From a legal perspective, the use of EMR generally, and by spiritual caregivers in particular, is not at all unproblematic. Safeguarding the patient's privacy is a central issue in the discussions about EMR and many other such systems in the Netherlands. A project by the Dutch government to develop a nationwide EMR was canceled due to massive resistance from the general public. Tellingly, quite a few doctors, on becoming patients themselves, are reluctant to consent to having their data recorded in EMR. In the Netherlands, the *Wet bescherming persoonsgevens* (Personal Data Protection Act 2000) has strengthened the patient's legal position, as it stipulates that data provided by the patient remain the patient's property and that the patient has the right to inspect recorded data at any time. Moreover, it is compulsory that the patient unambiguously consent to recording data in an EMR. Healthcare institutions are supposed to provide adequate procedures for this. As of May 2018, the Dutch Personal Data Protection Act has been replaced by the even stricter European General Data Protection Regulation EU 2016/679. This new regulation has a significant impact on the sharing of health-related information. Crucially, the client's explicit consent to documenting personal information about their health or to any other recording of personal data is now compulsory.

The sharing of recorded data is limited in principle to the healthcare professionals involved in a particular patient's therapeutic process. At the moment the *Wet beroepen individuele gezondheidszorg* (Individual Healthcare Professions Act) grants routine access to recorded data to the practitioners of some professions, but, importantly, not to spiritual care workers. In addition, Article 6 of the Dutch Constitution stipulates that each person has the right to practice his or her worldview, without any interference by others. That is why, traditionally, spiritual ministers have been bound not only to professional confidentiality but to ministerial confidentiality as well. The ministerial confidentiality regulations of the principal churches in the Netherlands are even stricter than most professional confidentiality regulations. Thus, as far as the use of EMR by spiritual caregivers is concerned, their legal status and their ministry would seem to constitute a double impediment

(Lammers/Smeets 2016). In practice, many EMR systems, including the one that is used at Radboudumc, do allow limited access to spiritual caregivers, legally underpinned by the hospital's legal experts. (It should be noted that patients are typically unaware of all this, assuming that spiritual caregivers are just normal healthcare professionals with normal access to the records.)

#### **3 Why Use EMR?**

With all the legal and ministerial strings attached to using EMR, why bother to even try? Actually, we think there are some valid reasons, pertaining to the patient's wellbeing, to healthcare generally, and to spiritual care as a profession.

As far as the patient is concerned, one might argue, first, that healthcare is an intrinsically multidisciplinary endeavor. Communication between care providers is essential so as not to confront the patient with fragmentation and contradictions in diagnosis and treatment. Some of this communication has to be in written form, in order to guarantee a reliable transfer of information. Second, the process of recording enables care providers to focus on what the patient needs right now. Third, EMR allows for the planning of the therapeutic process, as it not only records diagnosis and treatment so far but has medical appointment scheduling functionality as well. Fourth, the use of EMR allows the spiritual caregiver to influence the therapeutic process in such a way as to better serve the interests of the patient – even advocating them should they be contrary to those of the therapeutic team – for instance, by drawing attention to aspects of the patient's well-being that have been neglected so far.

As to the therapeutic process generally, one might argue, first, that EMR enhances mutual understanding between care professionals. Based on each other's findings and planning as recorded in the EMR, and through personal or multidisciplinary consultation, they develop a better understanding of each other's disciplines. Second, EMR allows for more efficiency in the therapeutic process, as it reduces overlap and duplications of work. And third, EMR facilitates a better assessment of the effectiveness of the treatments used to cure particular diseases.

Finally, there is an argument in favor of the use of EMR that specifically pertains to spiritual care, viz., that it has a positive effect on the professionalization of spiritual care. It makes us reflect on what we are actually doing and document it in such a way as to be transparent to others, i.e., to professionals from other disciplines as well as to fellow spiritual caregivers. The use of EMR induces the spiritual caregiver to take other professionals' perspectives. Which elements from our conversations with a patient are relevant to and need to be shared with other professionals to ensure good care for that patient, including their spiritual well-being – not only within the present context but in possible follow-up phases as well? Already, our EMR entries have started to play a role in multidisciplinary consultations. Even if long-term effects cannot be assessed as yet, it is our firm impression that other disciplines are beginning to develop a better understanding of the specifics of spiritual care as a profession. In addition, we are confident that the sharing between spiritual caregivers of information contained in EMR entries will help us realize a common standard of practice.

#### **4 What to Record**

There is a broad agreement among spiritual caregivers working with EMR that the data to be recorded in the system should concern the substance of the contacts, typically conversations, between spiritual caregivers and their patients. The basic strategy is to write a more or less condensed account of the conversation. This idiographic approach focuses on the individuality of the patient as a unique person with his or her own unique narrative. The main argument in favor of this approach is that it is the best way of doing justice to the patient as a person. Theoretical backing is provided by narrative approaches in theology, psychology, and, recently, medicine. From a person-centered care perspective, it has also been argued that reading these recorded conversations makes it easier for care providers to relate to individual patients, encouraging them to provide the best care they can.

A second approach has a rather more nomothetic character, as it focuses on similarities and differences between patients, for instance, through a classification of the topics addressed in a particular conversation. In the Netherlands, several classification proposals have been put forward. Some are theory-based, declaring and arranging topics in theoretically defined structures, while others are empirical, working with the topics that are actually raised by patients. An example of a theory-based proposal is the hermeneutic-diagnostic scheme developed by a group of spiritual caregivers in mental healthcare, using work by authors such as Erikson, Nagy, Capps, and Pruijser (Bos et al. 2003).

From a nomothetic-empirical angle, in the 1990s, a group of Roman Catholic healthcare chaplains in the Dutch province of Overijssel came up with a catalogue of 28 topics they found to be regularly addressed in pastoral conversations. The catalogue was used in a survey among all Dutch spiritual caregivers by the *Nijmegen Institute of Studies in Empirical Theology*, in cooperation with the *Netherlands Association of Spiritual Caregivers in Care Institutions, VGVZ*. The topics most frequently addressed were sickness, bereavement, life-changing events, relationships, suffering, meaning and appreciation of life, solitude/loneliness, worldview and faith, death, expectations, and the treatment received (Smeets 2009). Recently, a group of spiritual caregivers working in hospitals that use the HiX system have started work on a new catalogue of topics.

One benefit of this topic-based approach is in its user-friendliness. To record a conversation with a patient, the spiritual caregiver only needs to check the topics that have been addressed. In addition, it allows for various types of quantitative research into patient contacts, such as frequency rankings of topics. On the negative side, the selection of topics to be included in the catalogue is inherently problematic. In drawing up such a catalogue, one would typically start with concrete, reallife topics. There should not be too many of these, however, lest the catalogue become unmanageable. So the possibility remains of a topic being discussed which is not in the list. A solution to this problem could be to use more abstract "topical groups," as proposed by Van der Ven (1994, 10). Based on audio recordings of pastoral conversations, this author came up with ten "topical groups," viz., health, the self, social relations, societal problems, existential questions, religious questions, spiritual questions, moral issues, church-related issues, and pastoral issues. In our Nijmegen CPE training courses, we still use Van der Ven's topical groups in the analysis of pastoral conversations. However, the assignment of a topic to a topical group can still be controversial, and no categorization is everlasting: Who could tell the difference between "church-related issues" and "pastoral issues" nowadays?

The use of rather more formal categories appears to be a viable alternative. At Radboudumc we have drawn inspiration from George Fitchett's work in *Assessing Spiritual Needs* (2002). His model comprises seven thematic fields to categorize the topics that have been addressed:

Dutch society is much more secularized than American society. Topics such as faith, authority, and guidance are not typically addressed in pastoral conversations. That's why we have tried to bring the categories more in line with the topics that do come up; in other words, we have created a more secularized version of Fitchett's model:

"Faith" has been replaced by "sources of inspiration," which may comprise other sources such as music, nature, or science. "Vocation" became "goals in life" – as it is very rare for people to define their work, life, or activities as the response to a vocation. "Community" is no longer exclusively understood as a religious community; but the term can also refer to other types of community, such as a village community, a commune, a group of good friends, or a family. Therefore, the topic "relationships" was added. The notions of "authority," as represented by the church, and "guidance" by a pastor do not occur as topics in our conversations with patients; they have therefore been eliminated. In our experience, the resulting six main topics fit our conversations much better than Fitchett's seven do (see Smeets/de Vries 2016).

Conveniently, an unlimited number of topics addressed in pastoral conversations can be assigned to this limited number of fields. Also, the model allows spiritual caregivers to identify their favorite areas of religion and/or spirituality, as well as any possible blind spots in their contacts with patients. Third, it communicates to other care providers that spiritual care is not just about religion and ecclesiastical matters but encompasses much broader areas. In our teaching experience, we find that other care providers are typically quite sensitive to this. Fourth, the fields just mentioned coincide with other well-known categorizations in religion and worldview, such as those by Cobb, Glock and Stark, and Smart (Smeets/De Vries 2016). The model thus provides an excellent base for comparative studies on an international scale. Finally, it provides a framework for recording the essential aspects of a patient's narrative as defined above, without recording the narrative as such. It can therefore be seen as a compromise between the idiographic and nomothetic approaches.

#### **5 Recording at Radboud University Medical Center**

Recording the substance of a conversation with a patient, essential as it may be, is not sufficient for the use of EMR by the spiritual caregiver – which is only modest, when compared to its use by nurses and doctors – to be relevant to the therapeutic process as a whole. What else is needed? Vandenhoeck (2007, 2009) has developed an integral recording method, building on the model by the American author A. Lucas, in *The Discipline for Pastoral Care Giving.* Vandenhoeck's method comprises the following elements:

In our recording practice, we use this method in combination with our own version of Fitchett's model of spiritual assessment. The "findings" or, as we prefer to call this element, the "brief spiritual impressions," is where the substance of a patient contact is recorded. In our experience, the Fitchett assessment just mentioned is helpful in structuring the findings (see below, first case in point). Vandenhoeck stresses the need for factual recording, containing as few interpretations or other personal notes by the spiritual caregiver as possible. Thus, other care providers can get quick updates on the support by the spiritual caregiver, both on the findings and on the planned follow-up, and take these data into account in their treatment.

#### **6 Cases in Point**

At Radboudumc, the Department of Spiritual Care uses the EMR system *Epic* in the way just outlined, as the following cases in point may illustrate. A spiritual caregiver reports:

One of my colleagues was called in for a baptism ritual on the neonatal ward. A ʻspiritual care' order was placed in Epic. On the spiritual care page, my colleague reported: "Conversation this morning with the parents on baptism of X. Baptism took place at 13 hours, with parents and other family members present. The parents were very happy with it." Afterwards this colleague informed me, the order was transferred to me and I went to visit mother and child. I recorded our conversation as follows in Epic (in consultation with the mother).

A. *Why the visit took place*

Follow-up contact after baptism ritual, spoke with the mother.

	- *Meaning and sources of inspiration*: Being together with her child is what inspires Mrs. N. at this moment and what gives meaning to her life.
	- *Goals in life, values, and responsibilities*: Talked about the balance between care for others and care for herself – the latter being as essential as the former.
	- *Impactful experiences and emotions*: Mrs. N. would very much like to be in agreement with her husband with respect to the continuation of the treatment. She feels a tension.
	- *Courage, hope, and growth*: The mother is cherishing hopes about the medical treatment of her child.
	- *Rituals and practice*: Both parents have experienced the baptism ritual as supportive in a difficult moment.
	- *Community*: Mrs. N. needs to be at home from time to time, in order to be in touch with her loved ones.

Mainly been attentively listening to what Mrs. N. had to say.

D. *Results*

Mrs. N. had a sense of relief after the conversation.

E. *Follow-up*

Talked about possible further counseling, involving husband as well.

F. *(Multidisciplinary) referral – primary/secondary care*

#### Not applicable.

The referral category is not in Vandenhoeck's recording method. We added it with a view to our potential involvement in transmural care, specifically in providing spiritual care in the patient's home environment.

Notwithstanding all the modeling and structuring behind EMR, there is still considerable freedom when it comes to the actual recording of our conversations. Here is an example of a rather more succinct entry:

*A. Why the visit took place*

Patient had asked for a visit.

*B. Brief spiritual impressions*

Patient is emotionally tired and sad.

*C. Interventions*

Have listened to her experiences and sorrow and talked with her about end-oflife issues.

*D. Results*

Patient feels being heard, sense of relief.

*E. Follow-up*

Promised to visit her again Wednesday next week.

The perfect way to record data on patient contacts still needs to be worked out. On the one hand, the wording should be concise, as in the above examples, both to enable other care providers to quickly examine the records and to protect the patient's privacy. On the other hand, brevity carries a risk of misinterpretation, and the patient's individual narrative should not be obscured. Consultations within our team on this subject take place regularly and are likely to continue for some time.

#### **7 Perspectives**

In this contribution we have discussed our own use of EMR as implemented at Radboudumc, i.e., a system containing one spiritual care "page," which is accessible to all care providers involved in the therapeutic process. However, alternative setups are conceivable – each of them giving rise to their own legal, moral, and practical questions – such as having two pages, one accessible to all and the other

with access limited to fellow spiritual caregivers, allowing more sensitive data to be recorded. Another option might be the inclusion of data from the realm of spiritual care in other care providers' pages. Also, in addition to EMR for hospital care, one might wish to have a system for outpatient care. At Radboudumc, some of these variants are already being worked on and we plan to report on them in due course. As mentioned already, the best way of recording data (in terms of wording) still needs to be worked out, possibly in consultation with patients and/or relatives as "producers" of the data and with the other care providers as "consumers."

#### **8 Finally**

Digital recording of spiritual care remains a contested issue in the Netherlands. At Radboudumc we feel that, on balance, the use of EMR in spiritual care is to be welcomed, as it serves several interests. It is in patients' interest that their concerns are remembered and taken into account beyond the conversation with the spiritual caregiver. It is in the other caregivers' interest to know the contribution of spiritual care and to integrate it into the therapeutic processes we are all working on together. Through EMR, healthcare managers can obtain a clear picture of what meaning and spirituality, as components of integral care, really entail. Finally, EMR helps spiritual caregivers to account for what they are doing and to study and improve their own practices. To ensure a stable future for our profession in healthcare, EMR seems, in our view, indispensable.

#### **Commentary**

David Neuhold (\*) University of Zurich, Zurich, Switzerland e-mail<EMAIL_ADDRESS>
#### **1 Basic Reflections on Documentation**

In their contribution, Smeets and De Vries provide a range of arguments to the effect that spiritual care workers should be involved in the documentation process and thus actively participate in EMR ("electronic medical records"). Nevertheless, they do not denigrate skeptical or even opposing positions. Rather, they think that there is a lot to be gained from listening to such critical voices. However, these "isolationist" voices, as Smeets and de Vries call them, are becoming quieter and quieter. The discussion of the article at our workshop at the beginning of 2019 confirmed this. There is also a generational gap. "Isolationist" voices often tend to be those of elder spiritual care workers.

According to Smeets and de Vries, it is important first and foremost that documentation does not become an end in itself: it should only be a means to an end. Secondly, documentation should not be excessively time-consuming (as it has already become in the Netherlands, and probably not only there). And thirdly, the written word cannot become a substitute for everyday interprofessional (oral) communication in the clinical context. As already clearly demonstrated in the book by Wim Smeets (*Spiritual Care in a Hospital Setting: An Empirical-Theological Exploration* from 2006), the author has an impressive knowledge of a number of concrete contexts. Great importance is attached to empirical investigation and to everyday conditions.

#### **2 Importance of the "Narrative Approach"**

An "idiographic approach focuses on the individuality of the patient as a unique person with his or her own unique narrative," Smeets and De Vries note in their contribution. From such approaches to documentation they distinguish nomothetical approaches. These focus more on general, prefabricated classifications. Indicators in such nomothetical approaches can be determined on the one hand through theory and on the other through empirical research. Smeets and De Vries prefer a narrative, idiographic approach to documentation, but see a workable compromise in empirically supported indicators for documentation systems. However, narrative documentation patterns are also problematic in many respects, at least for some authors. Many questions arise: Are the narratives understandable for others? Do they make sense to the members of an interprofessional team? Don't they pose a danger to pastoral confidentiality? After all, don't narrative entries take a lot of time? In addition, do they really benefit the patient? Especially for interprofessional documentation in EMR, a standardized documentation format has many advantages, although it undoubtedly submits itself to a certain institutional logic. On the other hand, the use of standardized formats creates a new opportunity for cooperation in the design of the formats and may facilitate further cooperation, provided that hospitals and healthcare facilities have an open ear. The further integration of spiritual care does not only depend on the spiritual care givers themselves but essentially on the appraisals and judgments made by others, that is, spiritual care providers are dependent on the willingness of other parties to include them in the patient's care. They need medical and other hospital professionals to approve of what they are doing.

#### **3 The Pastor-Patient Relationship and Pastoral Confidentiality**

Pastoral confidentiality is a crucial point in many debates on documentation. Repeatedly it has been the subject of discussion. Often the issue is raised by actors who are themselves hostile to documentation. It is important to emphasize that the patient is the bearer of (t)his secret, not the pastor or chaplain. Moreover, there are wide areas of interpersonal communication that do not fall under the scope of pastoral confidentiality. The recording of many encounters is therefore unproblematic. In addition, it is possible to maintain professional secrecy within a team. However, the field is undisputedly delicate; and it is particularly delicate in narrative documentation processes. The case study Smeets and De Vries mention in the main text therefore merits more close examination. The use of documentation in this case may or may not be illegal, but it is certainly morally questionable. For the entry appears to suggest family dissonance.  If not, then I would consider such a narrative entry problematic.

What comes into play in this case – apart from pastoral confidentiality – is the relationship between pastor and patient. In the discussion of his contribution to our workshop, Smeets showed particularly clearly how this relationship can lead to differences in perception. There are divergences. Spiritual care givers often see themselves in a different role than patients do. Intensive empirical research is needed in this area, as Smeets points out. Such research will be easier with spiritual care documentation as a resource. I would like to add that PROMs ("patient reported outcome measures"), that is, feedback created by patients, could be an especially meaningful addition to this field of research. It is undisputed that research work in this area has enormous potential. These considerations really affect the core of patient-oriented care and concern in the hospital context. As many studies have shown in detail, spiritual care givers do not need to have any worries: Their contribution in the clinical context is highly appreciated by patients.

#### **References**

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## **The Spiritual Care Giver as a Bearer of Stories: A Belgian Exploration of the Best Possible Spiritual Care**

**Anne Vandenhoeck**

Belgium consists of three regions, defined by the use of language: the Flemish-, French- and German-speaking regions. In what follows, I will focus on the Flemish part of Belgium as professional spiritual care is more organized and integrated in healthcare there than in the French- and German-speaking regions. This observation is based on the fact that Flanders has the highest number of paid spiritual care givers in healthcare institutions in comparison with the other regions and has a professional association for spiritual care givers.1 Professional spiritual care in Belgium is mainly provided by Roman Catholic spiritual care givers and Humanist spiritual care givers. Spiritual care givers from those two groups are hired and paid by general hospitals or other healthcare institutions, such as mental health hospitals, nursing homes or homes for people with disabilities. Healthcare institutions are by law obligated to give patients access to the support of a representative of their faith or life view. Representatives of other religions or life views are usually not staff members in hospitals, but external representatives who are called in and are paid per (requested) visit. The profile of a Catholic spiritual care giver in Belgium is no longer that of a male priest. In Flanders, the majority of Catholic spiritual care givers are lay women. The change in staff has also provided a paradigm shift in Catholic spiritual care: since the late eighties it has no longer been focused on sacraments but on narrative hermeneutical pastoral care.2 Patient and spiritual care giver both enter

A. Vandenhoeck (\*)

<sup>1</sup> http://www.pastoralezorg.be/page/beroepsvereniging/ (access 13.04.2019) This association is called: The Professional Association for Catholic Spiritual care givers in Health Care.

<sup>2</sup>See the works of Charles Gerkin, who reinserted a theological foundation in pastoral care after the therapeutic paradigm. His theological foundation was based on the hermeneutics of Ricœur and Gadamer, on the theology of Moltmann and Niebuhr. See for example: C.V. Gerkin, The Living Human Document: Re-Visioning Pastoral Counseling in a Hermeneutical Mode, Nashville, TN,

Catholic University of Leuven, Leuven, Belgium e-mail<EMAIL_ADDRESS>
the encounter with their own horizon of (pre-)understanding. In their meeting, the dialogue between their horizons of understanding can influence them both and lead to a new understanding, adding to the spiritual story of both patient and spiritual care giver.

For some time now there have been spiritual care givers in Flanders who chart in electronic patient files. However, this does not apply to everyone: there are spiritual care givers who have only recently received access to the electronic patient file and there are those who still have no access at all. Thus there is no uniformity regarding charting in spiritual care in Flanders. What is remarkable is the variety of visions that are at the origins of the differences: for one hospital management, it is selfevident that spiritual care givers should have access to patient files and chart, because they contribute to the care of patients. For others, spiritual care givers shouldn't have access to patient files because they are not a recognized medical or paramedical profession. Some managers or directors see spiritual care givers as non-professionals, *einzelgänger* who are there to convert patients to their life views. They have no clue what spiritual care givers do and don't see a reason to give them access to patient files. Spiritual care givers themselves also differ in their motivations of charting. Some are very happy to chart and to have a forum to share their care for patients and loved ones. Others are very hesitant and not convinced of the necessity to chart. Doubts regarding charting almost always have to do with confidentiality.

In this article we limit ourselves to the situation of spiritual care in general hospitals in Flanders. At the request of several Catholic spiritual care givers in general and university hospitals, an exchange group met twice in 2017 about the opportunities and tensions of electronic charting. This includes the perspective of patients, who can view their file online. The text below is partly based on the discussions at these meetings.

#### **1 A Lack of Uniformity Regarding Spiritual Care in Electronic Patient Files**

There is a great variety in the possibilities that spiritual care givers have regarding charting. A first determining factor in the differences is the software for the electronic patient files. Some of the developed software programs, especially those of an Anglo-Saxon design, include ample space for spiritual care and are not limited to a box for denomination and/or sacraments received. As a consequence, spiritual care is really integrated in a whole person perspective on the patient. Within this perspective, there is often less limitation in access for spiritual care givers to the charting of other healthcare professionals on the same patient. Even if the patient is transferred or admitted to a different unit than their own, spiritual care givers can obtain

Abingdon, 1984. C. V. Gerkin, Widening the Horizons. Pastoral Responses to a Fragmented Society, Philadelphia, PA, Westminster John Knox Press, 1986.

temporary permission to access the electronic patient file, provided that this can be justified. Some hospitals develop their own software for patient files. Examples of this in Flanders are the University Hospitals of Leuven, connected with the Catholic University (KU Leuven). The design of their software provides ample space for spiritual care.3 This system is shared by all affiliated hospitals. The spiritual care givers of these hospitals formed a task force where they discussed the possibilities and limitations of the software while it was developed and put into practice. In other words: they had an input as spiritual care givers in the development of the system and the language used for their sections. The differences in charting are thus partially down to the differences in software.

But software development is also based on perceptions of healthcare. If the perspective is truly one of the whole person, not merely theoretically but in reality, then spiritual care will also be integrated in charting systems. In an important development, the University Hospitals of Leuven are currently working to develop a new interdisciplinary patient file. The current patient file is still too much based on the kind of charting that doctors and nurses do. Most systems are not designed for paramedical but for medical charting. It is not always easy to be integrated as a paramedic or as a spiritual care giver in a way that does justice to the work and the perspective of a different discipline other than the medical one. The new interdisciplinary electronic patient file will start from the importance of empowering patients, communication, working together and of a whole patient perspective. It is based on WHO's International Classification of Functioning (ICF). Spiritual care givers will have a checklist to assess the spiritual needs of patients and to communicate the outcomes of spiritual care. At the same time, they will have boxes to chart in a narrative way. The checklists for spiritual needs and outcomes are based on the model of *Discipline for Pastoral Care Giving* (Vandecreek and Lucas 2001), which I will discuss later in this contribution.

Spiritual care givers in Flanders try to work as well as they can with the system that is used in their hospital. They testify to the fact that they are looking for ways to make the system work as well as possible in pursuit of the best possible spiritual care. An example of this is the so-called final report within the Nexus EHR system. If a care giver makes a ʻfinal entry' in counselling (or caring for) a patient around the time of his/her discharge, the system considers this care relationship as terminated and the care giver is not informed when the patient is re-admitted. Spiritual care givers who have to work with this system do not make a ʻfinal entry' or report so that they are informed when the patient is re-admitted and they can visit him or her again.

As already mentioned above, a second determining factor in the lack of uniformity is the level of access spiritual care givers have to patient files. The question arises on what principles (legal and others) the hospital managements decide to allow spiritual care givers access to electronic patient files or not. There is no general rule, but it is good to know that all spiritual care givers are hired and paid by hospitals in Flanders and are technically staff members who are involved in patient

<sup>3</sup>The software for electronic charting is called KWS: Clinical Work Station.

care. Moreover, quality control systems like JCI have been designed to integrate spiritual care in order to enhance the quality of patient care and facilitate charting by spiritual care givers.4 Visibility, accountability and transparency are key features in quality control.

A third determining factor in the lack of uniformity is the level of access to the charting of other professional staff in patient files. If spiritual care givers have access to patient files, they do not necessarily have access to the charting of all the other healthcare professionals (and vice versa). There seems to be no uniformity in who has access to whose charting on the patient in the different hospitals in Flanders. In one hospital, spiritual care givers have only access to the charting of the nurses and in another hospital to the charting of nurses and social workers but not, for example, to the charting of psychologists or doctors. Again, the differences in access to charting of other professional groups reflect differing perspectives on team work. A multidisciplinary take will emphasize the importance of different disciplines but not necessarily of working together for the same patient goals as an interdisciplinary approach does. Decisions about access to charting are taken according to the perspective taken.

Among the spiritual care givers themselves, there is no unity either regarding feelings or beliefs about charting. Spiritual care givers who are not allowed to chart in the electronic patient file often feel isolated. This feeling is exacerbated when they see spiritual care moving to the periphery of healthcare. There are spiritual care givers who have the opportunity to chart but deliberately choose not to or write down as little as possible or chart exclusively with document protection so that what they write is not visible to others. Their motivation rests mainly on the value of confidentiality in the spiritual care giver–patient relationship. Other spiritual care givers feel limited in their care or find that they cannot provide optimal spiritual care because they are denied access to parts of the electronic file, such as the reports of the psychologists or the doctors' follow-up papers. Lastly, there are spiritual care givers who chart out of the perception that they are professional care givers like the others and that they have to contribute to team work by means of charting. It is noteworthy that few spiritual care givers have negative feelings towards oral communication about patients with other members of staff. Naturally, charting does not exclude oral communication.

#### **2 Different Forms of Charting Used by Spiritual Care Givers**

In the last 10 years, Catholic spiritual care givers in Flanders have regularly committed themselves to reading articles, taking training courses and holding discussions about the challenges and possibilities of charting. A distinction has always

<sup>4</sup> JCI stands for Joint Commission International. It is a US-based organization that works internationally towards improving healthcare by evaluating the quality of care provided. See https://www. jointcommission.org (Access 17.04.2019). Other international or European-based organizations aim for the same goals regarding evaluating quality of healthcare.

been between charting for oneself, disciplinary charting and interdisciplinary charting. With charting for themselves, spiritual care givers refer to the notes that they make for themselves about the patient. These notes serve to record the main story lines and details from the patient's story and determine the quality of possible future spiritual care for the same patient. In this regard, spiritual care givers are bearers of stories. Disciplinary charting refers to those notes about the patient that can be useful for colleagues (spiritual care givers) when the patient needs follow-up in the absence of the spiritual care giver or when the patient is moved to another unit where another spiritual care giver works. Interdisciplinary charting refers to sharing information about the patient that can be useful to healthcare professionals from other disciplines in regard to the overall care for the patient. Every form of charting takes place in the interest of the best possible spiritual care for the patient. The answer to the question why these different forms of charting exist next to each other is quite simple: confidentiality. Spiritual care givers in Flanders often struggle with the question how much of what a patient or loved one confides in them can be shared with others.

A second difference refers to charting via a checklist or through a narrative. In a checklist, spiritual care givers tick boxes that say something about the contact with the patient with calibrated terms. This form of charting is most evident in the context of interdisciplinary charting. A second form of charting is narrative charting. Mostly in complete sentences, the spiritual care giver notes several aspects out of contact with the patient that are important for the overall care plan. There are pros and cons for both ways of charting. The experience of spiritual care givers is that checklists are not often read through. On the other hand, it is a much used tool in healthcare. It takes practice and experience to write comprehensive narrative notes without disclosing too much information and breaching confidence. It is not easy. On the other hand, it is more likely to be read.

#### **3 Tensions and Opportunities**

Most Flemish spiritual care givers experience the possibilities of charting as positive. The main motivation to chart in an electronic patient file is the contribution that personal, disciplinary and interdisciplinary charting can offer to the patients the best possible spiritual care. Accurate retention of important facts and storylines is a fundamental contribution to high quality and continuous spiritual care. It contributes strongly to the spiritual care giver as a bearer of stories. Colleagues of a spiritual care giver who receive sufficient background information through charting can continue or take over the care for patients during absences. Other healthcare givers who see that the spiritual care giver is involved with a patient will call more quickly when necessary. Furthermore, spiritual care givers also report that they often receive positive feedback from other care givers on what they chart and their charting makes them more visible in an interdisciplinary team. Charting is also perceived as a way of self-care. Spiritual care givers stop between visits to chart and take a break from

visiting. They also report that charting is a way to reflect on what they have done, thus enhancing their professional skills. But in addition to the contribution to quality and efficient spiritual care and the positive side effects of better integration, spiritual care givers also experience a number of tensions and disadvantages in charting.

#### *3.1 Protected Files for Charting Spiritual Care*

Charting takes time – often, more than spiritual caregivers are willing to invest. That is why they are looking to use the needed time as efficiently as possible. One of the things that turns out to be an obstacle is the difference between charting for oneself and for others. Spiritual care givers are bearers of stories. Patients entrust them with their life stories. The spiritual care giver is expertly trained to see in those life stories the windows that are opened on the spiritual dimension, the meaning system that enables the patient to live as meaningfully as possible, despite the limitations of age, disease or condition. Spiritual care givers carry these stories together with the patient and connect them, if desired, with the greater spiritual stories that are important to the patient. In order to be able to remember the patient's stories, it is necessary for the spiritual care giver to record important facts and story lines. However, these are not relevant for the whole of the care or/and are often told in confidence. In other words, spiritual care givers need to keep more information on a narrative level than they want or can share with other healthcare providers. Nothing is more annoying than meeting a patient again and not remembering what he has entrusted to you during the previous visit a few months ago. That is why many spiritual care givers use the possibility to check a document marked as ʻprotected' in the electronic patient file. Other healthcare givers cannot open the file. However, there are hospitals that strongly discourage the creation of protected documents because of shared confidentiality in the context of interdisciplinary care or whole person care. They then ask what the value of an electronic patient file if a part of the information is not shared. Does it still show a multi-dimensional image of the patient? But if protected documents are not possible, should the pastor chart separately in notebooks, index cards or word documents outside the electronic file and do double work?

#### *3.2 The Tension Between Being Sent by a Faith Community and Being Hired by a Hospital*

The tension between being sent by a faith community and being hired by a hospital is increased by charting in the electronic patient file. It is the tension of being affiliated with a tradition that evokes trust and confidentiality and being a professional care giver paid by the hospital. What can you chart and for whom? These are questions that arise in the context of the trust that the patient places in spiritual care givers. Supporters of charting will state that patients know that every healthcare provider is part of a team and that it is necessary to communicate in order to coordinate the care as well as possible. Good care means shared and coordinated care. Critics will argue that the patient often sees the spiritual care giver as an outsider, someone who does not really belong to the team and whom you can trust. That trust has not only to do with the eccentric place in the care team but also with the background of spiritual care giving. Catholic spiritual care givers suspect that the ecclesiastical tradition of the confessional confidentiality, which is absolute and of the altar as a sanctuary, still plays a role in the perception of the spiritual care giver. In other words, patients have an archaic image of the spiritual care giver as a confidential advisor par excellence. This image is passed on from generation to generation regardless of whether patients are Catholic or not and regardless of secularization. Spiritual care givers notice this image with patients of all ages and life views. Patients are right in their perception that spiritual care givers are part of a faith community, though they are hired by and working in the hospital.

Formally this is confirmed in their contract with the hospital and in their appointment by the faith community to work in the hospital. They are sent by a faith tradition not to convert people but to assist and support them in their suffering. Spiritual care givers feel called or motivated to do so out of their own faith. The trust of patients and patients' perception of spiritual care givers make many spiritual care givers feel uncomfortable with charting. That discomfort or tension has two layers. On the one hand, there is the suspected ignorance of patients around charting by spiritual care givers. They suspect that everyone charts except the spiritual care giver and the cleaning lady or cleaning man. It is no coincidence that both function as persons whom patients trust their life stories with. On the other hand, there is the constant tension about what to chart and what not to chart. Does the patient's trust, enhanced by an archaic layer of confessional confidentiality and a feeling of a free space, allow charting? This tension will increase in the near future when patients can access the charting of spiritual care givers during their stay in the hospital or from their personal computers. At this point in Flanders, patients can already access their patient files, but so far only the medical part. Spiritual care givers think they will chart differently knowing that patients can read what they write. This evolution will change the central focus from charting in order to coordinate care better to charting in order to inform the patient. Spiritual care givers also ask themselves whether patients would not be shocked if they noticed that they are charting about their visits to them. A fundamental question also arises regarding the protected documents. Will patients get access to these?

It remains important to mention that patients do not only see spiritual care givers as persons who keep confidentiality. They also see them as professionals, members of the staff in hospitals. Spiritual care givers wear badges (and sometimes also uniforms), are on call, provide worship services and rituals, are on the payroll, have a code of conduct, etc. It has also been observed that the more spiritual care givers see themselves as professionals hired by the hospital and part of the team (and not so much as being sent by a faith community), the more likely they will chart and have fewer problems with charting, also with confidential issues. Confidentiality is thus also tied to how a spiritual care giver perceives him or herself in the tension between

being sent and being hired. Both ends of the spectrum provide a safe space: you never chart because of confidentiality or you chart everything because of your profession. In between the extremes of the spectrum lies the most interesting challenge: discerning how, when and what to chart within the reality of being hired and sent.

#### **4 The Language of Charting**

It is remarkable that spiritual care givers, as a professional group in Flanders, do not have just one template to chart with and do not have an agreement on the language they use. This is not just typical for Flanders, but is the case in the rest of the world too. There is not just one system spiritual care givers chart with, but many. Before electronic patient files, each spiritual care giver also had his or her own system or mode of charting. The contemporary practice of charting in different forms (ticking boxes in a checklist or narrative charting and everything in between) and using different words and concepts has the advantage of seeing what works and what doesn't. The downside is that it makes research into charting, the impact of charting and the content of contacts with patients much more complicated.

In what follows I would like to describe how I came to introduce a particular model for spiritual care in Flanders and how the language used in the model still influences charting in patient files today. Around the year 2001, I myself was a spiritual care giver in the University Hospitals in Leuven. The hospitals were being evaluated by the global management consulting firm McKinsey, which was later renamed as Accenture. The goal was clearly to enhance (financial) efficiency. The spiritual care service had to participate in all the exercises the other services had to make. We soon noticed that we did not speak the language of numbers and outcomes. How were we going to survive without losing mandates? I made contact with Larry Vandecreek, a fulltime researcher in healthcare chaplaincy in New York, and asked if he knew of any hospitals or studies where outcomes were being used. He referred me to Art Lucas, head of the spiritual care service in Barnes Jewish Hospital (BJC Health) in Saint Louis, Missouri. The team worked with an outcomeoriented model for pastoral care and had just published about it with Larry Vandecreek (Vandecreek and Lucas 2001). I ended up going to Saint Louis and working with the model for almost a year. From 2003 till 2007 I did my doctoral research on the model and underbuilt it from a theological perspective with the concept of narrative hermeneutical pastoral care (Vandenhoeck 2007). Art Lucas called the model 'The Discipline for Pastoral Care Giving'. In Flanders I introduced the model as the 'Focus Model' as it requires a particular outcome-oriented mind set from a spiritual care giver (Fig. 1).

How would you describe what spiritual care givers do? Art Lucas and his team started from their observations that spiritual care givers assess and act. Up until then, models in pastoral or spiritual care usually focused on the assessment part of the visits to patients and loved ones. The Focus Model also starts with assessment. Spiritual care givers always start with listening to the stories of patients and their

**Fig. 1** The Focus Model. (Adapted with permission from Art Lucas. Copyright © 2004 Art Lucas. All rights reserved)

loved ones. They listen with spiritual antennas and are particularly listening to any needs, hopes or resources patients have on a spiritual level. While they listen, they also try to discern how the community around the patient, his/her hope, his/her relation to what is sacred in life and his/her meaning giving functions in relation to being admitted in the hospital. Spiritual care givers, while listening, start to discern how they could make a difference for patients, based on their needs, hopes and resources. The differences your visit makes are outcomes of spiritual care.

An important aspect in the model is that a desired outcome needs to be shared – it needs to be congruent with the overall care plan and it needs to be desired by the patient foremost. In order to make a difference, spiritual care givers have a wide range of interventions that they have built out of their experiences. During the whole visit with the patient, spiritual care givers are focused on the feedback patients give. The verbal and non-verbal measurement of patients determines interventions and outcomes. One of the unique aspects of the model is that it starts from the observation that spiritual needs, hopes and resources (and thus interventions and outcomes) are influenced by medical pathologies. Patients with a chronic lung disease have other spiritual needs, hopes and resources than patients with heart failure. This of course is an incentive for research into shared needs, hopes, resources, interventions and outcomes by medical pathology.

One of the most important assets of the Focus Model is that it gave spiritual care givers a language to communicate within an interdisciplinary context. The language used in the model is a spiritual language. The concept of being a multilingual spiritual care giver was thus introduced. It was Paul Pruyser who stated that chaplains should use a theological instead of a psychological language to assess patients with (Pruyser 1976). But almost 40 years, later a broader spiritual language seems to be more understood by healthcare professionals. The language the Focus Model uses was checked with other healthcare professionals. They were asked if they thought this is what a spiritual care giver does. It is a small leap from language to charting. The model emphasizes communication in an interdisciplinary context. When I was trained to chart with the model in Saint Louis, the training started with checking boxes on a check list. After every visit I was required to go through a checklist and determine what my reason was for visiting this patient, how I would follow up, if there were any recommendations for the team and if I could name my interventions and the outcomes of the visit. Checking boxes proved to be beneficial for learning a language. Going over and over the possibilities introduced me to the language used (Fig. 2).

The next step in the learning process of charting was the challenge to no longer tick boxes but to chart in a narrative way. The model ideally advocates a functional, narrative way of charting. Narrative, as in full sentences, and functional, as in based on the difference between ʻneed to know' (what other care providers need to know for the best possible care) and ʻnice to know' (which refers to sharing unnecessary and often confidential information). Functional, narrative charting is based on five simple principles: (1) How did I end up with this patient? (2) What is my spiritual assessment of this patient? (3) What is the outcome of my contact with the patient? (4) Which interventions did I undertake? (5) What responsibility do I take further for this patient? (accountability). The Focus Model argues for a narrative registration, because experience shows that care providers prefer to read a short piece of text instead of going over a checklist. It also advocates a functional charting that focuses on how contact with the spiritual care giver functions for the patient instead of on the content of the contact.

Two examples of functional, narrative charting:

#### *Initial visit*

*Spiritual care giver visited patient x, referral from the attending physician. The patient expressed feeling anxious after a conversation with the doctor about her diagnosis. The spiritual care giver actively listened and explored possible future stories with the patient. The patient felt listened to and expressed feeling calmer. The spiritual care giver will visit the patient again tomorrow.*

This charting describes what the spiritual care giver did without disclosing confidential information. The physician referred the patient to the spiritual care giver because she was upset after her diagnosis. When the spiritual care giver visited the patient, she expressed her fear that her husband would leave her after this diagnosis. He had been having trouble coping with her disease and had sought comfort in a relationship outside their marriage. The patient feared that this would definitely break their marriage. Nobody in her family knew of the other relationship her husband had. The patient clearly counted on the confidentiality the spiritual care giver could offer. The charting reveals what is important to the team: the patient felt anxious before the visit and calm and listened to after the visit. What was confidential

**Fig. 2** Checklist. (Adapted with permission from BJC HealthCare. Copyright © 2001 BJC HealthCare. All rights reserved)

thus remains confidential. If the spiritual care giver felt the need to share this information with others because it was relevant for the care of the patient, it would have been good to ask the patient if this was okay. Another rule in functional, narrative charting is to stick with the facts and not to give interpretations. Only chart what the

patient did or said: the facts. Use observations and if necessary quotes of the patient to stay as close to the patient as possible.

*Follow up visit # 3 Pre-surgery visit. Patient expresses feelings about upcoming surgery. The cause for surgery makes patient feel like having to reconceive her future: can she continue to live alone? Spiritual caregiver explored vision of future with patient. To patient ʻfuture' seems to be defined as ʻclosure' and ʻletting go'. Patient asked to be blessed for surgery and upcoming future. Spiritual care giver prayed with patient.*

*Spiritual care giver will follow up post-surgery.*

In this short functional, narrative charting, the spiritual care giver indicates some concerns for the whole of the team: the patient doubts her ability to live by herself and she has little hope. The content of the blessing and prayer remains between the patient and the spiritual care giver, but it seemed important to mention that the patient values spiritual support.

Today, the Focus Model and its language still influence the way a lot of spiritual care givers chart electronically in patient files in Flanders. I refer here to the system that was developed within the University Hospitals in Leuven and is used by every affiliated hospital. The categories of outcomes and interventions, of needs, hopes and resources are still prevalent in the charting.

#### **5 Points for Further Reflection**

not need to be written? Are there limits to confidentiality and what is shared confidentiality?

#### **6 Recommendations**

#### **Commentary**

Eva-Maria Faber (\*) Theological Faculty of Chur, Chur, Switzerland e-mail<EMAIL_ADDRESS>
#### **1 The Best Possible Spiritual Care**

It's like a refrain echoing throughout her whole article: Anne Vandenhoeck explores the *best possible spiritual care* as the primary goal of spiritual care givers. The best possible spiritual care involves helping and supporting patients in their suffering; it implies encounters where patients can express their needs, their sorrow and their hope and where they can entrust their stories to spiritual care givers that are willing to serve as bearers of these stories.

Anne Vandenhoeck rightly points out that charting is not merely another element in addition to these tasks of spiritual care givers but rather a means for better administering the broad spectrum of possible interventions.

The facilitating role of charting is particularly clear in connection with the task of bearing stories. Bearing stories involves remembering them – even when patients are discharged and later reappear. Charting promotes continuity in the provision of spiritual care.

Charting implies reflection that will improve future interventions. By documenting encounters with patients and by revisiting the documentation of previous encounters, spiritual care givers may discover hidden messages in what has been said and improve their understanding of how best to provide support in the future. Vandenhoeck also mentions a restorative function for spiritual care givers themselves: Charting allows carers to take a break and prevents them from carrying the burden and shadows of one patient to the next.

It is worth emphasizing this positive effect of charting on the provision of spiritual care to patients. Although the introduction of spiritual care charting was in response to the administrative need to monitor the interaction of the chaplaincy with other professions, the task of charting has in fact raised the quality of spiritual care given. Patients also stand to benefit from the greater inclusion of chaplains within interprofessional care-giving teams. For the increased visibility of the chaplaincy brings with it increased attention to the outcomes of spiritual care.

#### **2 Contributing to a Holistic Approach**

A crucial point concerns the question how far spiritual care givers can and should open their charting to interdisciplinary exchange. With regard to the different forms mentioned (narrative charting, ticking boxes in checklists), it seems reasonable to reserve narrative charts for personal use (protected files that help one to remember details of stories that, however, should not be shared with others or, at most, with fellow spiritual care givers). The checklists could serve as a way to give a more sparing account of the engagement of spiritual care givers.

However, the restriction of narrative charts for personal use would mean that interdisciplinary charting would be an instrument to strengthen the chaplaincy's position rather than enhance holistic care for individual patients in a hospital.

In discussions about her approach, Anne Vandenhoeck established that chaplains face a challenge concerning multilingual competence: The checklist is a tool that helps chaplains to speak a language that is understood by all healthcare givers. But at the same time it tends to focus on outcomes that are easily expressed in economic terms. For spiritual care givers, however, only narrative charting can assist them in bearing patients' stories. It is therefore important for them to participate in the development of the systems in order to obtain a form of documentation that corresponds to spiritual requirements. That means: only if spiritual care givers are allowed to and are willing to contribute their distinctive perspective on the patient can they take their responsibility for a holistic approach in healthcare. Only then will they promote the best possible interdisciplinary holistic care for patients.

In fact, Anne Vandenhoeck observes that, even in interdisciplinary contexts, narrative charting is more likely to be read than other forms of charting. This means: stories are a language that is also understood and appreciated from the perspective of medical agents.

#### **3 Confidentiality**

This is where the question of confidentiality arises that haunts the discussions about interdisciplinary charting of spiritual care. Vandenhoeck provides helpful distinctions concerning this important issue. She points to the distinction between facts and interpretation and furnishes different descriptions of the same situation: one that includes details of a patient's worries; the other to be shared without disclosing confidential aspects of his or her anxieties. Another way to meet standards of confidentiality is to focus on functional outcomes for the patient and not on possibly confidential communications. Charting will then deal more with the interventions that are intended to make a difference for patients (an inspiring wording of Vandenhoeck!) and not with information about the patient's story.

In addition to these very helpful indications it could be stimulating to reflect on the topic of the stories. If spiritual care givers are – in Vandenhoeck's beautiful description – bearers of stories, the question "What can you chart and for whom?" can be reformulated as: "What are the stories entrusted to spiritual care givers and for whom?"

Often stories are in fact entrusted confidentially to spiritual care givers. Patients may explain, or sometimes rather tentatively vocalize, how they experience their story – one that may have taken an unexpected turn as a result of a serious incident.  These stories are articulated in the presence of a spiritual care giver whose listening may help them to cope with a new situation. The spiritual care giver is a bearer of these stories not for others but rather a co-bearer of the story in solidarity with a person who – in telling a story – is trying to find his or her way in life. However, there may be aspects of a story that transcend the privacy and intimacy of a confident encounter. Nobody is *only* a patient. Whereas the medical history records the progression of an illness, the spiritual history commemorates the story and stories a person has lived and is living. Thus, spiritual care givers will often be bearers of stories not only by listening but also by reminding patients of their own stories when they become frail. Moreover, by charting some of the "public" aspects of these stories, spiritual care givers bear the stories to other members of the healthcare staff and help them to see the patient in the hospital as a whole human being.

#### **4 Discernment**

The best possible spiritual care is not a clearly defined measuring unit. It is a search item that depends on persons and situations and stories and, last but not least, on the feedback that patients give. This insight calls for responsibility on the part of spiritual care givers. They are called to discernment. For this reason, Anne Vandenhoeck even finds value in the tensions that spiritual care givers experience, for example in being part of the hospital team as well as belonging to the tradition of a faith community (or being sent by it). Tensions help one stay attentive – in pursuit of the best possible spiritual care.

#### **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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## **Charting in Switzerland: Developments and Perspectives**

**Pascal Mösli**

Pastoral documentation is developing rapidly in Switzerland: it is now an established part of the palliative complex treatment required of hospitals by guidelines drawn up by pastoral teams in the interprofessional context of mainly large hospitals and endorsed by pastoral expert committees. Despite this development, it remains controversial whether pastoral documentation is appropriate. In order to understand how pastoral care professionals throughout Switzerland think about documentation, a survey of German-speaking pastoral care professionals was conducted in Spring 2019.

This article gives an overview of the most important developments in pastoral documentation, summarizes debate surrounding it, and presents the results of the survey among chaplains. The documentation practice of three hospitals is then presented in order to provide a deeper insight into the concrete practice of documentation before the final section discusses some of the questions and future challenges pastoral documentation in Switzerland faces.

#### **1 Introduction1**

Healthcare chaplaincy in Switzerland operates in a very diverse regulatory landscape. Depending on the canton, there are different legal and ecclesiastical framework conditions. In many cantons, hospital chaplains are church employees; in

P. Mösli (\*)

<sup>1</sup> I would like to thank Simon Peng-Keller, who supports me a great deal in my research work and with the writing of this article, as well as my colleagues Saara Folini-Kaipainen, Claudia Graf, Livia Wey-Meier, and David Neuhold from the National Science Foundation research project Documentation, with whom I am in a creative, exciting dialogue. They have all read the article critically and given me a lot of helpful feedback.

University of Zurich, Zurich, Switzerland and Reformed Church of Bern e-mail<EMAIL_ADDRESS>
others, they are employees of the relevant institution; and in some cantons, the state contributes funds. In contrast, the professional prerequisites for pastoral work in hospitals are largely uniform: a university degree in theology, additional pastoral psychological training, and a mission from one of the three churches that are officially recognized in most Swiss cantons. These churches are the Roman Catholic Church, the Reformed Church, and the Christian Catholic Church. (The Jewish community is also recognized in many cantons.) 60.9% of the Swiss population are a member of one of these three national churches (36.5% Roman Catholic and 24.4% Reformed, with around 15,000 members of the Christian Catholic Church), 5.8% belong to other Christian communities, 5.2% are Muslim, 1.7% belong to other religious communities, and 25% are nondenominational.2

There are two national umbrella organizations for German-speaking healthcare chaplaincy in Switzerland: the Reformed and the Roman Catholic pastoral care associations. In some cantons, but by no means all, there are professional standards for pastoral care in hospitals, but there are none at the national level.

Until 5 years ago, most chaplains in Switzerland did not contribute to interprofessional charts. Most chaplains would not have considered doing so for a moment, and those that did would most likely have rejected the idea for reasons of confidentiality. On the other hand, many chaplains have been documenting their work for their own purposes for a long time. For example, they may have recorded which topics were discussed in a conversation and use the documentation as an aidememoire, to help maintain the relationship with the patient and for reflection.

Another field in which a form of documentation is used is training: For many years, excerpts of conversations have been used in Clinical Pastoral Training (CPT) courses for educational purposes. The purpose of the documentation here is therefore to help one reflect on one's own professional actions. Each week, the participants in a course bring with them minutes from a meeting in their field of practice. There is also a manual for writing the minutes of a discussion. The verbatim reports are analyzed and discussed in the training group, sometimes used as a template for a case discussion and then returned to the authors. This is an established and effective learning method in the context of pastoral training.

Only in a few hospitals, usually larger ones, have chaplains been charting in an interprofessional context, or within the pastoral care team, for more than a few years. Often this has taken place where pastoral care is administered on behalf of the institution or the state and is also financed by the latter. I will come back to this point.

<sup>2</sup>Figures for the year 2017, Federal Statistical Office: https://www.bfs.admin.ch/bfs/de/home/ statistiken/bevoelkerung/sprachen-religionen/religionen.html, accessed 20 July 2019.

#### **2 The Current Development**

The situation in Switzerland has been in a state of flux for about 5 years now. This change has to do with the digitalization of the healthcare system and with the implementation of electronic documentation methods. The electronic patient file (EPD) is a collection of personal documents with information about the health of the patient. This information can be accessed via an Internet connection. Patients grant access to caregivers and determine who can view which documents. The law and implementing provisions on electronic patient files came into force on 15 April 2017. Since then, hospitals have had 3 years to introduce the electronic patient file, while nursing homes and birth centers have had 5 years. This rapid development in the healthcare system raises the question of whether pastoral care should feature in interprofessional, electronic documentation.

But the mentioned change also has to do with developments in professional pastoral care itself – especially in the fields of emergency, palliative and spiritual care, and relating therefore to the concerns of interprofessional cooperation. These developments are described below.

#### *2.1 Emergency Care*

An important context in which documentation systems have developed is emergency pastoral care. On the one hand, the documentation serves as an information basis for intraprofessional work to enable other chaplains in the team to continue the work of companionship. On the other hand, documentation can demonstrate to the institution the importance of this care provision and the corresponding staff resource requirements.

#### *2.2 Palliative Care*

The decisive step for the integration of chaplaincy as part of the palliative care teams was taken by the National Strategy for Palliative Care of the Federal Office of Public Health,3 which regards spiritual care as an integral part of palliative care (following WHO standards). Interprofessional cooperation including pastoral care thus became standard for palliative care. This development was further supported by the financial incentive system. Since 2011, palliative services in Switzerland have been billed within the framework of the CHOP (Swiss Operation Classification4 ) system.

<sup>3</sup>Bundesamt für Gesundheit (BAG).

<sup>4</sup>Version 2019: www.bfs.admin.ch/bfs/de/home/statistiken/kataloge-datenbanken/publikationen. assetdetail.5808569.html

Pastoral caregivers and other psychosocial professional groups play an important role in fulfilling the two CHOP codes 93.8A.2 and 93.8A.3. These stipulate that the multidisciplinary treatment team, consisting of a doctor, nursing staff, and staff in at least two of the therapeutic areas (social work/pedagogy, psychology, psychotherapy, ergotherapy, speech therapy, nutritional counseling/therapy, pastoral care, art therapy), will work a total of at least 6 hours per treatment week. In many hospitals in Switzerland, specialists invoice their services electronically in a form specially created for this purpose, which automatically evaluates the criteria for the complex code. Support within the framework of palliative complex treatment is the only pastoral service in Switzerland which has direct financial consequences or which has an impact on a hospital's income. It belongs to the group of services that must be fulfilled in order to receive the financial contributions of the insurance companies and to guarantee the (re)certification of the palliative wards. The prerequisite for this, however, is the documentation of pastoral services, if only in respect of the duration of pastoral attendance. If the chaplain is not prepared to keep records, the ward will (have to) use other services, like the psychological service. Pastoral care thus runs the risk of dropping out of the treatment team.

#### *2.3 Spiritual Care*

In recent years, we have seen significant and quite diverse developments in spiritual care as an interprofessional task in Switzerland – in the field of palliative care and beyond. In this context, two documents have emerged that are very important for our topic.

First is the document of the "Spiritual Care Taskforce" of "palliative.ch", the Swiss Society for Palliative Care5 : "*Spiritual Care in Palliative Care. Guidelines on Interprofessional Practice*."6 This document contains the following statement on documentation: "Interprofessional Spiritual Care requires intensive communication, including medical documentation as an important tool. Requirements for the documentation of R/S7 : (a) it is part of the documentation system accessible to all members of the treatment team; (b) all professional groups involved are requested to chart observations and agreements on R/S if they are relevant to the treatment and (c) the special and context-specific professional framework conditions regarding the possibility and limits of pastoral communication must be taken into account (keyword: pastoral secret)" (Spiritual Care 2018, 12f).

Second, in June 2019, the professional pastoral care group of palliative.ch published its guidelines "*Pastoral Care as Specialized Spiritual Care in Palliative*

<sup>5</sup>The Spiritual Care Taskforce supports interdisciplinary work toward a better understanding of Spiritual Care in Palliative Care. It is made up of experts from various professions.

<sup>6</sup>The guidelines ("Spiritual Care in Palliative Care. Leitlinien zur interprofessionellen Praxis") can be downloaded here: https://www.palliative.ch/de/fachbereich/task-forces/spiritual-care.

<sup>7</sup>R/S means religious/spiritual.

*Care*".8 Guideline 7 (access to information and documentation of care) broaches the issue of documentation: "As a member of the treatment team, the pastoral care specialists have access to information that will allow them to adapt their concept of spiritual-religious support. [...] The formal and/or informal exchange of information contributes to the strengthening of the team spirit and a positive culture within the treatment team. The information is recorded in the part of the electronic data record intended for pastoral care. In the electronic patient file spiritual/religious elements can be noted; the elements of the electronic patient file are available for all involved experts; the pastoral care specialist is in contact with the interprofessional team" (Leitlinien 2019, 14f).

#### *2.4 Conclusion*

The developments described above show that the topic of documentation within pastoral care has developed intensively in recent years and gained in importance. External factors, such as institutional requirements and the financial settlement of complex palliative services, have been crucial, but so also have developments within the profession of pastoral care itself. The insight that documentation could contribute to the professionalization of pastoral care was increasingly important. Alongside the initiatives of some pastoral care specialists, important roles were played by pastoral care units in large hospitals and professional associations, such as the Protestant and Roman Catholic National Pastoral Care Association and the Professional Pastoral Care Group of palliative.ch. The National Pastoral Care Associations have recognized the importance of the topic since 2013. They initiated the research project for documentation and organized the first conference on the topic. In order to better understand the importance of documentation for chaplains and their attitude toward it, a survey with the support of the Pastoral Care Associations was commissioned. This survey will be presented in the next two sections.

#### **3 A National Survey**

#### *3.1 Occasion*

It was remarkable that all discussions about documentation – be they conferences or collegial meetings – provided an opportunity to discuss fundamental topics of pastoral work and its profile. When confronted with the documentation topic, chaplains discussed the possibilities and limits of language; the connections between spiritual

<sup>8</sup>The guidelines ("Leitlinien. Seelsorge als spezialisierte Spiritual Care in Palliative Care") can be downloaded here: https://www.palliative.ch/de/fachbereich/fachgruppen/fachgruppe-seelsorge.

and religious matters with physical, psychological, and social phenomena; the question of individuality; and so on. Also interesting was the high emotional intensity with which the documentation was discussed. The topic of documentation hardly ever leaves anyone cold. Obviously, the topic challenges pastoral professionals to take a stand.

But what exactly do chaplains working in institutions think about pastoral documentation? How do they assess documentation in the context of the development described above? Do they chart themselves? Would they be prepared to do so? – Or is documentation not an appropriate pastoral instrument, in their view? These and other questions were put to chaplains in order to better understand their selfconception and practice. The results of this survey are explained and discussed below.

#### *3.2 The Participants*

In March 2019 we sent the questionnaire to 142 Protestant and 134 Roman Catholic chaplains who are members of the Reformed and Roman Catholic Pastoral Associations. Most institutional chaplains in Switzerland are members of one of these two national associations.9 In total there were 276 people, 5 of whom were retired. Therefore, 271 people were relevant for the survey.

One hundred and forty eight chaplains completed the questionnaire, which corresponds to a response rate of 54%. We can therefore say that the survey provides a good insight into the Swiss situation.

Among the participants, 77 were Protestant chaplains, 70 Roman-Catholic chaplains, and one chaplain belongs to another denomination (unknown to us). 104 of the participants work in a hospital, 21 in a psychiatric clinic, 37 in old-age institutions, and 20 in other contexts (Fig. 1).

An important factor for questions about charting is the appointing authority. The employment conditions of institutional pastoral workers in Switzerland are complex: some employers are churches; sometimes the state plays this role and sometimes the institution. Moreover, there are also mixed forms of employment.

Thirty one participants in our survey are employed by the institution they work in, 120 by the church, and 16 by the government. One person has a different employer (Fig. 2).

The different employment arrangements bring with them different expectations, with consequences for the perception and assessment of documentation:

– With regard to health service providers, pastoral care must make clear what it offers as its service, which quality standards it is committed to, how it secures these, and what framework conditions and resources it requires for this purpose.

<sup>9</sup>Efforts are underway to establish the number of institutional chaplains in Switzerland. However, no results are available yet.

#### **Appointing authority**

**(multiple answers possible)**

**Fig. 2** Appointing authority

The employment arrangements of chaplains are an important framework condition for the questions of the necessity of interprofessional cooperation and of the depth and nature of the integration of pastoral care in the institution. Such arrangements therefore also have an influence on the treatment of professional and pastoral secrecy, which will be discussed later.

#### **4 The Results of the Survey**

#### *4.1 General Results*

An important result is simply the response rate: Documentation is a topic that many chaplains are occupied with or want to deal with. This finding is confirmed by the many responses from participants (more than 50% of those who took part in the survey), who told us that they were willing to participate in further discussion.10

It is also clear that the confessional background of chaplains does not influence response rate: Of the Protestant chaplains, 77 participated, and of the Roman Catholic chaplains, 70. In relation to the questionnaires sent, this corresponds to a rate of 55% of Reformed chaplains and 53% of Catholic chaplains.

It can also be assumed that the topic of documentation is more important in hospitals than in other institutions. 57% of the data were received on the institutional field of hospitals. This is perhaps a reflection of the interprofessional integration of pastoral care, which is tightest in hospitals.

#### *4.2 Charting: Yes or No?*

But to what extent do chaplains in Switzerland record institutional pastoral care in interprofessional documentation? All participants answered this question. 44 of the participants contribute to interprofessional documentation; 27 chart only in the context of complex treatment in the field of palliative care; 74 chaplains do not chart. In summary, 49% of all chaplains contribute to documentation in an interprofessional context (including palliative care); 51% do not chart at all. We will break down the number of those who currently do not chart further in connection with the question of who can imagine charting and who cannot (Fig. 3).

However, the fact that a chaplain does not currently chart in an interprofessional context does not necessarily mean that he or she does *not want to* chart now or in the future. There are several reasons why chaplains cannot chart interprofessionally or are not allowed to. The institution, as well as the commissioning church, may prohibit this, and there may be no possibility of making pastoral entries in the existing

<sup>10</sup>The field at the end of the survey was "contact permission."

#### **Basic question about documentation**

**(only one entry possible)**

**Fig. 3** Basic question about documentation

documentation. We therefore asked those who are not currently charting whether they would prefer not to chart under any circumstances or whether there are circumstances under which they would like to chart. Out of a total of 83 answers to this question, 15 people stated that they never wanted to chart and 9 people said that they do not know whether they want to chart under different circumstances. 59 people stated that they would chart under certain circumstances – 71% of respondents.

While the question above was about interprofessional documentation, we also asked chaplains whether they contribute to documentation for themselves (with nobody else having access) and whether they contribute to documentation for the members of the team (with access restricted to the members of the pastoral team). 109 respondents answered this question. 96 people chart for themselves and 39 for the members of the team. With this question, it was possible to agree to both answers. We therefore do not know whether there are chaplains who chart only for members of the team but do not keep additional records exclusively for themselves (Fig. 4).

However, we can see that 88% of all participants chart for themselves, while only 49% contribute to interprofessional documentation. We can conclude that documentation for one's own work is part of pastoral workers' common practice, while interprofessional documentation is on the rise. It would be exciting to investigate whether

**Fig. 4** For whom do you chart

personal documentation follows a conceptual basis or whether it is a rather accidental documentation of important experiences or insights, in order to be able to further inform the accompanying process.

#### *4.3 Reasons to Document*

We have already seen that employment arrangements, and the context of justification they create, are significant determinants of documentation practice. Pastoral workers were asked why they do or do not chart, and 132 responded (16 people skipped the question).

Most chaplains contribute to documentation on the instructions of their institution (65 people, 49%), while almost as many chart for personal reasons (61 people, 46%). 39 people (30%) chart in accordance with a team decision, 22 people (17%) in accordance with the decision of a superior, while 8 people (6%) do so on the instruction of their church (Fig. 5).

Given the initial situation outlined above, the findings are not surprising. Healthcare institutions have an interest in somehow being able to measure the effects of professional interventions, and in the case of the palliative complex treatment already mentioned, such measurements have financial significance. Where pastoral care work is on behalf of the institution and is paid for by it, it is naturally perceived to be part of the work of the institution, which often leads to increased interprofessional cooperation. In the context of this, documentation can be an important instrument of communication.

The interprofessional integration of pastoral care has already been discussed several times. When asked to document their reasons for charting, 24 out of a total of 36 comments in the free text fields referred to interprofessional cooperation. This is regarded as an essential prerequisite for the practice of pastoral care. Interprofessional cooperation was also cited in most of the comments in the free text field about the circumstances under which chaplains might consider charting.

**Fig. 5** Reasons for (not) charting

#### *4.4 Confidentiality*

Professional secrecy is a constraint on the exchange of information. Determining the nature and extent of the constraint pastoral secrecy imposes relationship is in itself a challenge for pastoral work, especially in the context of interdisciplinary cooperation. One response to this challenge is a handbook published in 2016 by the Federation of Swiss Protestant Churches on the subject (Famos et al. 2016). The various Reformed cantonal churches in Switzerland, as well as the Catholic dioceses, are familiar with different forms of the pastoral confidentiality. There are different views as to what, if anything, of the substance of an encounter it is permissible to pass on in interprofessional discourse and what scope there is for interprofessional cooperation and what practices are prohibited. The question of how pastoral secrecy relates to professional secrecy is also controversial.

The pastoral secret was not an explicit topic of the survey, but it did play a role in the respondents' answers. Chaplains who do not contribute to interprofessional documentation were able to explain their reasons in a free text field. 56 people took up this opportunity (42% of all entries). Of these 56 persons, 8 cited the pastoral confidentiality as a reason why they do not document (12 mentioned that they use other means of communication, 27 said that their institutional context does not allow them to document, 9 gave further reasons). It must be stressed that we did not explicitly ask about the importance of the pastoral secret, so the number of responses should be interpreted with caution. Taken together with the other results, one could perhaps give the following summary: the pastoral secret plays an important role in the whole discourse, but it is not principally a stop signal for the possibility of interprofessional documentation.

#### *4.5 The Practice of Documentation*

Finally, we asked the chaplains about their charting practices. The responses were as follows:

What is noticeable is that only a few chaplains chart according to specific rules or guidelines. This reflects the earlier observation that documentation as a standardized instrument is still in its infancy.

#### **Information in case you chart interprofessionally**

**(multiple answers possible)**

**Fig. 6** Information in case of interprofessional charting

#### **5 Three Examples of Charting Systems in Switzerland**

Now that the survey has provided a detailed picture of the attitudes and practices of chaplains in institutions in Switzerland, this section will outline a more concrete picture of existing documentation models in Switzerland. There is a wide variety of documentation practices in Switzerland. In some cases, documentation extends only to registration; in others, the involvement of pastoral care is registered without any further information; and in some cases, pastoral information is recorded to inform assessment-based treatment.

In his article "How do we measure quality in charting?" David Lichter (2015, 3ff.) described three forms of quality assurance in charting:

As shown above, professional standards for pastoral documentation have been developed in Switzerland in the context of specialized palliative care. These standards would be the basis for the form of quality assurance mentioned under (c). The consistent implementation of these standards, as well as the other forms of quality assurance mentioned by Lichter, is still a long way off in Switzerland. The standards express the ambitions of chaplains working in palliative care have for documentation, rather than requirements implemented in practice.

The following three examples come from pastoral care units in large hospitals in the cities of Zurich, Bern, and Lausanne. The documentation models in Zurich and Bern, like most Swiss models, have been developed as a pragmatic response to the need to deepen and consolidate interprofessional cooperation. The model in Lausanne is an exception to the Swiss norm, because, on the one hand, it has a pastoral-conceptual basis and can therefore be linked to the first two forms of quality assurance of process measures and outcome measures; and, on the other hand, it has been conceived as an instrument for interprofessional cooperation.

#### *5.1 Triemli Hospital in Zurich*

The "Stadtspital Triemli" is a central hospital in the city of Zurich with a supraregional catchment area. With 467 beds and around 3,000 employees, it provides around 400,000 people with comprehensive basic and emergency care. The pastoral care team consists of seven pastoral workers (three Reformed and four Catholic).

Pastoral care has gained access to the electronic documentation system in the hospital, but it has been a long road to this point. Only after several requests were the hospital's responsible persons prepared to set up a working group to deal with this issue. This working group was set up to determine what information from nursing documentation it is necessary and important for pastoral care workers to be able to access if they are to participate in the framework of interprofessional cooperation. The vessels of the electronic patient documentation, into which the pastoral care information can be fed, were then defined, so that the treatment team, in particular the nursing staff, has access to it. The results of the working group were submitted to the management of the hospital for appraisal and received approval. Since then, the pastoral care department has had partial access to the electronic patient documentation of all patients hospital-wide, passively (i.e., information can be collected) as well as actively (i.e., information can be fed in).

This access to the information system WiCare is restricted to selected modules, such as patient information, reports, and protocols as well as the Departure/ Transfer field.

Pastoral care information is fed into the system and may record, for example:

As the healthcare chaplains themselves note, this information about the patients does not have a great direct influence on the content of the pastoral work, but it is helpful for pastoral organization. Access to WiCare simplifies the interprofessional flow of information and makes it more reliable. It raises the profile of pastoral care with the treatment team as the work of the pastoral care team becomes more visible. This in turn leads to greater interprofessional networking. Information flows more directly between the people involved (nurses, doctors, therapeutic services, pastoral care, etc.). Less information is lost, and stored information can be quickly viewed by all. This leads to less duplication and thus helps to ensure good patient care. "Our entries in the system make our work visible to all carers. We show that we are part of the interprofessional care team and that we can often act as a hinge between patients, relatives and caregivers."11

<sup>11</sup>Martin Rotzler (catholic leader of the pastoral care team) and Christoph Wettstein (chaplain). This whole section about the pastoral documentation in the city hospital Triemli owes much to their information and assessments. I'm very grateful for their support.

#### *5.2 Inselspital, University Hospital in Bern12*

The Inselspital employs around 8300 employees who look after about 44,000 inpatients and over 300,000 outpatients. The ecumenical pastoral team consists of 10 Reformed and Roman Catholic chaplains. The team positions itself as a component of holistic care and is, as such, a supportive service alongside others (e.g., social counseling, psycho-oncology, and palliative care) within the extended treatment team. The pastoral team is in contact with the nursing staff and the ethics department and participates in interdisciplinary (IDR) and interprofessional (IPR) reports. It obtains information from the nursing anamnesis and the respective screening or assessment models of the clinics – and its work can be integrated into the therapy plans (e.g., in neurology and neurorehabilitation).

#### **5.2.1 Interprofessional Documentation: i-pdos**

The i-pdos contains a hospital-wide IT-supported patient file to which various occupational groups have access. Medical, nursing, and therapeutic documentation have central importance. Access rights are regulated individually. The "I" in the program name means "integrated" but also "Inselspital-wide," "IT-aided," "interdisciplinary," and "interprofessional." Pastoral care in i-pdos does not document the content of conversations but only the reason for the meeting, the mode in which it was conducted, and arrangements for any future pastoral care. The pastoral entries in the i-pdos inform other professional groups about pastoral intervention and serve as a basis for in-depth, interprofessional cooperation (Fig. 7).

#### **5.2.2 Internal Documentation: Seel:is**

In 2012, after other pastoral and psychological assessment tools had been examined, the internal pastoral information system "Seel:is" was introduced, following an intensive development and evaluation phase within the pastoral team after intensive study of other pastoral and psychological assessment tools. The entries in the Seel:is are, in contrast to those in the i-pdos, only visible to the pastoral team members and serve the purposes of intraprofessional cooperation as well as quality assurance for individual chaplains and the pastoral team as a whole. The system essentially consists of two tools, the cockpit and the process tool: General information about a patient is recorded in the cockpit. The process tool displays the current patient dossier and is updated each time the patient visits the hospital. Information that is subject to special secrecy restrictions is entered in the "History" field. This field is only ever visible to the user who submitted the entry, regardless of who is the

<sup>12</sup> I am very grateful to Hubert Kössler and Thomas Wild, the two co-leaders of the chaplaincy team at the Inselspital, for providing me with useful information and for reviewing this chapter.

current dossier owner. If the patient is later transferred to another pastor, the field remains hidden to this chaplain.

The objectives of Seel:is are:

The Seel:is documentation tool will now be presented in more detail using an anonymous case study. Here is the information displayed in the cockpit and process tool (Figs. 8 and 9):

Significantly, following the development of the electronic patient file, the Seel:is will be integrated into the unified documentation system of the "Inselspital."

**Fig. 8** Seel:is, Cockpit. (Reproduced with permission from University Hospital Inselspital Bern. Copyright © 2020 University Hospital Inselspital Bern. All rights reserved)

#### *5.3 Lausanne University Hospital13*

The "Centre Universitaire du Vaud (CHUV)" employs 11,364 people and has beds for 1568 patients. The pastoral care team comprises 18 Reformed and Catholic chaplains.

<sup>13</sup> I am very grateful to François Rouiller, team leader, and Annette Meyer, member of the chaplaincy team at the CHUV, for providing me with useful information and for reviewing this chapter.

**Fig. 9** Seel:is, progress entry. (Reproduced with permission from University Hospital Inselspital Bern. Copyright © 2020 University Hospital Inselspital Bern. All rights reserved)

The electronic documentation of pastoral care was introduced in all clinics 3 years ago (2016). The basic tool is the assessment instrument STIV (French acronym for "Sense, Transcendence, Identity, and Values") and the associated SDAT (French acronym for "Spiritual Distress Assessment Tool"). The two tools are briefly presented below.

#### **5.3.1 STIV and SDAT: The Conceptual Foundations of Documentation**

The STIV was developed in the field of geriatrics by the chaplain Etienne Rochat together with the physician Stéfanie Monod-Zorzi in order to support elderly, vulnerable people during their clinical stay in such way that their spiritual dimension would also be taken into account. The STIV is therefore not a general spiritual assessment tool but has its place in hospital life. In this context, the preservation of autonomy and the experience of the meaningfulness of one's own life are recognized as central spiritual needs.

Basic for the STIV is the bio-psycho-socio-spiritual health model, on the basis of which an assessment model was developed which understands the spiritual dimension as an integrative dimension of health: "The patient's spirituality is not only taken into account and evaluated in the same way as the other traditional biological, psychological and social dimensions, but also integrated into the construction of the patient care project" (Monod-Zorzi 2011, 47).

The objectives pursued are to (Monod-Zorzi 2011, 30):

The STIV model of spiritual needs provides a structured and systematic approach to the appraisal of patients' spirituality. This approach, based on the assessment of patients' spiritual needs, is consistent with the care approaches of medicine and nursing and is therefore understandable to caregivers (Monod-Zorzi 2011, 65). It is assumed that the chaplain is a full member of the treatment team. The interdisciplinary conference stage is therefore crucial, because it represents the real moment of integration of this spiritual dimension with the other traditional bio-psycho and social dimensions (Monod-Zorzi 2011, 59).

Rochat and Monod characterize the spiritual dimension of sick, hospitalized people in the following categories (Monod-Zorzi 2011, 51f):

On the basis of the STIV, Monod and Rochat developed a tool for measuring spiritual distress called SDAT for Spiritual Assessment Tool. This tool helps to identify unmet spiritual needs and determine their severity. Spiritual stress is determined with reference to the four categories of the STIV and recorded using a scale from 0 (spiritual needs are not fulfilled at all) to 3 (spiritual needs are fulfilled).

#### **5.3.2 The Documentation Tool**

Documentation is provided on two pages: one can only be viewed by the members of the pastoral team, while the other is also accessible to the interprofessional team.

The pastoral page collects general information about the patient (dossier aumônerie), records any interventions, and contains the patient's spiritual anamnesis, which is created using the STIV and is the basis for the spiritual evaluation:

*Evaluation STIV:*

The spiritual evaluation is accessible to the interprofessional team. The evaluation always refers to the current situation and is not a static value. It is determined by assessing which spiritual needs are currently in the foreground for the patient through the evaluation of the four categories. In addition to the spiritual evaluation, the interprofessional page records any recommendations for the treatment team and provides space for further observations and information.

*Chaplaincy Point:*

Efforts are already underway to develop the documentation tool further: The pastoral team is, on the basis of the STIV, currently developing another tool to be complementary to SDAT: the STIV-RePer, which will assess patients' worries (French: PERturbations) and the spiritual resources available to them. The pastoral care team is also currently revising the documentation tool itself, with the aim of (a) reducing time expenditure, (b) giving more weight to spiritual resources, and (c) reducing the room for interpretation.

<sup>14</sup>Valeurs 1 are the values that are important for the patient in general. Valeurs 2 are those values that are particularly relevant for the current hospital stay.

#### *5.4 Goals and Current Practice: Charting Systems in Switzerland*

In an essay with the programmatic title "Leaving Footprints" (Ruff 1996, 390f), Rob A. Ruff formulated for the first time the central objectives of pastoral documentation:

Since pastoral care can leave its footprints in the hospital's documentation in all three hospitals presented above, it seems that the objective of integrating chaplains into to interdisciplinary team is being pursued and has been at least partially achieved.

Comparison of the three documentation systems shows that the development of interprofessional cooperation has reached different stages in different hospitals.

The development in the *Triemlispital in Zurich* shows how the hospital has already made it far from self-evident that it is possible for pastoral care to have access to patient documentation. This is probably because pastoral care is not regarded as an integral member of the interprofessional team. Only when the pastoral care team was able to show how the insufficient exchange of information in patient care could actually lead to disabilities and difficulties the hospital management gave permission to the pastoral care team to read and to feed at least some of the information of their pastoral support. Pastoral care is thus enabled to leave footprints by documenting their encounters and recording whether faith, religion, or spirituality is a relevant resource for the patient. However, there is no detailed information about the concrete needs of the patient or the specific interventions of the pastoral care team.

The pastoral care team at the *Inselspital in Bern* has long been an undisputed interprofessional partner in most clinics and thus an integral part of many treatment teams. Consequently, the pastoral counseling department has access to electronic patient documentation in all clinics and can also make entries. It provides information about the patient's situation, about what led to the consultation (contact offer or request, crisis, death situation) and about any pastoral care activities (procedural support, crisis support, ethical support, etc.). In addition, the documentation informs the treatment team about future pastoral care support.

The footprints of pastoral care work are visible in the system and give an approximate idea of the nature of the intervention through the specification of pastoral activities. A special strength of the pastoral documentation of the Inselspital – also when compared to hospitals worldwide – lies in the fact that it generates very precise statistical data and can provide detailed information on a wide variety of interrelationships.

Interprofessional collaboration seems to be most advanced in *some CHUV clinics in Lausanne*. Indeed, the assessment instrument STIV, which is the basis for the clinics' documentation, was developed in interprofessional collaboration. This development took place against the background of long-standing efforts by pastoral care to understand and represent the spiritual dimension as part of health care. These efforts have been supported by cantonal legislation, which makes provisions for the spiritual dimension. In the pastoral care documentation, which the entire treatment team can view, the result of the spiritual evaluation is recorded, and recommendations for the treatment team are formulated.

For this form of documentation, the image of footprints is no longer appropriate. Here, pastoral care does not merely leave traces but intends to participate fully in the healthcare of patients with its own expertise. Its contribution is integrated into the work of the care team, and its assessments are considered by the other health professionals and influence their actions.

Although the documentation systems in the Inselspital and, perhaps most clearly, in the CHUV suggest that pastoral care has now been integrated into interprofessional care, some critical remarks are necessary. The existence of an interprofessional documentation tool does not necessarily mean that interprofessional work is actually carried out. "Paper is patient," they say, and electronic dossiers can just be as patient. Firstly, there is the question of who actually reads the documented pastoral contributions. Secondly, the question arises as to the consequences of interprofessional cooperation and, ultimately, of care support. Are there tools for quality assurance? How does using a documentation tool affect the work of health professionals? Are they properly trained in such a way that they can include the spiritual dimension in their actions? These and other questions will have to be addressed in further research projects if we are to understand the true relevance of pastoral documentation.

#### **6 Summary and Future Perspectives**

The survey and the discussions with Swiss chaplains about documentation reveal three things:

of chaplains are open to documentation as part of interprofessional collaboration.

– Third, there are worries about how the pastoral secret is affected, whether documentation changes the profile of pastoral care in an unacceptable way (e.g., to medicalize it), and whether it is appropriate to communicate pastoral information in written form, given the possibility of security breaches.

Many *of the factors that have promoted the development of documentation* arose first in the field of palliative care: the fact that interprofessional cooperation, in which pastoral care is integrated, is usually standard in (specialized) palliative care, the requirements of palliative complex treatment as part of financing, and the documentation standards developed by the Pastoral Care Section of palliative.ch. This results in requirements such as joint documentation.

Other factors that promote documentation have to do with the general task and cooperation of pastoral care with other professions in the hospital. Where pastoral care takes over the function of a hospital's internal care team, documentation is important for transfer of cases as well as for the purpose of assessing the quality of the service for the institution: Plausibility check of the service vis-à-vis the institution, the understanding of pastoral care as part of the interprofessional team and thus the standard of interprofessional cooperation as it is increasingly applied in larger hospitals in Switzerland and the need for statistical data to demonstrate the need for pastoral care on the part of the funding institution.

Some factors that hinder the development of pastoral documentation or question its necessity come from within the field of pastoral care and from the church. There is no consensus within the field of pastoral care because there are hardly any developed theories of pastoral documentation, with the consequence that documenting plays no part in pastoral education and training. Meanwhile the position of the churches with regard to documentation varies from canton to canton and from confession to confession.

Other hindering factors come from outside: the legal situation is unclear or controversial, and the political situation varies depending on the canton.

So, looking *to the future,* what should be done? First of all, and most fundamentally, it must be clarified how interprofessional cooperation can or should be structured and whether, or in what form, the documentation is a helpful contribution to this. Beyond that, clarification of the ethical and legal requirements is needed in order to define the possible scope of documentation and provide a clear ethical and legal framework for dealing with the secrecy of pastoral care.

Regardless of how one approaches pastoral documentation, the questions it raises lead to highly exciting and relevant discussions about the future shape of pastoral care in the institutional environment and beyond.

#### **Commentary**

Wim Smeets (\*)

Radboud University Medical Center, Nijmegen, The Netherlands e-mail<EMAIL_ADDRESS>
There are similarities and differences between the way charting has evolved in Switzerland – as reflected in Pascal Mösli's fascinating contribution – and its development in other countries. The challenges for charting in Switzerland are distinctive in some respects, but have much in common with those faced elsewhere.

#### **1 Similarities**

First I will mention the similarities. I see five of them. First of all, charting is developing rapidly in Switzerland, just like in other countries. Until recently only a few hobbyists were interested in an well-structured, shared written documentation of patient contact. Today the entire professional group is dealing with the theme. Second, this recent development is not due to a spontaneous awakening of professional awareness, but is driven by external factors. Just like in the Netherlands, for example, the emergence of integrated palliative care is one of the most important reasons. Palliative teams expect pastors to carefully and richly document their findings and actions, just like other professions do; otherwise the spiritual dimension cannot be properly integrated into healthcare. In our country, the Netherlands, this has even led to the development of a new professional position, the spiritual care consultant: he or she can fully participate in the team – and therefore also report – without being hindered by discussions about professional secrecy. The work of the Taskforce Spiritual Care of *Palliative.ch* and the influence of the "Pastoral Care as Specialized Spiritual Care in Palliative Care" guidelines can be compared with a similar Task Force and the revised guideline "Meaning and Spirituality in Palliative Care" in the Netherlands. It is expected that the application of such guidelines will stimulate the further development of charting. Third, the professional group of (German-speaking) pastors is very divided about whether or not to participate in the interdisciplinary registration of patient contacts. The same division can be seen in other countries; the debate is perhaps equally emotional everywhere. It slows the development of charting and makes it difficult to speak with one voice to companies that develop electronic documentation systems. In this way a mix of systems and documentation methods remains. Fourth, training is an important incentive to discuss data about patient contacts with others. Clinical Pastoral Education has also played a key role in other countries for many years, stimulated by the legacies of Boisen, Gerkin, and other inspirational figures who advocated for learning through living human documents. Fifth, there is the central role of the professional association. It is only since these associations have come to realize the importance of charting that we have seen the development from separate, in themselves valuable, initiatives toward a joint approach.

#### **2 Differences**

Then there are the differences. I will mention three of them. In Switzerland, the arrival of a national electronic patient file (the law of April 2017) might be an important stimulator for pastoral documentation, or should we say that the law leaves pastors no choice? In the Netherlands, the parliament has blocked similar initiatives for a national electronic patient file with an appeal to the privacy of the citizen. This aversion to government interference in private life is perhaps something typically Dutch – due to negative experiences during the Second World War – a sentiment that may be difficult to understand for outsiders. A second difference is the influence of emergency care on the development of documentation systems. It would be interesting to hear in more detail how emergency care in Switzerland promoted the professionalization of pastoral care; in the Netherlands we are still at the beginning (Pater, R., W. Smeets, and A. de Vries. 2019. A beacon in a storm: Competencies of healthcare chaplains at the Accident & Emergency Department. *Journal of Healthcare Chaplaincy* [in press]). The biggest difference, however, lies in conducting a national survey among pastors. Although opinions have also been canvassed in other countries, the recent national survey in Switzerland offers a very complete picture of pastors' opinions about charting. The significance of these empirical data, also for the international discussion, cannot be sufficiently stressed. This research is therefore of significant merit! It makes clear, among other things, what a difference it makes whether pastors are employed by institutions or are employed by the church (with variation by canton and by denomination). The largest group of pastors who chart do so on behalf of their institution and with a view to interprofessional cooperation.

#### **3 Challenges**

Partly based on the three cases presented by Mösli, five challenges can be formulated, which the Swiss situation shares with those in other countries. The diversity in design of the three examples firstly points to the need for greater uniformity in the reports. The practice of charting often develops pragmatically through the initiative of a few pastors. This approach has the advantage that these "footprints" are closely aligned with what is required for action. The disadvantage is that models depend on personal insights and beliefs and therefore they have a limited scope, as Mösli states: sometimes rather process-oriented, sometimes rather result-oriented, but rarely linked to quality standards, in order that the content of the work would also benefit from reporting. Second, it is desirable that the developed models have a scientific basis. The Lausanne model is a unique example in that regard, because it is based on the Spiritual Needs Model of Stéfanie Monod. This model is related to the Spiritual Needs Model of Fitchett, which we have taken as a starting point in Nijmegen and elsewhere in the Netherlands. With this scientific basis, the randomness of some lists can be avoided. It offers other professionals insight into the scope of pastors' work. Pastoral care is integrated into a holistic view of health. Ruff had arrived at that insight more than 20 years ago, Mösli rightly observes. Third, reporting in this way can be an important building block of research on the profession of pastors and spiritual caregivers. At the moment we are still very dependent on general sociological studies on the religious or spiritual status of the population of a country. With scientifically based reporting systems we can gain a deeper insight into the religious and spiritual attitudes of specific population groups, into the interventions that pastors undertake and the effects thereof. This type of data goes much further than the outcome studies that are currently being set up. Fourth, a full report also provides starting points for aftercare outside the institutions. Aftercare is not possible without a proper report. That is why the Netherlands is now also considering reporting activities by spiritual caregivers and pastors in the home context. This challenge was recognized many years ago by the international Rehabilitation Movement in psychiatry. This makes the documentation by pastors of their actions from the perspective of empowerment indispensable. At the end, Mösli lists what is needed for the further development of reporting. All the elements mentioned are important. What I miss – and this is the fifth and final challenge – is the further development of reporting by and through education and training. Collaboration by pastors among themselves and between pastors and other disciplines would benefit if best practice and critical experiences were shared, or if there were some form of joint supervision. This requires a thorough substantive report on the practical case studies. Working together this way would also encourage each participant in the training to deepen their own reporting. Guidelines only work when training increases knowledge, when skills are practiced and desired attitudes are developed.

The international sharing of reporting insights and practices will improve the quality of reporting systems. The examples presented here, especially the detailed descriptions from Bern and Lausanne, can provide inspiration for working groups of professional associations to lay alongside their own models. In that sense, the initiative of the Swiss to organize an international meeting of experts and to publish their findings is to be commended. It is now the responsibility of other countries to take up the initiative!

#### **References**

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#### **Charting Spiritual Care: Psychiatric and Psychotherapeutic Aspects**

**Eckhard Frick**

A sick person's spirituality demands a high level of protection, discretion, and confidentiality on the part of the caregiver. At the same time, the caregiver must provide an open and safe setting in order for a patient to feel comfortable addressing his or her spiritual needs or distress. This *interpersonal conflict* between disclosure and non-disclosure depends on professional roles, the spiritual care provider's integration into the healthcare team, and systemic pressure emanating from juridical, ethical, or institutional norms, which usually regulate the patient–caregiver relationship.

In addition, the handling of spiritual confidentiality may provoke an *intrapersonal conflict* in patients, family members, and professional caregivers. Proactively addressing religious and spiritual (r/s) issues has a strong interventional impact on patients. This effect is generally more important than detailed contents gained from spiritual screenings and assessments (Paal et al. 2017):

Oftentimes they need permission to talk about those kinds of issues. Without some signal from the physicians, patients may feel that these topics are not appropriate or welcome (Puchalski and Romer 2000, 130).

When asked about r/s needs or problems, patients may feel ashamed, bothered, surprised, annoyed, or, conversely, satisfied, supported, and acknowledged in their coping efforts. Consequently, documentation should first and foremost reflect the patient's reaction towards the clinician's r/s intervention and to what extent the patient wishes this interaction to be shared within the healthcare team. There is growing evidence that patients want their caregivers to take into account the spiritual dimension of healthcare (Best et al. 2015). Health professionals must, however, respect individual and general boundaries (non-coercive, non-proselytizing, nonneglecting approach). In psychiatry and psychotherapy, patients' spirituality is less

© The Author(s) 2020 171 S. Peng-Keller, D. Neuhold (eds.), *Charting Spiritual Care*, https://doi.org/10.1007/978-3-030-47070-8\_10

E. Frick (\*)

Technical University of Munich, Munich, Germany e-mail<EMAIL_ADDRESS>
pathologized than in former times. In fact, it is increasingly accepted as a universal dimension to human experience, transcending individual religions. In mental health and other medical fields, r/s may be part of the problem, part of the solution, or both (Pargament et al. 2003, 1346). Consequently, spiritual charting should not only differentiate pathological/negative and resilient/positive coping but should also encompass the patient's r/s healthcare preferences and goals, as well as the role he or she attributes to the healthcare professional. A hermeneutical approach is required both when communicating with the patient and when documenting the case for the healthcare team, i.e. when "translating" the patient's spirituality and sharing it with different team members. Team members must, however, always keep in mind their own r/s and their professional affiliations, as well as their experiences and competencies in this field.

#### **1 Some Definitions**

Guarding one's *boundaries* – protecting bodily, emotional, and narrative secrets – is not only a human right but a basic anthropological asset. According to Plessner, a physical, inanimate thing (e.g. the objectified anatomical body: "Körper" in German) is distinguished from other things by a border (demarcation or limit) (Plessner 1928/1975, 126). The living body ("Leib" in German), however, is "boundaryrealising" ("grenzrealisierend") and has a specific, active relation to this boundary. The living body actively negotiates the "radical conflict between the necessity for closure as a physical body and the necessity for openness as an organism" (218).

From birth, an infant, in its nakedness, seems completely exposed to the caregiver's gaze, attitude, and manipulation. Napkins, clothes, and the caregiver's respect provide boundaries which the infant needs in order to thrive. Slowly, the child learns to invest (psychoanalytically speaking: to cathect) in his or her skin, in the physical and emotional boundaries of his or her own living body. During the second year, the child will learn to feel shame when those boundaries are violated, perhaps only by the other's gaze, be it in a real situation or in his or her imagination. Philosophically speaking, the human being is characterized by its eccentric positionality: it is able to relate to its own centre and "step outside his own physical boundaries by means of reflection. This ability allows man to gain distance from his subjective body (Leib) and perceive it as a separate object (Körper)" (Dobeson 2018, 42). Perceiving or imagining the other's gaze, or reflecting upon oneself entails shame, even in the empathetic embarrassment of "Fremdschämen" (feeling ashamed for somebody else).

*Confidentiality* protects boundaries and also shame, the leading affect (Leitaffekt) expressing eccentric positionality (Merten 2005; Frick 2015). Confidentiality is a shared attitude between patient and caregiver. We use the term *secret* (i) for everything the patient wants to keep from the knowledge of third parties ("personal secret") and (ii) for the caregiver's confidentiality ("professional secret"). Even matters in no way private may be secret for a person: the term secrecy is different

from *privacy*. The professional secret may be individual or collective (*shared secret*). "This difference lies in the means required for maintaining shared secrets. Benjamin Franklin's remark 'Three may keep a secret if two of them are dead' points up the problem" (Bok 1989, 108). Consequently, multiplying the number of confidants may be necessary for facilitating shared teamwork. Nevertheless this sharing requires strict conditions (Liégeois 2010).