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Getting to One Voice in Professional Health Care Chaplaincy

After my recent talk at HCCN’s Caring for the Human Spirit Conference in Orlando, one of the questioners raised the issue of the long-time and oft-acrimonious splits within professional chaplaincy membership organizations.  The issue focused especially on the rift between the College of Pastoral Supervision and Psychotherapy (CPSP) on one side and the Association of Professional Chaplains (APC) and the Association for Clinical Pastoral Education(ACPE) on the other.  For those who may not be professional chaplains or who may be new to the profession, one of the great embarrassments in the profession (to me and many others) is our inability and/or unwillingness to have one organization that would speak for the profession- or even sometimes to get along among ourselves.

This questioner focused on the lack of reciprocal certification between CPSP and the other groups and within that, the lack of recognition by groups like APC of training by CPSP that would fulfill a requirement for certification. Currently those with only CPSP training cannot apply for certification in the APC. This issue is likely the one that is most apparent and troubling to the respective memberships and those preparing to be certified as chaplains. 

While I had not thought a lot about this particular issue, it occurred to me that, rather than tinker with and try to reconcile the current systems of training and certification - which likely would just devolve into discussion about whose system is better - we should start over with the whole enterprise. Many of us have come to the conclusion in any case that the whole system of training and certification for health care chaplaincy is not reliably or demonstrably producing competent chaplains and needs a ground-up overhaul. And I say this as one of the people who led the effort that established Common Standards for Certification and as a former APC Certification Chair.  

Further, I would suggest an approach that (1) seems more appropriate to the current way professionals do things in health care and (2) would help us operate with a clear slate because none of us have done it this way before. I would suggest proceeding as follows:


  • The first premise is that everyone who wants to be at the table is welcome as long as they covenant to treat everyone else at the table with respect publicly and privately and agree that all past hurts and disagreements are past and not part of this process.
  • The second premise is that (1) the relevance of any and every part of a new system will be evaluated only on the extent to which it brings benefit to patients, their caregivers and the health care system and (2) the patients, their caregivers and the system would have a voice in defining what constitutes “benefit” for them. The corollary of this premise is that no consideration would be given to any proposal whose primary purpose is to serve or preserve particular groups of chaplains, particular faith communities, or particular membership associations.


The process would seem to need to proceed in the following steps:


  1. Building consensus around outcomes, with the process requiring the inclusion of patients, caregivers, members of other health disciplines, health care leaders, payers, and policy makers. What are the benefits that chaplains do or could provide? What beneficial outcomes can be anticipated in the near and long term future?
  2. What does our best evidence suggest are interventions that promote these desired outcomes?
  3. What competencies do chaplains need to deliver these interventions with maximum effectiveness?
  4. What are the components of a system that would most reliably, efficiently, and fairly evaluate whether a given chaplain has these competencies? The evaluation system is going to be critical because this proposal does not require any particular prior training or assume that any kind or amount of prior training produces competence. 


We have little or no evidence that the current system of training or certification of any of our associations produces chaplains who actually help people or support the deliver of good health care. We owe our patients and caregivers a better effort. 


The Problems and Opportunities of Change

I should state right up front that I’m not a person who does change all that well. My default position on almost anything is to stick with what I have, what I’m doing, or what I believe. Staying with the familiar is comfortable. Changing is stressful. Sometimes this characteristic works for me in that I always try to work out issues with where I am rather than change but often it keeps me from realizing and taking advantage of new opportunities and experiences that would enrich my life.

So it is I think with many businesses, organizations and professions. Despite all we know about how our world and society is changing at an increasing pace and that to prosper and even survive in the new world emerging around us calls for at least re-examining if not changing some basic assumptions about how we function professionally, we resist-often to our detriment and to the detriment of the people who benefit from what we do.

I have had only one career in my life- clergyman. And for almost all of that career I have done my work focused on one setting- the acute care hospital and how to minister to people who are sick and suffering. Health care chaplaincy and ministry in general is based on some assumptions that are so fundamental that they are often not even acknowledged or discussed- let alone disputed. Maybe the most basic is that, to be “successful” -which I will translate as being able to help people relieve pain and suffering- one must be in “relationship” with them.  Further, this “relationship” is assumed to be most effective or even only effective if it is face-to-face. It is assumed that to be “helpful’ we as chaplains need to be physically with the person to whom we are ministering. Anyone who wants to be certified as a chaplain must take clinical pastoral education (CPE) that focuses on teaching us how to satisfy this standard. To foster this goal, CPE has required that students be able to meet with a peer group face-to-face and meet in person with a supervisor.

To be clear, I do not want to argue that this model or the assumptions that drive it need to be abandoned. I know that the training I received and my ability to relate deeply to people has helped a lot of patients, caregivers and health care providers. However, it is increasingly clear that this model of training and assumptions about how chaplaincy care needs to be delivered are barriers to both raising the level of training for health care chaplains generally and to the deliver of spiritual care to many, many people in need. There are many people doing spiritual care who want to be trained but cannot do it because they live at a prohibitive distance from a training center, cannot take the time, or cannot afford the tuition.  There are many people who want the services of a chaplain who cannot access one because they are home bound, live in rural areas, or otherwise have no way to go to a chaplain.

But maybe most importantly, these assumptions about how chaplaincy training and how chaplaincy itself “must” be done have never been tested. Do we have any evidence that CPE done remotely with virtual groups would produce less effective chaplains than the current model? No. Do we have any evidence that patients and their caregivers would feel less supported and have their suffering less well addressed by a chaplain who communicated with them over the telephone or even by email or Skype than one who communicated with them in person? No. What we do know is that our long-held and sacred assumptions are keeping many people from receiving care for their spiritual and religious suffering.

All health care disciplines are currently struggling with the pros and cons of delivering care remotely. Chaplaincy is not special in that regard. Many of us went into health care because we want to be with people and relate to people. Delivering care or even being trained over the phone or by Skype simply may not be as fulfilling. However, it seems very evident to me that given the realities of health care in the US and, more importantly, given the fact that our assumptions are barriers to delivering spiritual care to many people, new models have to be tried. The time for remote or virtual CPE has come. The given reasons for not doing this have no evidence to support them. Likewise, the time has come for leveraging emerging technology to deliver spiritual care to many who need it and want it but who won’t receive it any other way. There is no evidence that these delivery systems will produce results inferior to the current model.

Finally, this is all not about us- the chaplains. It is about what best serves those in need. What will be effective in the end? I have no idea. I do know we owe it to those in need of spiritual care to try new methods and models. 


But Who’s Attending to Spiritual Suffering?

The NY Times published a very interesting piece on February 17th  entitled Doctors Strive to Do Less Harm by Inattentive Care. It got my attention immediately because the first word of the article was “suffering” with a period after it.

As I have become more of a student of communication in general and communication in health care in particular, I have realized the truth of something I heard a long time ago that amounts to “you have to use the right word”. Euphemisms have their uses of course in situations where the most descriptive word can be harsh and even brutal. However, more often, the use of “kinder” words is a cover that allows us as health care providers to pretend we have communicated clearly when we have not and thereby to avoid the painful emotions and even whole topics that we would rather not deal with.  Many times in my career as a chaplain I have sat with families who have been told that their loved one “passed away” realizing that the family does not understand that their loved one is dead. 


This article points out correctly that we have long avoided in health care discussing suffering or even admitting that it exists. As the article describes, mention of suffering has often been actively discouraged if not prohibited. We much prefer to discuss pain. Pain is an expected part of health care. For many years during my career, it was accepted that pain just came along with certain conditions. Post-surgical pain, for instance, was long just something that you had to live through at least up to the point that it actively interfered with your surgical recovery. In some situations pain is even to be desired. “No pain, no gain” is the mantra in every gym I’ve ever been in. While we have largely moved on to an understanding that this kind of physical pain should just not be tolerated, recent stories in the news have reminded us that many still believe that physical pain at the end of life is often inevitable when it is not.

But suffering is another matter. While we now routinely discuss emotional pain and even, much less often, existential or spiritual pain, discussion of pain still mostly focuses on the physical. However, to discuss suffering as this article points out immediately opens up a whole array of suffering that, since we then know about it, we are obliged to deal with. Many of these sources are, like pain, areas that have long been assumed to be unavoidable in health care. Of course you need to wait, how else can we do it? Of course there is noise in the hospital in the middle of the night, how else can the staff take proper medical care of you? Of course you have to wait for your test results to come back and wait for your provider to call you even though you know that the result may confirm that you have cancer.

So I am thrilled that we finally seem to be reaching the day when these kinds of suffering will not only be acknowledged and spoken about but no longer accepted as an unavoidable consequence of being sick and in a hospital. There is growing appreciation and evidence for the idea that these kinds of suffering, not only affect patient satisfaction scores, but medical outcomes and medical costs as well.

But, as usual, at least one kind of suffering is missing here. That is spiritual or existential suffering (I don’t want to get hung up on the modifier). I think this avoidance arises for much the same reasons that other kinds of suffering have been ignored. We have very little understanding of what “spiritual suffering” looks like or even any sense of how to define it. We have a growing understanding that patients have “spiritual needs” and some growing sense that spiritual suffering as defined by the patient is common, but as yet no real appreciation for how much suffering those needs cause, and even less understanding of how or even if that suffering impacts health outcomes. And finally, even if we do start to describe spiritual suffering, we do not have much idea of how to treat it. Spiritual suffering is rarely assessed and patients generally assume we as health care providers do not want to even hear about it. Any attempts to help patients with spiritual suffering tend to be idiosyncratic to the individual provider and the outcome of even those is rarely documented.

The naming of suffering (using the word) is a great first step. The second may be naming and measuring all the sources of suffering even the ones that we may think are inevitable. The third step is at least working on the premise that no manner of suffering is inevitable and unavoidable. As I mentioned, there was a day in my career that a certain level of physical pain and even a certain level of emotional pain like depression and anxiety when one is sick were thought be unavoidable. We now know better. There are those like Gary Kaplan, CEO at Virginia Mason hospital, who does not accept that making a patient wait for a test is unavoidable.

There are many of us who suspect that spiritual suffering is not only common and has serious impact on quality of life but also can have a big impact on health outcomes and costs. Moreover, we suspect that ameliorating that suffering is not only possible but also straight forward and inexpensive.

So bravo to the authors of this piece in the Times and to those in health care who not only are now willing to acknowledge suffering but find ways to do something about it. It is now up to us who are concerned about spiritual suffering, particularly those of us who are professional chaplains, to keep raising the need to extent this new-found concern to the realm of the spiritual and continue to develop measures to assess for it and help reduce it.



Reflections on the For-Profit/Not-For-Profit Debate

The recent series of articles in the Washington Post on the relative strengths and weakness of for-profit (FP) vs. not-for-profit (NFP) hospice has produced a lot of emotional response and some insight. However, in many people’s opinion, the Post pieces have not been the most objective and have been biased toward presenting FP hospice in a negative light. As is usually the case, bias in a report does not lead to objectivity in the discussion. There are a couple of issues to my mind that have either not surfaced or not been given enough attention.

This is not a new issue in health care. Long term care in a number of states long suffered from unscrupulous operators who took advantage of their relatively defenseless “customers” to make a profit. It should be noted that some of these operators ran FP operations and some ran NFPs. This point is not to excuse those who may take advantage of the dying in the same way but just to point out that this is not something particular to hospice.

Demonizing for-profit health care is simplistic and unhelpful to the debate. There are clearly good and bad actors on both sides.  FPs who are mission driven (and there are many) often provide state of the art care as well as pay off investors. Successful companies in all fields are successful exactly because they both satisfy their customers and reward their investors.  There are many NFP hospitals now owned by FP companies that have not missed a beat in continuing to provide patient-centered care. Yes, NFPs can do fund raising but, put simplistically, fund raising and raising capital are just two different ways to raise cash. Neither one is inherently good or bad. Its what the cash goes for that counts.

Even though chaplaincy is unreimbursed and not clearly a revenue generator or cost saver, I know some for profit hospices which provide the most professional, best trained (and therefore most expensive) chaplaincy and I know some NFPs that provide the cheapest and substandard chaplaincy just so they comply with regulations.  

The big issue that I have heard peak its head up but not be seriously addressed is the issue of quality of care. The Washington Post has framed the debate by at least implying that the quantity of care is positively correlated with the quality of care. They strongly imply that spending less nursing time on a patient or not sending a nurse to visit over the last two days of life is substandard care just by virtue of it being less care. This claim invokes a classic US premise that More care is necessarily Better care. It is this premise that is at least partially responsible for the US spending so much on health care but having less than optimal results. We are starting to learn and palliative care is teaching how false this premise can be. Do we know that having a nurse visit in the last two days of life is “better” care? We don’t. Is this even what patients and families want and need? We don’t know. And maybe the “pain” is social or spiritual generating anxiety so maybe the visitor should be the chaplain or the social worker.  We don’t know that either.

I believe that a major reason why quality is not discussed is that quality measures are not used in much of US health care and often we do not even know what a quality measure would be in a given context. We are getting better and some recent findings indicate that less care can even lead to, not only better QOL but to longer life, but we have a long way to go.

The more is better premise is also common in chaplaincy. A lot of us still work on the basis that the more we visit a patient the better without any real evidence for (1) whether the patient even wants this and (2) whether we are accomplishing anything positive. We are nice people and patients like us but do we “help” and what does help mean in this context?

It is on the basis of agreed upon quality measures that hospices ought to be compared. The only question should be does the particular hospice deliver quality care (effective and efficient), not whether it is FP or NFP. We often claim we don’t have time for quality measures and even sometimes imply that we deserve to be trusted because we are good and honorable people in this for the right reasons.  But that is no longer good enough. Our patients deserve better no matter what our business model is.



The New Year for Health Care Chaplaincy

Recently, I’ve been asked in several settings to address the question of the future of health care chaplaincy. In each case, it was either implied or explicitly stated that the question arose from a real fear that professional health care chaplaincy was fundamentally endangered as a component of US health care. I frankly find it very odd when I’m asked the question in this way. Maybe the fact that I’ve worked in health care chaplaincy for close to 40 years gives me a longer view than others, but I’ve never been more optimistic about the future of professional chaplaincy than I am today, and I have never been known as a person who underestimates the downsides of situations.  

But what about all the places where chaplaincy budgets are being cut? And what about the chaplains who can’t find a job? Yes, certainly those exist but it is also true that the line of chaplains crossing the stage at the Association of Professional Chaplains convention to receive their certification grows longer every year. It is true that the business case for including professional chaplaincy grows stronger by the year. I recently did a paper on the state of the science in the efficacy of chaplaincy and had over 70 references. So it is no longer correct to say that there is no case for professional health care chaplaincy.

I am convinced that the road to further successful integration of chaplaincy care in health care in the US is a fairly straightforward one- at least in theory.  (1) It is very clear that palliative care is becoming, not only a fully integrated specialty in health care, but also a part of generalist education for all practitioners. It has now been shown to positively impact health care cost, patient satisfaction, quality of life, readmissions, and even length of life in some illnesses. (2) Every model and set of guidelines for palliative care in the US and internationally includes spiritual care as a required component and most of those include the professional chaplain as the spiritual care lead on the team. (3) As mentioned, the evidence case for the inclusion of spiritual care is quite solid and the case for chaplaincy is significant and growing rapidly. 

I am not suggesting that palliative care is the only path for integrating spiritual care in health care. However, it is one that is certainly going to yield positive results across almost every segment of health care in the US. It is where I am putting my time and energy going forward.

So why is chaplaincy not growing faster than it is and why are chaplaincy budgets cut in some places and chaplaincy positions eliminated?  First, let me be very clear that budget cutting and layoffs happens even to chaplains who have the best training and do all the right things in terms of integrating chaplaincy into their hospitals. Often these kinds of cuts happen in health care institutions whose leadership is still narrowly focused on budget cutting rather than pursuing a strategy in which keeping or even expanding non-revenue producing services like palliative care and chaplaincy can wind up saving more money than they cost. Those are also the institutions that are failing at a great rate.

That all said, as I talk to chaplains and hospital administrators, I often see chaplains having some of the same issues which repeatedly put their positions in jeopardy and often cost them their jobs.

A lack of understanding of the evidence or business case for professional chaplaincy so they can sell chaplaincy to their system. Many chaplains simply do not keep up on the literature in the field and many, unfortunately, still don’t understand that selling chaplaincy is essential to the preservation of spiritual care in their institutions.

A lack of appreciation for the necessity of structuring chaplaincy according to what the institution values rather than according to what the chaplains prefer to do or think is best.  I know many chaplaincy jobs that have been cut, not because the institution did not value spiritual care, but because the chaplains essentially refused to provide care that the institution valued. A common example of this mistake is holding on to the “we have to visit everyone” strategy when the hospital wants chaplaincy resources allocated more strategically- including having a dedicated chaplain for palliative care.  A related issue is some chaplain’s unwillingness to participate fully in institutional quality assurance or cost cutting programs that every other department is participating in.

The misunderstanding that completing four units of Clinical Pastoral Education and even being board certified fully qualifies a chaplain to function successfully in today’s health care environment. With a few exceptions, while CPE programs generally train chaplains to function well at the beside, very few train in a number of other areas essential today. Successful chaplaincy today requires the ability to function in an interdisciplinary environment, to communicate well with other disciplines both verbally and in writing, and to make documentable contributions to the carrying out of the institution’s mission and strategic plan.  All of this content and more should be taught in CPE and required in certification and that very does not often happen.

I am very enthusiastic about the future of professional chaplaincy’s role in health care. It is certainly more central and more accepted and understood than at any time during my career. I see more and more chaplaincy colleagues stepping up to practice chaplaincy in the ways our current health care system demands. I look forward to the time soon when the barriers above will be relics of the past and all patients will receive the spiritual care they deserve and need.