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PARISH NURSING

PROBLEM: Many health problems seem to have causes other than the physical conditions addressed by traditional medical practice.

SOLUTION: Parish nurses seek to help people with health problems by addressing their spiritual well-being.

      Jan Erlenbaugh is the parish nurse at Holy Cross Catholic Church located at 125 N. Oriental Street in Indianapolis. Erlenbaugh ministers to the church�s parishioners, but she generally doesn�t provide the type of medical care associated with a nurse. So why is she called a parish nurse? What kind of care does a nurse provide if not medical?

      Parish nursing began with Granger Westberg, a Lutheran minister and hospital chaplain in the Chicago area from the 1940s to the 1990s. He observed that physical illnesses often had roots that reached beyond the scope of ordinary medical treatment. As Westberg put it, physical problems "seemed to originate in some personal struggle, often related to grief."

      In response, Westberg helped found a free health care center. Situated in a poor neighborhood in Chicago, it was staffed by volunteer doctors and nurses who "would treat these people�s complaints holistically, recognizing that their problems stemmed from and affected not only the body but also the mind and the spirit." That first clinic was replicated in several other poor and middle-class neighborhoods. But even the clinics located in neighborhoods where customers paid for services lost money.

      In the early 1980s, Westberg hit upon a plan to preserve the essence of the centers while making them financially feasible. A fundamental component was the support of churches. "At a time when many congregations feel they are stagnating, spending too much time talking about God and too little making the Word come alive in action, perhaps they should reexamine the most fundamental Christian concept, salvation, and remember that it means �being made whole,�" Westberg wrote. "The time has come for the church to resume its concern with health care and to once again pick up the reins of innovation and leadership in the crucial and sometimes forgotten area of ministry."

      The most intriguing aspect of Westberg�s plan was the way he reconceived the role of nurses, based on his experience with health clinics. In a typical clinic, doctors were regarded as the most important members of the medical team. Westberg noticed something curious, though: "I realized that the nurse was the key member of the professional team in these clinics," Westberg once told an interviewer. "She had the sensitivity � the peripheral vision, I call it � to see beyond the patient�s problems and verbal statements. She could hear things that were left unsaid. Nurses seem to have one foot in the sciences and one in the humanities, one foot in the spiritual world and one in the physical world."

      Combining these components � holistic health care, churches, and nurses � Westberg conceived the idea of parish nursing. The details would vary from place to place, but the basic idea was that churches would add a nurse to their ministerial staff. This nurse would not serve the functions typically associated with a nurse; she would provide no �hands-on� or invasive treatment, but would focus on ministering to the spiritual aspects of her patients� health. Treatment could involve simply listening to people talk about their problems.

      This did not mean the parish nurse would be nothing more than a counselor or pastoral psychologist. Physical illness may have deeper roots, but the physical manifestations of illness must also be addressed. Ideally, the parish nurse would serve as go-between for the health care community and the church, referring parishioners to the appropriate medical services when needed.

      Parish nurses could offer educational programs and monitor the more obvious indicators of health such as blood-pressure. They could invite special guests to give talks on topics such as cancer and stroke prevention, or on dealing with alcohol abuse and depression.

      Granger Westberg did not specify the duties of a parish nurse. He knew that any individual program would evolve according to the energy, interests, time and resources of the nurse who directed it. What Westberg did provide was a general theoretical foundation, and he helped the movement gain momentum by promoting the idea to Chicago�s Lutheran General Hospital. In 1983, Lutheran General agreed to sponsor a test-run of parish nursing. The hospital paid three-quarters of the salary for a parish nurse in each of six Chicago-area churches. The hospital�s contribution decreased each year, until by the fourth year the churches assumed the entire financial burden. Lutheran General also provided space for a continuing education program, where the parish nurses met occasionally for instruction by Westberg, and a teaching nurse and doctor. Those early programs were a success, and parish nursing has since spread across the US and abroad.

PARISH NURSING INDIANAPOLIS: TWO EXAMPLES

      St. Paul�s Episcopal Church began the first known parish nursing program in Indianapolis in 1989. Parish nursing did not really take root here, though, until the mid-1990s, when the nursing program at the University of Indianapolis introduced a course on the subject. Many of the nurses who took that course now serve as parish nurses in congregations around Indianapolis and form a network of people who know each other and stay in close contact.

      U of I�s efforts have been crucial to the growth of parish nursing in Indianapolis. In addition to training nurses, the university got local hospitals involved as sponsors. Each nurse who takes the course is required to be sponsored by an organization that pays the nurse�s tuition. These sponsors are generally, though not exclusively, hospitals.

      St. Paul�s is something of an anomaly; its parish nurse, Jean Denton, neither took U of I�s course nor has an affiliation with a local hospital. She started her ministry before the course existed, and as she is a staff member at St. Paul�s she doesn�t require the financial support of a hospital.

      Below are the stories of two more "typical" parish nurses. Each took U of I�s parish nursing course, and each is sponsored by a hospital. They are also both motivated by a sense of Christian mission.

Jan Erlenbaugh/Holy Cross

      Jan Erlenbaugh enrolled in the course at the University of Indianapolis in 1996, and in 1997, she started a parish nursing program at Holy Cross.

      Erlenbaugh�s sponsor, St. Francis Hospital, now pays her half-time salary (technically a sixteen-hour a week, but she often volunteers an additional three or four hours.) The arrangement allows Erlenbaugh to devote more time to her role as a parish nurse, but the program is dependent on an outside source of funding.

      "We haven�t yet had to make the hard decision to fund it," said Fr. Larry Voekler, pastor of Holy Cross. "An entity over here says, �We�d like to give you a parish nurse.� And we say, �Sure, we�ll take whatever you want to give us.� We haven�t had to make the choice of whether to put our own resources into it."

      Erlenbaugh organizes an annual health fair as an outreach to the church�s neighbors. Held early in the spring on the church�s grounds, the fair attracts about 100 people every year. Erlenbaugh has gained the cooperation of several agencies and organizations, among them St. Francis Hospital, the Marion County Health Department, and Wishard Health Services. For the three-hour duration of the fair, they offer screenings and services to the public free of charge.

      The bulk of her work involves talking with parishioners individually � sometimes explicitly about their health, but often not. Erlenbaugh�s goal is to create an environment where the issues underlying the indicators of poor health can surface.

      "In nursing, we talk about whole-person health and spirituality, but in reality it�s hard to apply that in hospitals," Erlenbaugh said. "Healing happens from within. The medical model addresses the external � take this and this. Listening to patients, helping them process things, is part of the healing process. When you�re running them in and out, you don�t have time to do that."

      Erlenbaugh couldn�t possibly serve all of the 300 or so people who come to Holy Cross�s food pantry twice a week for help. Instead, she tries to have an influence on them indirectly, by working with the volunteers who staff the pantry.

      "I minister to the ministers," Erlenbaugh said. �The focus for me is on the volunteers. I don�t know whether that makes an impact or not. When you bring the God spirit into it, you can�t measure the impact."

      This lack of measurable results can make parish nursing difficult to sell. At Holy Cross, Erlenbaugh holds a prayer service for parishioners. Few people attend, and Erlenbaugh has considered discontinuing it. She has not done so because parish nursing is premised on the notion that the measures of success and failure � like the sources of illness � go beyond surface indicators.

      Holy Cross�s monthly blood pressure screening program has strong support from parishioners, and yields quantifiable results. In medical terms, the program is a success. But Erlenbaugh isn�t inclined to talk about it that way. The point isn�t simply to find out who has high blood pressure, but why.

      "You�ll take their blood pressure," Erlenbaugh said. "Then they�ll say, �Can I talk to you about something else?� One person took a whole year before she came to my office and confided what was really on her mind. So it�s a matter of building trust and a relationship and being visible, finding out what�s underneath it all. What�s your relationship with God? What�s your faith crisis? How does the stress of life affect physical health? Underneath � that�s where I see my call to ministry."

Pat Thorlton/Greenwood United Methodist

      Pat Thorlton started a parish nurse program at her church in 1997, after she had completed the course at the University of Indianapolis. Her sponsor for the course was her employer � Community Hospitals of Indianapolis, where she is a registered nurse at the South campus. Her church, Greenwood United Methodist, is located at 525 N. Madison Avenue.

      Her first year as parish nurse, Thorlton distributed refrigerator magnets listing the warning signs of a stroke.

      Later, one of the parishioners placed a cell-phone call to Thorlton�s office at Community South. The parishioner was driving to work and had sensed that something was wrong. Based on the info-magnet (which she had with her), she feared she might be having a stroke. The woman�s speech was slurred and seemed to be getting worse.

      Thorlton directed her to come to Community South, and arranged for her to receive immediate treatment from a doctor. The apparent stroke was arrested in an early stage.

      This story of successful intervention is appealing because it conforms to popular notions of what a nurse does: diagnose a problem and provide or arrange for care. But the fruits of Thorlton�s efforts are not always immediate and obvious. A principle of parish nursing is that bodily health cannot be separated from spiritual health. The closer parish nurses move toward the ideal, the more difficult it becomes to define precisely what they are doing or how their work should be judged. The emphasis on integrating mind, body, and spirit requires a new definition of success and failure.

      "The medical model says death is a failure," Jan Erlenbaugh has noted. "In this model, death is not a failure."

      Consider the case of a long-term member of Greenwood United Methodist � a retired schoolteacher who died of cancer. Thorlton could do nothing for her physical illness. But as a registered nurse she could serve as a liaison between the medical community and the parishioner, explaining the implications of the treatment options available to her. And along with the other members of the church�s health ministry she could be a comforting presence during the parishioner�s last days.

      A parish nurse�s work largely goes on away from the spotlight; most often, it does not involve a dramatic intervention, and its value cannot be added up in terms of lives saved. Existing on the border between the medical and faith communities can make parish nursing vulnerable from both sides: dismissed as being neither scientific nor distinct from pastoral care.

      Parish nurses have encountered opposition primarily on the first count, though resistance has abated somewhat. Community Hospitals had no involvement with parish until Thorlton took the course at the University of Indianapolis. Little more than a year later, Community Hospitals was sponsoring enough parish nurses to add a parish nursing coordinator to its staff. Thorlton was offered the job and accepted it.

      Community South�s parish nurses work under a different arrangement than Jan Erlenbaugh at Holy Cross. They are full-time employees of Community Hospitals, and their parish nursing work is done on a volunteer basis, in their spare time. The hospital system is their sponsor for the course at the University of Indianapolis, and it provides a parish nurse coordinator (Thorlton) to bring them together for networking and educational opportunities.

      The drawback to this arrangement is apparent: parish nurses who work elsewhere full-time have less time for their ministry. But it involves almost no risk to the church. Justifying a parish nursing program is not so difficult when no money is at stake. There is the possibility, too, that a volunteer effort will become a paid position as congregations come to understand the role of parish nursing and its value.

PARISH NURSING OPTIONS

      Jean Denton, Jan Erlenbaugh, and Pat Thorlton represent three possible models for implementing a parish nursing program. Denton, who is supported by her church and is completely independent of a hospital, is unusual. Erlenbaugh�s situation � St. Francis Hospital pays her half-time salary to be the parish nurse at Holy Cross � is only somewhat less rare. Thorlton, who works full-time for a hospital and does her parish nursing work on a volunteer basis, has the most common arrangement. Whether all of these models will survive remains to be seen.

      For congregations interested in starting a parish nursing program, the hardest work has already been done. In contrast to a decade ago, there exists now a network of practicing parish nurses to provide a support system.

      U of I�s course requires that the prospective participant be a registered nurse with at least two years of experience, whose tuition will be paid by a sponsoring organization. The sponsorship is mandatory, Larson said, "because we feel that community relationships are important, and it gives the parish nurse a support system to fall back on." The cost of the course is approximately $1,300.

      The value of the course extends beyond what is learned in the fifteen weeks of classes. Equally important are the contacts that the parish nurse will make � friends and colleagues whose help they can draw on as they build their ministry.

      The parish nurses profiled above each have a committee or health ministry team to support their work and represent it to the church. This is fundamentally important. The parish nurse can train team members in tasks (such as visiting the sick) that are part of her vision for the program but do not require any medical skill.

      Finally, there is much to recommend moderation in the initial stages of the ministry. Having a parish nurse for even a few hours a week is better than having none at all. Starting slowly allows the parish nurse time to define her role and gives the church a chance to get used to the new ministry. It�s always easier to expand a program than to scale back.

      "Take things slowly," Pat Thorlton advised, "because it grows rapidly."

POINTS TO REMEMBER:

�        Parish nursing is measured by different standards of success and failure than traditional nursing.

�        Parish nursing�s holistic approach to health may require some initial explanation and "selling� on the part of the parish nurse and congregational leadership.

�        A parish nursing program can range from a volunteer effort requiring a few hours a week to a full-time paid position.

�        Communication with other parish nurses is crucial; taking a course in parish nursing is the best way to establish the necessary contacts.

�        Particularly in the early stages, the support of a health ministry committee or team can mean the difference between success and failure

�        Begin small, and expand the program as time and resources permit.

CONTACTS & RESOURCES:

Parish nursing does not occur in isolation. There are numerous resources for parish nurses to draw on and opportunities for them to share ideas.

St. Paul�s Episcopal Church
10 West 61^st St.
Indianapolis, IN 46208
(317) 253-1277

Jean Denton has written extensively about parish nursing and has done much work in gathering resource materials of interest to anyone planning a ministry. The introductory material, including a booklet by Denton entitled "An Episcopalian Answers Questions About Parish Nursing", is available for free. In addition, Denton has a book-length publication, assembled in a binder format, that deals exhaustively with issues related to planning, implementing, and maintaining a health ministry. The cost is $40.

School of Nursing, University of Indianapolis
1400 E. Hanna Ave.
Indianapolis, IN 46227-3697
(317) 788-3503

Registration for U of I�s parish nursing course is ongoing; enrollment is limited to 25. The university also sponsors a monthly meeting that provides continuing education and networking opportunities for parish nurses. The meeting is open to anyone; call U of I for time and location.

Health Ministries Association
P.O. Box 7853
Huntington Beach, CA 92646
1-800-852-5613

HMA, whose scope encompasses more than just parish nursing, can be a valuable resource for information and networking. It sponsors an annual meeting at various locations, publishes a quarterly newsletter, and offers consultation on health ministry-related questions. HMA�s website is located at www.interaccess.com/ihpnet/hma/.

International Parish Nursing Resource Center
205 W. Touhy Ave., Suite 104
Park Ridge, IL 60068
1-800-556-5368.

In addition to the annual Westberg Symposium, IPNRC offers a newsletter and orientation sessions twice a year for prospective or newly established parish nurses. Information on the Center is available through the Advocate Health Care website: www.advocatehealth.com. Click on the "Missions, Values, Philosophy" button, then click on "The Offices of Congregational Health." The site offers for sale numerous publications on parish nursing practice.