Documenting and Measuring Spiritual Care
Chaplain Documentation in the ICU
Brittany Lee, MD(s), Duke University
Farr Curlin, MD, Duke University
Philip Choi, MD, Duke University
Addressing a patient’s spiritual concerns is widely embraced as central to holistic care, emphasized by a shift from the biopsychosocial model to the biopsychosociospiritual model. Spiritual care is particularly salient in the intensive care unit (ICU), as addressing spirituality is more important to patients with more severe illness. Additionally, patients’ and their families’ spiritual beliefs are known to affect their end-of-life care decisions. Hospital based chaplains are trained both to conduct spiritual assessments and to help with clinical decision-making.
Although the role of the hospital chaplain is still debated, many have argued in recent years that the work of chaplains should become more evidence-based. Similarly, leaders in the field have emphasized documentation of chaplain visits to allow multidisciplinary review of the spiritual assessment and plan. However, the format of chaplain documentation remains variable, even within single institutions. Despite widespread support for chaplains addressing spiritual concerns in the ICU, chaplains’ activities in this setting – and the documentation of such activities – have not been adequately studied.
This study seeks to characterize chaplain documentation in the ICU. We examined all chaplain notes in the medical record for all patients admitted to the adult ICUs of a major medical center in the southeastern United States over a six month period. At this institution, chaplain notes consist of a close-ended checklist and an optional entry of free-text. This study focused on the free-text from those chaplain notes that included such an entry. Each text entry was coded and analyzed for emergent themes through an iterative process of qualitative textual analysis. The analysis focused on what chaplains document doing during the patient encounter, clinical information, the setting, the patient’s story, and comments about the spiritual plan.
Several themes emerged from this analysis. Among them, we found that chaplains often use code language, such as “facilitated expressions of lament” or “compassionate presence,” to recapitulate interventions already documented in the checklist of ministry interventions. Second, chaplains’ notes focused much on describing the setting, such as who was present in the patient’s room. Few notes provided any information about the patient or their family that was not otherwise accessible by members of the healthcare team. In particular, few notes described the patient’s story or any spiritual dimensions of the patient’s experience.
This study of chaplain notes in the ICU suggests that recent emphasis on evidence-based practice of chaplains may be leading, at least in the medical center we studied, to a shift in chaplains’ documentation towards reduced, mechanical language insufficient in illuminating patients’ individual stories.
The Assessment and Relevance of a Child’s Spiritual Formation and Religious Identity in the Diagnosis and Management of Mental Illness
Theodote K. Pontikes, MD, Loyola University
The spiritual dimension of a child’s psyche has been recognized as contributory to character formation, as well as to cognitive and moral development. However, it is an area that has traditionally been under-researched. In assessing risk and protective factors regarding the predisposition and precipitants to mental illness, an understanding of a child’s evolving religious identity can be an important and meaningful variable in diagnostic clarification that informs treatment planning towards building resilience and optimizing a child’s overall developmental trajectory. The exploration of a child’s premorbid worldview should include an examination of the entire family system’s religious beliefs, both in theory and practice, and their impact on daily functioning. The purpose of this paper is to review approaches of researching the formation of religious identity from an interdisciplinary perspective and to understand, via case examples, the application and implications of this research in clinical practice, towards supporting a child’s development of a meaningful, integrated sense of self. The stage progression of faith and identity from infancy to adolescence will be discussed, with a comparative review of similarities and differences among religious traditions. The role and influence of the psychiatrist’s respective faith tradition and identity, as well as the management of any transference and/or counter-transference issues will be examined. A discussion of barriers to assessing the role of religious identity in the diagnosis and management of mental illness in children and the potential adverse consequences will also be addressed. Lastly, the inclusion of religious institutions and professionals as a resource in the healing process of children with mental illness will be considered.
Clinical Applications of the Meaning Systems Interview
Stuart Nelson, MA, Institute for Spirituality and Health
Interactions between patients and physicians regarding religious and spiritual matters have been found to increase quality of care and patient satisfaction, particularly at the end of life. While patients report the desire to engage in religious and spiritual (R/S) discussions with their physicians, physicians report that worries about intrusiveness, manipulation, and cultural competency often prevent them from taking such steps. Several spiritual assessments, including the popular FICA and HOPE models, have been promoted as means to address these concerns, to varying degrees of success.
This paper introduces the Meaning Systems Interview (MSI) as a means to bolster the scope and utility of existing assessments so that physicians (and other caregivers) are able to feel more equipped to initiate R/S discussions and to deal with them responsibly as they arise. These efforts move towards an answer to “How should particular spiritual and religious needs of patients be addressed and by whom?”
To create MSI, a research team (UC Santa Barbara) modified and infused James Fowler’s Faith Development Interview with language compatible with Ann Taves’ Building Blocks Approach for the study of religions, which is rooted in cognitive linguistics, psychology of religion, and the comparative history of religions. The result is an interdisciplinary, cross-culturally stable means for understanding and evaluating systems of meaning within or without the context of religious traditions.
Originally, MSI was created to evaluate meaning-system narratives that had been both recorded and preserved historically and elicited clinically and ethnographically. The team that created the interview asked: How can we gather data (analyze narratives) in a more systematic way that will allow us to:
In settings such as urban hospitals where interviewees may have mental health concerns, a history of emotional and physical trauma, or other medical circumstances, systems of meaning vary from traditional to highly unusual. It is in these circumstances that an interdisciplinary, cross culturally stable tool such as MSI seems ideal.
The interview has been tested both formally and informally over the last two years in diverse contexts, yielding encouraging results that speak to its efficacy as an assessment. Most recently, MSI was used as the foundation for a spiritual care initiative at The Women’s Home, a non-profit organization that guides at-risk clients through an 18-month comprehensive recovery program addressing both physical and mental health. Though the population was extremely diverse with regards to religious and spiritual outlooks, the interview allowed for a genuine conversation to take place between care providers and clients in a group context.
In summary, this paper covers the need for and creation of MSI, as well as its implementation and future directions in clinical contexts.
Brittany Lee, MD(s), Duke University
Farr Curlin, MD, Duke University
Philip Choi, MD, Duke University
Addressing a patient’s spiritual concerns is widely embraced as central to holistic care, emphasized by a shift from the biopsychosocial model to the biopsychosociospiritual model. Spiritual care is particularly salient in the intensive care unit (ICU), as addressing spirituality is more important to patients with more severe illness. Additionally, patients’ and their families’ spiritual beliefs are known to affect their end-of-life care decisions. Hospital based chaplains are trained both to conduct spiritual assessments and to help with clinical decision-making.
Although the role of the hospital chaplain is still debated, many have argued in recent years that the work of chaplains should become more evidence-based. Similarly, leaders in the field have emphasized documentation of chaplain visits to allow multidisciplinary review of the spiritual assessment and plan. However, the format of chaplain documentation remains variable, even within single institutions. Despite widespread support for chaplains addressing spiritual concerns in the ICU, chaplains’ activities in this setting – and the documentation of such activities – have not been adequately studied.
This study seeks to characterize chaplain documentation in the ICU. We examined all chaplain notes in the medical record for all patients admitted to the adult ICUs of a major medical center in the southeastern United States over a six month period. At this institution, chaplain notes consist of a close-ended checklist and an optional entry of free-text. This study focused on the free-text from those chaplain notes that included such an entry. Each text entry was coded and analyzed for emergent themes through an iterative process of qualitative textual analysis. The analysis focused on what chaplains document doing during the patient encounter, clinical information, the setting, the patient’s story, and comments about the spiritual plan.
Several themes emerged from this analysis. Among them, we found that chaplains often use code language, such as “facilitated expressions of lament” or “compassionate presence,” to recapitulate interventions already documented in the checklist of ministry interventions. Second, chaplains’ notes focused much on describing the setting, such as who was present in the patient’s room. Few notes provided any information about the patient or their family that was not otherwise accessible by members of the healthcare team. In particular, few notes described the patient’s story or any spiritual dimensions of the patient’s experience.
This study of chaplain notes in the ICU suggests that recent emphasis on evidence-based practice of chaplains may be leading, at least in the medical center we studied, to a shift in chaplains’ documentation towards reduced, mechanical language insufficient in illuminating patients’ individual stories.
The Assessment and Relevance of a Child’s Spiritual Formation and Religious Identity in the Diagnosis and Management of Mental Illness
Theodote K. Pontikes, MD, Loyola University
The spiritual dimension of a child’s psyche has been recognized as contributory to character formation, as well as to cognitive and moral development. However, it is an area that has traditionally been under-researched. In assessing risk and protective factors regarding the predisposition and precipitants to mental illness, an understanding of a child’s evolving religious identity can be an important and meaningful variable in diagnostic clarification that informs treatment planning towards building resilience and optimizing a child’s overall developmental trajectory. The exploration of a child’s premorbid worldview should include an examination of the entire family system’s religious beliefs, both in theory and practice, and their impact on daily functioning. The purpose of this paper is to review approaches of researching the formation of religious identity from an interdisciplinary perspective and to understand, via case examples, the application and implications of this research in clinical practice, towards supporting a child’s development of a meaningful, integrated sense of self. The stage progression of faith and identity from infancy to adolescence will be discussed, with a comparative review of similarities and differences among religious traditions. The role and influence of the psychiatrist’s respective faith tradition and identity, as well as the management of any transference and/or counter-transference issues will be examined. A discussion of barriers to assessing the role of religious identity in the diagnosis and management of mental illness in children and the potential adverse consequences will also be addressed. Lastly, the inclusion of religious institutions and professionals as a resource in the healing process of children with mental illness will be considered.
Clinical Applications of the Meaning Systems Interview
Stuart Nelson, MA, Institute for Spirituality and Health
Interactions between patients and physicians regarding religious and spiritual matters have been found to increase quality of care and patient satisfaction, particularly at the end of life. While patients report the desire to engage in religious and spiritual (R/S) discussions with their physicians, physicians report that worries about intrusiveness, manipulation, and cultural competency often prevent them from taking such steps. Several spiritual assessments, including the popular FICA and HOPE models, have been promoted as means to address these concerns, to varying degrees of success.
This paper introduces the Meaning Systems Interview (MSI) as a means to bolster the scope and utility of existing assessments so that physicians (and other caregivers) are able to feel more equipped to initiate R/S discussions and to deal with them responsibly as they arise. These efforts move towards an answer to “How should particular spiritual and religious needs of patients be addressed and by whom?”
To create MSI, a research team (UC Santa Barbara) modified and infused James Fowler’s Faith Development Interview with language compatible with Ann Taves’ Building Blocks Approach for the study of religions, which is rooted in cognitive linguistics, psychology of religion, and the comparative history of religions. The result is an interdisciplinary, cross-culturally stable means for understanding and evaluating systems of meaning within or without the context of religious traditions.
Originally, MSI was created to evaluate meaning-system narratives that had been both recorded and preserved historically and elicited clinically and ethnographically. The team that created the interview asked: How can we gather data (analyze narratives) in a more systematic way that will allow us to:
- Examine what scholars place under the heading of “religion” and “spirituality” as broadly conceived as possible and without worrying about whether we capture “too much”
- in a way that is workable (translatable) across times and cultures
- and amenable to both humanistic (qualitative) and scientific (quantitative) modes of analysis?
In settings such as urban hospitals where interviewees may have mental health concerns, a history of emotional and physical trauma, or other medical circumstances, systems of meaning vary from traditional to highly unusual. It is in these circumstances that an interdisciplinary, cross culturally stable tool such as MSI seems ideal.
The interview has been tested both formally and informally over the last two years in diverse contexts, yielding encouraging results that speak to its efficacy as an assessment. Most recently, MSI was used as the foundation for a spiritual care initiative at The Women’s Home, a non-profit organization that guides at-risk clients through an 18-month comprehensive recovery program addressing both physical and mental health. Though the population was extremely diverse with regards to religious and spiritual outlooks, the interview allowed for a genuine conversation to take place between care providers and clients in a group context.
In summary, this paper covers the need for and creation of MSI, as well as its implementation and future directions in clinical contexts.