Transcript The Role of Assessment in Patient-Centered Pastoral Care Chaplain John Ehman 8/1/12 The purpose of this presentation is not to prescribe a particular assessment.

The Role of Assessment in
Patient-Centered Pastoral Care
Chaplain John Ehman
8/1/12
The purpose of this presentation is not to
prescribe a particular assessment but to
explore a framework appropriate to
patient-centered pastoral care
-- into which you may place the
particulars of your own assessment
practice that you will develop over time.
Assessment here refers to all the ways that we,
as pastoral professionals, try intentionally to
understand a present situation in order to
get our bearings on how to work with
that situation moving forward,
for the patient’s benefit.
Assessment here refers to all the ways that we,
as pastoral professionals, try intentionally to
understand a present situation in order to
get our bearings on how to work with
that situation moving forward,
for the patient’s benefit.
Assessment is part of a
chaplain’s professional discipline.
From your experience providing pastoral care
and your reflection through verbatim work,
how do you get your bearings in working
with patients? In other words, what kind
of assessments do you make?
From your experience providing pastoral care
and your reflection through verbatim work,
how do you get your bearings in working
with patients? In other words, what kind
of assessments do you make?
Which of these are issue-oriented assessments,
and which are process-oriented assessments?
Attention to process is important
in patient-centered pastoral care…
…because patients are invited to take the lead,
tell their story, and find help and healing
through an interactive experience
with a chaplain.
When a chaplain interacts with a patient,
the chaplain isn’t the only person in
the room making assessments.
See handout:
What Is the Frame for Patient-Centered
Pastoral Assessment Practice?
Not simply…
Issues Assessment
(“Spiritual Assessment”)
What Is the Frame for Patient-Centered
Pastoral Assessment Practice?
►
Process Assessment
Issues Assessment
(“Spiritual Assessment”)
◄
Pastoral Process Assessment: Some Basic Elements
Pastoral Process Assessment: Some Basic Elements
Is the patient able & willing to indicate informed consent?
Pastoral Process Assessment: Some Basic Elements
Is the patient able & willing to indicate informed consent?
Is the patient empowered to take the lead?
Pastoral Process Assessment: Some Basic Elements
Is the patient able & willing to indicate informed consent?
Is the patient empowered to take the lead?
Are there special, practical circumstances complicating
clear communication (including cultural diversity)?
Pastoral Process Assessment: Some Basic Elements
Is the patient able & willing to indicate informed consent?
Is the patient empowered to take the lead?
Are there special, practical circumstances complicating
clear communication (including cultural diversity)?
How is the patient engaging cognitively and emotionally?
Pastoral Process Assessment: Some Basic Elements
Is the patient able & willing to indicate informed consent?
Is the patient empowered to take the lead?
Are there special, practical circumstances complicating
clear communication (including cultural diversity)?
How is the patient engaging cognitively and emotionally?
What is the patient’s style of communicating and
“testing” whether or not he/she is being heard?
Pastoral Process Assessment: Some Basic Elements
Is the patient able & willing to indicate informed consent?
Is the patient empowered to take the lead?
Are there special, practical circumstances complicating
clear communication (including cultural diversity)?
How is the patient engaging cognitively and emotionally?
What is the patient’s style of communicating and
“testing” whether or not he/she is being heard?
Are other people in or near the room?
Pastoral Process Assessment: Some Basic Elements
Is the patient able & willing to indicate informed consent?
Is the patient empowered to take the lead?
Are there special, practical circumstances complicating
clear communication (including cultural diversity)?
How is the patient engaging cognitively and emotionally?
What is the patient’s style of communicating and
“testing” whether or not he/she is being heard?
Are other people in or near the room?
How may role expectations be structuring the interaction?
Pastoral Process Assessment: Some Basic Elements
Is the patient able & willing to indicate informed consent?
Is the patient empowered to take the lead?
Are there special, practical circumstances complicating
clear communication (including cultural diversity)?
How is the patient engaging cognitively and emotionally?
What is the patient’s style of communicating and
“testing” whether or not he/she is being heard?
Are other people in or near the room?
How may role expectations be structuring the interaction?
Is the chaplain feeling uneasy or distracted?
Pastoral Process Assessment: Some Basic Elements
Is the patient able & willing to indicate informed consent?
Is the patient empowered to take the lead?
Are there special, practical circumstances complicating
clear communication (including cultural diversity)?
How is the patient engaging cognitively and emotionally?
What is the patient’s style of communicating and
“testing” whether or not he/she is being heard?
Are other people in or near the room?
How may role expectations be structuring the interaction?
Is the chaplain feeling uneasy or distracted?
How much leading is the chaplain doing, and why?
The degree of leading that a chaplain does during a visit
may be a critical indicator of how much the interaction is
really following a patient-centered pastoral care approach.
See “Types of Leading” handout:
An example of how process assessments
may figure into pastoral visits:
I am called by a nurse who reports that a patient "wants to see a chaplain."
When I ask the nurse if she's aware of any particular circumstances
surrounding the request, she says, "She's going to have to have both legs
amputated, and she's been crying."
An example of how process assessments
may figure into pastoral visits:
I am called by a nurse who reports that a patient "wants to see a chaplain."
When I ask the nurse if she's aware of any particular circumstances
surrounding the request, she says, "She's going to have to have both legs
amputated, and she's been crying."
I approach the room and notice a contact isolation placard. A curtain is drawn
across the doorway. I gown and glove, then knock on the open door. "Ms. B.,
I'm the chaplain, may I come in?" "Yes, please do," a woman's voice replies.
An example of how process assessments
may figure into pastoral visits:
I am called by a nurse who reports that a patient "wants to see a chaplain."
When I ask the nurse if she's aware of any particular circumstances
surrounding the request, she says, "She's going to have to have both legs
amputated, and she's been crying."
I approach the room and notice a contact isolation placard. A curtain is drawn
across the doorway. I gown and glove, then knock on the open door. "Ms. B.,
I'm the chaplain, may I come in?" "Yes, please do," a woman's voice replies.
I see a middle-aged woman in the bed with her head raised. She is adjusting
her gown up around her shoulders. There is no immediate sign from her face
that she'd been crying. She looks eagerly at me and smiles. On each side of
the room are two men. They are silent and make no obvious action to engage
me (e.g., no eye contact, no move to shake my hand). Both seem to be sitting
at a maximum distance from the patient.
I walk to the patient, and she shakes my hand. "My name is John Ehman. I'm
the chaplain for the hospital. Your nurse just told me that you wanted to see a
chaplain, and so I wanted to see how I might be of help to you. Let me also
just say hello to… [and I go over to each of the men and shake their hands -they appear to engage me at the most minimal level].
I walk to the patient, and she shakes my hand. "My name is John Ehman. I'm
the chaplain for the hospital. Your nurse just told me that you wanted to see a
chaplain, and so I wanted to see how I might be of help to you. Let me also
just say hello to… [and I go over to each of the men and shake their hands -they appear to engage me at the most minimal level].
I say to the patient: "I don’t mean to interrupt your visit, so I'd be happy to
come back in a few minutes if that works better for you." "Oh, no," she says. "I
want to see you"; and she holds out her hand. I go to her and take her hand.
She pulls me close to the bedside. I now have my back to one of the men, and
the other I notice (out the corner of my eye) is looking at the floor.
I walk to the patient, and she shakes my hand. "My name is John Ehman. I'm
the chaplain for the hospital. Your nurse just told me that you wanted to see a
chaplain, and so I wanted to see how I might be of help to you. Let me also
just say hello to… [and I go over to each of the men and shake their hands -they appear to engage me at the most minimal level].
I say to the patient: "I don’t mean to interrupt your visit, so I'd be happy to
come back in a few minutes if that works better for you." "Oh, no," she says. "I
want to see you"; and she holds out her hand. I go to her and take her hand.
She pulls me close to the bedside. I now have my back to one of the men, and
the other I notice (out the corner of my eye) is looking at the floor.
The patient looks me directly in the eyes and says, "I need you to talk to me
about God." She closes her eyes tightly, takes a deep breath, and suddenly
appears to be holding back emotion. I smile slightly and say, "We can surely
talk about God. Tell me what's on your heart and mind."
I walk to the patient, and she shakes my hand. "My name is John Ehman. I'm
the chaplain for the hospital. Your nurse just told me that you wanted to see a
chaplain, and so I wanted to see how I might be of help to you. Let me also
just say hello to… [and I go over to each of the men and shake their hands -they appear to engage me at the most minimal level].
I say to the patient: "I don’t mean to interrupt your visit, so I'd be happy to
come back in a few minutes if that works better for you." "Oh, no," she says. "I
want to see you"; and she holds out her hand. I go to her and take her hand.
She pulls me close to the bedside. I now have my back to one of the men, and
the other I notice (out the corner of my eye) is looking at the floor.
The patient looks me directly in the eyes and says, "I need you to talk to me
about God." She closes her eyes tightly, takes a deep breath, and suddenly
appears to be holding back emotion. I smile slightly and say, "We can surely
talk about God. Tell me what's on your heart and mind."
Emotion wells in her face. She says rather rapidly, "They want to cut off my left
leg and my right foot, and I just don't believe that God wants me to lose my
legs. I know that God can heal anything, and God doesn't want them to do
this. I'm not ready to lose my legs. I know God has something more for me."
She pauses, looking intently at me. I allow a few seconds of silence as we
look at one another and then say, "Yes. I hear you. Can you tell me more?"
She begins a long monologue looking constantly at me (never at the others in
the room), except for moments when she shuts her eyes in emotion. She
periodically cries as she speaks. The two men appear extraordinarily still and
silent. She talks about how she is a very faithful person, how God means
everything to her, how she loves to pray all the time, and then how she
doesn’t want to lose her legs, how she's done everything she could for the
past two years to get her legs to heal and how that effort has meant staying
inside all the time with her feet up and keeping them wrapped; how she's done
nothing for the past two years but concentrate on her legs.
She tells of going to another hospital last week and being told that her legs
would have to be amputated, how she insisted on coming to Penn for a
second opinion, and how she had just been told again that amputation was
necessary.
Her story takes on more particular detail as we approach the present moment,
and she tells of a doctor saying to her, "The surgeon will be in on Friday, so
let's just do it then." She expresses outrage at the perceived casualness of
that doctor, saying, "These are my legs, and he's just saying let's do it
because it's convenient for the surgeon! God doesn't want me lose my legs!"
She becomes quiet, looking intently at me, appearing to expect my response.
In light of what you have
heard and assessed so far,
what might you do next?
So, how did this play out?
CHAPLAIN: You've said a great deal with deep meaning --about your faith and
how hard you've worked for years to get your legs to heal, how for over two
years you haven’t been able to do anything else in your life because of your
legs, how constantly you've carried that burden and prayed for guidance. And,
how much it hurt to have a doctor seem to treat all of this so casually.
So, how did this play out?
CHAPLAIN: You've said a great deal with deep meaning --about your faith and
how hard you've worked for years to get your legs to heal, how for over two
years you haven’t been able to do anything else in your life because of your
legs, how constantly you've carried that burden and prayed for guidance. And,
how much it hurt to have a doctor seem to treat all of this so casually.
PATIENT: He never should have said that. Walk in here and just schedule to
cut my legs off for people's convenience. After all I've done. [Pause.] I've
suffered for these legs. It's my decision.
So, how did this play out?
CHAPLAIN: You've said a great deal with deep meaning --about your faith and
how hard you've worked for years to get your legs to heal, how for over two
years you haven’t been able to do anything else in your life because of your
legs, how constantly you've carried that burden and prayed for guidance. And,
how much it hurt to have a doctor seem to treat all of this so casually.
PATIENT: He never should have said that. Walk in here and just schedule to
cut my legs off for people's convenience. After all I've done. [Pause.] I've
suffered for these legs. It's my decision.
CHAPLAIN: I want to honor your faithfulness through years of suffering. I can’t
begin to guess your experience through it all, but I sense the magnitude of it. I
also want to honor what it means to be faced now with a decision about
whether the way ahead for healing might be a way through loss, a loss you've
tried so hard to prevent.
So, how did this play out?
CHAPLAIN: You've said a great deal with deep meaning --about your faith and
how hard you've worked for years to get your legs to heal, how for over two
years you haven’t been able to do anything else in your life because of your
legs, how constantly you've carried that burden and prayed for guidance. And,
how much it hurt to have a doctor seem to treat all of this so casually.
PATIENT: He never should have said that. Walk in here and just schedule to
cut my legs off for people's convenience. After all I've done. [Pause.] I've
suffered for these legs. It's my decision.
CHAPLAIN: I want to honor your faithfulness through years of suffering. I can’t
begin to guess your experience through it all, but I sense the magnitude of it. I
also want to honor what it means to be faced now with a decision about
whether the way ahead for healing might be a way through loss, a loss you've
tried so hard to prevent.
PATIENT: I did everything I could. [Looks back and forth to each of the two
men – for the first time – and then closes her eyes, with tears.]
CHAPLAIN: You've been guided by your love of God through it all. That is a
powerful witness. Whatever you decide will also be a witness to your faith.
CHAPLAIN: You've been guided by your love of God through it all. That is a
powerful witness. Whatever you decide will also be a witness to your faith.
PATIENT: [Looks up at me.] Two years I suffered. I haven't been able to do
anything else. [Pause. Deep breath.] I know God wants me to do more with
my life. [Pause.] I know what I have to do. I know God doesn’t want me to sit
home like this forever. I don’t want to lose my legs, but He didn’t bring me this
far for this to be "it." [Pause.] Thank you. I'm ready.
CHAPLAIN: You've been guided by your love of God through it all. That is a
powerful witness. Whatever you decide will also be a witness to your faith.
PATIENT: [Looks up at me.] Two years I suffered. I haven't been able to do
anything else. [Pause. Deep breath.] I know God wants me to do more with
my life. [Pause.] I know what I have to do. I know God doesn’t want me to sit
home like this forever. I don’t want to lose my legs, but He didn’t bring me this
far for this to be "it." [Pause.] Thank you. I'm ready.
Process assessments help chaplains offer
a pastoral interaction that is in tune with
patients' felt needs and empowering for
patients' self-help. This may bring benefits
even before the chaplain is able to gain a
good sense of specific issues.
The process assessment often slightly precedes -- and
then runs along side of -- an issues assessment,
and can support communication about issues.
Process Assessment
Issues Assessment
(“Spiritual Assessment”)
The process assessment often slightly precedes -- and
then runs along side of -- an issues assessment,
and can support communication about issues.
Process Assessment
Issues Assessment
(“Spiritual Assessment”)
What should be the elements of an issues
assessment, a “spiritual assessment,” in
your own practice of pastoral care?
Strategy for Building Your Own Practice
of “Spiritual Assessment”
1) Start from what you naturally pay attention to in visits.
2) Consider how these indicators may limit your sense of
a patient, or be misleading under some circumstances.
3) What values and assumptions are implicit in your
assessment items? What theory and theology is
behind them?
4) Periodically list your most salient assessment items
and think of how they can be rounded out.
5) Write verbatims of difficult visits to spur your thinking.
6) Consult the research and professional literature on
“spiritual assessment” for new ideas to incorporate.
Examples of Popular “Spiritual Assessments”
in the research and pastoral literature:
FACIT-Sp
FICA
7x7 Model
(facit.org)
(Puchalski)
(Fitchett)
Brief RCOPE
Spirituality Scale
Spiritual Needs
(Pargament)
(Delaney)
(Galek)
See handouts:
Periodically write out a list of the most salient
assessment items in your own practice:
For an example, see handout:
What sets up, and what follows from,
the Process and Issues Assessments?
Process Assessment
Issues Assessment
(“Spiritual Assessment”)
What sets up, and what follows from,
the Process and Issues Assessments?
►
Pre-Visit Information Gathering
Process Assessment
Issues Assessment
(“Spiritual Assessment”)
◄
Pre-Visit Information Gathering
SOURCES: the medical record, care team members
(especially the primary nurse), family members
ADVANTAGE: this “background” information can help
identify special issues and can give context for
understanding/assessing the patient’s situation
DISADVANTAGE: it can suggest an agenda for the
visit and can skew the chaplain’s perception
and assessment of the patient
What sets up, and what follows from,
the Process and Issues Assessments?
Pre-Visit Information Gathering
Process Assessment
Issues Assessment
(“Spiritual Assessment”)
►
End-of-Visit Assessment
◄
End-of-Visit Assessment
Are there any loose ends to be addressed?
(--especially practical matters that might have pulled the
visit off course if pursued earlier in the conversation)
What is the patient’s expectation for follow-up?
A before-leaving-the-room check:
Is there anything else that you can do or get for the patient?
Is all that the patient might reach for (e.g., call button) within reach?
Is the overhead light, window shade, and curtain OK?
Are there safety issues apparent (e.g., falls hazards or
patient expressions of pain or breathing difficulty)?
Note about SPECIAL ASSESSMENTS that extend
beyond spiritual issues:
When encountering issues like abuse or intent to
harm, follow institutional policies and make referrals
to institution-identified specialists where necessary.
Assess how the disclosure of sensitive information
and the involvement of third parties affects
the patient-chaplain relationship as you
continue to offer pastoral care.
What sets up, and what follows from,
the Process and Issues Assessments?
Pre-Visit Information Gathering
Process Assessment
Issues Assessment
(“Spiritual Assessment”)
End-of-Visit Assessment
►
Communication of Assessment
and Pastoral Planning
◄
Communication of Assessment
and Pastoral Planning
The challenge of documentation:
Documentation often requires you to translate a subtle understanding
of a patient into a clinical language that “pigeonholes” information.
Thinking about the task of documentation can cause you to impose
the requirements of that task onto the course of the patient visit.
Current Epic/PennChart Categories for
Documenting Pastoral Care Interventions
●
Coping support, including pastoral dialogue
●
Pastoral de-escalation of crisis/conflict
●
Coordination of pastoral/cultural needs with staff
●
Prayer or special clergy action/ritual
●
Contact made with patient's faith organization
●
Decision-making facilitation
●
Grief support or end-of-life care
Current Epic/PennChart Categories for
Documenting Pastoral Care Interventions
●
Coping support, including pastoral dialogue
●
Pastoral de-escalation of crisis/conflict
●
Coordination of pastoral/cultural needs with staff
●
Prayer or special clergy action/ritual
●
Contact made with patient's faith organization
●
Decision-making facilitation
●
Grief support or end-of-life care
How might your awareness of such documentation
categories affect how you approach a visit or
perceive and assess a patient?
Communication of Assessment
and Pastoral Planning
The challenge of pastoral planning:
Your total assessment of a visit helps you plan for follow-up, but
it also may lead you to take an agenda into the next visit.
Planning for follow-up visits requires balancing
knowledge from the previous encounter with
openness for the new encounter.
Frame for Patient-Centered
Pastoral Assessment Practice
…takes into account how a “spiritual assessment”
does not occur in isolation
Issues Assessment
(“Spiritual Assessment”)
Frame for Patient-Centered
Pastoral Assessment Practice
Process Assessment
Issues Assessment
(“Spiritual Assessment”)
Frame for Patient-Centered
Pastoral Assessment Practice
Process Assessment
Issues Assessment
(“Spiritual Assessment”)
End-of-Visit Assessment
Frame for Patient-Centered
Pastoral Assessment Practice
Pre-Visit Information Gathering
Process Assessment
Issues Assessment
(“Spiritual Assessment”)
End-of-Visit Assessment
Frame for Patient-Centered
Pastoral Assessment Practice
Pre-Visit Information Gathering
Process Assessment
Issues Assessment
(“Spiritual Assessment”)
End-of-Visit Assessment
Communication of Assessment
and Pastoral Planning
[email protected]
Terminology pairings in Medline articles, 1998-2011
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