Are Hospital Chaplains Under Stress in Hong Kong? Preliminary Results from a Pilot Study

Round 1

Reviewer 1 Report

p. 7, line 265: "may affect the reliability" should read "may affect the power".

Reviewer 2 Report

I recommend publication

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

This study is about the stress burden of hospital chaplains in Hong Kong, the extent of their spiritual experiences, and the relationship between these two variables. Methodology and statistics are very simple but acceptable. The theoretical embedding and discussion are also basic but acceptable. However, the following points should be addressed. Furthermore, the manuscript needs copy-editing.

-   p. 3, line 144: It is not true that a response rate of 60% can be judged as an indicator of representativeness. Instead, you should check and compare the sociodemographic characteristics between sample and population (as far as you know them).

-   Table 1: What does “Percentage (5)” mean?

-   Table 2 and Table 5: In Table 2, the order of the variables is “depression – anxiety – stress”, in Table 5 it’s “stress – anxiety – depression”. The order should be harmonized.

-   Table 3: The heading of Table 3 erroneously addresses not only anxiety but also stress, depression, and spirituality that are not shown in Table 3. Furthermore, it should read “3<2<1”.

-   Table 5: The first line “DSES” should be deleted because the perfect correlation between DSES and DSES is trivial.

-   A section about possible limitations should be added to the discussion. The issues of representativeness and suitability of the DSES (which does not assess social support in a religious context) can be mentioned here, also possible uncertainties concerning the cut-offs applied for depression, anxiety, and stress.

Author Response

Thanks for your invaluable comments. the following points you mentioned have been amended.

representativeness of sample has been addressed in the beginning of the discussion section

table 1 "percentage" is amened "%"

table 2 and table 5 , the order is harmonized.

the heading of the table 3 is amended

the first line of "DSES" had been deleted

a section of limitation has been added in the discussion part.

Reviewer 2 Report

Thank you for allowing me to review this manuscript. The authors have investigated whether hospital chaplains in Hong Kong experience depression, anxiety or stress, and whether this correlates with their level of daily spiritual experiences. The theoretical assumption that appears to be underlying this research is that the spiritual experiences associated with the Christian faith of hospital chaplains might protect them from experiencing the same level of pressures as experienced by other healthcare professions.

Although this is a very interesting question, that could add to the existing body of knowledge on the relationship between religion/spirituality and mental health, the research design is not sufficient to address this issue. The main reasons for this are that: (1) due to the cross-sectional design and the use of the DASS - which is a generic instrument-, it is unclear whether the depression, anxiety or stress reported by the chaplains can be attributed to their work in hospital. No comparison is made to norm data from the general population, so it is unknown to what extent the findings are to be expected; (2) the bivariate correlations calculated between the subscales of the DASS and the DSES do not provide information on directionality and, with that, the existence of the assumed ‘buffering’ effect; (3) the sample size is quite low (n=60), which reduces the reliability of the statistical tests. In the conclusion, the authors suggest that qualitative data is needed to understand the emotional state of hospital chaplains, but this is not necessary if the adjustments to the research design suggested here are made.

Finally, English-language editing and corrections to the formatting of the in-text references and bibliography are needed. When discussing the results of the correlations the phrase “no statistical significant differences” is used (p5, l164 and p6, l191), but correlations reflect relationships between variables not differences between groups.

Author Response

many thanks for your comments. Points amended according to your comments are as follows:

A section of limitations has been added in the discussion part to address the issues you mentioned

no statistical significant relationships was amended in line 164 while differences was maintained in line 191 since it indicated not correlation with the demographic data.

corrections to formatting of the in-text references and bibliography have been done.

Reviewer 3 Report

Thank you for inviting me to review the paper “Are Hospital Chaplains Under Stress in Hong Kong?” This is an important paper to study the stress levels of hospital chaplain. It is well-known that the stress level is high among healthcare workers in Hong Kong and this study was conducted at the right time. I have the following recommendations:

1.     I found that Table 5 is not meaningful. As DASS is a validated questionnaire, the sub-components like anxiety, depression and stress must correlate with each other. It will be more meaningful to run regression analysis to identify factors listed in Table 1 and see which factor(s) is or are associated with depression, anxiety and stress among hospital chaplains. I advise the authors to consider re-analysing the data and re-write part of the results and discussion if there are significant findings.

2.     I recommend to compare the prevalence of anxiety and depression with caregivers and highlight the fact that caregivers may not have religious support. Please add the following statements:

Line 170: … showed hospital chaplains had a much lower prevalence. Similarly, the prevalence rates of anxiety and depression among hospital chaplains are lower than the prevalence rates of depression (40.2%) and anxiety (21.4%) among caregivers of stroke (Loh et al 2016) as well as the prevalence rates of depression (34%) and anxiety (43.6%) among caregivers of dementia (Sallim et al 2015). Nurses and caregivers need to look after the patients most of the time and they may not have religious support. As a result, nurses and caregivers report higher prevalence of depression and anxiety as compared to hospital chaplains.

References:

Loh A et al .(2016) The Global Prevalence of Anxiety and Depressive Symptoms Among Caregivers of Stroke Survivors. J Am Med Dir Assoc. 2016; 18(2):111-116. doi: 10.1016/j.jamda.2016.08.014. Review. PMID:27742585

Sallim AB et al (2015) Prevalence of Mental Health Disorders Among Caregivers of Patients With Alzheimer Disease. J Am Med Dir Assoc. 16(12):1034-41. PMID:26593303

Author Response

Sincere thanks for your invaluable comments. My responses are as follows:

regression has been run as suggested with the demographic data with the two dependent variables. no further significant findings were detected.

the prevalence of anxiety and depression with caregivers had been added to enrich the discussion of the present study.

Round 2

Reviewer 2 Report

Thank you for your response to the comments made. I fear, however, that the changes made are insufficient to remedy the concerns raised. The study suffers from serious flaws, that make that the conclusions are not warranted by the study design. The acknowledgement of these major limitations, does not remedy this issue. The authors should either adjust their conclusions to ones that are warranted by the study design (which in my humble opinion do not contribute significantly to the body of knowledge) or they should adjust the study design to be able to answer the question they wish to answer.

Author Response

Dear reviewer,

thanks again for your further feedback on the paper. I have added an explanation on why there is no relation detected on Stress with Spiritual Experiences in the revised manuscript. Please see if it can provide some points in the study.

Another reason may be that stress is a natural response to stressor or stimulus in our daily life, which is a protective mechanism to human being. Most of our participants are within normal stress level and may not be related to their spiritual experiences. On the other hand, other factors may have relation such as personality should be considered for further study.

Furthermore, the manuscript is sent for English editing

Regards

Andrew