Trauma Ward Mental Health Chaplaincy Referral Consent Framing and Post-Traumatic Stress Disorder Treatment Initiation Among South African Survivors: A Stepped-Wedge Analysis of Spiritual Care Gatekeeping

Chaplaincy referral in South African trauma wards functions as an informal gatekeeping mechanism for post-traumatic stress disorder (PTSD) care, yet the consent framing through which survivors are invited into spiritual care has received no systematic methodological attention. Power was estimated across 2000 replications per design cell for cluster counts of 8, 16, 24 and 32 and effect sizes of 3, 5 and 8 percentage points. The analysis indicates that 54 clusters are required to detect a 5-percentage-point effect at 80% power, a requirement that exceeds the plausible number of trauma wards in most South African provinces. The intraclass correlation of 0.64 dominates the design's operating characteristics, compressing the detectable effect range and rendering small framing effects effectively invisible at feasible cluster counts. The contribution is a methodological demonstration that spiritual care gatekeeping research must confront clustering at the ward level before consent framing can be credibly evaluated, and that the field's current reliance on single-site studies cannot support causal claims about referral practice.