1. Challenges for chaplains in modern healthcare
I have beeninthe pastoral care realmsince 1990. I am definedasa chaplain.Istruggle withthe
definitionof true spirituality,mostlybecause there are somanythingssurroundingthe givingof pure
pastoral care that conflictwithmyabilitytogive itthe wayI wishI could. Employedchaplainsmust
operate withinthe confinesof the Institutionsexpectations.Theymustsupportthe hospital,physicians,
staff,familyandmostimportantly,the patient.
First,I am a championforthe patient.All thingsrelatedtohonesty,dignity,qualityof life andin
honoringa patients’wishesevenwhenIdon’tagree withthose wishes.
I findmynurse colleaguestobe amazingandkind-hearted,quietbrillianthumanbeings;peoplewhofor
the most part understoodyoungthattheyneededacareer;a wayto make a livingandbecause of their
personal drive,understoodthatsoonerwasbetterthanlater.Ittookme muchlongerto understand
whatcourse I wasdestinedto take.Ilivedina mouse maze forsome twelve yearstryingtofindmyway
out.
Some of the finestphysiciansare myprivilege toknow andassociate with.There are nosuperiority
issues;we workside byside toachieve acommongoal.As theycome to know whatpastoral care is all
about,we developamutual trust and deal withdifficultmedical conditionsthatpatientsandtheir
familiesface;doctorscaringforthe medical andchaplainscaringforthe soul.Sometimesourpaths
merge ina delicate dance byhelpingpatientsandfamiliestounderstandfutile treatmentsorwhenitis
time to move tocomfortcare. Theytrust me to discussadvance directivesindetail,eachexperience
beingone of teachingsothe patientcan make educateddecisions.
I became involvedinthe care of stillbornbabieswhenIwitnessedalackof trainingof staff to deal with
these complex emotional andlossissuesbutalsoincaringforthe tinybabiesthemselves.The major
issue surroundedkeepingabodydignifiedtogive parentstime tosayhellototheirchildbefore saying
goodbye.A standardof care beganto emerge amonghospitalstoraise the bar withrespecttothese
situations.Asismystandard (withthe help,trustandsupport of the Women’scenterdirectorsatmy
twohospitals) Idevelopedapremierprogramforsuchlossesbyeducationthrough RSTBereavement,
PLIDA and local funeral homes.Patientsstillgohome withbrokenhearts,butmostcommentthatthey
couldnot have walkedthroughthe experience withoutthe gentleguidance,experience,counselingand
emotional supportthatwasofferedbythe chaplain.
A fine priestbythe name of FatherHenry Piacatelli helpedtodevelopProfessional Pastoral Care training
inthe sixtiesandseventies.He presentedasgruff,especially duringthe nightatthe bedside of apatient,
but latercommentedthatwhenhe haddone hispriestlyduties,itwashispleasure tohandthe family
overto myself,andhe indicatedthattrust.Hiseffortsshouldhave snow balledintoathriving
community of spiritual caregiverscarryingonthe emotional supportprevalentinthe churchowned
hospitalsthroughoutthe country.

2. Unfortunatelyashiftoccurred.Hospitalsencounteredfinancial constraintsdue toregulationsand
insurance demands.The churchessoldoff the hospitalstocorporations.Whatusedtobe a concerted
efforttoprovide a full spectrum of patientcare thatincludedemotional andspiritual healing evolved
intostrictlymedical treatment. Some hospitalsthathadmanagerswhowere familiarwiththe needfor
spiritualityinhealingcontinuedthispractice anddevelopedthrivingpastoral care programs.These
evolvedintohighlyproficientclinical pastoral trainingprogramsthroughthisorganizationknownasthe
AssociationforClinical PastoralCare.A certificationmovementgrew intothe AssociationforPastoral
Care.
Today,chaplainsstruggle tomaintainpresence inhospitals. Hospitalsare requiredtoofferspiritual care
serviceshowevermaychoose tohave thiscare providedbynurses,physicians,social workers,
volunteersandsome providethe servicesof paidchaplains;the onlyonesqualifiedandtrainedforthat
purpose. CMSand Medicare require spiritual care tobe providedforhospice patients.Theystopshortof
givinganyprofessionalrequirementsforsuchcare and counseling. Hospiceswhoare untrainedinturn
hire untrainedclergy,returnedmissionariesorfamilytoserve the spiritual needsof theirflock.There
are often noprovisionstoprovide forthe diversespiritual andcultural concernspatientsface withinthe
wallsof hospitals either.
Nursingschools suchat the Universityof Utah have takenoverthe complex grief issuesencountered
whena lovedone dies.Social workstudentsvolunteertime toconductgrief support groups while
learningfromthe participants.Theyhave little experience withthe actual deathprocessandsometimes
horrificeventssurroundingdeathorinwalkingthe familiesthroughthiscrisis.Theirownexperiences
are whattheybringto the table.There isno invitationtochaplains,(whowalkthe familythroughthe
lossat the hospital) toparticipate infacilitatingthesegroupsandvalidatingthe lossexperience. Myself
and a handful of chaplainshave soughtprofessionaltrainingtoconductstructuredgrief supportgroups
throughthe AmericanCancerSocietyinSan Antonio,Texasknownas‘Life AfterLoss’. Manyof those
personsattendingthese groupshave alsobeenservedbyourchaplainsduringtheirhourof need.
ParticularlyinUtah,good andecumenical pastoral caregiversare the onesministeringquietlytoa
grievingwidow orfamily.Theirrole isoftenmisunderstoodbypractitioners,patientfamiliesand
administrators.Because chaplainsare considerednon-income producingdepartmentswithinthe
hospital, theirvalue remainsunrecognizedwhiletheyvirtuallycare forpatientsineveryincome-
producingdepartment.
The chaplainisoftenthe firstpersonto recognize ordetectanissue with the care of the patientand
solve the problemlongbeforedischarge. Theydevelopatrustingrelationshipwiththe familyinthe
EmergencyDepartmentandcarry that presence throughthe entire admission.Hospitalsthatactually
budgetforpastoral care servicesexpect24hour coverage everyday.Chaplainsare compensatedfairly
for that coverage butare oftenshortstaffedinan alreadystressful andemotional role.Noone physician
or nurse isrequiredtorespondtoeach crisis,deathor stillbirthinthe facilitysuchasthe chaplain.This
day andnightcoverage leadstoburn-outand highturnover.Notrainingcanprepare a professional
enoughforeverycrisisthatis encountered. Imaginesendinginanadvocate whohashad eighthoursto
a full weekendof trainingwhoisexpectedtohelpfamiliesthroughcrisis;yetthishappenhundredsof

3. timesinhospitalsandhospiceseveryday. Thishappensbecause the skillsof the chaplainare
unrecognizedandundervalued.
PublicPerception leadspeopletoassume thatchaplainsare volunteers. Due tothe religious
environmentinthe state of Utah and the fact that much of the publicisunfamiliarwiththe following
terms;chaplain,pastoral caregiverand spiritual caregiver,peopleassume chaplainsmustnotbe of their
faithalthoughmanyare.Those whoare opento the servicesof the chaplainare pleasantlysurprisedat
the amountof support,advocacyand compassionthe chaplainprovides.Educatingthe publicisan
ongoingprocessof acceptance throughexperience. Trainedchaplainsbecome expertsatthe spiritual
needsof personsfrommultiplefaithsandcultures.Theyare taughttocare for everyone regardlessof
theirfaithpreferences.Untrainedspiritual caregiversfall seriouslyshortof sucheducationandlower
the standard of expectations inspiritual care.Thiscreatesalack of trust and leadstoseriousmistakes
withvulnerablepatientsandtheirfamilies.
The complex issuesencounteredbyachaplaininthe hospital couldneverbe professionallyand
efficientlyhandledbysomeone withnomedical terminology orpastoral training.Professionalchaplains
are educatedatthe Master’s level andbeyondwithanadditional internshipof 1600 hoursinClinical
Pastoral Education.Noone personshouldrefertothemselvesasa chaplainwithoutthe professional
trainingrequired.Thisleadstoa lessthanprofessionalopinionof chaplainswhensomeone withno
professionaltrainingtakesthistitle.The misconceptionbegsme toaskthe question;“Whendidyou
hearof a volunteersocial worker?”Chaplainsmustbe responsible toafaithgroupbut are educatedto
be ecumenical andserve all faithsof personswithinthe hospital. If theyoffersuperiorpastoral care,
theycan supporta patientor familywithoutreligiousaffiliationbecomingabarriertospiritual support.
The future of pastoral care serviceswithinthe healthcare facilitiesisfragile,asbudgetaryconstraints
continue toforce hospitalstocut costs.The coststo the lossof spiritual supportare significant.A recent
surveymentionsthat 69% of patientsdesire spiritual supportwhile inthe hospital.Sadly,one chaplainis
typicallyassignedtoupto two hundredpatients,anumberthat is fourtimesthe recommendednumber
suggestedbythe Associationof Pastoral Care.Thismeansthatunlesspatientsrequestachaplain
specifically,the oddsare againstreceivingavisitduringtheirstay.Chaplainsmusttriage theirdaywith
the most urgentcasestakingpriority.The average chaplainmayonlysee tenpatientseachdayif there
are no ongoingcrisesordeaths.A chaplaincan expecttentotwentyfourdeathsinmonths’time andan
average of three to fourstillbirthsdependingonthe acuityof the patientpopulationandthe time of
year.
Nursesare increasinglyexpectedtoprovide emotional supporttofamiliesandpatientswhoare acutely
ill.Theyare not preparedtofill thisrole andoftenrequire the servicesof the chaplainwhentheirfirst
fewpatientsare facingendof life andpassaway.Nursesare taught the intricate detailsof medication
administrationandclinicalpatientcare.Theyoftenfeel ill preparedtosortout complex rolesandissues
that become a barrierto honoringpatientwishes.Theyare grateful tohandthese familiesovertothe
pastoral caregiversforvalidationand supportwhile theycare forthe patient.Toexpectthemtosolve
familyissuesisbeyondtheirscope of practice. Byofferinglisteningsupport,chaplainscansee thatall
familymembersfeel heardandhave achance to expresstheirwishes. Withtheirtraining,theycanalso

4. discoverthe boundariesinwhichfamilysystemsoperatethatpreventthemfromhonoringapatients
expressedwishes.
It ismy sincere desire tohelpthose involvedinmedical financial budgetingandforthose governmental
officialsinvolvedinpolicyregardingqualitypatientcare tounderstandthe trainingandrole of
professionalchaplains.Specifically,the professional requirementsfor those providingspiritualand
emotional care tothe most vulnerablemembersof oursocietyandpatientpopulation are myarea of
concern.Pastoral care isa necessityandhasbeendownthroughthe centuries.Itwasthe spiritual
caregivers,laypersonsandnunswhofirstcaredfor the sickand infirm.Onlymodernmedicine has
distancedthe spirituality fromthe healingprocess.
I wouldlike tosee higherrequirementsandlicensingforthose individualsseekingthe title of ‘Chaplain’
as a professional role.Because the educational andprofessional requirementsare vague itmakesit
unclearto administratorswhatvalue thisrole carriesinaprofessionalinstitution. Clearly,thosepersons
practicingspiritual care whodonot meetthese guidelinesshouldbe clearlygiventhe titleof volunteer
or spiritual care layperson.
At present,afamilyhasrequestedtomeetwithme inmakingdecisionsfortheir85year oldmother
whohas expressedherdesire todiscontinue aggressive measures.Withtheirexperience andtrustinthe
chaplainduringthishospital stay,theyhave askedthe chaplaintohelpthemsortthroughtheirissuesas
a familythatare creatingthe barrierto hearingherwishes.These are notskillsthatacouple of unitsof
pastoral care trainingcan develop,itwouldbe like expectingastudentnurse toautomaticallyknow how
to insertandplace a chest tube.Ittakesmaster’slevel education,fourunitsof qualitypastoral care and
the opportunitytopractice such skillsinasupervisedinternshipprogram.Additional experience ina
hospital isimperative.Thisleadsthe familytounderstandthat the hospital does care aboutthemand
theirlovedone.Theyfeelcared-forthemselvesandreturntothat institutionbecause of that
professionalsupport.
LeNae Peavey-Onstad
2015