BY: DAVID LEWELLEN
Illustration by: Curtis Parker
Years ago, Bonnie Burnett was doing spiritual care rounds at a hospital in Indiana when she was called to a very ill patient whose family gathered around the bedside. As a chaplain, the family asked, could she administer last rites to their mother?
Well … Burnett is not a priest, and the family was not Catholic and it wasn't the time or place to explain what "last rites" meant. But they had seen last rites on TV, they knew their mother was dying and they needed some kind of spiritual acknowledgment of the moment. Burnett suggested they conduct a prayer ritual. The family gathered around the bed and put their hands on the dying woman as Burnett prayed for peace for the patient and her loved ones. The family was satisfied and grateful for the opportunity to say goodbye.
As the unchurching of America continues, such encounters may become more and more common. People in moments of crisis feel the need to recognize their spiritual side, but they may not have a faith tradition or a clergyperson to call upon. Responding to such needs would seem to represent an important opportunity for a trained, professional chaplain — but the definition of "chaplain" remains murky, and, in an era of tight budgets, spiritual care providers struggle to explain the value of what they do.
Chaplains and their professional associations have worked hard to build a profession and an identity in the past half-century or so, particularly in health care. As the business of health care has changed, providers of spiritual care have worked to keep up in areas such as electronic records and outpatient ministry.
Chaplains strive to take a recognized place on the interdisciplinary health care team. They collaborate more, chart more and take on more responsibilities, but "the bigger change is who chaplains are working with" in terms of providing spiritual services, said Wendy Cadge, a professor of sociology at Brandeis University in Waltham, Massachusetts. Cadge specializes in studying chaplaincy.
SPIRITUAL GUIDANCE AND COMFORT
Whether in a hospital, military, fire department, college, or some other setting, people frequently ask for a chaplain to offer spiritual guidance or comfort during difficult times, especially when they have no regular relationship with a faith community — as in the example of the family that turned to Burnett for a prayerful ritual to acknowledge their mother's approaching death.
Any conversation about chaplaincy suffers from a central difficulty: There is no generally accepted definition of who a professional chaplain is and what he or she does. A chaplain may tend to follow a typical educational path and even become "certified," but the title "chaplain" is available to anyone who wants to appropriate it.
What to do about that? "There are a lot of options, and no one likes any of them," Cadge said.
At present, Cadge said, only three institutions in the United States require chaplains to be on staff — the military, federal prisons and Department of Veterans Affairs hospitals. But even those three federal institutions have very different standards and requirements for chaplains. And, Cadge pointed out, the world of chaplaincy is fragmented into separate associations and certifying bodies.
As some professional chaplaincy organizations differ on the qualifications necessary for a chaplain, "the job has become more complex," said Alan Bowman, vice president of mission integration at Trinity Health in Livonia, Michigan. "It should require more ongoing learning, not less."
Bowman got an MBA after his spiritual care studies were complete, "so I could understand the language of finance and accounting and the larger leadership role," he said. Chaplains who get promoted to administrative roles may give their departments a chance at more money or respect. But although many chaplains may be interested in leadership roles, administration doesn't offer the same kind of affirmative feedback that comes with helping patients and their family members.
Within hospital walls, the greatest change in recent decades has been integration of chaplains into the health care team.
"There's a greater partnership between spiritual care and mission," Bowman said. "We have not always viewed ourselves as partners in mission."
But as more patient care moves outside acute care institutions, spiritual care is trying to figure out how to keep up. Distance consulting is one possibility, as chaplains experiment with offering spiritual support by Skype or FaceTime technology.
ROLES AND PRIORITIES
Mary Lou O'Gorman, who retired as executive director of spiritual care for St. Thomas Health in Nashville, said that in bygone decades, chaplains did not chart — but that norm has changed. With smaller staffs, "we didn't used to have to prioritize. Now we do," she said. "How do you spend your time when there are fewer of you? Do you go to every death, or every code? Those were really hard questions, and we struggled with them."
Palliative care, which is both a growing field and a field into which spiritual care is better integrated than almost anywhere else in the health care ministry, represents an important role for chaplains. Prevention and wellness might be another field that chaplains can move into.
"We have the skills to do that work," O'Gorman said, such as facilitating grief support groups and senior support groups, or offering support to patients being discharged. "The future is in developing these collaborative partnerships."
Because the chaplains are integrated into the care teams, referrals from staff take up all her chaplains' time, according to the Rev. Amy Greene, a clinical pastoral education supervisor at the Cleveland Clinic and the board chair of ACPE, the association of supervisors who train aspiring chaplains. Having the chaplain collaborating with the others on a patient's team — rather than working solo and walking up and down halls, knocking on patients' doors in case anyone needed spiritual assistance — is "a testament to the visibility and quality of our care," she said.
The staffing of a spiritual care department, or the respect accorded to it, does not correlate with whether a hospital is secular or affiliated with a particular faith. Without pre-existing agendas or requirements, the Cleveland Clinic was more free to "reinvent what spiritual care should look like in the 21st century," Greene said.
Karen Pugliese, a chaplain at Central DuPage Hospital in Illinois, said she, too, has been free to identify needs and start new initiatives, and she even gets calls to bless new hospital units.
"It's not religious, but it's spiritual," she said. "When stuff happens, they think of us."
In her experience, hospital chaplains haven't always enjoyed that kind of recognition. At a Catholic health system where she worked more than 30 years ago, Pugliese recalled, the mission department didn't always understand what the spiritual care department could offer, and both departments struggled over who should be in charge of ritual.
To be sure, roles still aren't always clear cut. Being integrated into the care team also sometimes means dividing responsibility between the chaplain and the social worker.
"That has a lot to do with the personality and skills of both," Pugliese said, as well as with the individual patient and family. Her system recently hired more social workers, "and they like to do the grief and bereavement work that used to be ours entirely. My concern is that we don't get pushed back into ‘the chaplain is the one who baptizes or blesses.'"
DEFINITIONS OF SPIRITUAL CARE
Whoever undertakes it, is the practice of providing spiritual care growing or shrinking in health systems?
"No one knows empirically," Cadge said, "because there's no longitudinal data."
For accreditation from the Joint Commission, hospitals are required to offer spiritual care, but the commission asks only a single question about such services — namely, are they offered, Cadge said. That means "if you have a volunteer chaplain or a 10-person department, the answer is going to be yes," she said.
The yes answers to that very broad query consistently have shown that about two-thirds of U.S. hospitals offer spiritual care, she said. However, the Joint Commission does not define what it means by the term.
So, a hospital's spiritual care could be "Father Joe down the road," as Greene put it, or it could be a visit from a well-meaning volunteer who has received little training. And in any case, Greene said, "the Joint Commission has bigger fish to fry."
In Greene's 10 years at the Cleveland Clinic, the pastoral care staff has expanded dramatically. "We've been educating people about what professional chaplaincy can be and what it's supposed to do," Greene said. "The Cleveland Clinic's mantra is to offer world-class care, and we would go around saying, ‘This isn't world-class care.' Having Father Joe from down the road pop in doesn't constitute spiritual care."
But most chaplains say that their departments are shrinking. Burnett, who had the "last rites" encounter with the nonreligious family, draws a comparison between chaplain downsizing and the ongoing shortage of priests and men and women religious in the Catholic Church. As the numbers of vowed and ordained staff within the parishes shrink, laypeople have stepped into the gap, and she wonders if something similar will happen in hospitals.
"We've had to really grow and change. If you're the only one left in the organization, you could run yourself ragged," she said.
Using a parish analogy, Burnett said, chaplains' work can be extended to other hospital staff. In a religiously affiliated hospital, "everyone who puts on a badge at the beginning of the day has a charge to build the kingdom of God." The role of the professional chaplain, she said, might be to encourage others to reach out.
That said, opinions differ sharply about hospitals using spiritual care volunteers.
"There's no guarantee we're done losing people," said Burnett, who retired as senior vice president of mission integration for CHI Health in Nebraska. "We're forced to look at newer models." If a volunteer staff can provide screening and call in the professional for a patient's severe spiritual distress, "has God put you there for that purpose?"
Bowman thinks back to previous generations, when sisters held almost every role at a Catholic hospital, and many hospitals also had a live-in priest. That kind of presence served as a daily reminder, formal or informal, of the organization's mission of offering spiritual care.
But that mission cannot be taken for granted anymore. Greene began her career in a Baptist hospital in Atlanta, where "if a doctor walked in, they'd say, ‘Pardon me, Chaplain, I'll be back.'" Though it was respectful of her work, that environment "didn't teach me anything about explaining to the secular world. We cannot afford to be falsely humble. We have to tell others who we are and what we do, and be more aggressive about it," she said.
Greene sees an opportunity for chaplains to conduct advance directive conversations, which are now reimbursable if a doctor does them. Perhaps they could be reimbursable if a chaplain does them under oversight, as well, she suggests.
"We have to claim our real expertise in knowing how to talk about really difficult stuff," Greene said. "We have the ability to have those conversations, and it's billable now. Social workers can't do what we do. Nurses with a handy pocket guide can't do what we do."
"There's also vicious budget competition," said Mary Martha Thiel, a CPE supervisor at Hebrew Senior Life in Boston, "and chaplains are very bad at competition. The literature justifying what we do is in the early stages."
Thiel specifically addresses spiritual care of the nonreligious in her courses. "Human beings have the same spiritual needs, whether they are affiliated or not, whether they use religious or secular language. The chaplain's role is the same," she said.
Hospital administrators read the surveys that show the growth of "nones" as a religious category, "but it's not like spiritual issues are going to go away. Illness is still experienced as a spiritual onslaught," she added.
However, "chaplaincy groups do not speak with a unified voice. Not all certifications are equal, and that confuses things for administrators," Thiel said.
That lack of a unified voice is a problem, she explained. Though chaplains can offer healing to people of any background, they "feel insecure in the face of the medical hierarchy in hospitals," who may not even acknowledge that patients have spiritual needs.
"The old entitlement is gone, and that's probably OK," Greene said. "Now it's the days of market savvy and metrics. But we can save hospitals money. If we're doing it right, we're very cost-effective."
DAVID LEWELLEN is a freelance writer in Glendale, Wisconsin, and editor of Vision, the newsletter of the National Association of Catholic Chaplains.