Pastoral care in the LTC setting

Health Progress, Mar/Apr 2002 by Tomsic, Karin

Just as Death Is Part of Life, Spiritual Care Should Be Part of Long-Term Care

"Nursing homes," I once heard it said, "are built on a mountain of unexpressed grief." The speaker was referring not only to the grief of a resident facing debilitation and death but also to the grief of the resident's family and professional caregivers. The speaker went on to describe the psychological walls that people build to protect themselves in such an atmosphere. Staff turnover, difficulties in hiring and assimilating new employees, troubled relationships between staff members and residents and their families-all such problems are at least partly caused by unexpressed grief.

It is easy to understand the grief of residents and their families. Most people enter long-term care because of debilitating illness or injury. Frequently such people have outlived a spouse or family caregiver and are now losing home, routine, and everything familiar. Their family members often feel guilty about placing their loved one in a long-term care (LTC) facility. That guilt is sometimes expressed as anger and dissatisfaction, which can cause friction with both their loved one and the staff. Meanwhile all involved ask themselves, "Why is this happening?" "What does this mean?" and "Will this happen to me?"

STAFF GRIEF

Our institution, St. Joseph's Manor, is a 297-bed LTC facility in Trumbull, CT. I direct the Pastoral Care Department, which is composed of four certified chaplains, one appointed priest chaplain, and one pastoral assistant.

When I first began working in long-term care, I was struck by the complete dominance of the medical model. It seemed to me that the "nursing" part of the phrase nursing home had completely overshadowed the comfort implied by "home." I later came to realize that the medical model reigns in long-term care because people with medical backgrounds dominate the LTC regulatory process. Current regulations, rooted as they are in the concept of self-determination, are meant to help caregivers formulate care plans according to resident values and goals. Of course self-determination involves risk; self-determining elderly people sometimes fall and hurt themselves. Yet those who do the regulating question the resident's every fall, every pound of weight lost, and every decline in his or her health status.

In such an atmosphere, it is understandable that acute care methods have gradually become accepted as proper care for the chronically ill and aged. LTC professionals, who work very hard to care for their residents, sometimes feel overwhelmed and discouraged by a system that continually criticizes their efforts. Because people today live longer than they used to, society contains more people suffering incurable, progressive, and eventually fatal illnesses.' It is thus no wonder that grief is so common.

PROFESSIONAL PASTORAL CARE

One way LTC leaders can begin to address this situation is by adding staff members trained to deal with grief in all its varied forms, namely certified pastoral chaplains. Health care chaplains are generally certified by one of several bodies, for example the National Association of Catholic Chaplains (NACC). NACC certification is based on professionally determined criteria designed to produce competent, qualified chaplains.

The criteria are:

* Theological training (usually an advanced degree)

* Four units (a unit is 400 hours) of clinical pastoral education (CPE)

* Endorsement by a faith community

* Certification by the commissioning body

CPE combines pastoral theology and psychology. After completing it, a candidate for certification in NACC submits documentation of his or her compliance with 30 standards addressing personal, theological, and professional competencies.2 The NACC reviews these documents and then schedules an interview for the candidate with a certification team of three examiners. Following the interview, the team for-wards its recommendation to a seven-person certification commission. Although the commission often accepts the team's recommendation, it is not bound to do so.

Every five years, to maintain their status, certified chaplains submit documentation of 150 hours of continuing education and are quizzed by a peer reviewer on their skill in applying what they have learned. These actions, which ensure the chaplain's competence and ability, are important because the certifying body shares in the chaplain's liability, according to Michele LeDoux Sakurai, a former NAAC official. "Many healthcare administrators are unaware that they are liable for the actions of visiting clergy," Sakurai said in a telephone conversation. "But a certified director of pastoral care has the training and background to observe other ministers coming in to provide pastoral support and to assess their competency to 'do no harm. "'

Most chaplains also receive some training in ethics. Some people view the ethical issues that arise in long-term care as less dramatic than those in acute care, but LTC issues are equally challenging to discern. Professional chaplains have much to offer in helping residents, their families, and other LTC staff.