Monday, January 28, 2013

Standards of Practice: Standard 2, Part A

This is a continuation of my reflections on the Standards of Practice for Professional Chaplains in Acute Care. If you are interested, you can access Standards and related information from this page. You can find my earlier posts on this subject by clicking on the link for Standards of Practice under the Label menu in the sidebar.

The next section of “Section 1: Chaplaincy Care With Patients And Families” is “Standard 2: Delivery Of Care.” The specific standard is “The chaplain develops and implements a plan of care to promote patient well-being and continuity of care.”

My first reaction is that this goes without saying, as it were. If we’re not delivering care in some meaningful sense, we’re not really chaplains. This is not to say that someone praying for a patient at a distance isn’t meaningful, or that caring is wasted when one can’t be physically present. I’m convicted of the importance of the ministries of contemplatives, both in intercessory prayer and in other activities. It’s just that the expression of chaplaincy is in the delivery. If our work isn’t having a direct or indirect effect that can be felt at the bedside, how are we chaplains? (There is a much longer discussion to be had about that specific question, but that’s for another time.) And if we’re going to be effective at the bedside, it needs to be based on a plan, an understanding of what we want to accomplish; and on how accomplishing that will benefit the patient, family, and/or staff.

That said, the import of this Standards would seem less about whether something is delivered than about the quality of what is delivered. With that in mind, the Committee added their Interpretation:

The chaplain develops and implements a plan of care, in collaboration with the patient, the patient’s family, and with other members of the health care team. It includes interventions provided to achieve desired outcomes identified during assessment. Chaplains are able to adapt practice techniques to best meet patient needs within their health care setting. Care will be based on a comprehensive assessment.
The Interpretation provides some measures, if you will, about what makes for quality care. First, it not only involves a plan, but calls for a plan made “in collaboration with the patient, the patient’s family, and with other members of the health care team.” It reflects outcomes that are chosen based on a comprehensive assessment. Interventions should not only reflect the assessment, but should reflect needs specific to the health care setting.

Once again, all these might seem to go without saying. However, I think they do need to be said. Pastoral care generally, and some chaplains specifically, have been notorious for basing the plan, not on the needs of the patient or of the specifics of the setting, but rather on the expectations of the faith community and on the limited interventions acknowledged by the provider. There have been two common approaches to patients  that reflect such limitations. One I have called “a wave and a heave offering” (Exodus 29:27, KJV): the chaplain waves from the door, and then heaves ho. I am convicted of the value of the ministry of presence; but such a fleeting presence involves no assessment, and almost no intervention.

The other common approach is much less common than it used to be among chaplains, but it still happens; and it remains common among clergy and lay visitors from the congregation. It is the decision that prayer and/or certain rites are expected or even obligatory because of the connection to the faith community. Those interventions are commonly welcomed, and almost always accepted; but once again they reflect only a minimal assessment of the patient (“member of the congregation”), and little real collaboration. Rarely would the patient refuse them, but they are seen as impositions more often than the providers imagine. I say “imagine” because I attribute good will to those visitors. They don’t want to impose, but neither do they take the time to really determine what the patient is feeling, much less whether the patient wants that specific intervention right now. (Families do try to head this off: “Don’t mention anointing to Mama. You’ll scare her to death!”)

In this sense, then, Standard 2: Delivery of Care is integrally related to Standard 1: Assessment. The quality of the Plan of Care is directly related to the quality of the Assessment. As I noted in my previous post on the subject, the assessment is to be based on “relevant and pertinent data,” and “what is relevant and pertinent is data that assesses spiritual/religious needs, hopes, and resources of this person (which may not be expressed in religious language at all), as these are expressed in this situation and affected by biomedical and psycho-social factors.” This gives us meaningful interpretation of the Interpretation. Outcomes are identified based on the relevant and pertinent data, and interventions are chosen as appropriate to those outcomes. To those ends, the chaplain can adapt the interventions in ways to suit to the setting (which could be considered as part of how biomedical and psycho-social factors affect the situation).

There are two issues that this brings up for me. Let me deal with the easy one first. The fact is that the interventions available to chaplains are limited, both in number and in scope of adaptability. Our first and our pervasive intervention is listening – reflective listening or active listening or however you want to identify it. Beyond that, we use literature (Scripture or other); we provide or refer for appropriate rites; we help connect with the appropriate worshipping community; we help facilitate communication with hospital personnel and/or structures – in a real sense, we’re not using that many tools. Ask a group of chaplains (and I have), and they’ll say we have many tools. Really, though, they’re thinking of variations within each of those activities. We might listen in a therapy mindset or a spiritual direction mindset. We might focus on explicitly religious issues, or on cultural issues, or on institutional issues. We might give feedback or we might be silent, encouraging the person to self-discovery. But, really, all those are various ways to listen and various perspectives on what we hear. I may be a bit of a curmudgeon about this, but it seems to me that we’re really working with a small set of techniques, however much sophistication we might use in applying them. In the language of the Interpretation, we’re working with a small set of tools, that we become adept at adapting.

The second issue, and the more difficult one, is the issue of outcomes. And that’s enough of an issue to have a post of its own.

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