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.

Standards of Practice: Standard 3, Part A

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. 

The next section of “Section 1: Chaplaincy Care With Patients And Families” is “Standard 3: Documentation of Care.” The specific standard is “The chaplain enters information into the patient’s medical record that is relevant to the patient’s medical, psycho-social, and spiritual/religious goals of care.” This follows clearly from the Standards on Assessment and Delivery of Care. Information from the assessment directs provision of care; and having been provided, it is important that the care be documented. It is axiomatic in health care that “if it didn’t get documented, it didn’t get done” – that is, no one coming along later, whether another member of the team or a coder in Patient Accounts, will know what has been done for and with a patient, and what ought to be done next. If anything, this is more incumbent on spiritual care providers than on others. If a nurse gives a medication, there are very likely going to be measures affected – lab values, blood pressure, etc. As I have noted, our outcomes are rarely so readily connected directly to our work; and that makes it all the more important that our work be documented.

I have already considered that phrase, “relevant to the patient’s medical, psycho-social, and spiritual/religious goals of care” in a previous post, or at least about what is “relevant.” It should be noted, though, that central to this Standard, as understood by the Committee, is some further elaboration on “information… relevant to the patient’s medical, psycho-social, and spiritual/religious goals of care.” The Interpretation section includes this:

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.

This list of categories that we might call “necessary, if not necessarily sufficient,” provides its own framework of what is relevant. The question remains, though, as to whether these are the most appropriate categories.

Even accepting this list of “necessary if not sufficient” categories, there is another issue: what about our tools for documentation? Are they adequate to the task? Do we have adequate access? Are we using our tools as well as we can; and what might that mean? I will address that in a subsequent post.

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.

Standards of Practice: Standard 2, Part A

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.

The next section of “Section 1: Chaplaincy Care With Patients And Families” is “Standard 2: Delivery Of Care.” The specific standard is “The chaplain develops and implements a plan of care to promote patient well-being and continuity of care.”

My first reaction is that this goes without saying, as it were. If we’re not delivering care in some meaningful sense, we’re not really chaplains. This is not to say that someone praying for a patient at a distance isn’t meaningful, or that caring is wasted when one can’t be physically present. I’m convicted of the importance of the ministries of contemplatives, both in intercessory prayer and in other activities. It’s just that the expression of chaplaincy is in the delivery. If our work isn’t having a direct or indirect effect that can be felt at the bedside, how are we chaplains? (There is a much longer discussion to be had about that specific question, but that’s for another time.) And if we’re going to be effective at the bedside, it needs to be based on a plan, an understanding of what we want to accomplish; and on how accomplishing that will benefit the patient, family, and/or staff.

That said, the import of this Standards would seem less about whether something is delivered than about the quality of what is delivered. With that in mind, the Committee added their 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.

 

The Interpretation provides some measures, if you will, about what makes for quality care. First, it not only involves a plan, but calls for a plan made “in collaboration with the patient, the patient’s family, and with other members of the health care team.” It reflects outcomes that are chosen based on a comprehensive assessment. Interventions should not only reflect the assessment, but should reflect needs specific to the health care setting.

Once again, all these might seem to go without saying. However, I think they do need to be said. Pastoral care generally, and some chaplains specifically, have been notorious for basing the plan, not on the needs of the patient or of the specifics of the setting, but rather on the expectations of the faith community and on the limited interventions acknowledged by the provider. There have been two common approaches to patients  that reflect such limitations. One I have called “a wave and a heave offering” (Exodus 29:27, KJV): the chaplain waves from the door, and then heaves ho. I am convicted of the value of the ministry of presence; but such a fleeting presence involves no assessment, and almost no intervention.

The other common approach is much less common than it used to be among chaplains, but it still happens; and it remains common among clergy and lay visitors from the congregation. It is the decision that prayer and/or certain rites are expected or even obligatory because of the connection to the faith community. Those interventions are commonly welcomed, and almost always accepted; but once again they reflect only a minimal assessment of the patient (“member of the congregation”), and little real collaboration. Rarely would the patient refuse them, but they are seen as impositions more often than the providers imagine. I say “imagine” because I attribute good will to those visitors. They don’t want to impose, but neither do they take the time to really determine what the patient is feeling, much less whether the patient wants that specific intervention right now. (Families do try to head this off: “Don’t mention anointing to Mama. You’ll scare her to death!”)

In this sense, then, Standard 2: Delivery of Care is integrally related to Standard 1: Assessment. The quality of the Plan of Care is directly related to the quality of the Assessment. As I noted in my previous post on the subject, the assessment is to be based on “relevant and pertinent data,” and “what is relevant and pertinent is data that assesses spiritual/religious needs, hopes, and resources of this person (which may not be expressed in religious language at all), as these are expressed in this situation and affected by biomedical and psycho-social factors.” This gives us meaningful interpretation of the Interpretation. Outcomes are identified based on the relevant and pertinent data, and interventions are chosen as appropriate to those outcomes. To those ends, the chaplain can adapt the interventions in ways to suit to the setting (which could be considered as part of how biomedical and psycho-social factors affect the situation).

There are two issues that this brings up for me. Let me deal with the easy one first. The fact is that the interventions available to chaplains are limited, both in number and in scope of adaptability. Our first and our pervasive intervention is listening – reflective listening or active listening or however you want to identify it. Beyond that, we use literature (Scripture or other); we provide or refer for appropriate rites; we help connect with the appropriate worshipping community; we help facilitate communication with hospital personnel and/or structures – in a real sense, we’re not using that many tools. Ask a group of chaplains (and I have), and they’ll say we have many tools. Really, though, they’re thinking of variations within each of those activities. We might listen in a therapy mindset or a spiritual direction mindset. We might focus on explicitly religious issues, or on cultural issues, or on institutional issues. We might give feedback or we might be silent, encouraging the person to self-discovery. But, really, all those are various ways to listen and various perspectives on what we hear. I may be a bit of a curmudgeon about this, but it seems to me that we’re really working with a small set of techniques, however much sophistication we might use in applying them. In the language of the Interpretation, we’re working with a small set of tools, that we become adept at adapting.

The second issue, and the more difficult one, is the issue of outcomes. And that’s enough of an issue to have a post of its own.

Standards of Practice for Chaplains: Standard 1, Part B

I left off my last reflection on Standard 1 of the Standards of Practice for Acute Care with this paragraph:

Which confronts us with the qualifying term: what makes the data relevant? Actually, the Standard is to evaluate the data for relevance. Our models for evaluation are the frameworks within which we determine whether the data is relevant. So, let me think a bit and then come back in the next reflection.

So, how shall we evaluate the data as relevant and/or pertinent (in this case, that may be a distinction without a difference)? Well, we do have some help in clarifying that. In fact the Committee that drafted the Standards of Practice went farther, and did offer some further reflection. (Again, you can link to the Standards from this page, and then scroll down to the more detailed reflections.) The interpretation of the Standard includes,

A chaplaincy assessment in health care settings involves relevant biomedical, psycho-social, and spiritual/religious factors, including the needs, hopes, and resources of the individual patient and/or family.

A comprehensive chaplaincy assessment process includes:

• Gathering and evaluating information about the spiritual/religious, emotional and social needs, hopes, and resources of the patient or the situation
• Prioritizing care for those whose needs appear to outweigh their resources

.
My first reaction is that the first sentence doesn’t help us a lot. “Relevant biomedical, psycho-social, and spiritual/religious factors” would, in a hospital, seem to cover just about all the information gathered. However, I think the further categories are helpful. “[T]he spiritual/religious, emotional and social needs, hopes, and resources” do give us something to work with. Note, too, that both the persons (“the individual patient and/or family”) and circumstances (“of the patient or the situation”) are important.

So, if we return to the language of the Standard itself, “relevant” and “pertinent” are related to the needs, hopes, resources, and capacities (whether needs outweigh hopes and resources) of particular persons in specific situations. This, then, gives us categories that allow us to structure our assessments and organize our responses. It also allows us to set some boundaries and make appropriate referrals. For example, while the patient’s biomedical needs might well outweigh resources (after all, how else would someone end up in our institution?), our response is going to be limited primarily to advocacy. We can let the nurse know when the patient reports pain, but we won’t be providing medication ourselves. The same applies to psycho-social needs. Depending on how professionals relate in a specific institution, the chaplain can advocate about social needs, and may have some resources to bring to bear. On the other hand, except in particular circumstances, a chaplain will not be providing psychotherapy for a patient. (Let me say explicitly that I do think we all share in the same first intervention: therapeutic listening. And while therapeutic listening is therapeutic, it only extends into therapy per se if we’re trained for it.) And in most of our institutions even social needs will be referred. While we may have some resources, most chaplains depend heavily on the social workers, case managers, and discharge planners they work with to meet social and/or financial needs.

Which leads us to focus especially on “spiritual/religious factors,” which will certainly include “the needs, hopes, and resources” available. The fact is that this is something of a soapbox of mine. Institutions have or make available professionals trained in psychology and social work. Most of them are quite conscious that they aren’t trained to address spiritual/religious needs. We are. The reasons institutions have us is to address those spiritual/religious needs. So, while we want to be alert to the impact that biomedical and psycho-social needs have on spiritual/religious needs, it is the latter that are our domain and should be our focus.

So, what is relevant and pertinent is data that assesses spiritual/religious needs, hopes, and resources of this person (which may not be expressed in religious language at all), as these are expressed in this situation and affected by biomedical and psycho-social factors. We would hope that, as we would refer appropriate when biomedical and psycho-social needs are affecting the spiritual/religious needs, our colleagues in other professions would refer when spiritual/religious needs seem to be affecting biomedical and/or psycho-social needs. (Well, one can hope….)

Let me make one further reflection on the further explication of the Standard from the Committee. The examples they offer of how one might demonstrate compliance with the Standard is focused not on the data but on qualifications of the tools. Specifically, the Examples refer to “an accepted model” or to “published models for spiritual/religious assessment.” The problem is that these are really more aspirational than real. There are certainly published models for spiritual/religious assessment. However, none of them has been “accepted” across the profession. Each has its strengths. The good folks at Healthcare Chaplaincy Inc. have compiled a list of articles and book chapters that highlight a number of them. But, beyond publication per se none of them has been accepted broadly, or in any official sense.

Moreover, most of them were developed prior to the development of electronic documentation. While one would expect that the categories of any model could be adapted to an electronic platform, each platform has its own limitations – How many fields for data? How many characters per field? As we merge those two tools, we then have to make our own interpretive decisions. What is amenable to a list of bullets or boxes to check? What requires narrative? Knowledge of a variety of models is interesting, but we can only apply one or two in shaping our documentation – and that will inherently shape our assessment. (Remember the proverb that begins, “If your only tool is a hammer,….”)

So, it seems to me that the specifics of the tool – Which model? Which platform? How configured – are secondary to the intent. The measure has to be whether the assessment tool gathers information about spiritual/religious needs, hopes, and resources, with room to note how biomedical and psycho-social needs have impact on them. If the tool does that, it would seem adequate and appropriate to the task. If the tool does that, and the chaplain uses the tool faithfully, I think the chaplain would be meeting the Standard.

Standards of Practice for Chaplain: Standard 1, Part A

I know it’s been a while. Bear with me.

Many of the professions involved in health care have long had Standards of Practice. For example, you can learn about nursing standards here; or about social workers here.

In 2009 a group  with representatives from the Association of Professional Chaplains (APC) and the National Association of Catholic Chaplains (NACC) produced a set of Standards of Practice for Chaplains in Acute Care (which is to say, in hospital settings). You can learn more about that process and access the Standards here.  The Standards may have several benefits for us in the profession.

Having Standards of Practice will now help chaplains communicate with others about chaplaincy and assist chaplains in discussions with other chaplains. Ultimately, the goal is to ensure a consistently high clinical practice for our profession.

With these goals in mind, my department is embracing these Standards of Practice. Over time they should become the framework for our work, and the way that we “tell our story” to other chaplains and to administrators.

That means I need to be thinking through these Standards myself. I need to be able to speak to them if I’m going to help others embrace them; and one of my most effective ways to think is to think out loud here.

The Standards are divided into three sections. Section 1 is Chaplaincy Care with Patients and Families. The sections begin with “Standard 1, Assessment: The chaplain gathers and evaluates relevant data pertinent to the patient’s situation and/or bio-psycho-social-spiritual/religious health.”

As I look at the Standard, the first issue has to be definition of terms. For me, the hardest isn’t really the strangest. “Bio-psycho-social-spiritual/religious health” is simply – no, let’s just say really – a jargonistic way to speak to the health of the whole person, incorporating an expectation that a person who is holistically healthy is spiritually healthy.

No, I’m much more concerned first about “relevant data pertinent to the patient’s situation….” What are we considering data?

One of the older documentation frameworks, used in many cases in Social Work and also sometimes by chaplains, is the classic SOAP note: Subjective, Objective, Assessment, Plan. The categories that are about data are Subjective and Objective: what are the statements the person can make based on perception (Subjective – like “Patient appears anxious”); and what are the statements that others would also see as facts (Objective – like “Patient is holding a rosary”). Both the subjective and objective statements are data; and by identifying some as “subjective” and some as “objective” there is some acknowledgement of differences of authority.

So, for chaplains, what might we consider data? What we perceive, certainly; and what is reported. For example, both what we have in the present moment can inform us, and also what stories we hear from patients and family members. A patient’s statement about church membership is data, and so is the patient’s story about a childhood experience in Sunday School.

Which confronts us with the qualifying term: what makes the data relevant? Actually, the Standard is to evaluate the data for relevance. Our models for evaluation are the frameworks within which we determine whether the data is relevant. So, let me think a bit and then come back in the next reflection.