to examine. The hospice chaplain role requires careful navigation of the development of relationships that may end abruptly, the expectations of hospice organizations, and the needs of both patients and families. The current study uses the concept of competing role dialectics to further our understanding of the challenges chaplains face as they enact this crucial role. Data from 45 current and former hospice chaplains reveal four major role tensions hospice chaplains must develop strategies to handle: fostering relationships versus fostering autonomy, acting as team members versus acting as individuals, serving the family unit as a whole versus serving particular family members, and following the agendas of patients and families versus following one’s own agenda.]


II.  Hospice chaplains in particular may want to read, as a companion piece, our March 2017 Article-of-the-Month on what chaplains actually do. That research did not mention the need to manage stereotypes, though one of its themes that may implicitly touch on a need to deal with misconceptions was activity aimed at "introducing spiritual care," which was part of "chaplain craft."


III.  The July 2017 Article-of-the Month concerned perceptions of the chaplain's role by parents of hospitalized children (and this followed our feature exploring perceptions by hospital care teams in June 2017). Such perceptions are closely tied to expectations, and for more on patient's expectations of chaplains, see our March 2008 Article-of-the Month, plus the following two later articles by Katherine M. Piderman, et al.:

Piderman, K. M., Jenkins, S. M., Hsu, J. S. and Kindred, A. S. "Hospitalized young adults' expectations of pastoral interventions." Journal of Pastoral Care & 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., 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 (Nov 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.]


IV.  This month's article was written by a professor of communications, and chaplains should consider communications departments as resources for research partnerships. Our May 2017 Article-of-the-Month included as a co-author a communications researcher, Ashley Duggan, Ph.D., at Boston College. For a sample of spirituality & heath articles in recent years that involved researchers from departments or schools of communication, see the following. (Note especially the two articles by Cramer, Tenzek & Allen in pastoral care journals.)

Canzona, M. R., Peterson, E. B., Villagran, M. M. and Seehusen, D. A. "Constructing and communicating privacy boundaries: how family medicine physicians manage patient requests for religious disclosure in the clinical interaction." Health Communication 30, no. 10 (2015): 1001-1012. [(Abstract:) Religion/spirituality (R/S) is an important component of some patients' psychosocial framework when facing illness. While many patients report an increased desire for R/S dialogue in clinical interaction, especially when facing a frightening diagnosis, some physicians report discomfort talking about R/S and hold various beliefs regarding the appropriateness of such discussions. Not only do physicians manage conversations centering on patient disclosures in the clinical visit, they must also navigate requests to share their own personal information. Farber et al. (2000) found that over a 12-month period nearly 40% of physicians reported that patients asked questions that transgressed professional boundaries. This article uses Petronio's communication privacy management theory as a lens through which to situate our understanding of how family medicine physicians construct and communicate privacy boundaries in response to patient requests for religious disclosure. Results provide an in-depth theoretical understanding of issues surrounding religious disclosure in the medical visit and expand the discussion on health care providers' personal and professional privacy boundaries as documented by Petronio and Sargent (2011). Implications for health care training and practice are discussed.]

Considine, J. and Miller, K. "The dialectics of care: communicative choices at the end of life." Health Communication 25, no. 2 (March 2010): 165-174. [(Abstract:) Communication at the end of life poses important challenges for patients, families, and caregivers. Previous research on end-of-life communication has concentrated on areas including the provision of bad news and clinical and personal decision making. In this study, we turn our attention to the processes through which caregivers provide comfort in palliative care. Our ethnographic and interview study of spiritual communication among hospice workers and their patients is guided by a dialectical framework. We find a central dialectic in which hospice workers recognize the tension between "leading" and "following" patients and families in discussions of spirituality at the end of life. Our analysis reveals that though some care providers choose one pole of this dialectic, most workers try to manage the dialectic by shifting between leading and following in different situations or different points in time or by transcending the dialectic and addressing the multiple goals of interaction.]

Cramer, E. M., Tenzek, K. E. and Allen, M. "Recognizing success in the chaplain profession: connecting perceptions with practice." Journal of Health Care Chaplaincy 21, no. 4 (2015): 131-150. [(Abstract:) The current investigation examines the communicative hallmarks of successful chaplaincy work as articulated by professional chaplains providing spiritual care at the end-of-life. Data grounded in qualitative interviews with 32 chaplains of various denominations and lengths of service reveals a challenge in gauging success when working with dying patients and families. Chaplains reported nonverbal hallmarks of success consist of (a) intrapersonal sense of accomplishment, (b) progress in fulfilling patient needs, and (c) meaningful connection with patients. Verbal hallmarks of success include (a) patient affirmation, (b) family affirmation, and the (c) chaplain being asked to participate in religious rites. In practice, the authors conjecture, chaplains assess professional competency in the self, patient, and family domains. Implications and future directions are discussed.]

Cramer, E. M., Tenzek, K. E. and Allen, M. "Translating spiritual care in the chaplain profession." Journal of Pastoral Care and Counseling 67, no. 1 (March 2013): 6 [electronic journal article designation]. [(Abstract:) Chaplains provide a much-needed service to patients and families requiring spiritual care in the healthcare setting. Despite evidence documenting improvements quality of life for patients using spiritual services, chaplains experience challenges in translating the benefits they provide into concepts understood by patients, team members, and administrators. A qualitative study using interviews with 19 chaplains found that translation problems occur in three main areas: (a) justifying the role to patients and families, (b) determinations of what constitutes a "productive" employee, and (c) effective collaboration with other members of the health care team. This study outlines several strategies used by chaplains to ease the process of translation, as well as some directions for future research.]

Keating, D. M. "Spirituality and support: a descriptive analysis of online social support for depression." Journal of Religion and Health 52, no. 3 (September 2013): 1014-1028. [(Abstract:) This study examined supportive messages in spiritual and non-spiritual online support groups for depression. Both social support and religiosity have been associated with reduced depressive symptomology. Proportions of three types of support (i.e., informational, emotional, and network) were considered; messages were further delineated as being either religious or non-religious in nature. Messages (N=2,674) from two Christian and two unaffiliated online groups were analyzed. Results indicated that Christian groups communicated more informational support and General groups communicated more network support. Christian groups communicated more religious messages. This and future research is valuable to practitioners and clergy aiding depressed individuals and to the literature on social support and religion.]

Ledford, C. J., Seehusen, D. A., Canzona, M. R. and Cafferty, L. A. "Using a teaching OSCE to prompt learners to engage with patients who talk about religion and/or spirituality." Academic Medicine 89, no. 1 (January 2014): 60-65. [(Abstract:) PURPOSE: The objective structured clinical examination (OSCE) has only occasionally been used as a teaching tool. The authors describe the initial use of an educational innovation consisting of a teaching OSCE used as "sensitizing practice," followed by personal, guided, and group reflection. METHOD: Staff and resident physicians and one medical student (N = 28) at a community hospital's family medicine residency participated in the innovation during August 2012. The initial use of the educational innovation allowed learners to engage in a potentially challenging conversation with a standardized patient about religion and/or spirituality (R/S). The aim of the innovation was not to equip learners with a particular tactic to introduce or discuss R/S but, rather, to prompt learners to engage in mindful practice with patients who identify R/S as part of their biopsychosocial contexts. Written, dyadic, and group reflection added value to the OSCE by allowing participants to reflect on a difficult learning objective over time. RESULTS: Participants moved along the stages-of-change continuum when engaging in guided reflection compared with personal reflection. Additionally, all participants provided evidence of at least the preparation stage at the time of guided reflection. By following the OSCE's sensitizing practice with three periods of reflection, learners were enabled first, to recognize the need for readiness to address challenging communication topics (in this case, R/S) and, second, to reflect on practiced strategies for those conversations. CONCLUSIONS: The educational innovation can help learners become more aware of and skillful in dealing with difficult physician-patient communication topics.]

Mclaughlin, B., Yang, J., Yoo, W., Shaw, B., Kim, S. Y., Shah, D. and Gustafson, D. "The effects of expressing religious support online for breast cancer patients." Health Communication 31, no. 6 (2016): 762-771. [(Abstract:) The growth of online support groups has led to an expression effects paradigm within the health communication literature. Although religious support expression is characterized as a typical subdimension of emotional support, we argue that in the context of a life-threatening illness, the inclusion of a religious component creates a unique communication process. Using data from an online group for women with breast cancer, we test a theoretical expression effects model. Results demonstrate that for breast cancer patients, religious support expression has distinct effects from general emotional support messages, which highlights the need to further theorize expression effects along these lines.]

Neville Miller, A. and Teel, S. "A content analysis of research on religion and spirituality in general communication and health communication journals." Health Communication 26, no. 7 (October 2011): 615-620. [(Abstract:) Little research has been conducted within the field of communication regarding the intersection of religious faith and health communication. One step toward addressing the existing gap in health communication literature is to establish an accurate picture of the present state of affairs. The purpose of this study was to describe publication patterns in communication journals over the past 10 years with respect to the intersection and faith and health communication. We conducted a content analysis on four broad-based communication journals that have been identified as central in the communication field, and two health communication journals. We present results regarding specific health conditions, nationalities, faith communities, channels of communication, domains of religion, and purposes of communication studied; methods used; trends in publication across time and communication journals; and comparison to other disciplines.]

Rafferty, K. A., Billig, A. K. and Mosack, K. E. "Spirituality, religion, and health: the role of communication, appraisals, and coping for individuals living with chronic illness." Journal of Religion and Health 54, no. 5 (October 2015): 1870-1885. [(Abstract:) Currently, 10% of Americans are living with a chronic illness. One coping mechanism for individuals living with chronic illness is religion and/or spiritual (R/S). To better explicate the relationship among R/S and psychological well-being, we conceptualize R/S as an interpersonal process involving conversations that may facilitate positive reappraisals. We use a mixed-method approach from data collected from 106 participants, involving a content analysis of R/S conversations and test Burleson and Goldsmith's (Handbook of communication and emotion: research, theory, applications, and contexts, Academic Press, San Diego, pp. 245-280, 1998) appraisal-based comforting model. Partial support for the model was found. In addition, the majority of R/S conversations were considered positive, helpful, and supportive. Theoretical and practical implications are discussed.]

Wittenberg, E., Ferrell, B., Goldsmith, J. and Buller, H. "Provider difficulties with spiritual and forgiveness communication at the end of life." American Journal of Hospice and Palliative Medicine 33, no. 9 (November 2016): 843-848. [(Abstract:) BACKGROUND: Due to an absence of communication training, provider responses to patient/family spiritual distress are highly variable. Assessing spiritual and forgiveness concerns are important to ensuring quality holistic care. METHODS: Cross-sectional survey data were collected from providers attending 1 of 2 continuing education courses. The survey measured the frequency and initiation of communication about spirituality and forgiveness with patients/families, the perceived difficulty in communication across topics, and preparation and resources for these discussions. RESULTS: Most participants (n = 124) were nurses followed by social workers with over half of providers having 10 years or more of clinical experience. Participants reported the highest level of difficulty in spiritual communication when talking with family after the death of a patient, followed by conducting a spiritual history with a patient. Facilitating forgiveness communication between parent and adult child, followed by facilitating forgiveness between partners was most difficult for all participants. Social workers reported much lower difficulty than nurses on all items of spiritual and forgiveness communication. CONCLUSION: The majority of participants indicated they were involved in spiritual and forgiveness communication. The most difficult communication included talking with family after death and facilitating forgiveness between patients and families. These findings support the importance of spiritual communication in clinical practice, and the need for clinician training in communicating about spirituality and forgiveness with patients and families.]

Wittenberg-Lyles, E., Demiris, G., Oliver, D. P. and Burt, S. "Reciprocal suffering: caregiver concerns during hospice care." Journal of Pain and Symptom Management 41, no. 2 (February 2011): 383-393. [(Abstract:) CONTEXT: For many hospice caregivers, the constancy and difficulty of caregiving impact their physical quality of life and cause depression, psychological distress, guilt, loneliness, and restrictions on social activities. OBJECTIVES: Deviating from traditional unidimensional research on hospice caregivers, this study explored the transactional nature of reciprocal suffering by examining caregiver concerns through four dimensions: physical, psychological, social, and spiritual. METHODS: Researchers analyzed audiotapes of intervention discussions between hospice caregivers and research social workers. RESULTS: Results indicated that, of the 125 pain talk utterances, most referenced psychological concern (49%), followed by physical (28%), social (22%), and spiritual (2%) concerns. Reflections on concerns revealed a global perspective of caregiving, which highlighted the patient's needs juxtaposed to the caregiver's recognized limitations. CONCLUSION: By examining the reciprocal nature of suffering for caregivers, this study reinforced the need for assessing caregivers in hospice care, with specific emphasis on the importance of providing caregiver education on pain management.]



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