When in hospital people are often asked if they would like to be referred to chaplaincy and see a chaplain. So, what is the usual interpretation of the meaning of the word chaplain? Most people think a chaplain is an ordained Christian minister. In addition to providing religious support, chaplains are supposed to offer spiritual and pastoral support to people irrespective of their beliefs. Unfortunately, over time, the words spiritual and pastoral have become strongly associated with religion. Going back in time, spirit is derived from the ancient Greek word for breath and no one can live without that. Pastoral was originally related to farming but is now seen as a minister (pastor) caring for their congregation (flock).

There are many people now who regard themselves as spiritual but not religious. The censuses here since 1991 have shown a significant change in religiosity. From 1991 to 2018 Christianity decreased from 67% to 37%, other faiths increased from 4% to 9%, and non-religious increased from 20% to 48%. The 2023 census data for religiosity is due for release in October. If the trends of the past 33 years continue, it is highly likely that over 50% of the respondents will be non-religious.

Spiritual health is regarded as a significant element of holistic care. This is shown as part of Te Whare Tapa Whā and is also recognised by the World Health Organisation (WHO). So how are patients being provided with appropriate pastoral, spiritual, or religious support in order to ensure they are receiving holistic care? The simple answer to that question is they are not.

Here in Aotearoa/New Zealand the public hospital chaplaincy service is provided by the Inter-church Council for Hospital Chaplaincy (ICHC). The ICHC is a panel of 9 Christian churches which holds a contract with the Ministry of Health (MoH). ICHC has effectively held the contract since 1972. The MoH has not reviewed or revised the contract at any time and has no intention to do so.

Pretty much all of the ICHC’s salaried chaplains are ordained Christian ministers. Those who are not ordained are certainly practicing Christians. In addition to salaried staff, the ICHC has volunteer lay-people who are all practicing Christians too. When the chaplaincy service started in 1972 I suspect having a 100% Christian workforce would have met the needs of the vast majority of the population. Now we have a very different demographic.

In 2018 the MoH published the document Achieving Equity in Health Outcomes. On page 6 of the document the MoH states that offering the same service to groups with different needs is inequitable. By having a 100% Christian chaplaincy service when only 37% of the population is Christian is, by the MoH’s own definition, inequitable. I have written to the MoH on several occasions to bring this to their attention. Each time they have basically told me that they are happy with the service. This to me appears that the MoH are simply ticking a box to say that they are providing a chaplaincy service, but don’t really care whether it meets the needs of the population.

The ICHC meets its contractual obligations. The hospital chaplains I work with certainly provide all the support they can. The biggest problem is that the MoH has not changed the chaplaincy contract. By its own definition the MoH is inequitable but has no intention to address the problem. Many of the chaplains I have spoken with recognise that the service needs to change. They accept that I am not trying to get rid of chaplaincy on the grounds that it is religious and I am not. What I, and many people I have spoken with would like to see is a broader service which offers more to an increasingly diverse population.

What is spirituality?

This is an easy question to ask, but much harder to answer. The most commonly used definition I have come across has been:

Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.

(Puchalski et al 2014. Improving the quality of spiritual care as a dimension of palliative care. Journal of Palliative Medicine, 12(10), 885)

For my dissertation I interviewed 11 people. Each interview started with the question ‘What does the word spirituality mean to you?’. I effectively got 11 different answers to the same question. However, parts of each answer fitted in with some elements of the definition above. For those who were religious there was a sacred element, for the non-religious there wasn’t. Family was important across the board. Nature was far more of a feature for the non-religious. Interestingly there were some overlaps in the definition given by some religious and non-religious participants.

If you get the chance, write down your own definition of what spirituality means to you without discussing it with anyone. Then, if you have the opportunity, compare it with a friend or relative’s definition. Having done this with 11 research participants, I also did it with a group of 5 post-graduate students at the University of Canterbury. Again, I got 5 different answers. The differences aren’t necessarily big, but I doubt you would ever get two that were exactly the same. If you can’t compare your definition with others, just look to see how it fits in with the elements of the Puchalski quote.

I think it would be fascinating to ask sets of identical twins what spirituality meant to them and see how many of them gave identical answers.

Spiritual support in Public Hospitals – Offers and Barriers

The ICHC states that chaplains, be they salaried or volunteers, are trained to speak to people of all faiths or none. Unfortunately, the religious but not Christian and non-religious members of the population are not being trained to speak with Christian chaplains. The fact that a chaplain is a Christian can be an instant barrier for people seeking spiritual or pastoral care. When admitted to hospital people can be asked if they are religious and if they would like to see a chaplain. If they are Christian it is quite easy as the ICHC are there ready and waiting.

If the patient is religious but not Christian there is an immediate barrier. They are unlikely to want to discuss their faith and beliefs with someone from a different faith. However, there should be an alternative. The Chaplaincy offices in the hospitals are meant to have contact lists for volunteers to provide support from other faiths. Unfortunately, this isn’t always the case. Less than 5 years after the Mosques shootings in Christchurch the chaplaincy office here did not have contact details for an Imam to come in to see a Muslim patient.

If the patient is non-religious things are bad. At present there are no trained volunteer non-religious spiritual support providers available nationwide. Palmerston North is fortunate in having the only salaried non-religious provider. This means there is a significant barrier in the way of non-religious people being provided with appropriate spiritual care.

Over the past 33 years the population has increased. The number of people being admitted to hospital has also increased. The claim that chaplaincy can provide appropriate religious, pastoral, and spiritual support does not fit with this though. Data from the MoH shows that the number of people accessing the chaplaincy service has decreased. Between 2013 and 2018 the population rose by 9.6%, and the number being seen by 11.4%.

Individuals, be they religious or not, have spiritual thoughts, goals, and feelings. Not all of them will want to speak with a chaplain. Non-religious people do access the chaplaincy service and can find it very useful. However, we must never assume that because someone has declined the opportunity to speak with a chaplain, that they haven’t got anything to talk about. They simply haven’t got anyone they are happy to talk about it with. To comfortably speak with someone about personal issues you have to feel sure that the person you are talking to is empathetic and nonjudgemental. A non-Christian or non-religious person may immediately feel that a Christian chaplain is going to be judgemental, simply because there is a crucifix on their name badge. It is quite possible for a religious person to feel they are being judged too if they are having a crisis in their faith – for example they have cancer because it is a punishment from God.

Chaplains are not allowed to proselytise when speaking to patients. They can pray with them, but not preach to them. However, non-religious patients may still be worried that a chaplain will try to convert them if they ask to see one. One of the religious participants in my project said that she would not tolerate being preached to as she knew what her beliefs were and didn’t need to be told by a chaplain.

LGBTQ+ patients may be religious but reluctant to speak to a chaplain. Many churches have been severely critical of LGBTQ+ people, and in some faiths, it is a capital offence. Many of you will remember the self-appointed bishop of Destiny church blaming the Kaikoura earthquake on homosexuality. Such reluctance can be third party too. One paper I read included a woman who did not want to speak with anyone from a church not because she was in a same sex relationship, but because her son was.

Termination of pregnancy (ToP) can be a huge issue. About 95% of ToPs are the result of unplanned pregnancy and are carried out in the first trimester. The real challenges rise in the second trimester. These are usually in planned pregnancies when the 18-week scan has shown fetal abnormalities or non-viable pregnancies. Would the parents who opt for ToP want spiritual support from an ordained minister even if they were religious? What if they were practicing Catholics? The 2018 census recorded that 53.5% of people aged 19 to 45 were non-religious. This covers the vast majority of women of child-bearing age.

The majority of people who have been abused by clergy have lost their faith. Some do still believe in god. But is it likely that any of them would be comfortable if the only spiritual support option was an ordained minister?

The 2018 census also showed that 53.5% of people who identified as Māori were non-religious. Interestingly, many Māori are moving away from Christianity as they see it as a lever used in colonisation. One of the letters I sent to the MoH was specifically about the lack of spiritual support considering over 50% of the Māori population was non-religious. There again, the response was that the MoH was perfectly happy with the service as it was.

Another significant factor is likely to be the End-of-Life Choice Act. When the referendum was held there was a significant margin in favour of it. The margin could only have been reached by some religious people voting in favour of it despite most churches and other faiths being very much against it. If a religious person is given a terminal diagnosis and meets the criteria for End-of-Life Choice are they likely to speak to a religious chaplain about it?

Having a non-religious spiritual and pastoral support worker available can be beneficial in many ways. Obviously, having someone for non-religious patients to speak with who has a similar worldview as them is very important. Equally, it can be very important to have a non-religious third party available for LBGTQ+ people, parents opting for ToP, or the terminally ill choosing assisted dying to have someone they know isn’t going to judge them on a religious basis.

One of the Humanist chaplains in the UK told me of a patient who asked to see her. The woman was brought up in a Catholic family and still believed in God. She didn’t want to have anything to do with a religious chaplain though. This was owing to her having been disowned by her parents because she had premarital sex and then married a Presbyterian. She felt if she spoke to a priest, she would be judged in the same way she had been by her family. Talking to a non-judgemental non-religious chaplain helped her to feel at peace.

Participant information

Of the 11 people I interviewed, 5 were religious and 6 non-religious. Of the non-religious 3 had never followed a faith, and 3 had been religious but had lost their faith. All of the religious participants were Christian. Across the whole group one of the key points regarding spiritual support was having a good listener. This again linked to the listener being empathetic and non-judgemental. If people feel they are not being listened to, they won’t speak about the things that are important to them.

Among the non-religious friends and family were common providers of spiritual support. All but one of them felt they would be much more likely to access the chaplaincy service if a non-religious chaplain was available. The one who didn’t feel this way classed herself as a closed book who didn’t speak to people she didn’t know. This came as a surprise considering she had volunteered to take part in the project. All of those who took part agreed that people of all faiths or none should have the opportunity to speak with a person with a similar world view as them.

Family were also important among the religious participants. For one, her husband was an extremely important element of her spiritual support and belief even though faith was central. Interestingly, for some of the religious participants, it was more important relating to deceased family as they felt they would be reunited in the afterlife. For one of those who had lost her faith, the death of her older sister when she was a teenager was the point at which she and her immediate family stopped believing in God. They couldn’t understand how a girl who had gone to church every week for her whole life could be killed in a car crash. Interestingly, going back about 45 years, I found out that my Religious Education teacher in the UK wasn’t religious. She had done theology at university and been married to an Anglican vicar’s son. She lost her faith as her father-in-law died in what she described as a horrible death from cancer. She couldn’t believe that a god would subject a man who had devoted his life to the church to die in that way.

The feeling of being judged by a god or those in a church group had contributed to two of the participants losing their religion. One felt under constant judgement and fear resulting from that. The other found church goers hypocritical by saying only God can judge but then being very judgemental themselves.

Job Titles

In the UK a lot of discussion has taken place on what to call non-Christian and non-religious pastoral and spiritual support workers. Rather than inventing a new name, or using long terms on name badges, the decision was made to simply use Chaplain – Faith or Chaplain – Non-religious. There are many hospitals in the UK now which have chaplains from many faiths plus non-religious ones too. The best of these is in Leicester where they have Christian, Muslim, Hindu, Sikh, Jewish, and Humanist. Funnily enough as the service there has expanded to support the very diverse population, the number of people accessing it has consistently risen. The lead chaplain in Leicester is a Sikh. The lead chaplain in Sheffield (UK not Canterbury) is a Humanist.

Discussion and suggestions

The current chaplaincy service here falls far short of being equitable. Until the service is close to providing equitable spiritual, pastoral, or religious support the MoH cannot claim to be providing holistic care for patients.

Those who access the service find it appropriate, but this information solely comes from the feedback to ICHC chaplains. There are no records on why people do not apply or decline to be referred to the service. Without knowing why people are not accessing the service how can the service be improved to meet their needs? The majority of patients in hospital, even those who identify as Christian, do not access the current chaplaincy service.

A lot more research needs to be done nationwide. Fortunately, a group based at the University of Otago has been granted funding for 3 years. This will enable multi-faith and no-faith research to be done across many centres.

The MoH should review and revise the chaplaincy contract in order to meet its own definition of equity. Rather than having an Inter-Church council there should be an Inter-faith and no-faith council for Hospital Chaplaincy.

Hospitals have a duty of care to provide patients with who they see as the right listener. Not just a listener, but the right listener. The only person who can determine who the right listener is, is the person who is going to be talking about the beliefs, thoughts, or feelings.

One of the best quotes relating to spiritual support I have come across is:

‘Appropriate spiritual support must be available to all patients who desire it, the same way as we provide them with a meal and a warm blanket’

(Cohen 2018)

My dissertation in full is available online, where you can select the PDF version: