October 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 Trippon, M. "What chaplains wish nurses knew: findings from an online survey." Holistic Nursing Practice 34, no. 5 (September/October 2020): 266-273.
[This article may be purchased from the publisher, Wolters Kluwer Health, Inc..]
SUMMARY and COMMENT: This month's selection follows up on material presented in our January 2020 Article-of-the-Month by the same lead author, Elizabeth Johnston Taylor. Whereas the earlier publication focused on quantitative data about "Healthcare chaplains' perspectives on nurse-chaplain collaboration...," the report at hand offers qualitative findings that fill out a picture of how chaplains wish to be understood by interdisciplinary colleagues. The drive behind this is the expectation that "[b]y understanding each other's perspectives, nurses and chaplains can better collaborate" [p. 268]. The article may be especially useful to newer chaplaincy students getting started in the academic year as a challenge both to be aware of how others may perceive a chaplain's role and to be clear within oneself about that role.
Data were solicited by email invitations to members of the Association of Professional Chaplains to complete an online survey, for which they would receive a $20 Amazon promotional code. (For more on the overall methodology, see also the earlier study publication.) Response was quick, with 295 chaplains submitting usable data within the first four hours. Results presented here address the following questions [--see p. 269]:
- How often do you sense nurses creating resistance (or "gatekeeping") to your work? ...and... What are your thoughts about why this resistance exists? [297 responses]
- What 3 things should a nurse understand about chaplains? [262 responses]
- And the final question on the survey: What else do you want nurses to know about collaborating with chaplains? [249 responses]
Among the findings:
- Regarding the gatekeeping issue, 48.5% of participants indicated they sensed this only rarely or never, but "half of [the] chaplains reported they did experience gatekeeping at least occasionally," including 5% who said they encountered this often. [--see p. 269]
- As to why nurses may act as gatekeepers toward chaplains, "[t]he most common themes related to the chaplains' perceptions that nurses lack knowledge or understanding about the role and abilities of chaplains" [p. 269]. For instance, nurses may not appreciate chaplains as trained professionals, may not see them as part of the interdisciplinary team, may fear they will evangelize of be judgmental, may believe that chaplains only work with patients of their own religion, or may otherwise have a very narrow sense of the chaplain's role for religious concerns at he the end-of-life. [--See Table 1, p. 270.]
- One subtheme related to the idea that nurses may "overstep their role" [p. 269] as spiritual care providers themselves, potentially interfering with chaplains' duties around such things as spiritual assessments. Lesser subthemes on the issue of nurses' gatekeeping revolved around nurses' "personal religiosity or spirituality inhibiting collaboration... (e.g., 'Sometimes nurses don't value spiritual care because it is not a part of their life')" [p. 269].
- Some respondents speculated that nurses may have fears of chaplains' involvement because of poor previous experiences with chaplains or worries that patients may complain to chaplains about the nurse or will "gang up" with the chaplain over against the nurse. One respondent suggested that nurses may fear that a chaplain will upset patients by bringing up sensitive topics like grief. [--See Table 1, p. 270.]
- The authors found that chaplains were "eager to affirm nurses and collaborate with them" [p. 269]. They emphasize the eagerness of chaplains on this front, using the descriptor several times [--see pp. 269 and 272] along with such language as "deep enthusiasm" [p. 272].
Of special interest is the authors' summary of responses of What Else Do You Want Nurses to Know about Collaborating with Chaplains, presented as Table 2 [p. 271]:
This table is used by permission of Wolters Kluwer Health, Inc.
The audience for this article is nurses, and Taylor and Trippon make a couple of points to them that may be instructive for chaplains to keep in mind as well. For example, the authors comment that the lack of understanding about chaplains by clinical colleagues can be complicated by the reality that "clinicians typically perceive they do know about chaplain training and roles --even when they do not..." [p. 271]. Likewise, how much of chaplains' knowledge about other disciplines may be based on presumption? Also, the authors observe that "[a]lthough nurses recognize the import of spiritual self-awareness as a requisite for therapeutic spiritual care, nurses rarely acknowledge their potential for causing spiritual harm, such as when subtly coercing personal religious beliefs or offering unrequested spiritual advice" [p. 271]. Do chaplains sufficiently acknowledge their own potential for causing spiritual harm? That thought spurs this reader to wonder if the risk of this is greater among newer chaplains who lack experience but for whom the concern may be salient through recent CPE programming, or among older chaplains whose experience grounds their proficiency but whose very sense of proficiency may in turn dull a caution about risks. And further, the authors exhort nurses to pay attention and analyze the moments when they feel a need to "protect a patient from a chaplain" [p. 271]. Chaplains might take the moments when they feel a need to "advocate" [p. 271] for a patient as triggers for analyzing the impulse. The article may be aimed at nurses, but there's a lot here for chaplains.
Limitations for the study include the scope of merely three key questions near the end of a larger online survey, and the authors comment that "[r]icher data might be collected during face-to-face semistructured interviews" [p. 172]. Moreover, they astutely note that the question of "gatekeeping" may have biased responses to questions that followed it. (Each question -- indeed each word -- in a questionnaire steers the reader by some form of meaning and thus leads the person taking it in some way, hopefully along a line that draws out information as cleanly as possible but always potentially along a line that is counterproductive.)
Taylor and Trippon put forward here useful information to promote better communication and collaboration between chaplains and nurses. Along the way, they make a case that "nurses ought to recognize the added value of having these spiritual care specialists on the team" [p. 172]. The most immediate implication for this research would seem to revolve around improving referrals and the quality of patient care, but building close working relationships across interdisciplinary teams surely also holds advantages for the very work-life experience of all the team. This chaplain reader was ultimately left thinking about the authors' emphasis on the eagerness of chaplains to be known by, and to work with, nurses --that such relationship building doesn't just make work more efficient and productive, it likely makes it more enjoyable.
Suggestions for Use of the Article for Student Discussion:
This article could be timely for use in the early months of a CPE program, when students are actively engaging in issues of multidisciplinary relationships and professional role clarity (and identity), but it could be useful also for more advanced students and staff chaplains. It comes at the subject matter from a nurse's perspective, but it should be easy to connect the dots of the data to chaplains' own perspectives, since the data is from chaplains. Discussion could begin with a brainstorming session, perhaps with the use of a whiteboard to record ideas, about what the group wishes nurses knew about them. This could draw the group into the article, but at the end of the session the group could return to reexamine their own list n order to recognize which thoughts aligned with the article data and which might point in new directions beyond it. Moving to the article itself, the group might be asked about their sense of nurses as spiritual care generalists vis-a-vis themselves as spiritual care specialists. Then, the group could take up the question about gatekeeping. Have they experienced this? In what ways? Table 1 [p. 270] could be the focus of attention here, noting the items of greater frequency but not discounting the potential significance of the items that are marked as less frequent. Then, the group could look closely at Table 2 [p. 271] for additional themes that could be explored by the question of how to help nurses understand the various items and to work with greater communication and collaboration. It may be insightful for the chaplains to share when and how they themselves may have felt protective of patients, and what may be at play in them when this happens. Another point of discussion could be how the responses from the participant chaplains suggest an eagerness to work with nurses yet may still indicate a limited vision of what this could entail. For example, while the authors note that nurses and chaplains might have face-to-face debriefings after a visit or might otherwise huddle around a case [--see p. 271], the idea of nurses asking patients if they want a chaplain's visit is juxtaposed with the idea of allowing chaplains to take the initiative themselves to explore a patient's receptivity, but there could be other options, including the nurse introducing the chaplain or the nurse and chaplain going together to explore a patient's receptivity for spiritual care [--and see §IV, below]. How might chaplains think creatively of partnering more dynamically with nurses in patient care? Finally, if the group happens to consist of experienced chaplains, there might be opportunity to use the article for a joint discussion with nurses. Such a session, however, should also include the chance for nurses to say what they wish chaplains knew about them.
Related Items of Interest:
I. Our authors worked from a "motivated convenience sample" [p. 269], using a $20 Amazon gift card as an incentive for completing the online questionnaire. Incentives of monetary value have long been used to increase participation in surveys, though the effectiveness of this strategy with different study populations at different times is not entirely clear, and there may be trends of changes over time as well. Chaplain new to research who are considering some sort of incentive as part of a survey project might want to begin by reading the short description of options from online survey services like SurveyMonkey or Gallup. While the research literature on incentive methodology per se often requires some extrapolation in order to connect with spirituality research, chaplains may be served by browsing at least the introductory sections of publications like the following:
Asire, A. M. "A meta-analysis of the effects of incentives on response rate in online survey studies." Masters Thesis, University of Denver (June 2017): [Available online through Digital Commons. [(Abstract:) Meta-analysis was used to investigate the effect of incentives on response rates of web-based survey studies. Whereas numerous meta-analyses that address the effect of incentives on increasing response rates in survey studies are available in the literature, these analyses are based on mail surveys, so there is a need for an applied meta-analysis to examine the effect of incentives on response rates in online survey studies. A meta-analysis of an online method of survey administration was used because the use of online surveys has greatly increased, making web-based survey administration an important form of data collection in multiple fields of research. Out of 12 located experimental published studies, nine studies met the selection criteria. Log-odds ratio (OR) was chosen as the main effect size estimator. The result of the heterogeneity Q test showed a statistically significant heterogeneity among these studies around the mean effect size Odds Ratio = 1.72, Q (18) =70.16, p < .0001. Sample size, participants' description, number of reminders, and type and amount of incentives were investigated as potential moderators. The results indicate significant differences between groups, based on amount of incentives, which means that it was a significant predictor of effect size, p < 0.05. No evidence was found for relationship between response rate and sample size, participants' description, number of reminders, or type of incentives. Finally, sensitivity analysis related to dependence in the sample is discussed.]
DeCamp, W. and Manierre, M. J. "'Money will solve the problem': testing the effectiveness of conditional incentives for online surveys." Survey Practice 9, no. 1 (January 31, 2016): online article available at https://doi.org/10.29115/SP-2016-0003. [(Abstract:) In conducting surveys, incentivizing participation through the use of cash or other rewards has often been used to encourage participation. This is often done with the hopes of increasing response rates and, therefore, representativeness of the responding sample as well. The effectiveness of incentives has generally been shown to be positive, but results have been mixed for conditional incentives and for online surveys. Using an experimental design and leverage-salience theory, the survey uses a random sample of full-time undergraduate students to estimate group differences. Both official and self-report data are utilized to assess various social statistics. Participants were randomly assigned to one of three different groups, which determined whether they were offered five dollars, two dollars, or nothing for their participation. Results indicate that a five-dollar conditional reward credited to students' campus ID card account does increase participation rates, which does improve the representativeness of the sample by reducing differences in GPA and gender proportions. The difference in representativeness, however, does not appear to significantly bias substantive conclusions.]
Ulrich, C. M. Danis, M., Koziol, D., Garrett-Mayer, E., Ryan Hubbard, R. and Grady, C. "Does it pay to pay? A randomized trial of prepaid financial incentives and lottery incentives in surveys of nonphysician healthcare professionals." Nursing Research 54 no. 3 (May/June 2005): 178-183. [Available online.] [BACKGROUND: Monetary incentives in survey research may provide important gains from a methodological perspective in the control and reduction of survey error associated with potential nonresponse of participants. However, few studies have systematically investigated the use of monetary incentives or other methods to improve the response rates in the nonphysician clinician population. OBJECTIVE: To investigate differences in response rates to a mailed self-administered survey of nonphysician clinicians who were randomized to receive a prepaid monetary incentive, a postsurvey prize drawing, or no incentive. METHODS: A randomized controlled trial of financial incentives was conducted from November 2002 to February 2003. Nonphysician clinicians (nurse practitioners [NPs] and physician assistants [PAs]; N = 3,900) randomly selected to participate in a national ethics-related study were assigned randomly in equal allocations (n = 1,300 [650 NPs, 650 PAs]) to three incentive groups: (a) no incentive; (b) a $5 prepaid token incentive in the initial mailing; or (c) a chance to win one of ten $100 prize drawings upon completion and return of a self-administered survey. RESULTS: A $5 cash incentive increased survey response rates to an adjusted 64.2%: a 19.5 percentage point increase over the lottery group (44.7% response rate), and a 22 percentage point increase over the control group (42.2% response rate). DISCUSSION: A nominal cash incentive of $5 yields a significantly higher response rate from nonphysician providers than receiving either a lottery option or no incentive.]
Yu, S., Alper, H. E., Nguyen, A-M., Brackbill, R. M., Turner, L., Walker, D. J., Maslow, C. B. and Zweig, K. C. "The effectiveness of a monetary incentive offer on survey response rates and response completeness in a longitudinal study." BMC Medical research Methodology 17( 2017): 77 [electronic journal article designation]. [Available online from the journal.] [(Abstract:) BACKGROUND: Achieving adequate response rates is an ongoing challenge for longitudinal studies. The World Trade Center Health Registry is a longitudinal health study that periodically surveys a cohort of ~71,000 people exposed to the 9/11 terrorist attacks in New York City. Since Wave 1, the Registry has conducted three follow-up surveys (Waves 2-4) every 3-4 years and utilized various strategies to increase survey participation. A promised monetary incentive was offered for the first time to survey non-respondents in the recent Wave 4 survey, conducted 13-14 years after 9/11. METHODS: We evaluated the effectiveness of a monetary incentive in improving the response rate five months after survey launch, and assessed whether or not response completeness was compromised due to incentive use. The study compared the likelihood of returning a survey for those who received an incentive offer to those who did not, using logistic regression models. Among those who returned surveys, we also examined whether those receiving an incentive notification had higher rate of response completeness than those who did not, using negative binomial regression models and logistic regression models. RESULTS: We found that a $10 monetary incentive offer was effective in increasing Wave 4 response rates. Specifically, the $10 incentive offer was useful in encouraging initially reluctant participants to respond to the survey. The likelihood of returning a survey increased by 30% for those who received an incentive offer (AOR = 1.3, 95% CI: 1.1, 1.4), and the incentive increased the number of returned surveys by 18%. Moreover, our results did not reveal any significant differences on response completeness between those who received an incentive offer and those who did not.]
II. Our featured article uses the language of spiritual care "generalists" and "specialists" [--see p. 266, 271, and 272]. The concepts have played into various Article-of-the-Month features, but see especially the page for August 2016, addressing the work of Mary R. Robinson, Mary Martha Thiel, and Elaine C. Meyer.
III. One concern of chaplains that is mentioned a few times in the article is the misconception that chaplains only work with religious individuals. For material about chaplains' work with non-religious patients, see the following resources by ACPE Educator Mary Martha Thiel, which appeared in the January 2016 issue of PlainViews [vol. 13, no. 1]:
IV. Some research has suggested models for collaboration with physicians that could inform options for collaboration with nurses, including having physicians introduce the chaplain to the patient, and even joint visits.
Glombicki, J. S. and Jeuland, J. "Exploring the importance of chaplain visits in a palliative care clinic for patients and companions." Journal of Palliative Medicine 17, no. 2 (February 2014): 131-132. [Data were obtained from 21 outpatients and 12 of their companions during clinic visits. Among the findings: patients and their companions valued a chaplain's visit as part of their "overall visit" (average of 3.93 on a 5-point scale). If a medical provider introduced the patient or companion to the chaplain, the chaplain's visit was rated at an average of 4.38 vs. 3.43 for when there was no such introduction. Also, "Data suggested that 12.82 minutes was considered 'enough' time for an outpatient visit, challenging previous studies' hypotheses that SRE [i.e., spiritual, religious, existential] support in outpatient settings may be difficult due to complexity of providing SRE with limited time" [p. 131]. Analysis of comments by the patients and companions also suggested a handful of themes regarding how chaplains were positively valued: chaplain visits are different from other fields, the visits were helpful in the expression of thoughts and feelings, the visits were generally valuable in the outpatient setting, the visits give an additional layer of support, and the visits communicate encouragement. Illustrative quotes are given in a table on p. 131.]
Gomez-Castillo, B. J., Hirsch, R., Groninger, H., Baker, K., Cheng, M. J., Phillips, J., Pollack, J. and Berger, A. M. "Increasing the number of outpatients receiving spiritual assessment: a Pain and Palliative Care Service quality improvement project." Journal of Pain and Symptom Management 50, no. 5 (November 2015): 724-729. [(Abstract:) BACKGROUND: Spirituality is a patient need that requires special attention from the Pain and Palliative Care Service team. This quality improvement project aimed to provide spiritual assessment for all new outpatients with serious life-altering illnesses. MEASURES: Percentage of new outpatients receiving spiritual assessment (Faith, Importance/Influence, Community, Address/Action in care, psychosocial evaluation, chaplain consults) at baseline and postinterventions. INTERVENTION: Interventions included encouraging clinicians to incorporate adequate spiritual assessment into patient care and implementing chaplain covisits for all initial outpatient visits. OUTCOMES: The quality improvement interventions increased spiritual assessment (baseline vs. postinterventions): chaplain covisits (25.5% vs. 50%), Faith, Importance/Influence, Community, Address/Action in care completion (49% vs. 72%), and psychosocial evaluation (89% vs. 94%). CONCLUSIONS/LESSONS LEARNED: Improved spiritual assessment in an outpatient palliative care clinic setting can occur with a multidisciplinary approach. This project also identifies data collection and documentation processes that can be targeted for improvement.] [This article was our November 2015 Article-of-the-Month.]
V. Lead author Elizabeth Johnston Taylor publishes regularly on spirituality & health, and a number of her recent articles can be found in the Related Items of Interest section of our January 2020 Article-of-the-Month (§III). In addition, her most recent work as part of a research team should be of special note to chaplains with regard to supporting nurses:
Ada, H. M., Dehom, S., D'Errico, E., Boyd, K. and Taylor, E. J. "Sanctification of work and hospital nurse employment outcomes: an observational study." Journal of Nursing Management (2020): online ahead of print, 9/22/20. [(Abstract:) AIM: To explore nurse ascriptions of sacredness to work and measure its association with the employment outcomes of job satisfaction, burnout, organisational commitment, employee engagement and turnover intention. BACKGROUND: High portions of hospital nurses experience burnout. Many factors contributing to burnout also contribute to job dissatisfaction and other negative employment outcomes. Personal factors, such as religiosity, help nurses to cope with work. METHODS: Questionnaires measuring study variables were distributed to all nursing personnel at a faith-based hospital in Los Angeles; 463 responded. Regression analyses allowed measurement of how sacredness ascribed to work (measured by Sanctification of Work Scale) and religiosity (measured by Duke Religiosity Index) were associated with the various employment outcomes. RESULTS: Sanctification of work consistently was found to be associated with less burnout and intention to leave, and more job satisfaction, employee engagement and organisational commitment. CONCLUSION: The sacredness with which a nurse views work explains, in part, positive employment outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Nurturing a sense of sacredness for work in nurses may provide them with an internal buffer against negative employment outcomes. Suggestions for creating rituals and educating nurses are offered.]