Religious Bodies–Lutheran Chaplains Interpreting and Asserting Religiousness of People with Severe Dementia in Finnish Nursing Homes

Round 1

Reviewer 1 Report

Although this is a very interesting article, there are some points for improvement:

The theoretical part needs more references to focus on the differences of spirituality/religiousness and their influence on patients themselves, family members and caregivers of patients with Alzheimer’s Dementia. For a relevant review, please see: Giannouli, V., & Giannoulis, K. (2020). Gazing at Medusa: Alzheimer’s dementia through the lenses of spirituality and religion. Health psychology research, 8(1).

In addition to that, there is no mention for data concerning Catholic and Orthodox Christian patients, apart from Lutherans. There is a large body of research to consult regarding old age and religiousness (especially in Finland were apart from the majority of protestants, there are also many Orthodox Christians). Please read relevant research that could be added in the introduction and discussion, such as:

Giannoulis, K., & Giannouli, V. (2020). Subjective Quality of Life, Religiousness, and Spiritual Experience in Greek Orthodox Christians: Data from Healthy Aging and Patients with Cardiovascular Disease. In GeNeDis 2018 (pp. 85-91). Springer, Cham.

Giannoulis, K., & Giannouli, V. (2021). Religiosity and spirituality in the era of the COVID-19 pandemic: An overview of exploring emotional parameters. Brain, Archives of Neurology and Psychiatry, 58, 42-47.

Inclusion/exclusion criteria of participants have to be reported.

More detailed demographics have to be reported for the whole sample (quantitative). In this form this information is missing.

One more point that needs clarification is why IPA analysis of data was not follow (as it seems more appropriate). In addition to that, it is not clear how the authors analyzed the data. Please explain in methods section the steps in detail.

English language editing is also advised as some points in the text are not clear. Overall, this is an interesting study!

Author Response

Although this is a very interesting article, there are some points for improvement:

1. The theoretical part needs more references to focus on the differences of spirituality/religiousness and their influence on patients themselves, family members and caregivers of patients with Alzheimer’s Dementia. For a relevant review, please see: Giannouli, V., & Giannoulis, K. (2020). Gazing at Medusa: Alzheimer’s dementia through the lenses of spirituality and religion. Health psychology research, 8(1).

• Added several references into the Introduction to better discuss religiousness in connection to dementia and also demographic issues.

2. In addition to that, there is no mention for data concerning Catholic and Orthodox Christian patients, apart from Lutherans. There is a large body of research to consult regarding old age and religiousness (especially in Finland were apart from the majority of protestants, there are also many Orthodox Christians). Please read relevant research that could be added in the introduction and discussion, such as:

Giannoulis, K., & Giannouli, V. (2020). Subjective Quality of Life, Religiousness, and Spiritual Experience in Greek Orthodox Christians: Data from Healthy Aging and Patients with Cardiovascular Disease. In GeNeDis 2018 (pp. 85-91). Springer, Cham.

Giannoulis, K., & Giannouli, V. (2021). Religiosity and spirituality in the era of the COVID-19 pandemic: An overview of exploring emotional parameters. Brain, Archives of Neurology and Psychiatry, 58, 42-47.

• Added references to the above-mentioned articles and opened the Finnish context and the importance of majority Lutheran church (ELCF) more to the reader. Additionally added other references to spirituality of older Finns.

3. Inclusion/exclusion criteria of participants have to be reported.

• On pages 3–4, we explain how we recruited the interviewees, and we added some information about the inclusion criteria.

4. More detailed demographics have to be reported for the whole sample (quantitative). In this form this information is missing.

• We added Table 1 on page 4 to present the basic characteristics of the interviewees.

5. One more point that needs clarification is why IPA analysis of data was not follow (as it seems more appropriate). In addition to that, it is not clear how the authors analyzed the data. Please explain in methods section the steps in detail.

• Data-driven qualitative content analysis is an excellent method to find patterns in the data. We understand that IPA analysis would also have been suitable. We added Tables 2 and 3 on pages 5–6 to better familiarize the readers with the chosen analysis method.

6. English language editing is also advised as some points in the text are not clear. Overall, this is an interesting study!

• A native English speaker has checked the language of the manuscript.

Reviewer 2 Report

Thank you for the opportunity to review your manuscript on this very important topic.

The text stands as an easy to read and well layout article, good rigor in the research process, clear presentation of the findings and with only a few minor improvements is worthy of publication. 

The main comments for improvements centres around the mist opportunity of linking the findings (primarily derived from nursing home setting) to theories on person-centred care, that has become the golden standard in care for people with dementia. By including this, the findings can be easily incorporated into care practise and your findings find an easy uptake. 

I suggest you look into Tom Kitwoods theory on Person-centred care – more specifically on his flower model that describes the emotional needs that care for people with dementia must deliver. This touches so many points, both in the introduction on why religion is important to some people (see Kitwoods dementia equation), in the interpretation of the results on what chaplains deliver during visits in the care setting, and on the much relevant topic you bring up in the discussion on how to incorporate religion in a secular dominated society. This will greatly improve the article. 

Another suggestion that will bring the article closer to topics discussed in the care environment, is the addition of reminiscence theory. Specifically in the section on “Chaplains’ generational intelligence” but also in sections referring on how objects help the person with dementia experiencing religious connections and emotions. Key words in this context are the reminiscence bump (why 30’ and 40’ have specifically strong presence in the memory) and how props (objects) stimulate memory’s (also known as auto-self biographical memory). Reminisce is also used in planning and executing care tasks and general communication with people with dementia and will nicely tie your findings to the care context. 

I hope these comments resonates with the scope you have for the article and is primarily suggestions that strengthen an otherwise well written article that I am sure will be a good contribution to science. 

Good luck with reviewing the manuscript. Looking forward to reading the final article. 

Author Response

Comments and Suggestions for Authors

Thank you for the opportunity to review your manuscript on this very important topic.

The text stands as an easy to read and well layout article, good rigor in the research process, clear presentation of the findings and with only a few minor improvements is worthy of publication.  

1. The main comments for improvements centres around the mist opportunity of linking the findings (primarily derived from nursing home setting) to theories on person-centred care, that has become the golden standard in care for people with dementia. By including this, the findings can be easily incorporated into care practise and your findings find an easy uptake. 

I suggest you look into Tom Kitwoods theory on Person-centred care – more specifically on his flower model that describes the emotional needs that care for people with dementia must deliver. This touches so many points, both in the introduction on why religion is important to some people (see Kitwoods dementia equation), in the interpretation of the results on what chaplains deliver during visits in the care setting, and on the much relevant topic you bring up in the discussion on how to incorporate religion in a secular dominated society. This will greatly improve the article. 

• We added Kitwood’s model of emotional needs in the Introduction on page 2, and discuss it in the light of our results on page 14.

2. Another suggestion that will bring the article closer to topics discussed in the care environment, is the addition of reminiscence theory. Specifically in the section on “Chaplains’ generational intelligence” but also in sections referring on how objects help the person with dementia experiencing religious connections and emotions. Key words in this context are the reminiscence bump (why 30’ and 40’ have specifically strong presence in the memory) and how props (objects) stimulate memory’s (also known as auto-self biographical memory). Reminisce is also used in planning and executing care tasks and general communication with people with dementia and will nicely tie your findings to the care context. 

• Many thanks for this important insight! We have added ideas, articles and discussion on ideas of reminiscence therapy and bump. We present some ideas very briefly in introduction and results. In discussion section, we found out that these insights brings new impact to our results as well.