The Role of Assessment in Patient-Centered Pastoral Care Chaplain John Ehman Chaplain John Ehman 12/5/11

The Role of Assessment inThe Role of Assessment inPatient-Centered Pastoral CarePatient-Centered Pastoral Care

Chaplain John EhmanChaplain John Ehman

12/5/11

The purpose of this presentation is not toThe purpose of this presentation is not toprescribe a particular assessment but toprescribe a particular assessment but to

explore a explore a frameworkframework appropriate to appropriate to patient-centered pastoral care patient-centered pastoral care -- into which you may place the-- into which you may place the

particulars of particulars of your ownyour own assessment assessment practice that you will develop over time.practice that you will develop over time.

AssessmentAssessment here refers to all the ways that we, here refers to all the ways that we, as pastoral professionals, try intentionally toas pastoral professionals, try intentionally tounderstand a present situation in order to understand a present situation in order to

get our bearings on how to work withget our bearings on how to work withthat situation moving forward,that situation moving forward,

for the patient’s benefit.for the patient’s benefit.

AssessmentAssessment here refers to all the ways that we, here refers to all the ways that we, as pastoral professionals, try intentionally toas pastoral professionals, try intentionally tounderstand a present situation in order to understand a present situation in order to

get our bearings on how to work withget our bearings on how to work withthat situation moving forward,that situation moving forward,

for the patient’s benefit.for the patient’s benefit.

Assessment is part of aAssessment is part of achaplain’s professional discipline.chaplain’s professional discipline.

From your experience providing pastoral care From your experience providing pastoral care and your reflection through verbatim work,and your reflection through verbatim work,what kind of what kind of assessmentsassessments do you tend to do you tend to

make during visits to get your bearingmake during visits to get your bearingon how to work with patients?on how to work with patients?

From your experience providing pastoral care From your experience providing pastoral care and your reflection through verbatim work,and your reflection through verbatim work,what kind of what kind of assessmentsassessments do you tend to do you tend to

make during visits to get your bearingmake during visits to get your bearingon how to work with patients?on how to work with patients?

Which of these are Which of these are issueissue-oriented assessments,-oriented assessments,and which are and which are processprocess-oriented assessments?-oriented assessments?

Attention to Attention to processprocess is important is important in patient-centered pastoral care…in patient-centered pastoral care…

……because patients are invited to take the lead, because patients are invited to take the lead, tell their story, and find help and healing tell their story, and find help and healing

through anthrough an interactive experienceinteractive experience with a chaplain. with a chaplain.

When a chaplain interacts with a patient, When a chaplain interacts with a patient, the chaplain isn’t the only person inthe chaplain isn’t the only person in

the room making assessments.the room making assessments.

See handout:See handout:

What Is the Frame for Patient-Centered What Is the Frame for Patient-Centered Pastoral Assessment Practice?Pastoral Assessment Practice?

Not simply…Not simply…

Issues AssessmentIssues Assessment(“Spiritual Assessment”)(“Spiritual Assessment”)

What Is the Frame for Patient-Centered What Is the Frame for Patient-Centered Pastoral Assessment Practice?Pastoral Assessment Practice?


Process AssessmentProcess Assessment► ◄

Pastoral Process Assessment: Some Basic ElementsPastoral Process Assessment: Some Basic Elements


Is the patient able & willing to indicate informed consent?Is the patient able & willing to indicate informed consent?



Is the patient empowered to take the lead?Is the patient empowered to take the lead?




Are there special, practical circumstances complicatingAre there special, practical circumstances complicatingclear communication (including cultural diversity)?clear communication (including cultural diversity)?





How is the patient engaging cognitively and emotionally?How is the patient engaging cognitively and emotionally?






What is the patient’s style of communicating and What is the patient’s style of communicating and ““testing” whether or not he/she is being heard?testing” whether or not he/she is being heard?







Are other people in or near the room?Are other people in or near the room?








How may role expectations be structuring the interaction?How may role expectations be structuring the interaction?









Is the chaplain feeling uneasy or distracted?Is the chaplain feeling uneasy or distracted?









Is the chaplain feeling uneasy or distracted?Is the chaplain feeling uneasy or distracted?

How much How much leadingleading is the chaplain doing, and why? is the chaplain doing, and why?

The degree of leading that a chaplain does during a visit The degree of leading that a chaplain does during a visit may be a critical indicator of how much the interaction is may be a critical indicator of how much the interaction is really following a patient-centered pastoral care approach.really following a patient-centered pastoral care approach.

See “Types of Leading” handout:See “Types of Leading” handout:

An example of how process assessments An example of how process assessments may figure into pastoral visits: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 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 woman in the bed with her head raised. She is adjusting her gown up around her shoulders. She appears middle-aged, obese, and her hair is somewhat unkempt. 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 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."



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 In light of what you have heard and assessed so far, heard and assessed so far,

what might you do next?what might you do next?

So, how did this play out?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.




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 I'm sure 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.


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 The process assessment often slightly precedes -- and then runs along side of -- an issues assessment,then runs along side of -- an issues assessment, and can support communication about issues.and can support communication about issues.


Process AssessmentProcess Assessment



What should be the elements of an What should be the elements of an issuesissues assessment, a “spiritual assessment,” in assessment, a “spiritual assessment,” in

your your own own practice of pastoral care? practice of pastoral care?

The process assessment often slightly precedes -- and The process assessment often slightly precedes -- and then runs along side of -- an issues assessment,then runs along side of -- an issues assessment, and can support communication about issues.and can support communication about issues.

Strategy for Building Your Own Practice Strategy for Building Your Own Practice of “Spiritual Assessment” of “Spiritual Assessment”

1)1) Start from what you naturally pay attention to in visits. Start from what you naturally pay attention to in visits.

2)2) Consider how these indicators may limit your sense of Consider how these indicators may limit your sense of a patient, or be misleading under some circumstances.a patient, or be misleading under some circumstances.

3)3) What values and assumptions are implicit in your What values and assumptions are implicit in your assessment items? What theory and theology is assessment items? What theory and theology is behind them?behind them?

4)4) Periodically list your most salient assessment items Periodically list your most salient assessment items and think of how they can be rounded out.and think of how they can be rounded out.

5)5) Write verbatims of difficult visits to spur your thinking. Write verbatims of difficult visits to spur your thinking.

6)6) Consult the research and professional literature on Consult the research and professional literature on “ “spiritual assessment” for new spiritual assessment” for new ideasideas to incorporate. to incorporate.

Examples of Popular “Spiritual Assessments”Examples of Popular “Spiritual Assessments”in the research and pastoral literature: in the research and pastoral literature:

FACIT-Sp FICA 7x7 ModelFACIT-Sp FICA 7x7 Model (facit.org) (Puchalski) (Fitchett)(facit.org) (Puchalski) (Fitchett)

Brief RCOPE Spirituality Scale Spiritual NeedsBrief RCOPE Spirituality Scale Spiritual Needs (Pargament) (Delaney) (Galek)(Pargament) (Delaney) (Galek)

See handouts:See handouts:

Periodically write out a list of the most salient Periodically write out a list of the most salient assessment items in your own practice:assessment items in your own practice:

For an example, see handout:For an example, see handout:

What What sets upsets up, and what , and what follows fromfollows from,,the Process and Issues Assessments?the Process and Issues Assessments?





Pre-Visit Information GatheringPre-Visit Information Gathering► ◄


Pre-Visit Information GatheringPre-Visit Information Gathering

SOURCESSOURCES: the medical record, care team members : the medical record, care team members (especially the primary nurse), family members(especially the primary nurse), family members

ADVANTAGEADVANTAGE: this “background” information can help : this “background” information can help identify special issues and can give context for identify special issues and can give context for understanding/assessing the patient’s situationunderstanding/assessing the patient’s situation

DISADVANTAGEDISADVANTAGE: it can suggest an agenda for the : it can suggest an agenda for the visit and can skew the chaplain’s perception visit and can skew the chaplain’s perception and assessment of the patientand assessment of the patient




End-of-Visit AssessmentEnd-of-Visit Assessment► ◄


End-of-Visit AssessmentEnd-of-Visit Assessment

Are there any loose ends to be addressed?Are there any loose ends to be addressed?

(--especially practical matters that might have pulled the (--especially practical matters that might have pulled the visit off course if pursued earlier in the conversation)visit off course if pursued earlier in the conversation)

What is the patient’s expectation for follow-up?What is the patient’s expectation for follow-up?

A before-leaving-the-room check:A before-leaving-the-room check:

Is there anything else that you can do or get for the patient? 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 all that the patient might reach for (e.g., call button) within reach?

Is the overhead light, window shade, and curtain OK?Is the overhead light, window shade, and curtain OK?

Are there safety issues apparent (e.g., falls hazards or Are there safety issues apparent (e.g., falls hazards or patient expressions of pain or breathing difficulty)?patient expressions of pain or breathing difficulty)?

Note about Note about SPECIAL ASSESSMENTSSPECIAL ASSESSMENTS that extend that extendbeyond spiritual issues:beyond spiritual issues:

When encountering issues like abuse or intent to When encountering issues like abuse or intent to harm, follow institutional policies and make referrals harm, follow institutional policies and make referrals to institution-identified specialists where necessary.to institution-identified specialists where necessary.

Assess how the disclosure of sensitive information Assess how the disclosure of sensitive information and the involvement of third parties affectsand the involvement of third parties affects

the patient-chaplain relationship as you the patient-chaplain relationship as you continue to offer pastoral care.continue to offer pastoral care.





Communication of AssessmentCommunication of Assessmentand Pastoral Planningand Pastoral Planning► ◄


Communication of AssessmentCommunication of Assessmentand Pastoral Planningand Pastoral Planning

The challenge of documentation:The challenge of documentation:

Documentation often requires you to translate a subtle understanding Documentation often requires you to translate a subtle understanding of a patient into a clinical language that “pigeonholes” information.of a patient into a clinical language that “pigeonholes” information.

Thinking about the task of documentation can cause you to impose Thinking about the task of documentation can cause you to impose the requirements of that task onto the course of the patient visit.the requirements of that task onto the course of the patient visit.

The challenge of pastoral planning:The challenge of pastoral planning:

Your total assessment of a visit helps you plan for follow-up, but 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.it also may lead you to take an agenda into the next visit.

Terminology pairings in Medline articles, 1998-2008Terminology pairings in Medline articles, 1998-2008

0102030405060708090

100110120130140150

Spiritual Religious Existential

Frame for Patient-Centered Frame for Patient-Centered Pastoral Assessment PracticePastoral Assessment Practice

……takes into account how a “spiritual assessment” takes into account how a “spiritual assessment” does not occur in isolationdoes not occur in isolation



















Communication of AssessmentCommunication of Assessmentand Pastoral Planningand Pastoral Planning

Select bibliography handout:

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Documents

The Role of Assessment in Patient-Centered Pastoral Care Chaplain John Ehman Chaplain John Ehman 12/5/11