From Questions to Solutions

Administrators Can Ask Themselves Some Questions About Their Facilities.
You Might Be Very Surpised at the Answers You Get!

Some of the certification junkies and advocates of exclusionism and agendaism might have balked at what I had to say about the fallacies and deceit of certification by so-called professional organizations. I say, “So what?!?” Does membership in a professional medical society make a physician a better physician? I don’t think so! It does provide for better lobbying and special interest pandering than if she or he goes solo and concentrates on serving the patient, though.

Actually, most of those with whom I have worked and whom I know who have resorted to the “security in numbers” and have delegated their responsibility for adequate quality training and education to a legal fiction called a “professional association”; now they  have more baggage than Cirque de Soleil on international tour. But Hey! They pay their dues, kiss some butt, and get to put three obscure letters after their names. A hell of a lot easier than working for a university or seminary degree, right?

But, dear readers, it all boils down to one real question: What are we, as pastoral care professionals and administrators, doing for the client, the customer, the recipient of our ministrations, the beneficiary of our fine education, training, and whatever? I’d bet you administrators, directors, coordinators haven’t really asked yourselves such a client-focused question, have you? Other concerns. We know.

Recent qualitative research reports that the highest percentage of admitted inpatients visited by a chaplain, resident chaplain or other pastoral care professional at a single hospital was 40%. That’s not a good figure. In fact, in most facilities the number is much, much lower and the pastoral care provided is paltry, at best. Your facility might actually be one of them. Why would that be? Well, because no one’s really been asking the right questions.

In fact, there’s been a great deal of research done on the importance of pastoral care and spiritual and emotional support to customers, whether residents in a nursing home, patients in a hospital receiving acute or chronic care, even customers of funeral homes. But very few administrators and directors read any more. That’s too bad for everyone.

A leader in such research, Press Ganey, published some interesting information a couple of years ago (2010): The highest priorities of residents and patients tend to center around whether the institution is aware of, is sensitive to, and meets their emotional needs. Press Ganey, in fact, found for outpatients that the three top concerns center on the institution’s / staff’s  “response to concerns/complaints,” “sensitivity to needs” and “staff concern for questions/worries.” This observation is based on data from more than 2.2 million outpatient responses from 1,431 facilities in 2009. So we’ve now narrowed the focus down to three major concerns. Not bad at all.

A couple of years before that the JCAHO and HIPAA made some independent conclusions regarding pastoral care to recipients of healthcare services. New York State did, too. So why haven’t administrators of healthcare facilities charged ahead with compliance with the recommendations?

In a 2003 publication, researchers Clark, Drain & Malone suggested (I’m paraphrasing liberally) that we have to translate our organizational actions into empathetic and non-judgmental care responses that are aimed at satisfying the clients emotional and spiritual needs, and so to meet the client’s expectations in what frequently start out as highly emotional crisis moments, asking questions like:

  • Have the client’s or family’s concerns been handled in a timely, considerate and empathetic way?
  • Has all paperwork, policies, procedures, tests, and treatments are explained in an emotionally sensitive and supportive way as part of the interactive decision-making process?
  • Does administration and do staff proactively provide empathetic emotional support, and are referrals to pastoral care made?
  • Do administration and staff cooperate and collaborate to orchestrate local resources, including opportunities for referral, to respond promptly and efficaciously to the client’s needs? Or is the organization modular, insular, fragmented leaving the client’s needs on the wayside?
  • Does administration and do staff respect the client’s personal and statutory confidentiality and physical privacy?
  • Does administration ensure an inter- and multidisciplinary holistic model of care delivery?

What Are the Client’s and Families’ Emotional and Spiritual Needs?

The client’s general expectations for emotional and spiritual care tend to be rather modest (Taylor (2003) and Ross (1997)) and can be summarized to include:

  • Kindness
  • Respect
  • Talking & listening
  • Authenticity
  • Physical presence
  • Timely responses to requests
  • Mobilizing religious & spiritual resources
  • Quiet space for reflection or prayer
  • Information about church or chapel services
  • Transportation to the chapel

 Before we can discuss spiritual resources we have to take a stab at defining what we understand to be spirituality. For the moment let’s accept the definition that “Spirituality is the individualized, subjective experience of and from which a person derives purpose, meaning and hope.” (Miller & Thoresen 2003). That’s not a perfect definition but it’s good for use as an orienting definition of spirituality.

Patients frequently desire several common spiritual resources during their stay that the care facility and staff can provide or facilitate access to (Moadel et al. 1999; Shahabi et al. 2002; Tatsumura et. al. 2003).  Access to personal or unique faith or spiritual tradition resources is very important to the client faced with long-term care, existential crisis, or lifestyle conflict. Administration or staff can provide care resources that include, for example:

  •  Prayer
  •  Scripture reading
  •  Prayer or dialog with fellow faith or spiritual communit affiliates
  •  Acces to pastoral care from the facility chaplain or pastoral care assoicate
  • Visits by visiting clergy or faith community leaders
  • The opportunity for attending a religious liturgy, spiritual ritual, or worship service on a weekly basis
  •  Daily spiritual experience or events
  •  Meditation opportunites
  •  Spending time in a location of spiritual energy (e.g. chapel, sacred space, mediation room, a specific location, or nature setting)
  •  Help or counseling from the chaplain.

 Nursing Interventions are one of the first-line determinants of client satisfaction. Sheldon (2000) outlines several spiritual care interventions that nursing staff are capable of (after proper assessment) and should be able to provide, if needed. These include:

  •  Provide privacy, if appropriate
  •  Life review or faith history
  •  Encourage storytelling of one’s spiritual life.
  •  Suggest that the patient keep a journal.
  •  Reading a Bible story and discussing it as it may apply to patient
  •  Observe relationships with family
  •  Offer to pray with a patient/family
  •  Refer patient to the chaplain or to a pastoral/spiritual care assoicate, or visiting clergy person
  •  Show awareness of, sensitivity to, and willingness to facilitate religious or spiritual practices or rituals
  •  Incorporate the client’s spirituality / beliefs / values  in plan of care
  •  Actively listen to the client
  •  Show an openness to the client’s questions
  •  Provide spiritual reading or videos, as requested, or referring the request to the pastoral care office
  •  Convey a respectful, empathic, supportive, nonjudgmental attitude in regard to patient’s beliefs and values
  •  Offer group support or interdisciplinary intervention, if it will enhance improvement of quality of care.

Chaplains/Pastoral Care Teams

Chaplains and pastoral care associates must be selected to be persons who are  skilled, well trained and optimally equipped to provide complex spiritual care in a wide range of situations  (see Vandecreek & Burton, 2001). Administration must be validating and supportive of the pastoral care effort and staff need to be aware and capable of making timely referrals to the chaplain and to pastoral care staff (see Astrow et al. 2001). Yet all patients possess some basic emotional and spiritual care requirements and simple needs (see above) which, through everyday actions and care, can be addressed by the chaplain as a recognized healthcare professional and by the inter- multi-disciplinary care team. Effective and satisfying emotional and spiritual care requires proactive collaboration between nurses, physicians and chaplains/pastoral care associates and other spiritual leaders (Vandecreek, 1997).

I’d like to conclude this segment with some questions to ask yourself as you evaluate your performance in meeting the client’s emotional and spiritual care needs. Here goes…

  • Do you have effective client service behavioral standards in place that address privacy, respectful communication, kindness, etc.?
  • Do you systematically assess and regularly update, or proactively elicit, document, and respond to the client’s emotional and spiritual needs with screening questions like “How are you feeling?” “Do you have any needs or request that I can help with?” “Do you know about our pastoral care program?” “Would you like a chaplain to stop by and visit?”
  • As appropriate, do you have a referral protocol for referring clients with express or obvious spiritual or emotional concerns to the chaplain or to the pastoral care office?
  • Are you conducting admissions and updates on Emotional or Spiritual Assessments or taking Spiritual or Faith Histories using a standard instrument in order to understand patients’ preferences and assess needs? Are you connecting with patients? Are you reaching all patients?
  • Do you have an effective service recovery process? Have you trained all staff in service recovery? Do you have a service recovery or general discretionary fund?
  • Do staff receive training on how to communicate empathically to demonstrate to patients that they understand and empathize? Does staff know how to communicate in ways that can calm and soothe the angry or upset client?
  • Do you have a chapel or meditation space? Do patients know about it? Do you inform clients when and where regular religious or spiritual events are celebrated? Do you have arrangements to transport clients to the chapel or religious or spiritual event? Do you have and do patients know about religious programming on T.V.?
  • What do staff know about your patient population’s culture, spiritual beliefs and related emotions? What are your organizational learning needs in terms of cultural sensitivity?

Although it’s somewhat outside of my pastoral care speciality, there is recent research that indicates that client satisfaction, as in the case of any service line, affects profitability in a number of ways. Regardless of prior healthcare experience or type of care (routine, planned, acute, chronic), all clients consider a sensitive and appropriate response to their emotional/spiritual care needs to be an important factor in their overall satisfaction. The best data available indicate the existence of a significant relationship between satisfying patients’ emotional/spiritual needs and facility profitability, especially for facilities having more than 100 beds. Think about that for a moment and it becomes rather obvious, common sense, and intuitive.

I’ve done the research and have taken the findings, the recommendations, the standards, the scoring categories into consideration when drafting my regulatory scoring categories-compliant Standards of Practice and Continuing Quality Improvement Curriculum. The manuals themselves are too long to reproduce here; besides, they are templates and are adapted to the needs of the client facility. Nevertheless, in the continuation of this series of articles I’ll be discussing them, and what they are and what they offer to the serious administrator in terms of compliance, continuous quality improvement, client satisfaction, and ultimately, profitability.

Next Installment: How the Continuous Quality Improvement Curriculum incorporates and complies with the Joint Commission’s scoring categories for pastoral care.


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