complimentary sample issue - healthcare chaplaincy€¦ · daniel shenk, director of pastoral care,...

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Complimentary Sample Issue

PlainViews®, the preeminent online professional journal for chaplains and others who care for the human spirit, enriches your professional practice with stimulating content and dialogue that arrives in your inbox twice a month.

The contents of this special sample issue are representative of PlainViews’® depth and breadth:

1. Eight Things Every New Chaplaincy Director Needs to Know by David Fleenor 2. A Major Victory for Relief of Suffering by George Handzo 3. Ask the Chaplain: Dave Girardin by PlainViews® staff 4. Benchmarking Chaplaincy Staff: Who or What is Valued? by Margaret (Margo)

Richardson 5. Hell Hath No Fury by Holly Gaudette 6. Redirecting Magical Thinking by Doug Longstaffe 7. Unexpected Results from an Unexpected Resolution by Sue Wintz 8. News and Journal Watch 9. TalkBack: Should One Blog, Tweet, or Facebook One’s Suffering?

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Further information on subscription options can be found at the PlainViews® website at http://www.healthcarechaplaincy.org

In addition to the articles shared in this sample issue of PlainViews®, you can access previous special open access issues on these topics:

• Disaster Chaplaincy: http://bit.ly/1hUv65j

• 10th Anniversary of 9/11: http://bit.ly/1f7K07K

• Care for the LGBT Community: http://bit.ly/1ihQC2d

• Suicide Prevention: http://bit.ly/1fdZO4c • Hospice Chaplaincy: http://bit.ly/NJPWJI


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Eight Things Every New Chaplaincy Director Needs to Know By David Fleenor 2/19/14 Vol. 11 No. 3 “Employees tend to rise to the level of their incompetence,” so says the Peter Principle (http://bit.ly/1lMjMJ8). In short, many professionals are promoted beyond their competence. This is common in professional chaplaincy when very capable clinicians advance their careers and become department directors. Very little, if anything, in chaplaincy training (or divinity or rabbinical school) has prepared us for budgeting, strategic planning, and quality improvement projects.

This has certainly been true of my professional journey. Fortunately, colleagues and mentors have surrounded me and helped me get up to pace when I needed to. Recently I transitioned from a director’s role where I led a chaplaincy department at NYU Langone Medical Center to a new role at HealthCare Chaplaincy Network (HCCN) in which I oversee directors of chaplaincy departments and CPE Supervisors.

In preparing to orient my successor, the Rev. Christine Davies, to her new role as the director of chaplaincy services at NYU Langone Medical Center, I asked all the HCCN directors what one piece of advice they’d give her. Together we developed a list of eight things every new chaplaincy director needs to know.

1. Schedule time for relationships

“Don’t forget to build time into your schedule for cultivating and nurturing relationships with colleagues in other departments. It’s easy to get swallowed up by administration, close your office door, and spend all day at the computer completing reports, writing policies, etc. Regularly setting aside time in your schedule to invest in relationships will pay dividends later, especially when you need support for a new initiative.”- The Rev. David Fleenor, Senior Director, Chaplaincy Services and Clinical Education, HealthCare Chaplaincy Network, New York, NY

2. Find the eagles and fly with them

“Find the eagles and fly with them while motivating and encouraging others to spread their wings. Keep a list of things that baffle you about the organizations and what you are curious about.”- The Rev. Florine Thompson, Director of Pastoral Care, St. Luke’s-Roosevelt Hospital, New York, NY

3. Dream huge, think big, plan small

“Dream huge, think big, plan small. Dream the most outrageous dreams for your service – see things that could be if only…Think about (with others – discernment is always done in community) the biggest thing you can accomplish that will do the most good for the most people. Plan every step so that everyone will always know where you all are in the process.”- The Rev. Jill Bowden, Director of Chaplaincy Services, Memorial Sloan-Kettering Cancer Center, New York, NY

4. Make friends with everybody

“Make friends with everybody or as many people in the hospital from all parts and all departments as you can. You never know when you might need a favor from them – from housekeeping to security to the highest part of administration. Say ‘Hi’ to everyone you pass in the hall and be there for them when they need you.” - Rabbi David Keehn, Director of Pastoral Care, New York Hospital-Queens, Queens, NY


5. Deliver programs and services that add value as defined by the institution

“Always remember that your job is to deliver programs and services that add value as defined by the institution, not what you think adds value. If you do the former successfully, you will eventually be allowed to do the latter in addition.” - The Rev. George Handzo, Director of Health Services, Research and Quality, HealthCare Chaplaincy, New York, NY

6. Remember self-care

“Remember self-care. You can’t be an effective leader without it.” - The Rev. Karen Jones, Director of Pastoral Care and Education, Winthrop University Hospital, Long Island, NY

7. Know your hospital’s oral tradition

“Every place has its own oral tradition. Learn it and you’ll be a much more effective team leader.” - The Rev. Daniel Shenk, Director of Pastoral Care, St. Mary’s Center, New York, NY

8. Take time to schmooze

“Find out who really runs the hospital and get to know that person. Face time is very important. Take time to schmooze.” - The Rev. Paul Rickert, Director of Pastoral Care and Education, Beth Israel Medical Center, New York, NY

For a free, annotated bibliography on leadership, management, and organizational development written specifically for professional health care chaplains be sure to read The Management of Care: Literature on Leadership and Organizational Development from HealthCare Chaplaincy Network’s Practical Bearing: The Critical Bibliography Series for Health Care Chaplains, which can be found at http://bit.ly/1lvnryp

Question to Consider:

• Is there a piece of advice you would add to the list?

The Rev. David Fleenor is the Senior Director of Chaplaincy Services and Clinical Education at HealthCare Chaplaincy Network in New York City, NY.

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A Major Victory for Relief of Suffering By George Handzo 2/5/14 Vol. 11 No. 2 Editor’s Note: George Handzo BCC CSSBB regularly blogs on his website at http://www.handzoconsulting.com . This past week, the Executive Board of the World Health Organization passed its first free-standing resolution dealing exclusively with palliative care entitled Strengthening of palliative care as a component of integrated treatment within the continuum of care, which can be found at http://bit.ly/1f7ZE3f

The resolution in part urges member states to:

“…develop, strengthen and implement, where appropriate, palliative care policies to support the comprehensive strengthening of health systems to integrate evidence-based, cost-effective and equitable palliative care services in the continuum of care, across all levels, with emphasis on primary care, community and home-based care, and universal coverage schemes”

It also reiterates the WHO definition of palliative care as:

“an approach that improves the quality of life of patients (adults and children) and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual...”

We in the US I think don’t pay much attention in general to the WHO, which is unfortunate. The US is a member along with 193 other countries and territories. They are the major voice in world health policy. So to have this body speak out on this issue as clearly as this statement does is impressive. And some of the language will resonate with those of us who value ethical imperatives. For example:

“Acknowledging that palliative care is an ethical responsibility of health systems, and that it is the ethical duty of health care professionals to alleviate pain and suffering, whether physical, psychosocial or spiritual, irrespective of whether the disease or condition can be cured, and that end-of-life care for individuals is among the critical components of palliative care”

I think US readers will note in the resolution a heavy emphasis on physical pain relief and availability of pain medications, particularly narcotics, and with good reason. These medicines whose availability we take for granted in the US are at least rarely available and often not at all available in much of the world. And those places are often the same ones where no treatment is available for diseases like cancer so pain relief is the only option for care. We should also not take the somewhat tangential reference to spirituality lightly. That the word appears several times is a major victory as it would be if this were a document issues by a commission of the US government. We owe a significant debt to the people who advocated vigorously for its inclusion.

As important as this event is, my colleague Tony Powell in Nairobi reminds me that (1) the WHO General Assembly still needs to pass this resolution at its meeting in May (2) the WHO is notoriously underfunded and can’t be relied upon to do much about implementing this on their own and (3) the WHO has no legislative power. So it can “urge” its member states to do something but it cannot mandate anything.


Even assuming the General Assembly resolution passes which does seem very likely, this is not the time for any of us who support this effort to sit back and assume that the further integration of palliative care will just take care of itself. On the contrary, it is a call to action to encourage all of us to redouble our efforts to take advantage of this opportunity lest it languish and eventually be forgotten. As we have seen in the US and elsewhere, the proliferation of models for palliative care which all include spiritual care has not meant that spiritual care is included in any palliative care program.

But make no mistake, this resolution represents a major victory in the ongoing effort to end suffering caused by disease in all of its domains. This resolution does mean, I think, that there is now a flag that all of us worldwide can rally around to make common cause on this issue with common language. This is an important milestone on this journey, but we are far from done.

Ask the Chaplain: Dave Girardin By PlainViews® Staff 3/5/14 Vol. 11 No. 4

1. What must we do to strengthen our profession as a whole? Research, of course, is critical (see question no. 3). Chaplains need to contribute to research or do their own with other disciplines. We need to let other disciplines know what we are doing that impacts patients and how that impact is being expressed. In other words, we need to show outcomes and evidence-based practices. In this, the other disciplines will better understand the profession of chaplaincy. Another area chaplains need to grasp is medical terminology. I worked as a nurse years ago and I am familiar with the terminology, but I get frustrated when I hear chaplains say, “I don’t understand.” If a chaplain is choosing to work in health care it is incumbent upon the chaplain to be familiar with the language. This is fairly simple these days. As chaplains we could Google the word or diagnosis and have an answer in technical or lay terminology. Or, if the chaplain is weak in terminology he or she could take a class in medical terminology at a local community college. When we are familiar with and use the appropriate medical terminology this allows the other providers on the health care team to talk freely without having to translate for the chaplain. And more important, our having this knowledge of the language allows the chaplain then to help the patient understand what the health care team is saying; we use it to enhance our patient care.

The Rev. George Handzo MDiv CSSBB is a board certified chaplain and President, Handzo Consulting. He is also Director of Health Services Research and Quality at HealthCare Chaplaincy Network in New York City, NY. George is a past president of the Association of Professional Chaplains.

David Girardin is a staff chaplain at Chesapeake Regional Medical Center in Chesapeake, Virginia. He is endorsed by the General Conference of Seventh-day Adventists. In addition to an MDiv, he has an RN, MA in Pastoral Care & Counseling, and MS in National Resource Strategies. He is currently preparing for APC Board Certification. David has been involved in various aspects of health care for over 40 years. He is a retired Navy Chaplain (2011).


2. How can chaplains get more involved with the health care teams at their hospitals? By inserting ourselves into the teams! For example, attend grand rounds or other appropriate workshops for health care providers. Another way is to join in or lend a hand with others on the team. This is where communication again becomes so important. If you see a nurse or technician struggling to get a patient ready for transport, rather than ask, “Do you need some help?” ask instead, “What can I do to help?” or “How can I assist?” We must be more involved as members on the team rather than a separate discipline on the sidelines.

3. What areas of research are most important to you? I am a research junkie and like to keep up in several areas; for example, patient satisfaction. A leader in this area is Press Ganey; they have shown that spiritual and emotional care matters in patient satisfaction. When these needs are met, there are high scores on patient satisfaction—and satisfied patients are also more likely to pay their bills. We need to learn about and understand how patient satisfaction is measured. I am also interested in resistant behavior in patients, or, what is labeled “non-compliant” by the medical community. The research shows that often there are underlying reasons for such behavior; the patient may not even understand the reason. Chaplains need to be involved early on in a case where a patient is demonstrating resistant behavior because we are trained to listen—not only to the words, but to the underlying emotion. Perhaps by involving chaplains early in the process, “non-compliance” could be avoided. I’d like to see chaplains involved in research in this area. Another area is research on the care of survivors of sexual assault. I studied this academically and my MA project was on pastoral counseling of survivors of sexual assault. How do we care and counsel them? What do we even call them? Terminology has consequences, such as being called a victim rather than a survivor. 4. What do chaplains need to learn to become more effective? I really appreciated Tagore Jenkins talking about the importance of writing good SOAP notes (subjective, objective, assessment, plan) in the February 5 issue of PlainViews. He’s such a good communicator. Communication is part of efficacy, of having a positive mental attitude, and we need to learn more about how important that is. During one time when I was a chaplain at Naval Medical Center in Portsmouth, Virginia, we had monthly peer reviews and shared our reports and notes with an interdisciplinary team. It was painful at first but I also saw the growth, how I improved over time. Chaplains need to ask, does somebody review my notes? Or am I in a rut writing the same stuff over and over? 5. What article or book have you read recently that has had the most impact on your chaplaincy practice? My three areas of focus are my foundational roots, research, and current practice. As a foundation for how I practice pastoral care, I’m a big fan of The Discipline for Pastoral Care: Foundations for Outcome Oriented Chaplaincy by Larry VanderCreek and Arthur Lucas (Rutledge, 2001). Art Lucas, now deceased, developed this model of pastoral care at Barnes Jewish Hospital in St. Louis. In this model, basically, Art describes how pastoral care transitions from assessing a patient’s needs-hopes-resources, to what they consider holy, to collaboratively looking at desired outcomes, to developing a plan, to implementing the plan, and finally evaluating the outcome. In 2005, when I was the director of pastoral care at Naval Medical Center in Portsmouth, Art came in as a contracted advisor to help us implement this model. I still use this model today.


I read Crossroads newsletter from The Center for Spirituality, Theology and Health at Duke University regularly because it keeps me current with research abstracts. My dream is to attend one of their summer training workshops in order to expand my knowledge of how to do research in spirituality and health. To stay current with practice I use technology; tweets and RSS feeds. To name a few of the more active sites: George Washington University Institute for Spirituality and Health, Center to Advance Palliative Care, Gallup and Pew polls to see population trending of current events, Press Ganey, George Handzo’s blog, and Kevin Pho MD. 6. What effects do you think the new Affordable Care Act will have on chaplains and/or chaplaincy practice? Ah, that’s the million dollar question! I’m an advocate for reform in health care, but not for the ACA. It has advantages and challenges for chaplains. The economic challenge to health care, the corporate structure, budgets, will mean splitting hairs. Chaplains are often seen as a soft target when administrators fail to understand the bigger picture. Compared to other providers and in the grand fiscal budget, our salaries are typically not a significant burden, but our contributions certainly are profound. Perhaps some administrators have not looked at or been shown the evidence of our contributions to patient and staff care. Here’s one example from a recent shift at my hospital. I was called to provide support to a family of a patient that had just arrived in the emergency room and was receiving cardio-pulmonary resuscitation. For two hours I provided spiritual and emotional support to the family, was a liaison between the staff working with the patient, provided sacramental care at the bedside, and assisted the family with funeral resources in the area. If the chaplain isn’t there, then the hospital either doesn’t support the family or is left to pull a nurse from another area of the emergency department. There’s then a domino effect where the patients of the nurse pulled are negatively impacted. They receive less of that nurse’s time, attention, and care. I’m not sure that administrators see that impact when making cuts in chaplain staffing. Chaplains are more global than many administrators may assume; we provide spiritual, emotional, and in many cases social-system support and resources. The advantage of ACA is that it gives chaplains another reason to step up and promote the Press Ganey information about how spiritual and emotional support contributes to patient satisfaction. One of my former administrators routinely said, “”If change is inevitable, it behooves us to get on board early and impact that change; otherwise someone else will make the change for us.” Whether ACA stays or not; look for the opportunities to impact the changes needed to enhance patient care and satisfaction. Finally, the change happening around ACA is creating a stressful time for administrators and perhaps we should look for opportunities to care for the administrators?

Ask the Chaplain is a feature written by PlainViews staff.

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Benchmarking Chaplaincy Staff: Who or What is Valued? By Margaret (Margo) Richardson 12/4/13 Vol. 10 No. 22

“As soon as the coin in the coffer rings, The soul from purgatory springs.” –John Tetzel, Dominican indulgence vendor The practice of attaching a material cost to a spiritual service is not new. But it has taken a new form. Modern health care management calls the efficient costing of professional chaplain services “benchmarking.” Long a staple of controlling factory floor line-workers, time studies and the resulting “benchmark” for how many FTE’s (full time equivalent) are required for a process and how to reward or penalize for employee productivity is now currently seen as the answer to reigning in health care labor costs.1 Many hospitals seeking to make job cuts hire benchmarking consultants to come in, do time studies, crunch the data, and provide the necessary justification for staff reduction (usually direct care staff such as nurses, therapists, nursing assistants, etc.) while requiring the same or better quality and performance. Some chaplains in Canada are now being confronted with a benchmarking process. When I attended the Canadian Association for Spiritual Care in Ottawa this spring, confusion and concern about this process was strong. Woefully understaffed to begin with, Ontario chaplaincy departments (sometimes just a department of one) are being asked to report their activities to the consultant, who then tells them how many chaplain FTE’s the hospital system can have and how many visits they should be making and how long each visit should be. To be efficient, according to one presenter, a chaplain in his or her hospital is allowed to make 76 visits at only eight minutes and 17 seconds each. If he or she does more visits or spends more time than that, then the cost is over budget. That’s a bit over 10 hours of patient care a week. So one chaplain could then cover more than one hospital. The result? Almost 2.0 FTEs were cut.2 What data was being reported and what formulas were being used? This was not a transparent process. Yet the goal of this data collection was said to be “efficiency.” When did benchmarking start being applied to chaplain activities? The earliest article I found was published in Chaplaincy Today in 1998 by Dr. Elisabeth McSherry and Will Kinnaird. In response to the Veterans Affairs Healthcare System’s “Decision Support System” tool for funding and allocating resources, McSherry came up with 74 different chaplain interventions each assigned a code.3 McSherry explained how to create the benchmark: By using the annual volume of individual products, the relative value unit per product, and the current annual budget, the average cost per chaplain care intervention per case can be calculated. These annualized standard costs can provide benchmarks for resource use in comparing similar patient-cases over time and between providers.4 While McSherry did not reveal the details of how this worked out in actual numbers and dollars, she did publish her extensive list of chaplain services. Each chaplain was expected to record the interventions they did as codes on each patient. McSherry envisioned the next steps in using this data collection to show positive effects on patient outcomes. However, no follow-up research ever came of this that I’ve been able to find. Meanwhile, the Catholic Health Initiative in 2001 kicked off the most intensive and widespread use of benchmarking for chaplaincy.5 The Catholic Providence health system in Oregon, led by Fr. Bartholomew Rodrigues, and the Mayo Clinic hospitals in Rochester MN, led by Fr. Dean Marek, Director of Chaplain Services, have been the leaders. While Fr. Rodrigues has published widely on measuring the effectiveness of chaplaincy, Fr. Marek has focused on sharing the nuts and bolts of how to set up a benchmarking system for chaplaincy departments.6 In addition, Ascension Health, the largest Catholic health system in the U.S., presented its benchmarking process this last Association of Professional Chaplains conference.7 Finally,


Australian chaplains grappling with benchmarking have referred to Mayo hospitals’ system in developing their own “minimum data sets.” 8 Briefly, a chaplaincy benchmarking process works like this: First, your chaplaincy department has to come up with a “minimum data set,” which is a list of all chaplain activities. Then you have to count how many visits or “service types” you provide over a certain time period, from three to six months. After tracking this data for the set time period, you then find the average time spent for each service. Fr. Marek found, for example, that a death at Mayo took an average of 50 minutes of chaplain time. A “pastoral contact” took 10 minutes. The next step is to assign a number to one of these time increments. Mayo assigned a 1.0 “relative resource unit” to the ten minute pastoral contact. So that means a death takes 5.0 relative resource units (RRU’s). Finally, you attach a cost to each RRU. This is done first by multiplying the number of each service by its RRU, which equals a Unit of Service (UOS). Then you add up all Units of Service and divide that by your monthly department budget total. That number equals the Cost Per Unit. Marek uses a hypothetical example of a budget of $25,000 per month which he divides by a total UOS of 1,225. With those numbers, a single unit (Pastoral Contact) would cost $20.41. A death would cost an average of $102.05 (5.0 units of Service).9 This process, unlike the one going on in Ontario, is transparent. Systems for benchmarking nurse staffing have been around for decades. These systems follow the same basic formula above with more variables. The GRASP staffing tool was published in 1976 and the aim was to determine nurse staffing based on “direct care activities” rather than nurse to patient ratios.10 This system aimed to customize care for each individual patient and better reflect what actual patients’ needs were in order to staff more adequately.11 However, benchmarking management consultants have proliferated since then and promise big savings to management fulfilling the desire to cut costs. Their formulas are not always transparent, especially if they are considered proprietary, like an industry secret. To be transparent, in other words, would be to give away their competitive secrets. The argument for transparency fuels the current movement of nurses nationally to legislate nurse to patient ratios. Bedside nurses argue that staffing consultants hijacked control of patient care to appropriate the savings to themselves and to management.12 Despite many studies showing benchmarking results in declines in patient safety and low patient satisfaction scores while ratios increase them, hospitals resist requiring nurse to patient ratios claiming such measurements are not “efficient.”13 It seems to be assumed in much current chaplaincy literature that the benchmarking process is value neutral, that it is just a tool which helps achieve accountability and efficiency. But there can be as many minimum data sets as there are spiritual care departments. • Who defines each intervention and determines its efficacy? • How does a department determine what interventions are needed, given the different and diverse populations we serve? • Does the standardization of chaplain productivity for an entire health care system allow for regional or local differences and needs? • How do we choose health care computer software and how do we design assessment templates? • What research has been done to measure the effect on quality and patient satisfaction of imposing productivity requirements on chaplains?

There are many value-laden decisions embedded in each of these questions. Whose values are represented in this development of productivity metrics for chaplains?

In a faith-based hospital system, perhaps the manager of spiritual care is someone who supports providing professional chaplains for patients and families since that is a stated part of that institution’s mission. In this case, the staff chaplain could expect the manager to be a professional chaplain as well, and therefore be able to use the benchmarking system in a transparent, collaborative way that could assist chaplains to examine and improve their own practices. But even in a faith-based institution, chaplains are often managed by a


nurse or social worker. What concept and use of such a tool will they have? In non-faith-based settings, the benchmarking tool could end up reducing the chaplain’s activities to a very small minimum data set. If your productivity is closely monitored by a supervisor unfriendly to chaplaincy, your ability to advocate for spiritual care provision could be pared down to zero. If a hospital or hospice gets a director who wants to get rid of a professional chaplain and hire someone cheaper and less qualified, judging you on a narrowly focused set of interventions could trim your ability to demonstrate chaplaincy’s added value. Benchmarking that involves a focus on “time studies” is imposing a value system. Time studies are tools of market ideology, or “economic rationalism.”14 Time studies are not neutral practices that simply provide “accountability.” Time studies represent a value system that focuses on a financial transaction instead of a human relationship. The quality of your care provision becomes secondary to your productivity and cost-savings. Catholic pastoral theologian Ryan LaMothe observes that importing market ideology into health care has turned patients into “consumers.” Caring for patients is reduced to Relative Value Units. Time is money.”15 But chaplains work out of a moral system in which the foremost value is concern for the other person, (the patient, family, and staff) as a person. Empowering and enforcing a productivity focused benchmarking system is to privilege a financial relation instead.16 As LaMothe points out, “the Other as a person has ontological value, which cannot be commodified, objectified, or measured without distorting the relation.”17 Thus, I think chaplains need to be very careful in employing any metrics that tend to undercut our moral commitment to the patient. What can professional chaplains do?

• Continue research on professional chaplains and the difference we make for patients, i.e. outcomes. • Stick with ratios that are transparent and take into account all the realities of spiritual caregiving without reducing what we provide. • Define what accountability actually means and its relationship to real people as people, not “costs.” • Resist formulas for chaplaincy staffing which are imposed from outside our profession and which serve values that undercut our mission. • If you are already saddled with such a system, educate yourself about the values it really supports. In addition, developing a strong internal sense of pastoral authority would seem important in resisting the co-option of one’s identity as a healer. • Tap the support of our faith communities and pastoral theologians in securing fair and transparent chaplaincy staffing which honors the moral values we have been ordained to uphold. • Provide a prophetic critique of the values that privilege processing encounters over patient and family experience. What else can chaplains do? What are your experiences with this type of time study and productivity benchmarking? How does this tool demonstrate accountability or contribute to research? What ways are chaplains demonstrating accountability without time studies? Footnotes: 1. Frederick Winslow Taylor, The Principles of Scientific Management, 1911, New York http://www.gutenberg.org/ebooks/6435 2. Canadian Association for Spiritual Care, April 10-13 2013 Conference, “HCM Benchmarking of Spiritual Care Departments in Canadian Hospitals.” 3. William Kinnaird & Elisabeth McSherry, “The Development and Use of Codes for Chaplain Interventions (Procedures and Products) in the Veterans Affairs Healthcare System” Chaplaincy Today, 14:1, 1998. 4. Ibid. 5. Measures of Chaplain Performance and Productivity, Task Force Report, Catholic Health Initiatives, 2002. 6. Fr. Dean Marek, “How Much Does it Cost for Chaplain Services?’ Vision, National Association of Catholic Chaplains, 2005 http://www.nacc.org/vision/articles/cost-for-chaplain-services.asp


7. Ascension Health Chaplain Activity Time Study Training Manual http://www.professionalchaplains.org/files/continuing_education/annual_conference/handouts/sa1.14_handout.pdf 8. Ree Bodde, “Towards Benchmarking in Healthcare Chaplaincy and Pastoral Care in Australia,” Australian Journal of Pastoral Care and Health, Vol. 2 No. 2, December 2008. 9. Fr. Dean Marek, Ibid. 10. E. Louise Clark, GRASP Grace-Reynolds Application and Study of PETO, Kate B. Reynolds Health Care Trust to Grace Hospital. 11. GRASP Systems, www.graspinc.com Institute for Health and Socio-Economic Policy, 2009 http://nurses.3cdn.net/e7cbe233d85cdaed69_o7m6vv40v.pdf 13. Linda Aiken RN PhD, et.al., “Implications of the California Nurse Staffing Mandate for Other States,” Health Services Research, 2010, http://www.nursing.upenn.edu/chopr/Documents/Aiken.2010.CaliforniaStaffingRatios.pdf 14. Lindsay B. Carey and Christopher Newell, “Economic Rationalism and the Cost Efficiency: An Australian Study,” The Journal of Healthcare Chaplaincy, Vol. 10, No. 1, 2000. 15. Ryan LaMothe, “The Spirits of Capitalism and Christianity and Their Impact on the Formation of Healthcare Leaders,” Journal of Religion and Health, published online July 7, 2012. 16. Ibid. 17. Ibid.

Hell Hath No Fury By Holly Gaudette 9/18/13 Vol. 10 No. 17

Editor’s Note: Chaplain Holly Gaudette writes PlainViews articles that provide powerful lessons for chaplaincy practice with cancer patients, based on her own experience in dealing with a recurrence and now participating in a Phase 1 trial.

It started with a cord; the power cord to some electronic appliance or another. A cord that had been left, lazily, where it could easily be tripped over. By me. I tripped over it. I didn’t fall; it didn’t break. Stumbling, I growled in frustration at my own laziness. And like the whisper that triggers an avalanche, that small noise unleashed a flood of emotion. Like a toddler, I threw myself to my hands and knees. I howled wordlessly in rage. I believe I even pounded my fists on the floor. Suddenly, what had been a quiet Saturday afternoon exploded into an all-out temper tantrum. The part of my brain that did CPE observed my raging, howling self and thought, “It’s totally normal to be angry.” My raging, howling self laughed maniacally at that absurd understatement and continued raging.

It shouldn’t have surprised me, but it did. For all that I was the person in CPE who was given a list of feeling words and invited to choose from the list rather than just saying I was “fine” all the time, I know about anger. I know about mad, sad, and glad. I know that anger is a normal part of grief. And I know that, when facing a critical illness, anger is a normal response. Somehow, however, “I’m feeling mad” doesn’t quite describe my feeling. Had you asked whether I was angry – even five minutes before I tripped over that power cord – I probably would have said “no.”

Rev. Margaret (Margo) Richardson is a staff chaplain at Hennepin County Medical Center, Level 1 Trauma Center, in Minneapolis MN. She has been a Board Certified Chaplain since 2001 and is ordained in the Christian Church (Disciples of Christ) and will soon have her credentials approved by the United Church of Christ.


A few months ago, I attended a baseball game with a large group of Pan Mass Challenge riders and their families. A couple hundred of us had a section of the bleachers to ourselves, many sporting shirts and cycling jerseys with various slogans about beating cancer. And many of those slogans were angry, bordering on crude.

One young man in particular appeared to be in his twenties. He had a broad smile and spent most of the game teaching the gang of seven- and eight-year-olds in the seats in front of him cheers, leading them in the wave, and making them laugh with his antics. As he came up the stairs from buying himself a hot dog, his shirt was clearly visible, sporting a very clearly written statement about just what he would like to do to cancer. It was not polite at all. Another man stopped him and asked, “Aren’t people offended by your shirt?” For an instant, something flashed behind the young man’s eyes, and he said defiantly, “No. Most people ask where they can get one too.”

For that brief moment, the happy young man leading cheers was gone, replaced by the angry young boy whose mother had been stricken with cancer, and who had watched, helplessly, as she died. But then it was gone, and the smiling young man bounded back up the stairs, rude shirt and all. Later in the game, the same young man stood before us all, fist in the air. Everyone cheered. Then he pointed to the slogan on his shirt. Everyone roared. For an instant, every single person in the stands remembered a life torn asunder by cancer, and every single person felt that same flare of outrage. Every single mild-mannered person who would never in a million years say the phrase on that man’s shirt screamed with a furious desire to do just that to cancer. And as quickly as it flared, the anger faded, and the game continued.

Once, a stranger was rude to me in the train station, and that made me angry. If you had asked me, I’d have told you. I was mad. Somehow, this is different. The anger of the young man with the rude slogan on his shirt is not the momentary anger of someone stepping on your foot or cutting you off in traffic. This is cosmic, wordless, impotent rage. Rage that makes a person feel crazy. Rage that is so disconnected from ordinary everyday emotions that it feels utterly insane. Yet, if you’re brave enough to ask, it is a feeling that many people facing serious illness will endorse.

I told the story about tripping over the power cord to a woman whose spouse is currently in treatment for cancer. She immediately understood. She said, “I’m so mad that sometimes I just feel like taking off all my clothes and running through the streets screaming like a banshee.”

So, as chaplains, working with patients and families facing serious illness, I suggest three things:

1. Next time you say something along the lines of “it’s normal to feel angry,” add some descriptors. Throw out a generic example and see if the person jumps at it. “You know, they say ‘it’s normal to feel angry,’ but it’s not the same as getting ticked off when someone cuts you off in traffic. This kind of anger kind of makes you feel crazy. Like you just want to scream.” By offering this up, even if the person makes no indication that they’ve experienced that feeling, you’ve given them permission to feel it in the future. And when they find themselves banging their fists on the floor over a cord they’ve tripped over, they might remember what you said.

2. Add some more words to your vocabulary of anger. Get comfortable saying words like ‘rage,’ or ‘fury.’ I suspect that many people, like me, associate ‘mad’ with fairly trivial things. I’m not ‘mad’ that I have cancer. But sometimes, I am outraged at the whole darned situation.

3. Remember that this fury is not only destructive. When I was in training, we learned that grieving people are often angry. This is true. I learned that we should give people permission to express that anger. This is also true. But for the life of me, the only suggested action I can remember from training was to give the person permission to smash an old plate in their garage as a way of venting their frustration in a somewhat


safe way. Yet I watched fury propel 5,500 bike riders across 190+ miles of road a few weeks ago. I saw the rage on their faces, and in the photographs of lost children, parents, and loved ones they wore pinned to their cycling jerseys. This rage is powerful energy, and it can be put towards something that will allow the patient or family member to strike a blow at the disease, even if they are powerless to change their own situation.

We chaplains, like the people everywhere, aren’t always comfortable with anger. It doesn’t tend to be pretty. It tends to make a person look and feel like a howling lunatic. Yet it is after all, a normal response to a diagnosis, illness, or death. And we have a responsibility, therefore, to become comfortable inhabiting that space with our patients and families. For if we do not, who will?

Redirecting Magical Thinking By Doug Longstaffe 1/22/14 Vol. 11 No. 1 Spiritual Care has a distinct role within the health care system that arises from its unique blend of psychological and pastoral insights. The following outline of one such blended approach examines the synergistic value of our hybrid profession when working with children.

The younger a child is, the greater his or her degree of magical thinking. It is important for spiritual care practitioners to be familiar with this psychological concept. We can explore this through the example of a seven-year-old boy we'll call Sam, whose 14- and 17-year old brothers died in a tragic car accident.

Sam is left as the only child and after a few months his parents, who have separated since the accident, notice that he does not seem like the same child. Although formerly very interactive, he has become more withdrawn and exceedingly serious. He does not openly blame himself for the deaths as children have been known to do, but he is obviously anxious.

Sam is aware of a strong need inside himself to protect the members of his family who are still alive. Secretly he is developing thoughts of how he can protect them. When he was first told that his brother had been in a car accident and was in hospital, Sam’s response was that they should let him go down to the hospital and he would “fight the germs out.”

A week before the accident, Sam did not have the need to protect his family. He thought like most seven-year-olds that his parents could keep everyone safe. However, after the accident this belief was sorely challenged by the deaths and the separation. It was just too terribly frightening for Sam to contemplate a random event world, where no one including his parents, had any control over death. If the world was not within the control of his parents, then such loss could occur again without warning. Sam needed a way to believe such a tragedy would not strike again. After all, next time it could be him or one of his parents. A child cannot stand the thought that the world is so out of control. Better to believe that through magical

Holly Gaudette received her Master of Divinity degree from Duke University. She is certified in Thanatology through ADEC. She did her CPE residency in EOL/Palliative Care at Duke. Holly is currently on medical leave as a staff chaplain at NYU Langone Medical Center in NYC, a HealthCare Chaplaincy partner institution. She is certified as a chaplain by the Association of Professional Chaplains.


thinking somehow you yourself can protect your own family even if such a belief comes at the price of bearing the responsibility. But how do you protect them?

Protection comes through magical thinking. Some children like Sam develop small compulsive rituals. Sam’s particular compulsion was turning light switches on and off multiple times. For example, he would turn his bedroom light on and off until he felt he had just the right thought of his family being safe before going to sleep. This was how he protected them. In this way, Sam had at least the illusion of control.

We see cultural examples of similar thinking in superstitious songs that children may sing. For example, do you remember chanting “don’t step on a crack or you’ll break your mother’s back.” Or as an adult, how often have you received an email threatening you with some terrible bad luck if you do not pass on a certain prayer or poem etc. Magical thinking is actually quite prevalent to some degree with many adults.

The thing is, while we hope adults will outgrow magical thinking, we cannot in all fairness have the same expectation of children, for whom it is age appropriate. So how can a spiritual care practitioner help? The answer is to be found at the core of our clinical pastoral education. That is to work within the world view of the patient or client to help them move towards a healthier understanding of that which is appropriate for them.

In this case, the question is; what is appropriate for this stage of development? If we do not consider this adequately, we may find ourselves actually doing some harm. For example, it is wise not to seek to extinguish a compulsive behavior if we have nothing better to put in its place. Trying to “argue some sense” into little

Sam would not be wise. Magical thinking is not a problem for a seven-year-old but how the child uses such magical thinking can be problematic.

We need to address the issue underlying the compulsive repetitive behaviors, but in a way that empowers the child and addresses his need for control. We do this by entering into a spiritual/ religious interpretation of the events, in a manner that frees the child from unreasonable responsibility, while maintaining his sense that he can still do something to help protect his family.

Sam has an intense need to feel safe. Because he is from a nominally Christian home we may be able to address his need for security by assuring him that there is someone in control of those things beyond his parents’ power. We may be able to emphasize that God is called our father or our parent. In this way we redirect the responsibility he is shouldering back onto God.

Sam also has a need to protect. We may be able to suggest prayer as a replacement for his compulsive ritual behavior so that he can still feel that he can participate in his family’s protection by expressing his desires to God. Such an approach is not in opposition to Sam’s magical thinking. It is simply redirecting it in a healthier spiritual way.

Through the above redirections, Sam develops an age appropriate version of the spiritual world view held by his parents and the family’s spiritual community. As a result of this shift, Sam is no longer isolated. If another tragedy does occur, he can now share openly. In this way, he can ask his parents how such a thing could happen if God is in control. This is much better than dealing with it in isolation and potentially blaming himself.

Finally, we cannot answer all Sam’s questions any more than we can answer all our own. But in ministering to him in this way, we have placed him in a much better position from which to cope. If we had not addressed issues of control with him on terms with which he could relate we would not have been nearly as helpful and we might have made things worse. Of course there are many other needs that one could explore with Sam


with respect to grieving, and possibly feelings of guilt. In each instance, the Spiritual Care Practitioner would need to apply age appropriate spiritual care, respectful of the magical world view of younger children and mindful of the religious/spiritual family context. In this way, the spiritual care practitioner brings a most valuable blended approach to healing and coping that arises from the practitioner’s hybrid education in CPE.

Questions:

• If Sam finds no one to speak with about his ongoing fears and compulsions, what are some of the ways that we might expect the sudden loss of two siblings and subsequent divorce of his parents to affect Sam’s spirituality as an adult? Are such losses or trauma typically given enough attention in our spiritual assessments of adults?

• Although young children think in magical terms, until about age seven, the work of Maria Montessori, Sofia Cavalletti, and more recently persons like Anna Giesenberg suggests that young children also relate innately to the world in a deeply spiritual manner that goes well beyond magical thinking. If Sam came from a home in which both parents were opposed to a spiritual world view, but Sam was expressing deeply spiritual thoughts about his family’s circumstances, how might a pediatric chaplain negotiate a therapeutic alliance with both parents and child and subsequently design appropriate intervention strategies?

Unexpected Results from an Unexpected Resolution By Sue Wintz 1/22/14 Vol. 11 No. 1

Editor's Note: This article was adapted from one that ran in the Huffington Post on January 17, 2014.

I usually don’t go in for New Year’s resolutions. Instead I tend to regularly review my goals and aspirations throughout the year and make plans to meet them. However, this year was different because my husband and I had a task that had been on our plates for – gulp! – 10 years. We needed to update our will. We had written one when our children were young but hadn’t reviewed it since. Not only did it still have guardians named for them (and our son is now 30 with a family of his own), it still had our daughter in it although she was killed 10 years ago. Actually when we talked about it, we realized that Sarah’s death was part of the reason we hadn’t rewritten our will. To take her out of it was one more painful reminder. But it was time, so we made an appointment with our attorney to could get all our legal papers in order: a will, durable power of attorney, mental health power of attorney, health care power of attorney, and living will. We both had the last two done and in place, but wanted to have our living wills updated. So we downloaded the packet from our state’s website. In our state (Arizona), the living will template is very comprehensive in that it encompasses not only health care decisions but also decisions about autopsies, burial or cremation, and organ donation with a place where one can add additional directives about what he

Doug Longstaffe, MDiv, STM is the Profession Leader and CPE supervisor for Spiritual Care and Multi faith Services for Vancouver Coastal Health Authority in Vancouver, British Columbia. His previous work experience includes appointments in acute care, corrections and mental health, as well as running his own private counseling practice. Doug has extensive experience advocating at various levels of governance for greater recognition of the importance of spiritual care. He is passionate about the humanization of institutions as well as integrative mind/body approaches to health care.


or she does or does not want in terms of medical interventions. We wanted to have that completed before we met with our attorney. We had quite a list on that “additional directives” section, for example not wanting interventions done in the case of a massive neurological event, refusal of a pacemaker if we had other underlying life-threatening conditions or dementia, the desire to donate not only our organs and tissues, but also our bodies for science research and naming the organization we preferred to facilitate that. The interesting part came when we met with our attorney to review our wishes so that he could draw up all the documents. When it came to our living will, he was a bit taken aback. It turned out that their practice had used a different – still legal but much older – document and he suggested we might use that. You probably know the one: If at any time I should have an incurable injury, disease or illness certified to be a terminal condition, a permanent vegetative state or an irreversible coma by two physicians who have personally examined me, one of whom is my attending physician, and the physicians have determined that my death will occur unless life-sustaining procedures are used and if the application of life-sustaining procedures would serve only to artificially prolong the dying process…

Nope, I said. Not want we want. We’d rather use the one we brought in…verbatim.

When he asked why, I explained that I’d been in clinical practice for 30 years and knew living wills quite well as I had assisted many patients in completing them as well as families and doctors in interpreting and abiding by them. While the form their practice had was perfectly legal, it wasn’t the current one recommended in end of life planning.

Besides, I said, that form does exactly what it shouldn’t: it places the decision-making in the hands of two physicians, not in the hands of the patient, and it avoids any opportunity for the patient or their agent to say what they do and do not want in terms of treatment. And in my experience, getting two doctors to agree on anything in the current health care environment is very difficult.

We went with our original document.

Yet the story doesn’t end there. Our attorney looked at me and said that their practice needed to reexamine the documents they use. Very seldom, he said, do clients come in with documents of their own or having thought about what they would and would not want for medical treatment.

Would you be willing to come in and talk to our attorneys about advance directives and how we might not only change our documents but be able to have meaningful conversations with our clients?

Here are the take-aways from our “we don’t do New Year’s resolutions, but we need to this one” experience:

1. For anyone, completing legal documents, especially a will or living will, can be a task that is often put off. Many times the spiritual issue behind it may be the reluctance to face one’s own mortality. For us, the spiritual issue wasn’t that, but it was tied to our grief as bereaved parents. Even after 10 years things crop up that remind us of Sarah, not only her birth and death anniversaries, but things like mail still delivered in her name (yes, 10 years later and at an address where she never lived). Rewriting our will meant removing her as a beneficiary and instead naming her as deceased in it.


When encountering persons who need to talk about and complete health care advance directives, it is essential to always do a spiritual assessment in advance of or in conjunction with that conversation. Asking the questions about what might be one’s hesitancy in talking about the issues might bring you an answer that you didn’t expect.

2. Always look for opportunities to share your professional experience. In talking to our attorney, I had a choice. I could have simply said that we wanted our living wills to be as we written them and stopped there. Instead I shared my clinical experience and expertise as the rationale for why we wrote them the way we did, and why we wanted the form we chose. That opened a door that I didn’t expect: an opportunity to speak with a group of attorneys about end-of-life issues, living wills, and the spiritual aspects of working with their clients around them.

Have you found unexpected results in resolutions you’ve made this year that have impacted not only our personal spiritual life but your professional practice? If so, what changes will you incorporate into your chaplaincy work?

News and Journal Watch 2/5/14 Vol. 11 No. 2

1. A pioneering palliative care program “walks alongside” patients The Miami Herald ran a story on Dr. Pamela Sutton, who began Broward Health Medical Center's palliative care program in Fort Lauderdale, FL, in 1994, and said the initiative is a way of "walking alongside the patient" during the disease process. At the University of Miami Hospital's palliative care program, Dr. Tariq Mahmood works with late-stage cancer patients while familiarizing medical students with the use of pain medications.

The article can be found at http://hrld.us/1oA3i6A

• To consider: The story emphasizes that “Medicare only recognizes and compensates for palliative services if they’re delivered through a hospice program, which means the patient has to give up seeking a cure” and the need for a more expansive use of palliative care as a reimbursable treatment option. How can chaplains be proactive within their organizations for the expansion of palliative care services?

2. As parents age, Asian-Americans struggle to obey a cultural code The New York Times published an article that examined how Asian-American and Hispanic families can place great value on caring for aging or sick loved ones at home, but providing the care can put stress on families and finances. Language barriers also can prevent many people from seeking outside care. The article

Sue Wintz MDiv BCC is Managing Editor of PlainViews® and Director, Professional and Community Education at HealthCare Chaplaincy Network in New York City, NY. She is a past president of the Association of Professional Chaplains.


also points out that more nursing homes and retirement communities are seeking to address the needs of Asian-Americans and Hispanics.

The article is at http://nyti.ms/1eSyeva

• To consider: Chaplains are often – or can be – the cultural brokers for their organizations. How can chaplaincy departments, not only in hospitals but especially in assisted living, long-term care, and communities, be champions in developing culturally-sensitive care?

3. Measuring quality of care for older adults with serious illness Health Affairs has published the third post in its series about palliative care, health policy, and health reform. It refers to a 2012 report to the Agency for Healthcare Research and Quality finds evidence for three types of care to improve health outcomes: expert pain and symptom treatment, communication to engage patient preferences for treatment decisions, and interdisciplinary palliative care. In the article, they identify six key steps in the work yet to be done to measure and improve the quality of care for seriously ill patients. “Seriously ill older adults deserve quality health care – care with evidence-based interventions to promote communication and shared decision-making, expert pain and symptom management, and access to specialty palliative care.” The article is at http://bit.ly/1eB2dch To consider: One of the identified key steps is “Respect preferences and promote shared decision-making. We need new ways to support and reward the use of decision aids, structured clinical communication, and intensive clinician training to improve shared decision-making.” What are the opportunities for chaplains to demonstrate that their professional interventions make a significant difference in this area?

4. How oncologists and palliative care specialists can work together A video interview with Dr. Eduardo Bruera, the Department Chair, Palliative Care and Rehabilitation Medicine at the UT MD Anderson Cancer Center examines ways in which medical oncologists and palliative care specialists can work more collaboratively to deliver better care to patients.

The interview can be found at http://bit.ly/1iwV3tp

• To consider: The issues Dr. Brura raises in terms of integrating palliative care are virtually identical to the issues of integrating chaplaincy. In what ways can your chaplaincy department make common cause with palliative care doctors?

News and Journal Watch is written by PlainViews staff to bring readers new articles of interest to consider and engage with others in dialogue about their implication for professional practice.


TalkBack: Should One Blog, Tweet, or Facebook One’s Suffering? 1/22/14 Vol. 11 No. 1 In The New York Times Opinion Pages on January 12, writer Bill Keller wrote a piece called "Heroic Measures” (found at http://nyti.ms/1eH7i3o ) in which he questioned the blogs and tweets of Lisa Bonchek Adams, who has been writing of her journey with breast cancer--now at Stage 4--over the past seven years at her blog found at http://lisabadams.com . For him, Adams’ writing raises several ethical issues on whether one’s dying should be shared in social media. Megan Garber, a staff writer for The Atlantic, wrote a response on January 12th, "Tweeting One’s Suffering" (http://bit.ly/1doMugP ) She offers a critique of Keller’s “fairly patronizing” view not only towards Adams but to anyone who utilizes social media as a way of coping with a diagnosis, especially a terminal one, and judging their motives. With the rise in social media, many are turning to Facebook, Twitter, and personal blogs to share not only their journey with terminal illness but also with life-altering events such as stroke, trauma, chronic illness, or the death of a loved one. As one commenter wrote in response to the article in The Atlantic, “I would defend any patient's desire to write or blog about her/his condition. Whatever is cathartic, whatever helps, whatever is therapeutic should be allowed--and encouraged. As I said, no one is forced to read such accounts, and yet, many such accounts can be very helpful to a "newbie" just starting through a similar situation. People deal with emotional trauma in many different ways.” Have you met a patient who utilizes social media to share their experience? How did – or didn’t – you describe that as a support in your spiritual assessment? Do you follow blogs or tweets of anyone sharing their experience of a life-altering or life-threatening illness? Why or why not? Can you learn from a blogger/tweeter in such a way that it will improve your professional practice? Why or why not? How active are you in social media? Is this a venue that professional chaplaincy should become more proactive about to reach out both to chaplains and the public?

TalkBack is a feature by PlainViews staff that seeks to engage readers in discussing current topics of interest in the news or journals.

PlainViews® is published by HealthCare Chaplaincy Network. Learn more about the leadership HealthCare Chaplaincy Network provides in the areas of professional chaplaincy clinical services, education, research, and innovative online services to provide spiritual comfort for people who are seriously ill and their caregivers by visiting its website at http://www.healthcarechaplainy.org