Spirituality and Hospice Social Work

Ann M. Callahan

• Publisher: Columbia University Press
• Year: 2017
• eBook ISBN: 9780231543187
• Topic: Social Sciences
• Subtopic: Public Health, Administration & Care
• Index: Social Sciences

Many hospice social workers must address spiritual issues with their clients, but do not feel competent to do so effectively. This targeted volume draws upon multidisciplinary theory and research to advance a relational model of spiritually sensitive hospice care. The book will help readers elevate their spiritual competence and foster a relationship with their clients that will enrich the experience for all involved.

Spirituality and Hospice Social Work helps practitioners understand various forms of spiritual assessment for use with their clients. The book teaches practitioners to recognize a client's spiritual needs and resources, as well as signs of spiritual suffering. It also discusses religious and spiritual practices that clients may use to enhance their spiritual coping. Spirituality and Hospice Social Work stresses the need for interdisciplinary collaboration with other members of the hospice team, along with the value of maintaining professional ethical standards when addressing spiritual issues. Throughout, the importance of spiritual sensitivity and its effect upon client well-being is emphasized.

PART

Understanding Key Components

Champion of Spiritual Care

HOSPICE SOCIAL WORKERS HAVE BEEN members of interdisciplinary teams with the responsibility of providing holistic care since the beginning of the hospice movement. Each team member has an area of expertise, with hospice social workers being primarily responsible for the delivery of psychosocial care (Connor, 2007–2008). Although certified hospice chaplains are primarily responsible for the delivery of spiritual care, as interdisciplinary team members, hospice social workers must be prepared to ensure patients have access to the spiritual care they prefer. A hospice social worker can be a spiritual resource by cultivating a spiritually sensitive therapeutic relationship that may lead to a referral for or delivery of spiritual care. It can be difficult to address a patient’s spiritual needs, particularly when those needs are ambiguous in nature and are likely to change as part of the dying process. Nevertheless, the need for a timely response requires hospice social workers who are spiritually sensitive to respond independently and in coordination with interdisciplinary team members for patient access to quality spiritual care. This chapter will highlight the essential role of hospice social workers as champions of spiritual care.

LIFE QUALITY UNTIL DEATH

Palliative care is coordinated interdisciplinary care for patients with a serious chronic illness; it strives to promote the best quality of life for patients and their families (Payne, 2009; Puchalski et al., 2009). Palliative care adds an “extra layer of support” for symptom management as care providers work in conjunction with a patient’s regular physician (Center to Advance Palliative Care, 2012, p. 2). When an illness is no longer curable and is certified by a physician as being likely to lead to death within six months, a patient may elect hospice care, which is a form of palliative care (Almgren, n.d.; Centers for Medicare & Medicaid Services [CMS], n.d.; Monroe & DeLoach, 2004). This approach continues to provide biopsychosocial-spiritual resources but focuses on cultivating an environment that honors a patient’s need for dignity, self-determination, and comfort throughout the dying process (Clark et al., 2007; Frank, 2009; Monroe & DeLoach, 2004; Oliver, Washington, Wittenberg-Lyles, & Demiris, 2009). In providing hospice care, there are four primary objectives that include (1) promoting comfort essential for maintaining life quality; (2) allowing for self-determination congruent with patient culture, values, and lifestyle; (3) creating opportunities for growth in keeping with the developmental challenges associated with the end of life; and (4) meeting the multidimensional needs of patients and caregiver(s) (Parker-Oliver & Peck, 2006). As such, an interdisciplinary team is necessary to coordinate a multiskilled effort to address patient biopsychosocial-spiritual needs (Muehlbauer, 2013). This not only involves the work of multiple professionals but also informal caregivers over the course of illness (Bliss & While, 2007; Monroe & DeLoach, 2004; Payne, 2009).

INTERDISCIPLINARY TEAMS

Joint efforts between multiple professionals and informal caregivers have long been a part of the therapeutic quality of hospice care (Monroe & DeLoach, 2004; Parker-Oliver & Peck, 2006). The hospice movement began in 1967 with the opening of Saint Christopher’s Hospice in England by Cicely Saunders. Efforts to reform health care for the terminally ill in the United States began in 1973 under the direction of Florence Wald (Lawson, 2007). The hospice movement was founded on the belief that patients needed the services of different professionals during the dying process (Parker-Oliver, Bronstein, & Kurzejeski, 2005; Parker-Oliver & Peck, 2006). Saunders herself was trained as a social worker, nurse, and doctor. This interdisciplinary approach was further established when the U.S. Congress first authorized a hospice benefit under Medicare in 1982 and private health insurance companies and the Veterans Administration began to pay for hospice care (Almgren, n.d.; National Hospice and Palliative Care Organization [NHPCO], 2015a; Oliver et al., 2009). The Joint Commission began accrediting hospice providers, which further established Medicare-certified hospices to provide services through an interdisciplinary team that includes a registered nurse, social worker, and spiritual caregiver under the supervision of a physician (CMS, n.d.; Condition of Participation: Core Services, 2010; Joint Commission, 2016; Lawson, 2007). Membership may be extended to ancillary staff, such as home health aides and informal caregivers (Monroe & DeLoach, 2004; Muehlbauer, 2013; Oliver et al., 2009; Parker-Oliver et al., 2005). To help ensure hospice care remains responsive to patient needs, the Joint Commission requires a patient’s care plan be reviewed and updated during interdisciplinary team meetings at least every 15 days (Oliver et al., 2009). Hence, hospice care requires collaboration for intervention (Monroe & DeLoach, 2004).

Team collaboration involves a synergistic interaction between professionals with a range of perspectives and skills (Blacker & Deveau, 2010; Parker-Oliver et al., 2005). As described by Blacker and Deveau (2010), interdisciplinary team members are responsible for patient-centered care that involves (1) assessing patient condition, (2) helping patients understand the trajectory of illness, (3) assisting patients in making decisions, (4) connecting patients to resources, and (5) helping caregiver(s) manage the consequences of illness. In the process, according to Payne (2006), an interdisciplinary team is an interpersonal space in which a “community of practice” emerges (p. 138). Interdisciplinary teams generally streamline service provision by connecting patients with the most appropriate professionals to ensure patient needs are met (Blacker & Deveau, 2010; Lawson, 2007). This requires thoughtful cultivation of mutual respect among interdisciplinary team members that starts with an understanding of each member’s professional roles and competencies (Blacker & Deveau, 2010; Lawson, 2007; Wittenberg-Lyles, Parker-Oliver, Demiris, Baldwin, & Regehr, 2008; Payne, 2006). This process has the potential to shape formal and informal roles, give meaning to work relationships, forge a sense of belonging, and build a commitment to care that prevents burnout (Blacker & Deveau, 2010). This presupposes work conditions that allow for a collaborative process to emerge. Team members need the flexibility to stretch professional boundaries to support patient care (Blacker & Deveau, 2010; Payne, 2006). It is through this process of team collaboration that members share in responsibility for assessment, planning, intervention, and outcomes, all of which inform the quality of care (Clark et al., 2007; James, 2012; Lamers, 2007; Lawson, 2007; Parker-Oliver et al., 2005).

More research is needed to measure the effect of interdisciplinary teamwork; however, it is generally believed that good team collaboration enhances the quality of hospice care (Auty, 2005; Goldsmith, Wittenberg-Lyles, Rodriguez, & Sanchez-Reilly, 2010; Parker-Oliver et al., 2005; Payne, 2006; Reese, 2011b; Wittenberg-Lyles et al., 2008). For example, in a national survey based on a random sample of 66 hospices, Reese and Raymer (2004) found that team collaboration correlated with fewer than average hospitalizations and lower overall hospice costs. Goldsmith et al. (2010) found that team collaboration enhanced symptom control and patient satisfaction. Conversely, poor collaboration between interdisciplinary team members can compromise service provision. Different disciplines may have stereotyped views of one another (Auty, 2005). Even when professional roles are distinguished, role ambiguity and conflict can still occur (Blacker & Deveau, 2010; Wittenberg-Lyles et al., 2008). This is particularly true for social workers and spiritual caregivers, whose roles may not be as clear (James, 2012). Turf issues may also arise when team members cover for one another (Lawson, 2007). For example, Medicare does not require hospice organizations to employ hospice chaplains on interdisciplinary teams, so other spiritual caregivers as well as interdisciplinary team members may share in this work (Condition of Participation: Core Services, 2010). Wittenberg-Lyles et al. (2008) found that one-third (35 percent) of chaplains reported having experienced role conflict with either social workers (19 percent) or nurses (14 percent). Hence, additional efforts may be required to coordinate responsibilities for spiritual-care provision (Blacker & Deveau, 2010; James, 2012). Despite these challenges, team members can learn from one another and gain a broader understanding of patient needs as they work together (Blacker & Deveau, 2010; Clark et al., 2007; Goldsmith et al., 2010; Lamers, 2007; Parker-Oliver et al., 2005). Team members can further provide services that complement one another’s work and multiply the resources available to patients.

SOCIAL WORKERS AS TEAM MEMBERS

Professional roles, group norms, and organizational factors can influence the collaborative process (Goldsmith et al., 2010; Payne, 2006; Wittenberg-Lyles et al., 2008). Social workers have a range of competencies that enable them to be essential interdisciplinary team members across treatment settings. In hospice care, social workers have been team members since the beginning of the hospice movement and later, as per Medicare rules (CMS, n.d.; Condition of Participation: Core Services, 2010; Holloway, Adamson, McSherry, & Swinton, 2011; Parker-Oliver et al., 2005; Lawson, 2007). Hospice social workers have been described as being “at the heart of palliative care” (Stirling, 2007, p. 24), for they provide compassionate, skilled care that builds on patient and caregiver strengths to promote psychosocial-spiritual well-being (Connor, 2007–2008; James, 2012; Lawson, 2007; Meier & Beresford, 2008; Puchalski, Lunsford, Harris, & Miller, 2006). Intervention starts with an assessment of patient needs and resources that inform care planning, treatment, and referral. Social workers seek information about, for example, psychological challenges anticipated with grief and the influence of family dynamics and other social systems that broadly include culture. Death and dying can have implications for families and communities that may require social workers to build on family resilience and community capacity. Social work intervention generally includes patient education, crisis intervention, and supportive counseling. Social workers further enable caregiver use of medical, financial, legal, and community resources to support patient care and bereavement after death. This includes social work intervention as patient advocacy and mediation and coordination with team members for timely access to care (James, 2012; Monroe & DeLoach, 2004).

Social workers are responsible for ensuring treatment conditions support life quality (Gert, Culver, & Clouser, 2006; National Association of Social Workers [NASW], 2004, 2008; Payne, 2009). This involves ongoing assessment of how social systems, including interdisciplinary teams, influence patient well-being (Blacker & Deveau, 2010; Lawson, 2007; Meier & Beresford, 2008; Monroe & DeLoach, 2004; Reese, 2011b). On interdisciplinary teams, hospice social workers are needed to help team members see how multiple dimensions inform this process. For example, social workers may address the nonphysical aspects of pain as described by Terry Altilio, a leader in hospice social work, in Meier and Beresford (2008):

“When you look at pain from a multidimensional perspective—not to minimize the importance of physical aspects of pain management—there is meaning to the symptoms of illness for the patient and family. There are emotional consequences of uncontrolled pain and spiritual issues: Does this patient feel that pain is redemptive—or a punishment from God? Some patients feel that pain means they are dying. If we don’t ask patients about what the illness and the symptoms mean to them, we never hear their worst fears.” Pain and suffering also cause enormous distress for family members. There can be fear and anticipation of witnessing suffering in a loved one, and concerns about the social–economic aspects of pain, such as the huge costs of many analgesics. “People tend to talk to social workers in a different way, because we don’t ‘do things’ procedurally, write orders or give medications,” Altilio says. Social workers experienced in pain management also bring skills such as relaxation therapy, guided imagery or cognitive restructuring to help patients feel more in control of their symptom experiences. “Pain management is a shared responsibility with our colleagues,” Altilio says. “I have profound respect for doctors’ and nurses’ training and expertise. But as social workers, we bring a different view of the world. We’re trained to see the situation in a way that integrates the physical with the psychosocial–spiritual.

(p. 12)

Therefore, a multidimensional, systems perspective makes social workers uniquely qualified to serve on interdisciplinary teams (Parker-Oliver et al., 2005; Payne, 2009). In addition to recognizing a patient’s needs on the micro level, social workers see the consequences of the dying process on the mezzo and macro levels through patient caregivers and friends. This involves facilitating access to psychosocial services that may extend to spiritual care. Part of this responsibility is to support good team functioning by employing coordination and mediation skills and education and advocacy skills to ensure patient access to quality hospice care (Meier & Beresford, 2008; Stirling, 2007).

Not only are social workers essential members of interdisciplinary care teams, social work services are linked to positive treatment outcomes and reduced costs (Reese, 2011b, 2013). Reese and Raymer (2004) found that having qualified social workers on interdisciplinary teams allowed for better team functioning. Social workers were able to address more issues with the teams, particularly when the social workers were only responsible for providing social work services. This was also significantly correlated with a reduced need for patient visits by other team members. The authors suggested that social workers facilitated early identification of patient risk for psychosocial crisis, intervention to meet psychosocial needs, and better communication with hospice staff. Most importantly, social workers were positively related to patient satisfaction. The extent of social work involvement, however, is likely to be related to professional expertise. Reese (2011b) conducted a national survey of hospice directors (n = 43) to see whether there were any changes in social work utilization compared with the results of an earlier study by Kulys and Davis (1986, 1987). Social workers were still perceived to be the most qualified to provide financial counseling (98 percent) and make referrals (83 percent); however, new areas of expertise emerged. Social workers were considered qualified to conduct an intake interview (75 percent), facilitate social support (66 percent), promote cultural competence (54 percent), and facilitate community outreach (50 percent). Social workers were also considered to be the most qualified to perform counseling, particularly when patients wanted to hasten death (67 percent) or were in denial of impending death (54 percent).

Of greatest concern, Reese found that social workers were considered qualified to perform only half of the interventions they were trained to perform (12 out of 24). Seventy-nine percent of hospice directors viewed psychosocial assessment to be within a social worker’s role, but only 21 percent viewed social workers as being the most qualified to perform this role. Social workers were not considered qualified to address the spiritual experiences of patients (0 percent) and minimally qualified to discuss the meaning of life (19 percent). However, in Reese and Ray...

Table of contents

• Cover 
• Series Page
• Title Page
• Copyright
• Dedication
• Contents 
• Introduction
• Part One: Understanding Key Components
• Part Two: Facilitating Quality Spiritual Care
• Works Cited
• Index