‘Beyond Boundaries or Best Practice’ Prayer in Clinical Mental Health Care: Opinions of Professionals and Patients

Round 1

Reviewer 1 Report

22: The author needs to clarify what prayer means and particular what is meant by "use." There's a difference between a mental health professional hoping for a good outcome for a client and for the same person using tradition specific rites during a session with a patient. The examples used in the first paragraph seem to not necessarily be talking about the same sense of prayer, and the introduction should be very specific about what is meant and why that term is stipulated so as to help readers navigate through the research. Defining whether the "use" occurs in sessions or outside of them would also help. Finally: the severity of mental health disorders would seem to be an 

46: The shift to nursing is one element, but you need to specify whether the nursing in question is specific to mental health, and whether the "holistic" acceptance of it is particular to one school of nursing or whether you want to claim that nursing is more holistic than other forms of care in general. 

54-55: This seems oddly formulated grammatically, and the upshot (that patient opinion "could be important") seems problematic given most theories of care (including Noddings), which state that the recipient opinion is vitally important. This whole paragraph makes it hard to know what kind of nurse (shift vs. regular attending of LPN vs. RN) and what kind of prayer is discussed. All of these variables would seem necessary to mention as a way to frame the studies cited. 

76-77: The specific framing of the question in terms of whether attitudes differ in CC vs. SC helps, and in a way starting with the question of "Christian" prayer rather than just "prayer" would provide some focus, even though there are many types of Christianity. This limited scope makes the production more productive.

Overall, the introduction should be tightened up to be either more general (issues of secularity) or more specific (issues about Christian care/prayer). 

154-162: The results overall indicate that the biggest difference is between patients and providers, but it is difficult to know if this measures the same element. Be more clear (the grammar is a bit off here in English) about whether the professionals are responding as MHP, as individual persons, and how they negotiate the responsibilities of care as similar/different. 

164: The reasons for/against make sense, but giving your reader more context and educating in terms of more literature about the therapeutic benefits of prayer would help to explain why some MPH thought it a good thing for nurses to do, but not for them. One also suspects that social workers, nurses, psychoanalysts and psychiatrists who have very different educational backgrounds may not have the same opinion even if relative to patients their tasks seem similar. 

274: The policy of the CC and the SC concerning prayer, as written, would be useful information so your reader knows what the patients expected. 

374-380: This provides very necessary information that needs to provide some of the introductory framework, in terms of what kind of prayer is deemed appropriate/inappropriate, helpful/unhelpful.

395-400: Your list of troubles here is a good summary of the issues with the scope of this project. Knowing if you're primarily interested in the overlap of opinions, questions of professionalism, efficacy, appropriateness, etc. are all qualities determined from different viewpoints. 

Overall, I think that this is an interesting project, but that it needs to be reframed slightly to be maximally beneficial. The data that you get from the study is not focused enough to be conclusive, and while you do not make conclusive claims it would seem necessary to provide your reader with a better sense of why the study is complicated and more clear paths forward in order to show the full worth of what you have here. 

Author Response

22: The author needs to clarify what prayer means and particular what is meant by "use." There's a difference between a mental health professional hoping for a good outcome for a client and for the same person using tradition specific rites during a session with a patient. The examples used in the first paragraph seem to not necessarily be talking about the same sense of prayer, and the introduction should be very specific about what is meant and why that term is stipulated so as to help readers navigate through the research. Defining whether the "use" occurs in sessions or outside of them would also help. Finally: the severity of mental health disorders would seem to be an 

Thank you for these points of feedback. We have now added a theoretical framework (43-83) about definitions of prayer, explaining which definition we have used and what types of prayer our study is about. Since our study concerns clinical patients and health professionals of various disciplines, their opinions about the use of prayer are about ‘spontaneously’ occurring prayer during individual patient-caregiver contacts (either at initiative of the professional or after a patient request). So our study does not reflect prayer in specific (therapeutic) sessions. We have added this specification to our research aim (130-131), hoping that this is more clear now. Furthermore we added some explanation in the method section (139-142). Important to realize is also that some of the interview candidates spoke about the idea of prayer together with a professional (hypothetic, in case they had not experienced it – which was also regularly the case).

Furthermore we added some information about the patients’ clinical stay in the method section (158-160), though unfortunately we could not distinguish the exact meaning of the last sentence because it has been blanked out.

46: The shift to nursing is one element, but you need to specify whether the nursing in question is specific to mental health, and whether the "holistic" acceptance of it is particular to one school of nursing or whether you want to claim that nursing is more holistic than other forms of care in general.

Thank you for this remark, we have specified the information (88-101).  

54-55: This seems oddly formulated grammatically, and the upshot (that patient opinion "could be important") seems problematic given most theories of care (including Noddings), which state that the recipient opinion is vitally important. This whole paragraph makes it hard to know what kind of nurse (shift vs. regular attending of LPN vs. RN) and what kind of prayer is discussed. All of these variables would seem necessary to mention as a way to frame the studies cited.

We have changed our formulation and added some details about the studies cited (102-115). As all the studies are about hospitalized patients, the reader may now see more clearly that in cases that nurses are mentioned those working in team/shift are meant.

76-77: The specific framing of the question in terms of whether attitudes differ in CC vs. SC helps, and in a way starting with the question of "Christian" prayer rather than just "prayer" would provide some focus, even though there are many types of Christianity. This limited scope makes the production more productive.

We have considered to follow your suggestion by changing the research question towards: What are opinions, possible reasons, objections or conditions of mental health professionals and inpatients about the use of Christian prayer in mental health care in a Christian and a secular clinic in the Netherlands? At the same time we thought the addition ‘Christian’ prayer would not fully cover the area. We will explain this below the following remark.

Overall, the introduction should be tightened up to be either more general (issues of secularity) or more specific (issues about Christian care/prayer). 

Thank you for making this understandable point of feedback. However with respect to our study there is a difficulty in following your suggestion. We may have given the impression that our study particularly focused on Christian prayer in a secular country. By including a Christian clinic, opinions about Christian prayer indeed were prevalent. But by also including the secular clinic, also other outlooks on life are represented and we were able to map whether in such a context for example more reticence towards prayer would be present (which on average was not so).

Instead of getting more and more secular, the Dutch society is more and more considered to be a plural society concerning R/S and we have now added this point to the introduction (117-122).

154-162: The results overall indicate that the biggest difference is between patients and providers, but it is difficult to know if this measures the same element. Be more clear (the grammar is a bit off here in English) about whether the professionals are responding as MHP, as individual persons, and how they negotiate the responsibilities of care as similar/different. 

The way we started to describe our results indeed left some ambiguity about whether MHPs and patients were talking about the same thing. We have now changed the paragraph (220-231), hoping it is better readable.

164: The reasons for/against make sense, but giving your reader more context and educating in terms of more literature about the therapeutic benefits of prayer would help to explain why some MPH thought it a good thing for nurses to do, but not for them. One also suspects that social workers, nurses, psychoanalysts and psychiatrists who have very different educational backgrounds may not have the same opinion even if relative to patients their tasks seem similar. 

In the introduction we have now tried more clearly to describe possible different views belonging to different disciplines, which indeed is not very surprising. Furthermore, the introduction mentions that unmet R/S care needs – to which also an unmet need for prayer with a nurse belongs – are associated with a lower treatment alliance. However, empirical studied benefits of prayer to our knowledge are scarce.

274: The policy of the CC and the SC concerning prayer, as written, would be useful information so your reader knows what the patients expected. 

We have added some information in the method section (156-158).

374-380: This provides very necessary information that needs to provide some of the introductory framework, in terms of what kind of prayer is deemed appropriate/inappropriate, helpful/unhelpful.

Thank you for this suggestion, we have replaced the information to the introduction (73-77).

395-400: Your list of troubles here is a good summary of the issues with the scope of this project. Knowing if you're primarily interested in the overlap of opinions, questions of professionalism, efficacy, appropriateness, etc. are all qualities determined from different viewpoints. 

Thank you for this point. The explorative character of the study – investigating opinions about prayer in interviews (with a heterogeneous population) that were focused on the broad area of R/S care needs and mental health – made a very specific orientation difficult. In The Netherlands the area has been studied now for the first time and some of the results were surprising to us (like the point of a patients’ request).The exploring nature of our study possibly makes it a point of departure for many elaborating studies following, which we have described in the final paragraph of the discussion (516-529).

Overall, I think that this is an interesting project, but that it needs to be reframed slightly to be maximally beneficial. The data that you get from the study is not focused enough to be conclusive, and while you do not make conclusive claims it would seem necessary to provide your reader with a better sense of why the study is complicated and more clear paths forward in order to show the full worth of what you have here. 

We have adapted the last paragraph of the discussion, in order to make more clear indeed that further, more focused studies are needed in order to be able to make more conclusive remarks.

Author Response File: Author Response.docx

Reviewer 2 Report

I have two proposals to make in order to improve the article, which is already interesting and well written.

1) Some parts of the discussion can be moved forward to the introduction or a separate section on 'earlier research'. This would be good to read before entering into the empirical part and the final discussion.

2) More background should be provided about the 'religiosity gap' and the discussion around this concept and this should be part of the expanded 'earlier research' mentioned in 1)

Author Response

I have two proposals to make in order to improve the article, which is already interesting and well written.

1) Some parts of the discussion can be moved forward to the introduction or a separate section on 'earlier research'. This would be good to read before entering into the empirical part and the final discussion.

Thank you for this useful suggestion. We have added a theoretical framework (43-83) to the introduction and replaced some of parts the discussion to that framework.

2) More background should be provided about the 'religiosity gap' and the discussion around this concept and this should be part of the expanded 'earlier research' mentioned in 1)

Additionally we have provided some background information about the religiosity gap (78-83).

Author Response File: Author Response.docx

Reviewer 3 Report

The paper has potential as the practice of prayer in clinical mental health care remains controversial in many parts of the world.

However, the paper is too descriptive and lacks theoretical tools to make an original contribution to the body of literature in this field. The author should give at least a short discussion of the theories of prayer to help locate the paper in the current context of this subject.

There is a lot of literature engaging prayer in the context of health care from various approaches. The author needs to demonstrate the knowledge of such work by engaging them and demonstrate how this piece makes a unique contribution. The author has taken granted that everyone knows what the meaning the concept of prayer.

I would suggest that the author define the term as part of the theoretical development of the paper. I think this descriptive nature of the paper could allude to a literature review which should have methodologically developed from a particular theoretical assumption/s.

In addition, the author should be encouraged to give exact page numbers for all the direct quotations.

Author Response

The paper has potential as the practice of prayer in clinical mental health care remains controversial in many parts of the world.

However, the paper is too descriptive and lacks theoretical tools to make an original contribution to the body of literature in this field. The author should give at least a short discussion of the theories of prayer to help locate the paper in the current context of this subject.

There is a lot of literature engaging prayer in the context of health care from various approaches. The author needs to demonstrate the knowledge of such work by engaging them and demonstrate how this piece makes a unique contribution. The author has taken granted that everyone knows what the meaning the concept of prayer.

I would suggest that the author define the term as part of the theoretical development of the paper. I think this descriptive nature of the paper could allude to a literature review which should have methodologically developed from a particular theoretical assumption/s.

Thank you for these useful and correct points of feedback. We have now added a theoretical framework about definitions of prayer, explaining which definition we have used and what types of prayer our study is about (43-83).

In addition, the author should be encouraged to give exact page numbers for all the direct quotations.

That is a correct remark, we have now added the page numbers.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The additional framing in the introduction helped to resolve many of the frustrating ambiguities in the first draft. Thank you!