More Good Stuff on the Radio

Yesterday was an interesting day for a chaplain’s ears. I heard two interviews that I would like to call to your attention. As will not surprise regular readers, both were from NPR, my most common news source.

The first was on Fresh Air. There host Terry Gross interviewed the Rev. Carroll Pickett. For 13 years Pickett was the death-house chaplain at the Walls prison in Huntsville, Texas, where he ministered to inmates executed by lethal injection. What caught my attention early in the interview was the fact that after each execution he recorded his thoughts and experiences on tape. He did it as a means of self-care, based on his own experience in CPE; and the reference to CPE caught my attention. The interview is about 40 minutes, but it’s well worth the time. (Chaplain Pickett was also interviewed for the 1999 Frontline episode, “The Execution.” You can find a transcript of that interview here.)

Later in the day I caught a portion of All Things Considered in which Melissa Block interviewed Chinese Christians and clergy in the area of the recent earthquake. She asked the clergy how they cared for their parishioners, and how they discussed the earthquake. It was a classic discussion of the problem of suffering; and as one who has to address that problem with some frequency, I was interested in their responses. Take some time, and hear for yourself.

Things Worth Reading

Let me call to your attention two new posts at Episcopal Cafe, neither of them mine. Andrew Gerns, a parish priest and former hospital chaplain, and a valued colleague, has written two posts on cost shifting in health care, and on the moral issues involved. You can read them here and here, and I encourage you to do so.

Andrew also has his own blog, "Andrew Plus;" and you can read that here.

Some Final Comments on Volunteers in Chaplaincy (at Least for This Year)

Let’s return to volunteers in chaplaincy once again. Specifically, let’s return to PlainViews one more time. They have published another collection of comments on volunteers in chaplaincy in the Advocacy column, including one from a current volunteer, and one from a professional chaplain who began as a volunteer. I encourage you to go over and take a look. (They have decided that this will be the last column on the topic for a while, although they will continue to publish comments in TalkBack.)

Now, in discussions like this many opinions get aired, but I’m honestly not sure how many minds get changed. Some positions have been made clear.

• There are some chaplains who decline to employ unpaid persons in pastoral care at all. While for some it is an issue of prestige, for almost all it reflects a distrust of health care administrators to either trust or learn from professional chaplains about the nature of the work, or the needs of patients.
• There are some chaplains who are concerned about employing unpaid chaplains who do not have the credentials they would expect of paid chaplains. Once again, they are concerned about administrators; but they are also concerned about maintaining the highest level of professional competence in each patient encounter, even if that means fewer encounters.
• There are some chaplains who are prepared to work with unpaid pastoral staff to increase the visibility of the service to patients, even if sometimes the patient’s first experience is not with the most trained or experienced person. These chaplains may also be concerned about administrators who expect certain levels of productivity.
• There are some chaplains who must work with unpaid staff if they are to reach beyond patients in crisis to any great extent.
• All chaplains who work with unpaid staff trade some time they might be with patients for time supervising volunteers.
• The chaplain’s own sense of his or her own gifts, as well as some sense of administrative expectations, will contribute to each chaplain’s decision. Chaplains with an administrative bent, or with expectations from administration of participation in committees and programs, will choose differently from those who do not feel either that vocation or those expectations.

Some years ago the Association of Professional Chaplains sponsored a pilot study to learn whether it would be possible to study the practices of chaplains in one-person departments. The hope was to determine some professional standards and benchmarks based on the research. Eleven centers participated, and the results were reported at the annual meeting of APC in Cincinnati in 2002. At one end of the group, one chaplain spent about 90% of his time in patient care, and about 10% in administrative activities. At the other end another chaplain spent about 10% of his time in patient care, and about 90% of his time in administrative activities. Graphing between those two poles one could see an almost straight diagonal line as one noted how the other nine chaplains varied their balance of patient care and administrative work. The first two points we noted were that, first, we could study what those chaplains did; and, second, that each chaplain balanced his or her work according to individual choices and needs. Another point to note was, as I recall, that the greater the chaplain’s administrative time, the greater the likelihood that the chaplain would work with unpaid staff.

So, for the time being, that’s where I think we will leave this discussion. I am happy with the support of the volunteers who work with me, with their varied gifts and responsibilities. I am certainly blessed with the sense that I’m not trying to hold all this down by myself. Patients are blessed by the care that they provide. Those blessings are, to me, sufficient justification for my volunteer program.

On Chaplains as Ministers

I was looking back at the conversation on PlainViews regarding Volunteers in Chaplaincy. You can look back at my comments here by checking my posts under the Volunteers label in the sidebar. You can find the posts on PlainViews in the Advocacy column. Look for articles on 8/16, 11/1, 11/15, and 12/6.

One sidelight came up for me. At least two colleagues took issue with my comments about chaplains being “advanced practice ministers.” They were concerned at my observation other allied health care professions made a distinction between levels of function within a broad professional purview.

Do chaplains have this separation, this designation of levels of function? At first it would not appear so. However, that reflects our failure to recognize ourselves within the context of ministry. The normative context of the believer is the local congregation, and the normative clergy is the clergyperson of the local congregation. Like the registered nurse, there are a variety of educational paths to becoming a clergyperson in a congregation, depending on the specific requirements and culture of each faith community. Still, there is so much in common across those specificities that ecumenical community clergy groups can become important sources of support.

I would suggest that we think of ourselves, as are advanced practice ministers. There are others—academics, spiritual directors, monastics—but that is where we are in the context of ministry.

For the concerned colleagues, to say we need as chaplains to see ourselves within “the context of ministry” was to tie our work closely – too closely – to the authority of the local congregation, and to deny that we functioned as allied health professionals.

Now, the second concern seemed easily enough addressed. After all, as I noted elsewhere, school nurses work in schools and provide some education, but we still recognize them as nurses. A physicist may work in research, or teach in high school or college, or work as radiation safety officer in a hospital. Their practices are different, but all are rooted in their training in physics, and in all of them they are physicists. So, while the most common experience a believer has of a cleric is in the local congregation, missionaries and health care chaplains and school chaplains and church administrators, each in their different venues, all continue to be ministers.

But I have to admit the first concern never crossed my mind. You see, I’m an Episcopalian, an Anglican. In the Anglican tradition, all ministry is first and foremost Christ’s, exercised in and through the Body; that is, the Church. And for an Anglican, the Church is, first and foremost, the whole Church. The Church is not the assembly of local congregations, but the Body of Christ. The local congregation is derivative of the whole Church, and not the other way around. Notwithstanding all the current arguments within the Anglican Communion and The Episcopal Church, there is consensus within the Anglican tradition that all ministry is an expression of the ministry of the whole Church, the whole Body, and not simply of an individual congregation.

In that image, I often speak of chaplains as the fingertips of the Body, reaching out and touching the tender, hurting places in creation. That is, of course, a function that all Christians are called to in one sense of another. However, we are quite self-consciously there, tips and fingers and hands, to provide sensitive and delicate touch to fragile and wounded persons.

For some colleagues, that may be entirely too theological, ignoring pragmatic considerations. Some come from traditions where the theology of the Church does hold that the whole Church is the assembly of congregations. Some of us – perhaps many of us – are sufficiently out of the mainstream within our own faith communities that any apparent link of our own individual ministries to local congregations and congregational clergy seems to undermine the independence and the openness that are hallmarks of clinical ministry. Some of us – and, again, perhaps many- have had to fight so hard to be recognized as professionals functioning within the clinical context that any acknowledgement of our accountability to our faith communities, faith communities that may not appreciate or accept the academic and scientific culture of the clinical world. There may be a number of reasons that colleagues may be anxious about acknowledging “the context of ministry,” if that is too closely associated with the local congregation.

I realize, too, that I write as an Episcopalian, a Christian. I cannot write otherwise: I respect and appreciate my chaplain colleagues who are not Christians. I can speak to their traditions in only a limited sense. I can’t speak from their traditions at all.

At the same time, my observation as one who has worked with and listened to non-Christians for many years is that all persons of faith have some sense that ministry serves the community of faith, is shaped in fundamental ways by it, and is accountable to it. That must necessarily include the ministry of the chaplain. That would suggest that within some faith communities the ministry of the chaplain would be impossible. It simply wouldn’t fit within the community’s understanding of the ministries to which a person might be called. With that in mind, while I can only speak as a Christian, I believe that my colleagues from other faith communities can translate the concepts into the forms of their own traditions.

So, I will stand by my position: professional chaplains are advanced practitioners in the field of ministry. We find our practice in health care, and serve congregations made flesh often in one person at a time. We spend much of our time planning for accreditation surveys instead of weekly sermons. But we are first and foremost ministers, carrying into rooms of anxiety and suffering the care and compassion of the faith communities that called us forth.

Volunteers In Chaplaincy: The Discussion Goes On

Just a little update. The discussions regarding volunteers in chaplaincy at PlainViews have been going on. New comments (yes, including one from me) were posted at that site on November 15 and December 6. My friend Susan at Rickety Contrivances of Doing Good has shared her own thoughts and enthusiasm.

I will say that this has been the broadest discussion, at least in terms of venue and of shades of opinion, that I have seen on this topic. I think that, in the end, this will serve chaplains and patients well.

Even More on Volunteers in Chaplaincy

There has been even more discussion published on PlainViews on working with volunteers in health care chaplaincy. For those of you who have been following, you can find comments, including my own, here. I don't have anything new to add today, but I think the ongoing discussion is worthwhile.

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.

I Came In for an Argument!

It seems I’ve generated some professional debate. A colleague has submitted an article on volunteers in chaplaincy that has been published on PlainViews. Chaplain D. W. Donovan of the Bon Secours Richmond Department of Pastoral Care shares his thoughts. He disagrees with me; but, then, that’s what makes for good discussion.

Susan Palwick, a frequent reader and occasional commenter here, has offered her own reaction on her blog. She also points to an interesting article here reflecting on parallel issues in nursing.

I will be writing a response for the TalkBack page on PlainViews; and once I’ve completed it I’ll post it. In the meantime, these all make for interesting reading for reflection.

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.

Volunteers in Chaplaincy: Doing What?

I ended my last reflection on volunteers with the question, “So, what can volunteers do?” For those of us who do call for a high level of quality of care for patients in health care institutions, that is not a simple question. I have suggested that there are a variety of qualifications that we might consider for a person who wishes to volunteer. But, as I have noted, the variety of qualifications simply begs the question.

Or, perhaps it only appears to do so. I say that because the variety of qualifications suggests that volunteers can do what they’re asked to do and trained to do. That is, there are people out there, and perhaps available, who have one or more of the various qualifications I suggested. Granted, there will be more un- or underemployed folks with CPE who might volunteer in major metropolitan areas. I have a colleague who has a Board Certified Chaplain serving on a volunteer (unpaid) basis. However, the other sorts of preparation I mentioned, from seminary courses to education programs for lay ministry, are widely available, and may well reach into small towns. We speak of folks as “volunteers” because we’re not prepared to pay for their service. But that in and of itself doesn’t describe the limits of what a given volunteer, with certain individual talents and preparation, might be able to do. Rather, it clarifies the question from “What can volunteers do?” to “What do we want volunteers to do?”

Two responses, one to the original article and another to the last post, can illustrate this. Barbara Jackman, a Board Certified Chaplain, wrote in response to the PlainViews article, “I've worked too often with volunteers who mean well, but simply don't have the training in communicating, in working with those of other faiths/cultures, or with those in crisis. At times that simply has given chaplaincy a bad name, and affects all of us.” David Fleenor, who has recently entered CPE supervisory training, responded to my last post with reflections from four years working in a hospital as a Patient Representative. His department considered and decided not to use volunteers, even to make initial visits simply to inform patients of the availability of the service.

The reason we decided against using volunteers for this was b/c often during the initial visit the patient would reveal a concern that required immediate attention.

You can see the parallels to chaplaincy. Volunteers might be useful to make initial visits, but what if an immediate need arises that require the sensitivity and pastoral skills of a trained chaplain? The volunteer could make a referral. That is not optimal, however, b/c of the golden moment when a patient takes the risk and finds the courage to reveal his/her anxiety, dilemma, etc. It seems less than a best practice for a volunteer to be in a situation where he says, "You have raised a very important issue. Let me make the chaplain aware of that so she can visit you within the next 24 hours." I guess one could counter all of this by asserting that the chaplain would never know of the patient's need for a chaplain had the volunteer not made an initial visit.

Nevertheless, as a Patient Representative department we were not willing to take the risk of putting an untrained* (unqualified?) person in the situation to deal with what we believed were issues that required our skills.

Both clarify that the issue to be discussed is precisely what we might expect volunteers to do.

And that is a more complex question. The answer will have to be individual to the institution and to the chaplain in the institution. There is a certain level of function that we through our professional organizations have identified with professional practice. That level of function is articulated in the standards for certification of our various professional certifying bodies. While the words and titles are not identical in all our organizations, I believe there are some consistent characteristics described:

• the capacity to establish and interact in a pastoral relationship based in active listening;
• to be able to develop that relationship across lines of faith and culture while respecting the faith and culture of the person served;
• to determine from that interaction a pastoral assessment or diagnosis, and to develop an appropriate plan for spiritual care;
• to educate other professionals as well as patients about spiritual care and about ethics;
• to administer a program of spiritual care, and to participate in the administration of the institution in which one serves;
• to represent in our practice, and to represent our practice to, the faith communities in which we are grounded.

(If I’ve missed something significant I know I can depend on my chaplain colleagues to call it to my attention.)

As I suggested in my PlainViews article, there are many parts of this that we can’t delegate. After all, I can’t delegate doing my budget or orienting new staff to the program. More to the point, I can’t leave it to another to determine a pastoral assessment or care plan. The capacity to function as a professional among other professionals in the institution is a major part of our training. However, it is arrogant to suggest that only we can listen sensitively and establish a relationship, or contribute information toward the assessment. Colleagues Barbara and David have valid points: persons poorly trained and/or poorly supervised can do harm, both to the patient, and to the reputation of the spiritual care program. But if we are Advanced Practice Ministers, as I want to suggest, we are prepared and called to take responsibility for that training and supervision, and for the careful screening that is implicit in it.

I appreciate David's comments regarding "missing the golden moment." I also appreciate his recognition that a referral and delayed response to an issue may be preferable to no response at all. In his comments he makes some comment regarding "legal issues." While always seen as a patient service, patient advocacy and representation are often perceived to have a link to risk management that we in chaplaincy do not share (and that could be the topic of another post). From that perspective, a case not handled may well create less risk than a case mishandled. I would question, though, whether we would share that perspective. Pastoral relationships are not established to solve problems. Generally, pastoral issues may change in intensity but will not change in form with some delay. Moreover, we can address with training the ability of a volunteer to determine urgency and decide just how soon that referral needs to be addressed.

I also think we can fall into an “expertism” about our practice that overlooks or denigrates the importance in pastoral care of simple presence. As an Episcopalian I speak regularly of the importance of “sacramental presence,” God’s capacity to work through material means, including us. Those who would not use sacramental presence would still appreciate the importance of the community of faith, and of the “ambassador for Christ” to represent the faithful concern of that community simply by being there. And any of us can appreciate the existential crisis of isolation, so exacerbated during an institutional admission, which is broken simply by the interest of another in reaching out to us. As I have said before, it has been my experience that people of faith appreciate the concern of people of faith, even if they do not share the same faith. A volunteer with sufficient training to do no harm can in fact often to good simply by being present and interested.

This is a lesson we can learn from our colleagues in congregations. Many of them have seen their role primarily as empowering and overseeing the ministries of others, and not trying to do everything themselves. Many have developed parish visitation programs, reflecting that the call to visit the sick with the love of Christ and the support of the community is a call to all Christians, and not simply to a professional class. As in our practice, they do not want their visitors to assess or treat. Rather, they reflect the love of the faithful; and any information that indicates need for further discussion is faithfully reported. The pastor then has the opportunity to function as pastor or confessor or director, as the situation warrants. So, we have the opportunity to educate and supervise to enable the ministries of others.

I have put this in explicitly Christian language because it is the language that comes to me most readily. I am, after all, an Episcopal chaplain, whether at the bedside or elsewhere. However, I believe this concept will translate well: that representative believers can help us, under our supervision and with our guidance, to demonstrate a caring and compassionate community within our institutions. They cannot do everything, any more than (to follow my PlainViews article) a Certified Nurse Aid can function as a Registered Nurse. They can, however, be present at times and places when the simple limitations of space and time prevent us. They can free us, too, to provide other kinds of care for which we are specifically qualified. If we so “expertize” our practice of pastoral care that we fail to consider how we might enable and support the vocations of others, all suffer: the volunteer stifled from sharing a charism, the chaplain frustrated and exhausted at what couldn’t get done, and the patient who did not experience the representative presence of the community of faith.

Keep watching. There is still more on this to come.

More on Volunteers in Chaplaincy: Education and Training

Let me continue my reflection the use of volunteers in chaplaincy.

Several professional colleagues have sent responses to my article in PlainViews, and the editor kindly forwarded them to me. The first one was from an old friend, Chaplain Dick Cathell. Dick is currently Chair of the Commission on Advocacy of the Association of Professional Chaplains. His primary concern was a question for the editor, and the decision to post my article under “Advocacy,” rather than under another category. However, in addition, his response included this statement:

I would suggest Chaplain Scott and other single-chaplain pastoral care departments first explore ideas of becoming a satellite CPE program, or at least having a CPE student or two from a nearby program assist with their pastoral care needs....or partner with a nearby seminary or faith-based college to start a field education assignment. [His] area, and especially [his] System has (sic) ample resources to access without advocating for volunteer chaplains.

His response points to two related arguments raised by professional chaplains who believe it unwise to use volunteers in chaplaincy. The first is that volunteers cannot provide the quality of care that these chaplains want to provide in their program. The second, related argument is that the programs that might teach appropriate skills are not available. That’s particularly highlighted by Chaplain Cathell’s reference to CPE programs. The first is worthy of a post all its own. For the moment, let me acknowledge that there is a level of quality that we as professional chaplains expect of ourselves, and that it takes training to provide that.

So, what is the requisite level of training? The norm to function as a professional chaplain is four units (1600 contact hours) of clinical pastoral education (CPE). This is agreed by all the major professional organizations of professional chaplains in North America. Should this be expected if someone is to volunteer? There are many congregational clergy that have had one unit (400 contact hours), whether required or recommended by church or seminary. In most metropolitan areas there are lay people who have pursued CPE, either in exploration of vocation or for personal growth. Is that required to assist a professional chaplain?

Graduate seminaries, and some undergraduate religious programs, provide courses in pastoral care and counseling, including some with supervised clinical experience. While many who take those courses go on to pursue certification as pastoral counselors and psychotherapists (a different professional practice from clinical chaplaincy), what about the congregational minister who took such courses? Some seminaries, at least in my area, have provided something called clinical pastoral training (CPT). These were programs of exposure to chaplaincy and pastoral care experiences, including use of verbatim case studies and small groups experiences, for a period of several weeks. Or, what about other kinds of training in giving support and care? I have known students who came to CPE programs who were clinical psychologists or licensed clinical social workers. What would the value be of these backgrounds in extending the work of a professional chaplain?

What about other programs? There are a number of programs currently used to train lay people in parishes for various ministries. One that was created by a chaplaincy program is the Community of Hope of St. Luke’s Episcopal Hospital of Houston. Another would be Stephen Ministries, based in St. Louis. Both programs provide training in relating sensitively one on one to a person in crisis. Other programs exist, and some have been developed by individual congregations to train their own members on giving care and support. Some chaplain departments have developed their own programs for the own needs and contexts.

On the other hand, there are programs to provide theological education by extension. As a Sewanee graduate I’m most familiar with the Education for Ministry (EFM) program based in that seminary. These programs provide a level of theological education and sophistication and experience in personal growth and reflection. So, with programs providing either some level of functional training or of theological education for lay people, do any of these provide the training appropriate to extend the work of a professional chaplain?

And what about basic skills? Of what value is a sense of vocation to caring, or a reputation as “a good listener?” Knowledge can be shared, and skills taught; but on what base should that education build? There are faith groups for whom the requisite credential for ministry is the call of the Spirit. How important is the call of the Spirit (or whatever phrase would best parallel in a different faith tradition) for a potential volunteer to work with a chaplain?

I’ve proposed a number of different tracks and backgrounds. They differ quite a bit, over all; and yet any of them would give a potential volunteer something to bring to extending the ministry of a chaplain. But because they differ so much, because what each would bring differs so much, knowing all these possibilities doesn’t really answer our question. They don’t answer our question because they beg the previous question: specifically, if a chaplain were to accept using volunteers to extend the ministry, what would the chaplain want the volunteers to do?

You see, we can talk a lot about what I have posed as the second question. There are a variety of backgrounds, and I’ve had some person ask me about professional chaplaincy, much less volunteering, based on most of them. But I want to hold to my premise that the clinically trained professional chaplain is an advanced practice minister. I think that at least some of what we do we cannot delegate without a clear and fairly high level of preparation. So, before we make a decision about what is the appropriate training, we need to think further about the first concern, stated a little differently. If there are tasks and aspects of chaplaincy that volunteers may not be prepared to do, what tasks can they do? Then, the appropriate preparation would be that relevant to the tasks assigned.

So, what can volunteers do? And that will be the topic of the next post on this issue.

On Chaplaincy and Volunteers

Let me begin by calling to your attention the PlainViews web site. PlainViews is an online newletter on healthcare chaplaincy. Each issue includes a variety of articles for chaplains, usually by chaplains, along with other useful information and resources. It's worth subscribing and checking regularly.

The August 16 edition includes an article of mine (you saw that coming, didn't you?). The topic is using volunteers in chaplaincy programs. While it's not long, rather than reproduce it here, I encourage you to link and read it here. Go on. Take a minute and read it, and then come back.

Done? Okay; let's continue.

As you might guess from the colleague's comment to which I was reacting, the use of volunteers has long been a hot topic among professional chaplains for some time. I participate in a Yahoo Group of chaplains in one person departments, and it's a particularly hot topic there. Those who think it's a bad idea to use chaplains are especially ardent.

My colleagues in one person departments are divided on the topic. Many of them are in small towns in small regional hospitals. They fear administrators who do not see the distinction among clergy, much less between congregational clergy and, as I describe us, “advanced practice clergy.” They fear being eliminated by administrators who believe they can be replaced by well meaning lay volunteers, supervised by a volunteer coordinator, and trained (to the extent they are trained) by a local pastor from a church that does not require graduate education for ordination. They fear spiritual abuse of patients by folks who, while arguably well intended, don’t understand that patients are better served by pastoral support than by encouragement to conviction.

But this also leaves my colleagues in small regional hospitals in a bind. One chaplain can only do so much. And these days there is much for chaplains to be involved in. Ethics committees, programs in cultural diversity, and organ and tissue donation are all programs in which chaplains have been intimately involved. Privacy issues have become important, and chaplains have worked to defend the rights of patients to visits by their clergy, and the rights of congregational clergy to have access to their members. Chaplains, too, have all the administrative responsibilities of any other manager. There are budgets to prepare, statistics to track, and reports to prepare. And there is ministry to the staff of the institutions themselves, from the administration and medical staff to the cook and the housekeeper. These activities are no more “optional” for chaplains than they are for any other member of the institution’s leadership. Chaplains are particularly clear on the issues of being “wise as serpents and innocent as doves.”

Too, many are sufficiently remote from any theological educational institution, clinical or academic, as to make recruitment of "more trained" volunteer support difficult at best. One can be that remote either geographically or theologically. I have certainly been interviewed by students interested in chaplaincy whose background is in a small, fundamentalist Christian community with a high reverence for evangelizing (as opposed to a ministry of evangelism). They're vision of a medical crisis as an obvious opportunity for conversion excludes them from my consideration.

And so in many instances, and not all of them rural, using volunteers to extend the chaplain’s ministry isn’t a luxury but a necessity. For those chaplains, to proclaim that this undermines chaplaincy isn’t helpful. Not using volunteers undermines the ministry, the patients, and the chaplain himself or herself. Should the chaplain tough it out, either trying to do too much or telling the institution to expect little? Or, should the chaplain take the initiative and be the professional to set the standards, both of what volunteers might do, and what training they might require for those tasks? At the other end, are our "advanced practices" so different from simple Christian caring that none of them can be delegated? Or have we so delimited the definition of chaplaincy as to eliminate from consideration those functions that might be delegated?

Central to my argument is this image of "advanced practice ministry," in parallel to differences among practices of nurses, physicians, and rehab therapy professionals, and perhaps educators and attorneys, as well. Perhaps this is a place to continue this reflection. I'd love to hear from others on this. I'll let this become another ongoing project for the blog, and share what my colleagues have to share.