Friday, November 03, 2006

On Volunteers Once Again

I mentioned in my last post this article on PlainViews from Chaplain D. W. Donovan. I’m happy to see further response to my original article on volunteers in chaplaincy. As I have said, I think we’ve expressed opinions on whether to have them, but haven’t really articulated professional reasons beyond “If administrators believe a volunteer can do what I do, my position is at risk.” I appreciate that he is approaching this question from a perspective of bringing together the needs of patients and families with the training and capacities of the clinically trained chaplain.

There are a number of his statements with which I agree in part, but differ with him about application or implication. For example, he states, “The functions he describes, such as passing ice water and distributing literature, are not truly nursing functions;” and goes on to say, “Today’s nurse is a true medical professional, charged with assessing the medical needs of the patient (this is not just a role for doctors) and helping to coordinate their overall care.” First, I would suggest that nurses would assert that they assess nursing needs rather than medical needs. Nursing as a profession has indeed worked hard to express it’s own distinct purview and body of knowledge (and some nurses of my acquaintance would be offended at the word "medical" in this context, as it smacks of still being the "handmaids of the physician"). Within that I would suggest, second, that historically these were functions of nurses of generations past, and while they are not now commonly done by RN’s or LPN’s, it is because those professionals have delegated those tasks, not because they have excluded them from their professional purview. Those functions are supervised and delegated by professional nurses, and so are within the sphere of the profession of nursing. (We can find an interesting perspective of a parallel professional debate among nurses on the web log “Nurse Ratched’s Place.”)

I would certainly agree with Chaplain Donovan that we are “an integral part of the health care team.” At the same time, we are part of the health care team to bring ministry. To be more clear, we are part of the team as spiritual providers, and not as medical, much less generic “health care” providers. We are there precisely because we are not physicians and not nurses, and so on; and that spiritual competence is our distinct purview and body of knowledge. We have noted recently physicians interested in being more spiritually informed (and nurses for a longer period), in much the same way – perhaps in exactly the same way – that they seek to be culturally competent. In general, despite the anxiety we sometimes feel, the result is physicians who are more interested in working with us and not somehow thinking they can do our job.

I can further appreciate the definition of the role of the Chaplain in Chaplain Donovan's department: “to assess the degree to which the patient's emotional and spiritual equilibrium has been disturbed by the healthcare event and to determine what interventions would be appropriate to help the patient restore his or her equilibrium and when such interventions should be employed.” It is remarkably parallel to his understanding of the role of the nurse: “charged with assessing the medical needs of the patient (this is not just a role for doctors) and helping to coordinate their overall care.” Nurses coordinate nursing care that they delegate rather than necessarily providing themselves. By the same token, Chaplain Donovan’s definition of the role of the chaplain speaks to assessing spiritual needs and determining interventions. That does not foreclose the delegation of some of those interventions to properly supervised students or to properly trained volunteers.

Let me make a specific example. In my center volunteer Extraordinary Ministers from a Roman Catholic parish come to the hospital to offer communion to Roman Catholic patients and to some staff members. While they may be from the local parish, they are there under my supervision. They are specifically there under an agreement with the local archdiocese. They are trained for their ministry by a chaplain Board Certified by NACC. Their training includes information about patient privacy and the requirements of HIPAA. They have their access to patients under my purview and through my coordination. At the same time, if there is a problem with one of them, I am the person the hospital holds responsible to address and resolve the problem. They offer a ministry that I can’t: sacramental care that I as an Episcopal Priest can’t authentically offer. Their care may come from the local parish, but they see patients from many parishes; and those patients see this first and foremost as a ministry of the hospital. This is not an intrusion of the church into the hospital; nor have I decided that rites and rituals for patients are not part of my responsibility. Instead, I meet this responsibility through a collaboration with the church. It is, I think, comparable to a physician specialist referring to a subspecialist.

As Chaplain Donovan notes, administrators certainly want those who “cook the best vegetables.” To follow that metaphor, we need to be clear that we are trained as chefs. And to helps us feed more people, it may well be poor use of our professional time to mop the floors when we need to be at the fresh market. This is not to say that the mopping is not important for health and safety, or that it is not our responsibility to see that it is done and done right. The importance of our clinical training, on which Chaplain Donovan and I agree, is that capacity for development and implementation of a broader vision of spiritual care for the patient, family members, and staff. To find ways to incorporate the ministries of people with gifts but less training, for those specific ministries for which they are or can be trained, expands our ministries, rather than diluting or diminishing them.

I continue to assert that providing caring presence and information about the availability of a clinical chaplain are within our professional purview, even though they don’t require our highest expertise. To delegate those functions does not make them less the responsibility of the chaplain, and does not make us less chaplains; but it may well mean more patients are aware of and have access to compassion and spiritual care.


Susan Palwick said...

With all due respect, I'm not sure that the "mopping the floor" analogy is entirely complimentary either to me, as a volunteer ED chaplain, or to the patients I serve. Likewise, although I certainly provide "caring presence," and "information about the availability of a clinical chaplain" when that's appropriate, I think both patients and staff see the volunteer chaplains in the hospital -- all thirty or forty of us -- as more than nice people who exist primarily to hand out the Real Chaplains' business cards.

But then, that's probably because the staff chaplains at my hospital see us as more than that. They pay us the enormous compliment of treating us as colleagues.

I recently started working a shift when one of our staff chaplains is sometimes in the hospital. Before that, I'd been working a shift when I was usually the only chaplain in the building, so another staff chaplain had asked me to respond to codes on the floors.

When I started the new shift, I asked the second staff chaplain if he wanted me to respond to non-ED codes, or if he wanted to handle those. He told me that we should both respond and figure out who was doing what according to needs and timing. He didn't say, "I'm the Real Chaplain, so I'll handle the Real Emergencies."

Now, since I work primarily in the ED, he knows I've responded to codes before. Perhaps he would have said something different to a volunteer chaplain who'd been working mainly in peds or L&D. But instead of deeming me incompetent for not completing CPE (and he was my CPE supervisor), he's chosen to view the two years I've spent volunteering in the ED as on-the-job training.

If I'm a good chaplain -- and sometimes I'm better than others, of course -- it's because the people around me trust me and give me that responsibility. That precedent is set by the staff chaplains.

If you only trust your volunteers to mop floors, if that's the only thing you ever let them do, that's all you'll ever see them do. It becomes a self-fulfilling prophecy.

Marshall Scott said...

Duly noted. Actually, I take mopping the floor, either in a restaurant or in the hospital, very seriously. I've worked in unclean kitchens, and I know all the housekeeping staff in my own institution do as part of protecting all of us from infection. What they do is absolutely necessary to patient care. Perhaps a better analogy would have shown that respect better.

My own volunteers have great deal of independence, and it's largely because they've worked with me a long time. It takes students who work in my institution time and several joint calls to get that.

I noted on your blog references to chaplaincy as a vocation. I would agree. At the same time, I've known some folks with the interest and all the wrong images of what to do. I've never known someone who did have the vocation who couldn't learn to do it better. certainly including me. I think the training difference, and the interest of certifying bodies, is in making sure of the administrative and visioning capacity. That's what allows us to become integrated into the health care team. Consider your own ministry: what would the environment for chaplaincy be in your hospital if your predecessors, and especially the staff chaplains, hadn't established the climate and culture within which you work? I've been in places where that hadn't been done, and the work it took to become part of the place rather than an outsider - valued perhaps, but still outside the institution.

I'm sure that the staff chaplains in your hospital select out those folks who could not function as good chaplains and as colleagues. You bring the experience you did gain in the CPE you were able to take, and the capacity for self reflection (that has been my experience of writers), and bring that to your ministry. That makes for good collegiality, and for good chaplaincy.

Susan Palwick said...

I completely agree that some training is absolutely essential (in part to screen out anyone prone to proselytize or preach about damnation). Volunteers go through a three or four-weekend training course; when I dropped CPE, I asked if I should wait to volunteer until after I'd done that, but the volunteer coordinator (who was also a staff chaplain), said, "No, you've gotten enough training in CPE."

And certainly I give the staff chaplains -- and their extensive training -- credit for creating a good climate. I'd never argue that staff chaplains aren't necessary; it just pains me when some staff chaplains (not you, obviously, or the folks at my own hospital!) act as if all volunteers will automatically wreak havoc.

Actually, some of the best pastoral care I've seen in the hospital has been patient-to-patient. Patients who don't want to have anything to do with me -- because I'm a chaplain, and too scary -- will accept comfort from people they see as peers.

Mmm said...

Susn's comment strike me as very odd--coming from someone who professes Christ as Lord! Didn't Chrtist tell us to shout out the Truth on rooftops, not to hide our light, etc. but to go and 'preach' the good news to the ends of the world!?! If he is indeed worthy of proclaiming, if the saviour of the world, than we should not be embarassed in any way but wanting to do so--certainly not, 'heaven forbid', actually forbidding any proselytizing as she seems to suggest--the very thing a minister of Christ is first and foremeost called to do! I suggest there needs to be a serious re-read of the New Testament!

Marshall Scott said...

Duncan, remember that hospital patients and their families are vulnerable and afraid. If pressed, they may well tell us what they think we want to hear. As Pope Benedict said today (one of the few things i know I would agree with), the Church does not want to compel anyone; and certainly doesn't want to compel belief.

Now, the patient who sees the compassion of the chaplain, and the respect of the chaplain for the tradition the patient brought to the hospital, will have an entirely different experience and perspective of Christians in faith and practice. That is a compelling witness. As Francis of Assissi said, "Preach the Gospel always. If you need to, use words."

Mmm said...

Yes, I see your point Marshall, but I guess I don't entirely agree with St. Francis as the Bible makes it celar that "faith comes by hearing, and hearing by the Word of God." that means it is spoke. Elsewhere in the N.T. it says how will they beleive if they don't hear? Yes, if a geuine faith we can't help but show them the fruits of it but we must also "prosletyse" and tell them, giving a reson for the hope that is within us, wouldn't you agree?

I'm curious have you found that the approach you are recommedning has actually led to anyone who was a former non Christian fiding the light of Crist, becoming aware of their need of salvation adn actually becoming a Christian, asking Jesus to be Lord? Bascially, I'm wodnering if being a loving witness only is enough? I think both are needed and I go the impression from Susan's answer she seems to indicte that no prosletising be if somehow that is wrong which would be backwards. Statements like that can suggest one isn't fully convinced in the inerrancy of the gospel message...and man's utter need for salvation offered through Christ alone!

Thanks for your comments.

Marshall Scott said...

Duncan, I hear what you're saying. I guess my answer is, in part, sometimes loving witness has to be enough. In that context, it is all that is appropriate, even to the spiritual needs of the non-Christian served. And, after all, all of this is trusting in God's work in the person served. To paraphrase Paul, one serves, another waters, but growth is up to God. It is gracious and evangelical to work persuasively with a person whose mind and body are whole, and who is open to hearing. It is spiritual violence to undermine the spiritual history that has sustained a person to this point when the person is physically threatened, and so mentally and emotionally threatened as well. A positive way to look at it is to remember that we evangelize persons, and we have to recognize and respect their personhood first. A more practical point is to remember that, "The greatest sermon in the world will never be heard over a growling stomach," much less a serious disease. That statement may have been made by the Buddha, but its practical wisdom is something we can recognize and acknowlege.

Mmm said...

I don't know Marshall, I get the impression you would have found Jesus far too "violent" and offensive in his willingness to call a spade a spade and confront people's (usually the Pharisees)religious/spiritual deception, calling them white washed tombs and what have you. We are not to respect those veiws that lead to death. Yes love the person, of course, but nowhere in scripture does it say any of us are off the hook with verbally sharing the good news--and how much more so if someone is on their death bed facing their eternity and when not in the postion of knowing Christ as Lord. To say nothing would actually be cruel. You, as a Christian minister, are especially called to a higher account to share that good news--you often may well be their last chance to hear it and I'm sure God would want to use your position as such. When death is around the corner we are not called to simply be PC (or use soime exttrab biblical justification) in fear of offending their sensibilites. As Jesus said, better to lose an eye than go to Hell--so how much more so 'better to be offended by hearing the gospel, and (possibly) be saved as s result of hearing the truth then to die in a state of denial.'