Tending to the Whole Person: Healthcare Chaplaincy and the United Nations Millennium Goals 2015
Rabbi D’vorah Rose
Founder, director at Integrating Spirituality with Healthcare Practice.
Abstract: Healthcare chaplaincy is a young field. The study of the impact of spirituality and religiosity upon health status is also a newer field. This essay examines in broad strokes what healthcare chaplaincy currently offers, reviews some of the current spiritual care assessment tools in use, introduces some new assessment approaches, and demonstrates how healthcare chaplaincy can help accomplish the UN Millennium Goals.
Keywords: spirituality, religion, religiosity, healthcare, chaplain, chaplaincy, UN, United Nations, millennium, goals, development goals, spiritual care, spiritual assessment, healthcare, professional chaplain, ethnography and healthcare, anthropology and healthcare, cultural competency, religious competency, cultural assumptions, religious assumptions
Thanh, a Vietnamese patient in his 40’s, is admitted to his local hospital’s ICU in Canada. His family brings with them their own food and bedding supplies. The charge nurse explains that they cannot bring in their own items because the patient has lowered immune function and anything not sterilized could make him even more ill. Hearing these instructions, the family becomes deeply distressed and discusses removing Thanh from the hospital. If the hospital’s healthcare chaplain uses the robust spiritual care assessment tool and orientation that I will present in this article, she will learn that: In the 1970s to the early 1990s in Southern Vietnam, where the patient was born and raised, admission to the hospital was often regarded as the setting of last resort, and was often the place where patients died. Furthermore, a patient had to bring his own supplies if he was to have food or bedding¹. While this is not an obvious religious or spiritual issue, by eliciting this information, the chaplain can be a reassuring presence to the family, an advocate for them, and help them move from the experience of what the hospital used to mean to what it can mean for them now. This will help the patient and family become partners with the healthcare team and will enable the patient and his family to more readily confront whatever comes next for him, medically.
We know our world is becoming increasingly connected via technology and travel. It is also becoming increasingly mixed culturally, religiously and ethnically as migrants, immigrants and refugees enter states and nations within which their peoples have not previously resided, or have resided only in small numbers. One consequence of these population shifts is that there are now interactions in local communities and in local community healthcare institutions of religions, cultures and ethnicities that have never met before but about whom are often held long-standing beliefs and misperceptions; and in some cases, these peoples have met only through being opponents during war or when one group was actively oppressing the other. Further, it is no longer unusual for a healthcare chaplain to work with a patient, family or healthcare provider who is from a culture or religion to which the chaplain has not had prior exposure.
Moreover, due to technology and personal interactions, cultures, religions and spiritual traditions the world over are influencing each other more quickly than ever before. Some consequences of these exposures is that personal self-identities and religious communities’ identities are forming and reforming – morphing, one might say – at incredible rates and in ways that are unprecedented. For instance, in the past, a generation was understood to span around 20 – 35 years. Now, they can span as little as just a few years, in great part due to the influence of new technologies quickly arising and creating new ways of understanding one’s self and one’s world. With the incredible cultural and religious interactions now occurring, now more than ever we cannot make assumptions about a patient’s background or needs, just because we have been told the person’s religious or cultural identity.
I have been in the healthcare field for most of my professional life, first as a registered nurse, and now as a rabbi and interfaith healthcare chaplain. I have seen these changes taking place and have had the delight of serving some of the most culturally and religiously diverse communities in the United States. In serving these communities I have noted these issues directly.
In this essay I would like to reflect on two related issues:
1.) Our world has become so connected that healthcare chaplains need to be familiar with many different cultures and religions/spiritual traditions. While there are good resource materials on Cultural Competency (a good example is the Ethnogeriatic Program at Stanford University), it is not possible to be deeply knowledgeable about every group with which one might interact. Thus, I will propose some supplementary spiritual care assessment tools and approaches for healthcare chaplains to use. These will enable a healthcare chaplain to elicit a more robust picture of a patient’s cultural and religious background, experiences, and beliefs.
2.) Healthcare chaplaincy, especially when practiced from a multicultural, multifaith and advocacy perspective, can support many of the UN Millennium Goals.
The first question might well be, why does healthcare chaplaincy matter? We now have over twenty years’ of scholarship and anecdotal evidence that spirituality² and religiosity³ can have significant impact on a patient’s well-being. In general, this is no longer the primary question in healthcare settings. Rather, we are now focusing on finding best practices, refining assessment tools, integrating this knowledge into healthcare providers’ training, and looking to move the field forward into new areas of research and application.
Healthcare Chaplaincy is still a young field. While there are good working definitions of what it is and how it functions, what this healthcare practice can provide is still being discovered and discussed. We do know that professional healthcare chaplaincy does have a positive impact on the well-being of patients, their families and upon healthcare providers themselves. I believe professional healthcare chaplaincy can also have a positive financial impact upon healthcare systems and institutions. This is an area not yet explored.
Healthcare chaplains in North America were initially primarily male, Caucasian, and from mainline Protestant or Catholic communities. Increasingly, clergy and religious/spiritual lay leaders are entering the profession who are from a wider range of religious and spiritual communities, many who are female, and some who identify on the LGBTQI spectrum. We now have chaplains who serve their own communities as well as chaplains who serve multiple religious and spiritual communities. So, for instance, a professional healthcare chaplain in a hospital may be an ordained female, African-American Baptist minister who is serving those from her own church community as well as Wiccans, Jews, Muslims, Catholics, and Buddhists. Healthcare chaplains are also trained to provide meaningful support to those patients and healthcare providers who identify as atheist or agnostic.
In the field of spirituality and health, quite a few spiritual care assessment tools have been developed. Two of the currently best known are FICA and HOPE. These have been created by physicians. There have been some created by nurses and by social workers, but they have not attracted the same degree of popularity as the ones created by physicians. A few have been created by healthcare chaplains, such as the 7 x 7 Model. In general, all of these assessment tools focus primarily on overt religious, spiritual or theological questions. This reflects the overall emphasis within spirituality and health training and research – a primary focus on theological beliefs and practices, with a secondary focus upon family systems theory and systems psychology. Since healthcare chaplaincy was initially called pastoral care (and in many places still is), it makes sense that the primary focus was upon overtly theological issues and experiences. But, if these are the only issues for which the provider is looking, then he is going to miss all of the other factors that can be impacting upon the patient’s experience. Just as the same medicine or identical dosage does not work for all patients, spiritual care is not a one-size-fits-all healthcare tool.
Current spiritual care assessment tools most definitely should be used within the practice of healthcare chaplaincy (and the study of spirituality and health). I would argue, though, that there has not been nearly enough focus on how to understand the patient’s and family’s experience outside of that overt theological orientation. We really cannot start working with a patient and her family (or healthcare providers, for that matter) with the idea that they exist only in the present moment, and that we are only looking for the obvious, standard religious or spiritual needs queries such as, “what type of religious or spiritual community do you belong to; what gives you meaning in your life; and how have you dealt with difficult situations before?”
To most fully capture nuanced experiences and beliefs so as to accurately assess the patient’s/family’s/staff’s spiritual/religious and cultural needs, the healthcare chaplaincy field needs to develop more robust spiritual assessment tools.
Example One: Misha, an elderly Russian Jewish patient, does not wish to be admitted to the local hospital in his town in Iowa because he had distressing experiences with the medical system as a child in the Former Soviet Union, some of which he experienced as directly related to being Jewish. His physician convinces him to allow the admission. Once in the hospital, he becomes increasingly anxious and the patient and his family start questioning everything the healthcare providers are recommending. Ultimately, the patient and his family become non-compliant and leave the hospital Against Medical Advice4.
The chaplain could have elicited information from the patient and his family at the beginning of his admission that might have prevented the above scenario from occurring. Had the chaplain used spiritual care assessment tools that invited the patient and his family to share about their past experiences and their current reactions to the hospital setting, the chaplain could have advocated for their particular needs and explained their historical and religious sensitivities to the healthcare team. The chaplain could have gone on to be a reassuring presence for the patient and family, and helped cultivate a positive experience for the patient, his family, and his healthcare providers.
The approach I describe first with Thanh and then with Misha is one of cultural, historical and religious curiosity. The spiritual care assessment skill is framing one’s questions from a sociological and anthropological perspective, with a special focus on ethnography.
These are some of the core issues to consider from this perspective:
1.) How does the historical background of the patient and his family influence how they approach and experience the current healthcare event, setting, and healthcare providers?
2.) What communities/cultures has the patient interacted with in the past that might impact how she responds to the current healthcare setting and providers?
3.) What does the patient hear (e.g.: what is the meaning of the words to the particular patient and family) when certain words are used such as ill, well, cancer, discontinue life support, dead, prayer, blessing, miracle. Does the meaning change based upon the person relaying the information? What impact does the communicator’s gender, race, ethnicity, age, status, religion, etc. have upon how the message is received, processed and integrated? Using a basic ethnographic orientation is particularly useful here5.
Example Two: A Filipina nurse regards her two female patients with Hispanic names as basically interchangeable, because they are both female, both speak Spanish, and both are Catholic. She assumes that Maria will be simpler to work with and more willing to do what the doctor has ordered, since she appears to be well-educated. Moreover, the nurse assumes that she and her two patients will automatically understand one another as they all speak Spanish, are female, were not born in the U.S., are the same religion, and are approximately the same age. The nurse makes automatic referrals to the hospital’s Catholic priest to visit the two patients to offer Communion. If the nurse applies the curiosity and basic sociological and ethnographic approach, she will learn that:
Maria is from a wealthy family based in Mexico City. She is fluent in three other languages, has been educated in Britain and Switzerland, and prays to the Virgin of Guadalupe. She has been exposed to enormous violence as a child due to the narcotics cartels in her home town. She has strong symptoms of Post-Traumatic Stress Disorder when she hears certain sounds or hears certain words pronounced a particular way. As a result of this violence, although she is Catholic, her religious and prayer life are now profoundly different from the traditional Roman Catholicism of her parents, and she has significant spiritual distress because of this divergence from her family’s traditions, beliefs and practices. She feels very guarded around those whom she regards as placing themselves in authority positions and so has significant distrust of her physicians, especially the ones whom she thinks look similar to the narcotics dealers from her home city. She is nervous around Catholic priests.
Rosa is from Guatemala and grew up in a fairly poor farming community. Her family is also Catholic, with a strong faith in the Catholic Saints, especially the local ones (some of whom are not recognized by the Roman Catholic Church). Rosa’s community has not been impacted by violence, so she has a fairly secure sense about her place in the world and in a beneficent transcendent presence watching over her and her family. She does not feel the need to be guarded around authority figures and easily discusses her health care needs with her nurse and doctor. She is at ease with Catholic priests6.
As you can see from the spiritual care assessment tools listed earlier in this essay, they are not well designed to capture the cultural or historical milieu that help shape these patients’ and families’ beliefs about the meaning of being in the hospital and the subsequent needs for support and reassurance that are needed. I suggest that the healthcare chaplain will often serve the patient, family and other healthcare providers (and the healthcare institution) more effectively by identifying early on in the admission these types of experiences and the beliefs arising from them. Then, the chaplain can move more easily, with greater rapport and greater relational trust into approaching more standard religious or spiritual issues.
One of the current difficulties in the field of spirituality and health research is the attempt to quantify what effective spiritual care looks like, as well as the effects of this care. There is much important research already conducted of this nature and much more in progress. However, we will miss a lot about this work if we do not also employ skillful qualitative research. As more research is conducted in more regions and countries, amongst a wider array of cultures and amongst those who are and those who are not religious, using a meaningful qualitative approach combined with quantitative studies will help the field become increasingly nuanced and rich.
The UN Millennium Goals are compelling because of their holistic view of humans’ needs and rights. Since the UN is transnational, these Goals become a unifying organizational tool for all nations. Professional healthcare chaplaincy can contribute toward the fulfillment of the UN Millennium Goals by striving to make healthcare accessible for everyone. This can be accomplished via the chaplains’ focus upon the conditions (emotional, spiritual, sociological, economic, historical, etc.) that create barriers for the patient and her family. These UN Goals either are already integrated into regional and national planning, or are in the process of being integrated. I would urge that robust healthcare chaplaincy be recognized as a powerful tool that can help nations address accessible and inclusive healthcare for all their people. For instance, in the United States, as the Joint Commission continues to address standards of care within accredited healthcare institutions, the healthcare-related UN Goals could become woven into their expectations. Especially in the focus upon patient rights, including the right to non-discrimination based on gender, sexual or gender orientation, age, religion, etc., the UN Goals are already reflected. It might be a powerful support to U.S. healthcare providers to know that these standards are reflected internationally.
Professional healthcare chaplains are either ordained clergy or recognized religious/spiritual leaders within their traditions. All religious and spiritual traditions teach that clergy are to help the poor, the disenfranchised, and those who are without power; in other words, the vulnerable. One can easily argue that the vulnerable include those who are in need of medical support.
For the sake of length I will not parse out every goal for which healthcare chaplaincy can be a supportive element, but will instead provide a few examples.
As written so eloquently in the UN Millennium Goals
Goal 16. We acknowledge the diversity of the world and recognize that all cultures and civilizations contribute to the enrichment of humankind….
The whole point of meaningful, appropriate and robust healthcare chaplaincy is the recognition of different cultures and religions – that diversity is complex and multifaceted and needs to be approached as such.
Goal 23. Adopting policies and measures oriented towards benefiting the poor and addressing social and economic inequalities….
Meaningful healthcare chaplaincy helps open up the healthcare delivery system so that those who have experienced oppression or barriers to care feel (and are) safe to enter into that system. For instance: An impoverished Muslim Afghan lesbian with a breast lump may have experienced so much judgment about being Muslim and homosexual that she has not tried to enter the healthcare system for diagnosis or treatment. Most likely she will become seriously ill and die an agonizing death – neither of which necessarily need occur if she can receive effective medical treatment and management. The healthcare chaplain can be an advocate for the patient and a reassuring, non-judging presence. The chaplain can also become a support and guide to healthcare providers and policymakers who would withhold healthcare access to patients they consider to have become ill due to perceived poor moral character.
Goal 28. We recognize that policies and actions must focus on the poor and those living in the most vulnerable situations, including persons with disabilities….
Healthcare chaplains act as advocates and a reassuring presence for patients who are the most vulnerable. This includes those who are impoverished and those with disabilities. Not infrequently, if a patient has developmental disabilities, physical or emotional disabilities, or has hearing or vision impairments, they are often unable to access the healthcare system or if in it, are unable to receive the support needed for them to receive appropriate care. If the patient lives in poverty, they may have no access to care or may be unable to afford the care that is available.
These are situations in which healthcare chaplains can work one-on-one with the patient/family but also use their clerical authority and community-organizing skills to work toward making the changes necessary in the local community so that all who need healthcare are well-served.
Healthcare chaplaincy that recognizes and supports each patient as an individual with full rights to healthcare and support at the end of life is, at its foundation, practicing respect for, promoting, and protecting human rights.
Goal 54. We acknowledge the importance of gender equality and empowerment of women….
So often, healthcare is still skewed toward only male family members receiving care and acting as the family healthcare decision-makers. Healthcare chaplains can act as advocates for the women and girls in the family or community who are prevented from being regarded as fully deserving of healthcare, or worthy of making healthcare decisions for themselves and their families.
Example: The patriarch of an Afghan family declares he wants his wife to be cured as quickly as possible and for as little cost as possible so that she can return to the home to care for him and his children. The physician supports the patriarch’s desires. Because both the physician and the patriarch assume the decision-making authority and family structure is accepted and agreed upon by the wife, they fail to learn from the wife that she is fearful of returning home because she feels too weak to tend to the large family’s demands.
Promoting global public health for all to achieve the Millennium Development Goals
We commit ourselves to accelerating progress in promoting global public health for all….
Preparation for emergencies should include a well-trained emergency response chaplain team. We know that spiritual and emotional needs must be tended to just as strongly as physical needs during and after emergencies and disasters. Providing this care concurrent to physical care diminishes Post-Traumatic Stress Disorder and related stress responses afterward. It promotes faster and more complete recovery – physical as well as emotional.
Millennium Development Goal 4 – Reduce child mortality
(g) Working to ensure that the next generation is born HIV-free by providing, on an urgent basis, extended and sustainable coverage and improved quality of services to prevent mother-to-child transmission as well as increasing access to paediatric HIV treatment services….
Because HIV infection continues to be regarded by so many as a morally-derived illness, healthcare chaplains can act as advocates, educators and non-judging presences for individual patients, their families, their healthcare providers and their communities.
In general, professional healthcare chaplains are patient advocates, educators, non-judging clerical presences and religious and moral authorities. Chaplains can help remove healthcare barriers, especially when they are culturally, religiously, or morally-derived.
Healthcare chaplaincy is still a young field and we are constantly learning what this work can offer patients, their families and friends, healthcare providers, and healthcare institutions. We are just learning how it can have a positive impact upon a region’s and nation’s healthcare system and well-being of its citizens. Part of understanding what this discipline can provide is to keep pushing at its edges to see how and where it intersects with other more-established disciplines. Moreover, as introduced in this essay, healthcare chaplaincy can help support the accomplishment of the UN Millennium Goals. This is an important leadership role that healthcare chaplains around the globe should be cultivating.
 Example is a composite with no real names used, derived from my professional experience.
 There is no agreement on how to precisely define or measure spirituality. It is typically understood as the inner experience a person has in regard to or in relationship with the divine, sacred or transcendent, or with what provides meaning to that person’s life. A person may identify as spiritual but not religious.
 There is no agreement on how to precisely define or measure religiosity. It is typically understood as the external activities and practices of a person who identifies with a religious community.
 Example is a composite with no real names used, derived from my professional experience.
 Examples are composites with no real names used, derived from my professional experience.
Craddock Lee, S.J. (2003). In a Secular Spirit: Strategies of Clinical Pastoral Education.
Health Care Analysis, Vol. 10, 339–356.
Feldstein, B., Rose, D., & Winograd, C. (2008). Judaism. In S. Brangman, M. Grudzen, C. Pan, & G. Yeo (Eds.), Doorway thoughts: Cross-cultural healthcare for older adults (Vol. 3, pp. 99-118). Sudbury, MA: Jones and Bartlett Publishers.
Koenig, H.G., MD. (2004). Religion, Spirituality, and Medicine: Research Findings and Implications for Clinical Practice. Southern Medical Association, 1194-1200.
McArthur, J.W. (2013, March/April). Own the Goals: What the Millennium Development Goals Have Accomplished. Foreign Affairs, 152-162.
United Nations, Sixty-fifth Session, 19 October 2010, Resolutions adopted by the General Assembly, Keeping the promise: united to achieve the millennium development goals (A/RES/65/1).
This article was published on April7th: World Health Day in Global Education Magazine.