Tuesday, June 09, 2009

Dear Terri

Commenting on my post about the lack of chaplains on Nurse Jackie, Terri said:
Well, maybe if there were more on TV, people would insist on them in the hospital! And, I haven't jumped into this one because I really don't want to hurt your feelings, but I am training to be a professional chaplain--I do think there is a place for theological and clinical training in the work--so I don't look with optimism at models that have all the care done by volunteers with a "staff chaplain" who serves mainly as a scheduler. In your hospital, which staff are designated requestors for organ and tissue donation? Which staff assist patients with advance directives? Mortuary selection? This varies but in the system where I work chaplains are expected to do these things, also coordinate with Red Cross, military, prisons for compassionate leaves or phone calls. Chaplains also serve on the ethics board etc. Some volunteers can certainly do some of these things, but in all honesty work that is done largely by volunteers tends to become work that is seen as "less valuable" systemically, so while I do not devalue the work that you do, I do worry about the future of chaplaincy at a time when it has never been needed more.
This raises points that I think deserve their own post, so here goes.

First of all, I agree with you in being nervous about "models that have all the care done by volunteers with a 'staff chaplain' who serves mainly as a scheduler." I don't advocate such models, and this isn't how things work where I volunteer. At my hospital, the Spiritual Care Department consists of five staff chaplains, four of whom are also clergy. A half-time office employee schedules the several dozen volunteer chaplains; that's not done by actual chaplaincy staff.

Several times I've obtained advance-directive paperwork for patients, and once I helped an ER patient who'd already filled out the paperwork find someone to witness the document. I've never talked anyone through the various options, although I could if I had to. Nor have I been involved in tissue/organ donation issues, although I know those scenarios have occurred in our ER. I was working once when the Red Cross came in: the RN case manager had called them. As for mortuary selection, we have a pamphlet we give families, although many have already made their own arrangements. Again, the RN case manager or social worker usually help out with all of that, as well as notifying coroners.

I don't serve on the ethics board. I don't know any volunteers who do. I'm sure at least one of our staff chaplains does.

I don't dispute the value of professional chaplains any more than you dispute the value of volunteers. I do find it significant, though, that your examples involve the very worst situations: death. My struggle as a volunteer chaplain has been to teach medical staff that chaplains do much more than minister to the dead, dying and bereaved, that our role is to be a compassionate, non-anxious presence in any situation requiring one.

At your hospital, who comforts the anxious mom who's brought her sick firstborn to the ER when the nurses are too busy to spend much time with her, and when -- since nobody's died -- no one would think to call a staff chaplain? At my hospital, I do that, and so do other volunteers. We also deal with death, dying and grief, and we're instructed to respond to all codes in other parts of the hospital, just in case a staff chaplain isn't there. I'm frequently the only chaplain at a code, but that may be because of the hours I work. Staff chaplains and community clergy are always on call in case something comes up that a volunteer can't handle, but this usually takes the form of, "I want a priest," and several times when patients have requested priests and one hasn't shown up, I've visited instead, and usually been warmly welcomed and appreciated.

The compassionate-presence piece, though, is most of what I do. In the ER, it's rarely a choice between the patient seeing me or seeing a staff chaplain: it's a choice between their seeing me or not seeing anybody. Because I'm dedicated to this one department (except in rare cases when I'm asked to go elsewhere), I can deal with issues that are crises for the patients but that the medical staff wouldn't see as such, which means -- among other things -- that certain anxieties and resentments are defused before they have the chance to become crises for our overworked medical staff.

As far as I know, no one sees my work as "less valuable" because I'm a volunteer. The ER staff have repeatedly requested more volunteer chaplains to be scheduled there. Nurses and case managers are often visibly happy when I arrive. I think it's also significant that they very clearly think of what I do as work. "Oh, hi, Susan: how late are you working today?" A few weeks ago my husband and I went to a concert and ran into an ER nurse I know; when I introduced her to Gary, she said, "I work with your wife," not, "Your sweet little wife helps us out a few hours a week even though she's clueless and underqualified." (She wouldn't have said anything like that anyway, because she's polite, but can you hear the tone difference between the two approaches?) Shortly after that, I went in for an evening shift, something I haven't done in over a year, and a nurse I haven't seen in that long gave me a hug and said, "I saw you before and thought, 'Oh, good, she's still working for us!'"

Mind you, I think certain ER staff find me annoying, but so do people in the rest of the world. That's a personality issue, not a functional one, and being slightly abrasive sometimes makes me more effective; I'm willing to get into people's faces when I have to. As a volunteer, I think I have more immunity to do this without disrupting institutional hierarchies. When I called a homeless shelter after hours to get a bed for a patient -- something the staff had sworn would be impossible -- the case manager thanked me, even though he was one of the people who'd said "We can't do anything after hours" (and who, since then, has studiously ignored my gentle reminders that this shelter will always accept referrals from hospitals or social-service agencies).

I see myself as part of the ER team; at least some of them, I think, see me the same way. But I'm not about to put staff chaplains out of business, at my hospital or anywhere else. First of all, the arrangement at my hospital, as far as I can tell, is very unusual: most places seem to be moving toward using only professional, board-certified chaplains. I don't think you need to worry about the future of chaplaincy, except inasmuch as the increasingly stringent qualifications to do the work will raise the bar too high for people who'd be very good at the work.

I do think (and I've said this here before) that all of us need to consider the patients' perception of whomever's arrived at the bedside. When professional chaplains hear the phrase "volunteer chaplain," many of them hear, "someone who isn't qualified enough to be paid." When patients hear the phrase "volunteer chaplain," they hear, "someone who's come to be with me in my pain and fear even though she's not being paid." Volunteers are walking manifestations of grace, in the sense of free unearned gift. I can't count how many patients have said to me, "What you do is so wonderful! I'd like to do something like that someday." Maybe professional chaplains get the same response; I wouldn't know.

Alice Walker, in my favorite of her poems, says something along the lines of "Perhaps our revolution will be to value what is abundant as much as what is scarce." Volunteers are avatars of abundant compassion, rather than the scarcity of stringent professional training. The professionalization of compassion dismays me.

All that said, I know I'm going to have to do CPE sometime, because I can't work anywhere except my own hospital without it. I won't have the time, energy or money for that until I retire, though -- another ten years at the soonest -- and many people never have those resources. This isn't a tragedy; there are plenty of other places for all of us to spread our abundant compassion. Wouldn't it be nice, though, if hospital patients were graced with more of that particular resource?


  1. What a wonderful post. I saw a patient today who is in hospital waiting for tests to confirm or rule out a scary diagnosis. She was obviously distraught, and in my hurry to do all the little jobs on the ward that needed doing, I didn't have time to talk her through her anxiety. Would that we had someone like you to call.

  2. Susan, you know how I feel on this subject. I responded to terri at the earlier post.

    But then, what do I know? I"m just a simple country preacher....

  3. Anonymous7:34 PM

    I have a lot of health issues and have consequently spent more than my fair share of time at local hospitals. To the extent that I have a choice of which hospital to go to, I always choose the hospital with a religious affiliation in part because it seems to have a larger than usual chaplaincy staff.

    I've received visits from several chaplains there, ranging from a knock on the door, asking how I was doing, to asking a nurse for prayer, which she offered, then asked if I would like to speak to a chaplain. These visits have always helped ground me, and I have never even thought to ask the status of the chaplains who visited. It just wasn't relevant to my immediate needs at the time.

    Obviously, I wasn't dying at any of these points (I'm still here at least!) but having someone to, as Beach Bum said, talk me through my anxiety probably helped speed my recovery as much as most of what the doctors did.

    Chaplains rock!

  4. Thanks, everyone. And Anon, I'm glad you've had such good experiences with chaplains! That speaks well for the changes in the profession (since I've heard horror stories from back in the day).

  5. Well, crap, I had a lovely long comment and my computer ate it. Susan, why ever would you think that professional chaplains don't receive appreciation for our work? Do you think that, because we are paid, this is "just a job?" and is given no heart? This is what I hate about the discourse--it ends up being, Well VOLUNTEERS are BETTER because... and Well PROFESSIONALS are BETTER because... and all I am saying is, there is a place for theologically trained spiritual caregivers. Health care systems would not dream of staffing their accounting departments with volunteers to save money, yet routinely they consider staffing the spiritual care department in that way. And, who knows? there are probably people in the community who have gifts for accounting who could do as good a job as some of the trained, paid accountants. I know you have compassion, Susan--and so do I, and I have to say that my studies, etc., have made me a better chaplain, not a less caring one. I will grant you, of course, that not all paid chaplains are walking manifestations of grace, but please grant me that not all volunteer chaplains are, either. I think back to the early days of the AIDS epidemic when the hospice in my area that saw the most AIDS patients had to decline the services of any number of "volunteer chaplains" who came solely to lecture AIDS patients about the evils of their lives. It's really not that simple--it's not that everyone on one side is good and everyone on the other is bad.

  6. Hi, Terri. I certainly didn't mean to say or imply that it's that simple! I've seen good and bad volunteer chaplains and good and bad professional ones (and yes, bible-thumpers are the scourge of the volunteer ranks; volunteer training in my hospital includes very stern warnings against that behavior). And I certainly know that professional chaplains are compassionate.

    I do think, though, that for many patients, being visited by someone who's more like a peer than like a paid expert is in itself a big comfort. Hospitals are so full of rank and hierarchy: I think it's a relief for patients to be able to talk to someone who knows the institution but is also just a plain person. (Other patients, of course, want Clergy with a capital C, and don't want to have anything to do with laypeople, whether they're volunteer or paid.)

    And as for grace, I wasn't talking about personality. I was talking about the fact that volunteers, by definition, aren't there for money. In that sense, volunteers of any sort are manifestatios of a certain kind of theological grace, even if they're bumbling idiots. Not, mind you, that volunteers are completely selfless or have completely pure motives, because no one does. But many patients feel very cynical about healthcare (y'think?), and seeing volunteers in action can reassure them and make them feel better about the hospital.

    I can't tell you how many times a patient has begun beaming the minute I say I'm a volunteer. That word often seems to be the most powerful thing I bring to the encounter. Once I visited with a patient who'd spent years as a professional chaplain, who reminded me that Jesus was a volunteer, too.

    As for staffing fears: that's really the issue, I think. The worst invective I've heard against volunteer chaplains (not from you!) clearly comes from people who are scared that their jobs are being threatened, a completely understandable and human reaction. In that sense, volunteers arouse the ire of some professionals not because volunteers aren't good at what they do, but because they are, or are perceived to be by other people in the hospital. If we were truly as useless as all that, nobody would be wasting time and energy on the debate.

    As I said before, though, I'm not threatening anybody's job. To use Marshall's term, I'm a "chaplain-extender," and the staff chaplains at my hospital appreciate that. A lot. So do the patients and the medical staff. It's a win-win situation.


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