Spiritual Care Person Centred Care

The Scottish Journal of Healthcare Chaplaincy Vol 16 (special) 2013
Spiritual care as person centred care: a

thematic analysis of interventions
Authors: Austyn Snowden, Iain Telfer, Ewan Kelly, Suzanne Bunniss & Harriet Mowat.
What we know already
The Lothian PROM has shown us that chaplaincy benefitted all in this sample not just the faithful,
religious or spiritual. However, this deduction arose from statistical analysis of tick box responses in
the previous paper. Whilst this is a powerful finding we do not understand the deeper meaning of this
in relation to how chaplains could better target their time, or better use the time they have with
patients.
What this paper adds
This paper adds depth and context to the findings in the previous paper. It analyses responses to the
free text question: Please add any final comments you wish to make about how the chaplains input
affected you. The results illuminate and explain not just the correlations established in the numerical
analysis but also provide solid evidence that chaplains deliver person centred care. The importance of
this observation to the NHS in particular cannot be overstated.
Why this is important.
The finding that the responses articulated person centred care is particularly valuable in light of:
a) the policy imperative to deliver person centred care
b) the growing recognition of the complexity of this agenda, and
c) its consistency with the findings from CCL discussed in the following papers in this special edition of
SACH.
How this impacts upon chaplaincy
The comments analysed here add explanatory depth to the statistical evidence of the impact of
chaplaincy. They show the personal value of chaplaincy to a wide range of people. In particular they
show the importance of having someone other than a clinician wholly present with people to be with
them in testing times.
Key Words: Chaplaincy, health care, person centred care, impact of chaplaincy, chaplaincy
interventions, PROM
23

Background
The background, ethics, process and
participants are identical to the previous
paper. This paper describes responses from
39 patients.
content validity by crosschecking where free

text comments added depth to existing items,
and where they did not, thereby highlighting
where responses fell outside this framework.
If any free text fell outside the framework this
could mean we had failed to capture all
salient aspects of chaplaincy encounter within
the quantitative items of the PROM. If this
was the case then we could amend future
iterations too account for these omissions.
This process was supported by NVivo9
software, and final interpretation was
checked and agreed by all members of the
research team.
Method
Responses to the invitation Please add any
final comments you wish to make about how
the chaplains input affected you were
thematically analysed using a framework
method (Smith & Firth 2011). The framework
was provided by the questionnaire items in
the PROM (table 1). Each item was created as
a node in NVivo in order to code content at
the appropriate node. An other node was
created to capture free text comments not
covered by the existing PROM items. The
rationale for this method was to establish
Items from the Lothian PROM used as coding framework
During my meeting with the chaplain I felt:
I was listened to.
We focused on decisions about my/my relatives/friends health care.
I was able to talk about what was on my mind.
My situation was understood and acknowledged.
My faith and/or beliefs were valued
After meeting with the chaplain:
I could be honest with myself about how I was really feeling.
My levels of anxiety had lessened.
I had gained a better perspective on my illness/the illness of my relative/friend.
Things seemed under control again.
A sense of peace I had not felt before.
Statements that describe me now:
I see myself as a spiritual person.
I believe in God or in some Higher Being.
I am a religious person.
I feel a need to experience love and belonging.
I feel a need to find meaning and purpose in life.
I feel a need to be hopeful.
I feel I have something to be hopeful about.
I feel I am in control of my situation.
Other codes not covered by items above: please specify
Table 1. Framework for thematic analysis of responses to the invitation Please add any final
comments you wish to make about how the chaplains input affected you
Results
The main finding from a validation perspective was
that the free text comments only raised one issue not
captured within the body of the questionnaire. This
pertained to the special contribution of having a non
medical person to talk to and will be discussed

presently. Rather, on the whole they added depth to
the quantitative findings by explaining context and
offering rich detail. For example, although the PROM
item I was listened to, explained a lot of the free text
24

loss of his twin. [Chaplain] was very respectful of our
beliefs and wishes.(A32)
in terms of coding density, the narrative of these

responses offered specific instances of the impact and
importance of this, allowing for detailed thematic
analysis. In other words, although the primary
purpose of this exercise was to establish the content
validity of the PROM (Streiner & Norman, 2008), the
depth of narrative allowed for a discrete thematic
analysis. The main themes identified in this analysis
were:
This snapshot of the obvious importance of the

service to people of different faiths would suggest
that screening referral to chaplaincy using faith alone
would be appropriate for those of religious nature,
but would exclude people for whom the service is
clearly very valuable. That is, chaplaincy is an essential
service for religious people, but in these cases just as
important for the non religious. This is consistent with
the wider literature as Mowat & Swinton (2007) show.
Chaplains in this study were equivalently valued by
people across the spectrum of faith.
The significance of religion,

Grateful recognition of the unique skills of the
chaplains (the guide through the gruesome),
Unmet needs in routine hospital care,
The need for peaceful resolution to hideous
time.
The unmet needs of routine hospital care

Many participants referred to having needs that could
not be met by clinical staff in hospital. They described
how important a non clinical person is in meeting
these needs:
These themes are interrelated. However for ease of

discussion they are discussed here in turn.
The significance of religion.
Three respondents described the importance of their
religious needs in their comments, referring to the
chaplain as a source of meeting these needs.
Examples are given below.
I most enjoyed having someone non-medical to talk to

and the support of her prayers. (P5)
[Chaplain] has an understanding of both [illness and
spirituality], but she makes it clear that she is not
there to address my illness, more to give me a
listening ear and she does make helpful suggestions,
which I can use. She was especially helpful during an
extended period of absence from church. (MH2)
As a Christian my need was totally met by the

chaplaincy person who read from my Bible for me as I
was not well enough to do this for myself. This was
the greatest service that they could do for me.(A5)
helped lift my spirit [and] made to feel more like a

friend than patient I would highly recommend the
service to others in my situation who are far from
home in hospital with no one(A4)
I have been a Christian since I was youngster and old

enough to understand. We talked about family; she
asked how my son was coping with situation. She was
very kind and I valued her visits immensely. I think it is
a wonderful service. (A6)
The comments point to a distinct and necessary

service uniquely delivered by chaplains in these cases.
I have an excellent CPN, but she is not familiar with

Christian beliefs and experiences even though she sees
the value of them in my life. [Chaplain] has an
understanding of both.(MH2)
Grateful recognition of the unique skills of the

chaplains (the guide through the gruesome)
Many people who responded were grateful for their
treatment and so took this opportunity to express
that gratitude:
Conversely religion was not significant in many

encounters. For example one participant spoke of the
functional benefits of the chaplains in supporting
diverse beliefs:
I always felt that while my mother had [chaplain]

looking after her spiritual needs, she had a good friend
and, if I was perfectly honest, an angel on earth to
look after her. I can't really give anyone higher praise
than that! (A2)
[Chaplain] was very patient with us and took time to

explain and offer suggestions as to how we could
respectfully mark the birth of our baby boy and the
25

[We] decided to get our son christened when he
became very ill, the nurses organised for the chaplain
to come and it was all done with such ease and grace
at a time of utter despair for us. So I can't thank him
enough for the peace of mind he has given us now
knowing [our son] was christened before he passed
away.(P6)
evidence for this claim. For example one respondent

referred to the chaplains timing as just the right call,
suggesting important sensitivity to that persons
individual needs. The capacity to intervene without
intruding, visit but not overstay was gratefully
portrayed by P5:
[Chaplain] was very supportive, friendly a great
listener and encourager. She was never intrusive only helpful. She visited regularly and I always felt she
made just the right call with how often to call by and
for how long. (P5)
This theme had the most comments, suggesting that

the respondents were pleased to have the
opportunity to thank the chaplain. However, the
detail of the comments allowed for further
investigation into what the people were grateful for.
For example the gratitude expressed often entailed
describing the skilled presence of the chaplain (ease
and grace) in guiding them through unknown and
unwanted times (despair). The necessity of this
function was summarized eloquently by A10:
This sensitivity to individual needs entails practical

aspects. For example the discussion of time and the
importance of sharing it with someone knowledgeable
and interested in them was also mentioned by others:
My time with the chaplain was generally the only time
I got to think about myself. (P3)
[Chaplaincy is] a vital service which is a must in that

most gruesome environment of the intensive care
ward (A10)
The chaplain has always listened to me with full

attention and seemingly complete recall of our
previous conversations Now I am home I continue to
meet occasionally with the chaplain and she always
puts my mind at ease. (A14)
This recognizes that a guide helps navigate people

through the harsh environment of serious illness
(Kelly 2011), and in the case of P6 the nurses
recognised this and organized a chaplain visit. In this
instance the act of christening was something only
chaplains could do, so referral was quite
straightforward for the nurses to recognize. This is not
always the case. For example intensive care nurses
have been found to become less sensitive over time
to the emotional nature of the environment (Bakker
et al, 2005), thus raising the possibility that they may
be less able to recognize when onward specialist
referral may be appropriate. Contrasting this with the
description of intensive care as gruesome by A10
raises important issues pertinent to the
operationalisation of person centred care. The quote
conjures unpleasant images of alien surroundings and
thereby justifies the need for the emotionally
congruent specialist skills of chaplains working there.
Only chaplains can deliver such care because they sit
outside the medical environment, and their focus is
on the relationship with the person as an end in itself.
Again the CCL research reinforces these ideas.
This gratitude category therefore had many

respondents pointing to the unique skills and qualities
of the chaplains in providing personally relevant,
continuous, compassionate and difficult care. This is
specialist, person centred care described by the
evidence from patients in the later CCL papers in this
edition.
Need for peaceful resolution to hideous times
The capacity of the chaplain to facilitate peace was a
major theme. Peace of mind and comfort were
significant outcomes of a successful chaplaincy
intervention:
My conversation with the chaplain helped me find a
sense of peace and the naming ceremony for my
daughter and her funeral were of great benefit to me,
my partner, our son and my best friend. It helped us
all grieve for [her] and even though the pain is still
very raw I know she is at peace. (A13)
Due to the possibility raised by Bakker et al (2005)

that other staff may not always be in a position to
recognize when a chaplaincy referral may be
necessary this makes the skills of the chaplains even
more prescient. The responses provided further
I can't thank him enough for the peace of mind he has

given us now knowing [our son] was christened before
he passed away.(P6)
26

[chaplain]several times in the months since [my
partner]has died, with him even visiting me at the Sick
Kids hospital where my daughter was staying at the
time. I have been through a roller coaster journey of
emotions and I am incredibly grateful for his continued
support. I have received counseling before under
much lesser situations and felt that on reflection this
was by far the most effective I have received. I do not
follow any faith and although at first I thought the
help from a chaplain might be inappropriate for me, it
immediately transpired to be irrelevant and [chaplain]
seemed to tailor his counseling to suit my life. I am
indebted to his help in those final days for [my
partner] and wonder how I might ever have survived
myself without it. It's a vital service which is a must in
that most gruesome environment of the intensive care
ward.(A10)
We met with [chaplain] a few times during our stay at

the Infirmary. [He] was very patient with us and took
time to explain and offer suggestions as to how we
could respectfully mark the birth of our baby boy and
the loss of ... [He] was very respectful of our beliefs
and wishes. He composed a beautiful reading and
performed a sincere and poignant blessing for our
babies and this really helped my husband and I to get
through a very difficult time. We really appreciated
[his] support during our stay and were very grateful to
him for making time for us - it was a huge
comfort.(A32)
Whilst these comments also articulate the qualities
discussed in the section above they are illustrated
here to show the endpoint of the interventions. In
these cases the outcome of the chaplaincy
interventions was peace and comfort from potentially
unbearable times. In one case the outcome was
transformational:
Discussion
Across the spectrum of faith, belief and non belief, the
chaplain guides people through difficult times by
facilitating person centred care to the end of finding
peace. The following discussion situates these themes
in the wider literature in order to examine the degree
to which these findings may be generalisable.
My treatment has helped me find who I truly am.

Without this treatment, I would never have found the
true me. [Chaplain] is a fantastic, special person, who
I will always think of.(A11)
On religion and spirituality

Religion is discussed extensively in the chaplaincy
literature, and is contextualised differently around the
world in relation to the local culture. It is the biggest
predictor of self referral to chaplaincy in US (Piderman
et al. 2010). It predicts how chaplains act, to the
extent that Galek et al (2009) found chaplains
exhibited a statistically significant higher rate of
prayer with patients from their own religion than they
did with patients of different religion. Prayer did not
factor overtly in our sample. Rather, all people in NHS
Lothian who saw a chaplain reported benefits from
chaplaincy interventions, whether they were religious
or not.
Finding peace is an important outcome of chaplaincy.

Case example of all four themes
We would like to finish this section by including the
full transcript of one of the responses. We have
obtained permission from the writer for this. The
reasons are twofold. First, it shows examples of all the
thematic categories discussed in this section and is
therefore a good illustration of the whole (Tofthagen
& Fagerstrm 2010). Second, it speaks louder than
any secondary analysis to the impact of chaplaincy:
The final days of my partners life was the most
distressing situation of my life. I had no idea how to
deal with it or my feelings. The counseling that I
received [from the chaplain] during those final days
and in the months thereafter has been immensely
helpful. I had also built up a lot of anxiety in
anticipation of how her life might end. [Chaplain] was
incredibly helpful in ensuring that was able to have
those final moments with her and that I could say all
the things that I needed to say, without later regret of
missing the moment. It was also vital that I was given
the reassurance from a non clinical body about how
the end would be for [her] and that she would not
suffer, which was so important. I have also seen
Chaplain skills
The skills and personal qualities chaplains
demonstrate are also the subject of considerable
literature, often expressed in the narrative style of
case studies. Case studies often use metaphor to
articulate the togetherness and partnership involved.
For example King (2012) used the metaphor of
faithful companioning to encompass the essence of
spiritual care as he saw it. By contrast 20 years earlier
Dykstra (1990) had used the metaphor of the biblical
Stranger to describe the chaplains role in entering
27

are all valuable functions, but case studies are not the
best test of the efficacy of chaplaincy care as King
(2011) argues. They do not support the necessary
professionalization of chaplaincy. This requires more
systematic evidence of efficacy as gathered in a
PROM. The Lothian PROM showed that chaplains
listen to people, enable them to speak their mind,
value them and their beliefs, and facilitate peace and
honesty. These functions are mirrored in the literature
(Ai et al, 2005; Almond, 2002; Whitford & Olver,
2012). What is needed is more evidence of the value
of these skills, not ever finer discussions on semantics.
someones life at a time of great distress. This

suggests something of an evolution from stranger to
companion, although both are still present when
Edmeads (2007) talks about being present to, and
withpatients (p549), articulating something of the
dual roles of witness and companion.
This use of language is interesting when compared
with the competence based descriptions of more well
established health professions (Nursing and Midwifery
Council 2008). The need to articulate skills and their
impact (professionalise) has become more pressing in
the current climate given the strategic imperative to
provide evidence based care (Scottish Government
2010). Because the religious aspect of chaplains
legitimacy is diminishing this creates an extra threat
to chaplaincy as many other professions lay claim to
the delivery of spiritual care (MacKinley, 2006), such
as the ICU nurses discussed earlier. One of the
reactions to this in the chaplaincy literature has been
a proliferation of case studies, the purpose of which is
to
advance our individual and collective abilities, learn to
better articulate to other disciplines what we do and
why/how it is important (i.e., evidence-based care),
and build a foundation of multiple case studies for
further analysis, theory building, and research.(King
2011, p45)
Unmet needs
The free text comments provided evidence that
chaplains can mitigate the iatrogenic spiritual harm
caused by the hospital environment.
These
comments pointed to a distinct and necessary service
uniquely delivered by chaplains. Respondents needed
someone unrelated to the medical environment who
could see them as a person, not an illness. This is
extremely important as these unmet needs entail a
request for person centred care. Meeting these needs
thereby fulfils the requirements of person centred
care. This may seem obvious but there is mounting
acknowledgement that person centred care is easier
said than done (Cribb 2011) 1. Therefore, any
articulation of person centred care in practice should
be valued, analysed and disseminated, not just in
chaplaincy but in healthcare generally.
The evidence base

Kings statement suggests two key points:
1. King doesnt believe other professionals
understand the skills of chaplains
2. After Fitchett (2011), he believes that more case
studies are needed to build theory and research
The first point is supported by the fact that there is
limited literature on the efficacy of chaplaincy
interventions (Jankowski et al. 2011; Mowat 2009).
However, the second is not necessarily true, and could
in fact be counterproductive. Generalisable data is
possible even in the absence of a clear understanding
of the impact of chaplaincy, and it is generalisable
data that is required to support empirical evidence for
chaplaincy. In brief, this evidence can be produced by
articulating the skills of chaplains that other people
think are valuable. This is where their value lies. There
is already enough theoretical data to work with in a
practical sense.
There is confusion over who should be providing this

care (Wright & Neuberger 2012), and the current
maxim that spiritual care is everyones business
(MacKinley, 2006) does not easily translate into
practice. Everyone has spiritual needs (Walter 1997),
and it is clear from the free text responses here that
clinical staff cannot (and perhaps should not) meet
some of these needs. Whilst the evidence for generic
spiritual interventions is equivocal (Candy, 2012)
there is a better case for complex spiritual needs to be
met by specialist interventions. Chaplains are
specialists in spiritual care.
On peace
The claim for peace being a primary outcome of
chaplaincy is uncontroversial. It is a significant
endpoint in numerous case studies (Cooper, 2011;
This is not to argue against case studies. Case studies

stimulate reflection, engender personal engagement
and a recognition of the complexity of living with
many different points of view (Schlauch 2012). These
28
Cribb is a pharmacist and philosopher. His deconstruction

of shared decision making in this citation is an excellent
practical deconstruction of the person centred care agenda.

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29

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The Scottish Journal of Healthcare Chaplaincy Vol 16 (special) 2013

Spiritual care as person centred care: a

The Scottish Journal of Healthcare Chaplaincy Vol 16 (special) 2013

content validity by crosschecking where free

medical person to talk to and will be discussed

The Scottish Journal of Healthcare Chaplaincy Vol 16 (special) 2013

in terms of coding density, the narrative of these

This snapshot of the obvious importance of the

The significance of religion,

The unmet needs of routine hospital care

These themes are interrelated. However for ease of

I most enjoyed having someone non-medical to talk to

As a Christian my need was totally met by the

helped lift my spirit [and] made to feel more like a

I have been a Christian since I was youngster and old

The comments point to a distinct and necessary

I have an excellent CPN, but she is not familiar with

Grateful recognition of the unique skills of the

Conversely religion was not significant in many

I always felt that while my mother had [chaplain]

[Chaplain] was very patient with us and took time to

The Scottish Journal of Healthcare Chaplaincy Vol 16 (special) 2013

evidence for this claim. For example one respondent

This theme had the most comments, suggesting that

This sensitivity to individual needs entails practical

[Chaplaincy is] a vital service which is a must in that

The chaplain has always listened to me with full

This recognizes that a guide helps navigate people

This gratitude category therefore had many

Due to the possibility raised by Bakker et al (2005)

I can't thank him enough for the peace of mind he has

The Scottish Journal of Healthcare Chaplaincy Vol 16 (special) 2013

We met with [chaplain] a few times during our stay at

My treatment has helped me find who I truly am.

On religion and spirituality

Finding peace is an important outcome of chaplaincy.

The Scottish Journal of Healthcare Chaplaincy Vol 16 (special) 2013

someones life at a time of great distress. This

The evidence base

There is confusion over who should be providing this

This is not to argue against case studies. Case studies

Cribb is a pharmacist and philosopher. His deconstruction

The Scottish Journal of Healthcare Chaplaincy Vol 16 (special) 2013

King, 2011; Maddox, 2012) and appears in most

The Scottish Journal of Healthcare Chaplaincy Vol 16 (special) 2013

The Scottish Journal of Healthcare Chaplaincy Vol 16 (special) 2013

The Scottish Journal of Healthcare Chaplaincy Vol 16 (special) 2013

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