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March 2007 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Cavendish, R., Edelman, M., Naradovy, L., McPartlan Bajo, M., Perosi, I. and Lanza, M. [City University of New York: College of Staten Island, Kingsborough Community College, and New York City College of Technology]. "Do pastoral care providers recognize nurses as spiritual care providers?" Holistic Nursing Practice 21, no. 2 (March/April 2007): 89-98.


COMMENT and SUMMARY: The value of research articles can be as much or more in the questions they raise as in the results they report. From this reader's perspective, this is certainly the case with this month's featured article, which presents findings that are "not generalizable" [p. 89, abstract] but which poses a pertinent question for chaplains. Emphasis on spirituality in health care in recent years has, in nursing circles, encouraged nurses to attend to patient spiritual issues--sometimes by referral to chaplains and other clergy, yet often by directly providing spiritual interventions. In the words of Cavendish, et al., "Nurses are prepared to provide spiritual care, and the provision of spiritual care is within their scope of practice" [p. 90]. So, do chaplains recognize nurses as spiritual care providers? The answer would seem to inform the working relationship between the two disciplines.

The six researchers here come entirely from the field of nursing. In fact, they "comprise the Research Committee" [p. 91] of a chapter of the Sigma Theta Tau International Honor Society of Nursing. Their subjects were eight full-time, experienced chaplains: five male, three female; five Catholic, two protestant, one Jewish; all White [--see table 2, p. 92]. Interviews using fourteen open-ended questions/probes lasted 30-60 minutes and were audiotaped and transcribed for qualitative analysis. The authors claim that data saturation was achieved in these eight interviews.

The interview questions/probes fall generally into three categories: one set asking about how these chaplains understood and defined spirituality and spiritual care and how they assessed for spiritual needs, one set asking about what the authors call "Interdisciplinary Spiritual Care Committees" (for which a reference is given to a brief 1997 essay by Larry VandeCreek [--see Related Items of Interest, below], who never uses the term), and one set--of immediate interest--asking the following:

  • Do you see the nurse as a provider of spiritual care? (If the response is, "No," ask, "What makes you say that?" If "Yes," continue to [the following question].)
  • How do you think that nurses might provide for spiritual as opposed to physical comfort?
  • Are you comfortable asking the nurse to assist patients with their spiritual care? (If the response is "No," ask, "What makes you say that?" If "Yes," continue to [the following question].)
  • Can you tell me more about that and provide an example from your experience?

Responses to this latter set of questions, indicated:

Pastoral care providers do perceive the nurse as a provider of spiritual care but few were comfortable asking the nurse to assist with patients' spiritual care. The primary reasons stated by the pastoral care providers for this lack of comfort included not knowing the nurses on a personal level, how they would react to such a request, or whether they were personally inclined to want to provide spiritual care, and observing that nurses are more involved in technology. A request for assistance would only be made if the chaplain were certain of a nurse's response because the nurse's attitude was learned from repeated interactions over time. From one pastoral care provider's perception, there are no clear nursing spiritual care activities that meet a patient's human responses in the spiritual domain. [p.96]

This specific area of questioning begs for further study, perhaps using the very same questions. The authors give illustrative quotes to the question about comfort/discomfort in asking nurses to provide spiritual care [--see especially the table on p. 95] but do not go further in analyzing chaplains' hesitancy about asking for assistance. This would be a relatively easy topic to pick up for chaplain researchers. Are there age or age cohort patterns to these attitudes in chaplains? The sample here is weighted toward older chaplains. Are these attitudes influenced by chaplains' religious traditions? Are concerns about nurses rooted in issues of pastoral competence or professional turf? When chaplains concede that nurses provide "spiritual care," do they use that language more loosely or more narrowly than they do when they think of their own provision of care (such that there may be ambiguity that needs to be teased out with additional questions)? How do chaplains feel about the fact that nurses are nowadays taught and increasingly urged in the nursing literature to provide spiritual care? Chaplains have long talked about the resistance that we meet in health care, but there is need to explore what sort of resistance we bring to interdisciplinary collaboration. That goes far beyond the scope of our present article, but Cavendish and her colleagues inspire these further questions.

A final comment must be made about the article as a whole: this reader found some of it irritatingly cursory in its snapshot of chaplaincy, especially in its assertions and generalizations under the heading of The Pastoral Care Provider's Role [pp. 90-91]. It appears that the authors' understanding of chaplaincy came primarily from the website of the National Association of Catholic Chaplains and from Wikipedia! This is an article that chaplains should be aware, is currently being read by nurses, and that pastoral care researchers should be aware presents some questions worthy of follow-up; but it is an article with some serious weakness.


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

The article should be used cautiously with students, for reason of the aforementioned weakness, but may still be used productively. Students could be asked to consider how they feel about being talked about by the nurse researchers here and whether they think the authors' method and findings have suffered from the apparent lack of involvement of chaplain researchers or advisors. If so, what might this tell them about how they--as chaplains--may look at or investigate other disciplines. Students could also be challenged to think about how the findings of chaplains' views and utilization of nurses for spiritual care resonate with them. How would they answer the core questions put to the subjects in the study? Do they see nurses as provides of spiritual care? How do they feel about collaborating with nurses? Finally, the article could open up discussion about collaboration itself and what strategies, structures, rules, and initiatives may foster more productive interdisciplinary efforts.


Related Items of Interest: 

Cavendish, R. "Response by Cavendish." Western Journal of Nursing Research 26, no. 2 (March 2004): 219-221. [In this author's reply to comments by others to an article about nurses' spiritual perspectives that appears in this same journal issue, Cavendish mentions "interdisciplinary spiritual care committees" (p. 219), and gives here as a reference: Matzo, M. L. and Witt Sherman, D., Palliative Care Nursing: Quality Care to the End of Life (New York: Springer, 2001).]

Cavendish, R., Konecny, L., Naradovy, L., Luise, B. K., Como, J., Okumakpeyi, P., Mitzeliotis, C. and Lanza, M. "Patients' perceptions of spirituality and the nurse as a spiritual care provider." Holistic Nursing Practice 20, no. 1 (January-February 2006): 41-47. [(Abstract:) This qualitative study explored patients' perceptions of spirituality and of the nurse as a spiritual care provider. Semi-structured interviews were conducted with 8 adults older than 21, who were living at home, and had been discharged from the hospital within the past 3 months having had at least a 5-day length of stay. Participants agreed that during their hospitalization, nurses were kind and caring but these behaviors were not perceived as spiritual care. Study findings suggest that patients do not perceive spiritual care within the role of nursing and therefore they did not share their spiritual concerns with nurses. Study findings are limited by sample size; however, implications for practice are that nurses need to be aware of a patient's spiritual needs to provide spiritual care.]

Emblen, J. D. and Halstead, L. "Spiritual needs and interventions: comparing the views of patients, nurses, and chaplains." Clinical Nurse Specialist 7, no. 4 (July 1993): 175-182. [This often-cited older qualitative study of 19 surgical patients, 12 nurses, and 7 chaplains focuses on definitions of spirituality and on identification of spiritual interventions to meet patients' needs. "Respondents identified five common nursing interventions: prayer, scripture, presence, listening, and referral" (--from the abstract).]

Grant, D. "Spiritual interventions: how, when, and why nurses use them." Holistic Nursing Practice 18, no. 1 (January/February 2004): 36–41. [In this study of a large, southwestern, university hospital (with an active CPE program), 299 of the 597 nurses there completed a survey. A majority of respondents indicated that they had recommended or employed as spiritual therapies "holding a patient's hand, listening, laughing, prayer, and being present with a patient" (p. 39). The authors present their findings in detail in several tables.]

McEwen, M. "Spiritual Nursing care: state of the art." Holistic Nursing Practice 19, no. 4 (July/August 2005): 161–168. [This review article covers nurses' spiritual assessment, diagnosis, and interventions, with emphasis on the research literature. See especially Table 1: Barriers to Spiritual Nursing Care (p. 152) and Table 2: Spiritual Nursing Interventions (p. 164). The author states that "spiritual nursing care…is a responsibility, not an optional extra," asserting that "referral (e.g., to a hospital chaplain)…does not constitute spiritual care" --"Rather, spiritual care should involve (1) assessment; (2) nursing diagnosis; (3) nursing interventions; and (4) monitoring outcomes" (p. 163). The bibliography contains 75 references.]

Stranahan, S. "Spiritual perception, attitudes about spiritual care, and spiritual care practices among nurse practitioners." Western Journal of Nursing Research 23, no. 1 (February 2001): 90-104. [Among the findings from this survey of nurse practitioners licensed in Indiana (a 40% return rate from a sample of 269) were that 57% said they rarely or never provided spiritual care, but 18% said that they did so every day; 45% said indicated that their ability to provide spiritual care was weak or limited, yet 25% indicated that they believed their ability was strong and comprehensive; and 33% said they were uncomfortable providing spiritual care, while 31% said they were very comfortable. "The most frequently practiced spiritual intervention was praying privately for a patient followed by referring a patient to clergy or religious leaders. Respondents seemed more likely to practice interventions that did not require them to be noticeably or directly involved in a spiritual care intervention with a patient." (See p. 97.) When specifically asked about referral to a chaplain, 49% said "rarely," 33.3% said "sometimes," 11.8% said "often," and 1% said "always."]

US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing. Nurse Practitioner Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric, and Women’s Health [HRSA Contract 00–0532(P) with the National Organization of Nurse Practitioner Faculties]." Rockville, MD: HRSA, April 2002. [This consensus report lists under the domain of Cultural Competence six Spiritual Competencies: "1) Respects the inherent worth and dignity of each person and the right to express spiritual beliefs as part of his/her humanity; 2) Assists patients and families to meet their spiritual needs in the context of health and illness experiences, including referral for pastoral services; 3) Assesses the influence of patient’s spirituality on his/her health care behaviors and practices; 4) Incorporates patients' spiritual beliefs in the plan of care appropriately; 5) Provides appropriate information and opportunity for patients and families to discuss their wishes for end of life decision-making and care; 6) Respects wishes of patients and families regarding expression of spiritual beliefs" (p. 48). Note that the second competency indicates that spiritual interventions may not be limited to pastoral referral.]

VandeCreek, L. "Collaboration between nurses and chaplains for spiritual caregiving." Seminars in Oncology Nursing 13, no. 4 (November 1997): 279-280. [This brief essay observes, from a chaplain's perspective, areas of ambiguity affecting collaboration between chaplains and nurses: namely, "confusion about the meaning of 'spiritual' and related terms, spiritual assessment and the referral process, and the role of clergy" (p. 279, abstract). The author offers practical suggestions to nurses and recommends Guidelines for Pastoral Services that were published in 1993 by the Association for Community Cancer Centers --the nine guidelines are reprinted here (p. 280). The first of these guidelines is: "Pastoral care is supervised by a qualified clinical chaplain with adequate education…." The author acknowledges that nurses have a role in the spiritual care of patients, but he generally emphasizes the role of chaplains/clergy as primary.]

[Added 10/31/07:] Wallace, M. and O'Shea, E. "Perceptions of spirituality and spiritual care among older nursing home residents at the end of life." Holistic Nursing Practice 21, no. 6 (November/December 2007): 285-289, with a continuing education text on pp. 290-291. [This research out of the Yale University School of Nursing surveyed 26 residents at 2 faith-based nursing homes "to better understand residents’ spirituality and perception of spiritual care" (abstract, p. 285). "The results indicate that residents in both faith-based nursing facilities had broad perspectives on how they felt nurses could help promote their spiritual health" (p. 287). Eight nursing interventions are identified: arranging visits with religious personnel, showing kindness, spending time listening with residents (presence), showing respect for resident’s needs, supporting friendships, supporting need for forgiveness, playing music, and facilitating time with nature (--see Table 2 on p. 288). The researchers used the Spirituality and Spiritual Care Rating Scale (SSCRS), which is discussed in the Methods section (p. 287).]


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