Tuesday, January 28, 2014

Standards of Practice for Chaplains: Standard 3, Part B

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.

I ended my last post focused on examples in the explanation of Section 1, Standard 3 Documentation. I was thinking about principles of the Standard that I suggested might be necessary but not sufficient:

Documentation should include but is not limited to the following:
  • Spiritual/religious preference and desire for or refusal of on-going chaplaincy care. Reason for encounter.
  • Critical elements of spiritual/religious assessment .
  • Patient's desired outcome with regard to care plan.
  • Chaplain's plan of care relevant to patient/family goals.
  • Indication of referrals made by chaplain on behalf of patient/family.
  • Relevant outcomes resulting from chaplain's intervention.

My questions were, first, whether these principles were really those we would focus on; and second, how our tools for documentation would affect our efforts at documentation. Let me begin with my first question.
Let me begin with a note about how these principles contribute to the explanation. They can shape our thoughts, our plans. At the same time, they are neither the Criteria of Measurement, nor are they among the Examples. They are to help us think, to help us plan; but in one sense they are "neither fur nor feather, neither fish nor fowl." The thing is, though, that we must avoid getting too hung up about these words – indeed, about any of the words, including the Criteria of Measurement and the Examples. The Standards of Practice are works in progress, and subject to revision over time. Lived experience should over time shape these Standards. So, in considering any of these words, these concepts, we can remember that they are to help us think and talk more than they are to become "the law of the Medes and the Persians that cannot be changed." So, the real question is how these principles and criteria and examples can be useful for us, and not how can we fit our work into these parameters.
So, in asking whether these principles are the ones we want to live with, we have room to discuss how we might use them. One stands out to me. While I can readily see the importance of spiritual/religious preference, I wonder whether "desire for or refusal of on-going chaplaincy care" should be necessary. First and foremost, is that a matter that will come out of an authentic conversation? We might hear that; or we might elicit it with a question; but we might not. Further, it presupposes that the patient has a clear understanding his or her own needs or that the patient has a clear sense of all a chaplain has to offer. Also, pairing follow-up care with spiritual/religious preference appears to presuppose that the chaplain's work will be valued more by those who have a preference than by those who don't.

I could raise a related question about "Patient's desired outcome with regard to care plan." If we are professionals with a body of knowledge that we bring to goals for the patient, how do we balance the patient's desired outcome against our assessment of the patient's needs? I think the patient's desires are certainly of diagnostic value. I am also clear that a patient will pursue with more commitment outcomes that the patient agrees with. On the other hand, patients may have goals that in the eyes of the practitioner aren't possible, or aren't reasonable. We see that often enough with physical care. As I considered what it might mean in our work, I thought of the person who wanted reconciliation with a separated family member, but only on his or her own terms. I thought of the patient who wanted a closer relationship with God, to be measured by unalloyed happiness. Those goals are indeed where we start; but they are, as I said, of more value in assessing the patient's needs than as an outcome measure. Again, my point is not to reject these recommendations (even if they appear phrased as directions), but to consider how they might or might not be useful.

On the question of our tools: I have discussed this already when discussing assessment. As the structures within our tools will shape our assessment, so will they shape our documentation of care. In this case, we are like other practitioners in health care: we have processes that are easy to document, and outcomes that are harder. In our time of electronic documentation, this is no small issue. Processes are, if you will, binary: either they happened or they didn't. That makes them amenable to check boxes. Outcomes, on the other hand, are much more nuanced. We know reconciliation when we see it; but just to check a hypothetical box marked "Reconciled" won't tell us or anyone else anything. We can check a box marked "Renewed Hope," but we may well need to be specific about hope in what and for what.

Moreover, as much or more with our documentation of service as with our assessments, we need to pursue as best we can having our documentation read. That will, I think, take a two-pronged approach. The first is documenting, and documenting as clearly as we can. The second is knowing how other colleagues can and should see our documentation and taking opportunities to remind them it is there. In paper charts there have been divisions (physicians, nurses, social workers, lab work, etc.) and a risk that information would get "siloed" – separated in parallel but not intersecting categories, with boundaries crossed only by those interested when interested. Sometimes there was a clinical note process used by more than one profession, and that helped; but only when we used it diligently.

The same is true in electronic documentation. Some models might still separate information by practice. This can sometimes be aggravated by guidelines overzealous about HIPAA. An incomplete understanding of our participation on the health care team and some hyper-vigilance can end up cutting us off from relevant information, and cutting others off from us. So, it is important that we recognize the capacities and the limitations of our tools, our electronic medical records, and where necessary supplement them. That is, the best documentation is no substitute for engagement with colleagues on the units. We no that to be the case with paper documentation, and it does not change with electronic documentation. We will need to document effectively, and still periodically point others to our documentation. That, too, will be an ongoing educational process as nurses, social workers, and physicians come and go. 

So, as we live with the standard on Documentation, we can reflect and learn about what works for us, and how. We can also continue to pursue the professional relationships within which our documentation will have meaning. These are, really, issues we face with any new tools. Our opportunity in living out the Standards of Practice is to take on those issues with renewed energy and conviction of their value – and of ours.

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