Bullet Point Spiritual Assessment Gordon J. Hilsman, D.Min. Franciscan Health System Tacoma WA

Objectives Focus on documenting spiritual assessments as professionally collaborative Value spiritual assessment as a major, perhaps the primary component of patient oriented health care experience Consider bullet points as a style of charting spiritual assessments

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To Assess or to Sedate? Sedere – to sit, remain, take a seat, perch Sedare – settle, allay, calm down, (sedate, sedative, sedation) Ad – next to, right up close (adjust, adorn, adhesion) Assess - Ad+sedeo= to sit next to, to consider together – implies depth

Rapport- First Three Minutes Creatively establishing a helping relationship in ways that are: Beyond social Time/space-creating Transcendence allowing Profoundly accepting Earthily engaging

Communicating about Spiritual Care The art of Combining: Creativity regarding human perspectives Substance, worth reading/considering by other clinicians Usefulness to colleague chaplains and interdisciplinary teams, for patient care

Clinician (Greek – clinos = bed) A professional prepared to use direct observation, developed frameworks of understanding, and pertinent data in order to fashion interventions of assistance to people in serious need.

Why Bullet Points? The day of a physician The day of a nurse The day of a social worker The day of a chaplain

Types of Listening Diagnostic Personal / Pastoral Collaborative Intimate Love

Bullet points are efficient, focused, useful, easy to comprehend and the most likely way to slice through to the human side of other interdisciplinary team members who are intensely engaged in completely different professional missions and assessment frameworks.

Bullet points are: Efficient Focused Useful Easy to comprehend Effectively penetrating for other IDT members

Narrative and 3 or 4 Bullet Points Intro narrative: Why did you converse with this patient / family? Who is this patient/family (Capture the soul)? How did this patient/family relate to you? Assessment: 2 to 4 bullet point issues that surfaced in the conversation? Functions: What did you do to help this person/family? Plan: What do you plan to do to help this person/family?

What issues surfaced or were dealt with in the conversation? Assessment What issues surfaced or were dealt with in the conversation?

This is not your first unit of CPE!!! “Without agenda???” This is not your first unit of CPE!!!

Spiritual Assessment Framework A basic structure with which to organize spiritual care work for enhancing patient care through interdisciplinary and intra-disciplinary communication

Professional vs. Interdisciplinary Assessment Assessment frameworks for certification Assessment frameworks for data collection Assessment frameworks for interdisciplinary teamwork

Paragraph chart note: I saw this patient at the request of her father who I had met in the hallway. She is a 57 year old widowed Philippine woman with a daughter in California and a son that lives in town. She spoke in sad tones about her nagging knee pain leading to tomorrow’s surgery and her mother who died in February. She has been crying this morning, somewhat overwhelmed by her inability to lift her grandson and by her grief over her mother’s death. I listened, facilitated her grieving and prayed with her, though she is currently not practicing her Catholic heritage. I will suggest the evening chaplain drop in on her for further support. She declined my offer of her being visited by a priest.

JACHO Ready Spiritual Assessment Form What are the needs? What did we provide? Talking Points Before our chaplain’s notes were subjective narratives depending on the writing style of the individual. Survey on chaplain notes did not provide satisfactory results—did not always find information to be useful. Using our framework, we improved our documentation from subjective narratives to a more formal way to document Spiritual care needs of the patient Services provided Plan of care Our policy is that anytime chaplains are called upon to provide assistance, we will document in the patient’s medical record in the progress notes using this form. Our framework gives us common language on spiritual care services to use in our conversations among: Chaplains, with CPE students: More focused dialogue among themselves regarding the services they provide. (Will show more specific examples shortly) Interdisciplinary colleagues Able to explain services and relate it to the need they are addressing. IMPROVEMENT: Able to articulate from “I can’t describe it, but you will know it when you see it.” What is the plan of care?

Chaplain Focused Bullet Point Note 57 year old widowed Pilipino woman with a supportive father and a son living here, and a daughter in California Teary today, open and verbal with me about her life situation. Pt aware of surgery and its implications, fairly hopeful of a favorable outcome to improve her life. Mother died in February, knee pain prevents her from lifting her grandson. We began grief work. Appreciates prayer though she is currently not practicing her Catholic heritage. Declined being visited by a priest. I will continue grief work tomorrow and suggest the evening chaplain drop in on her for further support.

IDT Bullet Point Assessment Saw pt. on suggestion of her father in the hallway. She is a 57 year old widowed Pilipino woman with a son living here, and a daughter in California. She is teary today, open and verbal with me about her life situation. Pt fairly hopeful of a favorable surgery outcome Active grief issues, mother died in February, knee pain prevents her from lifting her grandson. Appreciates prayer, currently not practicing her Catholic heritage. Declined being visited by a priest. Chaplain began grief work, prayed with patient, and supported. to be continued tomorrow Chaplain to continue grief work and support after surgery

Reduce Defensive Entries Excess verbiage Unnecessary Rationalizations Pedantic Over-explaining Superfluous Self reference Annoying redundancy Subtle image enhancement Justifications for your worth Critique of other professionals’ care

Bullet Point Assessment? Questions about Bullet Point Assessment?

One Assessment Framework Franciscan Health System – Tacoma WA

Four Axes of Spiritual Needs Assessment Emotional Support Loss/Adjustment Religion/Spirituality Advocacy/Referral

1. What does this person need from me emotionally right now? 2. What losses, recent and previous, has this person experienced that continue to surface painfully at times? 3. How does this person nurture her/his own human spirit, relative to established religious traditions and apart from them? 4. What does this person need that I can’t provide?

Bullet Point Issue Recording Saw pt. on suggestion of her father in the hallway. She is a 57 year old widowed Pilipino woman with a son living here, and a daughter in California. She is teary today, open and verbal with me about her life situation. Pt fairly hopeful of a favorable surgery outcome Active grief issues, mother died in February, knee pain prevents her from lifting her grandson. Appreciates prayer, currently not practicing her Catholic heritage. Declined being visited by a priest. Chaplain began grief work, to be continued tomorrow

Axis One: Emotional Support What does this person need emotionally right now, (from me)? (Mad, Sad, Glad, Hurt, Afraid, Ashamed) 30

EMOTIONAL SUPPORT 1. The Crisis Need for Stabilizing 2. The Expression Need to Engage and Share 5. The Regression Need to be Empowered EMOTIONAL SUPPORT 4. The Bewildering Need for Basic Information 3. The Anxious Need of Waiting Too Long

Helping people pull themselves together 1 - Stabilizing - Personal support when familiar patterns are disrupted by crisis events Helping people pull themselves together

2. The Expression Need to Engage and Share Supportive validating (listening) - the Need to cry, yell, share, or just tell somebody how you feel about what is happening to you

Supportive Validating 2. An Expressing person Function Desired Outcomes Talks openly Expresses Feelings Cries Relaxes Considers Resources Supportive Validating Chaplains can help you be ok with your crying or your angry feelings and can listen to how this new situation feels to you. Supportive Validating - Chaplains show : Empathy Knowledge Personal availability Broad frameworks of understanding people A calming presence that help people work through anger, fear, sadness or regret. Outcomes Talks openly about a serious personal issue Expresses one or more of the named primary feelings, i.e., anger, fear, sadness, or regret. Cries Appears more relaxed Requests further resources 34

3-Information Need for basic information Informing in the wilderness of healthcare systems

Presence and Networking 4 - W a i t i n g Upset feelings from waiting too long in an important situation Presence and Networking

4. A person who is waiting too long Function Desired Outcomes Expresses situation Acknowledges health care system limitations Prays Expresses Gratefulness Calm Presence & Networking Presence & Networking – Chaplains companions with waiting people with: calm support realistic understanding of the limitations of healthcare serving as an information liaison and a non-anxious presence that honors the importance of this unique healthcare need Outcomes A waiting person: Expresses the importance of the situation and the exasperation Is able to pray, alone or with a caregiver Acknowledges awareness of the limitations of health care Expresses appreciation for the companionship Appears more calm. 37

5-Empowering - Need to find and use your own best ways of 5-Empowering - Need to find and use your own best ways of dealing with difficult times Helping people extricate themselves from regressing after being overwhelmed

Axis Two: Loss and Grief What has this person lost, recently and historically, that still disturbs her/him at times?

6 - Current Grief Major loss in previous 48 hours Facilitating saying goodbye to somebody recently lost

7 - Prior Grief Major past loss being currently grieved Recognizing current warm-sad memories and facilitating the past loss grief that enkindled them

7. Prior Grief Grief Counseling Function Desired Outcomes Mentions previous loss Expresses emotion Receives validation Shares reminiscences Cries while talking about the lost loved one Receives referral for further grief assistance Expresses greater hope Grief Counseling Grief Counseling –Chaplains respond with careful listening & gentle questions that promote reminiscing to further integrate the loss into that person’s life Outcome Mentions previous loss Expresses emotion Receives validation Shares reminiscences Cries while talking about the lost loved one, or Receives referral for further grief assistance Expresses greater hope 43

Grief Counseling Outcomes (%)

8 - Dying Dealing with the goodbyes of the dying process Helping people say goodbye when they’re dying

Getting used to the new way things will be 9-Life adjustment Making peace with a major change in appearance or function Getting used to the new way things will be

Axis Three: Spiritual-Religious Care How does this person maintain and nurture her own human spirit? 47

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10 – Religious and Spiritual Instruction Need to learn religious/self care modalities

“I want to feel God all around me!” 11 - Religious Support - Needing to feel the immediate positive presence of Transcendence “I want to feel God all around me!” Needing to feel God all around you When you are really scared, sad or confused, you might want somebody to pray with you or talk with you about God. Chaplains help you pray or find the minister, pastor or other spiritual leader you know and that you want to be there with you. 50

Person who is needing God Function Desired Outcomes Sacrament/ spiritual ritual Spiritual leader of choice Religious questions/problems Prays Religious Support Religious Support Chaplains provide: prayer ritual Sacrament or liaison with the patient’s valued spiritual leader. Outcome Participates in a sacrament or other spiritual ritual Is contacted by a spiritual leader of his/her choice Openly discusses religious questions or problems Prays with chaplain or support person 51

12 - Spiritual Support - Need to share unique ways one nurtures one’s human spirit “Let me tell you about what I do and believe that deeply feeds me personally!”

13 - Spiritual Counseling - Mulling – The Need to discuss ultimate matters, and/or heal old religious wounds “What I want to know is ….” “What really turned me off ….” “I couldn’t believe it when….”

14. Self-Forgiveness Need for relief from guilt or shame “I did that and I’ve never told anyone!”

15 – Estrangement - Need to re-connect with relationally separated loved ones Wanting to get back together with somebody you love.

A person regretting estrangement Function Desired Outcomes Talks with emotion about an estranged relationship Agrees to receive contact with an estranged person Agrees to take initiative to contact an estranged person Accepts the adequacy of one’s efforts at reconciling Reconciling Reconciling – Chaplains serve as transitional facilitators of re-connection, and if possible, healing, of previously strained relationships. Outcome Talks about an estranged relationship Agrees to receiving contact with an estranged person Agrees to take initiative to contact an estranged person Accepts the adequacy of one’s efforts at reconciling 56

Axis Four: Advocacy and Referral What does this person need that may be beyond my relationship with her/him?

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16 - Ethics Questions - Need to understand or 16 - Ethics Questions - Need to understand or discuss treatment outcome concerns Begin the process of using professional help to sort out options when there is no clear best care direction

17 - Family Conflict – Needing help with upset feelings among family members Facilitating healing/referral of family conflict

18 – Advocacy Need for support in finding appropriate care Feeling neglected

19 - Mental Health/Addictions - Need to explore concerns about one’s mental health or mood altering chemical abuse 62

19.Person with mental illness or addiction concerns Function Desired Outcomes Concern verbalized Feelings expressed Calm conversation Accepts consultation Referral Referral - Chaplains recognize the need for forms of care other than a patient or family is receiving, and work towards referral to: counseling psychotherapy psychiatric assessment alcoholism/ drug abuse assessment Outcome Concern verbalized Feelings expressed Calm conversation about mental health symptoms or consequences of addictive behavior Accepts consultation with a specialist on addiction/mental health. 63

20 - Family Mental Health/Addiction Concerns Need to address concerns about behavior of a family member

21. Love Life Pain Need for listening, advice or referral about one’s love life 65

Recap Rapport first Creativity & imagination Identify issues in bullet points Framework for assessment Augment electronic charting Reduce defensive chart entries

FINIS