Wednesday, May 30, 2007

Getting this party started

Today was the second day of orienting our new summer interns. I'm so excited about how its going.

This new orientation also represents the first step on a new journey for me: This summer will be my first opportunity to supervise Clinical Pastoral Education (CPE) students, and as such is my first step on the challenging road towards becoming a certified supervisor of CPE students.

We have four seminarians as our summer interns: three from the Lutheran Seminary in nearby Philadelphia and one from Yale Divinity School. I am very impressed with them -- and their motivation to serve others.

I am also very pleased and excited about how the orientation is going. Me and my supervisor have been talking for some time now about the best way to orient people to the training and work they will be doing by serving as a student chaplain in our hospital. A few basic principles have arisen:
  • To try and reduce as much as possible the amount of information and pure classroom time involved in the orientation.
    • (The thinking behind this is that folks are usually completely overwhelmed by the amount of information thrown at them in a CPE orientation. The result is not only that they (become bored and) really don't learn as much as you want, but that their anxiety about the work before them goes up).
  • To instead focus on two things
    • Getting as much of the orientation (out of the classroom and) onto the floors where the students will actually be working. (We call this Teaching in Context.)
    • Making as much of the classroom time as possible about orienting the students to the general culture and values of our department and the specific tasks and competencies in which we are engaged.
  • To engage in a team approach to orientation. That is, to engage every member of our department (as well as other people from the medical care team) in orienting our interns, instead of having it done almost entirely by their supervisors (as I was oriented in my first unit of CPE). (The team approach also helps support the relationship-building goal I discuss below.)
  • Finally, to keep in mind two guiding goals throughout:
    • "It's all about relationship" -- that is, we want our interns to learn to trust our staff (ie, form relationships with them) and to know that they are available to them when they need to seek consultation or need support.
    • Anxiety-reduction -- Anxiety is the number one barrier to effective pastoral care. It is the number one barrier to learning in the clinical educational setting. You cannot learn in the pastoral clinical setting unless you are willing to take risks and to make some mistakes. The best way to address the unnecessary anxiety (and to encourage risk taking) is the relationship building I talked about above -- when the student trusts that someone cares about them and their learning (and knows that that person or persons will be available when needed) that emboldens them to go out and take risks.
The reason I am so happy about how things went, today, is that I feel we did an excellent job of putting these principles into effect. The subject today was the business of documenting our work in the patient's chart. This is typically one of the most anxiety provoking parts of an orientation ("what if I write the wrong thing in the chart!??!?! Will a doctor yell at me?!?!?"), as well as a part that causes the most glazing over of the eyes (translation, it's boring).

We decided to address these challenges by starting off with a discussion about the purpose of documenting our visits. We asked folks (most of our interns have quite a lot of life experience in previous careers) to recall previous uses of documentation in their lives. One student brought up an example (which surprised me!) that had some excellent parallels to why and how we document in a hospital -- his use of contact managment software as a manager of a team of salespeople.

Here are some of the principles we identified from the student's example for why we document:
  • For our own learning (that is, to help us understand what we have done so we can become better chaplains).
  • To help us care better for an individual patient (by, for example, being able to easily recall important details from our previous contact with an individual patient -- if there's a family member they're worried about for some reason, for example).
  • To help us communicate with the rest of the care team (about the work we're doing with a patient and what needs that patient has that we might have identified).
  • For management/oversight of our own work -- so our managers can have a picture of what the work is that we are doing and they can use that to make administrative decisions to help us improve the quality and quantity of our patient care.

After we had laid out the principles in the classroom, we moved on to the next step -- the actual details of how we document in our hospital. In the old days that would have meant everybody sitting around a classroom table while we handed around copies of the forms and tried to explain how they are used as the confused new students furiously take notes.

But, today, we instead did Teaching in Context. Each intern was paired off with one of our staff chaplains or an experienced chaplain resident. They went out onto the floors where the intern shadowed the experienced chaplain on a patient visit. This, by the way, helped reinforce the basic elements of pastoral care visitation that we had emphasized in day 1 of our orientation. But, it also provided an opportunity for the intern to witness exactly how we do documentation in the actual setting.

We closed the day with a group debriefing of the day, which allowed us to take opportunities to underscore for the interns how their experiences out on the floors related to the broad principles we had focused on in the morning.


I, by the way, was fascinated by idea that there are strong parallels between sales contact software and the chaplain's work of documentation. I know that there are a good number of very advanced sales contact software programs that are available off the shelf. Even if using one of these actual software packages might be inappropriate for the chaplaincy setting, there may be great opportunity for learning here -- the "business world" does indeed have a good deal to teach to us folks who work in ministering to people (at least when it comes to the how of it . . . I think we clergy types should keep our claim to be the best why people around!).


One thing I thought we might have added to our morning documentation overview session was some kind of in-class exercise. For example, we could have described a patient contact for the students and asked them all (individually) to write a short free text note of how they might have documented the experience (and used the documentation guidelines we suggested for them). Then we could have asked the students to share and compare what they had written.

One guideline we offered them, by the way, went something like this:
  • What the patient said (I'm so alone).
  • What the chaplain did in response (helped the patient identify resources of support that have helped them feel less alone in the past).
  • Result (patient appeared cheered as a result).
I, however, tend to aim more for what I think is the basic form of the three-part division that shapes just about every discipline's notes in a medical chart:
  • Contact (just the facts -- patient had a fever)
  • Impression (the assessment of the professional making the note -- patient may have a new urinary tract infection)
  • Plan (do cultures to determine if infection present; use antibiotics if/as indicated)

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