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THE ADVANCED PRACTICE PARISH NURSE
IN THE RURAL COMMUNITY:
A MODEL POSITION DESCRIPTION

By

Gerri L. Hagadon-Blevins

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree

Master of Science in Nursing

College of Nursing
1999

ABSTRACT
THE ADVANCED PRACTICE PARISH NURSE
IN THE RURAL COMMUNITY:
A MODEL POSITION DESCRIPTION
by

Gerri Hagadon-Blevins

As a result of health care reform, health promotion in the rural faith community
calls for strategies which are reflective and focused towards a variety of health needs
across the lifespan. The Advanced Practice Nurse, working within the domain of the rural
faith community, is in a prime position to promote healthy behaviors by placing an
emphasis on health promotion and disease prevention in the rural community. Currently,
Advanced Practice Parish Nurses are rarely utilized in the faith community. This scholarly
project describes the need for Advanced Practice Parish Nurses in rural communities and a
position description is developed. The areas of education, health promotion, research and
practice are identified and can be modified to adapt to the needs of any rural faith

community.

This project is dedicated to my wonderful and caring parents, Charles & Geraldine
Hagadon and my loving children Jessica and J .C. Without their love, support and
patience, this project would remain unfinished. I would like to thank my sister Denise
who stood beside me during the course of my graduate work and motivated me through
each step of my last year. Without the support of my parents, my sister and my children, I

would not have come as far as I have today.

iii

ACKNOWLEDGMENTS

I would like to thank my Chairperson, Linda Keilman, for her assistance and
encouragement. She kept my hopes high and reminded me to “take care of you”. She
provided counsel and assistance under a very confining time frame and made herself
available day or night. Her rapid tum-over of proofing my drafts is what made this
project an accomplishment.

I would also like to thank Laura Struble and Joan Wood for including me in
their busy schedules to take time and serve on my committee. They provided
encouraging advice and instruction which enabled me to focus on what I wanted to

accomplish.

iv

TABLE OF CONTENTS

List of Figures ..................................................................................................................... vi
Introduction .......................................................................................................................... 1
Background .......................................................................................................................... 3
Purpose ................................................................................................................................. 4
Conceptual Framework ........................................................................................................ 4
Review of Literature ........................................................................................................... 11
The Components Of A Model Position Description .......................................................... 21
Implications ........................................................................................................................ 26
Summary ............................................................................................................................ 29
List of References .............................................................................................................. 31

LIST OF FIGURES

Figure 1 - Health Promotion Model (Pender, 1996) ............................................................ 5

Figure 2 - Adaptation of Health Promotion Model including
the Advanced Practice Parish Nurse in Rural Communities .............................. 9

vi

Inkeduction
Community based strategies offer the greatest potential for effectively meeting the

needs of rural communities (Krout, 1994). Rural residents have fewer available health

care services, reside or work far distances from available health care providers, and
usually do not have access to public transportation (Magilvy & Brown, 1997). A critical
factor in the health status of rural communities is that they suffer from a lack of health
care providers and have access to a smaller number of health care services (Coward, Bull,
Kukulka, & Galliher, 1994). Lack of funds can be a major deterrent to obtaining
professional care (Krout, 1994). The wide variety of health care concerns indicate a need
for health promotion and disease prevention programs in rural communities.

Opportunities to creatively meet the health care needs of rural families and
individuals resides in the localness and diversity of the rural community. Rural
communities traditionally have very strong ties to their churches, tend to be very family
centered and hold traditional spiritual values as an integral part of their lifestyle
(Halverson, 1996). The church has the opportunity to be the true community center for
more than worship. In many rural communities, the church functions as the education and
informational center for the area (Westberg, 1988). Congregation based health care is a
creative approach to increasing access to health care within the rural community.

Churches have been involved in the delivery of health care for more than 2000
years and the healing ministry of the church is now being reclaimed through parish
nursing (Shank, Wiess, & Matheus, 1996). Advanced Practice Nurses (APNs) are

particularly well prepared to identify community health care needs (American Nurses

Association, 1997). With the diversity of practice settings, advanced knowledge and
skills, and the congregation as their base, APNS are in a position to Offer expertise in the
health care arena of rural communities. Congruent with the principles of primary health
care, the faith community is an innovative site for APN practice and an emerging area
gaining increasing recognition.

Primary health care is an approach that focuses on the promotion of wellness and
the prevention of disease across the continuum of care (Institute of Medicine, 1994).
Health problems may be attributed to lack of knowledge, limited access to health care and
the decreased availability of health promotion programs. Primary health care
strategies encourage self care and self management through education and empowerment
of individuals and families. These strategies enable individuals to use their skills and
attitudes to improve their health and the health of their community. Health care
reform calls for communities to share in the responsibility for health care. However, the
coordination, management, and delivery of supportive and restorative care for rural
communities has fallen victim to geographic and demographic forces (Lee, 1993).

Changes in the nature of the delivery of health care, resulting from the health care
reform movement, have led to a shift in emphasis from high tech care to community
based care (Magilvy & Brown, 1997). To achieve effective community based health care,
interdisciplinary approaches are needed that combine the skills and experience of a wide
range of health care providers. Many physicians who could provide primary care do
not locate in rural areas. It is costly for health care providers to deliver health care and

social services to rural areas because of population disbursement, low population

densities, great distances, financial constraints and lack of public transportation (Evans,
1996). The limited number and distribution of health care professionals result in a break
in the continuity of follow up care for individuals and families. These factors impede
healthcare, especially long term chronic care. Rural populations have high rates of
chronic illness, such as hypertension and cardiovascular disease, and many rural residents
experience terminal or life threatening illness as well (Coward, Duncan, &
Freudenberger, 1994). Individuals living in rural areas continue to work regardless of
illness or injury and they are less likely to take part in preventive behaviors, due in part to
the limited access to health care providers (Hassinger, Hicks, & Godino, 1993).

The need for health care services in rural communities remains an issue, and
creative approaches to provide these services are needed. Health services that are
community based are more likely to be accepted and last longer because of the
involvement of the community members (Miskelly, 1995). With community involvement,
programs and services are more likely to meet local needs and reflect the local cultures
(Miskelly).

Background.

Faith communities have long been identified as effective sites for community
based programs because they are accessible and provide a comfortable environment for
people to learn and discuss their health care concerns (Magilvy & Brown, 1997). Basic to
the mission of the faith community is the commitment to the whole person, addressing
not only the spiritual component, but physical, emotional and social aspects as well

(Miskelly,]995). Thus, the faith community is alogical partner for primary health care

because of its historical concern for the whole person, health, and quality of life (Magilvy
& Brown, 1997). The partnership formed between the professional and faith
communities are congruent with the principles of primary health care. The focus of this
scholarly project was to introduce the role of the Advanced Practice Parish Nurse in a
rural community setting.
harness

The goal of this scholarly project was to introduce the concept of the Advanced
Practice Parish Nurse (APPN) in a rural community setting through the development and
marketing of a model position description. It is postulated that the APPN role, and the
introduction of a position description, will promote the dignity and wholeness of each
person, integrate the healing ministry of the faith community with values-based advocacy,
and encourage personal and social responsibility for individual and rural community
health. A position description includes responsibilities, qualifications, work experience,
and personal characteristics of the Advanced Practice Nurse in the parish (Pell, 1995).

ConcepnIaLEramemrk

The Health Promotion Model (HPM) was selected for this project because it
involves the individual, family, and commtmity’s perceived understanding of health. The
HPM also takes into consideration the influencing factors that play a role in deciding
whether an individual will engage in health promoting behaviors (Pender, 1996; see
figure 1). The HPM has three major concepts: (1) cognitive-perceptual factors,
(2) modifying factors, and (3) participation in health promoting behaviors.

The Health Promotion Model (Pender, 1996) can serve as a foundation for the

Cognitive-Perceptual
Factors

Importance of health

Perceived control of
heahh

Perceived selfeflicacy

Definition of health ‘*

; Perceived health status 7

Perceived benefits of health i
promoting behaviors

Perceived barriers to health. _
promoting behaviors

Modifying Participation in Health
Factors Promoting Behaviors
L
Demographic
thaetpdgics_ i

 

7
_ V i,f,M

‘ Biologic characteristics

AAA . A AA . iLikelihoOd ofengagiiig in
Interpersonal 3 health promotingbehaviors .
influences '

 

i i Cues to Action l

Situational factors

I
l— _ .
_ ,— _ ‘

l

Behavioral factors

flgmej, Health Promotion Model (Pender,]996)

5

development of an APPN position description. The HPM is based on the assumptions that
emphasize the active role of the client in shaping, maintaining and modifying health
behaviors (Pender, 1996).

C . . -P. I F.

The importance of health influences how individuals seek to create living
conditions where they are able to demonstrate individual health potential (Pender, 1996).
Perceived control of health is the awareness of one’s actions in promoting health, while
perceived self efficacy is an individual’s decision to engage in behavior that may or may
not promote health (Pender, 1996). Through self efficacy and control of health, an
individual ascertains a definition of health and structures their lifestyle around that
interpretation. 'Self efficacy gives the individual the accountability to make every day
choices and thus enhance wellness through health promoting behaviors.

Definition of health directly influences the daily behaviors that an individual
develops. Individuals seek to regulate their own behavior based on the understanding of
the health concept.

Perceived health status is how an individual understands their level of well being.
It is how individuals envision themselves in relation to health wellness. Health is more
than being sick or well, it is an ongoing journey of wellness. This awareness can aid in
determining the benefit of health promoting activities because healthy aging is dependent
on initiating and maintaining healthy lifestyles (Pender, 1996).

Perceived benefits of health promoting behaviors are intrinsic and extrinsic beliefs

about the effectiveness of the recommended health promoting behaviors (Pender,]996).

Individuals tend to invest time and energy in activities that have positive outcomes, such
as increased alertness and decreased feelings of fatigue (Pender, 1996).

Perceived barriers to health promoting behaviors are parallel to perceived
benefits; they exhibit a direct influence on whether or not to participate in health seeking
behaviors (Pender, 1996). Barriers such as, limited access to health care and health
promoting activities, unavailability of educational programs, cost of attending programs
and the distance traveled to receive the informative offerings, are viewed as blocks,
hurdles and personal costs of undertaking a given behavior (Pender, 1996). Loss of
satisfaction from giving up health damaging behaviors such as smoking or eating high fat
foods to develop a healthier lifestyle can also be a barrier (Pender, 1996).

l 1 TE . F.

The assumptions of the theory focus on the active role of the individual, family,
and/or community, in shaping and maintaining healthy behaviors (Pender, 1996). The
modifying factors of the HPM are those factors which influence the decision making
process of health promotion.

Demographic characteristics are variables such as environment, age, and health
status which directly affect an individual’s health seeking behavior. Biological
characteristics are those factors that an individual cannot control. These consist of birth
defects, genetic make up, gender, and disabilities.

Interpersonal influences are those expectations of significant others, social
support, and modeling learned through observations (Pender, 1996). Values, attitudes,

beliefs and behaviors of families and peers influence an individuals’s lifestyle

( Pender, 1996 ). The likelihood of engaging in health promoting behaviors can be
enhanced through family activities and community programs (Helvie, 1998).

Situational factors are perceptions of available options, demand characteristics
and aesthetic features (Pender, 1996). Individuals across the lifespan are concerned with
health promotion and serve as sources of support for one another. Behavioral factors are
those self initiated behaviors which restructure an individuals environment and influences
the capability and willingness of‘launching behavior change (Pender, 1996).

Likelihood of engaging in health promoting behaviors is the outcome of health
behavior modification. The sources of behavior motivation for any given individual have
unique combinational properties from health promotion or approach oriented motives
(Pender, 1996). Cues to action are activities that directly or indirectly influence health
promoting behaviors through an interest and willingness to participate in self - directed
change (Pender, 1996). These may be items such as illness, hospitalization, education
programs, or counseling sessions, all of which may impact an individual or community in
seeking healthy behaviors.

WWW

The HPM has been modified to reflect the applicability to this scholarly project
(see figure 2). The power to change health behaviors or modify health related lifestyles
are within the domain of the individual ( Pender, 1996 ). The expertise to provide

educative developmental programs supportive of healthy behaviors are within the domain

of the professional nurse (Pender, 1996).

Cognitive-Perceptual Modifying Participation in Health
Factors Factors Promoting Behaviors

Importance of health

 

 

Demographic
characteristics
_ Rural
Perceived control of health 7 Community
Perceived selfefficacy 7 Biologic characteristics
Interpersonal . . Likelihood of engaging in
Influences health promoting behaviors
Definition of health Faith -
Community , . W 7 7
Perceived health status Situational factors { Ram
Health Educator ‘
g _ I - screenings 7
Perceived benefits of health _ l ; 7 Personal Health Counselor

Behavioral factors

- health concerns

Volunteer Coordinator

, - leadership & delegation

Perceived barriers to health _ Support Group Facilitator

promoting behaviors - recruiting, & organizing

Referral Source

- access resource & services ‘

Interpreter of Faith l

- relationship between faith
& health,

promoting behaviors

figure; Adaptation to Pender’s Health Promotion Model (1996)
9

l l [E . E

The rural and faith communities are specific variables which can inspire healthy
behaviors. These variables are the essence for intervention because they can be tailored to
develop and maintain healthy lifestyles. Decisions are made daily by individuals which
shape their lifestyles and social and physical environments ( Pender, 1996 ). Through
nursing interventions such as, educational programs, decisions can have a positive
outcome in health promotion.

Interpersonal Influences consist of social support, friends, neighbors, family,
clergy, and community, referred to as the faith community. Through the various
interpersonal influences there is enhanced opportunity for information exchange (Pender,
1996). The potential is present for widespread change in social norms regarding health
and health behavior related to the rapid circulation of health informatio ( Pender, 1996 ).
If an individual has the capacity and interest for self directed change, then an obligation
to one’s self to promote a healthy lifestyle can be established and assumed. Health
promoting behavior is directed toward attaining positive outcomes for the individual,
family, and community, which results in positive health experience throughout the
lifespan (Pender, 1996).

Cues to Action focus on the role of the APN in the rural faith community.
Presently there is not a defined role, responsibilities or position description clearly
identifying an APN role in a faith community. The development and introduction of such
a position description should enhance health promotion within the rural community. The

APN has highly developed specialized skills and expertise to conduct health risk

10

assessments, answer questions concerning disease process, medications and health related
problems. The APN can develop health promotion activities which may include
immunization clinics, health screening, educational programs tailored to the community’s
needs, counseling sessions, and newsletters with a different health topic each month.
Through the implementation of modifying factors, the perception of positive health can
be promoted. The process of empowering individuals, families and communities to
improve their own health and to increase control over their own actions, is reflective of
the concept of health promotion. Through the adaptation of healthy behaviors, increasing
access and awareness of health promotion programs, and social, congregational and
community involvement, healthy lifestyles can be achieved.
W

The review of literature includes the following categories: the rural community
and health, the faith community, the parish nurse, the role of the APN and the details of a
position description for an Advanced Practice Parish Nurse in a rural community. The
definitions of key terms, rural community, parish nurse, Advanced Practice Nurse, and
position description are included in this review.
IheRuraLCQmmuniDLamLHeaIth

Rural populations, in comparison with urban populations, experience greater
morbidity and have higher crude rates of mortality, along with higher rates of chronic
illness (Yawn, Bushy, & Yawn, 1994 ). Specific data demonstrate that when compared
to older adults ( 65 years and older) living in all other residential categories, rural non-

farrn elders report a higher number of medical conditions, more firnctional limitations,

11

and difficulty performing activities of daily living (Yawn, Bushy, &Yawn, 1994 ). As
with other population groups, the incidence of chronic illness increases with age, making
elderly persons who reside in rural areas particularly vulnerable ( Krout, 1994 ). Chronic
illness and other health problems are exacerbated by rural populations higher rates of
poverty, low education levels, and their access to fewer health care services and
programs ( Shreffler, 1996 ). To further complicate the picture, rural individual continue
to work regardless of illness or injury and they are less likely to take part in preventive
behaviors because of limited access to health care services, which in turn increases their
risk exposure ( Bushy, 1992 ). Specific risk behaviors include, not wearing seat belts,
smoking, not having regular blood pressure checkups, pap smears, or other screening
tests and not performing self breast examinations ( Sheffler, 1996 ). When compared to
urban populations, individuals living in rural areas have higher rates of adolescent
pregnancy, suicide, deaths, smoking and heavy drinking among adults, and serious,
unintentional injuries ( Randolph & Migliozzi, 1993 ). Areas noted as rural have higher
rates of communicable diseases and lower rates of immunizations of both children and
adults ( Evans, 1996 ). Eventually, these factors can lead to an increased need for
supportive and restorative care.

Forty five percent of all US. residents describe themselves as rural (US. Bureau
of Census, 1995). The distinctions between urban and rural are blurring as the population
migrates to rural settings in search of the mystical “country life”, and the economy forces
rural dwellers into more urban settings in search of employment ( Redford & Sevems,

1994 ). One of the challenges in addressing health needs of rural communities is defining

12

the concept of rural. It is very difficult locating an accurate and inclusive definition for
rural related to the various meanings assigned to the concept by different professions.

Rural, for the purpose of this scholarly project, is defined as open country and
small towns, of less than 2500 persons, which are widely dispersed and remote from large
metropolitan areas ( Helvie, 1998 ). The place of residence among urban and rural
populations serves as a basis for issues such as social, cultural, and health beliefs that may
be more prevalent in one setting than the other.

For the rural community, illness means not being able to do one’s usual work
( Weinert & Burman, 1994 ). Health, as viewed from a rural community view, can be
defined as the ability to do work and to do what needs to be done ( Bushy, 1992 ). Beliefs
that govern one’s behavior are shared within a culture, and knowledge of these beliefs are
learned through verbal or nonverbal interactions within the family and community
( Helvie, 1998 ). All aspects of the culture, including health beliefs, are instilled through
the family and within the community as part of the socialization process (Helvie, 1998).
Through the socialization process, rural families place special importance on neighbors as
sources of informal help and neighbors are relied on for support in dealing with health
problems more often than formal health care agencies or providers ( Hassinger, Hicks, &
Godino, 1993 ). Self help is a significant strategy used to cope with illness by rural
individuals and it is a critical factor in decisions regarding the use of health care services
( Hassinger, Hicks, & Godino, 1993 ). Rural individuals often delay seeking health care

until they are seriously ill or incapacitated ( Weinert & Burman, 1994 ). This delay in

13

seeking health care is consistent with the rural populations’ function based definition
of health.

Access to health care is problematic for the poor and the elderly because many are
uninsured (Helvie, 1998). Health care services are not as likely to be found in rural areas
but if they do exist, they result in higher provision costs in terms of time and money
(Helvie, 1998). A characteristic of rural environments is the dependency on small family
enterprises (Helvie, 1998). Small businesses do not always provide employee benefits,
particularly health insurance (Evans, 1996). If insured, these groups are covered by
Medicare or Medicaid and fees for service may be pre-determined (US. Bureau of
Census, 1995). Because these fees may be limited in amount, more and more physicians
do not accept these clients. Medicare reduction of fees for physicians office visits has led
to an eight percent reduction in Medicare patients seen by physicians in 1990 and 12% in
1993 (U .8. Bureau of Census, 1995). F urtherrnore, patients with predetermined fees are
43% more likely to be discharged from the hospital in an unstable condition with a higher
risk of dying (US. Bureau of Census, 1995).

In the dispersed populations, rural communities are viewed as difficult and costly
settings in which to deliver health care services (Shreffler, 1996). Services that are
available may be incomplete or of poor quality to meet the level of diversity of need
(Shreffler, 1996). Rural elderly persons may have a low awareness of the services or
programs that are available in their areas, the services may be too costly or may not be the

services needed (Schank, Weis, & Matheus, 1996). When combined with the locality of

14

their residence, the individuals of rural communities have poor health outcomes.

Iheflealthcfthefiommmity

The health of a community is characterized by norms, roles and established
methods of health promotion ( Reese, 1998 ). A strong point of rural communities is the
ability and willingness to enter into joint activities at times of need and family crisis
(Helvie, 1998). The concept of cohesiveness has long been known under the heading of
fiiendship, community togetherness, caring, or unconditioned positive regard for one
another ( Weinert & Burman, 1994 ). The level of trust between community members is
high and there is a large degree of similarity in the needs of rural populations ( Weinert &
Burrnan ). The need for accessible health care services, level of trust in providers,
sensitivity to the issues and the need for privacy are concerns of rural communities
( Helvie, 1998 ). Health care services, tailored to fit the needs of a rural population,
provide the foundation for community involvement. Individuals and families are more
likely to participate in the development of programs that would enhance their community
when they are integrally involved in the design, organization and provision of services
(Helvie, 1998).
W

As part of their healing mission, churches are involved in activities that promote
individual, as well as family, wholeness. The church is viewed as a strong community
support system with a high level of trust instilled by the members of the congregation.
Currently more than 60% of Americans are members of a church or synagogue, while
40% say they attend some sort of worship service at least weekly ( Ryan, 1995 ).

15

Congregations have long been identified as effective locations for implementing
community based programs ( Magilvy & Brown, 1997 ). Many active congregation
members search for ways to make the message of Christian faith more relevant to present
culture (Westberg, 1988). These dedicated members are disturbed that the present health
care system does not approach an individual as a whole person, incorporating the spiritual
dimensions of illness along with the physiological and emotional aspect (Westberg,]988).
With the involvement of a congregation, the whole - person emphasis can be addressed
within the context of community health care services.
W

The Parish Nurse (PN) is defined as a registered professional nurse who serves as
a member of the ministry staff of a faith community to promote health as a “wholeness”
of the faith community, its family and individual members and the community it serves
( ANA & Health Ministries Association, 1998 ). Parish nursing first emerged in 1984
through the efforts of Granger Westberg, a retired Lutheran Minister at Lutheran General
Hospital, Parkridge, Illinois ( King, Lakin, & Striepe, 1993 ). Westberg developed
holistic health centers which provided holistic health through the services of spiritually
oriented physicians, nurses and clergy ( Westberg, 1988 ). Holistic health is a philosophy,
which views the person as a whole and recognizes the interrelationships between, the
physical, mental, emotional and spiritual aspects of the individual within the context of

their world ( Micozzi, 1995 ). The goal is to achieve maximum well being ( Micozzi).
With holistic health, people accept responsibility for their own level of well being and

everyday choices are used to take charge of one’s own life (Micozzi, 1995).

16

The interest of holistic concepts declined in the Western societies during the 20th
century when scientific medical advances had created a dramatic Shift in the concept of
health ( Collinge, 1996 ). Germs were identified as outside sources causing disease,
therefore gaining health became a process of killing microscopic invaders with drugs

( Micozzi, 1995 ). People developed the belief that they could get away with unhealthy

lifestyle behaviors and modern medicine would fix the problems as they developed. For

some conditions, medical cures have proven more harmful than the disease ( Micozzi,
1995). Many chronic conditions do not respond to scientific medical treatments (Evans,

1996). In looking for other options, individuals are turning back to the holistic approach
to health and healing.

The conceptual role of parish nursing was initially established as an alternative to
the medical model. Based on the effectiveness of the nurse in the health centers, and
Westberg’s leadership skills, the first parish nurse program was developed in 1984 (King,
Lakin, & Striepe, 1993 ). Since that time, parish nurse services have been developed
across the nation in rural, suburban and urban communities ( Shank, Weiss, & Matheus,
1996 ).

In 1994, an estimated 2,000 nurses were practicing in parish nursing roles, serving
in both paid and voluntary positions (Magilvy & Brown, 1997). Parish nurses are
prepared at a variety of educational levels from diploma to doctoral degrees. Parish
nursing consultation is provided by nurses prepared at the master’s and doctoral levels of
education. For example, university-based nursing programs consult or form partnerships

with local churches or synagogues to assist with parish nurse program development,

17

implementation, and evaluation ( Magilvy & Brown, 1997 ). While a position description
which clearly describes the responsibilities of a parish nurse has been developed
( ANA, 1998 ), there is no current position description for an APN in the parish setting.
The role of an APN as a parish nurse should compliment the relationships of the faith
communities, ministry, and parish nurse; a position description is essential to the
development of this role. Master’s preparation is essential because of the independent
nature of the role within the context of a community based setting, community needs
assessment, and program planning and evaluation aspects essential to this practice
( Magilvy & Brown, 1997 ).

Parish nursing is described in the Scope and Standards of Practice set forth by the
American Nurses Association ( ANA ) and the Health Ministries Association ( HMA ),
( 1998, see Appendix A). The Standards of Practice provide parish nurses, the nursing
profession, health care providers, insurers and their clients with the professional
expectations of a parish nurse ( ANA&HMA, 1998 ). The development of the Standards
of Practice for Parish Nurses reflects the commitment of the HMA in promoting parish
nursing as a specialized practice of nursing and health ministry ( ANA & HMA, 1998 ).
The Standards of Practice address the independent practice of professional nursing as
defined by the Nurse Practice Act in health promotion within the context of the client’s
values, beliefs, and health practices ( ANA, 1997). Similar to the independent practice
of nursing, parish nursing promotes health and healing through the empowerment of the
faith community, family and individual, by incorporating health and healing practices

from its faith perspective with the goal of achieving mutually desired outcomes.

18

The Standards of Care of Parish Nursing are reflective of the nursing process, including

assessment, diagnosis, outcome identification, planning, implementation, and evaluation
(ANA, 1998).

While parish nurses provide health education programs, screening and
assessments, counseling, referrals and support to members of the congregation, they also
provide services to the community as well (educational programs and health fairs)

( Magilvy & Brown, 1997 ). These services combined with everyday choices and actions,
give rise to an understanding that achieving health is an ongoing personal journey
toward a goal of functioning at the highest level possible. Parish nursing, in summary, has
the ability to directly impact the cost and quality of health care by emphasizing health
promotion, disease prevention, and increasing the access to health care through services
provided in the faith community ( Shreffler, 1996 ).

RolenfltheAdr/aneedhacticeblurse

The Advanced Practice Nurse (APN) is a registered nurse who has masters or
doctoral preparation in a specific area of advanced nursing practice, has had supervised
clinical practice during graduate education and maintains an ongoing clinical practice
( ANA, 1997 ). APN’s perform the same interventions used in basic nursing practice,
however, there is a greater depth of knowledge, a greater degree of data collection, and
greater utilization of complex skills and interventions (ANA, 1997).

The APN is a skilled health care practitioner who provides comprehensive health
assessments, diagnoses, and prescribes pharmaceutical agents in the care and

management of both acute and chronic conditions. APN’s practice in a variety of settings

19

for individuals, families, and communities by promoting wellness and preventing illness
and injury. APN’s can make a meaningful contribution to program development,
implementation, and outcome evaluation. The various role characteristics of the APN
include collaborator, researcher, leader, consultant, counselor, clinician, educator and
change agent, all of which can be utilized when providing health promotional services to
rural communities. By using these advanced skills, the APN can actively contribute to
program planning for the health of a rural community ( Reese, 1997 ).

Providing health care in the rural faith community offers the APN unique
opportunities. Community based nursing practice, set in communities of faith, can
promote health and prevent disease by increasing individual access to health care and
educating individuals, families, and groups. Preventing illness presents a particular
challenge to the rural faith community, because health promotion programs are severely
lacking in many rural areas ( Reese, 1997 ).

Health promotion is motivated by the individual’s desire to increase personal well
being and actualize their human health potential ( Pender, 1996 ). The APN is in a prime
position to develop and conduct health promoting programs in rural faith communities.
The APN’s focus on the concept of health promotion and illness prevention, including the
ability to interpret the close relationship between faith and health, places her / him in an
ideal position to enhance the health and well being of individuals and families in the faith
community and the broader rural community. Parish nursing is a significant practice

model allowing the APN the opportunity to contribute to healthier communities.

20

EH]: ..

An initial step for this project was determining if a position description for an
Advanced Practice Parish Nurse had already been developed. The International Parish
Nurse Resource Center (Nancy, personnel communication, March 9, 1999 ) denied
having records indicating that a position description was in existence. Master and
Doctoral prepared nurses provide consultants to various parishes, however, there are no
set guidelines or descriptions of the roles and responsibilities of an APN in the rural faith
community.

An insignificant amount of information was divulged during the literature review
pertaining to a position description of the APN and role in parish nursing. The APPN
position emphasizes population focused care by integrating physical, social, cultural,
emotional, and spiritual health, thereby impacting the entire rural faith community
(Magilvy & Brown, 1997).

Because many parish nurses currently practicing are educationally prepared at the
baccalaureate level or below, they may not be prepared to utilize and evaluate the skills
required to promote an optimal level of health promotion in the rural faith community
( Magilvy &Brown, 1997 ). Many opportunities exist for APPN’S to contribute
significantly to individuals, families and groups residing in rural communities.

The development of a position description for the APPN needs to be applicable to
an APPN in any faith community, yet flexible to meet the needs of that community
( Yates-Lee, 1998 ). The target audience of the position description is the APN, however,

the position description can also be used as a guide for parishes to employ an APN.

21

The position description which has been developed models the components of the generic
position description for an APN in Home Health Care ( Yates-Lee, 1998 ). The position
description also reflects aspects of the modification of Pender’s Health Promotion Model
( Figure 2 ). The content of the position description includes a title, purpose, scope,
qualifications, responsibilities, education and experience.

Title

A position description maintains a title which identifies the position of interest
( Yates-Lee, 1998 ). For this scholarly project the title is labeled, A Model Position
Description for an Advanced Practice Parish Nurse in the Rural Community
(see Appendix B).

39912:

This section identifies the purpose and dimensions of the APPN within the rural
faith community. These responsibilities are consistent with the Standards of Practice set
forth by the ANA and the Health Ministries Association, Inc. (1998). The scope includes
the responsibilities of the APPN. Responsibilities include: 1) providing quality of
care through the overall health ministry program which is accountable to all clients, the
profession and the rural community, 2) enabling the continuation of spiritual and
professional education, 3) collaborating with other health professionals, 4) providing
ethical decisions, 5) conducting or contributing to research within the rural faith
community, 6) assessing the health needs of a community and mutually identifying
health related goals, and, 7) acting as a guide and expert to other health professionals who

contribute to health promotion and wellness.

22

C l'fi .

This area of the position description lists the minimum requirements and essential
responsibilities of the position ( Yates-Lee, 1998 ). The APPN is extending health care
from health related institutions into the anal community and is creating health ministries
within congregations who become new partners in preventive and holistic health care.
Each function is numerically identified for clarity. One proposed function, that of health
educator, includes promoting an understanding of the relationship between lifestyle,
attitudes, faith, and well being. A second function, personal health counselor, includes
discussing health concerns with individuals and visiting them at home, in hospitals, in
nursing homes and other facilities. A third function, volunteer coordinator, includes
recruiting and coordinating other health care professionals and non - health care
professionals, from their respective faith communities, to provide holistic, preventative
services as volunteers. A fourth function, facilitator of support groups, includes
organizing and recruiting groups with the same identified problems, needs or concerns.
A fifth function, referral source, includes helping individuals access community resources
and services. Sixth, the APPN acts as an interpreter to the faith community detailing the
relationship between faith and healing.

Typical duties of the APPN in the rural community include providing services
which address the holistic health needs of the individual, family and faith community.
This should include data collection of demographics, response to health and illness,

environmental factors influencing health, health promoting and health compromising

23

behaviors, individual, family and community expectations, and accessible services and
resources. Additional duties include: utilizing the nursing process through the formation
of nursing diagnosis, intervention plans, goal establishment, outcome identification and
the evaluation of goal progression; having an understanding of the sociocultural factors,
health care beliefs, practices and values within the rural faith community, in order to
collaborate and coordinate health education activities, programs and / or newsletters;
participating in managing problems using problem solving skills with individuals or
groups and focusing on the spiritual, emotional, and physical aspects of coping behaviors;
and providing advice which is within the scope of practice and faith community
guidelines.

The APPN should also perform ongoing self-evaluation of the Advanced Nursing
Practice role in relation to the professional standards, relevant statutes, regulations and
individual faith community guidelines ( ANA, 1998 ). The APN also assists individuals,
families, and/or communities in ethical decisions’which respect the values and belief
systems of the community or family; maintains confidentiality at all times; and
collaborates with the health ministry, community, and other health care providers in
designing a health promotion plan, interventions, and desired outcomes. Through
collaboration, the APPN can maintain safe and effective health promotion programs
based on the appropriateness, accessibility, acceptability and affordability of resources
( ANA, 1998 ). Research should be utilized to validate health promotion interventions
and participation in research to improve the parish nursing practice and health ministry

( ANA, 1998 ).

24

Education

The required education for the position of APPN should be in accordance with the
American Nurses’ Association ( 1997 ) statement that the APN is a nurse in advanced
clinical practice who has a graduate degree in nursing. Additionally, the APPN should be
in accordance with the ANA & Health Ministries Association ( 1998 ) statement that a
parish nurse is a registered nurse who serves as a member of the ministry staff of a faith
community to promote health and practices nursing within the definition of the Nurse
Practice Act. These categories include the need for the APPN to maintain continuing
education and clinical practice requirements for professional licensure. For the position
description proposed for this project, the APPN needs to have a masters degree in nursing
and an NP specialty certification license. The APPN must also maintain the required
continuing education credits as outlined by the state. It is preferred that the APPN have a
certificate from a parish nurse course or a minimum of one (1) year experience working
with faith communities.
Experience

Preparation for the APPN role requires experience in several areas; individual
and/or community needs assessment and analysis, program planning, implementation and
evaluation, outcomes research, care management, and primary, secondary, and tertiary
prevention strategies for families, individuals and groups ( Magilvy & Brown, 1997 ).
The APPN would require added experience in theology, spirituality and health, pastoral
care and individual and family counseling, along with the course work usually found in

graduate nursing programs ( Magilvy & Brown, 1997 ). The faith community may revise

25

this section of the description to make it appropriate to their specific community
environment and needs.

After identifying what is inclusive in each section, the description is titled a
Model Position Description for the Advanced Practice Parish Nurse in a Rural
Community. This position description is the product of this scholarly project.

W

There are many implications for the development of a model position description
for an APPN. This section examines different avenues of applying the position
description in reference to advanced practice, education and research.

I l' . E I I IE .

The APPN as a primary health care provider is in an excellent position to increase
access to health care in rural faith communities. Developing a position description for the
APPN offers rural faith communities access to health promotion services. Health
conscious communities are those in which individuals and families take responsibility for
their health and practice health promoting behaviors ( Magilvy & Brown, 1997 ). An
APPN has the ability to educate the community regarding health practices. Through the
development of educational programs, activities, and newsletters an APPN can improve
the health of the entire rural faith community.

As a leader, the APPN could form a consultation group within the parish
consisting of various health professionals. These individuals could work together to
organize support groups, volunteers, and to act as consultants with the APPN.

The APPN acts as a counselor by assisting individuals in decisions that may be

26

ethical in nature using advanced decision making and critical thinking skills. For
individuals who are homebound, the APPN can assess their needs and develop an
intervention program that will promote optimal health and spiritual well being. The
APPN may assist a family, individual or community to cope with losses, such as death
of a family member, loss of crops due to enviromnental factors, or losses such as those
experienced by families going through divorce. The APPN, using advanced assessment
skills, can collaborate and consult with other health care professionals and make
appropriate referrals to those providers specializing in grief and loss issues.

As a facilitator, the APPN can increase access to health care by conducting
preventive health screening and providing blood pressure screening afier worship
services, therefore making health care more accessible for the rural community. The
APPN, as a consultant, utilizes this expertise to broaden the scope of health care planning
for other health care professionals by linking spirituality and health.

As a coordinator, case manager, and evaluator the APPN can implement a needs
assessment to the rural faith community within the domain of the local church. The
APPN can develop a health needs assessment tool or utilize any of the existing
assessment tools which are applicable to the faith community. Once the assessment tool
has been explained and distributed, the APPN can collect, analyze, and interpret the data,
then provide feedback to the community. A tailored, health promotion plan can be
developed and implemented by the APPN and the health ministry of the congregation.
Once the health education plan has been implemented, the APPN may want to evaluate

it’s effectiveness over a one month, three month or six month time frame. The APPN

27

could be an innovative method of improving access to health care in rural faith
communities and the position description could initiate a program which would serve as a
positive impact in the movement of improved and comprehensive health care services in
rural communities.

Since the role of the APPN is a new concept in parish nursing, a position
description would introduce the position and set the guidelines. This new area of
Advanced Practice Nursing would need to be introduced to the various resources within
the community. Great emphasis should be taken to explain that there is no duplication of
services with the APPN. The APPN should contact the various health care providers
and/or community resources in the community. For a faith community to promote the
role of the APPN, the roles, responsibilities, and benefits must be understood.

Education for the APPN should be considered as part of a potential graduate
program specialty. Graduate programs could offer courses in theology, pastoral care,
advanced counseling and spirituality, along with providing opportunities for clinical
rotation in a rural faith community. The University of Colorado School of Nursing has
developed a faculty practice in parish nursing ( Magilvy & Brown, 1997 ). This practice
site provides nursing doctorate and master’s level community health nursing students
opportunities to work in an existing parish nurse practice or to assist in program
development ( Magilvy & Brown, 1997 ). If expanded further, the APPN could become

an NP specialty certification with licensure.

28

I l' . E E 1

After developing the position description, research should be done to determine
the completeness of the responsibilities and duties. To begin, an evaluation form could
be attached to the description and sent out to rural faith communities; currently those with
a parish nurse program and those without. The health ministry board of each would be
asked to review the description. Another method of evaluating the position description
would be to send the description out with an attached questionaire to various faith
communities, inquiring as to whether or not they would utilize the position of an APPN.
Evaluation of the position description should also be critiqued by a governing body such
as the Parish Nurse Resource Center, Park Ridge Illinois and also by the governing body
of the particular state in which the APN practices. Another group to evaluate or critique
the position description are other APN’s. The position description, in this sense, is
utilized as a marketing tool for APN’S because it opens up an avenue for proliferation of
advanced practice into another health care arena.

There is little publication describing evaluation and outcomes of parish nursing.
With the role of the APPN, this opens the gateway for program evaluations, utilization of
services, and the degree to which families, individuals and groups utilize the services
offered by faith communities. The APPN is in a prime domain to perform such research
and eventual publication.

Summary
APPNs can play an important role in the rural faith community. This scholarly

project indicates the advantage of having APPN’s in the rural community and is based on

29

Pender’s( I996 ) Health Promotion Model. The outcome, A Model Position Description
for an APPN in the Rural Community, allows the APN to promote healthy behaviors
among rural faith communities through the integration of mind, body and spirit. The
position description has numerous implications for practice, education and research.

Empowered by faith, the APPN offers individuals in the rural community a basis
to be hopeful and strive to maximize all available resources to meet the proliferating
health care challenges of society. Overtime, the escalating quality and diminishing cost of
health care could be significant in the magnetism of the APPN. It is a tremendous

opportunity to educate, grow spiritually and be an advocate in the truest sense of the term.

30

LIST OF REFERENCES

Refetences

American Nurses’ Association & Health Ministries Association, Inc. (1998). Senne

andfitandardsoflfiatishlflutsingflractice Washington D 0: American Nurses
Publishing.

American Nurses’ Association (1997) WWW
Wing. Washington D. C.: American Nurses Publishing.

Bull, M. J ., Maruyama, G., & Luo, D. (1995). Testing a model for post hospital
transition of family caregivers for elderly persons. WWO), 132-138.

Brown, N. J ., Congdon, J. G., & Magilvy, J. K. (1996). An approach to
care management for rural older adults: Parish nursing. Newflgfiznngj (27), 7.

Bushy, A. (1992). Rural nursing research priorities. Winning
Administratiomlfll) 50- 56

Collinge W (1996) IheAmericanHolistieHealthAssociationcornpleteguideJo
aliemafiyemedicine, New York: Warner Books.

Coward, R..,T Bull, C.N., Kukulka, G. & Galliher, J. M. (Eds.). (1994). Healih
wicnmralelders. (pp.-1-32) New York: Springer.

Coward, R.T., Duncan, R.P., & Freudenberger, KM. (1994). Residential differences
in the use of formal services prior to entering a nursing home. fiemntnlngistflfl), 44-49.

Dossey, MB. (1997). Communism. Gaithersburg, MD: Aspen.

Evans, CA. (1996). Public health: Vision and reality. Amerimlonrnamffluhlic
WM), 476-479-

Halverson, C. (1996, December). Health ministry in the agricultural community. Small
Wigner. Jefferson City, MO: Center for Rural Ministry.

Hassinger, E., Hicks, L., & Godino, V. (1993). A literature review of health issues of
the rural elderlx loumalomealflealM, 68-75.

Helvie, C- (1998). Advancedfiracmehlmngrnrhefiommunm Thousand Oaks,
CA.: Sage Publications, Inc.

Institute of Medicine. (1994). W Washington,
DC: National Academy Press.

31

King, J. M., Lakin, J. A., & Striepe, J. (1993). Coalition building between public health
nurses and parish nurses ImmalcfflursrngAdministrationflQ) 27- 31

Krout. JA- (Ed-)- (1994). WWW
Thousand Oaks, CA.: Sage Publications, Inc.

Lee, H. J. (1993). Rural elderly individuals: Strategies for delivering nursing care.

Mbmffloflhflnencalfim, 219- 230.

Magilvy, J. K, &Brown, N. J. (1997). Parish nursing: Advanced practice nursing model
for healthier communities. WW2“), 67- 72.

Micozzi, M. S. (1995). Alternative & complementary medicine. Part of the human

heritage. IbeloumalcfAltemahsandflomnlememamMedmnealfl), 1-5

Miskelly, S. (1995). Applying the community health nursing process in a church
community JournalcflCommuniDcHealthNursinaiZU) 1- 14

Pender, N. (1996). Heannnmmmiminnmsingnmctice. (3rd ed.). Stanford, CT:
Appleton & Lange.

Randolph, S. A., & Migliozzi, A. A. (1993). The role of the agricultural health nurse:
Bringing together community and occupational health. WW
OccupanonaLHeaJhflurLaAl, 429- 433

Redford, L. J., & Sevems, A. B. (1994). Home health services in rural America. In

Krout, J A (Ed) Mmmmmmmmmm Thousand
Oaks, CA. Sage Publications.

Reese, S. (1998). Community analysis for health planning: Strategies for primary care
practitioners. W00), 46- 59.

Ryan. J. A. (1995). AnarishnurseprenatationjnstinnezMsconsinmodel (Brochure)-
Milwaukee, WI: Marquette University College of Nursing.

Schank, M..,J Weis, D., & Matheus, R. (1996). Parish nursing: Ministry of healing
Qenatneliursngalfll), 11- 13.

Shreffler, M. J. (1996). An ecological view of the rural environment: Levels of

influence on access to healthcare.Ad_y_anc_es_1n_Nnrs_mg_S_qence._l_8(4), 48- 59.

United States Bureau of the Census. (1995). mmmmmfi;
LilflEdifinn), Washington, DC: Government Printing Office.
32

United States Department of Health and Human Services. (1992). HealihLRerle
MW. Boston, MA.: Jones & Bartlett.

Weinert, C., & Burman, M. E. (1994). Rural health and health seeking behaviors.
AnnuaLRexiemfNursingResearchJZ, 65- 92.

Westberg, G. (1988). Parishes, nurses and health care. Wm. Nov/Dec,
26-29.

Yates-Lee M (1998) Ihedexelopmentofagenericnositiondescrinfionfomn
WWW. Unpublished master’s thesis, Michigan State

University, East Lansing, MI.

Yawn, B. P, Bushy,A., & Yawn, R..A (Eds). (1994). Exnlnringflnmlmedicine;
WW Thousand Oaks, CA: Sage Publications.

33

APPENDIX A

Role & Responsibilities of the Parish Nurse

Role:
A parish nurse promotes health and healing by empowering the client system
(faith community, family, or individual) to incorporate health and healing
practices from its faith perspective to achieve desired outcomes. The standards of
care describe a competent level of parish nursing care as demonstrated by the
nursing process: assessment, diagnosis, outcome identification, planning,
implementation, and evaluation. Standards of care delineate care that is provided
to all clients of parish nursing services and should take into account cultural,
racial, ethnic, and world view diversity (ANA & Health Ministries Association,
Inc., 1998).

Responsibilities:
The parish nurse:
1) Utilizes the nursing process through data collection, diagnosis, interventions,
implementation, outcome identification, goal establishment and evaluation of goal

progression.

2) Systematically participates in evaluation of the quality and effectiveness of his
or her nursing practice.

3) Utilizes a systematic approach to coordinate educational activities, programs
and or newsletter, enhancing health promotion.

4) Functions as a client advocate to individuals, families and groups focusing on
improving individual, group and community health behaviors.

5) Participates in problem solving management with a focus on spiritual,
emotional and physical aspects of problem solving, with individuals and families.

6) Provides advice within the scope of practice and within the faith community
guidelines.

7) Counsels individuals, families and groups using problem solving skills and
facilitates coping behaviors.

8) Performs self-evaluation of nursing practice in relation to the professional

nursing standards, relevant statutes, regulations, and individual faith community
guidelines.

34

9) Provides health promotion services to promote the desired health outcomes,
based on personal, societal, and professional beliefs and values.

10) Will maintain confidentiality at all times.

1 l) Assists individuals, families and community in ethical decisions, in a
systematic manner, which respects the individual, family, and community values
and belief system.

12) Collaborates with the client system, other health ministers, health care
providers, and community agencies in promoting client health.

13) Maintains safe and effective health promotion programs based on the
effectiveness, appropriateness, accessibility, acceptability, and affordability of
resources.

14) Is responsible for using current research findings and contributing to the
improvement of his or her own current and future parish nursing practice

American Nurses’ Association & Health Ministries Association, Inc. (1998). Scope

andfiandardsoffiaushflursmgfiracuce. Washington D 0: American Nurses
Publishing.

35

 

APPENDIX B

POSITION DESCRIPTION FOR AN

ADVANCED PRACTICE PARISH NURSE IN THE RURAL COMMUNITY

Job Title:
Purpose:

Scope:

Role:

Advanced Practice Parish Nurse in the Rural Community
To provide health promotion in the rural faith community

The APN is responsible for providing health promotion services that
address the holistic health needs of the rural faith community consistent
with the Standards of Practice set forth by the ANA and the Health
Ministries Association, Inc. The APPN is an expert and serves as a guide
to other health professionals to assist in promoting health, healing and
wholeness to individuals, families and communities. The APPN provides
quality of care through the overall health ministry program linking
spirituality to health, is accountable to all clients, the profession and the
rural community, maintains a continuation of professional and spiritual
education, provides ethical decisions, and conducts or contributes to
research to improve the Advanced Parish Nursing Practice and health
ministry.

Essential roles of the position include, but are not limited to:

1) Health Educator
- promote an understanding of the relationship between lifestyles,
attitudes, faith and well being
2) Personal Health Counselor
- discuss personal health concerns, making home visits, hospital and
nursing home and other facility visits
3) Volunteer Coordinator
0 provide leadership and guidance to individuals volunteering their
time and interest in the designated parish activities
0 delegate responsibilities among the volunteers
4) Facilitator
- recruiting, coordinating and organizing support groups
5) Referral Source
- assisting individuals and groups in accessing community resources
and services
0 working with various health care agencies, health ministries, and
health care professionals to promote overall wellness
6) Interpreter of Faith
0 educate, discuss, and promote the detailed relationship between
faith and healing

36

Responsibilities:

The APPN:

Acts as a health care provider by formulating diagnoses and providing
direct primary care based on sound theory and advanced clinical
judgement, to promote self care abilities, maintain health, prevent
complications, cope with health care problems and manage disabilities.

Performs self-evaluation of advanced nursing practice using professional
standards, relevant statutes, regulations and individual faith community
guidelines, to evaluate the quantity and quality of effectiveness of
programs through outcome measures.

Applies learning theories and selected learning methods to teach and assist
individuals or other appropriate groups in identifying and meeting their
health educational needs.

Collaborates with the individual, family, community, health ministry, and
other health care providers, to achieve joint responsibility and
accountability for planning for decisions made regarding individual,
family or community outcomes.

Uses counseling interventions with individuals and families to promote
and facilitate coping behaviors through advanced problem solving
techniques.

Uses advanced decision making and critical thinking skills with
individuals, families, and the community in ethical decisions, using a
systematic approach, which respects local values and belief systems.

Intervene in crisis situations taking action within the APN Scope of
Practice or referring to the appropriate health care provider

Initiate consultation activities with other health care providers and
evaluates the effectiveness of the interventions.

Uses advanced communication skills, in both speaking and writing, to
formulate strategies for grant writing for funding contractural relationships
with the government.

Provides the highest quality nursing care through the utilization and/or

conduction of research in nursing practice, standard setting, peer review,
evaluation of care, and continuation of professional education.

37

Qualifications:

Additionally:

A master’s degree in nursing from an accredited college or university.

A current RN license from the state wish to practice in (or eligible for one)
Current national certification as a nurse practitioner.

A current NP specialty certification license from the state wish to practice

rn.

Certification from a parish nursing course or evidence of additional parish

nurse education is highly recommended.

The APPN must maintain advanced, comprehensive knowledge and skills
related to nursing care across the lifespan and a general understanding of
the sociocultural factors, healthcare beliefs, practices and values of a rural
faith community.

The APPN would require added experience in theology, spirituality and
health, pastoral care and individual and family counseling.

One (1) year minimum experience working with the health ministry of a
faith community is preferred.

38

 

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