Sunday, March 27, 2011

A Nursing Study on Touch - And What We Might Learn

When I’ve reflected on what it means to be “research-informed,” I have observed that we need to read research in the journals of other professions.  With that in mind, last week I did a bit of bouncing through journals to see what I could find of interest.  Because I believe clergy function more like nurses than like physicians, in this case I went looking in nursing journals.  And I found several articles that I found interesting.

One of those was titled “How Should I Touch You?: A Qualitative Study of Attitudes on Intimate Touch in Nursing Care.”  (AJN, March 2011: Vol. 111, No. 3, pp. 24-31) Now, I will admit that I was intrigued by the title before I read the subtitle.  Chaplains are almost never involved in “intimate care” as specified by the authors (although I can’t say never: patients have asked chaplains to stay through care when they would normally have excused themselves), much less in “intimate touch.”  However, there are still themes that I think are worth noting for any physical touch during care, even when it’s not “intimate care.”

For the study, the researchers gathered three focus groups, for a total of 24 participants (12 male and 12 female). Potential participants who were nurses or who had been nurses or nursing students were excluded.  Participants were gathered from ROTC students from a Catholic university; parishioners from a Catholic parish; and from a Protestant congregation (the congregations where the researchers worship).  Discussions were guided through a series of questions:

What do you think about, or how does it make you feel when you think about, a nurse having to touch you in private areas of your body in order to take care of you?

If a nurse had to help you take a bath, what things might a nurse do that would make you anxious?

Let’s say you are confined to bed.  After using a bedpan, you realize you accidentally soiled your pajamas and bedsheets, and the nurse has to clean you up.  What things can the nurse do to help you maintain your dignity?

Let’s pretend you have been in a terrible accident and have to have other people do everything for you.  John is your nurse today, and he has dome to do your personal hygiene.  What should John do to show you that he is professional and respectful?

How should John touch you?

Does anyone have a different thought about this?

Is there anything else we should teach nursing students about touch?

The facilitator or recorder will summarize key points and comments from the discussion to validate accuracy and provide an opportunity for clarification.

As in any focus group, these questions provided context and framework, and generated other questions and comments.  Each group lasted 60 to 90 minutes, and was both taped and transcribed.

From the groups, recordings, and notes, the researchers identified four themes.  First, “Participants in each focus group said communication was of the utmost importance before intimate touch could take place…. Also, participants said that communication should convey professionalism and respect.”  They wanted some sense of rapport, and not a clinical distance, and even “welcomed some self-disclosure from nurses….”

A second theme was the desire of participants for choice.  “Participants said they wanted to be involved in deciding whether intimate touch was necessary and whether there were alternatives.”

A third theme was that gender was an issue to be addressed: participants would want to be asked.  Having been a patient who had received care from a nurse of the opposite sex could make a difference in the concern if the experience had been professional and supportive; but not always.  In addition, having a chaperone addressed one issue and raised another.  Participants felt they would want rapport with and involvement by the chaperone in addition to the caregiver.

Finally, the manner in which the nurse approached and touched the patient were also important.  Participants expressed a desire that the nurse appear confident and professional.  The nurse should respect the patient’s privacy as much as possible, including closing doors whenever possible, and not just curtains.  Finally, the nurses touch should also be confident and professional, neither lingering nor rapid and rough.

For the chaplain, presence for, much less participation in, intimate care will be far and away the exception.  At the same time, our interactions are emotionally intimate, and we can apply these same principles in some sense.   Even though between short hospital stays and the priority of treatments and other activities our time with patients may feel quite limited, it is still important for us to communicate clearly our interest in the patient as person, and our role and reason for visiting.  There is power in asking the patient’s permission, not only to touch, but also to be present.  The comments about the chaperone may apply, too, in educational settings where a student may shadow an experienced chaplain, or a supervisor may accompany a student on a visit.  Both persons present should engage the patient, while being clear between themselves who is responsible for care.

It is also important for chaplains to take seriously issues not only of gender but also of other expressions of diversity in encountering patients.  While we as professionals are called to provide care across the boundaries of our differences, our patients are not required to accept it.  While we may chafe if we’re rejected over issues of gender, race, creed, etc, we are still called to respect the individuality of the patient as best we can. At least, by accepting the patient’s refusal with good grace, we allow the patient to exercise some control.

At the same time, we, too, are called to be sensitive about how we touch, both physically and metaphorically.  Even to take a hand or to touch a shoulder for prayer requires the patient’s consent.  We might accept it implicitly if the patient reaches for the chaplain; but we do well to confirm consent in all circumstances.  By the same token, we need the patient’s consent for intimacy regarding the patient’s history and feelings.  There is a point to bringing a limited agenda to the chaplain’s approach to the patient; and the short-term focused psychotherapy appears to demonstrate benefits that we can parallel.  However, the patient in the bed is not the client on the couch, present largely at his or her own request.  It is important that we present ourselves professionally and confidently.  It is also important that we appreciate the patient’s sense of timing.  We are called to approach the patient clearly (and so not be “too slow”), while also accepting the patient’s sense of readiness (and so not be “too fast or too rough”).  There are times and settings where direct confrontation is appropriate, but they are relatively specific.  In general, a sense of the patient’s readiness and timing is an appropriate part of spiritual assessment.

I expect many of my readers will respond to all this with, “Yes; and?”  It seems to me that this is information we know, information we have intuited from our own experiences and our concern and respect for each patient’s individual dignity.  However, the authors of the study were surprised to find that this topic had never been studied and published.  While there is value to our inferences, it is important to test them.  The researchers have studied the topic, and so questioned the inferences among nurses.  We can benefit from their work as well, by respecting what they learn in the process for their own profession, and by considering what we might also learn in the process.

Saturday, March 26, 2011

Nice News About Another Episcopal Chaplain

Another note from this year’s gathering of chaplains in APC and especially in AEHC this year.  One of our own has been honored.  Carolynne Fairweather, DMin and Board Certified Chaplain, and member of AEHC, was recognized as one of two recipients nationally of the APC Outstanding Local Leadership Award.  According to the APC web site,

The Outstanding Local Leadership Award is given to a member in good standing who has exhibited outstanding dedication to and promotion of APC through active involvement and initiative at the local level, including substate, state, or multistate levels.

 Among the comments reflected in her biography for the award was this quotation: “Her enthusiasm and gift for hospitality is both amazing and contagious.  You feel truly welcomed and you want to become involved when you are around her.”

So, for Carolynne, blessings and congratulations!

Friday, March 25, 2011

Raising Up One of Our Own

One of the joys of gathering with colleagues is discovering wonderful things they have done.  I have one of those to announce.  My colleague, Episcopal priest and chaplain and AEHC member the Rev. Dr. Hiltrude Nusser-Telfer has written a book, and it's now available for purchase.  The title is Outcomes of Faith During Hospitalization: A Case Study Method.  It describes her own steps in reviewing cases, and offers a number of cases to illustrate.  It is available from Author House in paperback and as an ebook; and also from Amazon and Barnes and Noble.

Case studies, both in the form of verbatims, and in other formats have been essential parts of clinical learning and professional development for chaplains.  We need to share the stories, and also how we analyze and learn from them.  Chaplain Nusser-Telfer is sharing her stories with us and offering herself.  It's one more opportunity to learn from one another's experience.

Thursday, March 24, 2011

A New Voice

You may have noticed that I have a list of blogs whose authors write about chaplaincy and issues important to chaplains.  Well, I've added a new one to the list.  Martha Jacobs, a Board Certified Chaplain and valued colleague will now be blogging at the Huffington Post.  Since HuffPo is one of the most active news aggregator sites on the web, this should bring a lot of attention to issues of pastoral care, and bring a well reasoned perspective to issues of health care.  Go take a look: Martha's well worth knowing.

Monday, March 21, 2011

An Important Issue - or At Least I Think It May Be

I suppose it’s a case of what did we know and when did we know it.  A story came to my attention.  It’s online at Mother Jones, and it’s titled, “Death By a Single GOP Cut?” According to the author, Suzy Khimm,

The House GOP's 2011 budget would chop $156 million from the Centers for Disease Control's funding for immunization and respiratory diseases. The GOP reductions are likely to hit the CDC's support for state and local immunization programs, the agency's ability to evaluate which vaccines are working, and its work to educate the public about recommended vaccines for children, teenagers, and other susceptible populations.

So, the cuts would result in less money for vaccinations through public health providers.  That means fewer children vaccinated, and more children at risk for avoidable infectious diseases.

We have recently seen outbreaks of whooping cough and measles.  We know the risk is real enough between those who can’t take vaccinations and those whose parents have been so misinformed as to withhold vaccinations.  Reducing vaccinations as a result of reducing federal dollars would only exacerbate the problem.

Now, as liberal as I am, and as sympathetic in general to the editorial perspective of Mother Jones, I’d like more documentation.  So far, no one else has picked up this story, at least as far as a search in Google News will show.  I did look at the site of the American Public Health Association (APHA), and found a press release: “APHA Strongly Urges U.S. House to Oppose Deep Cuts to Core Public Health Initiatives.”  Unfortunately, that single sentence is all that’s available on the web site.

So, we have one news site referring to a possible risk to a very important public health function (and, no, Huffington Post is not a second reference, because all HuffPo does is cite the Mother Jones article), but without specifics (like the name or number of the bill, and – even better – the paragraph number and a link, so that we could read for ourselves).  We have a statement from a reputable professional organization, but it’s very generic; and while it might well include the specific program of concern, it doesn’t say so.

I certainly want to know more.  I’m going to pay attention.  On the other hand, I wouldn’t put such a short sighted decision beyond the imaginations of someone in Congress, I find it hard to imagine that most members are so badly informed as to allow this to happen.  So, with all due respect to Ms. Khimm, I’m going to watch for this, but I’m not going to get upset until I hear more. 

Thursday, March 17, 2011

Let's Go Through It One More Time - at the Episcopal Cafe

I have something up again at Episcopal Cafe.  It is a reflection on music and repentance and Lent.  Feel free to let me know what you think, whether at the Cafe or here.

And once again while you're at the Cafe, take some time to look around.  There are many good essays and reflections to read there, and good information in issues important to Episcopalians and other Anglicans.  As one of the contributors, we're always happy to have folks read, mark, and learn - and then comment, so that we hear what others are thinking.

Wednesday, March 09, 2011

How? How Else?

How is it that we find these words to be words of hope, and not of fear:

Remember that you are dust, and to dust you shall return.

How is it that we find these words to be words of promise, and not of despair:

Remember that you are dust, and to dust you shall return.

How is it that we find these words to be words restoration and return, and not of loss and desolation:

Remember that you are dust, and to dust you shall return.

How, save by trusting in Christ and in the grace of God?

Monday, March 07, 2011

The Case in Montana

A while ago I shared my appreciation for psychiatrists and psychologists, and the appreciation I’ve found among many for patients’ spiritual concerns.  If you recall (or as you’ll discover if you read the earlier post), that was illustrated by the story of the psychiatrists who regularly consulted me when a foreign-trained medical resident heard a patient say, “If it’s my time to die, if God calls me, I’m ready to go,” and identified it as “suicidal ideation.”

I thought of that story again when I read about a court case in Missoula, Montana (you can read about it here and here).  A woman, identified in court documents as L.K., was diagnosed with Stage I cervical cancer.  She has hesitated to have a hysterectomy.  Reportedly, she made this decision so far in part because she might want to have a child (something a physician has stated is unlikely but possible), and in part for “religious reasons.”

Her “religious reasons” were a matter of concern for one of her physicians and one of her nurses, who between the two of them sent three letters last fall to the Missoula County attorney’s office.  The point of the letters was to question, based on her “religious reasons,” whether she was competent to make the decision regarding surgery and a condition that would eventually be fatal if left untreated.  A medical guardian was appointed, who signed a consent for the hysterectomy.  The surgery was scheduled for last Thursday, but has been postponed by the State Supreme Court to allow an appeal by a public defender.

In a hearing last week, a psychiatrist stated that the patient had “religious delusions,” including that “God had healed her.”  These delusions prevented her from making the appropriate decision to accept the surgery.  The patient, on the other hand, said she did understand her condition and her risk.  She simply wanted to make her own decision on her own schedule.  Her public defender said she is not delusional, but simply very religious, and that forcing this surgery would harm her religious freedom, her physical integrity, and her dignity.

Now, let me say that it is entirely possible that a person might be delusional with religious ideation.  It is possible that is the case with this woman.  However, without actually hearing the conversations, I couldn’t say for myself which I thought was the case.  And while I do have respect for psychiatrists and psychologists, and find that the great majority of them have respect for patients’ religious concerns, there are exceptions.  There are still those who feel that any religious thoughts are by definition dysfunctional.  Again, without actually hearing the conversations, I hesitate to express an opinion.

There is, though, another point from which to consider this.  I have observed that autonomy has become the driving moral principle in health care decisions these days.  This case has in tension the patient’s autonomy with the physicians’ concern for the patient’s best interest (Beneficence).  Now, if and to the extent that this woman is delusional, she may be limited in understanding her own best interest (and I say “to the extent” because decisional capacity isn’t really all or nothing); but if and to the extent that she is not delusional, she has the right to make this decision, even if she ends up dying for it.

That’s really the hard point of the principle of Autonomy for many health care providers.  If we are to allow patients to make their own decisions, we have to respect their right to make even decisions we thing are wrong.  Yeah, we might think a particular decision is wrong, or even crazy; but that doesn’t make the patient crazy in the clinical sense.

We can certainly hope that the judge will give the appeal careful and thorough consideration.  L.K. certainly needs for the review to be thorough, but so do the rest of us.  If it appears that a patient has been declared incompetent only because the patient refuses a treatment, even a treatment that may be life-saving, there is the risk that a court decision may result in loss of rights for many of us.

Saturday, March 05, 2011

Thoughts for the Last Sunday After Epiphany (A)

As they were coming down the mountain, Jesus ordered them, "Tell no one about the vision until after the Son of Man has been raised from the dead."

Why in heaven’s name would Jesus do that?  They’d just had the spiritual experience of their lives.  They had just seen God’s glory reflected in their rabbi.  In light of Peter’s confession that Jesus was the Messiah, it was as reasonable as they could imagine – if one could describe as reasonable an experience they could not have imagined before it actually happened.  This was, in a way, the ultimate confirmation of the time they had spent with Jesus.  They had been with him almost three years.  They had left it all to follow Jesus, friends and family and good careers, and now they had the confirming experience.  God had show unmistakably, unequivocally, that his favor shone on Jesus.  There he was, in light they could hardly bear, flanked by the heroes of their faith, Moses and Elijah.  And after all that, Jesus says, "Tell no one about the vision until after the Son of Man has been raised from the dead."  How could he do that?

Perhaps it was to prevent them becoming, as folks say, “too heavenly minded to be any earthly good.”  If they spent all their time looking in awe at Jesus, they might well miss all that went on around him – and from this point, there’s still a lot to see around Jesus.

Perhaps it was because of the distance they still had to travel.  The journey from the foot of the Mount of the Transfiguration leads up to Jerusalem – and to the cross.  The story would not end, and could not be understood, if they never left the mountain, even in their own minds.

Perhaps it was because they hadn’t yet understood their vocations, vocations that would not actually be set until after the resurrection.  Indeed, as the story could not be understood if they never left the mountain, neither could their ministries take form if they never left the mountain.

One way or another, they had much yet to see, far yet to go, and a lot yet to learn.  For all the excitement they had experienced – and for all of the joy found in simply adoration – there was more to experience; and they would never see it if they stayed, even in their own minds, up on the mountain.

Icing on the Cake

It has been a fun day here in West Missouri.  Today by God's grace and with God's people gathered, Martin Scott Field was ordained the eighth Bishop of West Missouri.  It was, or course, quite a service.  The ordination of a bishop is not something we experience that often (okay, well, bishops do; but not most of us) because our diocesan bishops are, by and large, pretty healthy and serve for a while.  So, it is a rare and exciting event.  But, then, we do grand ceremony like nobody else.

For me personally, too, it was a great day, at least as an Episcopal blogger.  George Clifford, who blogs at Ethical Musings, and who is with me a regular contributor at the Episcopal Cafe, was the preacher.  He knew Bishop Field when both were Navy Chaplains together.  Indeed, I met George because of his Navy chaplaincy.  He and I worked in several General Conventions tracking resolutions for Bishop George Packard, then Bishop of Federal Chaplaincies (which is the current title of the office).

And after the service, I heard a voice: "Aren't you Marshall?"  Lisa Fox of My Manner of Life and Maria Evans of Kirkepiscatoid had come to Kansas City for the celebration.  Both are in Missouri (although in the other diocese), and so were able to make the trip for the day.  As happens with bloggers, we've read each other's stuff.  We just haven't had the chance to meet.

That's the way it can be, really: we live in our own places, and put our thoughts out there for everyone to share.  But, living in our separate places - and perhaps more so here in the middle of the country - we Episcopal bloggers don't often gather.  It was a nice addition to a good day to be able to share it with colleagues who, like me, want to reflect on, among other things, the joys (and occasional frustrations) of life in the Episcopal Church.

Tuesday, March 01, 2011

A Thought This Morning

Lord, I have long ago lost my surprise that the unrighteous prosper.  But, Lord, the obnoxious?