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Weaving the Effective by Renae Schumann, Ph.D., R.N.
To read Sidebars, click on the sidebar reference. This will open a new window with the side bar. Close the new window with the sidebar to continue reading the article. Economic and financial forces have caused a shift in focus from the traditional in-patient model to the outpatient model of care delivery. Hospitals now see a loss of bed-based services, physicians see a decrease in revenue and control, and nurses experience a loss of jobs and influence. Health care consumers have fewer options and less service and society has fewer entitlements (Porter-O'Grady, 1999). Wellness, health promotion, and disease prevention are increasingly the focus of the healthcare system and of the community. Hospitals and other entities are pooling and blending their respective resources to create new programs designed to meet life span needs of the communities they intend to serve. For example, wellness and holistic health centers which provide health education, specialized life-style classes, and opportunities for exercise are developing. These centers are not intended to replace hospital services, but are designed to empower clients to participate in their own well-being. They represent a shift from sickness and prescription to health and prevention. They can be beneficial because they address the spiritual, mental, physical, and social needs of the clientele in an effort to decrease hospital admissions and costs. But a disadvantage of these centers is their client cost, which is often higher than a typical health club or gym, and therefore prohibitive to those such as the underserved who could gain the greatest benefit. The shift in health services causes change in the definition and description of the concept of health. Some still consider health a strictly physical state of wellness or absence of disease without regard to the influence or effect of one's spiritual, emotional, and social well being. For them health involves cure for the disease and the body, which may be more important than care for the spirit, mind, and relationships. To those holding this view, hospital services are of primary importance. Others believe that health can only be described holistically and with respect to the spiritual, emotional, physical, and social conditions. Personal health is often regarded as an adaptive process to achieve one's highest level of functioning within the current circumstances and regardless of pre-existing conditions. Using that definition, personal care of the spirit, mind, and relationships are as important as physical cure to achieve a state of holistic health. Indeed, care of the whole person promotes physical cure. These authors consider health to be holistic and inclusive of the person's spirit, mind, body, and relationships. People are created as complete beings in God's image after His likeness (Genesis 1:26-27), and are born into a relational world. From the creation of Eve as a companion for Adam to the couple's ongoing communion with God within the Garden of Eden, it is clear that humans were created as relational beings. God inspirits and gives life to all. True health and wellness exist only in relationship to God, the Creator and Giver of Life. Without that relationship there is a spiritual deficit as the person lacks true meaning, purpose, and significance, so there is no possibility for total health or wellness. The resulting disruption in spiritual health contributes to disruption in other relationships, which contributes to the possibilities of isolationism and poor physical health habits. Conversely, physical or emotional distress can result in spiritual turmoil ultimately leading to a separation from God. Wellness centers mentioned previously can provide content and counseling regarding holistic health and well being, but they rarely promote a specific worldview, such as Christianity, which would hold specific truth for participants. Clients are forced to apply the principles in the way they find most meaningful. A program in which clients can participate in their health and wellness matters while looking through the lens of their own personal worldview or belief system is better because they would find meaning within their lives. These programs exist in the form of congregational health initiatives such as congregational (parish) nursing and health ministries. Many of today's hospital systems strive to encourage holistic healing, so they are in favor of and often support health programs such as health ministries that address or enhance spirituality. While most hospitals cannot promote one faith belief over another, nor can they prevent congregations from practicing their own beliefs, they are in a unique position to foster a broader view of health (Schumann, 2000). Faith communities are increasingly more interested in establishing congregational health ministries. Some congregations find them desirable or fashionable because a nearby congregation has one or because the upper administration of the denomination mandates the establishment of such a ministry. Some begin a congregational health ministry in an attempt to address the congregation's and community's now unmet needs through health fairs, health screenings, or educational programs. Many of these programs still focus on the definition of health as a purely physical state, again disregarding its holistic nature. This type of congregational health ministry is shallow and is easy to establish by appointing a nurse or other interested party to make contact with hospitals and other agencies that can provide supplies, technical support, and human resources to staff the events supporting physical care. A real and complete congregational health ministry requires a focus on holistic health, and has as its basis the person's spiritual nature. Establishment of such a program does not occur overnight. It requires collaboration, communication, and teamwork. Strong and effective congregational health programs must be woven together among the existing ministries using the knowledge and resource threads of the congregation. Ownership of the ministry belongs to the congregation, not just to the nurse or to the pastor. It is a program designed to glorify God, not the health ministers. Conflicts are sure to arise because of the diversity of the people involved in establishing the ministry. Though people often think of work in faith communities as typically good and happy, it is important to remember that when people in any setting come together, egos and personal agendas will abound, and conflicts will result. The purpose of this paper is to describe the process of weaving the health ministry programs into the congregational structure. Included in the description are things that congregational nurses and congregations should know about each other, and about implementing the woven health ministry. The final section provides a discussion of potential turf wars, misuse of resources, and conflict management within the congregation family.
Effective implementation of any new program or ministry requires communication, cooperation, and teamwork. The number of people involved in establishing a congregational health ministry depends on the organizational structure of the congregation, denomination guidelines, and type of program needed. Knowledge of each person or group contributes to the strength and success of the new effort and decreases the likelihood of unmet expectations. Described below are the important knowledge threads or issues that congregations should know about the nurses and that the nurse should know about the congregation to weave an effective holistic health ministry. Knowing About Congregational (Parish) Nurses Congregational Nurses can be very helpful in establishing and implementing effective congregational health programs. Described below are some of the most important things a congregation should know about the nurse, including the definition and function of congregational nurses, motivation for this type of nursing, preparation, job guidelines, and need for congregational support. Definition and Function. A Congregational or parish nurse (CN) is usually a Registered Nurse who provides non-invasive, holistic health education, projects, or other services to a faith congregation. Instead of relying on high-tech monitors and equipment to care for the congregation, the CN draws on assessment, planning, and evaluation skills. He or she is usually compassionate, and since there are no invasive procedures performed, the CN is able to touch others without wearing gloves. More important, the CN seeks to promote personal and congregational health and wellness from a spiritual perspective. He or she may serve the congregation as a volunteer or as part of the paid ministerial staff. Motivation for Congregational Health Service. Motivation for congregational health ministry is one of the most important indicators of success within health ministries. Congregational nurses often feel called by God to this type of nursing and will serve the congregation as a response to His love and grace in their lives (Smith, 2000). In fact, lesser motivations often result in short-lived health ministries. These nurses are not as interested in recognition for their work as they are in the welfare of the congregation. They are more likely to publicize an upcoming health ministry event than to publicize the results of the event after the fact. They would prefer not to dwell on the success of the past programs, but to focus on whom within the congregation can benefit from future care programming. They typically involve as many as possible in the health ministry, and they depend on God to direct the ministry. Not all CNs experience a call from God, and worldly recognition and rewards sometimes motivate them. The pastor or other congregation leader often appoints them to the CN position and as a result the nurses feel important and powerful. These CNs may not share the responsibilities of the program with congregants, but will instead assign duties from one event to the next, never fully releasing control. They are often more interested in personal recognition received after an event instead of publicizing the event beforehand to achieve the greatest attendance and greatest good. In other words, their concern is their own status within the congregation, not the congregation's welfare. Educational Preparation. Congregational nurse preparation takes various styles and formats ranging from short orientation programs to long distance learning offerings to graduate level degrees. Because the usual undergraduate nursing school curriculum has limited spirituality or spiritual care content, CN preparation courses include sections on promoting spirituality and helping others recognize and draw strength from their personal faith to enhance their well being. Some training in pastoral listening is given, and many CN education programs recommend or include at least one unit of Clinical Pastoral Education (CPE). A relatively new trend for CN preparation is a master's level degree combining nursing and ministry. These programs enhance listening and communication skills, but also teach ministry. Job Guidelines. The CN intervenes within specified roles to meet the needs of individuals, families, the congregation, and sometimes the community of which the congregation is part. The nurse does not give physical or hands-on care, but looks at care needs from a broader perspective. The nurse seeks to promote continuing health and wellness through individualized and personal care planning. Typical CN care roles include health educator, personal health counselor, advocate and volunteer recruiter, referral agent, developer of support groups, and facilitator of the link between personal faith and health. Congregational nurses do referrals for problems that are beyond their scope of congregational nursing practice. Though they have been trained as registered nurses, performing some invasive nursing procedures would put the nurse and the congregation at risk for liability. They intervene according to guidelines set by the Nurse Practice Acts of their respective states, and practice independently within those guidelines. These predetermined boundaries prohibit nurses from performing skills or interventions for which a physician's order is required or for which they have not been educated. For example, most of the skills that the community might consider part of a nursing role, such as giving shots, are invasive and therefore require a physician's orders. Nurses can teach people to perform appropriate skills and can refer those skills requiring special techniques, but they cannot prescribe without advanced practice training. Congregational nurses are usually not ministers or pastors and would not normally function within those roles, though there are some exceptions. Most matters related to the spiritual needs of the congregation are referred to the pastor or appropriate staff member, such as a pastoral counselor. Graduates of the combined nursing and ministry programs may serve in joint roles, but the nurse, the denomination, and the congregation's leaders would set specific role descriptions. Communication among the parties involved is essential to achieve highest possible functioning. Definite job descriptions decrease the possibility of confusion among congregation members. Need for Congregational Support. Congregational nurses need the support of the congregation, its leaders, and the community, if involved in outreach, to be effective in the ministry. They cannot operate in isolation, and many would prefer others take responsibility. Whether or not the nurse shares the workload, responsibility, and recognition, he or she needs assurance that the congregation will attend special programs and will make an effort to help if necessary. Nurses often spend months assessing congregational needs and planning appropriate intervention strategies, so it is discouraging when the people do not attend programming or take advantage of special speakers. Many nurses complain that although they donate a great deal of time and energy to a project, the congregation seems to ignore the effort. If a special health speaker has been secured, little or no turnout can be painfully embarrassing to both speaker and nurse. Even CNs who feel called to service feel angry and disillusioned at the perceived lack of congregational interest and support. Some very effective health programs have suffered or been eliminated due to a perceived lack of interest and value for congregational health. Congregational nurses must know as much as possible about the congregations they serve to effectively weave a health program. They must know not only the needs of the congregation, but the resources, leadership, and organizational structure. Needs and resources. Concurrent assessment of congregational needs and resources is best for quickly solving the congregation's health and wellness education needs. Needs and resource assessments can be formal written documents or informal questionnaires. It is unnecessary to use complicated forms to determine congregational needs when simple and understandable checklist forms are more efficient [ SEE SIDEBAR 1: CONGREGATION NEEDS ASSESSMENT ]. Some health ministries determine congregational needs and programming based on the church's regular prayer requests. Whatever method of needs assessment is chosen, it is important to know how to meet those needs. Some problems may require special education programs with personalized health counseling to make a difference, while some problems require establishment of informal support groups or other persons to help the needy with activities of daily living. People to help meet the identified needs could be within the home congregation. Therefore, the initial resource search must include the congregation. The reason most people never volunteer to help
is that they have not been asked. Many people want to help others,
but do not know how to help. The most important participants
or helpers within a health ministry are those who want to serve
God by serving others. They may or may not have medical backgrounds
or training, but they are willing to help "behind the scenes".
The CN must know these people and be willing to utilize them
for the ministry to be effective. These medical or lay volunteers
may have the knowledge, time, or expertise required to meet
the personal or congregational need. Allowing the congregation
to care for itself and for its own people is one way of facilitating
the link of faith and health, because it helps caregivers and
care receivers feel significant as they take ownership of the
ministry while giving and receiving God's love.
Consider the story of Moses in Exodus 17. When the Amalekites attacked the Israelites, Moses sent warrior Joshua and some of the best men to fight. While Joshua was in the battle, Moses, Aaron, and Hur went to the top of the hill where Moses held the staff of God towards heaven to show their recognition of God as the true Commander-in-Chief of the Israelite army. While Moses held the staff up, the Israelites were stronger in battle. But if he lowered his arms, the Amalekites were stronger. As time went on, Moses became tired, and his hands became heavy. Aaron and Hur found a rock upon which Moses could rest. Then each supported one of Moses' arms. Aaron upheld one arm, and Hur upheld the other arm, and they stayed until the sun went down. Amalek was defeated. Most stories about Moses would show his importance above other men, but in this passage Aaron and Hur, who played no other part in defeating the Amalekites were as important. Moses could not have done his part without them. The same could be said for the CN who must utilize the resources of the congregation to properly serve. The CN attempting to operate the ministry alone will become weary just as Moses did. Leadership and Organizational Structure. Congregational leadership and organizational structure will influence health ministry development. The nurse must consider and secure support from the power base. Some congregations are autonomous, and its leaders are "in house" and often available for consultation and help. Some congregations have a pastor who is the recognized leader and decision-maker, while others have a group of pastors or elders who lead and make decisions. In single pastor congregations, the decision-maker is also the most visible person in the congregation because he or she typically delivers the pulpit message. The pastor often initiates or motivates new programs. When a group of pastors leads the congregation there is typically another person who is more visible than those leaders. That person delivers the pulpit messages and may hold other responsibilities within the congregational structure, but does not usually have decision-making authority. Some leaders answer to denominational superiors outside their own congregation. These leaders may or may not have complete authority to establish programs which are not a traditional part of the denominational practices. Congregational nurses must know whom to approach regarding program establishment and operation. Approaching the wrong person or group of persons leads to confusion and the impression of "getting the run-around" by the administration. Potentially useful programs may never get started if the CN believes that the congregation or denominational leaders are uninterested. Determining whom to seek with regards to new program establishment can be difficult, but is worth the effort. A CN serving his or her home congregation may be familiar enough with its leadership structure to find the appropriate leader, but that may not always be the case. Part of the congregation assessment process involves becoming familiar with the congregation's existing ministries and ministry leaders, and they may be able to guide the CN appropriately. If current ministry leaders are unsure of the proper chain of command and procedures to be followed, a current organizational chart should provide the answers. Often the church secretary gives the most useful direction. There are other leaders in addition to the true decision-makers. These are people who are highly esteemed and trusted within the congregation. They are often considered wiser than others, and they often get what they want from the decision-makers. Sometimes they are leaders within the elder adult groups or they are long-time Bible school teachers. Sometimes they make the most sizable contributions to the building fund. These unofficial leaders may not hold a prominent role within the congregational structure, but their power and influence is undeniable. Congregational nurses should be able to identify them and gain their support to establish effective ministries. Another important piece of the organizational structure is currently operating ministries or service programs. The CN must be familiar with existing ministries and ministry leaders to establish a health ministry. Many congregations have various ministry programs in place, such as programs for prayer, benevolence, visitation, and transportation ministries. Developing a new health ministry would cause some overlap of services while still not meeting all the needs of the congregation. Nurses must examine the workings of each ministry including its leadership qualifications, purpose, scope, intended beneficiaries, duties, and if possible the budget. Many congregations have this information written in the form of ministry directories, so it is not difficult to obtain. If no ministry directory or written detail is available, the CN can gain the needed information from the appropriate congregational leaders. When the CN becomes familiar with the other ministries, he or she can weave the health ministry into place using the existing congregational resources when possible. There are many advantages to this method, including more efficient service with less overlap, shared responsibility for ministries, and shared budgets. For example, a local congregation had a monthly social newsletter which was distributed at the end of a morning worship service. The newsletter came out every month no matter what its content. The CN was aware of the publication and its potential for health education, so every month she or one of the many health professionals within that congregation contributed a health ministry article. The publication came from the budget of another ministry so it was not a health ministry budget item. The editor of the newsletter also became interested in other aspects of the health ministry so he supported and publicized events regularly. Contributors to the health ministry column took responsibility for their contributions and began to take ownership of the entire ministry. Successful development and implementation requires the CN to know a great deal about the congregation served. Health ministry service can not be accomplished alone. The greater the CN's knowledge of the congregation's needs and resources, leadership, and organizational structure, the more effective the program.
The purpose of this paper is to describe the process of weaving a health ministry into a congregational structure. Discussed has been the need for health ministries within today's definitions of health and health care systems, what congregations should know about CNs and what CNs should know about the congregations they serve. This section will describe briefly the actual weaving of the health ministry into the congregation. [ SEE SIDEBAR 3: HEALTH MINISTRY CHECKLIST FOR PASTORS/CONGREGATIONS ] After the congregation and the CN are familiar with each other as described in the previous section, the CN will constantly assess and reassess individual, congregation, and community needs and resources. Care strategies for meeting the needs will not include invasive, hands-on procedures, but will involve education, referrals, advocacy within the congregation or other system, and application of faith and health principles. Here is a benefit of including many components into the ministry. During a congregational blood pressure check a young father was found to have blood pressure well above normal limits. The CN referred him to his physician and gave him information regarding the dangers of hypertension. Because he preferred a severely high fat diet, the nurse and a nutritionist from the congregation met with the man and his wife to develop a diet plan more compatible with healthy living. His physician placed him on medication, the side effects of which were devastating to a couple planning for more children. The CN monitored his pressure every week and taught his wife to do the same. Eventually his blood pressure was under control, and he seemed happy, but after months of stable pressure he again became hypertensive. He was still taking his medications and following his diet, and his wife continued to take his pressure daily. Finally he shared with the CN his frustration at the current situation and his wish that the nurse and his family had let him die instead of making him "less than a man." Recognizing his problems as spiritual and emotional rather than physical, the CN gained his permission for referral and then spoke with the counselor who was on staff. After visiting the counselor, the man's pressure returned to normal. Had the CN been unaware of the counselor or unwilling to use the other resources the man would not have had the benefit of care from his own safe environment. He was acquainted with and trusted all who helped him and he expressed a feeling of significance because of the love and help he received. Because others were able to help him, he continues to seek opportunities to help others. All plans and programs should involve some sort
of evaluation and a health ministry is no different. If personal
or congregational goals are set, they should be evaluated. Without
evaluation, program effectiveness cannot be determined. Like
assessment, problem identification, and care strategies, evaluation
is part of a circle
How sad to think that something as potentially good as CN health ministry programs can go wrong. Turf wars, misuse of resources, and conflict management as it relates to congregational health ministry will be discussed within this section. Turf Wars There are a few cases in which the CN, though not the pastor, is also an ordained minister. There are also instances in which the pastor of a congregation, though not serving as CN, is also a registered nurse. Most of these congregations have experienced some level of role confusion which led to unmet expectations, hurt feelings, and anger. Eventually, these health ministries were unsuccessful because the lack of role definition prevented the CN, the pastor, and the people from differentiating between the roles. In the case of the CN who was a minister, though she was serving the denomination in which she was ordained, she found that she did not agree with the administrative style and practices of the pastor. She felt it was her duty to the congregation to point out the pastor's flaws, making sure everyone knew that she, too, was ordained. Though the pastor was not doing anything wrong or inappropriate, the CN's lack of respect for him as congregational leader caused many problems. The people were led to believe that the church leadership was unstable and they felt unsupported and abandoned. The congregation no longer trusted the pastor or the CN, and many left. In the case of the pastor who was also a registered nurse, though she had a part-time CN who had developed many useful programs, she found that she did not always agree with the CN's assessments or care strategies. Therefore, when the CN was away from the church building, the pastor would often change the nurse's lesson plans or other strategies to those she felt were more appropriate. It was not uncommon for the pastor to tell the congregation that the CN might be incorrect in her planning process. The congregation became mistrustful of the CN's abilities, and started to take their health concerns directly to the pastor. Eventually the pastor found herself doing both jobs, and became bitterly resentful of congregational health ministry programs. The above cases speak to the need for role descriptions and differentiation. Nurses who go into ministry may receive ordination according to his or her denominational practices. Since congregational nursing is based on spiritual care and facilitating the link of faith and health, nursing and ministry seem to fit naturally. The problem occurs when the nurse/minister does not establish and maintain role boundaries. Lack of boundaries and the resulting confusion is destructive to the congregation as its members lose faith in the leaders. Due to territorial conflict, many could question the need for a faith based life since it so resembles a non-faith based life, and they may leave the congregation. Examples like the foregoing of turf disputes and the accompanying disrespect force CNs to reexamine their motivations. Are they delving into the domain of the spiritual in order to quench their own thirst for power and greater credibility, or are they truly seeking to fulfill a broad range of needs that constitute healthiness? Most ministers and church leaders will welcome the useful ministry and emphasis on health that a nursing professional brings. However, there may be occasions when a pastor is resistant or wishes to maintain close oversight. In such cases, since many pastors are given extensive oversight and are primary decision-makers, it may be best to accept the limitations until a more opportune time. There are more important matters within a church than promoting a parish nursing agenda, one of which is unity. Misuse of Resources People will often line up as victims when something free is available. Health ministry programs often face the decision of need. Nurses must determine whom among the congregation could benefit most from the limited resources, and they are often forced to make resources available only to those in the greatest need. One CN was faced with such a problem. The pastor informed her of a mother of five children within the congregation who was requesting that the health ministry deliver prepared meals to her home every night because she did not want to cook for her family. The mother had heard that the CN arranged meals for people and she felt entitled to the service. The woman was married and had a full time job, and their double income family did not appear to be in financial need. The CN questioned her regarding the need for the service, stating that meals were brought for those who were too sick to care for themselves or could not afford the food. She also explained that providing food unnecessarily might prevent someone in real need from being fed. The mother grumbled that she shouldn't have to cook for her family when she is "sick of them," and that the CN should stop being judgmental. The mother finally told the pastor that she could no longer worship in a church "that didn't have its act together," and she left. Conflict Management Conflicts are part of life and part of work, especially in a congregation. More personal pain comes from congregational interactions than from any other source. Conflict management requires thorough communication of expectations, patience, and wisdom. Consider the following. Nehemiah dealt with and overcame many potential and real conflicts in an effort to rebuild Jerusalem's walls. He had to manage a potential conflict with the king, conflicts with soldiers, the wall construction crew, and enemies. He managed internal and external conflicts and his progress toward goal completion became apparent. He was successful in his ability to manage the conflicts. The key qualities of Nehemiah seem to have been his humble prayerfulness, his passion for the project, and his ability to inspire others to catch his passion. Congregational nurses and leaders should remember Nehemiah's primary principle of conflict management; consult God first and always. Since everything, including resources, education, status, and health belong to Him, then ask Him how they should be used. Some congregations with developing health ministries do not like to include God in the process. Those programs have failed without exception. When the CNs, health ministers, or other congregational leaders seek to serve their own agendas, conflicts will arise. When God is included, the motivation for service is His calling, and the health ministry seeks to glorify God instead of the individuals. Conclusion
Today's health care system is shifting from inpatient to primarily outpatient services. With this shift comes a change in the meaning of personal health from physical status to holistic well being. Though healthcare systems try to meet the community's holistic well being, they can not truly prescribe the personal relationship of faith and health for each individual. Only through a personal worldview can faith and health truly be united, and it is from that standpoint that congregational health ministry is so important. Congregational nurses and leaders must learn about each other to develop an effective health ministry program. Because this level of knowledge cannot occur immediately, communication is very important. People can benefit from congregational health programs, especially when they participate in serving those programs. Service to others helps people feel significance as they serve God, but that service can be corrupted or terminated when CNs and congregational leaders allow themselves to feel more important than the others. Maintaining the ministry for the right reason is important to its success.
Porter-O'Grady, T. (1999). Strategic partnerships for the future. In J. Ryan (Ed)., Market-driven nursing: Developing and marketing patient care services. (pp. 1-15). Chicago: Health Forum, Inc. Schumann, R. R. (2000). Collaborating for mission. Journal of Christian Nursing, 17(1). 22-23. Smith, S. D. (in press). Theoretical models from which to view parish nursing. Journal of Healthcare Chaplaincy.
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Last updated: April 10, 2000