Friday, February 15, 2013

Standards of Practice: Standard 2, 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.

So, in “Section 1: Chaplaincy Care With Patients And Families” we continue to reflect on “Standard 2: Delivery Of Care: The chaplain develops and implements a plan of care to promote patient well-being and continuity of care.” I’ve been thinking about that especially in light of the added 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.
When I ended the previous post, I noted that the topic of “outcomes” was more important and more difficult than that of “interventions.” However, it is important to think about outcomes, and about how we as chaplains choose and measure them.

I have written before about measuring outcomes for chaplains (and readers might want to review that post).  As I have noted before, the difficulty we wrestle with is that the outcomes most important for us are not readily amenable to measure; while the outcomes amenable to measure aren’t necessarily most important. In my earlier post I noted some difficulties related to outcomes

  • Correlation is not causation. Just because we can show something happened during the time we were engaged with the patient doesn’t mean we can demonstrate that it was the chaplain’s intervention that made the difference.
  • Some high correlations might still not be specific to chaplains or to spiritual care. For example, there is plenty of evidence that social support benefits emotional health and a sense of wellbeing. However, good social support might not require the skills of a chaplain, or any professional. For many folks (perhaps for most), a good friend or supportive family member is just as effective. Much of the studies with high correlations demonstrate the value of support in religious communities. However, we can’t somehow show that “religious” communities are inherently more effective than other communities that support the individual in a disciplined, healthy lifestyle.
  • Some of the outcomes we might want to track can be hard to talk about. What does “a sense of peace” look like; and what impact does it have on this patient’s health? We believe profoundly that peace, hope, and reconciliation are good not only for the soul, but also for the body and the mind. How do we make that argument to our colleagues on the healthcare team?
  • Some of the outcomes we might want to track aren’t ours to measure. For example, we might want to show that a chaplain’s visit can lower a patient’s blood pressure. However, that measurement isn’t ours to make. For such measures we’re dependent on the support of other members of the team.
With all that, I still agree that we need to be tracking outcomes. As I said in the earlier post,

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.

I wanted to wrestle with this especially in light of one of the Examples offered in the interpretive material in the Standards of Practice: [the chaplain] “Uses an outcome-oriented plan of care as found, for example, in The Discipline for Pastoral Care Giving: Foundations for Outcome Oriented Chaplaincy.” (Let me note that I don’t think the committee working on the Standards of Practice wanted to automatically prefer one such work over another. The fact is that there just aren’t that many examples of a systematic approach to the subject.) In the opening paper in The Discipline, Arthur Lucas addressed outcomes, and specifically “desired contributing outcomes,” as he and colleagues had come to understand them.
Lucas began by distinguishing between outcomes and activities – or as others would say, between outcomes and processes. He established three parameters in establishing the goals: that they be sensory-based, or essentially observable and demonstrable; that they be communicable to other members of the healthcare team; and that they be shared, agreed and recognized by the chaplain and the patient. In addition, and relevant to them being communicable, they should be outcomes that contribute to the goals of the healthcare team for the patient; and they should be straightforward enough that the chaplain can describe to the team in three sentences or less that the outcome either did or didn’t happen.
I think there is much to be said for the standards and parameters that Lucas and his colleagues set for outcomes. It will not surprise anyone that I also have some reflections. First, I think Lucas and his colleagues underestimated the importance of good processes. Many of the measures used in evaluating our colleagues in healthcare are in fact process measures. For example, among the measures reported to the Center for Medicare and Medicaid Services (CMS), and publically reported about our institutions, are process measures. When a patient comes to an ER with chest pain, does that patient receive an aspirin? When that patient is sent home, did he or she get a prescription for a beta blocker? Is every patient above a certain age offered a vaccination for pneumonia? Notwithstanding that whether a process is or is not performed is in and of itself a measurable outcome, most of the time these processes are offered when the outcomes of the specific processes with the specific patients may never be known. Rather, they are based on population studies that show that these steps have benefited most recipients. While I can see the attraction of outcomes, I think we should not underestimate the value of our own processes. Indeed, we might want to evaluate our interventions not only for their value in pursuing specific outcomes, but also as valuable processes.
Second, I am thoughtful about how we consider outcomes that contribute to the work of the healthcare team. It is indeed worthwhile to choose outcomes that contribute to the healthcare teams goals for the individual patient. How, then, would we identify what contributes? Certainly, we want to determine those for ourselves, based on our spiritual competence. As Lucas wrote,
What are our contributing outcomes? How are they uniquely spiritual? How do we define and contextualize them? How can that be done in the case-by-case care of patients and in the larger context of health care? Defining our contributions out of a ministry of presence, relationship, process, dialogue, knowledge, and faith continues to be hard work.
No one appreciates the difficulty more than I. At the same time, I think we can meaningfully use choose processes and interventions that we share with other colleagues. For example, we might consider Kenneth Pargament’s work on religious coping, or the research on the health impacts of spiritual practice coming out of centers at Duke or George Washington Universities. We might meaningfully apply Benson’s work on the Relaxation Response, or the various studies on the benefits of meditation. The fact that these researchers are not themselves spiritual professionals does not change how well established both these processes and their positive outcomes in many spiritual traditions. And as much as I regret having to say so, there is value to the rest of the healthcare team that so many of those researchers have M.D. after their names. On the other hand, we are called (well, at least many of us are) to be wise as serpents, as well as innocent as doves.
We can also think about the goals of the healthcare team, and of the institutions of which we all are a part. While goals for individual patients are essential, so are goals for the healthcare team and for the institution as a whole. These are in fact addressed later in the Standards.
However, there are points where the institution’s goals and the patients experience are directly related. The most important, and another against which our institutions are measured, is patient satisfaction. While the questions on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys do not include questions about chaplains (or almost any other ancillary service), they include a number of questions about how well the patient was listened to by physicians and nurses. We can make a significant contribution to the patient’s experience of being listened to over all. While this will certainly contribute to pursuit of specific outcomes, it is in itself an intervention, a process. It is a process that will, I believe, contribute significantly to the patient’s experience of support during hospitalization.
Moreover, I would want to consider recent research. We would want to consider the work done at Mayo Clinic, and published as Predicting Patients’ Expectations of Hospital Chaplains: A Multisite Survey (Mayo Clinic Proceedings, November 2010; 85 (11): 1002-1010). To quote from that article,
The results of the current study provide insights that may be helpful to health care administrators, hospital chaplains, physicians, nurses, and others involved in the clinical aspects of health care as they consider allocation of staff and other resources. First, the results showed that most hospitalized patients in the 3 diverse geographic regions studied wanted to be visited by a chaplain. Second, an affiliation with a Catholic or Protestant denomination was the strongest predictor of wanting a chaplain to visit. Third, participants who wanted to be visited were most likely to value a chaplain as a reminder of God's caring presence and as one who prays or reads scripture with them. (Op cit, p. 1008)

At the same time, it should be noted that many patients in the study did not request or did not know how to request a chaplain.
As chaplains we have moved away from a “denominational model” for deploying chaplains, in favor of a clinical model that may be structured by territory (unit assignment) or acuity (crisis and/or referral response). If we take seriously that we want to meet patient needs and expectations, and that our involvement leads to “contributing outcomes,” we need to consider this information with as much respect as we consider the psychosocial contributions we might want to make related to specific medical and nursing diagnoses.
So, I am convinced indeed that identifying “contributing outcomes” is important, and that selecting relevant interventions to pursue those outcomes is important. I also think that our comprehensive assessment and the outcomes we identify from them will certainly need to bring to bear information from other disciplines; research from within our own disciplines; a sense of participating in institutional goals in addition to patient-specific goals; and an appreciation that in our communities there continues to be appreciation for the more traditional roles of clergy that chaplains can reflect within the institution. I am convinced that these are all part of what it means for chaplains to meet the second Standard of Practice.

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