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January 2020 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


Taylor, E. J. and Li, A. H. "Healthcare chaplains' perspectives on nurse-chaplain collaboration: an online survey." Journal of Religion and Health (2020): online ahead of print, 1/7/20.

[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: This very well written article revisits a topic previously explored in our March 2007 Article-of-the-Month [--see Items of Related Interest, §I, below] and offers a "quantified and nuanced picture of how chaplains perceive nurse collaboration and provision of spiritual care" [MS p. 11]. It also presents a 15-item instrument -- the Chaplain Perspectives on Nurse-Provided Spiritual Care Scale (CPNPSCS) -- with good potential for wider use. The authors are from Loma Linda University: Elizabeth Johnson Taylor, RN, PhD, is a Professor in the School of Nursing and a prolific writer/researcher who has often focused on spirituality and has previously contributed to our ACPE Research site [--see Items of Related Interest, §III, below]; and Angela H. Li, PhD, is an Assistant Professor and Director of the Master of Science in Chaplaincy Program, as well as an Association of Professional Chaplains board-certified chaplain.

Taylor and Li note the practical need for chaplain-nurse collaboration and some evidence that "this relationship may not be always as respectful or functional as it should be" [MS p. 2]. Yet, there is overall a "paucity of evidence describing nurse-chaplain collaboration" [MS p. 3]. Therefore:

This study sought to acquire knowledge to inform both nurses and chaplains. That is, knowing how chaplains perceive nurse-provided spiritual care and what barriers they perceive to interdisciplinary spiritual care can help nurses to understand how to better collaborate with chaplains. It can also provide insights into how their practice of spiritual caregiving may be improved. Conversely, findings from this study can crystalize for chaplains what are typically unidentified issues with providing collaborative care with nurses. Bringing interdisciplinary issues and differences in perspective "out of the closet" can ultimately improve collaboration.

An online survey of members of the Association of Professional Chaplains yielded 295 responses within the first three-and-a-half hours after an invitation was sent out by the APC, with another 20 responses over the following week. After exclusions, the final sample was 266 chaplains who currently work in healthcare settings. "The sample was evenly split by gender, but was overrepresented by older adults of at least 50 years of age (M=52.2, SD=11.6, range=24-77)" [MS p. 5]. Average years of experience was 11.8 (SD = 8.9, range 1-41). Detailed sample characteristics are provided in a table [--see MS p. 6]. The CPNPSCS was developed by the principal investigator and tested for content validity through a panel of five board-certified chaplains. As an incentive, those who completed the survey could claim a $20 Amazon promotional code. "While the incentives were used to show participants appreciation for their contribution, it was also hoped that they would assist in recruiting a more diverse sample (e.g., not just chaplains motivated by anger toward nurses would participate)" [MS p. 4]. The survey was designed to close after 216 people obtained the promotional code; "82...completed at least parts of the survey without taking the incentive" [MS p. 5].

Among the results:

  • "This sample of APC members endorsed that nurses were collaborative in providing spiritual care. ...[T]hese chaplains' perceptions of nurses providing spiritual care were fairly positive." [MS p. 11] "...[A]lthough they perceived nurses were fairly often helpful..., these respondents' rating of how often nurses were harmful was not much less than their rating for helpfulness...." [MS p. 7]

  • "The findings that are most intriguing, indeed, are those indicating that there are negative perceptions of nurses providing spiritual care. ...[C]haplains were concerned about how nurses sometimes are leading in the interaction, introducing their own religiosity, or misreading patients as wanting their spiritual care." [MS p. 12]

  • "...Negative perceptions were associated with less-frequent nurse referrals, and positive perceptions were associated with receiving more referrals." [MS p. 12]

  • "A provocative question that went to the core of this project was one inquiring How often do you sense nurse creating resistance (or "gate-keeping") to your work? While nearly half (48.7%) reported never or rarely, many (46.5%) indicated occasionally or sometimes. Five percent indicated often." [MS p. 9]

  • "[R]espondents who reported never or rarely experiencing nurses as gatekeepers had more positive perceptions of nurse spiritual care. Thus, it is likely that the attitude and approach a chaplain takes while collaborating with nurses (i.e., the degree to which they hold either a positive or negative view of nurses providing spiritual care) influence how the nurses respond with making referrals and gatekeeping." [MS p. 12]

  • "Particularly noteworthy is the finding that just over half did want nurses to conduct a spiritual screening; likewise, 56% did want nurses to inquire of patients as to whether a chaplain visit was wanted." [MS p. 9]

  • "It is important to note that study participants perceived nurses as rather infrequently completing a spiritual screening/history." [MS p. 7]

  • "While the percentage of nurse-initiated referrals received varied considerably, two-thirds of the respondents reported less than 40% of patient encounters occurring as a result of a nurse's referral. These referrals were most often for emotional support; however, referrals to religious rituals and spiritual struggle were also common." [MS p. 9]

  • "[R]espondents who worked on specific units/departments had a significantly more positive view of nurse spiritual screening/history skill than did those who worked throughout an institution." [MS p. 9]

  • "A slim majority (57%) reported having no protocol for nurse referrals." [MS p. 9] "[C]haplains who received higher volumes of nurse referrals tended to work in an environment where there was protocol." [MS p. 11]

The authors comment:

...[T]hese findings ought to prompt chaplains to reflect on how to nurture collaboration with nurses. Presenting themselves to nurses with respect for what they can do to nurture patient spiritual well-being likely will result in less gatekeeping and increased referrals. The finding that chaplains who are stationed to serve a specific unit or area have more positive appraisals of nurse spiritual screenings/histories also suggests that this closer working relationship may breed better patient care, if not better collegiality. Collaboration requires relationship and communication. Chaplains will do well to consider various methods for educating nurses to be helpful colleagues (e.g., how to complete spiritual screenings and inquire regarding a chaplain visit in ways the chaplain prefers, how to therapeutically respond to spiritual struggle). [MS p. 12]

Regarding the CPNPSCS, this new instrument deserves further psychometric evaluation for test-retest reliability, confirmatory factor analysis, and criterion-related validity [--see MS p. 13], however, this chaplain reader found its items quite interesting, as well as the analytical breakdown into items for "Nurse as Helpful" and "Nurse as Harmful." The question of nurses' "gatekeeping" is not part of the CPNPSCS, but a correlation was found with chaplains' perspectives of nurses as harmful [--see MS p. 11]. On the whole, the construction of the instrument and the data from it suggest that chaplains' tensions with nurses may be based largely in concerns about their competence in providing spiritual care, yet what does not seem to be explored here is whether professional turf issues may be at play. [Note: Professional turf issues have been indicated between chaplains and Social Workers, where there may be some analog to chaplains' views of nurses; see, for instance: Harr, C., Openshaw, L. and Moore, B., "Interdisciplinary relationships between chaplains and social workers in health care settings," Journal of Health Care Chaplaincy 16, no. 1-2 (2009): 13-23.] Other limits of the study include the use of a convenience sample from a professional chaplaincy organization that is mostly Protestant

Taylor and Li advocate for greater collaboration between nurses and chaplains, recognizing the position of nurses as "the clinicians most physically present to a patient" [MS p. 13] and "often the most intimately aware" [MS p. 2] of patients' suffering --with the best vantage for referral. And, "[a]lthough nurses may be the healthcare professionals who most frequently make chaplain referrals, evidence also indicates low referral rates" [MS p. 2]. There is clearly room for improvement, and the authors hope that their study may "prompt further examination, education, and negotiation" [MS p. 13] among and between the two disciplines. They ultimately see better collaboration "indirectly improv[ing] the spiritual succor patients receive" [MS p. 13].


Suggestions for Use of the Article for Student Discussion: 

This month's article is carefully written and should be useful to all student groups as well as to chaplain researchers, though some students might have difficulty reading the Analysis and Results sections [MS pp. 5-11] because of the statistical language; however, anyone skipping from MS p. 5 to the Discussion section on MS p. 11 will still find the core content well articulated. Discussion could begin with a general go-around about students' experience of working with nurses, getting referrals from nurses, and views of nurses' role(s) in spiritual care. The group may want to go through the items of the Chaplain Perspectives on Nurse-Provided Spiritual Care Scale [MS p. 8], though the analytical breakdown there of the items there into "Nurse as Helpful" and "Nurse as Harmful" may affect responses. Are the students in favor of nurses asking patients whether they want a chaplain's visit? Why or why not? If the students have regular patient care unit assignments but also take general call throughout the hospital, do they view nurses with whom they work regularly differently than nurses they do not know on other units? How might they work to build collaborative relationship with nurses? While the research on the present topic is sparse, the article's authors do a good job at carefully relating their work to other research in different socio-cultural contexts, and students may wish to give some thought to the task of connecting diverse studies. This could be an article to discuss with one or more invited guests from Nursing, though it might be paired with a second article about nurses' perceptions of chaplains [--see Related Items of Interest, §IV, below]. Finally, while the article notes concerns about nurses' gatekeeping, in what ways have chaplains engaged in gatekeeping information about patients that has arisen during visits, wondering how much to disclose to nurses?


Related Items of Interest:

I.  The topic of this month's article was previously explored in a small study that was featured as our March 2007 Article-of-the-Month:

Cavendish, R., Edelman, M., Naradovy, L., McPartlan Bajo, M., Perosi, I. and Lanza, M. "Do pastoral care providers recognize nurses as spiritual care providers?" Holistic Nursing Practice 21, no. 2 (March/April 2007): 89-98. [This descriptive qualitative study was conducted to explicate pastoral care providers' perceptions of nurses as spiritual providers. Spirituality is especially meaningful in contemporary society as a whole with spiritual care an expectation of hospitalized patients. Spiritual care given by nurses is grounded in nursing's history, inherent in its philosophical framework, and supported by research and professional mandates. In hospitals today, the primary responsibility for the spiritual care of patients resides with pastoral care providers. Collaboration between pastoral care providers and nurses may improve patients' spiritual care outcomes. Before collaboration can occur, it is important to learn whether pastoral care providers recognize nurses as spiritual providers. Guided by qualitative research methods, participants were sought until data saturation occurred. This qualitative study consisted of 8 participants who were experienced, full-time pastoral care providers from general and religious-affiliated hospitals. Data were collected through audiotaped open-ended interviews, a demographic data form, and exploratory questions or probes. The analysis included concurrent data collection, constant examination of conceptual interactions, linkages, and the conditions under which they occurred. Themes emerged: quest, conscious response, and essence of caring. Pastoral care providers perceive nurses as spiritual providers. Few felt comfortable initiating collaboration. Study findings are not generalizable.]


II.  Taylor and Li note the language of spiritual care specialists and spiritual care generalists to contextualize the roles and relationships between chaplains and nurses, respectively [--see MS p. 2]. That specialist-generalist model has been a subject in chaplaincy for many years. See especially work by chaplains Mary R. Robinson and Mary Martha Thiel to refine the conceptualization with an eye toward research. Note the delineation of Roles and Tasks of Spiritual Care Generalists and Specialists on p. e726 of Robinson, M. R., Thiel, M. M., Backus, M. M. and Meyer, E. C., "Matters of spirituality at the end of life in the pediatric intensive care unit," Pediatrics 118, no. 3 (September 2006): e719-729 [--our November 2006 Article-of-the-Month]. Then, see the identification of 15 spiritual care generalist skills used to assess an educational initiative on p. 818 of Robinson, M. R., Thiel, M. M., Shirkey, K., Zurakowski, D. and Meyer, E. C., "Efficacy of training interprofessional spiritual care generalists," Journal of Palliative Medicine 19, no. 8 (August 2016): 814-821 [--our August 2016 Article-of-the-Month].

A new Interprofessional Spiritual Care Education Curriculum (ISPEC) is based upon the generalist-specialist model. Among the authors is the Executive Director of the Association for Clinical Pastoral Education.

Puchalski, C., Jafari, N., Buller, H., Haythorn, T., Jacobs, C. and Ferrell, B. "Interprofessional Spiritual Care Education Curriculum: a milestone toward the provision of spiritual care." Journal of Palliative Medicine (2020): 8pp.; online ahead of print, 12/31/20. [(Abstract:) Background: Spiritual care is a key domain of quality palliative care. Spiritual distress is highly prevalent in patients and their families facing serious illness. Guidelines support the ethical obligation of health care providers to attend to spiritual distress as part of total distress. All clinicians require education and support to provide this care to patients and their families facing serious illness. Objective: This project focused on the development of a curriculum for education of health care professionals in spiritual care. It was based on a consensus-derived generalist-specialist model of spiritual care, with all clinicians providing generalist-spiritual care and trained chaplains providing specialist spiritual care. Design: The curriculum was designed for classroom and online learning. Setting: The curriculum is appropriate for all clinical settings in the United States and internationally. Measurements: Needs assessment surveys and course evaluation data have provided a basis on which to develop and refine the curriculum. This curriculum is built on a pilot Interprofessional Spiritual Care Education Curriculum (ISPEC) course held at the Veterans Administration, DC. Results: Needs assessment and course evaluation data support the ISPEC course content. Conclusions: The ISPEC curricula serve as a much-needed training resource to improve spiritual care for all people with serious illness.]


III.  Elizabeth Johnston Taylor's work on "Nurse responses to patient expressions of spiritual distress" was the topic of our August 2013 Article-of-the-Month, and that web page lists a number of her earlier articles of potential interest to chaplains. She also was one of the authors of the reviews of the "State of the science of spirituality and palliative care research," which we featured in October 2017. In addition, she penned a reflection for our Fall 2013 Newsletter: "Nurses: The Chaplain's Gatekeeper?" [--see that Newsletter item #3].

Below is a select bibliography of research of particular interest since 2013. Much of the recent work from Dr. Taylor and colleagues focuses on the perspectives and practices of nurses.

Mamier, I. and Taylor, E. J. "Psychometric evaluation of the Nurse Spiritual Care Therapeutics Scale." Western Journal of Nursing Research 37, no. 5 (May 2015): 679-694. [(Abstract:) To measure nurse-provided spiritual care, robust instrumentation is needed. This study psychometrically evaluated an instrument that operationalizes frequency of nurse-provided spiritual care, the Nurse Spiritual Care Therapeutics Scale (NSCTS). The 17-item NSCTS, with an established content validity index of 0.88, was administered online to registered nurses (RNs) in four hospitals. Responses from 554 RNs (24% response rate), most who identified as Christian, provided evidence for the NSCTS' reliability and validity. Internal reliability was supported by an alpha coefficient of .93. Validity was evidenced by item-total correlations ranging from .40 to .80, low to modest direct correlations between the NSCTS and Daily Spiritual Experience Scale and Duke University Religiosity Index, and strong loadings between 0.41 and 0.84 on one factor (explaining 49.5% of the variance) during exploratory factor analysis.]

Mamier, I., Taylor, E. J. and Winslow, B. W. "Nurse spiritual care: prevalence and correlates." Western Journal of Nursing Research 41, no. 4 (2019): 537-554. [(Abstract:) Many nurses embrace spiritual care as integral to holistic care. Evidence documenting the frequency of spiritual care provided in acute care settings, however, is sparse and weak. For this cross-sectional, correlational study, data were collected from N = 554 tertiary care nurses using the Nurse Spiritual Care Therapeutics Scale (NSCTS) measuring their self-reported spiritual care with patients/family members over the last 72 to 80 hours at work. While the most frequently endorsed practices centered on presence, listening, and spiritual assessment, the overall NSCTS score remained modest (M = 37; SD = 12; possible range = 17-85). Several associations were found; 32.4% of the variance in frequency of spiritual care provision was explained by nurse perception that spiritual issues come up often in the work setting, high nurse spirituality score, not working in pediatrics, and having received education about spiritual care. Findings allow for benchmarking of nursing practices that have often been invisible.]

McMillan, K. and Taylor, E. J. "Hospitalized patients' responses to offers of prayer." Journal of Religion and Health 57, no. 1 (February 2018): 279-290. [(Abstract:) Most Americans pray; many pray about their health. When they are hospitalized, however, do patients want an offer of prayer from a healthcare provider? This project allowed for the measurement of hospitalized patient's responses to massage therapists' offers of a colloquial prayer after a massage. After the intervention, 78 patients completed questionnaires that elicited quantitative data that were analyzed using uni- and bivariate statistical analyses. In this sample, 88% accepted the offer of prayer, 85% found it helpful, and 51% wanted prayer daily. Patients may welcome prayer, as long as the clinician shows "genuine kindness and respect."]

Neathery, M., He, Z., Taylor, E. J. and Deal, B. "Spiritual perspectives, spiritual care, and knowledge of recovery among psychiatric mental health nurses." Journal of the American Psychiatric Nurses Association (2019): online ahead of print, May 18, 2019. [(Abstract:) BACKGROUND: Promoting spiritual well-being aids the mental health recovery process. Furthermore, nursing governance bodies and national mental health care regulators support spiritual care as a mental health-promoting approach. Although spiritual well-being is integral to quality of life in people with mental illness, little is known about the psychiatric mental health (PMH) nurses' provision of spiritual care. AIMS: Spiritual perspectives, frequency of spiritual care, and knowledge of recovery-oriented practice were measured. Variables were explored to identify a model of spiritual care. METHOD: A descriptive correlational cross-sectional design was employed. Analyses of data using descriptive statistics, correlations, and hierarchical multiple regression were conducted with a convenience sample of 171 PMH nurses. RESULTS: Participants scored high on measurement of spiritual perspectives, moderate on measurement of knowledge about recovery-oriented practice, and indicated a moderate degree of frequency of provision of spiritual care. Nurses who viewed themselves as "spiritual and religious" provided more frequent spiritual care and had higher levels of spiritual perspectives than those who viewed themselves as "spiritual but not religious." Significant contributors to spiritual care were spiritual perspectives and years of experience as a PMH nurse. Knowledge of recovery-oriented practice, however, did not contribute to a model of spiritual care. CONCLUSIONS: Nurses' spiritual perspectives, religiosity, and years of experience are factors that may explain nurse-provided spiritual care. Findings imply that spiritual and/or religious development may support PMH nurses to provide spiritual care.]

Taylor, E. J., Gober-Park, C., Schoonover-Shoffner, K., Mamier, I., Somaiya, C. K. and Bahjri, K. "Nurse opinions about initiating spiritual conversation and prayer in patient care." Journal of Advanced Nursing 74, no. 10 (October 2018): 2381-2392. [(Abstract:) AIM: The aim of this study was to understand nurses' opinions about initiating spiritual or religious conversation during patient care and to measure how these perspectives are associated with demographic, religious and work-related characteristics. BACKGROUND: Nurses are expected to provide spiritual care and do so in diverse ways. Little is known about how nurses think about initiating spiritual or religious discourse. DESIGN: Cross-sectional, quantitative. METHODS: Online survey methods allowed data collection from 445 nurses. The survey, accessed from the homepage of the Journal of Christian Nursing for 6 months beginning June 2015, included scales measuring various facets of religiosity, and items assessing nurse opinions about introducing spirituality or religion during patient care and demographic and work-related variables. Variables showing significant associations with Nurse Opinion items in bivariate analyses were examined using binary logistic regression. RESULTS: About 90% of participants believed it appropriate to initiate conversation about spirituality/religion and nearly three-quarters thought it appropriate to self-disclose spirituality/religion or offer prayer under certain circumstances or anytime. All personal religiosity indicators except tentativeness of belief were found to be associated with responses to Nurse Opinion items. That is, higher religiosity was associated with opinion one could initiate such conversations, whereas lower religiosity was associated with waiting for patients to initiate. Nurses working in a faith-based organization were 276% more likely to believe they could initiate such conversation and 153% more likely to think they could initiate an offer of prayer. CONCLUSION: Nurse religiosity and work environment were associated with nurse opinions about initiating spiritual/religious discourse with patients.]

Taylor, E. J., Gober-Park, C., Schoonover-Shoffner, K., Mamier, I., Somaiya, C. K. and Bahjri, K. "Nurse religiosity and spiritual care: an online survey." Clinical Nursing Research 28, no. 5 (June 2019): 636-652. [(Abstract:) This study measured the frequency of nurse-provided spiritual care and how it is associated with various facets of nurse religiosity. Data were collected using an online survey accessed from the home page of the Journal of Christian Nursing. The survey included the Nurse Spiritual Care Therapeutics Scale, six scales quantifying facets of religiosity, and demographic and work-related items. Respondents (N = 358) indicated high religiosity yet reported neutral responses to items about sharing personal beliefs and tentativeness of belief. Findings suggested spiritual care was infrequent. Multivariate analysis showed prayer frequency, employer support of spiritual care, and non-White ethnicity were significantly associated with spiritual care frequency (adjusted R2 = .10). Results not only provide an indication of spiritual care frequency but empirical encouragement for nurse managers to provide a supportive environment for spiritual care. Findings expose the reality that nurse religiosity is directly related, albeit weakly, to spiritual care frequency.]

Taylor, E. J., Gober-Park, C., Schoonover-Shoffner, K., Mamier, I., Somaiya, C. K. and Bahjri, K. "Spiritual care at the bedside: Are we practicing what we preach?" Journal of Christian Nursing 36, no. 4 (October/December 2019): 238-243. [(Abstract:) Little is known about how nurses' personal spirituality and religious (S/R) beliefs impact their spiritual care of patients. An online survey was used to collect data from 445 nurses, assessing facets of religiosity, their opinions about introducing S/R during patient care, demographic, and work-related variables. Findings indicated that even in a sample of Christian nurses who scored high on religiousness measures, spiritual care is infrequent. Nurses' opinions about whether it was appropriate to initiate S/R conversation, self-disclosure, and prayer were associated with aspects of nurse religiosity. Nurses working in a faith-based organization were more likely to believe they could initiate S/R conversation and offer prayer.]


IV.  For an exploration of how nurses experience and view chaplains, see our January 2017 Article-of-the-Month:

Kim, K., Bauck, A., Monroe, A., Mallory, M. and Aslakson, R. "Critical care nurses' perceptions of and experiences with chaplains: implications for nurses' role in providing spiritual care." Journal of Hospice and Palliative Nursing 19, no. 1 (February 2017): 41-48. [(Abstract:) We explored critical care nurses' experiences with chaplains and perceptions of spiritual care. This was a qualitative study, using in-depth interviews and focus groups with critical care nurses at an academic medical center. Data were audio recorded, transcribed verbatim, and analyzed using inductive coding methods. The study included 31 nurses (19 interviews and 2 focus groups). Participants did not feel completely prepared for spiritual assessments; they felt the urge to consult with spiritual providers predominantly for end-of-life situations. Respondents reflected several factors in the provision of spiritual care to patients and their families, such as patient's and/or family's spiritual needs, resources available at an institution, and the nurse's own religious and/or spiritual beliefs. Nurses' perceived role of chaplains overlapped what nurses can offer as part of holistic care, such as listening, praying, and counseling. Yet, participants acknowledged they paid more attention to the physical facets of a patient's illness. Participants noted a need for better system-wide approaches to enhance nurses' capacity for spiritual care, as well as earlier spiritual assessments of patient and family spiritual needs. Future research should address how integration of the spiritual care providers into the care team can improve spiritual support of patients, families, and clinicians.]



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