Experiences of moral distress in a COVID-19 intensive care unit: A qualitative study of nurses and respiratory therapists in the United States.

The COVID-19 pandemic has placed extraordinary stress on frontline healthcare providers as they encounter significant challenges and risks while caring for patients at the bedside. This study used qualitative research methods to explore nurses and respiratory therapists' experiences providing direct care to COVID-19 patients during the first surge of the pandemic at a large academic medical center in the Northeastern United States. The purpose of this study was to explore their experiences as related to changes in staffing models and to consider needs for additional support. Twenty semi-structured interviews were conducted with sixteen nurses and four respiratory therapists via Zoom or by telephone. Interviews were transcribed verbatim, identifiers were removed, and data was coded and analyzed thematically. Five major themes characterize providers' experiences: a fear of the unknown, concerns about infection, perceived professional unpreparedness, isolation and alienation, and inescapable stress and distress. This manuscript analyzes the relationship between these themes and the concept of moral distress and finds that some, but not all, of the challenges that providers faced during this time align with previous definitions of the concept. This points to the possibility of broadening the conceptual parameters of moral distress to account for providers' experiences of treating patients with novel illnesses while encountering institutional and clinical challenges.

The content and effects of interactions with chaplains.

OBJECTIVES: Chaplains provide spiritual care in a variety of settings and are an important part of palliative and supportive care teams. This study aims to describe chaplain interactions from the perspective of the recipients of care. METHODS: The study draws on data from a nationally representative survey conducted by the Gallup Organization in March 2022. RESULTS: Two main groups of recipients were identified: primary recipients and visitors/caregivers. Current typologies of chaplain activities focus on primary recipients of care, but a similar proportion of chaplain interactions takes place with visitors/caregivers. Bivariate analysis was used to compare the experiences of the chaplains' primary recipients of care to other recipients of care and the experiences of visitors/caregivers to other recipients of care. Primary recipients of care were significantly more likely to have religious interactions with the chaplain and to experience the interactions as valuable and helpful. SIGNIFICANCE OF RESULTS: This study is the first to show the groups of people - primary recipients and visitors/caregivers - who receive care from chaplains. It demonstrates how care recipients experience care differently from chaplains based on their position, which has important implications for spiritual care practice.

How Do Healthcare Executives Understand and Make Decisions about Spiritual Care Provision?

OBJECTIVES: This pilot study explores how healthcare leaders understand spiritual care and how that understanding informs staffing and resource decisions. METHODS: This study is based on interviews with 11 healthcare leaders, representing 18 hospitals in 9 systems, conducted between August 2019 and February 2020. RESULTS: Leaders see the value of chaplains in terms of their work supporting staff in tragic situations and during organizational change. They aim to continue to maintain chaplaincy efforts in the midst of challenging economic realities. CONCLUSIONS: Chaplains' interactions with staff alongside patient outcomes are a contributing factor in how resources decisions are made about spiritual care.

Intensive care unit nurses living through COVID-19: A qualitative study.

AIMS: To understand how nurses experience providing care for patients hospitalized with COVID-19 in intensive care units. BACKGROUND: As hospitals adjust staffing patterns to meet the demands of the pandemic, nurses have direct physical contact with ill patients, placing themselves and their families at physical and emotional risk. METHODS: From June to August 2020, semi-structured interviews were conducted. Sixteen nurses caring for COVID-19 patients during the first surge of the pandemic were selected via purposive sampling. Participants worked in ICUs of a quaternary 1,000-bed hospital in the Northeast United States. Interviews were transcribed verbatim, identifiers were removed, and data were coded thematically. RESULTS: Our exploratory study identified four themes that describe the experiences of nurses providing care to patients in COVID-19 ICUs during the first surge: (a) challenges of working with new co-workers and teams, (b) challenges of maintaining existing working relationships, (c) role of nursing leadership in providing information and maintaining morale and (d) the importance of institutional-level acknowledgement of their work. CONCLUSIONS: As the pandemic continues, hospitals should implement nursing staffing models that maintain and strengthen existing relationships to minimize exhaustion and burnout. IMPLICATIONS FOR NURSING MANAGEMENT: To better support nurses, hospital leaders need to account for their experiences caring for COVID-19 patients when making staffing decisions.

The role of religious beliefs in ethics committee consultations for conflict over life-sustaining treatment.

Previous research has suggested that individuals who identify as being more religious request more aggressive medical treatment at end of life. These requests may generate disagreement over life-sustaining treatment (LST). Outside of anecdotal observation, however, the actual role of religion in conflict over LST has been underexplored. Because ethics committees are often consulted to help mediate these conflicts, the ethics consultation experience provides a unique context in which to investigate this question. The purpose of this paper was to examine the ways religion was present in cases involving conflict around LST. Using medical records from ethics consultation cases for conflict over LST in one large academic medical centre, we found that religion can be central to conflict over LST but was also present in two additional ways through (1) religious coping, including a belief in miracles and support from a higher power, and (2) chaplaincy visits. In-hospital mortality was not different between patients with religiously versus non-religiously centred conflict. In our retrospective cohort study, religion played a variety of roles and did not lead to increased treatment intensity or prolong time to death. Ethics consultants and healthcare professionals involved in these cases should be cognisant of the complex ways that religion can manifest in conflict over LST.

What do Non-clergy Spiritual Care Providers Contribute to End of Life Care in Israel? A Qualitative Study.

Spiritual care is an increasingly important component of end of life care. As it emerges in Israel, it is intentionally built on a nonclerical model. Based on interviews with spiritual care providers in Israel, we find that they help patients and families talk about death and say goodbyes. They encourage the wrapping up of unfinished business, offer diverse cultural resources that can provide meaning, and use presence and touch to produce connection. As spiritual care emerges in Israel, providers are working with patients at the end of life in ways they see as quite distinct from rabbis. They offer broad frames of meaning to which patients from a range of religious traditions can connect.

Strategies of emotion management: not just on, but off the job.

Intensive care nurses, like professionals in other intense occupations characterized by high degrees of uncertainty, manage the emotions that result from their work both on and off the job. We focus on the job strategies - calling-in, sharing their experiences with others and engaging in a range of activities oriented to emotional recovery - that 37 intensive care nurses use to manage their emotions off the job. These strategies show how the social organization and division of labor in intensive care units influences nurses' emotional management outside of them and how organizational troubles for hospitals becomes personal ones for staff. They further support theoretical approaches that view emotions as dynamic elements belonging to individuals rather than aspects of people that can be fully appropriated by organizations.

How does the American public interact with chaplains? Evidence from a national survey.

How does the American public understand the term chaplain? What fraction interact with chaplains and in what settings? What is the content of those interactions and do care recipients find them valuable? We answer these questions with data from a nationally representative survey (N = 1096) conducted in March 2022 and interviews with a subset (N = 50) of survey recipients who interacted with chaplains. We find that people in the United States do not have a consistent understanding of the term chaplain. Based on our definition, at least 18% of Americans have interacted with a chaplain. Among those who interacted with a chaplain as defined in the survey, the majority did so through healthcare organizations. Care recipients include people who were ill and their visitors/caregivers. The most common types of support received were prayer, listening and comfort. Overall, survey respondents found chaplains to be moderately or very valuable.

Negotiating health-related uncertainties: biomedical and religious sources of information and support.

This article explores how people experience health-related uncertainties and how they look to biomedical and religious sources of information in response. Data were gathered in a larger project focused on spirituality in everyday life. Respondents were not asked any direct questions about their health or health care, but almost all of the 95 participants brought up the topics in response to other questions. About one-third spoke of being uncertain about some aspect of their health or healthcare. We explore the health-related topics about which people were uncertain and how they looked to biomedical and religious sources of information, most often seeing the religious as a support for the biomedical. We outline the range of ways they experienced God in this process pointing to the multiple complex ways they make sense of health-related uncertainties.

Racial burdens in the work experiences of state-supported Black chaplains.

To understand and improve the experiences of Black chaplains, it is essential to consider how they experience and are integrated into their workplaces. This article draws from interviews with ten Black chaplains in the military and prisons. In light of historic, state-sanctioned, discrimination in these institutions, we ask how these chaplains experience their workplaces racially. All experience racial burdens in the workplace as part of being the first or only Black chaplain or in response to overt racial discrimination. They identify few to no formal workplace efforts to support them as Black chaplains and spoke of resistance to informal efforts that have been tried over the years. State and federal workplaces must recognize the racial burdens Black chaplains' experiences and take action to respond to and support these systemic workplace issues.

Chaplains in federal and state organizations: An institutional note.

Spiritually integrated care that includes collaborations among chaplains, psychologists, and other health care professionals can have a profound effect on people's lives. To facilitate this care, scholars and policy makers need to understand where chaplains work and how they are (or are not) formally a part of institutions, particularly those funded by the state and federal government. This article offers a short history of chaplaincy and provides snapshots about where chaplains work as federal and state employees in three sample states: Massachusetts, Illinois, and California. This institutional perspective is integral to understanding where and how chaplains are staffed and where collaborations are possible. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Chaplains of Color: Histories and Practices.

From the gallows and fields of war to the street and bedside, chaplains of color have been present and instrumental in providing spiritual and emotional support in public and private settings across the United States. Their histories and experiences are not well documented and integrated into the field of spiritual care and chaplaincy, a field often understood as predominantly White, male, and Christian. This article introduces this special issue by offering historical context-particularly for Black chaplains-and naming the key themes that weave through the articles included. Naming the experiences of chaplains of color is a central step in responding to historically grounded racial inequities in the work of chaplaincy and spiritual care in the United States.

Supporting chaplains on the frontlines of the COVID-19 pandemic: A mixed-method practice-based pilot intervention study.

During the coronavirus disease 2019 (COVID-19) pandemic, chaplains have played a pivotal role in patient, family member, and staff care. However, little empirical attention has been given to (a) the potential toll of frontline spiritual care on chaplains' mental health and occupational functioning as well as (b) the development of interventions that can help ameliorate these risks and promote resilience. Using a mixed-method practice-based design, we conducted a pilot study (n = 77) to evaluate a novel spiritually integrated support group intervention for chaplains across multiple industries, which consisted of five Zoom-based sessions cofacilitated by psychotherapists. Participants completed pre- and postintervention measures of traumatic stress, burnout, spiritual/moral struggles, flourishing, resilience, and overall experience in the group. Qualitative findings elucidated the salience of peer support, therapeutic group processes, and key intervention components that warrant further study. Quantitative results indicated significant (a) decreases in burnout and spiritual/moral struggles from pre- to postintervention as well as (b) increases in sense of resilience and flourishing. Findings of this pilot study offer preliminary evidence for the use of a spiritually integrated group model to decrease isolation, address moral and spiritual distress, and promote resilience among chaplains. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Reconsidering detached concern: the case of intensive-care nurses.

The concept of detached concern, as proposed by Renée Fox in Experiment Perilous (1959), is often used in the literature today in a way she did not intend. Rather than viewing detachment and concern as dualities, scholars frequently conceive of them as dichotomous, emphasizing detachment over concern. We reconsider detached concern here through the stories 37 intensive-care nurses told about their most memorable patients. While many described efforts to keep emotionally distant from patients, they also expressed concern for patients they felt connected to, especially those who were a first for them, who were long-term primary patients, who surprised them, or who died. The care nurses provide for these patients is shaped sociologically by their training and institutional contexts and is not an aberration or indicative of their losing control of their feelings. Instead, it is evidence of the dual nature of detached concern and of the importance of viewing the concept as describing more than emotional detachment.

The social significance of chaplains: evidence from a national survey.

How often do people have contact with chaplains? How valuable do they find that contact? We answer these questions with data from a 2019 NORC AmeriSpeaks survey. Twenty-one percent of respondents had contact with a chaplain in the past two-years, 57% in a healthcare setting. The majority find that contact moderately or very valuable. Christians were more likely than non-Christians and respondents with no religion to have contact with chaplains. People of color who were not Christians or had no religion were more likely than their white counterparts to have contact with a chaplain. Those living in the southern and western United States were also more likely than those living in the northeast to have contact with a chaplain. When contact with a chaplain did take place, Christians were more likely than those of no religion to find the contact moderately or very valuable. Respondents from the midwest, south, and west, those who were more educated, and those who were older were also more likely to find contact with a chaplain valuable.

What organizational and business models underlie the provision of spiritual care in healthcare organizations? An initial description and analysis.

Two-thirds of American hospitals have chaplains. This article explores the organizational and business models that underlie how chaplains are integrated into hospitals. Based on interviews with 14 chaplain managers and the 11 healthcare executives to whom they report at 18 hospitals in 9 systems, we identify three central findings. First, there is significant variation in how spiritual care programs are staffed and integrated into their hospitals. Second, executives and chaplain managers see the value of chaplains in terms of their quality of care, reliability and responsivity to emergent patient and staff needs, and clinical training and experience working within a complex environment. Third, few departments rely on empirical data when making decisions about staffing, tending instead to default to the budgetary status quo. These findings provide the basis for a larger more systematic study.

What do chaplains contribute to large academic hospitals? The perspectives of pediatric physicians and chaplains.

This article analyzes interviews with pediatric physicians (N = 30) and chaplains (N = 22) who work at the same large academic medical centers (N = 13). We ask how pediatric physicians understand and work with chaplains and how chaplains describe their own work. We find that physicians see chaplains as part of interdisciplinary medical teams where they perform rituals and support patients and families, especially around death. Chaplains agree but frame their contributions in terms of the perspectives related to wholeness, presence, and healing they bring. Chaplains have a broader sense of what they contribute to patient care than do physicians.

Staff-Care by Chaplains during COVID-19.

The aim of this study was to understand how chaplains delivered spiritual care to staff during the Covid-19 pandemic. The researchers analyzed data collected from an International Survey of Chaplain Activity and Experience during Covid-19 (N = 1657). The findings revealed positive changes that emerged and new practices evolved around the use of technology as useful tools for maintaining contact with staff.

Mapping the healthcare chaplaincy workforce: a baseline description.

Changing U.S. demographics and the growing emphasis on diversity in the healthcare workforce requires professional healthcare chaplains to examine the characteristics of its own workforce. Previous research suggested that chaplains were mainly Caucasian/White and Mainline Protestant. To explore further, this paper presents a baseline sketch of the workforce and identifies important differences among board-certified chaplains (BCCs), certified educators, certified educator candidates (CECs), and clinical pastoral education (CPE) students. Although missing data quickly became the central story of the analysis and thus requires caution in comparison, the preliminary results suggest BCCs and Certified Educators are older and Whiter/more Caucasian than CECs and CPE students. At least one-third of chaplains and Certified Educators identify as Mainline Protestant, but students and CECs reported greater variation in religious affiliation. Chaplains may be similar to users of healthcare and hospitalized persons in terms of gender and race/ethnicity. Recommendations include suggestions for improving the data infrastructure of professional chaplaincy organizations.

Education for professional chaplaincy in the US: mapping current practice in Clinical Pastoral Education (CPE).

In light of questions that have been raised about education for professional healthcare chaplaincy, we examined the skills and knowledge Clinical Pastoral Educators believe students need to perform the essential tasks and responsibilities of a chaplain. At 19 recently re-accredited ACPE centers across the country, we asked educators about the knowledge chaplains need to be effective, the specific content areas they teach, and how didactic education is planned and organized within their programs. Beyond a focus on religious diversity, we found little consensus among educators regarding a core knowledge base that should be taught during CPE. While most respondents in our study recognize the importance of didactic education in preparing students to become chaplains, there is a lack of consistency in didactic curricula across programs. Our findings suggest the need for broader conversation and collaboration among educators, national chaplaincy organizations, and theological schools regarding the goals, priorities, and outcomes of CPE.