Reverend Dr Steve Nolan is the chaplain at Princess Alice Hospice in Esher and the author of ‘Spiritual Care at the End of Life.
Here, he explores new ways of understanding the roles of hospice chaplains.
I never met Dame Cicely Saunders. The nearest I came to her was when I visited the chaplain at St Christopher’s, the south London hospice she established. My tour of the hospice had reached the old chapel, and as I chatted with the chaplain, I caught a glimpse of her as she walked slowly passed the chapel door.
Whether Dame Cicely should be considered ‘the founder’ of modern hospice care could be debated. But her dynamism and drive had a significant hand in shaping the direction and values of the nascent movement. Yet she was not the only dynamic woman to have influenced the history of hospice care.
In 1843, Mme Jeanne Garnier opened a home for the dying in Lyon. In Dublin, Sister Mary Augustine inspired first Our Lady’s Hospice for the Dying, which opened in 1879, then further hospices in Australia and Great Britain. And in New York, Mother Alphonsa established St Rose’s Home in 1899. Working independently of each other, these women shared not only a common purpose but a motivation that was inspired by their spiritual beliefs.
Spirituality was clearly one of the key motivators that drove Dame Cicely. In the late 1940s, she converted from agnosticism to a deep evangelical Christian faith, which transformed the way she understood her work. Caring for the sick had always been a priority; following her conversion it became a religious calling.
St Christopher’s Hospice, London
Cicely Saunders’ career spanned a period of significant social change, to which she made a major contribution in terms of social attitudes to death and dying. But following the Second World War, social change that had already been underway began to accelerate. The rise of youth culture, consumerism, the struggles for sexual equality and civil rights, sexual freedom, the Cold War and the hippy movement were all chapters in the history of the declining established order, which, among other things, had included an established place for religion.
So, when the NHS was founded in 1948, the year Cicely Saunders became a medical social worker, the assumption that a hospital should have a chaplain would have been unquestioned, and even less the idea that that chaplain would be a male Anglican priest.
How out of touch those assumptions seem now. Even when St Christopher’s opened in 1967, most admissions would likely have recorded their religion as ‘C of E’. A generation later, and the number of people who record any religion is much lower, with a new category emerging: ‘Spiritual, but not Religious’ (SBNR).
In this new context, those of us who have inherited the spiritual perspectives that inspired Dame Cicely and her forerunners, and especially those who are hospice chaplains, are having to learn new ways of thinking about what we do and find new ways of relating to the people in our care, which means chaplains in particular are having to find new ways to understand our role, both religiously and within our institution.
New ways of thinking about what we do
Although most of the current cohort of professional hospice chaplains have been trained in Christian theological colleges, and although our religion remains important to many of us, we are no longer primarily religious figures. For some of the people we care for religion is important. For them, we become a significant support during their time in the hospice, often serving as a link to their faith community, or on occasions reconnecting them with the faith they used to hold.
But the majority of people we see are either not particularly religious or not religious at all. For them, we may represent something they have rejected and want nothing to do with. Yet for us, they question our role in the organisation for which we work: what use is a religious person to a person who has no use for religion?
Dame Cicely pointed towards an answer when she developed her concept of ‘total pain’, the idea that all pain includes physical, emotional, social and spiritual dimensions of distress. Her analysis of ‘total pain’ has influenced the World Health Organization definition of palliative care and a good deal of contemporary healthcare policy. A person’s spirituality is, at some level, implicated in their distress.
As chaplains, we take the view that religion may be part of a person’s spirituality, but equally it may not be. Either way, we understand that caring for the spirit – our own and that of others – is vital to personal wellbeing. In this way, we see our work as embracing religion, but not as being defined by it.
New ways of relating to the people in our care
So as chaplains, we understand the importance of spirituality, but we also know that our religion is only the vehicle we use to explore and develop our spiritual lives. For some of us, that means believing that our religion contains truth not that it is Truth. This openness to uncertainty equips us to meet people where they are and to find in them whatever it is that feeds them spiritually.
There have been so many inadequate attempts to define ‘spirituality’ that some dismiss the possibility of finding a definition that could claim wide acceptance. However, I’d suggest that a seldom read study by David Elkins and his colleagues could provide some help (Elkins 1988). These researchers offer a view from humanistic psychology that values spirituality without over mystifying it. In brief, they suggest spirituality is related to the sense we all have that we are more than our flesh and bones. This sense allows us to transcend our biology and to experience ourselves as a self or a soul. In religious terms, spiritual care is concerned with saving the soul; in Elkins’ sense, spiritual care is about helping people to flourish.
Whether or not we accept the argument put forward by Elkins and his colleagues, taking a broad view of spirituality and spiritual care allows us as chaplains to be of use to people who have little if any use for religion.
New ways to understand our role
As hospice chaplains, we work with people who may never visit a religious building, attend a religious service or confide in a religious minister. But because we meet them at their point of spiritual need, they often use us as they might have used a parish priest or local minister: they ask us to take their funerals, or even name their babies.
Some may see this as an opportunity to coax people back into the religious fold. But those who use hospice chaplains in these ways are not using us as religious figures, but as support for an emerging form of spirituality that is independent of the religious institutions.
As such, hospice chaplains find ourselves to the fore of an interesting spiritual development. The period of social change through which Dame Cicely lived and worked has seen a form of spirituality emerge that is increasingly eccentric to the religious institutions. At the same time, the movement she did so much to influence meets people at moments of life crisis. As chaplains, we are uniquely placed to provide support to these vulnerable people and to offer them spiritual guidance in ways that acknowledge the integrity of their journey and aim at helping them flourish.
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The world has changed radically since Dame Cicely Saunders’ faith inspired her to reach out beyond the existing institutions and respond to raw human need as she encountered it. That need will always exist; the spiritually motivated response will want to find new ways to address it.
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I couldn’t agree more. As someone who spent 8 years in hospital and hospice chaplaincy, I would now place myself very definitely in the Spiritual But Not Religious category and recognise that this is where many people find themselves now. If hospital and hospice chaplaincy is to continue to have a vital and significant role to play in helping to manage total pain, then it needs to adjust to this change. Well done Steve and thank you for helping to make that important shift in perception.
Spiritual health is understood (or should be) by most clinically trained chaplains as where an individual finds meaning, hope, purpose and direction. This may or may not for some include a religious faith.