A case study of Jerry: emphasizing team communication through use of the Discipline

After the chaplain is well acquainted with The Discipline and has begun to implement it in daily pastoral practice, half of the work is done. The further work concerns how and what to communicate to the care team regarding the chaplain's observations. This article begins by offering a pastoral reflection on the chaplain's identity and pastoral practice within a multi-disciplinary care team. The pastoral reflection highlights key theological assertions used by The Discipline. The author then identifies the particular problems facing care teams and their communication that the chaplain can anticipate when using The Discipline. Thirdly, the author suggests workable, theologically based tools for the resolution of these problems. Lastly, through the case study of "Jerry," the author illustrates both the "how" and "what" components of care team communication using the working elements of The Discipline. The "how" component describes the informal and formal relational processes that have contributed to a working partnership. The case study also illustrates the "what" part of care team communication--the structure and delivery of observable and discernible content to physicians and nurses. These materials can ease the transition towards effective pastoral presence on the interdisciplinary care team regarding patient and family/support partner care.     

A Case Study Using The Discipline with a Clinical Team

SUMMARY

Health care delivery in hospitals and clinics promotes an interdisciplinary team approach. This article presents the use of The Discipline though the involvements of the chaplain as part of the Infectious Disease team as together they addressed the inherent spirituality of one HIV/AIDS patient. This narrative recounts the unfolding events of the patient's life and describes the use of The Discipline during a very difficult time period for the patient and the staff. The experience can serve as a model for other health care teams who must manage difficult, deteriorating patients.     

Occupational Therapists in the Interdisciplinary Team Setting

The interdisciplinary team approach to patient care provides an answer to the fragmentation and confusion patients feel when dealing with our complex healthcare system. Even though the team approach has been in use for the past two decades, implementation of a successful team is very difficult and rarely sustained over a significant period of time. This is especially true in general hospitals and in physical rehabilitation programs that spring from general hospitals where the physician and the nurse are the traditional care group. Occupational therapists, as they establish roles on interdisciplinary teams as staff members and team leaders, will require a knowledge of what makes a team function effectively. They can use this knowledge to evaluate the status of their own team and contribute to changes that will insure its long-term success. Six key issues should be addressed during the planning stage of any new healthcare team to insure its continued viability. These issues are: program philosophy, client focus, role clarification, collaboration and information sharing, policies and procedures, and staff supportiveness.     

Pediatric Family Care: An Interdisciplinary Team Approach

Providing adequate psychosocial support for hospitalized pediatric patients and their families is sometimes difficult An interdisciplinary team can help caregivers to assess needs and develop strategics for working with difficult patients and families This paper describes the development of a pediatric family care team that has been effective in one hospital outlining the general steps followed in establishing the team A review of practical considerations related to team membership, costs, and procedures is followed by a discussion of the problems encountered A case study demonstrates how the team helped meet thc psychosocial needs of one pediatric patient.     

Difficulties experienced by the patient care team at the intensive care unit

This interpretative case study aimed to identify the difficulties experienced by the patient care team while working at the Intensive Care Unit. Data were collected through participant observation and semistructured interviews with doctors, nurses and nurse's aides. Two major categories emerged from the data analysis: Care delivery in intensive care-- "it is difficult to deal with death and inform the patient's family" and care delivery in intensive care-- "the lack of material resources and the difficulty to work in a team". The difficulties are related to the contact with family members, dealing with death and the lack of material resources, and particularly with the relation between team members. Therefore, teams need to promote opportunities and discussions to reflect on the technical, scientific and ethic aspects of care for critical patients as well as family members, with a view to better care quality and interpersonal relations.     

First steps: approaching The Discipline based, outcome oriented ministry model

This article describes how a new staff chaplain is approaching and applying a discipline based, outcome oriented ministry model. He describes his move from being a lone, geriatric chaplain in a long term care facility to becoming a member of a team of staff chaplains in a teaching hospital who have disciplined themselves to an outcome oriented ministry model. The writer gives his perspective on The Discipline, and denotes ways in which his ministry has been impacted. Though the author has been involved with this process for only six months, both he and those in his care are experiencing some of the benefits of making tangible contributions and developing measurable outcomes in ministry.     

Attitudes toward social work in family medicine: a before and after survey

An initial survey of attitudes among Family Medical Center staff rated social work as highly consistent with the values of family medicine, capable of competently addressing difficult problems, and contributing valuably to a team approach to continuous and comprehensive family medical care. After integration of a social worker into the practice, a repeat survey documented significant attitude changes, rating social work as more competent, passive, and difficult, and lowering the estimate of patients potentially helped by a social worker from 38 percent to 31 percent. Such attitudes may influence the evolution of the social worker's role in the family medicine patient care team.     

ATTITUDES TOWARD SOCIAL WORK IN FAMILY MEDICINE

An initial survey of attitudes among Family Medical Center staff rated social work as highly consistent with the values of family medicine, capable of competently addressing difficult problems, and contributing valuably to a team approach to continuous and comprehensive family medical care. After integration of a social worker into the practice, a repeat survey documented significant attitude changes, rating social work as more competent, passive, and difficult, and lowering the estimate of patients potentially helped by a social worker from 38 percent to 31 percent. Such attitudes may influence the evolution of the social worker's role in the family medicine patient care team.     

Geriatric team dynamics: the dietitian's role

In 1980, a geriatric consultation team was formed at Massachusetts General Hospital to meet the complex medical, psychological, rehabilitative, nutritional, and social needs of geriatric patients. This team strives to provide elderly patients with the comprehensive care necessary to potentiate return to maximum independent functioning and to change attitudes of primary caretakers toward care of geriatric patients through increased recognition of the elderly as a heterogeneous group. The team consults on patients with changes in mental status, need for physical rehabilitation, "failure to thrive," or need for definitive planning for posthospital disposition. The dietitian conducts nutritional screening of each patient, is a nutrition resource for team members, and promotes collaboration in nutrition care planning. When the dietitian communicates nutrition concerns, goals, and care plans for patients to other health professionals, they use the information to reinforce her recommendations and integrate nutrition components into their care plans. A multidisciplinary approach has resulted in earlier identification and evaluation of functional ability, more comprehensive individualized care planning, and a reduced percentage of readmissions.     

Transitions in end-of-life care: the Oregon trail

Hospitals can create an environment that supports patients, families, and healthcare professionals so that they are better able to recognize the best way to care for each patient during times of transition. This article highlights some of the supports intentionally put into place to assist patients, family, and staff through difficult transitions at Oregon Health & Science University. These supports include an expert inpatient and outpatient palliative care team to coach patients, families, and staff at the bedside; statewide efforts to raise the skill level of all healthcare professionals through education; and the Physician Orders for Life-Sustaining Treatment (POLST) program, which helps ensure that care decisions made in one setting are respected as the patient moves to another care setting.     

The patient-centered medical home: how to advance patient care through technology

The process of applying for National Committee for Quality Assurance recognition as a Physician Practice Connections--Patient-Centered Medical Home (PPC-PCMH) can enrich even those practices already solidly committed to providing patient-centric care based on evidence-based medical guidelines. The goal is to leverage information technology to transform both operational and patient care procedures. But even with robust technology, PCMH certification requires team commitment and an unremitting big-picture focus. This article provides an in-depth case study that shows how one groundbreaking Arizona practice used technology to reach the pinnacle of PCMH certification--and continues to use it to improve the quality of patient care.     

Nutrition support in the morbidly obese, critically ill patient.

Nutrition support in the critically ill patient is challenging but is even more difficult in a morbidly obese patient. This case report chronicles the care of a 6-foot-tall, 256-kg male (body mass index 76.5 kg/m(2)) who spent over a month in the intensive care unit for respiratory failure, sepsis, and acute renal failure. Parenteral nutrition was provided throughout his critical care course. One of the major difficulties encountered was determining his nutritional needs. A hypocaloric nutritional regimen was used, along with moderate protein provisions. Numerous electrolyte imbalances occurred, including hypercalcemia that did not resolve by eliminating calcium from the parenteral nutrition solution. Enteral nutrition was desired but was not used initially because of a need for vasopressors, a diagnosis of pancreatitis, difficulty in documenting feeding tube placement because of diagnostic limitations secondary to the patient's large size, and concern about managing stools. Eventually, oral intake and supplemental enteral feeding were initiated. Nutrition support team members worked closely with the interdisciplinary care team to develop strategies to manage the nutritional problems related to his obesity. A discussion of the various nutritional issues encountered in the care of this patient is provided. Reasonable nutritional status was achieved, but this case reflects some of the challenges encountered in caring for the nutritional needs of select patient populations in clinical practice and the need for increased research and guidelines in this area.     

Delirium in palliative care patients: focus on pharmacotherapy

Patients receiving palliative care often possess multiple risk factors and predisposing conditions for delirium. The impact of delirium on patient care in this population may also be far-reaching: affecting not only quality of remaining life but the dying process experienced by patients, caregivers, and the medical team as well. As palliative care focuses on comfort and symptom management, the approach to assessment and subsequent treatment of delirium in palliative care patients may prove difficult for providers to navigate. This article summarizes the multifactorial nature, numerous predisposing medical risk factors, neuropsychiatric adverse effects of palliative medications, pharmacokinetic changes, and challenges complicating delirium assessment and provides a systematic framework for assessment. The benefits, risks, and patient-specific considerations for treatment selection are also discussed.     

Target-focused medical emergency team training using a human patient simulator: effects on behaviour and attitude

CONTEXT: Full-scale simulation training is an accepted learning method for gaining behavioural skills in team-centred domains such as aviation, the nuclear power industry and, recently, medicine. In this study we evaluated the effects of a simulator team training method based on targets and known principles in cognitive psychology. METHODS: This method was developed and adapted for a medical emergency team. In particular, we created a trauma team course for novices, and allowed 15 students to practise team skills in 5 full-scale scenarios. Students' team behaviour was video-recorded and students' attitude towards safe teamwork was assessed using a questionnaire before and after team practice. RESULTS: Nine of 10 observed team skills improved significantly in response to practice, in parallel with a global rating of team skills. In contrast, no change in attitude toward safe teamwork was registered. CONCLUSION: The use of team skills in 5 scenarios in a full-scale patient simulator environment implementing a training method based on targets and known principles in cognitive psychology improved individual team skills but had no immediate effect on attitude toward safe patient care.     

Reengineering the work of caregivers: role redefinition, team structures, and organizational redesign

Health care organizations are implementing new patient care delivery models with the expectation that operations reengineering will bring dramatic improvements in cost, quality, and patient satisfaction. Together with the fundamental redefinition of caregivers' work roles, the adoption of reengineering principles features the organization of work activities around team structures such that teams are considered the basic unit of work performance. This article draws from reengineering case studies to consider how hospitals are operationalizing team care concepts at the patient care unit level. Using a classification of caregiver work that distinguishes care production and care management tasks, evolving care team models are discussed through a conceptual framework that defines a continuum of team delivery strategies. The team models are illustrated by brief case examples.     

Using The Discipline for integrative ministry formation

One United Methodist Annual Conference has begun a program of ministry formation education for probationary, first-appointment ministers in conjunction with Emory Clergy Care, Atlanta. This program uses an adaptation of The Discipline as an integral part of their ongoing formation education. Participants have learned the basics of planned pastoral care delivery, family and congregational systems thinking and self-supervision. Using The Discipline, they have been effectively adapting it to their local church settings and ministries.     

Communicating Chaplains’ Care: Narrative Documentation in a Neuroscience-Spine Intensive Care Unit

Chaplaincy care is different for every patient; a growing challenge is to ensure that electronic health records function to support personalized care. While ICU health care teams have advanced clinical practice guidelines to identify and integrate relevant aspects of the patient’s story into whole person care, recommendations for documentation are rare. This qualitative study of over 400 free-text EHR notes offers unique insight into current use of free-text documentation in ICU by six chaplains integrated into the healthcare team. Our research provides insight into the phenomena chaplains record in the electronic record. Content analysis shows recurrent report of patient and family practices, beliefs, coping mechanisms, concerns, emotional resources and needs, family and faith support, medical decision making and medical communications. These findings are important for health care team discussions of factors deemed essential to whole person care in ICUs, and, by extension have the potential to support the development of EHR designs that aim to advance personalized care.     

A randomized controlled study of a home health care team.

This report describes the findings of a randomized study of a new team approach to home care for homebound chronically or terminally ill elderly. The team includes a physician, nurse practitioner, and social worker delivering primary health care in the patient's home, including physician house calls. Weekly team conferences assure coordination of patient care. The team is available for emergency consultation through a 24-hour telephone service. The team physician attends to the patient during necessary hospitalizations. This approach was evaluated in a randomized experimental design study measuring its impact on health care utilization, functional changes in patients, and patient and caretaker satisfaction. The team patients had fewer hospitalizations, nursing home admissions, and outpatient visits than the controls. They were more often able to die at home, if this was their wish. As expected, they used more in-home services, measured in weighted cost figures; their overall cost was lower than their controls, but the difference was not statistically significant. Their functional abilities did not change differently from the controls, but they, and especially their informal caretakers in the home, expressed significantly higher satisfaction with the care received.     

Ethical issues and the importance of consensus for the intensive care team

This paper draws upon an empirical study and combines moral philosophical insights and sociological analysis to shed light on the ethical issues in intensive care. It is argued that moral philosophical debate often leaves aside the social context in which ethical decisions are taken and carried through. In order to gain an understanding of how intensive care is accomplished and specifically how ethical issues are handled, the study focused primarily on nurses' accounts of and views on the practices which form the everyday work of intensive care. A qualitative approach was adopted involving theoretical sampling and the constant comparative method of analysis. The paper argues that the most difficult ethical issue in intensive care, namely the withholding or withdrawal of treatment, is an area in which nursing and medical perspectives are often at odds. However, when the social context of clinical practice is taken into account, this paper argues. there is common ground between the two professions. It was found that the period during which the decision to withdraw treatment is being made, the members of the intensive care team closest to the bedside, nursing and medical staff. become impatient for some resolution of the situation. The differences of opinion which arise over the decision to withdraw are not simply to do with the way in which the situation is experienced by each professional group, proximity to the patient had a part to play in shaping their views rather than, as it is sometimes presumed. a simple rift between medicine and nursing. The data suggest that intensive care has to be a team effort. Even though there is no legal requirement for nurses to agree with the ICU decisions, there seems to be a strong desire within the intensive care team that moral consensus should be achieved in the interests of good patient care. Intensive care relies on the integrity of the team and the unfailing functioning of teamwork. Consequently, achieving this, it seems, is more important than other temporary lapses in interprofessional relations and disagreements over treatment in individual cases. Consensus is important and its achievement is a central, day to day working arrangement for insuring the solidarity of the team.     

The Caregiver as Part of the Dementia Management Team

Care for older people with dementia living in the community involves not only a physician and the patient, but also a family member as the ‘primary caregiver’. This caregiver communicates medical information from the physician to the patient (screening this information as necessary), ensures that treatment plans are carried out, and relays patient (and family) concerns to the physician. Optimal patient care depends, in part, on inclusion of such caregivers in the dementia management team. However, review of the literature suggests that physicians do not make optimal use of family members as partners in disease management. Further research is required to assess the effect of efforts to include family caregivers as part of the dementia management team and to determine how best to support family members in their role as partners in dementia management.