58 Evidence-based Practice

“Does what I’m doing make a difference?”  That’s a question that people-helpers often ask. Sometimes we are asking out of our fatigue or despair. Sometimes we’re asking in the face of overwhelming demands and apparently insignificant acts.

“Does prayer even work?” “Why are they still sad after I talk with them?” “Why can’t I make them change?”

At our best moments, we can set aside our own frustration and move to a different question: “What is the difference that what we do makes?”

We often answer that question experientially: “I was feeling sad right after my dad died. A chaplain just sat down next to me and said ‘hi’ and just sat there. I think she said something more, but I don’t even remember. All I know is that when everyone else in the hospital was moving and talking and doing their work, someone was with me.”

As a result, we sit with people. We say hi. But that still doesn’t help us know the difference that what we do makes.

Healthcare uses the phrase, “evidence-based practice.” It simply means that you provide care based on what evidence shows, what data shows, what research shows. This is in contrast to providing care based on what makes sense to you, what you like, what you find comfortable.

That phrase is finding its way into chaplaincy and spiritual care as well. Which initially makes many of us hesitate. Historically, evidence and spiritual care feel uncomfortable together. “How can you measure what God is doing?” “How can we prove that our spiritual care is significant?”  “If we can’t control what God does in response to our prayer, what do we measure?

In the congregational context, we can measure offerings and attendance. But those don’t actually indicate change in lives and may actually direct our attention away from deeper changes.[1] In the hospital context, in the context of helping people grieve and plan and respond to crisis, we can look for the most helpful and least helpful behaviors for present and future care.

When we talk about research, we’re talking about something as simple as asking a question about our practice, suggesting an answer, and measuring things before and after the change. It can also include looking at the ways others have answered that question. And research can include massive multi-year, multi-step processes of study.

Our practice as chaplains in the health system where I work has been influenced by a number of questions and systematic answers, by research.

For example, we wondered whether wearing ties was important. The standard of dress was that male chaplains wore ties with slacks. Some people were comfortable wearing ties and some were not. The standard was based on an assumption that wearing ties conferred a sense of professionalism that would help patients be more confident in the care they received.

Rather than debate who felt comfortable, a coworker asked a couple key questions: Do ties carry infection? And do ties make patients more confident in their care. The research was strongly suggested that ties can carry infection and that patient are comfortable with physicians who don’t wear ties. [2]

This review of the research literature has literally changed the look of chaplaincy. Ties are only used if they can be laundered regularly, and new badges that say “chaplain” are now the way that chaplains are distinguished.[3]

In another example, spiritual care research suggested a connection between positive hospital experiences and spiritual conversations. When patients have conversations about a spiritual need, they give a higher rating to their overall care on the after-visit patient satisfaction survey. The study concluded that “many more inpatients desire conversations about religion and spirituality than have them. Health care professionals might improve patients’ overall experience with being hospitalized and patient satisfaction by addressing this unmet patient need.” [4].

In response to this research, our chaplaincy department began the practice of visiting in-patient units with lower overall patient satisfaction scores.  Chaplains stopped by the units, visited with staff, asked about patients, and then had conversations with patients.

Each time a unit has received this kind of attention, scores have gone up. Because this hasn’t been a structured research process that was designed to eliminate other variables and isolate the chaplaincy work, this is anecdotal.  It’s not possible to establish a causal relationship. Is it conversations with patients? Is it conversations with coworkers? Is it praying as we walk through? But we do have an inkling.

In the healthcare spiritual care, there seem to be two reasons for evidence-based practice.

The first is financial.  Medicare reimbursement is significant for hospitals. Medicare reimburses activities that are connected to measurable changes in health. So there is extensive conversation in the field of palliative care about measurement. They are creating standards of care which can be measured. As part of the palliative process, researchers are working to identify the role of spiritual care in the success of palliative care.

The second reason for evidenced-based practice is for determining whether and how we are providing the best possible help with our patients. It’s this reason that can encourage everyone who is involved in helping people in difficult times to grow in our capacity to be helpful. If I’m spending time with people at vulnerable moments, I have a responsibility to be as helpful as I can possibly be. Which means taking steps to improve the work I do.

+++

I offered my hand to the old man in the consult room. He grabbed it with a hand that an hour earlier had done emergency compressions on his wife of six decades. His hand was shaking.

He worked to slow his breath. I worked to find my next word. I was in the place between platitudes and prayer and presence and profoundness and sheer uncertainty.

And I thought about research. Not the research that reports the tiny percentage of people of a certain age who survive following CPR. Not the research that reports on brain damage following the loss of oxygen from cardiac arrest.

I thought about the practical research that chaplains and others do every day, a simple three phrase process:

  • Here’s what we do.
  • We think it helps.
  • Let’s find out.

In those moments when I know more than the family does about what’s happening in the patient’s room, there are several things I try to do because experience has shown they can be valuable. Our training says that we show up, we establish a connection, we provide presence. We are building a relational foundation for the bad news that may be coming. If the end comes before other support arrives, we are present when the doctor walks out of the room.

We’re also gathering relational information, finding context that will help the rest of the medical team and support team. Information about recent family events, about historic family events, can help all of us to know places to provide support.

I sat, next to the man. I started talking with the man.

I asked him what happened. He talked through the morning and I listened and looked at him. He talked about the steps he had done to get his wife to the ER room where, as far as I knew, a team was still working hard to get a pulse started. I made a mental note to affirm later that he had done all he could do.

I smiled when he talked about how long they had been together. I made a mental note about talking with him, if appropriate, about the way that memory in a couple is intertwined.

He talked about being at a loss. He mentioned a family death that had been hard, “But this is harder.”

When he mentioned calling his church, I made an actual note, which I would follow up on in a couple minutes. I said, “Would you like to pray right now?” We prayed. He wiped his eyes.

He went back to reviewing the morning’s events.

Our care team at this moment included another chaplain and a social worker. I stepped out of the room to call the church. The social worker helped the man make phone calls to family. When I went back to the room, additional family came. The pastor came. I left the consult room when there was enough family to provide support for the man. Because at that point, our best helpfulness is often elsewhere.

But we don’t like to leave families stranded because that increases anxiety. In the absence of information, they start filling in explanations and fears.

So I reported back when they had a pulse. I reposted back when they were taking additional steps to stabilize her. I reported back when the physician gave me the next steps of testing.

I went back to my office, to the rest of what was going on in my day, though very aware of this room. After a bit, when the scans should have been done, I headed back to the ER. The physician was ready to visit with the family, and so I joined her, without my usual orientation about who was in the room.

She started where they always start, where I had started: “Can you tell me what happened?”

And the family took over. “But what’s happening now?” the husband asked.

“We have a pulse and are working to stabilize her blood pressure,” the physician said. “What’s her blood pressure now?” the son-in-law asked. When she responded, the family said, “That’s a good pressure.” And they began to talk among themselves. The physician started to talk again and the family asked, “What did the scan show?”

At every turn, the family was running ahead, running the conversation. Until the doctor asked the next question: “Has she expressed how far she would like us to go in treating her?”

And the family took over. “Oh no,” as the husband dissolved in sobs. “Are you wanting to stop?” the son-in-law spoke immediately. “We have to decide now?” someone asked.

There was a level of intensity that surprised the physician and me. There were conclusions being leapt to with a speed and resistance that was different than other rooms.

We got the family to the patient’s room. We watched more family tension. We watched more family emotion. I was glad the pastor was present. I went back to the office.

I was doing my charting, thinking about the intensity, talking with my colleagues, wondering about the situation. Until a coworker said about an unrelated case, “I don’t know what it’s like to lose a child.” And I suddenly remembered what the man had said in my first minutes of conversation: “We lost a grandson. He was 20. It was something in his blood.”

And I understood the tension in the consult room. I understood the intensity of the grandson’s parent, the other ways of family members moving in the room. Remembering that one fact, “This is a family that has faced a difficult hospital death together”, would have softened how I interacted with the family. It would have given the physician a starting point of compassion which may have made our usual script feel less combative, allowed her to move to the point more quickly.

Everything the physician had said and that I had said had been consistent with good practice, rooted in at least some research. But the breakdown in this case provides some research about my own practice. When I leave out the orienting of the physician, things can go awry. And when I lose track of the conversations because of sharing care with other people, I go awry.

  • Here’s what we do.
  • We think it works.
  • Let’s find out.

That last statement is where research actually happens. When we do what we always do and we ask ourselves, “Does that really work the way we think?” There is a humility that comes, a learning that comes, when we look at the process inside and out in an effort to discern how we could be more effective, how we could be more helpful, how we could adjust our “here’s what we do” just a little.

This is the kind of research that can become a major study, with sample sizes and protocols and literature reviews and statistics. All of those are helpful in growing a discipline of study.

But it can also happen in a room with a man who is afraid for his wife. I can pay attention to my own practice, my own interactions with husbands and wives, parents and children, moments of excruciating difficulty. In each of those moments (or immediately after) I can ask myself, “What am I learning that will help me with the next one of those moments. What questions can I ask myself and others? What can I learn about attending to bits of information and infusing them back into the care all of us provide?”

Listening for facts and patterns is research. Bringing a principle into a specific conversation to see how it helps is research. Affirming the physician following her conversation with the family because I want to see if I can help docs get better in those moments is research.

But leaving off the phrase “let’s find out” is not research. “Here’s what we do. We think it works” without the humility of testing and refining and clarifying is not research. It leads to criticism of families: “Why do they always interrupt me?” “Why can’t they be comforted the way everyone is supposed to be comforted?” “Why can’t they let me be the expert on their pain?”

Practical daily research can happen every time I walk into the building, desiring to help.

  • Here’s what we do.
  • We think it works.
  • Let’s find out.

+++

What could this kind of practical research look like?

We can look at the crucial moments we encounter as individuals, formal teams within organizations, or informal teams across organizations. For example, in one healthcare system, a chaplain arrives in the room with every death. They talk with the staff, they talk with the family, they ask, “What funeral home?” That consistent intersection with people in critical moments invites us to ask several questions.

  • What do we know about the helpfulness of what we do?
  • What do we know about the value of each of the actions?
    What do we know about the helpfulness of the follow-up?
  • What do we know about our consistency in those situations?
  • What do we know about our role with staff?
  • Are there variations by unit?

All of these are questions that could be investigated with the intention of offering the best possible care, with the fewest distractions, to the family and friends and staff. Discovering the answers could include regular conversations with the team about how particular situations are approached. There could be self- assessments, journaling. There could be structured surveys of families.[5]

We can look at the conversations we have in less critical moments. What are we hoping to accomplish with those conversations? Relationship building? Spiritual assessment? Providing tools to navigate the current illness, the future crises that will arise?

Would we be more effective by learning listening skills, counselling skills, teaching skills? Would we be most helpful by learning about medicine, theology, or baseball standings? How much attention should we pay to our own personalities, the personalities of the people we are talking with?

All of these are questions that could be investigated through some of the methods suggested above.

 


  1. Karl Vaters describes what he views as the unfortunate assumption that big churches are better churches and small churches should get busy trying to become bigger churches. In “30 ways”, he identifies several measures for congregations other than dollars and attendance.
  2. "Doctors are told to ditch disease spreading neckties" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1382570/ “Study showing patient perception in regard to neckties and professionalism in the healthcare setting” https://www.jstor.org/stable/10.1086/675066#metadata_info_tab_contents; From a study of actual infections found on neckties of healthcare workers http://www.medicine.wisc.edu/sites/default/files/healthcare_personnel_attire_and_devices_safdar_9_7_16.pdf.
  3. Thanks to my colleague Michael Kinsey who did the research into the risks and rewards of ties.
  4. Williams, J.A., Meltzer, D., Arora, V. et al. J GEN INTERN MED (2011) 26: 1265. https://doi.org/10.1007/s11606-011-1781-y accessed 9/19/19.
  5. For example, many teams send bereavement notes. ___ assessed the value of those notes.

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Before You Walk In Copyright © 2019 by Jon Charles Swanson. All Rights Reserved.

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