Practice Models and Educational Pathways for Parish Nursing by Sybil D. Smith, Ph.D., R.N. Introduction Parish Nurse Education Practice Models of Parish Nurse Programs Educational Pathways Related to Practice Models References Sidebar articles Introduction Parish nursing in the United States emerged as a vision of Granger Westberg (1990). Westberg was a Chaplain and Professor at the University of Chicago Medical School and implemented the first parish nurse project in 1984 with six Chicago area churches in conjunction with the Lutheran General Hospital in Park Ridge, Illinois. It was Westberg's desire to stimulate dialogue between science and religion at the grass roots level (Westberg and McNamara, 1987). Westberg is legitimately acknowledged as the spark behind current day parish nursing, however meeting the wholistic needs of the community of believers has been a part of the Christian church since its inception (Zersen, 1994). Westberg (1990) envisioned churches as a natural setting, and "spiritually mature" parish nurses as natural organizers for promoting the integration and well being of mind, body, and spirit. As integrators of faith and health, parish nurses were encouraged to take on functional roles as health educators, personal health counselors, facilitators, resource persons, and trainers of volunteers. The Lutheran General Project drew much interest, and a year later the National Parish Nurse Resource Center was developed by the Lutheran General Health System. In 1996 it became the International Parish Nurse Resource Center (IPNRC). The Lutheran General Health System is now known as Advocate Health Care. Alongside the development of the IPNRC, the Health Ministries Association (HMA) was announced in 1989 as a membership organization commitmented to promoting parish nursing as a specialized practice of the discipline of nursing and health ministries. As a membership organization, the HMA is a multidisciplinary, interfaith group. The American Nurses Association recognized the HMA and jointly published the Scope and Standards of Practice for Parish Nursing in 1998. This document defines a parish nurse as a registered professional nurse who serves as a member of the ministry staff of a faith community to promote health and wholeness of the faith community and the community it serves. A health minister is not defined by the document; however a general consensus is that parish nursing fits under the larger umbrella of health ministries (1998). With the HMA having responsibility for standards of parish nursing, the IPNRC has delved into the development of a core curriculum for parish nurse education that is marketed as an "endorsed" curriculum through which they seek to standardize parish nurse education. Pressure for all parish nurse education programs to become endorsed by the IPNRC has created tension in the ranks (McDermott, et. al., 1998). Endorsed programs are listed on the website for the IPNRC (www.advocatehealth.com). The core curriculum programs are offered as specialty programs for continuing education credit and few are part of a professional academic curriculum. Most are offered as five to eight day programs usually held in a retreat setting. There are, however, programs of parish nurse education that intentionally do not seek endorsement of the IPNRC. Some of these are listed in Appendix A. [ See Appendix A ] This paper will present some of the questions raised about parish nurse education and describe some of the tensions that exist within the discipline of nursing in general that complicate parish nurse education. Since confusion surrounding parish nurse education impedes the development of the pastoral identity of a nurse seeking to become part of the ministry team of a parish, the purpose of this article is the two-fold challenge of 1) encouraging nurses going into parish nursing to pursue some form of theological education or clinical pastoral education (CPE). And 2) encouraging providers of CPE and theologial education to develop interdisciplinary programs that would meet the needs of parish nurses and health ministers. Parish Nurse Education Before we can consider the educational issues around parish nursing we must look at the bigger picture of nursing education in general. These issues can impact what a nurse can bring to parish ministry. Nursing is a secularly regulated discipline with an historical hierarchical structure. Until very recently education for nurses was deficit in processes that promote self-awareness and self-understanding. Reflective learning and theological contemplation are not traditional methods for nursing education even though they are essential to effective ministry. How does a nurse with aspirations of becoming a parish nurse learn these things? Nursing issues in general. There are disciplinary inequities within nursing that revolve around the level of education from which the nurse first enters nursing practice. It is requisite to discuss entry into practice for nurses because it contributes to the identity of the nurse. There are three basic pathways into nursing practice: 1) the two year associate degree, 2) the three year diploma, and 3) the four year baccalaureate degree (BSN). Graduates from all three pathways are eligible to sit for the same licensing exam, which, upon passing, generates the credential of Registered Nurse (RN). Graduates from all three pathways can become registered nurses, but only at those with the four-year BSN degree are known as a professional nurses (Jacobs, et. al., 1998). While nurses with associate degrees or diplomas can carry the RN licensing credential, they are considered to be technical nurses (Nursing Spectrum, 1999). The focus of the technical education process is learning the task and technical skills of the trade in preparation for bedside jobs in hospitals. Conceptual thinking is only implied within the coursework of technical education. In the four-year BSN entry into practice, conceptual coursework is explicit at a generalist level. The BSN nurse may work at the bedside, but is prepared to work also in the home and community (Hahn, et. al., 1998). It is at the graduate specialty level of the nursing master's degree preparation that nurses are, in a meaningful context, educated about conceptual ways of viewing the world. Tensions exist within nursing because the significance of varied pathways to nursing practice lose meaning when there is a nursing shortage. When nurses are in short supply, minimum qualifications for a job are often waived and a technically prepared nurse will be placed into a role requiring a skill set that is only available from a professional or advanced (masters) degree pathway. Maturity in years and professional development of the nurse can sometimes balance the discrepancy. Nurses who gravitate to roles for which they are not academically prepared contend with issues of acceptance from within and without nursing, even when the nurse has an outstanding performance record (King, et. al., 1993). Spiritual maturity can be a resource enabling the nurse to find a comfort zone; however, that comfort zone can become fragile when new stretches are required. The "entry into practice" issue within the nursing profession supports the view that all nurses are not equal when they enter an interdisciplinary environment such as health ministries or parish nursing. Some nurses will be more comfortable than others. Good relationship skills can only take one so far when specific knowledge is needed. Along with entry into practice issues and quantitative accountability traditions, nurses are socialized to be "others-directed" without a voice of their own (Stern and Spring, 1999). While being others-directed, nurses often practice from a position of authority that, without realizing it, ignores the client story and disregards the client's wisdom and agency. Only in recent decades have qualitative methods of knowing been valued in nursing, and opportunities contributing to self-awareness and self-understanding are rare. Educational methods in nursing do not reinforce a student becoming open to their own experience of nursing (Bevis, 1990). Student nurses reflect upon, "was the right intervention delivered to the right patient at the right time" and not about what the nurse felt or experienced during the interaction. Nurses do not get to affirm their humanity as part of vocational formation, and the need to reframe disappointments, stress, and discouragement into a positive light goes unmet. "Entry into practice" and parish nurse education. Parish nurse education as endorsed by the IPNRC is considered a commodity in the marketplace. One must examine whose interests are being served by the self-endorsed program. Do the two year associate degree nurse, the three year diploma nurse, the four year bachelor degree nurse, and the graduate degree nurse all need the same introductory course to serve as a parish nurse? Bethune and Wellard caution against the commodification of education that is vocational in nature (Bethurne and Wellard, 1997). A response to service needs is not always a contribution to professional education. A nurse should be given an opportunity to choose an educational pathway that meets the objectives of the role he or she desires in parish nursing. Many variables such as the program objectives of the employing agency can impact the educational pathway needed by a parish nurse/health minister. Practice Models of Parish Nurse Programs The role and the educational preparation of the nurse will vary depending on the objectives and motivations of the program in which the parish nurse practices. Three models for viewing motivations behind parish nurse practice will be discussed: Mission/Ministry, Marketplace, and Access (Smith, 1999). A comparison and contrast of assumptions for each model are displayed in Table One. It is important to point out that the writer has laid out discrete extremes in the table; in actual practice there is much overlap. Hopefully these insights will contribute to improved methods of program evaluation for parish nursing. Mission/Ministry Model. The parish nurse is on staff as part of the ministry team of the congregation. The parish nurse spiritually discerns a call to congregational care ministry, is motivated as a steward of one's faith, and is ministering within a home congregation from a whole-person health perspective. Objectives of the ministry are directed by the ministry goals of the parish through designated processes and structures. The power and authority of the program are based in the integrity of the faith, with the gatekeeper being the pastor or board. Marketplace Model. Health services are provided to a consumer and the church building becomes the site for delivery of health programs. The nurse may or may not be a member of the parish. The nurse gathers data about what the consumer wants or needs, implements programs, and interacts with bureaucracies. A nurse may live out his or her faith while practicing in a marketplace program but the underlying mission or "why" of the program has to do with the business of the employing organization, such as a hospital. Objectives and motivations are market driven and provide a product to a consumer. The consumer can be a church, a coalition, or civic group. Services can be provided within a congregation or purchased by a congregation for an underserved population. Access Model. As an advocate for the oppressed, the nurse is a catalyst or change agent to promote empowerment outcomes through collaborative processes. Equal access to health care is considered a basic right and motivation has to do with moral responsibility and civic duty. Objectives focus on changing the relationship between our government and our economy, with the faith community becoming a change agent for the community. An advanced practice nurse specialized in community health, community development, and public health nursing is required for best results. Knowledge of working with aggregates and capacity building is essential. Educational Pathway Related to Practice Model Mission/Ministry Model. In the Mission/Ministry Model the education decision should be based on whether or not the nurse discerns a spiritual call to professional ministry as opposed to lay ministry, and whether or not the denomination is open to ordination or formal commissioning of the parish nurse as a health minister. A seminary degree is appropriate if the nurse expects to be on the professional ministry team. A nurse without a bachelor's degree may not be eligible for seminary admission, so perhaps the vocational training in a specialty program is appropriate for a nurse without a bachelor's degree. From the mission/ministry perspective, sacred influences and faith values inform health care. At the time of this writing the writer is aware of two such programs offering an advanced degree for nurses combined with seminary education: The Divinity School at Duke University in Durham, NC, [www.duke.edu/divinity] and the North Park Seminary in Chicago [www.northpark.edu/sem]. Marketplace Model. From the perspective of the Marketplace Model, the nurse should be prepared in community and family health nursing and develop expertiese in the mobilization of resources. Community health concepts become a part of the nursing curriculum at the bachelor's level of preparation. Parish nurses who lack educational preparation and work experience in public health nursing may not grasp the community perspective within their role or the need to value cooperating with other disciplines (King, et. al., 1993). From the marketplace perspective the nurse needs to be academically prepared in community health and parish nurse educated in terms of what is valued by the secular regulating agencies. Access Model. The practitioner in an Access Model needs a generosity of spirit to do poverty justice work, as well as knowledge of community development concepts. Advanced preparation in public health policy and program evaluation is needed. As in the Marketplace Model, a nurse can live out one's faith working from an Access framework, but the program itself would not have to be faith driven. Conclusion Evaluating these three models, one can see that no single pathway for parish nurse education will have all of the answers. The dialogue remains open for years as the struggle between the sacred and the secular comes into play. This writer would like to refer back to Granger Westberg's thoughts as he envisioned a "spiritually mature" parish nurse as an integrator of faith and health. Is traditional nursing education alone going to deliver a spiritually mature nurse? Is a 40-60 hour specialty continuing education program going to produce a spiritually mature nurse? Where will the nurse learn about the integration of faith and health? Seminary Training. Professional nurse graduates now have the option of entering a seminary program of advanced nursing education that is appropriate for a nurse operating from a Mission/Ministry perspective on the ministry staff of a parish. Through seminary training the nurse would begin a journey in search of vocational and pastoral identity, and have opportunity to reflect theologically on one's experiences in ministering to another. Nurses working from the Marketplace or Access models may not need a seminary degree, but through seminary training they would be able to learn experientially about how their own family of origin issues affect their health beliefs and interactions with others. It is an appropriate environment through which nurses can reconcile differences in personal beliefs, professional beliefs, and institutional beliefs. Clinical Pastoral Education (CPE). Chaplains may hold part of the answer. For years chaplains have stood in the gap between faith communities and other institutions in the community. Clinical Pastoral Education (CPE) is professional clinical education for ministry that integrates theological reflection, behavioral sciences, and clinical practice through supervised encounters with living human documents. CPE for nurses who work in churches can bridge the gap for nurses who do not seek a seminary degree as a health minister. The CPE method of education can stand alongside the academic preparation of professional nursing, offering a nurturing environment from which the nurse can reflect on what the nurse is experiencing during interactions with persons. Can chaplaincy organizations soften long term boundaries and make the stretch to develop an appropriate educational offering for nurses desiring to serve in a parish ministry role?   Sidebars: Six Years of Learning - Smith College Chaplain to the Rescue - Haynie Needs and Tensions in Nursing: Crowell - Journey to Parish Nursing Schimmelpfenneg - Why I Look Forward to CPE Coffman - Position on Endorsed Curriculum Resource Addresses References: Bethurne, E. & Wellard, S. (1997). The commodification of specialty nurse education. Contemporary nurse, 6(3-4): 104-109. Bevis, E.O. (1990). Teaching and learning. In E.O. Bevis & J. Watson (eds.) Toward a caring curriculum: A new pedagogy for nursing. NLN pub. No. 15-2278. Yong, V. (1996). Doing clinical: The lived experience of nursing students. Contemporary nurse, 5(2), 73-79. Editor. (1999). Nursing as a career. Nursing spectrum [on line] , available: www.nursingspectrum. com/considernursing/nursingasacareer/index.htm/ Hahn, E.J., Bryant, R., Robinson, K.L., & Williams, C.A. (1998). Entry into community based nursing practice:Perceptions of prospective employers. Journal of professional nursing, 14(5), 305-313. Health Ministries Association, Inc. & American Nurses Association, Scope and standards of practice for parish nursing, 1998. Hess, J.D. (1996). Education for entry into practice: An ethical perspective. Journal of professional nursing, 12(5), 289-296. Jacobs, L.A., DiMattio, M.J., Bishop, T.L., & Fields, S.D. (1998). The baccalaureate degree in nursing as an entry level requirement for professional nursing practice. Journal of professional nursing, 14(4), 225-233. King, J.M., Lakin, J.A. & Streipe, J. (1993). Coalition building between public health nurses and parish nurses. Journal of nursing administration, 23(2), 27-31. McDermott, M.A., Sloari-Twadell, P.A., & Matheus, R., (1998). Promoting quality education for the parish nurse and the parish nurse coordinator. Nursing health care perspective, 19(1), 4-6. Smith, S.D. (1999). Response: Nursing in churches. Insights: Austin seminary faculty journal, 114(2), 29-32. Smith, S.D. (2000). Parish nursing: A call to integrity. Journal of christian nursing, 17(1), 18-20. Smith, S.D. (in press). Theoretical models from which to view parish nursing. Journal of health care chaplaincy. Stern, M.B. & Spring. N.M. (1999). Nurse abuse? Couldn't be! Nurse advocate [on line] available: www.nurseadvocate.org/nurseabuse.htm/. Westberg, G., (1990). A historical perspective: Wholistic health and the parish nurse. In A. Sloari-Twadell, A.M. Djupe, and M.A.McDermott (Eds.) Parish nursing: The developing practice. Edited by. Park Ridge, IL: The National Parish Nurse Resource Center. Westberg G. & Mc Namara, J.W. (1987). The parish nurse: How to start a parish nurse program in your church. Park Ridge, IL: Parish Nurse Resource Center. Wright, K.B. (1998). Professional, ethical, and legal implications for spiritual care in nursing. Image, 30(1), 81-83. Zersen, D. (1994). Parish nursing: 20th century fad?. Journal of Christian nursing, 11(2), 19-21. Dr. Sybil D. Smith is a volunteer chaplain at the Patrick B. Harris Psychiatric Hospital, SC Department of Mental Health. She has 25 years of community health experience with an interdisciplinary and collaborative perspective. She holds an MS in Nursing from Clemson University and a Ph.D. in Nursing Science from the University of South Carolina. She has completed an extended unit of CPE at the Patrick B. Harris Psychiatric Hospital. She is former faculty in the School of Nursing at Clemson University. For six years she was affiliated with one of the largest volunteer parish nurse networks in the Southeast, first as an advisor and consultant, and later to become education specialist and coordinator. She is currently an R & D consultant, free lance writer, and principle of The Smith Group. Hundreds have attended her classes on Health, Healing and Wholeness which is a mission/ministry model that emerged from her practice. The Health, Healing, and Wholeness Series© is developed for professionals, laity, and a version for youth. Copyright © 2000, Wayne E. Oates Institute. All rights reserved. Copyright and Bibliographic Information   This article is protected by international copyright laws and may not be reproduced or distributed in any form without written permission from the Wayne E. Oates Institute.