BY: DAVID A. LICHTER, D.Min., and MARY LOU O'GORMAN, M.Div.
Health Care Leaders and Chaplains Collaborate to Define Professional Standards
Dr. Lichter is executive director, National Association of Catholic Chaplains, Milwaukee, and Ms. O'Gorman is director of pastoral care, Saint Thomas Hospital, Nashville, Tenn.
Spiritual care services that contribute to the care of the whole person are integral to the ministry and mission of Catholic health care. Yet pastoral care, like other health care services, has been challenged to develop and implement professional standards and practices that provide evidence of its value, effectiveness and quality. Because chaplains deal in the spiritual realm, it has proved difficult to express in words the transcendence and mystery inherent in person-to-person encounters.
Some Catholic health care systems have made advances in professionalizing spiritual care services in select areas. Some, for example, have created productivity measures. But pastoral care as a ministry has progressed less rapidly than other disciplines in defining its benefits and the elements of its effectiveness.
As a result, questions have emerged regarding the contributions of chaplains. These questions are especially pressing in today's environment, in which health care leaders are pressed more than ever to evaluate resources, including the investment in pastoral care.
The need to set clearer standards for a chaplain's role has contributed to a national dialogue related to compensation, effectiveness and organizational benefit. How does the chaplain's ministry contribute to the mission of the organization? What are the deliverables?
The groundwork for analysis of a chaplain's performance and accountability was laid in 2003 when major certifying groups in North America formed a task force for the purpose of defining uniform certification standards. Although each association already had its own well-established set of standards and a process for certification, the work of the task force resulted in the Common Standards for Professional Chaplains for North America.1 Approved in 2004 by the six major pastoral care organizations that comprise the Spiritual Care Collaborative,2 these standards recognize the chaplain's role beyond the "bedside" — that is, their role as organizational leaders — and identify the competencies essential to that role.
The National Association of Catholic Chaplains then added to the common standards some specific standards that reflect Catholic identity and practice. In 2007, the United States Conference of Catholic Bishops' Commission on Certification and Accreditation approved the common standards with those additions.
The common standards require a board-certified chaplain (signified by BCC)3 to engage in extensive training and preparation, including graduate theological education and a year's clinical training, normally 1,600 hours of Clinical Pastoral Education. (Seventy-four percent of the members of the National Association of Catholic Chaplains who are currently functioning as chaplains have received board certification from the association.)
As a next step in professionalizing a chaplain's role, more than 50 representatives of Catholic health care systems, joined by other professionals associated with the spiritual care ministry, participated in the Pastoral Care Summit in Omaha, Neb., in 2007. The Catholic Health Association and the National Association of Catholic Chaplains were co-sponsors of the summit.
The following questions were among those raised by participants. Specifically, what does a board-certified chaplain do? If the pastoral care department of a hospital consists of certified chaplains, what should the organization expect? What does pastoral care contribute to the mission of Catholic health care? How does a health care leader determine whether a chaplain's work is done well? How should priorities be established? What productivity measures might be put in place? How can quality be measured? Are there ways to describe how chaplaincy services might be improved?
To begin addressing these questions, summit participants established four task forces.4
For the task force focusing on care services and staff development, the first step was to identify essential responsibilities and functions of a board-certified chaplain. The goal was to emulate the American Nurses Association's basic standards of nursing practice. In the task force report, the functions are distinct from, yet build upon and assume, standards for certification required by the National Association of Catholic Chaplains. Specific attention was paid to the chaplain's role as an organizational leader and his or her ability to facilitate ministry consistent with values of Catholic health care. An initial draft of the functions listed in the report was sent to vice presidents for mission integration and directors of pastoral care within and beyond Catholic health care to seek feedback and advice. The task force then revised its report based on their suggestions.
The hope of the task force is that the delineation of functions offers clear guidelines for organizational, mission and pastoral care leaders responsible for the delivery of spiritual care by a certified chaplain. In addition, the listing of core responsibilities establishes a foundation for identifying subjects/competencies for ongoing education and professional development.
These functions of a certified chaplain, which establish a national standard for high quality spiritual care, follow:
1. Provide leadership and education that shapes and supports the culture of spirituality, mission and values of the organization.
Chaplains serve on institutional committees, participate in significant initiatives and quality improvement activities, as well as educate colleagues on a range of topics related to mission and spirituality. They partner closely with the mission leaders to model and articulate core spiritual and human values for the organization. Their ministry directly and tangibly embodies Catholic health care's healing ministry of Christ.
2. Collaborate within his or her department and organizational setting, aligning spiritual care goals and organizational goals.
Chaplains ensure that their departmental goals are coherent with the institution's goals and complement and contribute to the fulfillment of the organization's strategic direction. Their knowledge of spiritual, religious and existential aspects of health care, as well as their relational skills, is invaluable in aligning spiritual and organizational initiatives. Chaplains demonstrate commitment to organizational goals through participation in activities that further those goals.
3. Advocate within their organizations and the communities they serve for justice, human dignity, stewardship of resources, quality, excellence and safety.
Chaplains promote the dignity of patients, families and associates through their ministry and model mission-driven behavior and patient-centered care. They also advocate for those entrusted to their care as they strive to support the goals, wishes and wholeness of those persons. They are in the process of developing, testing and implementing tools to benchmark their services in ways consonant with other professions in order to ensure that the care they deliver is safe, quality care.
4. Design, implement and assess a variety of programs across the continuum of care that address diverse religious, cultural and spiritual needs of clients and staff.
Chaplains possess knowledge and demonstrate understanding of diverse religions, cultures and spiritualities. They discern and address the religious, cultural and spiritual needs of each unique person and develop and implement practices and programs that are responsive to the needs of individuals and groups. In addition, chaplains provide education to staff to assist them in incorporating a variety of needs into care planning. This work supports compliance with Joint Commission standard RI.2.10 which states, "Each patient has a right to have his or her cultural, psychological, spiritual and personal values, beliefs and preferences respected." The commission accredits and certifies 16,000 health care organizations and programs across the nation.
5. Provide effective spiritual care as part of an interdisciplinary team that contributes to the well-being of staff, patients/clients and their families.
Chaplains assess the spiritual and emotional needs of the patient and family, initiate interventions and provide resources to address identified needs. This includes consideration of relevant biomedical factors and their potential impact on the individual's or the family's present and future. Through this ministry, chaplains enhance coping mechanisms not only for the patient, but also for the family. The chaplain also forms effective team relationships while serving as a resource to support and promote the well-being of co-workers across disciplines. Given chaplains' skills and availability in the clinical arena, team members rely on them to be a source of support, to process issues related to meaning and purpose of complex events, and to debrief sometimes troubling situations. As a result, the ministry of chaplains contributes to staff satisfaction and retention.
6. Document a spiritual assessment, intervention and plan of care. Chaplains are trained to develop, communicate and document an effective care plan.
Care plans are collaborative efforts that are understandable and accessible to interdisciplinary colleagues and promote continuity of care. Chaplains provide leadership in facilitating a cohesive team response to emotional and spiritual needs, which contributes to healing.
7. Promote the dignity of the human person through ethical decision-making and work within the institutional ethics process to meet the needs of a variety of settings.
Chaplains incorporate the principles of the Ethical and Religious Directives for Catholic Health Care Services in their ministry, and they have developed expertise in addressing suffering and in guiding "peace work" at the end of life. Patients, families and caregivers often approach chaplains seeking clarification as to the ethical and religious implications of potential treatment choices. Chaplains explore questions related to spiritual and religious values and/or the impact of a particular decision on quality of life. They often refer concerns to ethicists or to ethics committees, on which chaplains frequently serve.
8. Create and facilitate rituals for individuals or groups and to serve organizational needs.
Chaplains provide relevant rituals appropriate to diverse religions and cultures for individuals and groups. These include religious services to mark significant events in the life of a patient and family, such as removal of a ventilator in a terminal illness. They offer public worship for religious holy days. They commission new leaders and bless new or renovated spaces, as well as conduct memorial services for patients who have died. Chaplains also lead prayer and retreats and offer blessing services for staff. These professionals aid every person and group connected with the health care entity to mark, reverence and celebrate the mystery of life and death.
9. Facilitate patient/clinic groups to provide support during life/health crises and empower individuals/families and staff to utilize resources for healing.
On a daily basis, chaplains encounter diverse situations among patients and families that have the potential to change life as an individual (or a family) has known it. Chaplains identify sources of strength and viable resources that enable an individual or group to face the future with courage and hope. Chaplains often address patients' care-related complaints and concerns (i.e. engage in service recovery) and serve as front-line risk managers who are prepared to mediate volatile and sensitive conversations and crises, alleviating fears and diffusing emotions. Such timely and appropriate intervention can quell a crisis, facilitate cost avoidance, and defuse potentially litigious situations.
Naming what chaplains do at the bedside and claiming their role as collaborative organizational leaders committed to quality patient-centered care have previously been elusive challenges. This statement of functions and responsibilities, applicable across the spectrum of health care settings, provides for the first time a clear articulation of what a chaplain does in accessible and understandable language.
Task force members hope this work will contribute to a national dialogue to promote the profession of chaplaincy and the vital ministry chaplains provide to patients, families, staff and Catholic health care as a whole.
- Prior to development of the common standards, each of the certifying organizations had its own standards, primarily focusing on competencies for bedside care and addressing specific denominational needs. Development of the common standards involved setting the standards of each certifying organization side by side, putting denominational particularities aside, and selecting those competencies that are essential to chaplaincy. Substantial material regarding the role of chaplains as organizational leaders with professional accountability was added. As a result, the common standards are considerably different from the standards previously set by the individual organizations.
- The Spiritual Care Collaborative is an international group of professional organizations actively collaborating to advance excellence in professional pastoral and spiritual care, counseling, education and research. The organizations that make up the collaborative are: the Association of Professional Chaplains; National Association of Catholic Chaplains; the National Association of Jewish Chaplains; the Association for Clinical Pastoral Education; the American Association of Pastoral Counselors; and the Canadian Association for Pastoral Practice and Education. More information is available at www.spiritualcarecollaborative.org.
- Spiritual Care Collaborative participants, including the National Association of Catholic Chaplains and the Association of Professional Chaplains, have adopted credentialing processes based on the Common Standards and leading to the designation "board-certified chaplain," or BCC. (Prior to 2004, each of the associations had its own process for certifying chaplains.) In the case of chaplains certified by the National Association of Catholic Chaplains, the process works as follows: Each chaplain, as the final step for certification, meets with an interview team of carefully selected and trained certified chaplains or CPE supervisors who review and assess with the applicant evidence of having met the standards for certification. The interview team makes a recommendation to the association's certification commission, which makes its determination by a vote. Certification is conferred in the name of the association's board of directors. The certificate reads as follows: "Upon recommendation of its Certification Commission the National Association of Catholic Chaplains according to NACC Standards and Procedures approved by the United States Conference of Catholic Bishops Commission on Certification and Accreditation confers upon (name) certification as (chaplain or CPE supervisor)."
- The task forces are working in the following areas: measurement; recruitment; education and credentialing; care services; and staff development. Pastoral care professionals and health care leaders serving on the care services and staff development task force are: Linda Arnold, Ph.D., BCC, director of spiritual care, Holy Cross Hospital, Silver Spring, Md. (Trinity Health Systems); Sally Carlson, M.Div., BCC, manager, pastoral care, Alegent Health Immanuel Medical Center, Omaha, Neb. (Catholic Health Initiatives and Immanuel Health Systems); Nancy Cook, M.Div., MSW, BCC, manager of spiritual care, Mercy General Hospital, Sacramento, Calif. (Catholic Healthcare West); David Lichter, D.Min., executive director, National Association of Catholic Chaplains, Milwaukee; Teresa Lynch, M.A., board certified chaplain, Presbyterian Health System, Albuquerque, N.M.; Mary Lou O'Gorman, M.Div., BCC, director of pastoral care, Saint Thomas Hospital, Nashville, Tenn. (Ascension Health); Michele LeDoux Sakurai, D.Min., BCC, director of mission, Saint Alphonsus Regional Medical Center, Boise, Idaho (Mission Fellow, Trinity Health Systems); Edward Smink, Ph.D., ABD, BCC, vice president, mission integration and compliance, CHRISTUS Dubuis Health System, Houston; Jane W. Smith, D.Min., BCC, director, mission effectiveness, Fulton (Mo.) State Hospital.
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