Friday, September 15, 2006

Chaplains and Volunteers and Maintenance

In the last post I reflected on the feedback from my colleague, Chaplain Melvin Ray of Greenville, Texas. I responded to his concern about my suggestion that we see chaplains as “advanced practice ministers.” To sum up briefly, I thought his language seemed to separate the practice of ministry in health care institutions from ministry in general, and from our connections and commitments to our faith communities. I say “his language” because I don’t believe he really intended that result.

That said, let me reflect on the end of his message.

“Ill informed administrators, nurses, and physicians (and other health care providers) can not be blamed for misperceptions about our part in the healing art. Yes, volunteer ministers can minister to those believers who desire such help; let the “Pink Ladies” coordinate this. Chaplaincy is a documented clinical intervention accomplished by a highly trained, certified, and well paid health care professional. Chaplaincy should not be entrusted to volunteers.”

I have already reflected here on the difficulty of the label “volunteer,” and how unpaid staff may well have training to provide quality professional pastoral care. Chaplain Ray has been clear on what he’s talking about: “a documented clinical intervention accomplished by a highly trained, certified, and well paid health care professional.” Again, I don’t want to dwell on the issue of “paid.” My colleague who has a board certified chaplain prepared to work unpaid wouldn’t want to refuse the care available on that account; and too many colleagues who are paid would suggest they aren’t “well paid.” No, we’re clear together that his concern is with the interventions of a professional seen as a member of the clinical team with sufficient status to be included in the medical record.

Now, this is a topic on which there can be a good deal of discussion. First and foremost, what are the interventions of chaplain? Certainly they include pastoral presence. They include pastoral listening to patients and/or family members – or active or therapeutic or reflective listening or whatever title for this care is familiar. They include providing appropriate support at bedside for religious practice, whether by providing appropriate rites or scripture or making an appropriate referral. They include theological or “Godly” conversation, pastoral counseling, appreciation of cultural differences, ethical consultation, and sometimes confrontation. They certainly include prayer. Colleagues may offer other answers, although in my experience most would connect with one of these categories.

But just which of those interventions can’t be offered by someone with even minimal training? These interventions are offered frequently by folks other than chaplains: clergy, certainly; but also by family and friends, and by well-meaning strangers. Indeed, in the bedside work of the chaplain I would never want to underestimate the importance of simple presence. I have written before of the experience in which I learned most profoundly the power and importance of sacramental presence. A person with good sense and sensitivity, and some basic instruction in how to “do no harm” spiritually can in fact do some real, tangible good. Families do it all the time; and my reaction is to call them to see the ministry they are offering to those closest to them.

The problem is that each of these interventions can also be misused. I sometimes say that common sense seems an uncommon commodity, and I could say the same thing of good sense and sensitivity. We appreciate that saying that, “If one’s only tool is a hammer, soon every problem begins to look like a nail.” By the same token, we have all known instances where someone comes with good will and a good tool, and no sense or sensitivity. The person who can only pray to expect a miracle for the patient who is diagnosed as brain dead (and, yes, I have witnessed such a thing) only sets up both God and the family for failure. The person whose commitment to her own faith is so fragile and insecure that she cannot respect the faith of another projects rejection and not compassion. The person whose own unrecognized fear is such that he cannot hear the fear of another, cannot walk with person in that, leaves the patient feeling more alone and not less. My colleagues in congregations have been heard to jest that in the structures of the Kingdom they’re in sales. Mine is to say that I’m in maintenance, especially for all the time I’ve spent repairing the harm done by well-meaning and misguided pastoral care. “If one’s only tool is a hammer….”

What distinguishes the trained clinical chaplain is awareness of a wide variety of tools, and the self-awareness and awareness of context to know when and how to use them to best effect. Academic information is part of that: I can provide broader, more appropriate care if I know about traditions other than my own. However, the examined and reflected experience that is the heart of clinical training is also important. It is in that crucible that we learn about our own limitations, and about the limitations of each tool in our toolbox. It is in that process of learning by hearing and by being heard that we gain skill and wisdom to apply the right intervention in the right situation – at our best, as deftly as a paintbrush, and not as bluntly as a sledgehammer. And while charism and vocation are important, they can only take us so far. Any of us with practice can become better listeners, better prayers – better chaplains. It is because we and our predecessors have shown that wisdom and skill that we have a place on the team and in the medical record; and not for the “intrinsic value” of any of those interventions.

But if that is so, that work is too important to leave to “Pink Ladies,” even when the volunteers are visiting like-minded people. (Others will, I’m sure, call into question the identification of “Pink Ladies” here as at best anachronistic, and at worst dismissive and demeaning. I have the highest respect for the many valuable services offered by lay volunteers in many areas of hospital function.) If we are the professionals, with the academic and clinical education and the professional experience to use those tools appropriately, then we are also those with responsibility to supervise those ministries in our institutions. A CPE student could learn a lot about therapeutic listening from a social worker; but he or she could not learn about pastoral presence and listening with a chaplain’s perspective. So we must take responsibility in our institutions not just for what we do at the bedside, but also for oversight of what others might do. That’s not an exact statement. Certainly, we’re not called to interfere in established family or pastoral relationships (although even in the latter case there may be times to step in) precisely because those relationships are established and are not institutional. But if it’s going to be done representing our institutions we should take responsibility as the persons most able to respond. I have suggested that other professions find ways to delegate some of their functions; but they would never delegate supervision of those functions. Indeed, for licensed practitioners those responsibilities are in state regulations: physician assistants must be supervised by physicians and certified nurse aids must be supervised by nurses. So for our work: whether the extenders are volunteers or students, it is for us to establish the standards and to provide the supervision to see that the care is offered so as to benefit the patient. We risk harming patients, and certainly we harm our profession, if we delegate that to others.

Now, I know that we don’t have the opportunity in all institutions. There are many places that don’t understand the value for patients and for the institution of having a certified chaplain who can oversee an institution’s program. But if we establish that as the norm where we can, it will have an effect on the industry as a whole. Even those institutions that will only work with volunteers will recognize the importance of volunteers who show that good sense and sensitivity. They will set expectations and provide training and work only with those who can at least do no harm, and who may well provide care that well serves the patient. Even when we cannot act, we can model the importance of good care, and not simply well-meaning but insensitive care; and the institutions that cannot pay for us will still want to follow our example.

So, if the issue is the quality of pastoral care and support that a patient and family receive, than the question is not at bottom whether the caregiver is paid, but whether the caregiver is carefully selected and adequately trained. Would I like to see a board certified chaplain in every inpatient and residential health care setting? Certainly I would. That would not end the need in many cases to extend our ministries with students and volunteers. It would, however, provide those students and volunteers with supervision and guidance so as to provide those institutions and the patients, families, and staff within them with effective, compassionate, quality pastoral care.


Susan Palwick said...

We've arrived at the same conclusion! (And I loved the presence story, btw.) So tell me: would you anticipate any resistance within the professional-chaplain community to the "use volunteers as long as you train and supervise them" model? My sense is that there are at least some folks very invested in the idea that one can't be an effective chaplain on any level without having had 90,000 hours of CPE, although I'd love to be wrong about that.

And if anyone reading this is interested in a volunteer's take on the "pink ladies" nomenclature, here's my post on the subject.

Language matters. Professionals need to be careful how they talk to and about volunteers. A professional member of the volunteer-services department in my hospital once saw me in an elevator and said, "Oh, you're here for your little ministry?" I felt my face freeze, and she must have seen it, because she said quickly, "No, it's not little, I didn't mean that."

Whether my ministry seems little to her or not, it's not little to the patients.

Marshall Scott said...

I'm sure there are a rare few who would resist working with volunteers under any circumstances, believing that it would prevent administrators from hiring additional chaplains. However, I do think they're rare. And, I do have some colleagues who share Chaplain Ray's anxiety that there's no separating themselves from clergy in congregations where, as I suggested, charismatic call is the criterion, and not training.

However, I think that most chaplains ( and for that matter, most adminstrators and even some doctors) are teachable. I think that most would be comfortable with my standards. Now, the investment involved in training and supervising volunteers may be more than some want to commit to. In addition, as you've seen from what I write, I see chaplaincy as a global practice. If folks are so fixed on the work at the bedside that they can't see this as caring for the whole institution, they can't see the time in their schedule to do so.