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The Nurse-Chaplain-Family Spiritual Care Triad

A Qualitative Study

Sonemanghkara, Rocky; Rozo, Jose Andres; Stutsman, Sonja

doi: 10.1097/CNJ.0000000000000592
Feature: research/practice

ABSTRACT: This qualitative study utilized a phenomenological approach to better understand nurse, chaplain, and family member experiences with the delivery of spiritual services at the end of life in an inpatient intensive care unit. Triadic semistructured interviews (six with the patient's family members, six with nurses, and six with chaplains) were conducted. Family members perceived that the nurses' role was to care for the physical needs of their loved one, whereas chaplains were there to care for the emotional needs of those involved.

Rocky Sonemanghkara, BSN, RN, is a staff nurse in the Medical-Surgical Unit at Clements University Hospital. He served as principal investigator for this study, as part of his neuroscience nursing research fellowship.

Jose Andres Rozo, BSN, RN, is a staff nurse in the Medical Intensive Care Unit at Parkland Memorial Hospital in Dallas, Texas. He served as, Dallas, TX a research mentor.

Sonja Stutzman, PhD, is the clinical research manager, Neuroscience Nursing Research Center, Dallas, Texas, and served as the study's project manager.

The authors declare no conflict of interest.

Accepted by peer-review 8/6/2018.



It is well established that nursing care has a direct impact on patient outcomes. It is reasonable to infer that factors that positively and negatively influence the ability of the nurse to provide patient care will subsequently impact patient outcomes. One element of holistic patient care is the ability of the nurse to provide patients with the appropriate resources, at the right time, to manage their care. For the critically ill or dying patient, spiritual care is often a significant part of resources available (Stahl & Gambrell, 2014), yet may be overlooked as the nurse is focusing on the physical, or other, needs of the patient (Bush & Bruni, 2008). It is important for the nurse to not only understand the availability of these resources, but also to acquire or provide spiritual care resources for the patient or patient's family members in a timely fashion. Little research addresses the family member, chaplain, and nurse experience with interactions when providing in-hospital spiritual care. The purpose of this study is to better understand the experiences of the nurse, chaplain, and family member regarding the delivery of spiritual services in the hospital setting, when death is forthcoming.

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Spirituality can be an important factor to those facing end of life in intensive care units. According to The Joint Commission, (TJC, 2010), providing culturally sensitive care in regard to spiritual needs is important, and often, a chaplain can be of assistance in the delivery of care. Spiritual care historically has been included as an essential component of holistic care (Stahl & Gambrell, 2014), which is especially true in the palliative care literature (Chochinov, 2006; Edwards, Pang, Shiu, & Chan, 2010). However, research is lacking that explores the experiences and interactions of the dynamic relationship between patients' families, nurses, and chaplains.

Spirituality is defined by a variety of terms and has been shown to be important in the delivery of spiritual care (Walker & Breitsameter, 2017). With the perceived notion that chaplains provide spiritual care, the definition of spirituality is often misunderstood, as the word has been used synonymously with the term religion (Hermann, 2001). In prior studies, patients have associated spirituality with relationship to self, relationship to others, relationship to nature and music, relationship with God or a higher being, and one's purpose in life (Edwards et al., 2010). Understanding the definition of spirituality, as well as one's own comfort in providing this care, is also important (Noome, Beneken Genaamd Kolmer, van Leeuwen, Dijkstra, & Vloet, 2016; Noome, Beneken Genaamd Kolmer, van Leeuwen, Dijkstra, & Vloet, 2017; Walker & Breitsameter).

As hospitalized patients begin to seriously consider impending death, it may increase the patient's spiritual engagement. Although chaplains are often seen as the primary source of spiritual support, nurses, social workers, and physicians are also called upon for spiritual support, but these professionals have often not received formal training in providing spiritual care (Bush & Bruni, 2008). Previous literature has shown that when nurses described patients who desired spiritual intervention, specific themes emerged: end-of-life issues, resolutions associated with guilt and hope, and increased need for attention (Canfield et al., 2016). Interventions for comfort include: holding the patient's hand, listening, laughter, prayer, and being present (Chochinov, 2006). Nurses need support to increase comfort in providing spiritual care (Saunders, Harris, & Hale, 2017). Nurses sometimes reach out to pastoral care to support the patient's and family's spiritual needs when they are uncertain of how to appropriately respond (Canfield et al.). Identified barriers to providing spiritual care include lack of communication, environmental factors, and role ambiguity (Narayanasamy & Owens, 2001). Overall, the literature supports the presence of... a discrepancy between identifying patients' needs and responding appropriately.

Little literature has assessed patients' preferences after a spiritual intervention, including the relationship between nursing staff and chaplains (Penman, Oliver, & Harrington, 2009). Research suggests that hospital chaplains work regularly with nurses, although clarification on their symbiotic relationship is not apparent (Bush & Bruni, 2008; Cadge, Calle, & Dillinger, 2011). Nurses and chaplains accomplish the common goal of providing spiritual holistic care by recognizing the patient's needs and responding accordingly. Another element of spiritual care at the end of life is the care provided to family members, especially crucial when death is unexpected. Despite this being a hectic time, there has been a movement toward allowing family presence in all aspects of the patient's care, including resuscitation. Mureau-Haines et al. (2017) elucidated the importance of the spiritual provider as support for dying patients and their families during these difficult times.

In general, if the patient wishes for spiritual care, it should be provided. However, the literature is nearly silent as to how patients, families, nurses, and chaplains can work together to define and determine what a successful spiritual intervention looks like, especially when death is imminent in the hospital setting. This qualitative study explored the lived experience and interactions of patients' families, nurses, and chaplains as a triadic unit, when patients or family request pastoral care interventions in an intensive care unit setting.

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This was a prospective, qualitative study of experiences with the delivery of spiritual care from chaplains and nurses to families of dying patients. Institutional Review Board approval was obtained before seeking informed consent from any participants. A total of six triadic interviews (18 total interviews) were included in this analysis. The study used a phenomenological approach to interviews, coding, and analysis (Merriam & Tisdell, 2015).

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Participants were recruited in a 24-bed hospital medical intensive care unit. First, research team members approached the pastoral care and nursing teams by informing them of the study and securing consent for participation. Second, the research team began to identify potential patient family members who were eligible for the study and approached them for consent.

Chaplains were eligible for the study if they worked full-time and had on-call duties. Chaplaincy students and volunteer chaplains were not included. Registered nurses assigned to work full-time in the medical intensive care unit (MICU) at the time of consent were considered eligible. Nurse interns, nurses in orientation, float pool nurses, and contract nurses were not included. Patient family members were eligible if they spoke English, were willing to be followed up within a 2-week time frame, and their loved ones were either on comfort measures per standard of care in the MICU or their loved ones passed away unexpectedly, and chaplain services were already involved.

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Procedures and data collection

Potential participants were screened daily when the principal investigator (PI) was working at the bedside. On the days when the PI was not on a work shift, the team was asked to contact the PI about potential participants. The study was open for enrollment for 4 months. The study team interviewed clusters of participants. One cluster was defined as the triad of the: 1) patient's family member, 2) nurse, and 3) chaplain. A total of six clusters of interviews (18 interviews total) were completed (see Table 1 for semistructured interview questions). After family member consent was obtained, a research team member completed the semistructured interviews within approximately 2 weeks of the patient's death. Interviewees were asked different initial questions, based on their role. Follow-up questions were asked, based on the answer provided by the participant (Merriam & Tisdell, 2015). All interviews were completed separately and recorded. Thirteen of the 18 interviews were conducted in person (6 nurses, 6 chaplains, and 1 family). The remaining interviews were conducted via phone with family members. Following the recorded interview, a verbatim transcription was completed, changing names to protect confidentiality.

Table 1

Table 1

After each transcription, interviews were read and coded. Codes were then clumped into themes to find comparisons. Reliability and validity were verified by peer review, rich and thick descriptions, and triangulating sources. After individual review of the interview, the analysis continued by finding similar codes across the triadic interview (chaplain, nurse, family member). After the completion of all 18 interviews, codes and themes were formed across roles (chaplain role, nurse role, family member role) and then across all interviews.

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Data analysis

The PI conducted all 18 study interviews. After the first triad of interviews, the PI completed the preliminary coding. The PI and the co-investigator (Co-I) discussed the experience. Following the completion of three triadic interviews, the PI and two other qualitative researchers coded and discussed themes and findings, and additional follow-up questions based on the themes and findings. This served as peer review, thereby increasing the credibility of the development of rich and thick descriptions, which are a support means of generalizability in qualitative research (Merriam & Tisdell, 2015). Triangulation is a form of internal validity (Merriam & Tisdell). The PI triangulated findings with previous literature, observations prior and throughout the study, and feedback provided by the research team members with this and all other interviews.

After the initial review, the PI read and analyzed the interviews individually. The PI developed the initial codes. Then, the triad of interviews was examined to uncover emerging themes and subthemes within each interview. Subsequently, the PI assessed each interview a third time to develop cross-interview and cross-role themes. A second rigor check, involving peer review, rich and thick descriptions, and triangulation, occurred after all interviews and codes were completed by the PI and Co-I. The PI then composed a final summary of codes and themes to present the overview of the data that was agreed upon by the entire study team (Figure 1).

Figure 1

Figure 1

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The PI collected approximately 156 minutes of interviews and asked each participant to describe his/her interactions and experiences with the spiritual care team in regard to the patient's care, other parties in the triad, and his/her experience of the care provided. In the six triadic clusters, the chaplains visited with the patient and their family members twice due to a palliative care consultation, once by request of the family after comfort care was initiated, once by casual causation, and twice by responding to the initiation of a code blue. Chaplain intervention ranged anywhere from 10 minutes to a few hours, depending on the family's need. Each chaplain also mentioned that if a strong relationship was formed, he/she would follow up every other day while the patient was hospitalized. Through the process of data coding, several themes emerged: 1) roles and interventions, 2) implications of nurses' definition of spirituality, and 3) communication: obstacles and time constraints. The most salient theme encountered across the interviews was roles and interventions.

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Roles and interventions

The general observation of the care provided by nursing staff and chaplain services was seen as positive by the interviewed families. Each party reported that they perceived the nurses' main priority was the physical well-being of the patient, which ranged from helping the patient to be physically free from pain to resuscitation. Nursing comfort interventions included opioid administration, dimming the lights in the patient's room, inserting an indwelling Foley catheter, ensuring the patient was clean and presentable, reducing stimuli in the room (e.g., clustering care), and initiating of comfort measures (i.e., removing unnecessary lines, drains, airway adjuncts, and monitors).

Direct interventions between the nurses and patient's family were less frequent in comparison to the relationship between chaplains and family members. However, the primary intervention to ensure the patient and family were at peace, mentioned across interviews, was arranging a bereavement cart with beverages and snacks for family members. One nurse stated that the bereavement cart served as relaxation and comfort for the family. Other nursing interventions included supportive care to the patient and family, conveying empathy and sympathy, allowing family members to stay in the room, and assisting with tasks (e.g., packing up the patient's belongings, finding a funeral home).

Chaplains, nurses, and family members described the chaplains' role as one of emotional support of the family. Chaplain interventions included prayer, active and reflective listening, physical presence, guiding the patient's family through what was happening (e.g., in a code blue), using supportive language, keeping the patient's family member(s) calm in a time of crisis, therapeutic touch, and if needed, providing tangible items for comfort, which were consistent with previous literature (Chochinov, 2006).

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Implication of nurse definition of spirituality

Overall, nurses reported that spirituality is the quality of engagement in one's emotional well-being when dealing with end-of-life issues. One nurse stated that she sees “spirituality [as a] belief that there is something that is bigger than you. I don't know that you necessarily have to believe in a strict religion to feel like you are a spiritual person. [Nurses should be] open to the interpretation of spirituality.” Another nurse stated, “Spiritual care means to tend to the spiritual or religious needs of those affected by illness or those that are experiencing grief or loss.” Having this working definition is consistent with previous literature provided by Bush and Bruni (2008) that stated that the understanding of one's spiritual connection assisted in helping others to construct meaning around the difficulty of death. This working definition may also aid the nurse in identifying times when the patient or patient's family would like spiritual intervention but is unsure of how to initiate this process (Hermann, 2001; Noome et al., 2017). Eighty-three percent of the nurses in this study reported that when discussing death with a family member, they also inquired about initiation of chaplaincy services. Nurses also reported that chaplaincy services were initiated through the personal request of the patient, a family member, or as a request by the nurse.

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Communication: Obstacles and time constraints

A theme that emerged as a need from all three members of the triad (chaplain-to-nurse, nurse-to-chaplain, and clinician-to-family) was improved communication (Figure 1). Chaplains and nurses were consistent in reporting that nurses most commonly initiated chaplain services when death was imminent. Chaplains stated that earlier initiation of their services would assist in alleviating stress at the time of death. One chaplain explained that the palliative care team could come immediately, as that team has a system for urgent calls. This may also be helpful for intensive care units and may be improved by implementing communication between the interdisciplinary teams (Narayanasamy & Owens, 2001).

As a different chaplain reflected on the care she provided for a patient, she mentioned the gaps in care that could have been prevented if the healthcare team listened more:

“The one thing that all of us can do more is listen. Sometimes, the small things that they say like shaving really means a lot to them and... I missed that and didn't realize how important that was until I heard her voice the morning he passed. I really got it that, that was extremely important to her and sometimes, we just don't listen, and we don't hear the small voice that the family has in regard to their need, because we have our agenda.”

She also stated that she felt she could have communicated better with the nurse to respond to the needs of the patient and his family. This chaplain interview highlighted the risk for gaps in care, due to lack of communication between caregivers. However, most nurses interviewed expressed that they tend to build rapport with chaplains and trust in their abilities to provide holistic care.

Another issue involved the availability of chaplains during off times, including night shift and weekends. A night-shift nurse stated that she often did not involve chaplaincy services because there was no chaplain available in-house. She stated it would be an inconvenience because it could take the on-call chaplain up to 2 hours to arrive and/or the patient's family member(s) would be gone before intervention could happen. One chaplain stated that chaplains “[get] so busy... doing a medical power of attorney, advanced directive, [and] notary stuff... that [they] get short on actually providing care.” One family member mentioned that “it took [the chaplain] a long time to come up, but other than that, you know, usually, every time we called on them, they were pretty readily available.” The availability of adequate means to provide spiritual care is there, but improvements can be made to better fulfill the needs of patients and their families.

A chaplain discussed a model for palliative care that seemed to work well: the palliative care chaplain is notified as part of the initiation of the palliative care protocol, and this model would be helpful to use with patients throughout the hospital. A consistent undertone of initiating a protocol for calling on chaplains in times of patient need was evident from both nurses and chaplains in this study. Five of the six chaplain interviews included reports that palliative care protocols work well, yet there was a disconnect in how to initiate these within the general hospital population. Although nurses have previously reported varying levels of comfort in providing spiritual care, nurses in this study suggested that a protocol designed to include chaplain services during end of life may alleviate overall issues for the nurse.

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The dynamic relationship between chaplains, nurses, and family members remains critically vital to holistic care (The Joint Commission, 2010). The lived experiences of nurses, chaplains, and family members are impacted by the implications of nursing definitions of spiritual care, perceived roles, interventions used, and overcoming communication and timing obstacles. Based on this study, nurses who have a working definition of spirituality can relate, communicate, and assist in the process of spiritual care. In addition, findings support that a successful spiritual care intervention involves strong communication between the chaplain and nurse about the family needs, chaplain availability during urgent times (e.g., code blue) when death is imminent, and a clear definition of roles between the nurse and chaplain when death is imminent. The team would benefit from coordinating a plan of care between intensive care unit nurses and chaplains. Furthermore, the earlier this plan of care was initiated, the less strain for the nurse, chaplain, and family occurred. Although most nurses feel comfortable in providing support to the family, careful consideration should be given toward early chaplaincy involvement during hospitalization (Canfield et al., 2016).

During the patient dying process, nurses tend to lean on chaplains to address the emotional needs of the family. This allows nurses to focus on the patient's physical needs. Family members have shown significant gratitude for services provided by clinical staff when addressing their immediate needs, while simultaneously caring for the patient.

As reported by the interviewees, overall improvements that may help facilitate care include: a) timely initial consultation by pastoral care; b) verbally communicating needs; and c) being readily available. Addressing these concerns may help with future situations that hold the same context. This research has created a basis of inquiry for quality improvement in the hospital environment.

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As with all qualitative research, the information presented may not be generalizable and is designed to be hypothesis-generating. This study was based on experiences from one hospital, from one unit, which presents bias. The authors recognize that interviews were conducted with patients identified from a single hospital, and the experiences of patients from other hospitals, especially ones that have a protocol for spiritual care, may be different. Additionally, as participants had different roles and experiences, they were asked different questions, which can present some bias. The results of this study are not intended to be used as general practice, but to evoke additional research and quality improvement questions that can aid in assisting nurses, chaplains, patients, and patients' family members, when end of life is near for the patient.

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End-of-life care of patients in a hospital setting is unique for all involved. Perceptions of how events occurred or experiences of those involved vary. This qualitative inquiry study showed that roles and interventions, implications of nurses' definition of spirituality, and communication obstacles and time constraints, are critical elements to lessening stress at the end of life. Interviewees reported that spiritual distress might be challenging to identify, which can create a situation of urgent need for a patient or family member, and which causes additional stress for all involved in caring for the patient. Through better communication and clearly assigned roles, pressure may be lessened.

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The authors thank Dr. DaiWai Olson for his guidance and mentorship in this project and also thank the nurses, chaplains, and family members who participated in interviews.

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chaplain; end of life; nursing; research; spiritual care triad; spirituality

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