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Learning the available and supplied religious facilities for inpatient services: an example of Taiwan's hospital environment.

PROVIDING HOLISTIC NURSING care, including religious care, for hospitalized patients has been a challenge for clinical nurses. In mainland China, Wang and associates (2004) found that most clinicians felt that they were competent to care for the physical problems of dying patients, but had less confidence about their ability to deal with these dying patients' psychological symptoms, such as depression. As indicated in Figure 1, a patient-centered health care delivery system, which promotes holistic care, should cover the whole care continuum and involve family members and the entire health care team. Nursing services are indeed the center of a well-designed health care delivery system (Tzeng & Yin, 2006).


Previous research has primarily supported a protective effect of religion on patients' morbidity, mortality, depressive symptoms, and overall psychological distress (Levin, Chatters, & Taylor, 2005). A strong relationship between overall patient satisfaction and the extent to which staff addressed patients' emotional and religious needs was also indicated (Clark, Drain, & Malone, 2003).

In Taiwan's hospital environment, medical staff with the same cultural background (Chinese ideology) but having different religious beliefs may easily forget to respect their patients' religious beliefs and practices. The majority of people in Taiwan are polytheist. Because of a lack of knowledge of religions, health care providers' mistakes, committed intentionally or unintentionally, may violate the taboos of their patients and family members. As a result, this current study focused on the structural dimension of Taiwan's hospital systems and emphasized the religious aspect. This exploratory study aimed to illustrate the availability of religious facilities and religious services provided by Taiwanese hospitals, and to gather the perceptions of these hospitals' nursing executives concerning the necessity and the benefit of having a permanent religion service department for elevating the quality of religious care.


Strategies to meet patient's religious needs. Koening, McCullough, and Larson (2001) outlined possible approaches for health care professionals to respond to the religious needs of their patients in hospitals, including taking the religious histories of their patients, supporting their patients' religious beliefs, and ensuring their patients access to religious resources. It is also important to view and treat hospital chaplains as part of the health care team and respect visits by clergy.

Narayanasamy and associates (2004) found several approaches adopted commonly by the sampled 52 nurses in the United Kingdom, including respecting patient religious beliefs, helping patients to obtain connectedness, using nurses' own religions beliefs to assist patients, and assisting patients to complete unfinished business. Clark and associates (2003) suggested that hospital services include availability of religious resources and appropriate referrals to chaplains or leaders in the religious community. Hospitals should also form a team dedicated to evaluating and improving the emotional and religious care of patients' experience with health care professionals.

Barriers to discussing religious issues in acute care settings. Fletcher (2004) found that health care professionals in the United States generally lacked the education and training to address patients' religious needs appropriately. It was not clear to them whether patients' religious needs were addressed on admission, and when patients' religious needs were supposed to be addressed, how they could obtain support from hospital administrators. Thus, it is becoming increasingly important for chaplains to develop a relationship of acceptance and trust with patients, family members, and health care professionals (Mellon, 2003). As indicated in a study by Flannelly, Weaver, and Handzo (2003), the majority of staff referrals to chaplains were from nurses; more than 40% of these referrals to chaplains were for the family members of patients.

From patients' perceptions, providing facilities to engage in prayer and meeting the cultural needs of patients and family members have been identified as two of the patient-centered improvements in future health-care built environments (Douglas & Douglas, 2005). Thus, there is still a knowledge gap on the availability of religious facilities and religious services provided by hospitals in different cultural environments.

Confucianism, filial piety, and health care in Taiwan. Filial piety to parents is one of the core values in Confucianism. When Chinese patients face illness, their family members, primarily children, usually try their best to assure that their sick parents receive excellent care to extend their lives as long as possible. As a way to demonstrate filial piety to their parents, children of these sick parents feel obligated to pay additional fees for the privilege of having their loved one cared for in a medical center, and for an elixir or alternative/ complementary treatments outside the formal medical system. Consequently, medical centers in Taiwan usually have an almost 100% occupancy rate.

Family members might also demonstrate their filial piety through seeking miracles to prolong the patient's life, including seeking such things as divine advice. One way to show filial piety toward a deceased parent or relative is through the practice of religious ceremonies and rituals. This practice is popularly accepted by the majority of people in Chinese communities.


This study used a cross-sectional survey design, and was conducted in Taiwan, a Confucianism-value-based society. The data collection periods were from February to March 2005. The Human Subjects Review Committee of I-Shou University reviewed the project proposal to assure human subject protection.

Participants. The targeted population was nursing executives currently working for one of 484 hospitals in Taiwan: 23 medical centers, 70 regional hospitals, 384 local hospitals, and 8 psychiatric specialty hospitals (the Taiwan Joint Commission on Hospital Accreditation accredited these hospitals). The overall response rate was 42.6% (n=206). The demographic characteristics of these participants are shown in Table 1. The average length of operation of the participating hospitals was 25.86 years (SD=24.23); the average number of acute care beds was 198.30 (SD=325.95); and the average number of professional nurses employed per hospital was 148 (SD=270.35).

Data collection. Participation was voluntary and an informed consent form was included in the first section of the questionnaire. The questionnaire packages were sent to the attention of the nursing executive and included a self-addressed and stamped return envelope. To increase the response rate, a followup letter was sent 3 weeks later to those nursing executives who had not responded.

Data analyses. Data were entered and processed using SPSS 10.0 statistical software. Descriptive, one-way ANOVA and Spearman's rho correlational analyses (the alpha value was set at 0.05) were performed.

Study limitations. The response rate (42.6% response rate) was one of the limitations of this study. Those nursing executives who did not agree with the need to establish a religious service department may have tended not to respond to this questionnaire, and therefore, there was a possible selection bias in this investigation. Also, despite the fact that Taiwan has long been a society with a high amount of polytheism, it still is possible that some head nurses may have forbidden visiting and preaching by religious leaders in their wards. Conflict of interest among religious leaders also might be present in these hospitals. Thus, this issue was not discussed in this study.

Results and Discussion

Religious service facilities and chaplain resources. Only 23 hospitals (11.8%) had a permanent religious service department; 59.4% of them did not have any religious service facilities such as a chapel or designated room for prayer. Just six hospitals employed their own chaplains or clergy and/or recruited volunteers to provide religious services (see Table 1). The analysis of one-way ANOVA indicated that the number of chapels across different types of hospitals was statistically significantly different (F=17.396, p=0.00). Medical centers (mean=2.25, range=0-5) had the highest number of chapels, followed by regional (mean=1.33, range=0-4), local (mean=0.47, range=0-3), and psychiatric specialty hospitals (mean=0.25, range=0-2).

It appears that the hospital systems in Taiwan are not providing sufficient resources to meet patients' religious needs and might not recognize the importance of providing religious care in acute care settings. As indicated in the study by Flannelly, Weaver, Handzo, and Smith (2005) in the United States, meeting the emotional needs of patients and their relatives was perceived as chaplains' most important roles by hospital administrators. In Taiwan, the roles of chaplains in hospitals seem to have been overlooked.

Currently in Taiwan, it might be difficult for health care providers to support the religious beliefs and practices of patients and their family members and to ensure that patients have access to religious resources within a hospital. It would be beneficial for hospitals to employ their own chaplains or clergy, as well as to recruit volunteers to provide religious services.

A room designated for use for ceremonies related to the deceased within a hospital. A total of 45 hospitals provided a room for special ceremonies: 7 of 8 medical centers, 23 of 42 regional hospitals, and 15 of 148 local hospitals. All 8 participating medical centers (100%) were providing inpatient hospice care, compared with 33.3% of the participating regional hospitals and 6.8% of the participating local hospitals.

Most medical centers in Taiwan provide inpatient hospice care and a room for special religious rituals. In general, medical centers usually have more resources and larger facilities; they also have more patients with serious illnesses who are more likely to die. Consequently, the administrators of medical centers might be more concerned with the religious needs of patients and family members and be more willing to support religious care, in addition to providing physical and psychological medical care.

Quality of religious care. As indicated in Table 1, the average perception levels for the necessity of establishing a permanent religious service facility in hospitals was 3.87 (SD=0.76). The one-way ANOVA analysis indicated that this necessity item was statistically and significantly different across the different types of hospitals (F=5.114, p=0.00): medical centers (mean=4.38), regional hospitals (mean=4.07), local hospitals (mean=3.83), and psychiatric specialty hospitals (mean=3.13).

The perceptions of the surveyed nursing executives of the effect of having a permanent religious service facility for elevating the quality of religious care was 4.11 (SD=0.65), on average. The one-way ANOVA analysis showed that the effect item was statistically and significantly different across different hospital types (F=3.658, p=0.00): medical centers (mean=4.50), regional hospitals (mean=4.19), local hospitals (mean=4.10), and psychiatric specialty hospitals (mean=3.50).

Spearman's rho correlational analyses indicated that if hospitals had more chapels for different religions, these hospitals' nursing executives would rate a permanent religious service department as being more beneficial for improving the quality of religious services (rho=0.178), and would perceive more need for religious resources and support (rho= 0.238). Also, if nursing executives perceived more need for establishing a permanent religious service department, these executives also would rate having a permanent religious service department as being more beneficial for improving the quality of religious services provided in a hospital (rho=0.719).

Conclusions and Practical Implications

This research provides empirical data about the availability of religious facilities and religious services provided by Taiwanese hospitals that contribute to the quality of religions care. Base on the study findings, practical implications follow.

This study found that the medical centers had more chapels for people of different religions than the regional, local, and psychiatric specialty hospitals. If there is available space, regional, local, and specialty hospitals should be encouraged to establish chapels. Establishing chapels could become a major marketing strategy to attract future consumers, especially for regional and local hospitals that might not be as competitive as medical centers.

To best utilize limited hospital space, hospitals could create a flexible chapel space so that it can be used by a variety of religions. Such a multi-religion chapel should provide commonly used religious literature, such as the Old and New Testaments, Buddhist scriptures, and audio tapes/CDs of various religious music/recitation. In Taiwan, religious associations generally donate these materials and provide some supplies for certain religious ceremonies and rites. For example, some chapels in Taiwanese hospitals provide free lotus comforters that are used to cover the body of deceased patients who were Buddhists before moving them.

If possible, hospitals should provide a room or space for Buddhist family members so their deceased relatives can remain on the bed where they died for 8 hours. A common ancient rite for Buddhists, Taoists, and Chinese ideology is to call the soul of the deceased home from the hospital. An independent room with good sound isolation would help control the sound volume created during such rites to minimize possible disturbance to patients and their family members.

Believers of Taoism usually burn some special imitation money after performing certain religious ceremonies near the deceased for the living to communicate with God through the smoke from the burning "money." Some family members might burn the "money" in stairwells near the deceased patient's room, a practice that can create quite a lot smoke and is a fire hazard. Nurses usually are the first personnel to spot this activity. It is suggested that hospitals in Taiwan and other communities that serve the Asian population provide an outdoor space for this purpose.

For a hospital that promotes patient-centered services, religious beliefs and practices have become an essential component of the strategies used by patients and their family members to cope with physical and psychological distress resulting from illness experiences (Keening et al., 2001). Lo and colleagues (2003) emphasized that religious ceremonies and rites could provide comfort, meaning, hope, and solace to patients and their family members. Kao and associates (2003) investigated the possible role and impact of religious activities on psychological quality of life and symptoms of depression in 86 peritoneal dialysis patients in Taiwan. They found that for patients possessing a religious faith, fewer religious activities were associated with worse quality of life and higher scores of depression.

Concluding note. All these practical considerations are designed to decrease the potential for conflicts among patients, their family members, and health care providers. Nurses and head nurses, who are the frontline health care providers and who have the most frequent contact with patients and their family members, usually are in a position to deal with the religious needs of dying patients and their family members. Hospitals should have readily available religious resources and provide appropriate referrals to chaplains or leaders in the religious community. Each hospital and its nursing department should develop guidelines to assess the religious needs of patients and to evaluate whether health care providers are meeting those needs.

Appropriately employing religious service facilities and resources can decrease problems in hospital management and make a significant contribution to the provision of holistic and quality care. Patients and their family members would feel that their religious needs were being recognized, which would further increase their confidence and trust in their health care providers. Finally, by emphasizing the provision of holistic care within a hospital, the knowledge, attitudes, and actions of nurses towards religious care would have a favorable impact on how patients and their family members perceive the overall quality of hospital services.

ACKNOWLEDGMENT: The authors would like to thank Ms. Linda S. Orgain for her editing services.

EDITOR'S NOTE: This article represents one in an occasional series of articles designed to provide nurse leaders with an international perspective of key nursing issues and trends. While these reports may not be directly applicable to U.S. institutions, they nevertheless provide a worldview for advancing nursing leadership and nursing's impact on health care cost and quality outcomes.


Clark, P.A., Drain, M., & Malone, M.P. (2003). Addressing patients' emotional and spiritual needs. Joint Commission Journal on Quality and Safety, 29(12), 659-670.

Douglas, C.H., & Douglas, M.R. (2005). Patient-centered improvements in health-care built environments: Perspectives and design indicators. Health Expectations, 8, 264-276.

Flannelly, K.J., Weaver, A.J., & Handzo, G.F. (2003). A three-year study of chaplains' professional activities at Memorial Sloan-Kettering Cancer Center in New York City. Psychooncology, 12(8), 760-768.

Flannelly, K.J., Weaver, A.J., Handzo, G.F., & Smith, W.J. (2005). A national survey of health care administrators' views on the importance of various chaplain roles. The Journal of Pastoral Care & Counseling, 59(1-2), 87-96.

Fletcher, C.E. (2004). Health care providers' perceptions of spirituality while caring for veterans. Qualitative Health Research, 14(4), 546-561.

Kao, T.W., Tsai, D.M., Wu, K.D., Shiah, C.J., Hsieh, B.S., & Chen, W.Y. (2003). Impact of religious activity on depression and quality of life and chronic peritoneal dialysis patients in Taiwan. Journal of the Formosan Medical Association (Taiwan Yi Zhi), 102(2), 127-130.

Koening, H.G., McCullough, M.E., & Larson, D.B. (2001). Handbook of religion and health. New York: Oxford University Press.

Levin, J., Chatters, L.M., & Taylor, R.J. (2005). Religion, health and medicine in African Americans: Implications for physicians. Journal of the National Medical Association, 97(2), 237-249.

Lo, B., Kates, L.W., Ruston, D., Arnold, R.M., Cohen, C.B., Puchalski, C.M., et al. (2003). Responding to requests regarding prayer and religious ceremonies by patients near the end of life and their families. Journal of Palliative Medicine, 6(3), 409-415.

Mellon, B.F. (2003). Faith-to-faith at the bedside: Theological and ethical issues in ecumenical clinical chaplaincy. Christian Bioethics, 9(1), 57-67.

Narayanasamy, A., Clissett, P., Parumal, L., Thompson, D., Annasamy, S., & Edge, R. (2004). Responses to the spiritual needs of older people. Journal of Advanced Nursing, 48(1), 6-16.

Tzeng, H.M., & Yin C.Y. (2006). Demands for religious care in the Taiwanese health system. Nursing Ethics, 13(2), 163-179.

Wang, X.S, Di, L.J., Reyes-Gibby, C.C., Guo, H., Liu, S.J., & Cleeland, C.S. (2004). End-of-life care in urban areas of China: A survey of 60 oncology clinicians. Journal of Pain and Symptom Management, 27(2), 125-132.

CHANG-YI YIN, MA, is a Professor, Chinese Culture University, Department of History, Taipei, Taiwan.

HUEY-MING TZENG, PhD, RN, is Associate Professor, The University of Michigan, School of Nursing, Division of Nursing Business and Health Systems, Ann Arbor, MI.
Table 1.
Demographic Characteristics of the Participants and
Descriptive Information on the Included Variables
(N = 206)

Variable                                   n       %

Hospital Accreditation
  Medical centers                           8     3.9
  Regional hospitals                       42    20.4
  Local hospitals                         148    71.9
  Psychiatric specialty hospitals           8     3.9

Types of Funding
  Public/civil hospitals                   38    18.4
  Military hospitals                        7     3.4
  University hospitals                      3     1.5
  Hospitals owned by foundations           28    13.6
  Privately owned hospitals               130    63.1

Religion affiliation
  No affiliation                          182    88.3
  Affiliated with a
  specific religion (yes)                  24    11.7
      (If the response was yes,
      the participant was asked
      to indicate the
      primary sponsor.
    The percentage was
      calculated using 24
      as the denominator.)
    Sponsored by
      Catholic organizations                8    33.3
    Sponsored by other
      Christian churches                    8    33.3
    Buddhist affiliated                     6    25.0
    Taoist affiliated                       2     8.4

Provides Inpatient
Hospice Services
  Yes                                      32    15.5
  No                                      174    84.5

Offers Home Hospice Care
  Yes                                      47    22.8
  No                                      159    77.2

Education Background
of the Nursing
Executive Respondents
  Graduated from
    occupational high schools              12     5.9
  Junior colleges                          65    31.7
  Four-year university nursing school      75    36.6
  Held a master's degree or higher         53    25.9

Participants' Religious Belief(s)
  Did not have any religious beliefs       28    13.7
  Did not have a fixed
    religion or place of worship           29    14.1
  Catholic                                 14     6.8
  Another Christian denomination           30    14.6
  Buddhists                                68    33.2
  Taoists                                  28    13.7
  I-Guann Daw (translated                   6     2.9
     from Mandarin) a religious
     sect with a combination
     of Confucian,
     Buddhist and Taoist features

Had a Permanent Religious
Service Department
  No                                      183    88.2
  Yes                                      23    11.8

Had a Chapel(s) or Designated
  Room(s) for Prayer
    No                                    123    59.4
    Yes                                    83    40.6
    (If the response was yes, the
    participant was asked to indicate
    the type(s) of chapels.
    Multiple options can be chosen.
    The percentage was calculated by
    using 83 as the denominator.)
      Had Christian chapels                41    49.4
      Had Catholic chapels                 29    34.9
      Had Buddhist chapels                 65    78.3
      Had Taoist chapels                    8     9.6
      Had an I-Guann Daw chapel             1     1.2

Chaplain or Clergy Resources (Multiple
Options Could Be Chosen)
   Hospitals did not have access to
     clergy or a chaplain to provide
     religious care to patients            17     8.3
   Collaborated with agencies to
     provide such religious services       22    10.7
   Used patients' or family members'       38    18.4
     own resources
   Used the resources of health            48    23.3
     care professionals
   Employed their own chaplains or          6     2.9
     clergy and/or recruited volunteers
     to provide religious services

Perceived Necessity for Religious Services and
the Effect on the Quality of Religious Care
  Very little need                          0     0.0
  Little need                               6     2.9
  No comment                               56    27.3
  Needed                                  101    49.3
  Very needed                              42    20.5

Perceived Effect of Having a Permanent Religious
Service Facility for Elevating the Quality of
Religious Care
  Not very helpful                          1     0.5
  Not helpful                               0     0.0
  No comment                               27    13.2
  Helpful                                 124    60.5
  Very helpful                             53    25.9
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Title Annotation:International Perspective
Author:Yin, Chang-Yi; Tzeng, Huey-Ming
Publication:Nursing Economics
Geographic Code:9TAIW
Date:May 1, 2007
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