Creation and Implementation of the Evangelical Hospital Chaplaincy Services at the Institute of Infectology Emilio Ribas no Brazil
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This study aimed to identify the socio-historical circumstances of installing Evangelical Hospital Chaplaincy Service (EHCS) in a specialized public hospital, in 1990. A historical investigation was conducted through the analysis of written and oral. Max Weber was used as theoretical reference. The results were constructed by the discourse analysis and critique of written sources, and then organized in four categories: Historical Background and First Movements of Installing EHCS, Resources for Installing and Operation of EHCS, Activities of EHCS and Internal and External Relations of EHCS. The conclusions showed that creating and installing Evangelical Chaplaincy could be understood as social action, in the Weberian concept, since the actors involved intentionally directed their relations and manifestations. This social action occurred under the Protestant ideology, where working is viewed as a conduct and, therefore, an instrument of achievement.
Keywords: Pastoral care, Organization and administration, Humanization of assistance, Spirituality.
This study aimed to identify the socio-historical circumstances of the establishment of Hospital Evangelical Chaplaincy Service (HECS) in a Brazilian public specialized hospital that could be used as reference to other Hospital Chaplaincy Services as yet to be established.
The choice of a study in a specialized hospital - Institute of Infecology Emilio Ribas (IIER) - in Sao Paulo, is the fact that this hospital where the HIV positive patients look tor internment.
Although therapy evolved in this reference center, control of physical pain is only part of the comforts and assistance needed in this circumstance; stigma, discrimination eventual abandonment by family and friends, as well as spiritual pain are present.
This characteristic of HIV’s case offered an opportunity of starting a service where spiritual assistance is given to the patients as well as to the professional staff. This new chaplaincy work was called “Minutes with God” and was accepted by staff independent of personal religious faith.
Evangelical Chaplaincy is part of Brazilian social scenery for more than seventy years. This is a work that has been assisted by Hospital Evangelical Chaplaincy Association (HECA) founded by Eleny Vassão de Paula Aitken. It is “a Christian, religious, beneficent and cultural organization, with the objective of preparing chaplains, religious visitations, organizing and assembling hospital chaplaincies, offering continuous growth in theological and health questions” [1,2].
This study focused on one of the evangelical chaplaincies associated to HECS, Capelania in Evangélica Hospitalar no Instituto de Infectologia Emilio Ribas (Evangelical Hospital Chaplaincy Infectology Institut Emilio Ribas) (IIER).
Structuring and providing a service of spiritual assistance is almost obligatory in this hospital, due to its focus on caring for AIDS patients. Seeing this position of objective of IIER, it was a relevant object of study for this research.
Adding to this the fact that there are few studies about hospital chaplaincy services in Brazil, except for historical records of chaplaincy in the military and fewer yet about hospital chaplaincies, it is understood that this study was justified.
This is a descriptive study, characterized as socio-historical, developed based on analysis of physical and oral sources.
This research was conducted in the IIER, beginning in 1992, time of the establishment activities of HECS in that institution, and ends in 2004, time of the nomination of a Catholic priest to act with the Technical Direction of the Hospital in relation to the religious entities that assists the patients.
The oral documents resulted of interviews with individuals considered key persons to the understanding of the theme: two chaplains, a clinical director of the institution, one nurse and one attendee of the chaplaincy service, who later became part of HECS’ staff as secretary. All the interviewed were part of the establishment period of HECS’ service.
Written documents resulted of Departamento de Humanização [Department of Humanization] of IIER and of HECS’ archives. From those archives, 13 documents were chosen, among them summons, letters, reports, declarations, bulletins, newspapers, statutes and regiments.
Secondary sources used were: scientific literature on the subject, of which 64 were from reference database on health, resulting on a published report by Gentil, Guia and Sanna .
Data collected on interviews resulted of a first personal or phone contact followed by direct contact in the individual’s working place. A semi structured interview was designed , based on seven points, used to direct the interviews, collected by the main researcher of this study.
Interviews were collected from May to November of 2010. The legitimation of these interviews was finished in March 2011. After each individual narrative, the data was transcribed, printed and each printed page signed by the person interviewed, so as to ensure identity and right of use of the material.
The oral data was then submitted to the processed called transcription, by Meihy : action that results on the rewriting of the verbatum text, in order of refining a comprehensible final text. The original transcript, signed by each interviewed individual, is read with the intent of establishing the main guidelines for data organization. The text is then rewritten as a testimonial, incorporating the questions of the researcher to the oral report of the interviewee as well reorganizing the text according issues treated in the interview.
Having decoded the interviews, a new list of codes was created, as a result of the pertinence and similarity of themes. The analysis category was constructed based on this new code.
The thirteen written sources were treated by thematic report of each one, followed by theme affinity search. This resulted in the knowledge of similarities and idiosyncrasies that, together with the interview testimonies, resulted in the description of the results.
Lastly, the description was punctuated by the scientific literature read, so as to attribute a generalized sense to the different aspects outlined.
The propositions of Max Weber were used as analytical reference, not only in view of the comprehension of complex organizations, but taking in account the fact that the author includes in his considerations the Calvinist thought and work organization. This analytical reference resulted in the comprehension of the object of study.
The concepts of legitimacy, social action, ideal type and order, formulated by Weber, were used to interpret the results of the present research.
RESULTS AND DISCUSSION
Historical background and early movements of installing HECS
The Service of Hospital Evangelical Chaplaincy of IIER was installed considering the patient as a social actor and, in this research, a patient with AIDS in a troubled time when science was discovering specific treatment for this new infectious disease. This Service meets with a strong and real need of spiritual assistance. The Evangelical Chaplaincy of HCFMUSP existed since 1952 and in 1992 the Gideon’s International, who have engaged in the distribution of Bibles in places such as hotels and hospitals, asked for the help of Eleny Vassão, then chaplain HCFMUSP holder and president of ACEH, to distribute the “New Testament” - which is part of the Bible – in IIER since they had failed in their own efforts. This situation was the gateway to the Evangelical Chaplaincy in IIER, to meet the demand of assistance to AIDS patients.
It should be stated that the IIER composes, along with the Hospital das Clínicas, College of Medicine of University of São Paulo (HCFMUSP), a group of model-reference hospitals for the care, education and health research in Brazil. Both are located on contiguous buildings within the same block of the city of São Paulo and maintains academic relations, although two institutions identity of its own, independent of one another.
Thus, the conditions that favored establishment of HLHS was the ambience of AIDS in the early days of the acknowledgement of the disease, when there was a lot of despair and hardships, bringing substantial modification to the standards of care in a hospital that prior to this treated patients with acute and contagious diseases and begin to treat patients with AIDS and its associated illnesses. These circumstances favored not only beginning of its presence, but the stay and complete installation of the Evangelical Hospital Chaplaincy.
It is important to note that there was an aggravating factor for difficulties faced by the Evangelical Chaplaincy in the process of initialing its service in that hospital. A group connected to an African descent religion had held ceremonies in some of the patient rooms involving platters with crumbs, horns, red pepper, drums and conga. This caused strangeness among hospital professionals.
After this, a Pentecostal group that said they could cast out demons that were causing disease. For that reason, the doors were shut to any religious group, since both groups mentioned promised to cure AIDS and making the compliancy to therapeutic measures harder to the patients.
Despite these difficulties, and recognizing that evangelical religious services could be beneficial, Paulo Augusto Galvão Ayrosa, general CEO of IIER, made official the Evangelical Chaplaincy by creating the Evangelical Hospital Chaplaincy Services and placing Eleny as chaplain holder. After an experimental period, she was the acceptance of the chiefs of sectors of the IIER in 1992.
The Evangelical Chaplaincy at the IIER started with a team of volunteers composed almost entirely by HIV-positive patients, converted to Christianity after being infected. This important feature of the team played a key role in the work of the Evangelical Chaplaincy of IIER, since they could speak, to patients in the same condition, of peace and hope that they experimented in spite being infected with the virus of AIDS.
At that time, there was an average of ten deaths per week of patients with HIV. The survival of diagnosed patients was around a year and three months, with frequent hospitalizations due to opportunistic illnesses. This circumstance made possible the development of friendship between chaplains and patients, resulting in a deep bond. As the patients died during that year and a half, however, there was much pain to chaplains and hospital staff.
In a different situation, even today, in some of the largest health facilities related to religious institutions in Brazil, thousands of chaplains provide spiritual care and guidance essential for the good recovery of patients and families, as well as provide spiritual support for the health care team, in what might be called authentic social action [6,7]. One can state, in the present case, that creating and establishing the Evangelical Hospital Chaplaincy was also done through a social action, which was crucial to enable the Chaplaincy agents to enter that hospital environment and settle in it. The action in question, according to the Weberian point of view a social action, was established with the purpose of changing the meaning of the actions of another social agent.
This meaning was accepted and assumed and actually resulted in new meanings of action in a continuous process to transform, change, respond front of a legitimate social need: the despair of patients with AIDS and those who cared for them.
Thus, through the opportunities represented by the need of IIER and the intentionality of the actors involved, the Evangelical Chaplaincy of IIER was established.
Resources for the installing and functioning of HECS
When the team of Chaplaincy the Evangelical resigned from HCFMUSP to stay permanently in IIER, it already had training and experience in public hospital chaplaincy and this was beneficial to the successful installation of the Evangelical Hospital Chaplaincy in IIER.
Analyzing the composition, behavior and attitude of the initial staff of HLHS in IIER, according to Weber, we can say that these social actors with AIDS were agents who gave meaning to different social relationships and events in which they participated, indicating and justifying their behavior towards themselves and others.
Interestingly, the Evangelical Chaplaincy used human resources with great return of great efficacy and efficiency at very low institutional cost. Moreover, while attending inpatients spiritually, it attended and cared spiritually for the staff of the institution. This was done without assuming new costs of hiring more professionals, since the professionalization of chaplains is still incipient in Brazil.
This concern with the professionalization of the activity of the chaplain is present for some time already in the USA. There, the experience of the introduction of Pastoral Care Course - CPE (Clinical Pastoral Education)– using the hospital as internship experience, as in the object of this research, should be included as part of the planning of the program of preparation of the hospital chaplain .
Despite the training offered to chaplains the Evangelical Chaplaincy team by ACEH, in Brazil, its human resources do not have all of the prerequisites of those of US. The vast majority are people with diverse professional backgrounds and varied educational levels. Moreover, few have studied theology or had any biblical counseling classes.
To satisfy this demand, ACEH, also conducts open courses in the form of continued education, indicating books to read; at the same time, the team holds meetings aiming the promotion of experience exchange among the chaplaincies of many hospitals, in the specialties of religious care of patients under palliative care, intensive care and with children.
In Brazil, there are still no legally defined competencies prescriptions for chaplains, except those established by ACEH to guide the activities of its members.
Certification is another of the advances chaplains in the Brazilian environment lack. This would ensure the constant updating of professional, maintaining appropriate standards of performance skills and ensuring the quality of care provided.
Now, in the US to be certified as professional chaplains the candidate must demonstrate the following qualifications: have skill with the theory of pastoral care, articulate theology for spiritual care with the theory of pastoral practice, incorporate knowledge of the work of disciplines of Psychology, Sociology, religious beliefs and practices in the care of the pastoral care, incorporating the emotional and spiritual human development in the practice of pastoral care and incorporate knowledge of ethics appropriate to the pastoral context.
Recently, in the US, there was need to establish more knowledge in two points: theological and clinical training to chaplains, as well as to advance in professional certification. These aspects, according to the authors of the prescription, were necessary for the certification of competence of chaplaincy service by the hospital accreditation council .
Now, in England, a research of the training offered to hospital chaplains in different parts of the country, found no general pattern for the National Health Service .
In Europe, acting with the multidisciplinary health team, the chaplains developed and participate in education programs about health car of the professional, offer spiritual support, participate in research programs on spiritual care, as well as assist and evaluate the effectiveness of Hospital Chaplaincy Service. They also act as facilitators in assisting the needs and demands of patients and caretakers, for the Community Health System .
Chaplain are no always be regarded as a member of the health team, in Brazil, therefore, even though the spiritual care practiced along those lines are recognized as a legitimate social action, results in that the spiritual care and comfort are not yet legitimized. In other words, the social legitimization has not been formalized, indicating it is in transition, a situation that is functioning but is not consolidated.
In the US, due to the high degree of professionalism in the country, no hospital department has non-wage-earning professional workers assisting patients .
Another important certification besides the accreditation of professional chaplaincy is the accreditation of the Religious Service by an entity specializing in accreditation of health institutions, such as Joint Commission on Accreditation of Healthcare Organization (JCAHO). EHCS of IIER was licensed by the Association of Evangelical Hospital Chaplaincy of Brazil, but not accredited. In Brazil, JCAHO already accredits hospitals and begins to require of religious care service.
The discussion in around accreditation of the necessary competence and abilities to act as hospital chaplain is no new, but the institutionalization of such practices is very different in Brazil and the US.
Besides human resources, material resources for the basic operation of the Hospital Evangelical Chaplaincy Service in IIER were guaranteed by the hospital itself. Food was provided for the entire team as well as a room for EHCS. As changes occurred in the institution, these rooms would migrate from one floor to another, but were always guaranteed. The doctors' lounge was used for worship.
According to the American Protestant Hospital Association, in US, pastoral assistance should have suitable rooms, furnished, equipped and stocked with office supplies. It should also have balanced budget; maintain proper records consistent with the policy and conduct of the institution and the needs for pastoral practice. It should have a plan of continuing education for staff. Finally, the health institution should have plans reviewing and evaluating at regular intervals the pastoral services offered .
As one can see, the differences between countries with structured chaplaincy services and the Brazilian experiences are considerable. In this case, it can be seen that with the aid of ACEH, some effort to regulate the activity has been undertaken. Formalization, however, is not present in its legal dimension.
The standardization of education, training and supervision provide regulatory conditions, remaining to be done the legitimation by the government and representatives of civil society.
Activities undertaken by HECS
The activities developed by the Evangelical Chaplaincy of IIER were especially directed to the spiritual solace offered to many patients, at different stages of disease. It was a complex activity in view of the diversity between the patient in terms of values, beliefs, and experiences and, especially, the different meanings attributed by each one to the disease and death.
These activities included the holding of visitation to patients in various sectors of inpatient, outpatient, day hospital, the morgue and emergency room, and biblical counseling to family members. In IIER the HECS had no access to the patient record to make notes regarding patient care.
The likelihood that most patients would accept the spiritual care offered by Evangelical Chaplaincy was small, since these were mostly Catholics, as observed the Brazilian population, and might accept spiritual assistance coming only from the Catholic Chaplaincy. This, however, did not occur for the Evangelical Chaplaincy used in its practice of spiritual care, the legitimate order of which speaks Max Weber , which is expressed by the validity of the order in question, where the validity of an order means more than a regularity in the development of social action, simply determined by custom.
The care together with the team of palliative care of IIER was another important activity performed by the chaplain of the chaplaincy evangelical. Even home care was included in the activities performed, to accompany the patient under palliative care until the end of his life and in some cases, at the request of the family, a religious ceremony was held at the funeral of that person.
It was observed in the statements of the Catholic chaplain and nurse interviewed for this research that gradually the evangelical spiritual care was being recognized and valued by both patients and health professional. This is confirmed by the invitation to HLHS to be part of the palliative care team of IIER.
In official meeting with the leadership of the European Union in June 2005, the delegation of the European Network of Health Care - ENHCC - discussed the difficulties of chaplaincy in Europe and the importance of spiritual care in disease, especially in dialogue about palliative care. This event is considered a milestone because officially established relationships with other organizations chaplaincy in the US, Canada, Australia, New Zealand and Japan .
The authors reported that this meeting concluded that often the politics of health care results in such a commitment of hospital administrators to preserving the privacy of the patient and family, that ends up depriving them of their right to receive spiritual assistance, that was considered therapeutic .
The situation that brought AIDS to IIER, with many deaths, made evident the need to start the spiritual assistance to health professionals. This was done in an activity called “Minutes with God”, that consisted of working meetings, in inpatient units, with those who were on duty that day. The time spent on the activity was around seven minutes.
The analysis allows us to say that with this action, according to Max Weber, the Evangelical Chaplaincy created conditions for the development of a social action for social action occurs when the actor attaches a meaning to his conduct and this relates to the behavior of others . Therefore, the chaplain develops a social action while Chaplaincy establishes action in the social environment.
The flow of the patient's request for the spiritual assistance of a chaplain or another, in IIER, worked on a free demand basis, that is, the visitation was held of the patient’s bed by bed, by the chaplains, and the patients were free to accept or decline this service.
The request could come also from the healthcare team consisting of nurses, social workers, psychologists and physicians. The evangelical chaplain was called by nursing especially when there was much suffering of the soul, or to meet severe patients who would die in a few hours.
Compared to other services offered by the hospital to patients, spiritual care developed by a chaplaincy requires mainly human resources that, although qualified, have been obtained voluntarily. Physical resources and material inputs required for activity is small if compared to other types organizations outside the hospital in focus during the study period were offered by social organizations outside the hospital. Therefore, one can say that the establishment of Evangelical Chaplain Service of IIER was not influenced by budgetary constraints by the very nature of these services and the legal provisions that regulated them.
Internal and external relations of HECS
This category deals with relationship of people, services and institutions, internal and external to IIER, with whom HECS had relations to build its foundations, revisiting Weber’s thoughts, when he says that society is the result of the interaction of social actors, and that one’s actions are reciprocally oriented in the others’ actions. The individual’s roles as well as his actions are considered in the construction of reality.
HECS was directly subordinated to the general director of IIER, at the time of its establishment, according to IIER’s Statutes, and could create various commissions. Two years after the establishment of HECS, the Roman Catholic Metropolitan Curia nominated the priest João Midner as Catholic chaplain of IIER. The Catholic priest was directly subordinated do IIER’s director as well. In 2004, this priest was nominated as representative of all chaplaincies of the institution to the Direction of IIER. Through this nomination, the Evangelical Chaplaincy became subordinated to the Catholic Priest, situation that is still continues.
In the US hospitals, in 1985, it was observed that the priest that minister pastoral care reported to the administrator or whoever has a vice-president level. The level to which the chaplain reported might vary according to a series of factors, but it was mainly due to the internal organizational structure of each institution .
Although an instituted service, the Evangelical Chaplaincy was not formally so; no document instituted the religious assistance. This was reported in a testimony of a nurse interviewed - she only received a communication dealing with the provision of two rooms for the Evangelical and Catholic chaplaincies.
As far as the relationships of the Evangelical Chaplaincy with the Nurse personnel, in the mentioned testimony, it felt as troubled. The staff thought the chaplaincy team perturbed the patients’ assistance. In this evaluation, one has to consider a prejudice and moral judgment of the staff, as far as the HIV positive patients, especially the homosexuals and drug addicts. As time passed, the Evangelical Chaplaincy team was better prepared, by courses, and adapting to the profile of the patients. This resulted in a acceptance of the chaplaincy team by the nurse staff.
Of the relationship of IIER with HECS, there are two moments that stand out: a Research Ethical Committee, of which the titular chaplain was part during four years, and the Team of Palliative Care, of which the Evangelical Chaplaincy was initially sole participant, and later had a representative of the Catholic Chaplaincy.
Internal and, above all the external relations of HECS in IIER, as well as its the administrative bond and support, propitiated material, human and financial resources. It resulted in visibility and collaborated in the establishment of HECS in IIER.
This research’s interpretations and findings were much helped by the use of Max Weber’s “ideal type”. This concept was adequate in that by using it was possible to select and made explicit the dimension of the object of analysis - the Evangelical Chaplaincy - to a posterior presentation of this dimensions in a clear manner, related to the objectivity of the research. It was possible, therefore, to construct an ideal type of Hospital Evangelical Chaplaincy, connected to the lived reality, as demonstrated.
The request distribution of New Testament by the Gideon’s by a chaplain with experience in the hospital environment, resulted in a succession of events which led to the beginning of this work, and so triggered the creation of the SECH of IIER.
The situation of the times motivated the development of the new service and what started as an unfavorable situation of no availability of a specially prepared team, quantitative as well as qualitatively, to face such difficult circumstances as those of IIER, was shortly transformed.
The scenario was favorable, for they were times of AIDS. This circumstance made the HECS successfully in its answer to social needs present at disease onset and the early efforts of control.
All the activities developed by HECS had a purpose linked to moral and spiritual issues that were advocated by Protestant thought, which directed the operation of the chaplaincy.
The activities carried out by HECS were strategically planned to become effective and efficient, providing solace and deep spiritual comfort, causing changes in behavior and reframing of permanent values, repositioning these individuals in view of the big existential issues.
By its spectrum of coverage and results, the coexistence of other religions with HLHS was not peaceful. In fact, as it as a social institution, the hospital is a micro representation of society. At the IIER, HECS had to deal with a dominant religion, other than that which it preached, and at the same time religiously syncretic cultural environment. Nevertheless, the Evangelical Chaplaincy in IIER prospered not only in view of the enormous lack of spiritual care but because it offered were answers to difficult questions.
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