A Framework for Quality Chaplaincy Services
Quality Cost-Effective Chaplaincy Services in a Multi-Cultural Democratic Republic
Submitted by the Humanist Association of Ireland to the Acute Services Division, Health Services Executive
ABOUT THE HUMANIST ASSOCIATION OF IRELAND
The Humanist Association of Ireland (HAI) is an organisation whose aims are the promotion of the ideals of Humanism and the assurance of equality of rights and parity of esteem for those citizens of Ireland who do not subscribe to a religion. Humanism is a positive ethical philosophy of life based on concern for humanity in general and for individuals in particular. It is a view of life for those people who base their understanding of existence on the evidence of the natural word and its evolution, and which combines reason with compassion and empathy.
MOTIVATION FOR THIS SUBMISSION
The rapidly changing mix and diversity of Irish society, in particular in matters of religion and society’s secular outlook, is a reality. Although the majority of its citizens identify themselves, if only culturally or nominally, with Roman Catholicism, the percentage of the non-Catholic population has increased significantly. Based on the 2011 census over 269,000 respondents to the religion question answered, ‘No Religion’. (An additional 73,000 did not respond to the question.) This is the largest category under Religion other than Roman Catholic. The HAI speaks on behalf of this largest minority in Ireland.
Our goals are set by the membership. Over the years we have undertaken various projects to meet these goals. One such goal has arisen from the often-heard complaints from members of their experiences with the health services, particularly as patients in hospitals. Such complaints have arisen from patients as well as members of the HAI with instances as early as the admission process where presumptuous or intrusive questions on religion are asked, right up to inappropriate approaches by chaplains and staff at hospitals with respect to religion and a patient’s self-declaration of no religion. One member reported being engaged without invitation in a conversation with a chaplain on the value of religion as well as to an inquiry by staff of the patient’s interest in praying prior to surgery. Members have also expressed concern that their statements on religion are not properly kept confidential from hospital staff or chaplains.
Our expectation is that the product of the current review will, in part, establish a policy to mitigate against future occurrences of similar events.
On a broader scale we are also concerned in regard to the involvement of the government with the delivery of chaplaincy services, of the de facto discriminatory policy for remuneration with public funds for chaplains, and of the difficulty for equal access for the delivery of chaplaincy services by chaplains of all faith groups as well for those of the non-religious. We hope this review will also address such issues to assure all chaplains and the needs of all patients are respected and accommodated equally.
This submission is in response to an invitation extended by Dr. Ciaran Browne for ‘comments and suggestions from all interested parties’ in the context of the Government’s reform programme for the Irish Health Service ‘Future Health’. We note initially and extend recognition that the HSE is proactively responding to the demographic changes in Ireland as expressed in its statement, ‘Demographic changes also mean that pastoral care needs to have an emphasis on spiritual support if it is to respond to patients of other faith traditions or those with secular beliefs.’ We are very pleased to see that statement and prepare this submission within that context.
The invitation also seeks guidance ‘as to how chaplaincy services and spiritual care are being provided, to assess how our patients, service users and staff are accessing services, and to assess how their individual needs are being met’. The review ‘is also intended to identify areas of good practice, to identify areas where improvements may be required, and to receive suggestions which are intended to address these improvements.’ To that end this submission is presented in the named sections below. The discussions in this submission also have been mindful of the five areas listed in the invitation letter, namely: 1. Spiritual and religious care, 2. Access to chaplaincy Services, 3. Working relationships between faith groups and other groups, 4. Staff Supports, 5. Education training and research.
As a further note, we mention, unless stated to the contrary, chaplain and chaplaincy services also include their Humanist counterparts.
1. Current Chaplaincy Services.
2. Accessibility of Chaplaincy Services by Patients and Staff.
3. Organisational Structure.
4. Recommendations for Improvements.
5. Concluding Remarks.
1. Current Chaplaincy Services
The HSE currently has in place a national agreement only with the Catholic Healthcare Commission (CHC) for the delivery of chaplaincy services (HSE HR Circular 013/2006). This agreement pertains exclusively to the employment and duties of Catholic chaplains as accredited by the Catholic bishops and agreed to by the HSE. In essence the HSE is a party in assuring and funding the administration of approved religious practices to Catholic patients.
The document also states, ‘All religious groups and individuals offering a Chaplaincy service, other than those accredited by the Health Service Executive/Hospital shall firstly be approved by the Chaplaincy and shall be co-ordinated by the appropriate Chaplain.’ One difficulty in that statement is that members of an established chaplaincy are given the authority to approve (or disapprove) of other chaplains serving in HSE facilities. It should not be up to one body of chaplains to approve others. Likewise the qualifications for Catholic chaplains are made part of a contract with the HSE. We mention all this to describe the scenario into which we enter this discussion.
An extension of these practices in a multi-cultural society would require the HSE to enter into similar agreements with each and every sending body as to the qualifications of its own chaplains. The HSE is not and should not be expected to be competent to pass on the qualification of a hospital chaplain. That is a matter for the sending body. The HSE should, however, assure that the chaplain who holds him/herself out as accredited was in fact duly accredited by the sending body and meets other conditions generally required of individuals coming into contact with patients. As discussed and recommended later, these anomalies can be corrected whereby the HSE act as the approving authority on all matters not related to religion.
The practice whereby some religious chaplains are paid by the HSE has been in place for a considerable period of time. As a consequence of the fact that the principal duty of religious chaplains is to provide religious care to members of their own congregation, the remuneration by HSE to such chaplains is tantamount to the payment by the State for the administration of religious practices, and doing so only to selected classes of chaplains at the exclusion of all others, including those of no religion.
We do recognise the reality that many chaplains will chat without references to their own doctrine, but that does not over-ride our reservations. On the other hand any attempt to achieve an equitable remuneration scheme for all chaplains representing the large mix of the religious and philosophical subdivisions of the population would present a formidable challenge. Notwithstanding these difficulties and the reality of limited funds, we do not imply that chaplains should be funded by HSE on the basis of demands for chaplaincy services from their member-patients, or in fact on any other basis. On the contrary, we hold that funding of chaplains should be a matter between the chaplains and their sending congregation. A considerable financial savings is a consequential benefit to the HSE.
An additional, and very significant, benefit arising from the removal of State funding for chaplains is the considerable reduction of the risk of legal liability to the HSE arising from charges by patients of abuse or unethical behaviour against chaplains. The reality of this liability is based on recent experiences of financial loss by the State for payment of claims as a consequence of the contractual relationships between the State and church authorities.
2. Accessibility of Chaplaincy Services by Patients and Staff 4
We start by accepting the argument that chaplaincy services play a positive role in the well-being of patients who request such services. We fully endorse the oft-quoted statement that the welfare of the patient is paramount.
Currently and generally each patient shortly after admission is approached by a chaplain and asked if the patient would like to be visited by a chaplain. On the surface this appears appropriate, for how else would a chaplain know that a patient would like to see a chaplain? The difficulty is that some patients may not want to be confronted with that question, particularly at a stressful time, which is often the case. On other occasions patients may find it difficult to reject an offer from someone who presupposes that the patient may want to see a chaplain. And at other times some patients may feel offended by being asked the question by a person who by appearance is not of the same religion or life-stance as the patient. In short, patients should not have to specifically state that they do not wish to be approached by a chaplain. The question of the patient’s interest of a visit by a chaplain can be determined at the time of admission or by a leaflet advising on all services available to patients which could include non-physical/spiritual care.
On the issues of generic chaplaincy services, and whilst it may be true that religious chaplains may be willing to talk and listen to any patient regardless of the patient’s views on religious or spiritual matters, it obviates the need for a chaplain from a particular denomination and increases the importance of a ‘belief-neutral’ person in the role if it is so. Accordingly the designated chaplain should not make his/her religious beliefs apparent. If a particular faith chaplain is needed, each congregation or organisation should be responsible for that work and any expense thereby incurred.
We also note that it is somewhat disingenuous for chaplains of one religious persuasion to justify their payment by holding themselves out as being available to all patients regardless of their denomination. Otherwise any chaplain, regardless of his/her religious affiliation or lack thereof, could be a paid hospital chaplain providing generic chaplaincy services. Patients typically seek confidential counsel with someone ‘on their side’. And if indeed a patient just seeks someone to talk to, any chaplain on duty at that time, religious or secular, should be equally competent to respond appropriately.
3. Organisational Structure
Typically each hospital currently has a head or lead chaplain. The head chaplain not only delivers specific religious services to members of his/her religion but also is responsible for certain administrative duties. Thus the chaplain is paid to carry out administrative as well as religious functions. In addition the chaplain is primarily accountable to his/her religious superior. The implication in this arrangement is that the chaplain is being paid by the HSE to carry out secular functions but not directly accountable to the HSE. The seriousness of this situation arises in the case where a complaint may be lodged against a chaplain. Any such complaints by patients against chaplains or against staff for inappropriate approaches on matters of religion or religious preferences are referred in turn to another chaplain. These comments relate to the earlier ones on complaints from our members where patients have been inappropriately approached or spoken to by staff, and where at that time the only recourse was to contact an executive of the hospital long after the incident.
Many of the difficulties thus far presented can be corrected by establishing a management structure with clear lines of responsibility, clear practices for dealing with patients’ religion information, and clear lines of accountability. To this end we advocate the establishment of an office which we, for present purposes, call Coordinator of Chaplaincy Services, (CCS).
That office would have the responsibility to maintain the roster of accredited chaplains as accredited by their sending organisation; maintain the confidentiality of religion information of each patient; assure that only the chaplain relevant to the patient of his/her religion or secular outlook has that patient’s information; assure that information is not provided even to the relevant chaplain if the patient does not wish to be approached by a chaplain; specify the structure of the religion question for admission to assure it is not obtrusive or invasive (perhaps as simple as, ’Would you like to express a religious preference?); receive and act on complaints which patients may have; set up a rota system where all chaplains are accommodated according to the demand; take responsibility for research and training of chaplains for best practice for the delivery of chaplaincy services; establish procedures whereby family and staff may also have access to appropriate chaplaincy services; manage cooperative working sessions across faith groups as well as those of secular beliefs; establish and enforce conditions and procedures whereby a chaplain may approach a patient; assure each chaplain has been garda vetted; etc.
This proposed structure removes any appearance of conflicts where a chaplain is the manager of chaplains as well as a chaplain him/herself and who may place personal religious preferences above best practice. The religion of the manager of that office, of course, is not a qualification for the position: it is a secular position. All decisions and directives put forth by that manager are based on religion-neutral considerations and with the best interest of the patient in mind. The qualifications for that position are the standard management skills and experiences as well as knowledge of the service product. This office becomes the first and principal contact point between chaplains of any or no denomination and the HSE.
4. Recommendations for Improvements
Our primary recommendation pertains to the establishment of an office which, as stated earlier, we call ‘Coordinator of Chaplaincy Services’ (CCS). The key elements of this office are:
– The Coordinator of Chaplaincy Services is a secular position where the religion of the Coordinator or its staff is not a job qualification. The evaluation of candidates for this position should be religion/belief-neutral to assure credibility and effectiveness.
– All administrative duties currently held by chaplains are transferred to the CCS.
– The budget for this position is supported, perhaps entirely, by the financial savings to the HSE as a consequence of the fact no chaplain is paid by the HSE.
The responsibilities of the CCS include:
– All administrative duties currently performed by chaplains at the HSE.
– Co-ordinate services and the supervision of the work practices of chaplains.
– Assure chaplains are accredited by its sending body and that they agree to abide by HSE rules of conduct.
– Organise and chair chaplaincy group meetings, assuring equal access by chaplains of all faith groups on none on an equal footing.
– Make available office facilities, support, and similar resources to all chaplains
– Organise chaplain work schedules according to patient demand or other criteria.
– Hold sensitivity training and education for staff and other chaplains to assure all patients are treated equally and with respect in matters of their religion or world view.
– Prepare chaplaincy literature/brochures to inform all patients on the available chaplaincy services.
– Assure the proper collection, storing, transmittal, protection and use of patient confidential information/data pertaining to patients’ religious preferences if any.
– Establish procedures whereby only those who need-to-know are granted access to patient’s confidential information.
– Undertake research to introduce and monitor best practices.
– Initially review and modify the religion question at admission to assure it is non-intrusive and sensitive to all beliefs as well as to those who choose not to answer the question.
– Receive and respond to patient concerns and complaints which may arise with respect to chaplains or staff in matters of pastoral care.
Within this organisational structure the chaplains’ roles are, in part, as follows:
– All chaplains are accountable to the co-ordinator of chaplaincy services.
– Sole responsibility is for the provision of chaplaincy services to members of their own confessional and non-confessional communities.
– The funding of all chaplains, including Humanist chaplains, is a matter between the chaplains and the sending body.
– The HSE removes itself from the consideration of the qualifications and religious responsibilities of chaplains. Such duties are a matter between the chaplain and the sending body.
– Chaplains who will have unsupervised contact with children or vulnerable adults must agree to Garda vetting as condition to serve as a chaplain within the HSE.
5. Concluding Remarks
We feel that the acceptance of the recommendations made in this Framework will:
– Meet the goals of achieving quality chaplaincy services across the HSE for all its users.
– Assure professional management and accountability for the delivery of such quality services.
– Improve patient care, confidence, and trust in the HSE’s chaplaincy services.
– Potentially reduce the cost to the HSE.
This submission has offered a review of the current chaplaincy services and their impact on those clients of the HSE who are not of a religion. It also has offered recommendations for the adoption of a Framework to assure the best interests of the patients are paramount and to provide quality chaplaincy services for all the people of Ireland. We emphasise the phrase, ‘for all the people of Ireland’, for our recommendations do not favour or disadvantage any element or class of the population in the delivery of chaplaincy services. As such we hold that this Framework is structured to serve the best interest of people of religion as well as of secular belief who may at some time seek hospital chaplaincy services. It assures no such user will feel estranged in any HSE-funded hospital.
Nicolas Johnson, Director Chaplaincy Services
Humanist Association of Ireland
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September 14, 2013