The Role of Assessment in

1
The Role of Assessment in Patient-Centered
Pastoral Care Chaplain John
Ehman 12/5/11
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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.
3
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 patients
benefit.
4
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 patients
benefit. Assessment is part of a chaplains
professional discipline.
5
From your experience providing pastoral care
and your reflection through verbatim work, what
kind of assessments do you tend to make during
visits to get your bearing on how to work with
patients?
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From your experience providing pastoral care
and your reflection through verbatim work, what
kind of assessments do you tend to make during
visits to get your bearing on how to work with
patients? Which of these are issue-oriented
assessments, and which are process-oriented
assessments?
7
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.
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When a chaplain interacts with a patient, the
chaplain isnt the only person in the room making
assessments. See handout
9
What Is the Frame for Patient-Centered Pastoral
Assessment Practice? Not simply
Issues Assessment (Spiritual Assessment)
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What Is the Frame for Patient-Centered Pastoral
Assessment Practice?
?
Process Assessment
?
Issues Assessment (Spiritual Assessment)
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Pastoral Process Assessment Some Basic
Elements
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Pastoral Process Assessment Some Basic
Elements Is the patient able willing to
indicate informed consent?
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Pastoral Process Assessment Some Basic
Elements Is the patient able willing to
indicate informed consent? Is the patient
empowered to take the lead?
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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)?
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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?
16
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
patients style of communicating and testing
whether or not he/she is being heard?
17
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
patients style of communicating and testing
whether or not he/she is being heard? Are other
people in or near the room?
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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
patients 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?
19
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
patients 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?
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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
patients 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?
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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
22
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."
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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.
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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
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.
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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.
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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 dont 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.
27
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 dont 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."
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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 dont 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?"
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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 doesnt 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.
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In light of what you have heard and
assessed so far, what might you do next?
31
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
havent 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.
32
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
havent 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.
33
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
havent 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 cant
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.
34
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
havent 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 cant
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.
35
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.
36
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 doesnt want
me to sit home like this forever. I dont want to
lose my legs, but He didnt bring me this far for
this to be "it." Pause. Thank you. I'm ready.
37
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 doesnt want
me to sit home like this forever. I dont want to
lose my legs, but He didnt 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.
38
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)
39
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?
40
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.
41
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
42
Periodically write out a list of the most salient
assessment items in your own practice For an
example, see handout
43
What sets up, and what follows from, the Process
and Issues Assessments?
Process Assessment
Issues Assessment (Spiritual Assessment)
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What sets up, and what follows from, the Process
and Issues Assessments?
Pre-Visit Information Gathering
?
?
Process Assessment
Issues Assessment (Spiritual Assessment)
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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 patients
situation DISADVANTAGE it can suggest
an agenda for the visit and can
skew the chaplains perception and
assessment of the patient
46
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
?
?
47
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 patients 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)?
48
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.
49
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
?
?
50
Communication of Assessment and Pastoral
Planning The challenge of documentation Documen
tation 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. 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.
51
Terminology pairings in Medline articles,
1998-2008
52
Frame for Patient-Centered Pastoral Assessment
Practice takes into account how a spiritual
assessment does not occur in isolation
Issues Assessment (Spiritual Assessment)
53
Frame for Patient-Centered Pastoral Assessment
Practice
Process Assessment
Issues Assessment (Spiritual Assessment)
54
Frame for Patient-Centered Pastoral Assessment
Practice
Process Assessment
Issues Assessment (Spiritual Assessment)
End-of-Visit Assessment
55
Frame for Patient-Centered Pastoral Assessment
Practice
Pre-Visit Information Gathering
Process Assessment
Issues Assessment (Spiritual Assessment)
End-of-Visit Assessment
56
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
57
Select bibliography handout
58
john.ehman_at_uphs.upenn.edu