6/6/2007 Vol. 4, No. 9

Professional Practice

Advocacy

Rev. Jon Overvold on the importance of demonstrating how chaplains make a difference

Hospital Consumer Assessment of Healthcare Providers
and Systems Survey

The Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) is a new standardized survey tool developed by the Center for Medicare and Medicaid Services (CMS) that focuses on the patient’s experience of care. The survey questions were carefully developed so that despite the differences among hospitals it is still possible to accurately measure and compare the patient’s satisfaction with their care. These scores will be publicly reported in March of 2008 and, in the future, these scores, combined with the Core Measures of Quality, will be tied to reimbursement rates thus affecting the hospital’s bottom line.

As professionals who work in health care settings, chaplains need to be aware of the dynamic impact HCAHPS will have on our institutions. Of the 27 questions in this survey none specifically ask about spiritual care. However administrators will be carefully monitoring two key questions: one question asks for the patient’s overall rating of the hospital (1-10) and the other asks if the patient would recommend this hospital to family and friends. We are given a wonderful opportunity to demonstrate the contributions that chaplains make in improving patient satisfaction. Conversely, if we fail to make that case within our hospitals, at a time when so much is riding on patient satisfaction, we will have contributed to our own marginalization and the perception that spiritual care is irrelevant.

Because chaplains contribute significantly to the patient’s experience of care, it is essential that chaplains participate in the development and implementation of the hospital’s efforts to improve the satisfaction of its patients. In a study published in Joint Commission Journal on Quality and Safety,[1] researchers Clarke, Drain and Malone found a “strong relationship between ‘the degree to which staff addressed emotional/spiritual needs’and overall patient satisfaction.”This study includes an extensive literature review, which explores “whether patient’s emotional and spiritual needs are important, whether hospitals are effective in addressing these needs, and what strategies should guide improvement.”The study is invaluable to chaplains for the bibliography alone. The other component of this study includes original research on data collected by Press Ganey in 2001, which had findings that confirmed results of the earlier studies sited in the literature review.

Clark, Drain and Malone make the following recommendations to improve patient satisfaction by addressing spiritual needs:

1) Provide basic emotional and spiritual care resources, such as, sacred texts and religious materials, support groups, a chapel of meditation area, special diets;
2) Chaplaincy/Pastoral Care Team which can provide an in-depth spiritual care experience that results in improved satisfaction;
3) Multidisciplinary Emotional and Spiritual QI Team;
4) Standardized assessment tools to elicit spiritual needs and the meeting of those needs.

Especially significant are their recommendations to the pastoral care teams. They write: “A chaplain/pastoral care team can coordinate the elements of an emotional and spiritual infrastructure across disparate organizational boundaries. An isolated chaplain/pastoral care team exclusively responsible for patients’emotional and spiritual needs will be unlikely to influence organization-wide behaviors and processes needed to address patients’emotional and spiritual needs.”Evidently, chaplains need to insert themselves in places where they can systemically influence the spiritual dimensions of care. Why? Because we know it will have a greater impact on improving the patient’s experience of care.

In summary, HCAHPS gives chaplains an opportunity to demonstrate how spiritual care of patients contributes positively to the whole healthcare team’s care of the patient. On a basic level chaplains should be monitoring the routine services like availability of religious resources and the systems that provide special foods or sacramental services. Another important practice is regular review of the written comments by patients. This is available from your patient satisfaction vendor and can be very revealing of patient’s perceptions of pastoral care. Chaplains who can articulate how the goals of pastoral care are aligned with the institution’s goals will have a far better chance to influence the systems and infrastructure of an institution than those that cannot.

Reference/Footnotes

www.hcahpsonline.org

[1] Clark, P.A., Drain, M, Malone, M.P.(2003). “Addressing patients’emotional and spiritual needs.”Joint Commission Journal of Quality and Safety, 29, (12), 659-670.

Gerteis, M., Edgeman-Levitan, S., Daley, J., Delbanco, T. L., (Eds.), Through the Patient’s Eyes: Understanding and Promoting Patient Centered Care. San Francisco, CA: John Wiley and Sons, 1993.

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Education & Research

Deacon Mike Steele, Ph.D., on the need to be there to understand

New Doesn’t Mean It Is Accurate!

By now most of us have probably read or heard about the longitudinal cohort study, “An Empirical Examination of the Stage Grief Theory.”I finally took time to read this article that appeared in The Journal of American Medical Association.[1]

The researchers concluded that the familiar death-related stages of grief are more accurately defined as: disbelief, yearning, anger, depression, and acceptance. The newly defined stages are in disagreement with the Kubler-Ross stages of denial-disassociation-isolation, anger, bargaining, depression, and acceptance that most of us learned as CPE students. Equally important is the assertion that grief stages reach their climax by the end of twenty-four months.

I find fault with the studies conclusions. The findings are proven statistically; however, the cohort is not representative of the people who were in attendance at the majority of deaths that I experienced during the past decade as a chaplain. Additionally, the new grief stage theory only confirms what I already knew experientially: that is, older surviving family members who experience the natural death of an approximate similarly aged loved one, are more accepting and resolve their grief in a shorter period of time than younger family members who have suffered the loss of a younger loved one, especially someone whose death was medically unexpected or the result of trauma.

The researchers did not contact grieving survivors until more than six months after the death. They refined the cohort by excluding anyone meeting the definition of a complicated grief disorder, and anyone whose family members’death was related to a traumatic event. They also excluded family members who said they were too upset to participate. These disclosures place the study’s conclusion outside of the cohort I would construct –the very people I encountered on a daily basis when most of my time was spent in the ER trauma rooms –those loud and demonstrative survivors whose loved one was about to die from an event other than a natural death.

I was disappointed by the researcher’s lack of attention to the sociological, psychological, and theological dynamics of families caught up in the reality of a moribund death: the family who moves in-tandem with their loved to an ICU for the last hours or days of their life. Like so many comparative experiences of life, the researchers “would have to have been there to understand it.”

I believe these omissions and oversights disqualify the assertions of the study. The episodic memory of survivors after six-months is often a tainted expression of what has been suppressed or repressed immediately following the emotional moments of death –so much so that memory is no longer declarative, but non-declarative. This is the result of habit, not conscious thought, consequently putting “yes and no”responses to the testing instrument in doubt.

It would be harmful for me to generalize or suggest to family members in any imminent death situation that they will be accepting of their loved one’s death when it occurs and that they will only grieve for about twenty-four months.

This study shows that those who have been there and understand what is going on are the ones who should be writing these articles –we chaplains need to claim our knowledge and experiences so that we can ensure that the cohorts that we know will accurately reflect what these researchers were trying to prove, are included and count. However, most pastoral care departments are incapable of initiating or completing the long-term research that would have to be done. Not because the individual chaplains are unqualified; but because their "plate is already full."

On the other hand, there are pastoral service departments at Level One trauma centers at major university hospitals with ample medical and psych residents who are connected to on-campus seminaries that offer masters and doctoral degrees: that is where the human capital to see a project of this kind through might be found. The students and their department heads who might already be interacting with staff chaplains could assist in the design and completion of the longitudinal study. Furthermore, the students might be easily enticed by the possibility of graduate credit for their participation.

Foremost in all of this is that the creation-design process would begin with "us:" the chaplains who live the experience and bring it into the life of the design research.

Footnote

[1] Maciejewski PK et al. "An empirical examination of the stage theory of grief." JAMA 2007 Feb 21; 297:716-23.

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Spiritual Development

Rev. Jongmi Bae on transformation

From Subordination to Ordination

My heart is inundated with grateful joy when I think about how God has led me. On February 25th, 2007, I was ordained a Presbyterian Minister in PCUSA, with endorsement for Chaplaincy.

For the past 25 years, since I graduated from seminary in Korea, my dream of becoming a minister has lived in a deep, dark place inside of me. First, although I was an excellent student, traditional Korean culture did not ordain women. Since Confucius, we have been taught that women are “less than”men and so don’t deserve to be ministers. Second, there is an old saying in Korea that if a hen in the family cries aloud, that family will be destroyed. Even in the United States, I knew that if I followed my calling to be a pastor –instead of a pastor’s wife –I would add problems to my husband’s ministry in an immigrant Korean church.

So, I stifled my inner voice that told me to be myself –the self that God put me on earth to be –because it felt dangerous and painful. I echoed what I had been taught –that women should be humble and quiet. Then two years ago, I took CPE.

Through my first CPE unit at Greenwich Hospital in Connecticut, I increasingly became able to acknowledge, respect, and claim feelings and thoughts that I had silenced for decades. I felt anger towards myself and towards traditional Korean culture for treating me and teaching me that I was not worthy because I am a woman. When my Supervisor, Rev. Catherine Garlid, said to me: “I want you to fly,”I cried with happiness to discover that I could.

During my second CPE unit –the first unit of a Residency at The HealthCare Chaplaincy in New York City, I discovered that I didn’t want to deny my identity as a Korean woman –even with all of the anger that I felt toward Korean culture. My Supervisor, Rabbi Bonita E. Taylor, encouraged me to embrace Korean culture and to find sources of women’s authority and leadership within it. Among other things, I learned that before Confucius, women had a strong voice in Korea. I too found my voice as a leader, including becoming one of the founding members of the Association of Korean Chaplains (AKC).[1] I found balance as a woman who was a leader and also proud of being Korean.

For my ordination, I wanted to reflect my newly found understanding of myself. My mother had offered to make a hanbok (traditional Korean dress) for me to wear at this significant event. At first, I had declined because traditionally, this outfit symbolizes the subordination of women. However, I knew that if I wanted women to be seen differently, I would have to play my part. I took a deep breath and a courageous step forward. I wore the beautiful pink and gray silk hanbok that my mother lovingly fashioned for me. But, I wore it as a leader with the authority to transform its meaning. In those divinely inspired moments of February 25th, God transformed both the hanbok –and me –from subordination to ordination.

[1] See PlainViews, April 18, 2007, Vol. 4, Issue 6 (Advocacy)

Do you have thoughts about spiritual development you’d like to share with your colleagues? Send an e-mail of any length to info@PlainViews.org.

BioethicsWalk

BioethicsWalk addresses bioethical issues that chaplains face in their day-to-day work. PlainViews invites our readers to share their responses to each BioethicsWalk column, which will be published in the following issue. We also invite our readers to submit areas of concern/interest about which they would like Nancy to write.

If you’d like to respond to BioehicsWalk, please send a comment of no more than 100 words. You can use the e-form below (click on "hearing from you," link) or submit your commentary to the editors in the body of an e-mail (or as a Microsoft Word attachment) sent to Info@PlainViews.org. Please put the phrase “BioethicsWalk” in your subject line.

We look forward to hearing from you.

Being Present in the Grey Area

For the past seven years, I’ve spent a lot of time hanging out with professional chaplains. I got curious about this profession when I was working on a research project at The Hastings Center on the ethics of patient safety. At the time, I was also doing my M.Div. and the Center was my field education site. My ordination-track classmates were immersed in CPE, so I heard a lot about chaplains: about supervisors, verbatims, being sent to the morgue on your first day at the hospital, supporting grieving parents as they decided whether to withdraw life support from their son after a car accident left him with castastrophic brain injuries....

When The Center's research project took up the issue of disclosure, I figured that, if I looked into it, I’d find chaplains involved in disclosure. Weren’t my classmates, even as CPE students, in the room for all those “difficult conversations”? Surprise! Once I began to get to know and talk with professional chaplains about their place within the health care hierarchy, and about their professional culture’s knowledge and beliefs concerning medical error and its aftermath, I developed a much more nuanced, more clinically grounded, understanding of chaplains and chaplaincy, and of the barriers –some institutional, some self-imposed –that stood between chaplains and involvement in improving health care, in this case, by honoring the ethical obligation to disclose mistakes.

I learned that chaplains shared some of the same worries and believed some of the same persistent myths as physicians and nurses –if “we”tell the truth, if “we”apologize, we’ll get sued. I learned that chaplains, because of their uncertain –and unreimbursed –status within healthcare institutions, sometimes preferred to “fly below the radar,”by “being present”to patients and families but invisible to decisionmakers, a problematic decision that worked against their inclusion and involvement in improving policy and practices. I learned that some chaplains more readily identified with the clinicians involved in adverse events than with the injured patients and their families. I learned that other chaplains were deeply distressed by their inability to be present to injured patients and their families, if their institution’s practice was to quarantine these patients and families in “legal”or “risk management,”as threats, rather than as, perhaps, the most vulnerable persons in the system.

As these conversations continued and as I made fewer faux pas, I learned more about how chaplains did encounter the “grey area”of ethics, beyond the particular issue of medical error. I learned that many, perhaps most, professional chaplains serve on ethics committees; that some serve on IRBs; and that the ones on the IRBs seemed to be having more fun. I learned that most professional chaplains can recite the “Georgetown mantra”–Beauchamp and Childress’s four principles of biomedical ethics –but that, for some, this was “bioethics.”I learned that time-pressed chaplains may have few on-the-job opportunities for the challenges (and pleasures) of thinking about and discussing cases and theories; about what the “least worst”course of action may be in a particular situation (in health care, there is often no “best”course of action), and what steps can be taken to translate ethical reasoning into ethical policy to guide ethical practice.

I also learned that chaplains don’t like reading about chaplains. But I don’t believe that, or would never have agreed to write this monthly column on bioethics, for chaplains.

She is a graduate of Smith College and holds the Ph.D. in English Literature from the University of Glasgow and the M.Div. in Christian Ethics from Union Theological Seminary.

CaseConference

We post an ethical or situational concern that has arisen in a facility where one of our readers works. It has no identifiers included. It gives you only the facts of the case. Then, you can respond to that concern. This is an ongoing dialogue, with comments added as they come in. In the following issue, assuming it has been resolved, we give you the outcome from the facility where the incident took place.

We are always looking for cases. Please send any cases that you would like considered for inclusion to: info@plainviews.org We will ensure that it is stripped of any identifiers. For further guidance about how to write up a CaseConference, please refer to the CaseConference Archives, Vol. 4, No. 3 "How to Submit a Case for CaseConference." (Click HERE)

We hope that this will help to inform not only those who are dealing with the issue, but will enable all of our readers to learn from the experiences and perhaps mistakes of others.

PLEASE NOTE: Due to unanticipated continuing responses to both the case and the resolution of the case, added responses can be viewed in the archives. Click HERE.

Case #19 (See responses below)

I was recently hired as a hospice chaplain. My supervisor commented that I needed to obtain a "clinical jacket" that would readily identify me as a employee of this specific hospice. These jackets are the same as those worn by the clinical staff. I am appalled at the idea of wearing clinical garb for pastoral visits. I objected, noting that although the roles of clinician and chaplain might at times overlap, the focus of their work is quite different, and that pastoral care may be compromised by a uniform. (I also know the bereavement counselor and volunteer coordinator do not wear clinic jackets.) My supervisor spoke to the Human Resource Director, who backed down; although it was reported she was not happy about my refusal. Of course, I have no objection to ID badges or distributing information with the agency name on it. I am also specifically not referring to the collar/no collar conversation.

My feeling is that this issue is about "branding" the agency, not about security or role authority. There is tremendous competition among hospices –non-profit and for-profit –for visibility and clients.

Have others encountered this issue and have the same take on it?

Has anyone encountered real pressure to conform to an agency uniform code?

What other trends are in the "marketplace" that are likely to affect agency chaplains?

Case #19 Responses

What came to mind while reading of the insistance that the chaplain wear a "uniform": If the Hospice is dogmatic about its uniforms, is it also dogmatic about the kind of care it provides?
Rabbi Cary Kozberg
Columbus, Ohio

I have never been asked to wear a particular uniform in my work with Hospice and was surprised to hear of the request.
Jonathan Scott
Putnam, CT

Why not have uniforms that have disciplines noted on the front? It would clarify the roles to have differing uniforms.
Rev. Amy Jo Jones, BM, MM, MDiv., BCC
Chaplain/Grief Support Center Coordinator
Big Sky Hospice
Billings, MT

My question has to do with why this chaplain is "appalled" at the request that he/she wear a clinical jacket. Healthcare chaplaincy is a clinical discipline, as well as a pastoral one. I am aware that many hospice organizations do not require any CPE (and some not even Master's level theological education) for chaplains they hire. That this chaplain is "appalled" by such a request may indicate that he/she may not have any or much CPE or be aware of the clinical nature of what chaplains do. It's hardly unheard of for chaplains in hospitals to wear clinical jackets, especially in "on call" situations in which visibility is important.

I'd also ask the clinical/theological question about why this is a "cross" on which this chaplain is willing to "crawl up and die." The choice, for good or ill, has already been made by this chaplain in this organization. It hardly seems central enough to whether this chaplain can function "pastorally" to be worth the issue he/she made of it.

Jon Altman
APC Associate Chaplain
Petal, MS

I suspect that the wide range of responses indicates the breadth of experiences in the field. Today, the agencies offering hospice services run the gamut from small, local community non-profits to Fortune 500 "agra-businesses" that are looking to "horizontally integrate their services" with a continuum of care that takes grandma from discharge home care with her first wrist or hip fracture to assisted living to skilled nursing care and finally hospice as a way of maximizing the client interface.

I, too, work for a very large for-profit hospice that requires chaplains to wear a "uniform" as a matter of branding, not as a matter of presenting oneself as a qualified professional.

Chaplains were only exempted from the requirement of wearing "scrubs" when confronted with the argument that to do so would simply raise the facility's expectation that we ought be giving personal care, when of course we are unable to do that.

Perhaps the writer's strong feelings about being made to wear a uniform had more to do with the total ethos of his or her agency and the motivation behind being reduced to another generic representative of the monolithic service provider.

I doubt that it reflects his professional qualifications--as a rule of thumb, the big three for profits still prefer seminary trained, ordained M.Divs with CPE to less formally educated or uncredentialed religious, not because of the superior service they may or may not provide but because they tend to reduce the possibility of exposure to CHAPS violations by evangelizing or not being well equipped to deal with diversity.

If you are a chaplain for whom this all sounds strangely "corporate", be glad. It is a growing reality among the increasingly dominant major players whose first concern is to project competency rather than supply it and whose "high view" of the chaplain's contribution is to assure frequency compliance for Medicare billing.

Charlotte Ellison
Battle Creek, MI

It has become abundantly clear that some of the best ministry that we have to offer is delivered in our work with the clinical team and our preparation of the other team ministers to be spiritually sensitive to patients and to offer appropriate spiritual attention to patients. When we do that part of our ministry well, patients receive quality spiritual care, and their overall satisfaction with their clinical experience increases. I believe it actually enhances our pastoral care to look more like the rest of the clinical team, and it lets the patient know that the institution takes seriously their spiritual needs at the time of hospitalization. Furthermore, it is a very clear way to distinguish the Pastoral Care team from clergy who are “outside the entity”for HIPAA disclosure purposes.

Stan Jones
Chaplain Coordinator
Methodist Hospital
Clarian Health Partners
Indianapolis, IN

As an active duty military chaplain, most of my work is done in a uniform. While that may be the exception in the civilian world, I do not see how this would compromise the standing of a chaplain as part of a multi-disciplinary health care team. Each member of that team brings to the table his or her specific skills. To me, this does not seem to be an ethical issue for which one should go "to the mat."

Rabbi Maurice S. Kaprow, BCC
Command Chaplain
PCU GEORGE H W BUSH (CVN 77)

Please check the archives for comments made about previous CaseConferences.

Send your comments about CaseConference to info@PlainViews.org.

Reviews

Sarah Masters reviews the film

Prajna Earth

Picture the scene as the camera captures the immensity of Angkor Wat, the largest temple in the world, which covers more than 500 acres and is fully aligned in term of astronomical calculations, solstices and equinoxes. Share the evening with Buddhist monks and nuns who have traveled for days on pilgrimage to gather there for the full moon.

Visually, Prajna Earth is a wonder, a cinematic journey of the lost spiritual civilization of Angkor in Cambodia, of spiritual sites on Bali and in the jungles of Java.

Prajna in Sanskrit translates as “radiant wisdom”and this documentary is the second in the Yatra Trilogy series, narrated by Sharon Stone. You can select ambient sound with narration or ambient sound alone as you travel to places where Buddhist and Hindu influences have merged with the animistic beliefs of ancient cultures.

Director John Bush writes that he “…wanted to create a new kind of viewing experience that would allow someone to have a direct encounter with the sacred spaces of Southeast Asia. This timeless art and architecture is part of the world's cultural heritage. It's important to archive these things, to share them." He succeeds.

Completed: 2005
Running Time: 85 Minutes
Director/Producer/Cinematographer: John Bush

If you are interested in purchasing this film, you can do so at www.hartleyfoundation.org. Just click on “Masterworks”on the homepage for more information. The cost is $24.95 for the DVD.

Sarah Masters is the Managing Director of the Hartley Film Foundation, a non-profit foundation dedicated to cultivation, support, production and distribution of the best documentaries and audio meditations on world religions, spirituality, ethics and well-being.

Book Review

Chaplain Joan Paddock Maxwell reviews

Final Exam: A Surgeon’s Reflections on Mortality

Back in my CPE salad days, when I was young and green, a nurse told me, “I can almost always tell when a patient is dying.”“How?”I asked, wildly eager to be let in on such an important medical secret. “When the physicians stop visiting them.”

If you are a hospital chaplain and this scenario sounds familiar to you, then run, do not walk, to your nearest bookstore and get a copy of Final Exam, surgeon Pauline Chen’s extraordinary examination of herself and her medical colleagues and their relationship to death and dying. Her book is a highly readable, deeply personal, yet widely applicable analysis of how physicians are formed throughout their training to fight and deny death, even when the dying process is well advanced. Chen explains how immensely difficult it is to change this reality, and yet how important it is that we do so.

The next time you grieve over a dying patient in the ICU sprouting more lines than a hyacinth bulb has roots, perhaps even though she has an advance directive in her chart, Final Exam will help you better understand the factors at work in the situation. You’ll have learned about the profoundly distancing effect the lengthy and detailed dissection of a human cadaver in the first year of medical school has on young doctors-in-training. You’ll have learned about “turfing,”the way time-challenged physicians pass troubling situations, including discussing dying with a patient, on to someone else. And. you’ll have learned about the multi-million dollar SUPPORT study, which tried to reduce aggressive treatment at the end of life but had no notable improvements on the way terminal patients were treated.

Final Exam is skillfully crafted, weaving detailed personal stories of Dr. Chen’s own life, her medical training, and individual patients she has cared for with the findings of various studies involving the medical treatment of dying people. Trained at Harvard, Northwestern, Yale, the National Cancer Institute, and UCLA, Dr. Chen has turned her own experiences into something of a case study of physician formation. She backs her stories up with a couple of hundred endnotes and a bibliography 18 pages long.

I was surprised at her level of personal revelation, her stories of patients she feels she failed emotionally, her stories of her own family relationships and how they helped shape her attitudes towards death and dying. I was also impressed by how fully digested these stories and experiences seem to be. This is not a hysterical, “tell all”kind of book. Instead, Final Exam is an engaging, reasoned work, vivid and sophisticated, clearly the product of extensive reading, introspection, and analysis.

If the subject of physicians and the treatment of dying people is of interest to you, Final Exam is a must read.

Chen, Pauline W. Final Exam: A Surgeon’s Reflections on Mortality (New York: Alfred A. Knopf, 2007), pp 268.

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