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September 2022 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


Klitzman, R., Al-Hashimi, J., Di Sapia Natarelli, G., Garbuzova, E. and Sinnappan, S. "How hospital chaplains develop and use rituals to address medical staff distress." SSM -- Qualitative Research in Health 328, no. 2 (December 2022): 2:100087 [electronic journal article designation].

[This is an open access article, available freely online .]

SUMMARY and COMMENT: Rituals, in words and actions that are intentionally set and to some degree formalized, provide structures for meaning-making that are especially valuable for navigating distress, individually and socially. The present study out of Columbia University explores how healthcare chaplains "often develop various practices that appear to take the form of rituals" [p. 7], in the context of supporting hospital staff. There is much here that will resonate with chaplains and validate personal experience, but also a good deal to generate thought about what constitutes ritual, its function, and its application in our discipline. The authors encourage chaplains to share and to learn from one another's creativity, so the results here are well suited for professional dialogue. This research may also be useful to raise institutional awareness of the breadth of chaplains' effectiveness.

Principal author Robert Klitzman, MD, Professor of Psychiatry at Columbia University's Vagelos College of Physicians and Surgeons conducted formal, semi-structured, hour-long telephone interviews with a sample of 21 board-certified chaplains who were "from throughout the U.S. and represented diverse religions" [p. 2, and see Related Items of Interest, §I, below]. Data collection occurred during 2020-2022 [--from a personal communication with the principal author rather than the article text]. Twelve chaplains were interviewed more than once, "since some interviewees responded at greater length than did others to the questions posed" [p. 2]. The research team chose a qualitative approach to "best elicit the full range and typologies of attitudes, interactions and practices involved," and they recruited participants "through the listservs of the Association of Professional Chaplains and through word of mouth" [p. 2]. There were 33 interview sessions in total, before data saturation seemed to have been reached (--NOTE: the text contains a typo at one point, stating that there were only 31 interviews). The authors give a good description of their analytical method based upon grounded theory and involving a process of constant comparison [--see p. 3].

The study found that...

...chaplains not only engage in traditional religious activities with patients (e.g., praying) but at times also create their own innovative, new kinds of rituals for staff as well that vary in both form and content, specifically in timing (e.g., in frequency), audience, size and formality, and in goals. These rituals help families and staff cope with death, grief, and other stresses. [p. 3]

Results are laid out according to a number of characteristics, with each illustrated by participant quotes. Among the findings:

  • When?
Participants spoke of situations of death, including multiple deaths and the recent circumstances of the COVID-19 pandemic. One chaplain offered an example:
When a patient has died, it is impossible to walk out of the room for the last time. Everyone stands around. The attending usually comes and says, "I'm so sorry. Your daughter was wonderful." The parents say, "What do we do now?" When the family is getting ready to leave, I come in and say, "Before you say goodbye for the last time, would you like to pray again?" [p. 3]
The chaplains indicated that "[d]octors at times join these rituals, though may do so less commonly than nurses" [p. 3], and the leadership of the chaplain can create opportunity for a physician both to join in and to take leave of the gathering. Chaplains also recognized how their work regarding occasions of single or multiple deaths can have a "diffusing" or "debriefing" quality [p. 3]. Another chaplain described a practice of providing short staff sessions in response to the COVID-19 pandemic that were "almost like a debriefing" [p. 3] --sessions that subsequently were adapted to oncology contexts at the hospital. "These events can probe physical, emotional, and spiritual aspects of staff experiences" [p. 3].

  • How large and for whom?
"The various rituals chaplains hold for staff vary in size from involving just a single staff member to including many, depending on perceptions of staff needs" [p. 4]. Examples given describe an adaptation of the Code Lavender initiative (out of the Cleveland Clinic), a memorial service with the entire staff who cared for a patient (including the ambulance team), and a program called Refreshment for the Soul that involved transforming a conference room into a space with soft lighting, soft music, and some aromatherapy, where staff could eat and talk with one another and the chaplain. Study participants also brought up debriefings specifically for hospital administrators.

  • How often and for how long?
While some rituals pertained to single events, others became recurrent because of ongoing needs. One chaplain remembered a periodic session called What Matters at the End of the Day: "We did it at the end of the rotation for medical residents in neonatal intensive care, the pediatric intensive care and pediatric oncology -- the units most likely to have serious illness or death" [p. 5]. "At times, chaplains have initiated such activities in conjunction with one or more staff members who may have felt unhelped by clergy or others they have approached" [p. 5]. Initiatives could also entail brief interactions, and one chaplain developed a simple ritual of engaging individual staff while handing out Hershey Kisses:
"Hi, are you in need of chocolate today?" They say, "Yes! I'm absolutely in need of chocolate today." I then say, "I just wanted to thank you for all that you've been doing. I know it's been rough lately." Sometimes they'll say, "Yeah, it has been rough!" "Really?" I ask. "What's been the hardest part about it for you?" "Last week we had three codes and five deaths -- three of them were unexpected." Chocolate Rounds have been very successful.
  • With what structure
Respondents spoke of a range in structure and leadership of ritual events. For group sessions supporting administrators, there had been monthly themes, introduced by "a poem, a video, an article, something to get the conversation going" [p. 5]. For other groups, "All we have to say is, 'What case is keeping you up at night?'" [p. 5]
In the Refreshment for the Soul sessions mentioned above..., the sessions are free-form: "Staff are welcome to come and go, and we're available to talk...." Chocolate rounds, described above..., involves both verbal and gestural, non-verbal structures, offering, giving and taking of chocolate, followed by a general question about coping. [p. 5]
  • What goals and content?
Ideas shared around goals and content are presented in terms of exploring emotions, reframing experiences, making commemorative objects, and physical and mental relaxation. Chaplain-organized group events can "help staff reflect on the emotional and existential, not just medical, aspects of difficult cases" [p. 5]. "...[R]ituals can also help families and providers reframe their experiences and regrets, especially after a patient has died, establishing a helpful sense of community in the face of apparent sheer loss" [p. 5]. For instance, in the course of a ritual event, a chaplain might help distressed staff to "remember why they entered healthcare in the first place, and connect to that purpose" [p. 6]. Sometimes, chaplains can organize activities incorporating commemorative objects, ranging from written prayers to wreaths tied with ribbons memorializing patients who have died: "If the ICU is busy, I won't do a group session, but take the wreath door-to-door and say, 'I've got a memory wreath. Would you like to remember anybody?'" [p. 6]. Such rituals can be flexibly enacted, and respondents indicated they had become increasingly useful during the COVID-19 pandemic, helping staff to honor losses of relatives and co-workers as well as patients. And, "[c]haplains...draw on relaxation, behavioral and psychotherapeutic approaches, reconnecting [staff] with more positive feelings they've had" [p. 6]. One chaplain told of an intervention whereby a staff member was asked to identify where physically a feeling of stress seemed to be located and to reflect upon that.

In addition, the sample of chaplains offered thoughts on institutional contexts and challenges, like resistance from hospital leaders. Time pressures in the healthcare environment can alone be problematic for staff buy-in to what chaplains have to offer: "I have to care for the patients, so I don't have time to talk to you'" [p. 7]. Moreover, "Many hospital administrators and others also resist, minimize or dismiss staff needs for these activities" [p. 7]:

I tried doing [a group session] on the ICU with nurses. The nursing director said, "They don't need that. We just tell them, 'Suck it up. This is how it is.'" [p. 7]
"Within the long-standing hierarchy of hospital wards, the participation of staff may depend on the specific chaplain's status, related to length of time on the ward and earned respect" [p. 7].
I've been there long enough now that I'm respected and know the intensive care unit and the oncology attendings, so they're comfort- able with me and know I'm ok. I'm not going to make anybody un- comfortable by being too preachy or religious, even though I'm religious -- I'm a priest. [p. 7]
On this last point, the authors comment that "a key element in both starting and continuing...rituals over time may be the level of trust the individual chaplain has established with staff, which appears related partly to the length of time the chaplain has worked on the particular service, and the type of service (with hospice and palliative care services appearing, overall, to appreciate chaplains more)" [p. 8].

In sum,

"...[t]he present data reveal how individual chaplains...devise, on their own, ...rituals that vary in both form and content -- in frequency, duration, number and types of staff, degrees of formality or informality, structure and aims. Chaplains tend to conduct these rituals on their own initiative. ...Such interventions are especially important since the COVID-19 pandemic has added stresses for countless physicians and nurses" [p. 7].

The authors see practical implications for this research for education, practice, and future study.

These data...suggest needs to increase awareness of the potential benefits of such rituals among doctors, nurses, hospital administrators, chaplains and others, and to assist chaplains in recognizing the advantages and potential ways of devising such practices. Importantly, documentation of the types of forms and contents of such examples, as done here, can potentially assist. Creative development, use, and sharing of these varied activities should also be encouraged, so that others can gain from them.
Continued investigation in this area calls especially for larger samples of chaplains that "can further elucidate these issues and factors that may be involved" [p. 8].

This article should drive good discussion about the nature and place of rituals in chaplaincy and in the work of individual chaplains who might themselves overlook the ritual dynamics of their less ritually-obvious activities. This reader would offer two comments, however. First, the sample questions given for the semi-structured interviews [--see Table 2 on p. 3], do not appear to prime the respondents on a theme of death (except that it might be implicit in a question about COVID-19). So, it seems curious that the data so heavily emphasize circumstances of death. What, for instance, of how chaplains may employ ritual to address staff stress that results from the retirement of key leaders and colleagues, from the physical move of offices and units, from the economic and regulatory pressures of modern healthcare, or from the now commonplace threats of violence from patients and families? Such other foci hold great potential for qualitative exploration. Second, I would call out one specific word choice in the article, because it is likely to raise eyebrows among chaplain readers: in the section on when chaplains perform rituals, the authors refer to a "pivotal point of transition from battling to save a patient's life to suddenly giving up and accepting death" [p. 3]. While that might describe the experience of some people, the very language of "giving up" is problematic in end-of-life care.

The inclusion of a thorough figure [Figure 1, p. 4] outlining the study's central findings makes the clearly organized text even more user-friendly. The bibliography is quite current, including eight references from 2021 and five from 2022.


Suggestions for Use of the Article for Student Discussion: 

This article should be easily readable by students at any level of CPE and be appropriate even early in a program, as a way to think about the subject of ritual and the actions of chaplaincy. The many quotes/examples from study participants are engaging and elucidating, and students might be encouraged to pay close attention to them in order to see how in many cases chaplains use ritual to provide space for staff to take a lead (in contrast to a use of ritual that might have the effect of placing everyone but the chaplain leader in a passive position). Discussion could begin with a brief check-in to make sure that the group understands the basic process of qualitative methodology and the concept of data saturation in grounded theory [--see Related Items of Interest, §VI, below]. Then, perhaps, the group could brainstorm about all the various ways they use ritual in their work, in high-profile and low-profile ways, and someone could note them on a board. This should generate a significant list quickly. Does the list itself reveal any predilections for how the group thinks about ritual? Do the rituals revolve around certain circumstances or themes (like death/dying)? How many of the rituals are directed toward work with staff distress? In light of all this, the group could turn to the article's findings. What examples of ritual in the study stand out to the students, and are there any ideas new to them here? The group might look especially at the section on Goals and Content [pp. 5-6]. Does the educator or others have concerns about any of the interventions suggested in the findings, and what of the need to tailor interventions to particular contexts/settings? The potential importance of the development of staff-chaplain relationships and trust might be considered, particularly for students new to an institution. Finally, what rituals do the students use consciously for themselves?


Related Items of Interest:

I.  This is the same sample used by the research team for our June 2022 Article-of-the-Month: "Hospital chaplains' communication with patients: characteristics, functions and potential benefits." (See that page for other work by Robert Klitzman.)


II.  Our authors comment at a number of points on how staff may be pressed for time and how hindering that factor may be to their participation in chaplains' interventions. With this is mind, see also our November 2021 Article-of-the-Month and the evidence there that not only are staff very busy, but they may be generally inclined primarily to seek support only from resources convenient and familiar to them, like colleagues who are nearby.

Muehlhausen, B. L "Spirituality and vicarious trauma among trauma clinicians: a qualitative study." Journal of Trauma Nursing 28, no. 6 (November-December 2021): 367-377. [Among the findings of this study of 36 physicians, nurse practitioners, and physician assistants were that some staff had negative reaction to formal debriefing sessions, preferring opportunities to process experiences individually with trusted others, in the moment or immediately following their shift -- made by the physical proximity of colleagues. Without the ease of convenience, personnel may not prioritize debriefing.] [This article is available freely online from the journal.]


III.  In light of participants' sharing about the experience of Chocolate Rounds [--see p. 5], the following article should be of interest.

Callis, A., Cacciata, M., Wickman, M. and Choi, J. "An effective in-hospital chaplaincy-led care program for nurses: Tea for the Soul, a qualitative investigation." Journal of Health Care Chaplaincy (2021): online ahead of print, 6/24/21. [(Abstract:) Tea for the Soul (TFS) is an understudied care model, addressing bereavement and other emotional needs of nurses related to impactful patient care experiences. Nurses are at high risk for compassion fatigue, moral distress, and burnout. Facilitated by a Chaplain, the TFS program provides participants a venue to express their feelings and explore ways of adapting effectively with the death of a patient, and other traumatic workplace experiences. In this qualitative grounded theory study, hospital nurses (N = 7) who participated in TFS were interviewed. IRB approval was obtained. Questions were constructed within the context of the medical center research council and asked if TFS: (a) was personally beneficial, (b) helped nurses feel better about their work, and (c) affected job satisfaction. Four core themes emerged: (a) Nurses' Self-Care, (b) Professional Practice, (c) Community, and (d) Improved Patient Care Outcomes. The Roy Adaptation Model, Group Identity Mode was applied to the content analysis. Overarching themes were Compassionate Service, Ministry of Presence, Reflective Practice, and Sacred Encounters. Nurses reported that TFS facilitated a spiritual respite and a sense of enhanced community and was a source of strength and coping, thus may aid in the promotion of nurse well-being and the amelioration of moral distress, compassion fatigue, and burnout.]


IV.  Our May 2016 Article-of-the-Month presented a debriefing process developed by nurses and originally led by a chaplain, for use following resuscitations and trauma responses.

Copeland, D. and Liska, H. "Implementation of a Post-Code Pause: extending post-event debriefing to include silence." Journal of Trauma Nursing 23, no. 2 (March-April 2016): 58-64. [(Abstract:) This project arose out of a need to address two issues at our hospital: we lacked a formal debriefing process for code/trauma events and the emergency department wanted to address the psychological and spiritual needs of code/trauma responders. We developed a debriefing process for code/trauma events that intentionally included mechanisms to facilitate recognition, acknowledgment, and, when needed, responses to the psychological and spiritual needs of responders. A post-code pause process was implemented in the emergency department with the aims of standardizing a debriefing process, encouraging a supportive team-based culture, improving transition back to "normal" activities after responding to code/trauma events, and providing responders an opportunity to express reverence for patients involved in code/trauma events. The post-code pause process incorporates a moment of silence and the addition of two simple questions to a traditional operational debrief. Implementation of post-code pauses was feasible despite the fast paced nature of the department. At the end of the 1-year pilot period, staff members reported increases in feeling supported by peers and leaders, their ability to pay homage to patients, and having time to regroup prior to returning to their assignment. There was a decrease in the number of respondents reporting having thoughts or feelings associated with the event within 24 hr. The pauses create a mechanism for operational team debriefing, provide an opportunity for staff members to honor their work and their patients, and support an environment in which the psychological and spiritual effects of responding to code/trauma events can be acknowledged.]


V.  Our featured article mentions numerous times the Code Lavender initiative at the Cleveland Clinic, and they give the reference: Stone, R. S. B., (2018), "Code Lavender: a tool for staff support," Nursing 48, no. 4 (2018): 15-17 [which is available freely online]. The program is also highlighted on the Cleveland Clinic website and in the Newsletter of the Association for Patient Experience. And see further:

Davidson, J. E., Graham, P., Montross-Thomas, L., Norcross, W. and Zerbi, G. "Code Lavender: cultivating intentional acts of kindness in response to stressful work situations." Explore: The Journal of Science & Healing 13, no. 3 (May-June 2017): 181-185. [(Abstract:) CONTEXT: Providing healthcare can be stressful. Gone unchecked, clinicians may experience decreased compassion, and increased burnout or secondary traumatic stress. Code Lavender is designed to increase acts of kindness after stressful workplace events occur. OBJECTIVE/INTERVENTION: To test the feasibility of providing Code Lavender. HYPOTHESES: After stressful events in the workplace, staff will provide, receive, and recommend Code Lavender to others. The provision of Code Lavender will improve Professional Quality of Life Scale (ProQoL) scores, general job satisfaction, and feeling cared for in the workplace. METHOD/SAMPLE: Pilot program testing and evaluation. Staff and physicians on four hospital units were informed of the Code Lavender kit availability, which includes words of comfort, chocolate, lavender essential oil, and employee health referral information. Feasibility data and ProQoL scores were collected at baseline and three months. RESULTS: At baseline, 48% (n = 164) reported a stressful event at work in the last three months. Post-intervention, 51% reported experiencing a stressful workplace event, with 32% receiving a Code Lavender kit from their co-workers as a result (n = 83). Of those who received the Code Lavender intervention; 100% found it helpful, and 84% would recommend it to others. No significant changes were demonstrated before and after the intervention in ProQoL scores or job satisfaction, however the emotion of feeling cared-for improved. CONCLUSIONS: Results warrant continuation and further dissemination of Code Lavender. Investigators have received requests to expand the program implying positive reception of the intervention. Additional interventions are needed to overcome workplace stressors. A more intense peer support program is being tested.]

For Code Lavender's implementation at other institutions, specifically mentioning the involvement of chaplains, see examples from Indiana University Health (Indianapolis, IN), Penn Medicine Princeton Health (Plainsboro, NJ), Stoney Brook Medicine (Stony Brook, NY), and the Carilion Clinic (Roanoke, VA).


VI.  For more on the subject of data saturation in the methodology of grounded theory, see:

Aldiabat, K. M. and Le Navenec, C. "Data saturation: the mysterious step in grounded theory method." The Qualitative Report 23, no. 1 (2018): 245-261. [(Abstract:) The aim of this paper is to provide a discussion that is broad in both depth and breadth, about the concept of data saturation in Grounded Theory. It is expected that this knowledge will provide a helpful resource for (a) the novice researcher using a Grounded Theory approach, or for (b) graduate students currently enrolled in a qualitative research course, and for (c) instructors who teach or supervise qualitative research projects. The following topics are discussed in this paper: (1) definition of data saturation in Grounded Theory (GT); (2) factors pertaining to data saturation; (3) factors that hinder data saturation; (4) the relationship between theoretical sampling and data saturation; (5) the relationship between constant comparative and data saturation; and (6) illustrative examples of strategies used during data collection to maximize the components of rigor that Yonge and Stewin (1988) described as Credibility, Transferability or Fittingness, Dependability or Auditability, and Confirmability.] [This article is available freely online.]



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