Hindsight for Tomorrow Series

Pastoral Care by Crystal Ball

by Larry J. Austin, D.Min.

Four years ago I was functionally computer illiterate. I had the fortunate opportunity to have a friend with whom I worked who helped me learn about the computer. Mike had an MBA from Loyola and worked as a market analyst. He studied such things as demographic statistics, population trends, cost center profitability, feasibility studies for new service lines, and disease incidence by geography, gender, and population. I once asked him what he did and he replied, "I am responsible for the hospital's future plan of marketing and management. It is called management by crystal ball."

Crystal balls and dark glasses, what a way to envision the future. I have come to believe that the ability to reflect on the past may help us sometimes to see the future a little more clearly. If we explore history, we may come upon some clues to help us anticipate the future.

In the fall of 1969 I took a job at the Virginia Treatment Center for emotionally disturbed children. The Treatment Center was a division of the Medical College of Virginia and afforded me, as a student at the University of Richmond, an excellent opportunity to learn about the treatment of emotionally disturbed children.

The first three days of my orientation were concerned with the observation of children's interactions and recording my observations. The behavioral information I observed was entered in "pass on" notes for the next shift of workers. I was taught the SOAP (Subjective, Objective, Assessment, Plan) method and was supervised by an experienced Child-Care Technician Supervisor. My orientation and training in writing progress notes continued until he was satisfied that I had learned the proper techniques and language. John had only a high school education, but he was well trained and a very capable supervisor. After he was satisfied that I knew something of what I was doing, he allowed me to enter the notes in the patients charts for treatment purposes.

I went on to Southern Batist Theological Seminary in 1972 and in 1974 began my journey in Clinical Pastoral Education (CPE). I worked with a variety of supervisors over the next few years as I progressed through multiple units of CPE. Each of my supervisors contributed significantly to my learning. Sometimes they used techniques of teaching that were specific and direct; at other times they were more oblique. The supervision I received as a student chaplain was instrumental in establishing a Panglossian foundation for my own teaching methodology, even though I was not fully cognizant of the long term implications of such an educational model at the time.

Some of the things I learned were:

• Developmentally challenged patients could teach you about ministry, sometimes more poignantly than the most eloquent Supervisor.

• Hospital patients often presented complex problems that required complex professional solutions, which often felt beyond my capacity to deliver.

• Each supervisor (and chaplain) had had their own way of practicing their art of pastoral ministry and supervision.

• There would be times that I discovered pastoral information that needed to be passed on to the medical team for treatment purposes.
  

It took me a while to realize the importance of these things. Working and teaching in an acute care hospital helped me continue to reflect on the art of supervision and ministry. Progressing through CPE toward becoming a certified supervisor, I was required to reflect on the theoretical underpinnings of my supervisory theory. Students would bring significant information about their pastoral work to supervision. I found myself engaged in discussion with students about how they could communicate the pastoral information they had to the appropriate people in the treatment process.

Soon I found myself beginning to teach student chaplains to chart their pastoral insights and interactions. My initial forays into teaching about charting sounded much like the old psychological/sociological terminology of my younger days at the treatment center. The SOAP method fit with my professional understanding and was easily adaptable to pastoral care. Individual charting was something that was not new and was reasonably comfortable to me. Teaching pastoral care students about charting, however, was problematic at several points. A spiritual/religious methodology and language would need to be discovered that highlighted the chaplain's profession and training. Paul Pruyser's work on The Minister as Diagnostician (1976) was extremely valuable in developing an approach to pastoral assessment. One assumed that the chaplain's note would be different in content from a social worker or other hospital professionals. This would require the student to become versed in a spiritual /religious language that was professional, not esoteric, and was understandable to others who read the chart. It would be necessary for the student to learn to articulate pastoral dynamics in the similar methodology that a social worker would articulate social work dynamics or a psychologist would articulate the psychological dynamics of the patient interactions. Charting threatened to consume a great deal of time, if required for every patient. Students had a tendency to write dissertations in the charts, and had to learn how to be succinct in their writing process. Then there were issues with privacy and confidentiality along with professional obligations concerning the treatment, liability, and pastoral practice around all of these issues. These are daunting problems to say the least. But we pressed on and began to teach charting as a part of our Clinical Pastoral Education program.

In the early 1990's things began to change. The Ombudsman Act with its attached Patient Rights sections began to set a whole new process in motion. Everywhere you looked people were talking about the new emphasis on patient rights, spirituality, end of life issues, grief, and other issues that had been the chaplain's domain for a considerable time. A regulatory agency, the Joint Commission on Accreditation of Hospital Organizations (JCAHO) had said that any individual's spiritual issues should be attended to with some respect by the institution. In order to prove that spiritual assessment was being performed by the hospitals, documentation was required.

Suddenly documentation of pastoral interventions started to become an important issue in the preparation for JCAHO visits. Being on a JCAHO preparation team presented a unique opportunity to understand the other professions in the hospital. We chaplains were sometimes able to clearly draw the connections between Pastoral Services and others in the continuum of care. When that connection was accomplished and articulated successfully in a JCAHO survey, and your administrator affirmed your good work, it left one feeling quite excited. When the JCAHO surveyor wanted to read a copy of a chaplain's note in the patient's chart and commented on its quality and perceptiveness, it was positively exhilarating. The experience of charting as a child care technician those many years ago turned out to be an incredible, unanticipated advantage in my professional work as a chaplain and CPE supervisor.

When speaking to other chaplains about our program success in this area, I found that many chaplains still did not chart. CPE programs that made charting a part of the student's curriculum were scarce as well.

Imagine my surprise when I found a copy of a lecture by Russell Dicks in 1939 that encouraged chaplains to act as team members on the healthcare team and be like other healthcare professionals by "Note Writing". In their book, The Art of Ministering to the Sick, Russell Dicks and Richard Cabot (1936) make the point for keeping notes on patient interactions. They did not advocate placing the notes in the patient record, but did stress the importance of communication between the doctor and the chaplain as an important part of the healing tradition. Russell Dicks made this recommendation sixty years ago and it still took an outside agency to "light the fire" under chaplains to regularly chart on pastoral interventions in the patient record.

Education is an interesting process. I learned things in the past that I have not used since passing a particular course. Many of my educational practices of today are predicated and adapted from experiential practices passed on by past supervisors and past interactions in CPE programs. In the last few years, my awareness of the power of legislative, judicial, and organizational requirements upon professional standards of practice has increased exponentially. Adaptability has become an even more important skill in the learning process.

I recently did a workshop on charting for the Association of Professional Chaplains. I gave out over 200 copies of my outline and discovered several things. More and more chaplains are charting, or at least are considering learning that skill. Some chaplains, who have just finished multiple units of CPE, reported that they received formalized training in charting as a part of their residency programs. There were about 10 chaplains in the workshop that reported they have already begun electronic charting.

My own hospital is developing an electronic charting system. A pastoral/spiritual care screen is to be designed for pastoral interventions and will be a part of the system. The Information System Department of my institution wants the chaplains to help design the spiritual care screen. Point and click your way to pastoral diagnosis and documentation of pastoral interventions. After 30 years of charting by long hand, I was beginning to feel pretty comfortable with how things needed to be done. Now technological advances will give me the opportunity to learn a system that uses handheld computing devices, such as the Palm Pilot®, to record the chaplain's notes on patient interactions and download them directly into the electronic chart without having to re-enter the material manually.

There is an old song from the 1960's that says "the times they are a changing" (Bob Dylan). Still true. In these last few paragraphs let me draw some conclusions that might be helpful in coming years as we continue to teach and learn about the "Living Human Document" in our specialized institutions.

In the future, maybe more CPE programs will have didactics on charting and supervision of the chaplain's documentation in the charts. The Association for Clinical Pastoral Education may even move to include standards in accreditation and certification for the teaching and acquisition of that skill.

Technology will continue to develop and we will have to continue to adapt pastoral care to the new technology. We will have to convince some hospital administrators that pastoral care departments need computers and other technological devices to be like other professionals in the hospitals. We might even have to convince some chaplains and supervisors that they need to learn about this new way of doing pastoral care.

It took sixty years and a legislative act to help realize Russell Dick's admonition for note keeping and communication to become a more common reality. I think it is a fair assumption that some individuals and systems do not change quickly. You might even say that that there may be a modicum of resistance to change in some circles.

Clinical Pastoral Education, chaplaincy, and other specialized ministry situations have been good places over the years for creative individuals, mavericks, and "misfits" to do ministry. Surprise and adaptability are two characteristics found in abundance in the specialized ministry setting. As ministers in these settings, many of us learned to do ministry in different ways because the theories we learned about parish ministry often did not fit with the uniqueness of our contexts. Likewise, it is amazing to reflect on the seemingly small things we have seen that have impacted the field of pastoral care, such as JCAHO stating that the patient has the right to have their spiritual issues treated with respect.

Chaos/complex systems theory introduced the metaphor of the "butterfly effect," describing how a butterfly flapping its wings in Australia result in phase transition changes the weather in North Carolina. In the future it might be good for CPE supervisors to pay more attention to butterflies. I have been amazed at what my former supervisors taught me even when I was not always paying attention. Many times I have found myself saying things out loud to my students and wondering if those were my words or my former supervisors? This is much like children who grow up and find themselves repeating their parent's words to their own children. Experience has been a graceful teacher. As I got older, I found that I developed my own style of teaching, but incorporated into my teaching are the words, deeds, and theories of many past mentors. I have talked to colleagues whose students have complimented them on their words of wisdom, but they hardly remember the students, much less what they said to them. You might find it amazing what and how our students will learn from us in the future. What might be greater is what we will learn from them.

Technology will continue to advance at a dizzying pace. In 1970 Helmut Theicke wrote a little book, The Doctor as Judge of Who Shall Live and Who Shall Die, in which he comments on how medical science is moving forward at a pace that far outstrips ethics and theology. I wonder what he would say today? There is no doubt that spirituality, pastoral care, and chaplaincy will be impacted by new understandings of life, brought to us by such technologies as genetics, stem cell research, cloning, etc. We have already heard a lot about the "new frontier" of spirituality, and how many secular professional are attempting to prove scientifically the validity of the healing power of spirituality. We will be tempted to embrace the new technology simply because it is new and our society sometimes believes that if it can be done it should be done. While openness to change is intrinsically good, we should temper our embracing of indiscriminate change with a good old anachronistic attitude. In the future, more than ever, we will need to process new thoughts, new ideas, and new technological possibilities through our theological and historical perspectives, lest we find ourselves worshiping some idol of finite worth.

Computers will continue to influence the education of our profession. I recently read of a student who completed her Bachelor of Arts degree in Australia. Interesting thing is she completed the degree at East Carolina University in Greenville, North Carolina. She did all her work by computer class and only came to Greenville to walk across the stage for graduation. We are in a field that historically been a face-to-face process. We meet people in the institutions, we supervise the students face-to-face in their case conferences, and we communicate by voice and non-verbal kinesthetic communication. This is how pastoral care has been traditionally done in this century. Computer technologies require us to rethink our pastoral care traditions in the new millennium.

Will the CPE student in the future do CPE by distance learning? Supervision has already been done by fax and mail; due mostly to the unavailability of qualified supervisors close to the prospective student. Computers will make real time communication much easier, especially with video conferencing and the ability to exchange media files. Will we have virtual reality case conferences or interpersonal relationship (IPR) groups in the future, where students in various geographic areas "log on" and interact via computers with each other? Our patient care might even be a place where human contact is superceded by a spiritual care computer screen. Imagine writing pastoral paragraphs and publishing them on the hospital's Intranet, or providing a counseling service processed by email, or conducting pastoral care visits by virtual reality. How will these new ways of performing our vocation affect our teachers, clients, students and parishioners? Will the new methods of training be as effective as the old ways or will they be better?

I have had CPE accreditation committees tell me they don't care to see my pastoral care libraries anymore. They want to know if I have computers available, so students can access the web for reading material. Great educational opportunities abound on the web. But what about the classics that no longer are in print? They can be occasionally found in Chaplains' libraries. Computers and online services serve to get materials published faster than the printed page, but who will be responsible to make sure the classics are available? It would be a great project to get old copies of pastoral care books, histories of the pastoral care movement, and other significant pastoral care materials that are out of print and get them published in a place for all to have access.

Charting patient interactions was a skill I learned even before I knew any chaplains. Never in my wildest dreams did I suspect that this basic skill for a child care technician in 1969 would be such an educational and professional advantage in 2001. Who can guess what the future will bring? Who can guess what parts of our knowledge and experience will be useful or obsolete in the future? Through a glass darkly we see the future, but only in reflective hindsight does any of it make sense.

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