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April 2006 Article of the Month
 
This month's article was submitted by Joan Hemenway, ACPE President.
The summary and comments here are by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.

 

Norwood, F. "The ambivalent chaplain: negotiating structural and ideological difference on the margins of modern-day hospital medicine." Medical Anthropology 25, no. 1 (January-March 2006): 1-29.

 

SUMMARY: This month's featured article reports a 12-month ethnographic study of chaplains in a pastoral care department with a CPE intern program in 1997-1998, based on "data gathered by participant observation and in-depth interviews with 10 chaplains, the chaplain director, Roman Catholic chaplains, and other hospital staff" [p. 26, note 3]. Though this research is now over eight years old, and though some of the author's conclusions may strike many professional chaplains as debatable, the author puts forth a number of interesting points for discussion in chaplaincy circles. The author herself welcomes feedback from chaplains by e-mail to francesnorwood@aol.com.

As the title suggests, Frances Norwood characterizes hospital chaplains as "ambivalent" and "on the margins of modern-day hospital medicine," though the terms require some explanation. Her use of ambivalent is rooted in her observation that "the highly nuanced practice of modern-day chaplaincy includes a range of activities from the sacred to the profane that situates chaplains somewhat precariously between competing paradigms of science and religion" [p. 3] and that "the position of the modern-day chaplain within a world of medicine is a difficult one that is situated between structural differences that revere medical forms of power, hierarchy, and practice over religious ones" [p. 4]. In light of this, she perceives chaplains operating at times out of a medical paradigm and at times out of a religious one, resulting in a kind of ambivalence that may be professionally necessary "in order to survive" [p. 4]. Such survival, though, is located "on the margins of medical science, at the margins of medical power and hierarchies" [p. 15] --margins that are an "active, dynamic, and contested ground where agents negotiate for power and for place" [pp. 7 and 25].

The author focuses on the CPE interns in the pastoral care department of what appears to be a large teaching hospital (though the identity of the hospital, as well as the names of study participants, have been protected [--see note 1 on p. 26]), especially during their early acclimation to "the newness, the other-worldliness, of the hospital environment" [p. 7].

What tangled interns up the most in the beginning were: 1) the bureaucratic space of the hospital and some of the different rules for moving around the hospital and engaging others within that space, 2) figuring out how to approach patients in an environment that was not always set up to provide them with patients, and 3) becoming familiar and comfortable with medicine's view of the patient body. [p. 9]
Each of these points is illustrated and explored [--see pp. 10-14], leading to a discussion of socialization and acclimation to the medical setting that expands the theme of chaplains' "ambivalence": particularly how at times chaplains embrace their religious orientation (i.e., a religious way of thinking about and being in the world) and at times distance themselves from it in order to "negotiate and penetrate structural and ideological difference in the hospital" [p. 15].

Norwood seems to find chaplains consistently confronted with ideological and structural barriers (and often simply physical barriers to access to staff areas) as well as medical staff "gatekeepers" who may have "only a limited (or stereotypical) understanding of what chaplains do" [p. 18]. The author's depiction of chaplains is certainly not that of fully empowered and integrated members of a hospital staff, but she does point out their importance, noting that "medicine is not complete without the perspective and the orientation that chaplains bring" [p. 21].

What chaplains bring to the world of medicine is a different conception of the patient body. To the chaplain, the body is what I call a holy body, a (w)holy body that is not separated by organ, disease or skin; or by conceptions of sacred and profane. Nor is it separated from familial, societal, or Divine relationships. It is through the concept of the holy body that chaplains embrace their religious orientation to the world, bringing perspective, practice, and authority to the hospital setting that staff, patients, and families recognize. In the hospital setting chaplains embrace the religious structure, strategically distancing themselves from the dominant medical paradigm in at least three ways: 1) through their special kind of witnessing, 2) through touch, and 3) through serving as a stop-gap resource for patients who are suffering from issues deemed by staff to fall outside of medicalized versions of patient bodies and health. [pp. 21-22]
These points are illustrated [--see pp. 22-25] and are connected to the author's conclusion:
Chaplains are alive and well, if at the margins of medicine. By balancing paradigms of medicine and religion, the modern-day chaplain has been able to forge a strategic, ambivalent existence" [p. 26].

COMMENT: As a chaplain, and as part of a pastoral care department that has itself recently been the subject of an ethnographic study (as yet unpublished), I find value in the perspective on chaplaincy by anthropologists, who may have significant insights and who may raise up questions of how we appear to others and how we may need to interpret our activity and role to those who observe us. I appreciate that the present article has caused me to think specifically about ways that I may distance myself from--or embrace--a "religious orientation" in the course of my pastoral practice, and about what structural and ideological tensions and forces that I feel in the hospital may move me one way or the other. The article has also led me to muse about how my own experience of chaplaincy in a tertiary acute care hospital has tended to give me a very different sense of ministry in health crises than that of many congregational clergy. And, some of Norwood's anecdotes recall for me the feeling of being in a strange other world when I began CPE (though part of that was due to the strangeness of CPE as a learning process, over and above the strangeness of the hospital setting).

However, the article does not contain a section on limits to the study, typically found near the end of reports of research. I would like humbly to suggest a few potential limits. First, the data collection period (1997-1998) occurred while the present-day interest in spirituality by health care providers was still quite new, and since the time of the study it may be that the structural and ideological issues identified in the article have become less barriers for many pastoral care departments than have budget cuts due to broad changes in health care economics in the US. In the course of the past ten years, also, the structural and ideological dominance of medicine in health care institutions has itself been affected (so that today it might be argued that hospital staff are pressed into a kind of ambivalence between a medical orientation and a business orientation). Second, while the author focuses on the difficulty of CPE interns in their acculturation to the hospital context, she does not explore other potential paradigm shifts that the interns may be experiencing as they bring their own religious orientations into the practical realm of careers in ministry. For instance, is the paradigm shift required by the hospital as significant as that required by their seminary experience or by CPE as a learning modality? Perhaps such other encounters with structural and ideological difference are not central to the subject of the research at hand, but it seems worth noting that CPE interns may be learning chaplaincy in the midst of other profound challenges to their personal religious orientations. Third, and this is the most important to my mind, the data here, taken from a single hospital setting and focusing on CPE interns, are not given to generalization about chaplains per se.

In regard to this latter point, I have serious concern about the claim that the article "introduces readers to the modern-day chaplain" [abstract, p. 1]. While elements of the picture of chaplains that the author draws may be accurate in some hospital settings at some times (e.g., during CPE internship cycles or during the first unit of CPE residency cycles), it does not well depict experienced staff chaplains. Norwood notes that there is "difference between the novice chaplain and the experienced one" [p. 14], but her use simply of the noun chaplain (or chaplains) throughout the article to offer an interpretation of an observation about the participants in the study--most often the CPE interns--strikes this reader as an inappropriate generalization. So, a statement like, "…chaplains had to stay on the move, walking up and down the floors, in and out of waiting rooms, cruising for something to do and attempting to mimic the air of purpose that flowed from the constant motion of the other staff, " I found entirely unrelated to my daily professional experience (or to that of colleagues I know) and therefore unacceptable, though I do accept that it may describe the action of some CPE students in their first days on the floors.

It is my hope that chaplain researchers will devote more effort to ethnographic studies and that pastoral care departments will work with anthropologists to bring a research-mindedness to what is often left to informal observations and assessments of the place, perspective, and activity of hospital chaplains. As Norwood herself comments, chaplains are "a group largely absent in ethnographic literature" [p. 4]. [Though see the article by Lee, under Related Items of Interest (below).]

For other comments on the article--and the author's reply--see the Spring 2006 Newsletter (§2).


 

Suggestions for the Use of the Article for Discussion in CPE and in the ACPE Generally: 

The article may be suited more to Supervisory Education students than to CPE residents or interns, except perhaps late in their programs. The author organizes much of the piece within a theoretical framework based on the writings of Michael Foucault and Byron Good [--see p. 4 for an explanation], and that approach may interest or disinterest readers at the outset, but Supervisory Education students should be able to engage the material both theoretically and personally. There is a very clear outline of the plan of the article on p. 5, so students should be directed particularly to that. Otherwise, discussion should flow vigorously from any student group, and the characterization of chaplains as "ambivalent" could easily lead into the topic of pastoral identity. The article also deserves wider discussion among Supervisors and Clinical Members of the ACPE, especially in terms of how non-chaplains may perceive the place and operation of pastoral care departments with CPE programs. Also, at its very core, the article raises an important question of how much chaplains in any particular institution find themselves on the "margins," and what may be done strategically about marginalization.


 

Related Items of Interest: 

I. Another ethnographic study:

Lee, S. J. C. "In a secular spirit: strategies of clinical pastoral education." Health Care Analysis 10, no. 4 (December 2002): 339-356. [This ethnographic study was featured as the October 2003 Article-of-the-Month, with comments by Larry VandeCreek.]

II. Recent studies of perceptions of chaplains:

Flannelly, K. J., Galek, K., Bucchino, J., Handzo, G. F. and Tannenbaum, H. P. "Department directors' perceptions of the roles and functions of hospital chaplains: a national survey." Hospital Topics 83, no. 4 (2005): 19-27. [The article reports the results from 1,159 surveys from medical, nursing, social service, and pastoral care directors across the US (from a total sample of 5000). Questionnaires asked directors to rate on a 6-point Likert scale the importance of 19 chaplaincy activities or roles which were subsequently grouped into 7 categories: grief and death, emotional support, community liaison, advance directives and organ/tissue donations, religious services and worship, consultation and advocacy, and prayer. Among the findings: "directors in all four disciplines rated three of the seven chaplain roles (grief and death, prayer, and emotional support) to be 'very' to 'extremely' important," "physicians rated the importance of most chaplains' roles lower than did other disciplines," and " there was a tendency for directors in smaller hospitals, especially those with fewer than 100 patients, to place less importance on most of the chaplain roles investigated here" (--from the abstract, p. 19).

Flannelly, K. J., Handzo, G. F., Weaver, A. J. and Smith W. J. "A national survey of healthcare administrators' views on the importance of various chaplain roles." Journal of Pastoral Care & Counseling 59, nos. 1–2 (2005): 87–96. [This national survey asked hospital administrators about the importance of 11 roles and functions of chaplains. Among the findings, administrators tended to rate all roles/functions as relatively important, though those at hospitals without a pastoral care department tended to give lower ratings. "Meeting the emotional needs of patients and relatives were seen as chaplains' most important roles, whereas performing religious rituals and conducting religious services were seen as least important.... In all but a few instances, the level of importance that administrators assigned to the various roles were positively related to their ratings of their own religiousness and spirituality...." (--from the abstract, p. 87.)

 


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