What training should be required as an education standard for healthcare and hospital chaplains?

Abstract: This document discusses training for hospital and healthcare chaplains in the light of different UK standards applied by various interested parties. It considers the different standards and concludes that there is no single applied standard for training for National Health Service (NHS) hospital chaplains across the UK. Those models that do exist take differing approaches, with some basing their systems on normatively defined views of what a chaplain needs to be effective on functional (NHS managerial) or interpersonal (clinical pastoral) levels, while others take a more hybrid approach blending these approaches with doctrinal concerns. Equally, there is wide variation across different denominations and employers. This document seeks to identify where there is common ground on domains of competence for chaplaincy training and suggest some progress for training which fits into NHS structures and systems.

Key Words: chaplaincy, healthcare chaplaincy, hospital chaplaincy, training, education

Devolution, Change and Professionalization 

The United Kingdom's National Health Service (NHS) employs over 1.3 million people, from doctors and nurses to allied professionals and chaplains. In recent years, the result of increasing devolution of government within the UK has resulted in four separate NHS systems, each governed, managed and operationally funded in different ways. Chaplains as a part of the care team have been important in the NHS for many years.

Within the NHS, chaplains are traditionally placed in service provider agencies. (1) Chaplaincy needs to demonstrate its value as part of the care process within this framework. This article will seek to survey the key policy trends impinging on training standards for chaplains, and seek to identify some domains of competence which could be applied toward developing a unified approach to training.

There are at least three distinct but overlapping policy trends that intrude on the functions of chaplains, and which make the development of agreed standards of training and ongoing professional development salient.

Firstly, there are a range of inter-related developments in the field of healthcare professional education and governance at the UK level that are now impinging on how chaplains perform their functions within the NHS. While concerns such as productivity, safety and structure of provision are always behind such national human resource programs, the developments in the NHS are also explicitly driven by the growing Clinical Governance agenda, a system whereby NHS organizations must continually improve and safeguard quality and standards of care. (2) There has been an increasing formalization of professional education and registration (whether statutorily or by professional bodies) of different healthcare professions within the UK. (3) Many healthcare professions are now registered by statute (nurses, midwives, doctors, dentists and a range of other allied professions) or have their own self-organized arrangements run by professional organizations under Royal Charter (psychologists).

A further major factor in this has been that the Government has developed national normative frameworks for knowledge and skills throughout the UK, (4) which encompass the importance of identifying key knowledge for professional practice with professional reviews of competence and ongoing development. The NHS Knowledge and Skills Framework (NHS KSF) defines and describes the knowledge and skills that NHS staff need to apply in their work to deliver quality services. It provides a single, consistent, comprehensive and explicit framework on which to base reviews and development for all staff. It lies at the heart of the career and pays progression strand of Agenda for Change. The NHS KSF process has been developed in partnership between management and staff-side representatives. This partnership approach is intended to continue as the NHS KSF is used in development review with managers working with individual members of staff to plan their training and development and review their work. (5) Agenda for Change, a pay and grading system put in place in 2004, has further influenced the impetus to continuing professionalization and education. (6)

Secondly, there is the impact of increasing devolution of government, in effect federalization, within the UK. The NHS is effectively run by four different governmental systems across England, Northern Ireland, Scotland and Wales, respectively. The NHS in Northern Ireland is accountable to the Legislative Assembly through the Northern Ireland Department of Health. Social Services and Personal Safety and is run and commissioned by four joint Health & Social Services Boards at the local level. NHS Scotland is accountable to the Scottish Parliament through the Minister for Health and Community Care and is run and commissioned by 15 local Health Boards. In Wales, NHS Cymru is accountable to the National Assembly through the Welsh Assembly Government and is run and commissioned by 22 Local Health Boards. In England the NHS is accountable to the UK Parliament through the Department of Health, is performance managed by 28 Strategic Health Authorities (12 from July 12, 2006) and commissioned by 301 Primary Care Trusts. Each nation of the UK has a range of national specialist bodies such as the National Institute for Health and Clinical Excellence (NICE) which provides guidance on effectiveness of interventions for the NHS.

Policy on chaplaincy also varies across each of the four nations. In each nation, guidance is issued on ensuring chaplains are employed, managed and trained. Policy frameworks in Scotland (7) and England, (8) for example, specifically mention the need to ensure chaplains are trained and competent and arrangements for ongoing training are provided. Scotland has funded and developed a National Healthcare Chaplaincy Training and Development Unit. (9,10) Moreover, for some chaplains, their role is a full-time professional role, paid by the NHS, and with career development prospects. For other faith groups, the role of chaplain is tied to the notion of parish ministry or arises from within the faith community. Tensions exist between the need to ensure full-time chaplains are paid and protected effectively and the need to ensure that the part-time or sessional chaplaincies are effective, safe and of good quality.

Thirdly, standards are affected by changes in the NHS structures across the UK, and an increasing emphasis on moving healthcare out of hospitals and into the community. (11) Each nation in the UK provides its health services directly to individuals through a variety of arrangements for General Practitioners (GPs) in primary care, and NHS Trusts which run hospitals in both acute and mental health sectors. Presently, the NHS in England is facing substantial reorganization as part of a movement across the UK (12) to move healthcare provision from hospitals into local communities. (13,14) The fact that chaplaincy has been historically a valued part of NHS provision does not mean that it is entirely protected from financial cuts and other exigencies of change. Furthermore, the evidence base for chaplaincy's impact on health and well-being is still being developed, thus adding a further strand of weakness in regards to policy. This is in part due to the fact that the nature of chaplaincy interventions may be very complex, along with the state of development of research within chaplaincy itself. (15) That said, the National Institute for Health and Clinical Excellence recommended that people with cancer should have access to a range of supportive care, including spiritual care, (16) despite its own review of evidence for spiritual care identifying that the evidence base needed further development. (17)

Distribution of Chaplaincy Stakeholders 

Despite the existence of a national NHS Knowledge and Skills Framework, the elements of the NHS KSF that consider spiritual care are limited and provide a focus on meeting religious needs rather than a detailed map or curriculum for education.

Against this gap, a variety of stakeholder bodies are engaged in the development, professionalization and governance of hospital chaplaincy. In England, Caring for the Spirit, a program run through the South Yorkshire Strategic Health Authority has been engaged in a substantial range of development activities for chaplaincy as a workforce. The Hospital Chaplaincies Council, an agency of the Church of England, provides a range of training and other initiatives. Other faith groups and denominations; Jewish, Free Churches, Roman Catholic, Church of Scotland and so on, have arrangements for national coordination and training. The Multi-Faith Group for Health Chaplaincy, (18) through its Standards Committee and the Chaplaincy Education and Development Group, created a framework of occupational standards designed to link to the NHS Knowledge and Skills Framework and enable chaplains to explain their work to others in structured terms. These are functionally oriented rather than taking a normative approach to what knowledge and skills are needed. While one unit specifically mentions "providing a theological and ethical resource on health care issues," (19) providing a detailed specification on what this would be is difficult because of the variety of theologies and ethical perspectives which exist.

Development of Common Frameworks to NHS Chaplaincy Training

A range of attempts have been made to provide training and competency or other models for chaplains in the UK. Within the Catholic Context, one degree course run in London seeks to equip future chaplains by being relevant not only to spiritual and theological issues but equipping them to manage the nature of the healthcare workplace too. The importance of context in which chaplaincy is undertaken is increasingly prominent in discussions on training in the UK. Cobb (20) seeks to provide a model emerging from the context in which chaplains are placed and work, and speaks of the difficulty of organizing a single body of knowledge and expertise: "In the US the canon of knowledge and skills for chaplaincy finds its clearest expressions through Clinical Pastoral Education, but in the UK where this tradition has never taken hold to any extent, the canon is less organized and more nascent." (21) He also identifies that one of the distinctive characteristics of chaplains is that they are representatives of another community in which they will have already undergone some type of formation and training; a community that is grounded typically in a tradition of faith and practice, and in a body of theological knowledge. In this sense, healthcare chaplains can be considered specialist practitioners of what is typically a well-developed clerical or ministerial profession. (22)

To add to this, a range of professional bodies for chaplains, denominational bodies and a range of academic institutions, some aligned with particular denominations, run training of various types. The College of Healthcare Chaplains, which is both a professional body and part of a trade union, has been engaged in work with other professional bodies to develop the Chaplaincy Academic and Accreditation Board (CAAB), a voluntary, nonstatutory and advisory board to some of the professional associations within the UK. Not all denominations have signed up to this at the time of writing, but CAAB aims to accredit some aspects of education and training for chaplains. (23) They have recently produced a report on advancing the role of chaplains as a profession (24) which concludes that:

"The aspiration of chaplains to be recognized as health professionals is in a formative period ... At present the goal for chaplaincy is obscured by the contentions of various organizations over roles and responsibilities ... This is partly a debate about the social and institutional apparatus of a profession but more importantly it is an ideological debate about the meaning, value and identity of chaplaincy. For this reason alone we need less political posturing and more critical thought and rigorous debate which are themselves characteristics of a profession."

This paper is valuable in that it identifies a range of different aspects to the development of chaplaincy as a profession, and that education and training is simply one aspect of this.

Toward a Common Framework: Organizational Psychological Perspectives

Cobb's criticism of the multifaceted and somewhat unfocused attempts to develop healthcare chaplaincy into a profession can be mirrored in a criticism of the differing approaches to training and development taken by a range of bodies. It is arguable that in developing a wide range of training designs focused on practical skills, interpersonal skills, theological knowledge and other aspects, the development of education for chaplaincy in the UK has still failed to provide a unified approach that enables chaplains to acquire and develop skills they need for a rapidly changing workplace which is the NHS. (25) In particular, this may mean that the transfer of needed skills to the situation where a chaplain interacts with a patient or a member of staff is not assured across all training frameworks. (26)

This situation has developed in part because while some chaplains have arrived in chaplaincy work with high levels of theological and pastoral education, others have very little education. Historically, there also has been a need to develop increasing differentiation between "professional" chaplains and those who assist in one or more functions attached to chaplaincy. (27)

Many recent advances in training and development, especially professional training and development, identify that there is a need to ensure both a "knows how" element of knowledge and a range of "shows how" domains of competency in real life practice (28) to what healthcare professionals do. (29,30) Domain-based methods of learning are a means of ensuring that an integrated approach to learning is taken and may help chaplains better integrate the range of perspectives they need to function effectively in practice. (31) They fit with the developing systems-based approaches in healthcare and the UK Human Resources' agendas for healthcare, which focus increasingly on functions in healthcare systems. (32)

Within systems approaches, however, the environment for learning needs to be able to support domain-based and integrative learning to provide truly effective chaplains (33) and to be backed up by an emphasis on continuing education. (34) The development and identification of domains comprising such different elements of "knows how" and "shows how" are needed to ensure that chaplains can function effectively throughout professional life. (35,36) A recent attempt to do this for Roman Catholic chaplaincy has been developed as part of the work of the Healthcare Reference Group of the Catholic Bishops' Conference of England & Wales. (37) This approach explicitly developed domains across areas of practice and learning. The domains are outlined as follows:

Theological. The core knowledge specific to the faith community;

Spiritual. Understanding and approaching religious and spiritual needs including liturgy, spiritual direction and spiritual practice;

Ministerial. Interpersonal skills including self care and working with others, boundaries, and effective interpersonal intervention;

Reflective Praxis and Development. Including one's own spirituality and spiritual life;

Sectoral Knowledge and Skill. Specific structural and cultural competence and knowledge on health issues;

Health and Social Sciences Applied to Chaplaincy. Organizational behavior (management, leadership), health psychology, medical anthropology.

While this framework is still aspirational, it has been fleshed out in more detail in the table. Whether it will or can be fully applied remains to be seen, but it presents a set of aspirations for lifelong development for chaplains, whether ordained in ministry or not, full-time or part-time. It will need some adaptation to context and type of ministry. This approach may not work for all denominations and faith groups, but it is at least an attempt to identify that there are a range of knowledge and skills domains across which chaplains can and should be expected to function (Table).

Conclusion: Developing a Domain-based Agenda for Education

This paper has discussed the need to develop domain-based agendas for chaplain education. While this, I argue, sits well with the increasing systems-based professionalization of healthcare, it needs specific theological articulation to be able to sit well with the vocation-focused identity of chaplains in many faith communities. Moreover, it is unlikely that chaplains will become statutorily registered or that governments in the rest of the UK will follow the NHS Scotland lead on training and development. As long as the CAAB are not recognized by all faith communities, and as long as the key constituent domains of what identifies chaplain roles are not agreed upon universally, the nature of NHS chaplaincy will not be enhanced. Interested bodies, therefore, should come together in a truly inclusive framework and seek to pool efforts to this end. This may, at least, need some initial government intervention. A domain-based approach provides both the flexibility for different faith groups to meet the part-faith, part-function education of chaplains while enabling NHS employers to feel secure that the Clinical Governance agenda is being met.

References

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2. Vanu Som C. Developing the human resource dimension of clinical governance. In Gray A, Harrison S (eds): Governing Medicine: Theory and Practice. Buckingham, Open University Press, 2004, pp 152-162.

3. Cole M. Learning through reflective practice: a professional approach to effective continuing professional development among healthcare professionals. Research in Post-Compulsory Education 2000;5:23-38.

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6. NHS Employers. Agenda for Change Update. London, NHS Employers, 2005.

7. Health Department of the Scottish Executive, Spiritual Care in NHS Scotland NHS HDL (2002) 76. Edinburgh, Scottish Executive, 2002.

8. Department of Health. NHS Chaplaincy: Meeting the religious and spiritual needs of patients and staff. London, Department of Health, 2003.

9. Health Department of the Scottish Executive, Spiritual Care in NHS Scotland NHS HDL (2002) 76. Edinburgh, Scottish Executive, 2002.

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11. Moberly T. Health care moves into the community. Pharmaceutical Journal 2006;276:129-130.

12. Department of Health. Commissioning a Patient Led NHS. London, Department of Health, 2005.

13. Department of Health. Our Health, Our Care, Our Say. London, Department of Health, 2006.

14. Department of Health. Commissioning a Patient Led NHS. London, Department of Health, 2005.

15. Hundley V. Evidence based practice. What is it? And why does it matter? Scottish Journal of Healthcare Chaplaincy 1999;2:11-14.

16. National Institute for Health and Clinical Excellence. Improving Supportive and Palliative Care for Adults with Cancer: The manual. London, NICE, 2004.

17. National Institute for Health and Clinical Excellence. Improving Supportive and Palliative Care for Adults with Cancer: Research and Evidence. London, NICE, 2004. pp 170-183.

18. Multi-Faith Group for Healthcare Chaplaincy. Available at: http://www.mfghc.com/.

19. Multi-Faith Group for Hospital Chaplaincy. Healthcare Chaplaincy Occupational Standards: A Map of the Standards. Available at: http://www.mfghc.com/standards_map.htm. Accessed May 10, 2006.

20. Cobb M. The location and identity of chaplains: a contextual model. Scottish Journal of Healthcare Chaplaincy; 2004;7:10-15.

21. Cobb M. The location and identity of chaplains: a contextual model. Scottish Journal of Healthcare Chaplaincy; 2004;7:14.

22. Cobb M. Hospital Chaplains' Handbook. Norwich, Canterbury Press, 2005, pp7-48.

23. Chaplaincy Academic and Accreditation Board. Accreditation. Chaplaincy Academic and Accreditation Board. Available at: http://www.caabweb.org.uk/accreditation.asp.

24. Cobb M. Advancing the agenda for professional chaplaincy. Chaplaincy Academic and Accreditation Board. Available at: http://www.caabweb.org.uk/uploadedfiles/Advancing%20the%20agenda%202006%20final.pdf. Accessed May 10, 2006.

25. Gist ME. Training design and pedagogy: implications for skill acquisition, maintenance and generalization. In Quinones M, Ehrenstein A (eds): Training for a Rapidly Changing Workplace: Applications of Psychological Research. Washington DC, American Psychological Association Press, 2002, pp 201-222.

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27. Vandecreek L. Professional Chaplaincy and Clinical Pastoral Education Should Become More Scientific: Yes and No. New York, Haworth Press, 2003.

28. Sorrells-Jones J, and; Weaver D. Knowledge workers and knowledge-intense organizations, part 3: implications for preparing healthcare professionals. Journal of Nursing Administration. 1999;29:14-21.

29. Scally G, Donaldson L. The NHS's 50 anniversary. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61-65.

30. Oxman AD, Thomson MA, Davis DA, et al. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 1995;153:1423-1431.

31. Bretz RD, Thompsett RE. Comparsing traditional and integrative learning methods in organisational training programs. J Appl Psychol 1992;77:941-951.

32. Patrick J. Training: Research and Practice. London, Academic Press, 1992, pp 109-130.

33. Clarke N. Workplace learning environment and its relationship with learning outcomes in healthcare organizations. Human Resource Development International 2005;5:185-205.

34. Davis DA, Thomson MA, Oxman AD, et al. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA 1992;268:1111-1117.

35. Nijhof WJ, Brandsma J (eds.) Bridging the Skills Gap Between Work and Education. New York: Springer, 1999, pp 138-164.

36. Nijhof WJ, Heikkinen A, Nieuwenhuis L (eds.) Shaping Flexibility in Vocational Education and Training: Institutional, Curricular and Professional Conditions. New York: Springer, 2003, pp 201-249.

37. Healthcare Reference Group. Keeping Faith. Draft. London, Catholic Bishops' Conference of England and Wales, 2005, pp 34-41.

You have not coverted a man because you have silenced him.
--John Viscount Morley

Jim McManus, BD(HONS), DIP. SC, DIP. PSYCH, DIP. PSYCHOL, DFPH, FRIPH, CHARTERED MCIPD, MIHM, FSA. SCOT

From the Barking & Dagenham Primary Care Trust, Essex and the Healthcare Reference Group, Catholic Bishops' Conference of England & Wales, London, United Kingdom.

Reprint requests to Jim McManus, Assistant Director of Public Health Public Health Directorate, Barking & Dagenham Primary Care Trust, The Clock House, East Street, Barking, Essex, United Kingdom, IG11 8EY.

Disclosure of all financial support: This work was undertaken on a pro bono basis and attracted no funding, either public, voluntary or private

Proprietary Statement: The Healthcare Reference Group of the Catholic Bishops Conference of England & Wales identifies the training and competency model as its own production and this is copyrighted [c] by the Healthcare Reference Group.

RELATED ARTICLE: Key Points

* Healthcare chaplains require a multi-dimensional education and training across a range of domains.

* These include theological, interpersonal (clinical) and healthcare domains.

* As yet in the UK no model truly akin to US style Clinical Pastoral Education exits.

Table. One RC Model of domains of knowledge and competence for
healthcare chaplains

Domain                      Indicative Content

Theological                  1. Scripture
Ordained chaplains and       2. Ethics
  full-time lay chaplains    3. Bioethics and moral theology
  may have a higher level    4. Philosophy
  of training in this than   5. Theology
  part-time lay chaplains    6. Ecclesial teaching
                             7. Theological foundations for ministry
                             8. Theology of pastoral care
                             9. Theology of ministry
                            10. Theology of worship
Spiritual                   11. Personal life and discipleship
                            12. Prayer and worship life
Ministerial                 13. Practical theology
Ordained chaplains and          a. Boundaries and ethics
  full-time lay chaplains       b. Integrity
  may have a higher level       c. Self-care
  of training in some of        d. Canon law
  these than part-time lay      e. Pastoral practice
  chaplains, and some           f. Pastoral care including counseling
  chaplains will have              and other skills
  areas of specialty (eg,          i. The casework relationship
  bioethics)                       ii. The chaplaincy relationship
                                   iii. Integrating spiritual, religious
                                        and other needs to a chaplaincy/
                                        casework relationship
                                   iv. See also Health psychology below
                                g. Bioethics and moral theology applied
                                   to NHS healthcare
                                h. Management and leadership
                                i. Change management
                                j. Facilitation
                                k. Mentoring and supervising others
                                l. Being mentored and supervised
                                m. Pastoral psychology
                                n. Homiletics
                                o. Christian education
                                p. Faith development
                                q. Liturgy and worship
                            14. Sources and norms in practical theology
Reflective praxis and       15. Practical theology continued
  development               16. Self-care
                                a. Boundaries
                                b. Health, stress and coping
                                c. Self-care after difficult emotional
                                   situations
                                d. Self-care after trauma
                                e. Integrated self-care strategies
                            17. Lifelong development
                            18. Learning styles
                            19. Mentoring and supervision
Sectoral knowledge and      20. The NHS
  skill                     21. Clinical governance
                            22. NHS policies and practice
                            23. Confidentiality
                            24. Interprofessional and interagency
                                working
                            25. Key knowledge and skills for area (eg,
                                clinical field such as cardiology or
                                palliative care)
                            26. Managing chaplaincy departments/realms
                                (where appropriate)
                            27. Training/Developing other chaplains
Health and social sciences  28. Sociology of health and illness
  applied to chaplaincy     29. Sociology of NHS settings
Some parts of health        30. Comparisons of Catholic Health Care
  psychology should be          Ethics and current NHS Health Care
  applied at stage 2            Ethics frameworks
                            31. Health psychology and behavior
                                a. Psychological aspects of health and
                                   illness
                                b. Psychological development across the
                                   lifespan
                                c. Health behavior
                                d. Stress and anxiety
                                e. Coping
                                f. Grief and bereavement
                                g. Pain
                                h. Biopsychosocial pathways in health
                                   and healing
                                i. Patient professional communication
                                j. Social and spiritual support and
                                   dimensions of health
                                k. Behavior change and maintenance
                                l. Avoidant coping
                                m. Abnormal psychology
                                n. Trauma and response
                            32. Communication with patients
                            33. Sector-specific knowledge of diseases
                                (e.g., coronary heart disease, cancer,
                                etc)