Friday, April 22, 2011

Thought for Good Friday, 2011

For you have died, and your life is hidden with Christ in God. When Christ who is your life is revealed, then you also will be revealed with him in glory. (Colossians 3:3-4)

May we all have a Ghastly Good Friday - that is, one moved and sustained by the Holy Ghost.

Wednesday, April 20, 2011

A Sheep in Wolf's Clothing: More on Being Research Informed

I have written before about the importance of being a research informed chaplain. Two years ago I wrote,

Nurses, physicians, and social workers are publishing research related to spirituality. We as chaplains need to be looking at it for two reasons. First, some of it is actually useful, and we need to know about it. Second, some of it is really not good from our perspective, and we need to be responding critically to it. If those other journals started getting clear and reasoned responses from chaplains, our visibility would rise.
So, as a result, now and again I look through various nursing and medical journals for articles of interest. That’s how I ran across “Is Intercessory Prayer Valid Nursing Intervention?” by Cecily Weller Strang, MSN, RN (Journal of Christian Nursing, Vol. 28, No. 2 [April-June, 2011], pp. 92-95).

Now, before I get into the article itself, let me share my thoughts about the Journal of Christian Nursing (JCN). It is the official journal of the Nurses Christian Fellowship (NCF), and is a ministry of Inter-Varsity Christian Fellowship. Many of us will remember Inter-Varsity Christian Fellowship for its primary ministry on college campuses. This is, as we might say, a journal in which there is no deceit. There is no pretence about their editorial perspective, their target audience, or for that matter their theological perspective (there is a page describing the “Doctrinal Basis” of the NCF). I find it interesting to check out occasionally because in any one edition both my concerns may be apt. That is, there will be some articles that are useful and worth the consideration of chaplains. There will also be some articles that are explicit testimonies. I really don’t have a problem with either. The interesting articles give me something to think about. The testimonies are no worse, really, than the essays and anecdotal reports published in any other journal.

And then there are articles like “Is Intercessory Prayer Valid Nursing Intervention?” It is homiletical, but using the formal academic language of a literature survey. This is not to say that there’s anything terribly objectionable about the article, but there’s little about it that’s terribly exciting, either.

Moreover, there are points at which she seems to undermine her own point. She has a discussion on “Measuring Prayer Effects” that seeks balance. At the same time, since it’s largely in form a review of literature, she offers little interpretation. Instead, she makes an assertion and provides a citation, but with little detail about what in the source cited supports her assertion. Then, in the midst of that, she states, “Note that the use of IP [intercessory prayer] as if it were another drug or medical procedure is not appropriate.” Since she wants to argue that intercessory prayer is a definable intervention, at the very least this statement needs more explication. How is it an intervention, if different from “another drug or medical procedure?” (And, indeed, her abbreviations of IP [intercessory prayer], DIP [distant intercessory prayer], and PIP [proximal intercessory prayer] seems only to clinicalize prayer in parallel with other interventions.) Her attempt to balance this statement by following with, “Neither is it appropriate to deem IP as magical...” doesn’t really address this shortcoming.

She states, “There is precedent for studying IP in nursing care.” This would seem an apt point at which to review any specific studies. Instead, she makes several comments that assert the relevance of concern for spiritual needs in nursing practice, none of which reflect research. She does in an earlier part of the article make some reference to issues in prayer research. This could be strengthened with more explicit references to both past attempts to study prayer, and the difficulties and limitations of such studies. However, the articles cited are not clinical studies of prayer as an intervention. In this case, it would be meaningful to point to both conclusions of specific studies, whether in the earlier paragraph, or in her section on measuring the effects of prayer. (Full disclosure: as a staff chaplain I participated in such a study. You can learn about that study here. I will only say at this point that I am fully aware of important limitations in our study.)

Perhaps the question that caught my attention first was that of whether this was a “nursing intervention,” as opposed to an intervention available to nurses; that is, to what extent is it specifically a nursing function, instead of a function that many might engage in. My reaction was that the latter was true, but not the former. So, it a nursing function and not a chaplain function to manage a medication pump. By the same token, if the situation is appropriate, a chaplain might pray, or a nurse might pray, or another person might pray. If we want to see this as an intervention (and I do; but more about that in another post), it is not the specific purview of any profession. Strang notes “personal knowledge” as a “characteristic fundamental to nursing knowledge.” She goes on to say that “a nurse using personal knowledge of and offering IP to patients is a valid expression of nursing care.” If we understand this to include specifically information from the patient about the patient’s willingness and tradition, I can agree. By the same token, I think referral for a chaplain can be very important when the chaplain can bring to bear personal and professional knowledge about the patient’s tradition, and can explore with the patient an appropriate approach. (But, of course, bringing the chaplain into the discussion might appear to question whether this is an appropriate intervention for nurses to use.)

This, then, brings up a critical issue: the patient’s wishes. When I discussed this with my Best Beloved, who is, among other things, RN, BSN, CHPN, her reaction was, “Of course this is an appropriate intervention for a nurse to use, if it’s what the patient wants.” Let me state clearly that I don’t see evidence in this article that the author wants to impose anything on a patient, or to violate a patient’s tradition, dignity, or wishes. She cites several sources that she sees as offering appropriate guidance,

including applying careful listening, attempting to understand spiritual needs, employing prayer aloud with the patient only with permission, never pushing prayer or beliefs on another, and being authentic and fully present with the patient in the moment. In essence, professional use of IP entails careful respect of patients’ needs, wishes, and beliefs. As professionals desiring to offer the highest standard of care, Christian nurses should employ best practices for the use of IP in the clinical setting.
And so should non-Christian nurses, and chaplains for that matter.

So, here we have an article that pursues a specific point, that intercessory prayer with a patient can, in the right circumstances, can be an appropriate action for a nurse, even in our technological medical culture. It is a reasonable position to take, and published in a journal where it will be well received. At the same time, reading it as a chaplain, I wish she had done what she set out to do more thoroughly. She want to bring to bear her best self in her nursing care, and to do so in a way that supports and does not harm patients. Unfortunately, her effort to support her argument from the professional literature is not as successful.

Part of what this shows reflects my own contention. I think had she been more familiar with the professional literature of pastoral care she would have found better support and interesting reflection for her article. Had she been familiar, for example, with the work of Larry Vandecreek or with articles published in the Journal of Pastoral Care and Counseling, she would have had input from professionals for whom prayer is an intervention for which, while not limited to chaplains, chaplains have specific training.

So, as I said at the beginning, I think we need to read the publications of other professions; and I think other professionals need to read ours. It will offer all of us critique from a variety of perspectives; and I think that those varying perspectives will improve, not only the knowledge we can all share, but the care of patients, to which we’re all committed.

Thursday, April 14, 2011

A View of Things at the Episcopal Cafe

My newest piece is up at the Episcopal Cafe.  Let's just say it's a matter of perspective.  Take a look, and feel free to comment, either there, or here.

And as always I want to encourage you to read more than just my stuff at the Cafe.  I'm in good company there, with folks who put up good work.  Share with us in that, and let us know what you think, too.

Friday, April 08, 2011

Words Have Meaning

Insurance companies are in business to make a profit.  They do not, by and large, exist primarily to pay claims.  Yes, there are mutual companies and co-ops that have a closer relationship with clients because clients are members and owners.  However, commercial insurance companies make money by investing premiums, not by paying claims - a financial industry, and not a service industry.

If you have any questions about that, you need to understand the phrase "medical loss ratios."  You can find a technical definition here (scroll down to it), but essentially it’s the portion of premiums received that an insurer pays out for medical care; and the rest is presumed to be administrative expenses.  So, what they pay out for claims isn’t something they’re happy about.  It’s a “loss.”  If they were oriented to service and not to financial gain, wouldn’t it be something like “customer service ratios;” or perhaps “care provision ratios?”  Businesses committed to serving would, I think, want to take credit for service to customers, or for care provided.  No business wants to take a loss.

Now, commercial insurance is a for-profit industry.  Making a profit isn’t a crime.  By and large, it isn’t a sin (well, that’s perhaps the subject for a longer discussion, but for the moment stay with me).  So, if the proportion of premiums paid out was 100%, there would be no profit.  More to the point, there certainly are appropriate administrative expenses.  Without decent administration, claims wouldn’t get paid; and some payments would be wrong or inappropriate.

There’s also room for discussion about what constitutes “medical care.”  Some things are obvious: reimbursements for a physician visit, or nursing care in the hospital, or for the antibiotic prescription.  Others are clearly not, or at least are clearly not covered in the contract, such as over the counter cough drops or a massage.  Sure, they help us feel better, but we don’t expect them to be covered by insurance.  But, what about alternative care, like homeopathy; or cosmetic care, like some surgeries or weight loss plans?  Some folks find them useful.  Some of the procedures will benefit a small group of patients, but for most they will be matters of vanity.  So, should insurers pay for them?  Should they pay for the few who will benefit, while not paying for those for whom the procedures are strictly cosmetic?  The devil can be in the details, and details matter, if we want our insurers to be good stewards (which is to say, if we want our premiums to be used as well as possible, and stay as low as possible).

This is a particularly hot topic, because the Affordable Care Act now sets requirements for administrative costs and medical loss ratios.  That is, there are requirements that insurers pay at least 80% of premiums received for medical care. (You can get details here; and you can learn a bit about a recent study on the subject here.).  So, beginning this year there are limits on what they can spend on administrative costs; and beginning next year insurers have to report annually what their expenses are.  The law also allows the Department of Health and Human Services to grant waivers to states to allow more time for the insurers they oversee to meet the standard.  Health insurance plans are overseen by each state, and some states already have limits on administrative costs.  However, the Affordable Care Act mandates consistency across the country.  So, insurers won’t benefit by moving from one state to another, or canceling coverage in a state, to seek a better ratio of expenses to “medical loss.”

But, I still think it clarifies things to know they talk about “medical loss ratios.”  Folks, we pay good money for health insurance, and to cover those who can’t get insurance – in premiums, taxes, and the incremental price increases to cover unreimbursed care.  No, it’s not a crime to make a profit, nor (usually) even a sin.  However, while they’re focused on profits, we, the customers and clients, are focused on being served.  It seems pretty reasonable to me that we as a society set some standards about how much of our money gets spent on service, even if it means a little less profit for the company.

Monday, April 04, 2011

The Latest on Endorsement for Episcopal Healthcare Chaplains

"Becoming an Episcopal chaplain," and seeking "endorsement for healthcare ministries" in the Episcopal Church, are perhaps the two most common search strings that bring folks to this blog; and, of course, the two questions overlap.  Some changes are in the works, and I wanted to make sure folks who come here will be up to date.

Margie Tuttle, the Immediate Past President of AEHC, has had a conversation with Terry Foster at the Episcopal Church Center. Terry is the person who processes applications for endorsement.  The Episcopal Church web site is being redesigned once again. Therefore, the online application form for endorsement for healthcare chaplaincy may not be readily available.  Terry asked that we spread the word that anyone interested in endorsement call or e-mail her directly at (212) 716-6068 or e-mail her at I would presume she could also be reached through the Episcopal Church Center's 800 number: (800) 334-7626 , ext. 6068. If you're thinking about endorsement, or know someone who is, please pass this on.