Chaplain Gordon Robertson, LBSW, BCCHouston Hospice - Texas Medical Center1905 Holcombe Blvd. Houston, Texas 77030

Never document again: “Patient refuses Chaplain or Social Work visit”

Patient has the right to refuse a Chaplain or Social Work visit (CHAPS HII.1a

CFR §418.52 c 3) Condition of participation: Patient's rights.  

Any ideas how/why this occurs?

Does it happen to you?

Keep in mind Chaplain and Social Work services are required aspects of plan of care, whether patient refuses visit or not.

Hospice standards HII.2s , 418.64 (d) (1), 418.64 (d) (2)HII.2h (418.64 c)

Group Exercise- Identifying with the Patient and/or Family

Explore reasons as a Chaplain or Social Worker that might help you justify not visiting a patient or family. Be creative and honest.

Let us go a little deeper and talk about the distractions and interruptions that can prevent us from connecting to the patient/family

Obstacles to Listening- Our own road blocks to a visit

Distractions Interruptions Lack of interest Lack of understanding Preconceived notions Fatigue Work load The subject matter generates anxiety Anticipated rejection Preset agenda Timing Assumptions

The capacity to listen to others depends on the ability to listen to self and what is going on with you.

What are some distractions that can be occurring with the patient or family as you approach them?• They can be in the middle of a crisis• They can be overwhelmed• They may need personal space• They may not want to be here• Hospice is threatening to them in name

and concept• They don’t accept what is going on with

their body and don’t want to die

Listening . . . Yesterday . . . Today . . . TomorrowListening is a seven stage process of : Hearing- receiving raw data Selecting- choosing what to pay attention to Attending- focusing attention Understanding- assigning meaning Evaluating- analyzing and judging Remembering- drawing on your memory Responding- communicating that the message has been received

Let us examine how we initiate contact:

First Impression and acceptance of you occurs within the first few seconds of the interaction.

Let us examine how we initiate contact continued

Give scenarios of what occurs within the first 15 secondsContent-Simply greetingIntroductionCommunicating title & role

Examine the first impressions you have of others- what is your focus?

What is the message conveyed?

The first impressions message conveyed in wordsappearancemannerismeye contactgesturestone, volume and cadence

List reasons Clients have used to refuse a visit

List reasons Clients have used to refuse a visit

•I already have great support•I don’t need it•It’s against my faith and beliefs•We are fine- thank you•I am not sick enough yet

Lets examine and be sensitive to the patient/family needs, being very aware of what is happening- timing, asking permission for the visit. Do you have a rapport?

What do you do when a patient or family refuses a visit?

What do you do when a patient or family refuses a visit?

Examine honestly what is going on!

Lets examine what others may perceive as you make contact with them.

What are your word and actions saying- also examine non-verbals.

What are the first few words out of your mouth?

Rapport Building Tips, if refusal visits are occurring frequently for you-*Break the cycle – If you utilize phone contact as the first contact the odds are against you. *Utilize more personal contact (coordinate visit with other staff who have a rapport to confirm first visit)*Make joint visit with other staff

Rapport Building Tips Cont.* If you need to make phone contact try to establish rapport quickly. Reference understanding and or positive experience they may have had with other team members.

Albert Mehrabian, a pioneer researcher of body language in the 1950's, found that the total impact of a message is about 7 percent verbal (words only) and 38 percent vocal (including tone of voice, inflection, and other sounds) and 55 percent nonverbal.

Nonverbal communication examines how messages are communicated through physical behavior, vocal cues and spatial relationships.

Types of Non Verbal Communication (NVC)Proxemics: physical space in communicationMovement and body position* Kinesics-body movements* Posture* Gesture* Haptics: touching in communicationFacial ExpressionEye contactParalanguage: nonverbal cues of the voice-tone, volume, cadence

Use of body language and other non verbal communication

The moment I stop being aware and really listening is when I have the potential to be refused.

Some practical uses of Non Verbal Communication-

• SOLVER stands for: "The acronym S-O-L-V-E-R is a useful device for remembering

• Several nonverbal ways to show to engage and respect a patient or family member• S ——— : Sit SQUARELY facing the client, preferably at a 5 o’clock position to • avoid the possibility of staring. in a way that indicates you are alert and giving • them all your attention.

O ——— : Maintain an OPEN posture at all times, not crossing your arms or legs• which can appear defensive. As if to say, "I am here to receive whatever you • want to communicate.

L ——— : LEAN slightly in towards the client. This shows interest in what the • person is saying to you • V———vocal quality. Maintain a volume and intensity in your speech that is• neither abrasive nor hard to hear. Always let your voice reflect tenderness and • compassion rather than anger and irritation.• E ——— : Maintain EYE CONTACT with the client without staring. Especially• when they are speaking

R ——— : RELAX. relational posture. Coordinate all your body, head, and facial• movements in a way that is most conducive to the comfort of the client.• Your posture should not be still and robotic, but neither should it be so totally• relaxed that the person thinks you are about to go to sleep.”.

• ·

It takes just seconds to form an impression “According to Psychology Today, our minds process many details simultaneously in order to form a first impression—and it takes just seconds. Build awareness of your delivery skills by observing how others respond to you- it makes sense to be aware of first impressions and control those that you can.”

WHAT YOU DO WITHIN THE FIRST FEW SECONDS OF CONTACT IS EXTREMELY IMPORTANT!

Engaging and developing a rapport with strategic opened and closed ended questions allows brief but essential information. Avoiding questions that may end a no gives you and the patient the opportunity to stay engaged.

Open ended sample questions (allow fuller expression upon which can identify needs and current state of emotions).

I want to welcome you to hospice- What has it been like for you since you came on?

What is your understanding about hospice?

What are your main concerns?

Closed ended sample questions should be used carefully (answered usually with one or two words, and allow simple dialogue) not just yes and no.Are you in a position to talk or a moment?

Have you meet any of the staff?

Are you more comfortable than you were in the hospital?

Any concerns or needs that you have a this moment?

WHAT DO YOU DO WITHIN THE FIRST FEW SECONDS OF CONTACT ?

Awareness of what you say and do initially is so important?

You are giving yourself the opportunity to be apart of their lives. Minimizing preconceived notions about your role allows you to be seen for who you are.

The role of Social Worker and Chaplain often has charged negative and positive impressions associated with them that may or may not have anything to do with what you are offering.

Open discussion:

Consequences of a refused visit for the patient, Chaplain or Social Worker and the Team?

Conclusion

A Refusal Visit communicates more than simply – “I don’t want to see a Chaplain or Social Worker”

Resources 

Delivery Skills First Impressions. Gail Zack Anderson. 2011 http://www.applauseinc.net/delivery-skills-first-impressions-count

Hospice Care Electronic Code of Federal Regulations. Title 42: Public Health   Part 418- HTTP://WWW.ECFR.GOV/CGI-BIN/SEARCHECFR Hospice Standards, Community Health Accreditation Program, CHAP, INC 2008

Listening effectively. John A. Kline. 1996. http://www.au.af.mil/au/awc/awcgate/kline-listen/b10ch3.htm      MacArthur, Jr. and Mack , Dr. Wayne . Introduction to Biblical Counseling ,  Thomas Nelson 1994.

Pease and Pease The Definitive Book of Body Language,  2006 Print