June 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
Liberman, T., Kozikowski, A., Carney, M., Kline, M., Axelrud, A., Ofer, A., Rossetti, M. and Pekmezaris, R. "Knowledge, attitudes, and interactions with chaplains and nursing staff outcomes: a survey study." Journal of Religion and Health (2020): online ahead of print, 5/22/20.
SUMMARY and COMMENT: This month's article presents a quantitative, cross-sectional study of nursing staff who have regular contact with a chaplain at an academic, tertiary care hospital in the New York City metropolitan area. Though the sample size is relatively small, this research offers insights into how nurses may perceive and use chaplains, relevant to understanding the potential for chaplains to affect staff-focused outcomes. The study predates the current COVID19 pandemic but may be useful in generating discussion about support to nurses. One of the co-authors is a chaplain: Rabbi Abraham Axelrud, PhD.
The project sought to "investigate whether chaplaincy interaction is associated with decreased employee stress and increased job satisfaction" [MS p. 4] --an area where there has been a paucity of research.
Specifically, we evaluated whether more interaction with a chaplain is associated with: (1) decreased compassion fatigue (two dimensions: job burnout and secondary trauma), (2) decreased perceived stress, and (3) increased job satisfaction. Moreover, we also assessed if respondents' religiosity and spirituality are associated with the frequency of interacting with a chaplain and whether the length of time working in the hospital is associated with awareness, knowledge, attitudes toward and interactions with hospital chaplains. [MS p. 4]
A purposive sample 51 nurses with "routine access to a chaplain through daily rounds" [MS p. 13] answered an anonymous paper survey regarding their experience and sense of chaplains, items from the Perceived Stress Scale and Compassion Fatigue Scale, and demographic questions. The resultant data is quite thoroughly laid out in 5 tables and a figure, and detailed very readably in the text.
Among the findings:
- "The majority (98.0%) of respondents indicated being aware that there are chaplain services in the hospital, but only 56.9% reported knowing what services chaplains provide." [MS p. 5]
- "The majority of respondents appreciate having a chaplain at the hospital (74.5%), and believe chaplains provide spiritual support in the hospital environment to staff (80.4%)." [MS p. 7]
- "When asked whom participants talk with during stressful situations encountered in the hospital, respondents most frequently reported co-workers (74.5%), followed by family (51.0%), and friends (39.2%).... Only 11.8% indicated that they talk with a chaplain during stressful situations." [MS p. 5]
- "Approximately half (52.9%) of participants indicated 'never' when asked how often they talk with a chaplain followed by 'less than once a month' (19.6%) and '2-3 times a week' (11.8%)." [MS pp. 5 and 7]
- "For those that reported talking with a chaplain, the most common duration was '1-5 min' (29.6%)." [MS p. 7] No one reported talking to a chaplain for more then 20 minutes. [--See Table 3, MS p. 9]
- "Regarding importance and helpfulness of talking with chaplains, 39.3% indicated moderately/very important, and 37.3% reported moderately/very helpful. When asked what the reasons for talking with a chaplain are, respondents indicated 'intense situations with patients' (35.6%) and 'personal issues' (15.6%)." [MS p. 7]
- Regarding differences in responses between nurses who had worked at the hospital for more than 10 years vs. less than 10 years, there was no significant difference in terms of awareness and knowledge of chaplaincy services or attitudes toward and interactions with a chaplain, except in one way: "nursing staff with 10 or fewer years of working in the hospital were more likely to never talk with a chaplain compared to those with more than 10 years (43.3% vs. 33.3%)." [MS p. 7, and see also p. 5]
- "[T]here was a significant inverse relationship between the frequency of talking with a chaplain at the hospital and perceived stress...." [MS p. 8]
- "There was...a significant positive relationship between the rated importance of having a chaplain in the hospital to talk to and secondary trauma." [MS pp. 8 and 10]
- "There was a significant positive relationship between how religious participants rated themselves to be and their rated importance of having a chaplain at the hospital that they can talk to...." [MS p. 10, italics added]
- "The more religious participants reported being, the more helpful it was for them to have a chaplain at the hospital" [MS p. 11]. To the survey item, "Chaplain provides assistance for members of the staff who may be struggling with religious issues," 47.1% answered "yes." [--see Table 2, MS p. 8, and also text on pp. 5 and 8] Also, the more spiritual the respondent reported being, the more important and the more helpful it was for them to have a chaplain to talk to [--see MS p. 11], and "the longer on average participants reported their conversations lasting with a chaplain." [MS p. 12]
The authors emphasize in their relatively brief Discussion section [MS pp. 12-13] how, in spite of a strong majority of the nursing staff appreciating having a chaplain at the hospital and believing that chaplains support staff, "very few reported talking with a chaplain during stressful situations at work" [MS p. 13]. This, they suggest, should be a special topic for further research, hopefully with larger sample sizes. They hold in conclusion: "Our study shows that chaplains in hospital settings may...have a unique opportunity to impact nursing staff well-being at work" [MS p. 13], and "improving access to chaplaincy may be a cost-effective means of improving [job] satisfaction" [MS p. 14].
This is a fairly straightforward article with a good deal of data to consider. It's noteworthy that the sample was of nurses who had "routine access to a chaplain through daily rounds" [MS p. 13], which indicates a moderately high level of chaplaincy staffing. In fact, during data collection in 2018, there were three full-time chaplains on staff at the research site (according to a personal communication with the lead author). It would be intriguing to compare the results here with additional research in settings where chaplaincy interaction was less frequent. This reader was intrigued by the finding that 11.8% said they turned to chaplains during stressful situations at work, yet 74.5% reported talking to "co-workers." What might it take for a chaplain to be considered a "co-worker"? Are there other non-nurses on the multidisciplinary/interdisciplinary team who are actually thought of as "co-workers"? Could frequency of interaction play to this sense of colleagueship? Perhaps, however, the most striking finding in this research is that, even though a low percentage of staff seem to be talking personally with chaplains, there was "a significant inverse relationship between the frequency of talking with a chaplain at the hospital and perceived stress" and "a significant positive relationship between the rated importance of having a chaplain in the hospital to talk to and secondary trauma" [MS pp. 8 and 10]. If this finding were to be confirmed and elaborated via further studies, then the role of chaplains for support of nursing might be reinforced not only in terms of the quality of interactions but of the opportunity for frequency of interaction, which would in turn have implications for chaplaincy staffing levels and the practice of chaplains establishing their presence on patient care units. Since the COVID19 pandemic has turned a press spotlight on support of nursing and on the work of chaplains, research connecting the two might be attractive to grant funders. Replication of the present study could be an option, or questions like the ones posed to nurses here could be amended to explore how nurses might perceive a change in their use of chaplains from before the crisis that has overwhelmed hospitals.
The specific relationship between interaction with a chaplain and burnout is given only in Table 4 [MS p. 11], and the relationship with job satisfaction is addressed only as a summary finding. This reader also wondered whether those who sought support from a chaplain tended to be more or less satisfied with their job.
The bibliography contains 32 references.
Suggestions for Use of the Articles for Student Discussion:
Discussion of the article could be preceded by a sharing of chaplains' personal experiences of interacting with nurses: how often do they occur, and are they just with a small group of regulars? How much of the content of these interactions is about intense patient situations, and how much concerns religious struggles (and do these two areas overlap in conversations)? How much time do these interactions generally take? Do the they notice any sort of divide in their interactions by how long a nurse has been at the hospital? Do the chaplains make any systematic effort to be available to staff? The group's practical experiences could then be placed alongside the findings of the study. So, what findings resonate with the group, and do any seem to cut against the group's experience? The results here indicate that nurses tend to speak only briefly with chaplains. What might be ways to optimize the impact of interactions of less than five minutes? If a nurse wanted to talk with a chaplain about work stress and secondary trauma, how knowledgeable do members of the group feel in addressing these issues? What do the chaplains make of the item about "walk[ing] the halls to connect with people who might need spiritual support" [MS p. 8, italics added]? Does this description fit their sense of activity? CPE students might be encouraged to bring verbatims of interactions with staff members. Discussion of this article could be an opportunity to invite in certain hospital staff responsible for nursing education and perhaps Magnet (or similar) certification. Finally, the group could consider how their support to nurses and other staff may have increased or changed in some way because of the COVID19 pandemic.
Related Items of Interest:
I. Our featured article references studies previously highlighted as Articles-of-the-Month, including: Hemming, P., et al., "Chaplains on the medical team..." (December 2017), Cunningham, C. J. L., et al., "Perceptions of chaplains' value and impact within hospital care teams..." (June 2015), and Jeuland, J., et al., "Chaplains working in palliative care..." (March 2017). Additionally, the following research, not mentioned the article, may be of interest:
Aiken, C. C. "Chaplains' support of staff." Dissertation, Doctor on Ministry, Theological School of Drew University, Madison, NJ, 2016. [This qualitative research project involved interviews with staff at Women's & Children's Hospital in Adelaide, South Australia, exploring how they perceived and experienced chaplains' support of them. (From the abstract:) Two major themes are evident. One theme being the support that chaplains provide as part of the institution or organisation such as being part of a team, their educational contribution, their symbolic role and providing support in formal responses to crisis and trauma. The other is the relational role of the chaplains as they utilise spontaneous moments to care, such as conversations in the corridor, being available when needed, making time for coffee and combining this with an inclusive and respectful attitude. Staff members speak of the multi-cultural, multi-faith context and secular nature of the public hospital system, and the ways that chaplains both negotiate this environment and provide respectful and non-judgemental care to patients, their families and staff. They also value that the chaplains offer a different perspective from those of the medical and nursing staff by bringing pastoral and spiritual insights to the conversation. The context of this project is the Australian society with its suspicion of institutions and the church in particular. The patient, family and staff population of the hospital largely comprise a cohort who has little or no church affiliation. Australians speak of spirituality but are suspicious of religion. Yet, in the relational themes that staff members describe is the identification of the hospital as a village or community and the chaplains as the village priest or 'holy man.' Chaplains are also valued for their ability to engage with the spiritual conversations and provide appropriate rituals, blessings and prayers. Staff members overwhelmingly speak of how chaplains support them in their workplace, often in informal and relational ways. Chaplains are valued and appreciated. What began as a story of exclusion concludes with a narrative of inclusion.]
Austin, K., Flory, P., Maguffee, T. and Sneegas, J.
"Nurses' perception of the role of chaplain." Published online, July 2013, as a Special Ministry Project in Fulfillment of the Requirements of Clinical Pastoral Education Residency, Saint Luke's Hospital, Kansas City, Missouri. [This project compared data from 2010 with that from 2013. Among the findings: The majority of nurses (82.3%) stated that chaplains are supportive of nurses in stressful patient/family care situations. This percentage is down from the 2010 study (92.6%). The percentage of nurses who felt that chaplains support nurses by helping with personal and professional concerns declined from 2010 (48.4%) to 2013 (39.6%). Comments from a few nurses indicated a perception that chaplains were not as supportive and present during the night shift. Some nurses commented that they had not experienced chaplains supporting nurses, only patients. The full report of the study is available online.]
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. [Among the findings of this qualitative research involving 31 critical care nurses from a tertiary-care, inner-city academic medical center: Nurses felt that their own spiritual needs should be met in order to offer spiritually based nursing care among patients and their families. Participants repeatedly reported that their personal debriefing sessions with the spiritual care providers helped them deal with unpleasant clinical events in the ICU, but they noted that these sessions are not regularly offered. Participants also emphasized a need to build better preexisting connections and relationships between nurses and chaplains. (This was our January 2017 Article-of-the-Month.)]
Pater, R., Visser, A. and Smeets, W. "A beacon in the storm: competencies of healthcare chaplains in the accident and emergency department." Journal of Healthcare Chaplaincy (2020): published online ahead of print, 2/7/20. [Among the findings of this research from interviews with 14 chaplains and 5 nurses from various hospitals in The Netherlands: The nurses reported that the availability of healthcare chaplains provides them with a greater sense of peace and space for their tasks toward the patient. The article is available online.]
II. One in a series of hour-long webinars sponsored by Transforming Chaplaincy and ACPE is: "Advancing Chaplaincy with Innovative Staff Support Programs," presented on March 28, 2019 by Chick Deegan, Mark Grace, and
Matt Norvell, with a response by Robin Brown-Haithco. It is available on YouTube, and the PowerPoint from it may be downloaded from the Resources section of the ACPE website (--see under the Transforming Chaplaincy subsection). The presentation is informed by:
Edrees, H., Conners, C., Paine, L., Norvell, M., Taylor, H., & Wu, A. "Implementing the RISE second victim support program at the Johns Hopkins Hospital: a case study." BMJ Open (September 30, 2016): 6:e011708 (electronic journal article designation). [(Abstract:) BACKGROUND: Second victims are healthcare workers who experience emotional distress following patient adverse events. Studies indicate the need to develop organisational support programmes for these workers. The RISE (Resilience In Stressful Events) programme was developed at the Johns Hopkins Hospital to provide this support. OBJECTIVE: To describe the development of RISE and evaluate its initial feasibility and subsequent implementation. Programme phases included (1) developing the RISE programme, (2) recruiting and training peer responders, (3) pilot launch in the Department of Paediatrics and (4) hospital-wide implementation. METHODS: Mixed-methods study, including frequency counts of encounters, staff surveys and evaluations by RISE peer responders. Descriptive statistics were used to summarise demographic characteristics and proportions of responses to categorical, Likert and ordinal scales. Qualitative analysis and coding were used to analyse open-ended responses from questionnaires and focus groups. RESULTS: A baseline staff survey found that most staff had experienced an unanticipated adverse event, and most would prefer peer support. A total of 119 calls, involving ~500 individuals, were received in the first 52 months. The majority of calls were from nurses, and very few were related to medical errors (4%). Peer responders reported that the encounters were successful in 88% of cases and 83.3% reported meeting the caller's needs. Low awareness of the programme was a barrier to hospital-wide expansion. However, over the 4 years, the rate of calls increased from ~1-4 calls per month. The programme evolved to accommodate requests for group support. CONCLUSIONS: Hospital staff identified the need for a multidisciplinary peer support programme for second victims. Peer responders reported success in responding to calls, the majority of which were for adverse events rather than for medical errors. The low initial volume of calls emphasises the importance of promoting awareness of the value of emotional support and the availability of the programme.]
III. Our featured research employed the Perceived Stress Scale. It is available online from mindgarden.com.
IV. Though our article pertains to factors of compassion fatigue, burnout, and secondary traumatic stress among nurses, previous Articles-of-the-Month about these phenomena among chaplains may be of interest:
- Case, A. D., Keyes, C. L. M., Huffman, K. F., Sittser, K., Wallace, A., Khatiwoda, P., Parnell, H. E. and Proeschold-Bell, R. J. "Attitudes and behaviors that differentiate clergy with positive mental health from those with burnout." Journal of Prevention and Intervention in the Community 48, no. 1 (January-March 2020): 94-112. [March 2020 Article-of-the-Month]
- Galek, K., Flannelly, K. J., Greene, P. B. and Kudler, T. "Burnout, secondary traumatic stress, and social support." Pastoral Psychology (2011): 60, no. 5 (October 2011): 633-649. [October 2011 Article-of-the-Month]
- Hotchkiss, J. T. and Lesher, R. "Factors predicting burnout among chaplains: compassion satisfaction, organizational factors, and the mediators of mindful self-care and secondary traumatic stress." Journal of Pastoral Care and Counseling 72, no. 2 (June 2018): 86-98. [July 2018 Article-of-the-Month.]
- Yan, G. W. and Beder, J. "Professional quality of life and associated factors among VHA chaplains." Military Medicine 178, no. 6 (June 2013): 638-645. [October 2013 Article-of-the-Month]