Quenstedt-Moe makes an excellent case for the blending of parish nursing with home care. The early church did not see rigid boundaries between spiritual and physical care. The apostle James admonished the church: "What good is it, my brothers and sisters, if you say you have faith but do not have works? Can faith save you? If a brother or sister is naked and lacks daily food, and one of you says to them," Go in peace; keep warm and eat your fill, "and yet you do not supply their bodily needs, what is the good of that?" (Jas 2:14-16).
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When a nurse withholds needed skills from a congregant because of rigid role boundaries, we may be guilty of faith without works. However, although I believe that a blending of the roles of parish nurse with home care nurse may indeed be a future direction for parish nursing, it is a possibility that requires much dialogue at many different levels. It is not just a good idea that should be adopted by individual parish nurses. There are caveats for parish nurses involving both congregational liability and professional accountability.
Last year I coauthored a book, Parish Nursing: Stories of Service and Care (Templeton Foundation Press), compiling stories from parish nurses across the country, from many Christian denominations. Although most of the nurses defined their roles as occurring within the churches that they served, such as blood pressure screenings following worship services, health education programs and health counseling, some shared stories of visiting congregants in nursing homes, hospitals and homes. Visitation was not that uncommon.
However, all the nurses emphasized that their roles entailed what I refer to as ministries of action, word and presence, not hands-on nursing. This position is elucidated within The Scope and Standards of Parish Nursing Practice1 and accepted by the American Nurses Association. The Scope and Standards of Parish Nursing clearly supports the independent functions of nursing as the boundaries within which the parish nurse serves the congregation. The dependent functions of nursing, those that require a physician's order, such as insertion of a Foley catheter or the administration of an intramuscular injection, are excluded.
Quenstedt-Moe distinguishes in table one the interventions that were parish nurse interventions from those that were home care nurse and parish home care nurse interventions. Based on my experience, I had difficulty with some of the distinctions. Many of the nurses who shared stories with me were already engaged in providing the parish home care nurse interventions including making referrals, advocating for care needed by a congregant and calling community-based agencies to provide services for a congregant.
However, the majority were not involved in providing skilled care such as a physical, cognitive, emotional, social, spiritual assessment or a functional assessment focusing on the congregant's ability to independently perform activities of daily living. None of the nurses reported providing personal care or administering medications. These activities seem to me to be the dividing line for many parish nurses. In their roles as parish nurses they are uneasy with these hands-on activities.
The author suggests that the needed skills can be acquired through shadowing home care and/or hospice nurses and attending continuing education programs on home care nursing. She states that every home care nurse, regardless of specialty, is mandated by Medicare to complete the Outcome and Assessment Information Set system (OASIS), a comprehensive head to toe assessment. These positions are correct. However, as the national director of a behavioral home health program, I regularly confront the issue of medical nurses who are afraid to ask about depression and psychiatric nurses who never ask about incontinence or other medical needs. Competencies vary widely. Nurses frequently function within the comfort zones of their experiences and their specialties.
So, this raises several questions related to the blended role of parish home care nursing. How do churches and congregants ensure that their parish nurse has the skills required for a blended role? Would this blended practice require the type of scrutiny and government oversight required of home care and hospice nursing? If not the government, who would provide supervision for nurses practicing in a blended role? The variation in competency level suggests that oversight would be necessary. Would liability increase for the church and/or for the individual nurse? Would The Scope and Standards of Parish Nursing need to be revised?
In summary, although I believe this blended role is a good idea, it is one that still needs further exploration and intense prayer for the Lord's leading.
American Nurses Association and Health Ministries Association, Scope and Standards of Parish Nursing Practice (August 1998). [Context Link]