NACC: Vision Online

Informatics: Capturing and

measuring spiritual care

By Lisa Burkhart, Ph.D., RN

Chaplains have always intuitively known the importance of spiritual care. They have seen its transformative ability to shape people’s lives, particularly at those moments of great need, when the distressed, pained, and grieving find hope, acceptance, and salvation in those sacred moments of spiritual connections. There was never a doubt as to its power. However, chaplains also know they minister within an institutional infrastructure with scarce resources and are continually challenged to meet great needs with few resources. Decision-makers in health systems ask for data to help allocate scarce resources. Chaplains have been asked to provide “data” to describe what they do or measure the impact of what they do. This process of data collection, aggregation, report generation to justify one’s calling can be time-consuming, tedious, and frustrating.

However, rather than viewing this need for information as additional work, chaplains can take this as an opportunity to rethink and restructure how spiritual care is integrated in health systems. Because there is a legal requirement to document patient care, the health record can be a central place to assist in this restructuring. The movement toward an electronic health record (EHR) can assist in data collection and aggregation, depending on how spiritual care is integrated into the system. Chaplains may find an interesting partner with the Information Systems Department.

Catholic institutions have always known the importance of spiritual care, but research has also demonstrated that people who have higher levels of spiritual well-being are physically, psychologically, and socially healthier. Specifically, spiritual well-being is associated with better adherence to treatment regimen, and is associated with less symptom distress, less pain, lower anxiety, better quality of life, and lower mortality rates. Particularly for the oncology population, higher levels of spiritual well-being are associated with higher levels of well-being, hope, coping, social functioning, self-rated health, and quality of life and are associated with less psychological stress, depression, financial strain, and suicidal ideation (Burkhart & Hogan, 2007; Burkhart, Solari-Twadell, & Haas, 2007 -- primary sources available in these two articles). This suggests that spirituality is not only important in coping with disease, but increased spiritual connectedness has the potential to improve quality of life, relieve symptoms, and reduce disease.

This research has lead to a Joint Commission requirement to provide spiritual care within a multidisciplinary environment. As the experts in spiritual care, chaplains are called to assist in interpreting and operationalizing this requirement. This introduces several questions: What is multidisciplinary spiritual care? How can a health system provide spiritual care using an integrated approach? The first question requires one to look at discipline-specific research. In answering the later question, we delve into research and methods to integrate spiritual care in the electronic health record.

Multidisciplinary Spiritual Care

Provider groups define and approach spiritual care differently. The majority of the spiritual care literature identifies chaplains, nurses, physicians, and social workers as the providers of spiritual care within their own practice perspective. However, little to no literature presents methods to integrate spiritual care across disciplines.

Chaplains are clearly viewed as the experts in spiritual and religious care. However, in most institutions chaplains do not automatically visit all patients, and patients do not always request a chaplain visit. Bringing together the patient and chaplain requires another healthcare professional to recognize a spiritual need and to request a chaplain consult. Physicians and nurses are the primary gatekeepers to the chaplain.

Most medical literature integrates spiritual and religious care. Much of the medical literature has shown that religion is associated with coping patterns and, if the patient has a religious preference, promoting that religion can promote coping and healthy behaviors (Pargament, 1997; Koenig, 2001; Pulchalski, 2004). This work has resulted in adding questions related to spiritual and religious beliefs, preferences, and needs as part of the medical admission history and physical. The FICA assessment structure (Faith/Belief, Importance/Influence, Community, Address/Action in Care) is an example of how physicians can integrate spiritual/religious assessment as part of the patient history and physical (Pulchalski, 2004). Based on this assessment, the interventions primarily involve chaplain referral.

Nursing research in spiritual care has focused on what is spirituality and spiritual care in nursing practice and what are spiritual assessments and interventions. From a nursing perspective, spirituality is defined as a dimension of self that expresses and searches for meaning and purpose in life. Spirituality includes both faith and meaning perspectives, and spiritual care includes assessments and interventions to promote the patient’s spirituality. Spiritual assessment is the recognition of a spiritual need in the moment, rather than adopting a formal list of spiritual assessment questions. Spiritual interventions include promoting self-reflection, promoting relationships with family/friends, and facilitating the practice of religious rituals and prayer (Burkhart & Hogan, 2008; Taylor, 1995). Research also indicates that providing spiritual care can affect the nurses’ spiritual well-being, and, in turn, affect the nurses’ ability to provide spiritual care in the future.

Clearly different healthcare professionals interpret their role in providing spiritual care differently. The challenge is in creating an integrated approach to provide spiritual care for the benefit of the patient. The electronic health record can facilitate this integration by fostering communication among healthcare professionals.

Integrating spiritual care in the Electronic Health Record

Both professional organizations and state law affect what specific information must be documented in the health record. Required information includes assessment data, problem identification, intervention/treatment descriptions, and patient response to those interventions/treatments. To best communicate spiritual information across all healthcare providers, spiritual assessments and interventions must be integrated into this documentation structure.

The use of an EHR required healthcare professionals to create lists of terms, or taxonomies, of assessment areas, patient problems/issues, and interventions that relate to their practice. These lists have been standardized, accepted by their respective professional organizations, and published in both electronic form and dictionary-like books. All of these taxonomies have been merged into one database infrastructure for healthcare, called SNOMED CT (Systematic Nomenclature of Medicine, Clinical Terminology). SNOMED-CT has been designated a core terminology for the United States National Health Information Infrastructure (NHII) by the National Committee on Vital and Health Statistics (NLM, 2009). The terms in SNOMED CT are used to populate the drop-down boxes and check-off lists on the computer screens. Creating common lists of terms in one database infrastructure allows for more clear communication among and between healthcare providers and across health systems, as well as designing databases for statistical analysis. SNOMED CT includes spiritual and religious terms. This provides the building blocks to create a documentation system that integrates physical, psychological, social, and spiritual care.

When designing an EHR, individuals within the health system choose what terms to include in the documentation screens. Each health system develops a strategy for individualizing the EHR. It is critical for chaplains to be involved in this design so that spiritual care is integrated into the appropriate screens. Given that physicians, nurses, social workers, and chaplains claim to be involved in spiritual care, spiritual care terms should be incorporated in each professional’s documentation screens. Both documenting and sharing this information electronically can promote the provision of spiritual care in a multidisciplinary environment.

Case example at Loyola University Health System

Loyola University Health System purchased an EHR and developed multidisciplinary committees to individualize the system. The pastoral care department took primary responsibility in identifying how best to capture chaplain care and subsequently to suggest what spiritual terms should be available (or “common”) to all healthcare providers. Integrating spiritual care involved several steps, including analyzing current chaplain workflow, developing a list of SNOMED CT terms to reflect the workflow, manually piloting the system to identify the utility and accuracy of the terms, and developing the screens based on the results of the manual pilot test. Common terms were then identified and submitted to the Documentation Steering Committee and nursing task forces for approval. Definitions and measurement systems were modified based on nursing’s input. The following describes how spiritual care was integrated into the admission patient assessment, chaplain documentation, and nurse documentation.

The admission patient assessment includes a detailed multidisciplinary physical, psychosocial history and physical. A brief spiritual assessment was included, identifying a faith tradition and relevant spiritual practices. This assessment is consistent with what is commonly integrated in most EHRs.

The chaplain documentation screen has some unique characteristics. Many chaplains document descriptive information about visits, including type of visit (initial, follow-up, discharge), who is present during the visit, site of visit, and urgency/crisis of the visit. Religious needs are also documented (e.g., prayer, sacraments, information, religious resources). A unique feature to this documentation is the spiritual assessment. Pilot data indicated that patients’ spiritual issues relate to fear, hope, suffering, family coping. Chaplains measure those areas on a 5-point scale, with “1” being the worst and “5” being the best. For example, if a chaplain visits a patient preoperatively with a possible cancer diagnosis pending surgery, the chaplain may document “Fear” as “2” and Hope as “4.” This can be interpreted as the patient is fearful of the diagnosis, but is hopeful of a good outcome. Using a measurement system allows chaplains and other healthcare providers to derive meaning at a glance and can integrate that information in patient care. Data can also be statistically summarized and analyzed across time.

Chaplains also document a global measure for spirituality, called “Spiritual Assessment.” This item also appears on nurse documentation screens so that nurses can be informed of the patient’s spiritual well-being while they are documenting. Nurses can also measure the spiritual assessment item from their practice perspective.

Spiritual care is central to the chaplain role. Both the spiritual care Joint Commission requirement and the adoption of the EHR offer an opportunity and method to integrate spiritual care in health systems. The building blocks for the integration exist. Chaplains can become involved in this process. The benefit is to engage all healthcare providers in spiritual care, but, more importantly, to measure the impact of spiritual care on patient outcomes toward the ultimate goal of improving patient health.

Lisa Burkhart is assistant professor in the Marcella Niehoff School of Nursing at Loyola University in Chicago, IL. Her area of study is spirituality and informatics.

References

Burkhart, L., & Hogan, N. (2008). An experiential theory of spiritual care in nursing practice. Qualitative Health Research 18 (18), 928-938.
Burkhart, L., Solari-Twadell, P.A., & Haas, S. (2008). Addressing spiritual leadership: An organizational model. Journal of Nursing Administration, 38 (1), 33-39.
Koenig H.G., McCullough M.E., & Larson D.B. (2001). Handbook of religion and health. New York: Oxford University Press.
National Library of Medicine. www.nlm.nih.gov/research/umls/Snom.ed/snomed_main.html. Accessed May 28, 2009.
Pargament K.I. (1997). The psychology of religion and coping theory, research, and practice. New York: Guilford Press.
Puchalski C.M. (2004). Spirituality in health: the role of spirituality in critical care. Critical Care Clinics, 20 (3), 487-504.
Taylor E.J., Amenta M., & Highfield M., Spiritual care practices of oncology nurses.
Oncology Nursing Forum.1995; 22 (1): 31-39

SECTIONS

One Book, One Association

REGULAR FEATURES

Multidisciplinary Spiritual Care

Integrating spiritual care in the Electronic Health Record

Case example at Loyola University Health System

References