Tuesday, January 13, 2009

Performance/Quality Improvement for Chaplains: Measurement (4)

This is the fourth in a series of posts on Performance/Quality Improvement and measurement for Chaplains. If this is of interest, check the "Labels" section in the left column, and choose "PI/QI."

In addition to contacts, time, and interventions, chaplains have looked for opportunities to measure outcomes. That is, chaplains have sought to identify results or consequences of a chaplain’s interaction with a patient, and to measure how often those results might occur, and what actions of a chaplain might contribute.

Measuring outcomes would be the “gold standard” for determining the impact of a chaplain’s work. That would put the profession in concert with other professions in health care. The move toward “evidence-based practice” is established on discovering results and consequences, preferably those offering benefit, for the patient; and then refining practice to increase benefits and avoid injuries.

We might think of two sorts of outcomes that might be measured. The first would be clinical or objective outcomes. That is, outcomes that would themselves be measurable in terms of changes in the patient’s clinical results – lab values, increased function, etc. The various studies trying to measure the outcomes of prayer for patients have been efforts to see clinical changes.

The second sort of outcomes would be subjective, reflecting assessments of either patient or practitioner. This has in fact been the most common area for chaplain research, in that the largest category has been surveying customer satisfaction. That area is significant enough to require a post of its own. However, there have been a number of studies that assessed subjective reactions to the chaplain’s work, and they do have some value.

I think we also need to note that some studies seem to reflect both. Using a standardized instrument or set of questions gives greater consistency to the information gathered, even though the information itself is a subjective self-report. A favorite example might be the Myer-Briggs Type Indicator. It is an instrument many of us know and love. It has been “validated:” that is, it has been used many times over a long period of time, and the quality of the information gathered is consistent over time. Because of the large populations involved over time, the results can be applied to self-reflection and to analysis. At the same time, the information is largely about preferences and/or self-assessment, and so is subjective. Because the data gathering is standardized, the data gathered is more dependable, but still not necessarily objective. My own experience in taking the Myers-Briggs and the related Keirsey Bates Temperment Sorter is that the results change according to my mood, and according to whatever else is going on in my life. So, when life is difficult and I would like more structure, I am more likely to come out more “judging” than “perceiving” in my own results.

As I noted, there have been a number of efforts to quantify outcomes of prayer. More important have been a many studies done to correlate good health outcomes with religiosity and/or a religious lifestyle. Perhaps the most famous name for that research is Harold Koenig, MD, of the Center for Spirituality and Health at Duke University. He and similar researchers have found significant correlations between healthy spirituality and good health.

At the same time, there is criticism of this research. The most significant critique is to note that correlation is not the same as causation. That is, the fact that religious people are less likely to be depressed does not necessarily show that it is being religious that causes the effect. Some critics pointing this out do so because they are looking specifically for a spiritual, i.e. unexplainable, cause. They might, for example, suggest that better health outcomes come to, say, Amish farmers, not because they are religious but because they get more exercise in their daily life. However, they ignore the fact that they get more exercise precisely because their religious discipline shapes their daily life in that direction. While a consideration for any particular study, the aggregate information from multiple studies becomes more suggestive the more it is confirmed. Still, this is an important critique of the prayer studies.

We might also note that such research doesn’t necessarily help chaplains. Most of the correlative research has been done outside health care institutions, and so doesn’t suggest anything one way or another about the work of chaplains. The prayer studies by and large engaged prayer through prayer groups outside the institutions, and so once again didn’t really say anything about the effects of a chaplain’s work.

There have also been studies of the effects of a chaplain’s work, primarily by recording the subjective responses of patients to a chaplain’s support. Once again, much of this has been in the form of customer satisfaction studies, whether by independent researchers or by institutional quality and business research departments. However, some published studies have sought to measure effects at the bedside. One early study that stood out was that of Chaplain Greg Stoddard at Reading Memorial Hospital in Reading, Pennsylvania (“Chaplaincy by Referral: An Effective Model for Evaluating Staffing Needs;” The CareGiver Journal, Volume 10, Number 1, 1993) In Stoddard’s study, patients were evaluated by chaplains and CPE students using the nursing diagnostic categories of Spiritual Concern, Spiritual Distress, and Spiritual Despair. Patients were assessed at first contact and at subsequent visits, and determined to have improved (e.g., Distress to Concern) or gotten worse (e.g., Distress to Despair), based on relevant statements made by patients and families. While the purpose of the study was to evaluate staffing needs, it incorporated some measurement of outcomes of the chaplain’s visit. Once again, the measurement is subjective in both steps: both the patient’s report and the chaplain’s assessment. However, using standard terms and standard measures, significant efforts were made to standardize chaplain responses. In addition, this took place within the clinical setting, at the bedside, and so is more comparable to measurements of clinical outcomes in other disciplines.

There is the additional difficulty that the outcomes we are most aware of as chaplains are not those used by other disciplines. That is not to say that, like the studies of Koenig et al, we can’t look for such outcomes. They are not, however, those we most value in our own measures of our work. Nor are they within our practice to measure ourselves. That is, we might choose to track how blood pressure or agitation are affected by our work; but the actual measurement will be done by others, and without significant coordination, at their convenience and on their schedule.

Working as chaplains do in a environment of evidence based practice, measuring outcomes could be of great importance, especially in seeing pastoral care departments as necessary rather than as luxuries – useful and desirable, but still luxuries that can be dispensed with in hard times. At the same time, measuring outcomes can be difficult, especially because correlation is not necessarily causation, and because much of the information can be subjective. However, to the extent that we can measure outcomes and can relate those outcomes to patient wellness, it is worth our effort. It contributes to our claim that we are members of the team and important parts of the hospital’s purposes; and it adds to our abilities to communicate with professional colleagues in our institutions.

1 comment:

Anonymous said...

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