JOGNN I N F OCUS. Increasingly in the United States, faith communities

JOGNN I N F OCUS Providing Coping Assistance for Women With Behavioral Interventions P. Ann Solari-Twadell Correspondence P. Ann Solari-Twadell, RN, PhD, MPA, FAAN, Loyola University Chicago, Marcella Niehoff School of Nursing, 6525 Sheridan Rd., Granada Center, Room 383, Chicago, IL 60626. psolari@luc.edu Keywords parish nursing faith community nursing nursing interventions coping assistance support ABSTRACT Objective: To describe what parish nurses believe is essential to their practice and identify what nursing interventions they most frequently use. Design: Descriptive cross sectional study. Participants: The International Parish Nurse Resource Center provided a list of nurses who completed the standardized core curriculum on parish nursing and were currently working in parish nurse roles in faith communities in the United States. Methods: The Nursing Intervention Classification System Survey was mailed to 2,330 parish nurses with return envelopes. Results: The 1,161 parish nurse respondents (50% return) resided in faith communities in 47 states and represented major religious denominations from Christian and non-christian religious affiliations. Participants identified the most frequently used nursing interventions were in the behavioral domain and coping assistance system. Conclusions: Nurses working in faith communities are frequently using nursing interventions related to health promotion and coping assistance. The findings are valuable to all nurses in identifying strategies and collaborations for enhancing the well-being of women and their families. Improving quality of life through the collaborative support of community agencies, health care providers, and members of the faith community are integral to women s health. JOGNN, 39, 205-211; 2010. DOI: 10.1111/j.1552-6909.2010.01109.x Accepted November 2009 P. Ann Solari-Twadell, RN, PhD, MPA, FAAN, is the director of the Accelerated Nursing Program and an associate professor at Loyola University Chicago, Marcella Niehoff School of Nursing, Chicago, IL. Increasingly in the United States, faith communities have been identi ed as ideal settings for health promotion (Buijs & Olson, 2001). Religious beliefs and behaviors are particularly important among African Americans, the elderly, and women (Koenig, McCullough, & Larson, 2001). The nding that religion and spirituality are signi cant in coping has been noted in many studies (Charlton & Barrow, 2002; Lo, 2002; Ptacek, Pierce, & Ptacek, 2002). When discussing religion or religious belief it is important to begin by clarifying the di erence between religion/religiosity and spirituality as often the terms are used interchangeably, creating confusion. Religion is based on a system of beliefs, practices, and rituals that provides a speci c worldview and guidance on how to live harmoniously with others. Spirituality, on the other hand, is associated with meaningfulness and purpose in life, connection with that which is greater than ourselves, and is integral to being human (Taylor, 2002, pp. 10-11). A parish nurse or faith community nurse works as part of the sta of a faith community associated with particular religious beliefs. This nursing role is directed to the care of the whole person with an emphasis on the spiritual nature of the person. Parish nursing is often considered a community-based alternative health option in supporting individuals, families, and communities to make better choices regarding their health care resources (Mendelson, McNeese-Smith, Koniak-Gri n, Nyamathi, & Lu, 2008). Purpose of the Study The goal of the current study was to clarify what parish nurses believe is essential to their nursing practice and identify what nursing interventions they use most frequently. With increased use of faith communities for health services, evidence is needed to demonstrate the roles and value of the ministry of parish nursing practice. Findings of the study could be used to inform the professional and lay community regarding the contributions made by http://jognn.awhonn.org & 2010 AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses 205

I N F OCUS Providing Coping Assistance for Women With Behavioral Interventions It is important to clarify the difference between religion/ religiosity and spirituality as the terms are often used interchangeably, creating confusion. parish nurses and potentially enhance appropriate community health referrals to parish nurses. Understanding more fully the work of a parish nurse will assist in educating parish nurses more speci cally on what a parish nurse needs to know to care more e ectively for women and their families, address the needs of the communities they serve, and collaborate more e ectively in accomplishing the objectives associated with their ministry. Review of the Literature There are many issues and factors that can contribute to the ability of an individual to choose positive health promotion and coping behaviors. Coping assistance and social support have been studied in many di erent populations. Literature commonly refers to religion, church, minister, or a nursing intervention such as prayer as pertinent to health and coping assistance. Giugescu, Penckofer, Maurer, and Bryant (2006) noted that prayer was the most frequently used prenatal coping strategy (p. 356) among the high-risk pregnant women studied. Lo (2002) reported the use of ministers by 3rd-year nursing students as a strategy to cope with stressors. Charlton and Barrow (2002) also identi ed general approaches to well-being included keeping active, using medication and praying (p. 475) in their study of clients coping with Parkinson s disease. Gramling, Lambert, and Pursley-Crotteau (1998) conducted a qualitative study on coping in young women who reported prayer was used as a way to cope with life stressors. Rose, Campbell, and Kub (2000) reported on coping in battered women who talked to their pastor or counselor at church and found that very helpful (p. 31). Ptacek, Pierce, and Ptacek (2007) reported that religion was used by couples adjusting to cancer as a means of coping assistance. In addition to speci c research ndings relating to prayer and spiritual care, research demonstrated individuals had unmet support and coping needs during loss, caregiving, and illness. Ptacek et al. (2002) reported that in older married couples, support from the wife for the husband increases with age, and with the death of the wife men felt very isolated. As men age they tend to lose contact with their male friends, and the wife s supportive role becomes increasingly important (Ptacek et al.). Blank eld and Holahan (1999) reported ndings regarding support needs in their study of caregivers of head-injured patients and found that Women may be at a special risk in caring for a head-injured patient; women experienced greater caregiver burden and showed poorer psychological adjustment than men (p. 620). With women commonly living longer than men, the parish nurse often becomes a needed resource and part of the support system for women living with chronic health conditions (Cortis & Williams, 2007). These studies underscore some of the particular needs that women and their families have during loss, illness, and caregiving. The church, prayer, and social support provided by members of a faith community can be instrumental in the provision and maintenance of support and coping assistance. Methods The research design was a descriptive, cross sectional study. The current study was approved by the Institutional Review Boards of the university and a faith-based clinical agency. The Nursing Intervention Classi cation Survey 3rd Edition (LaDuke, 2000) was the instrument used to measure the most frequently used and essential nursing interventions identi ed by parish nurses. Introduction questions on the survey determined that the respondent was a quali ed parish nurse eligible to be a respondent. A research-developed demographic tool was also included in the survey packet. Brief response questions were added to the survey to collect further data on the role and practice environment of the parish nurse. The participants were asked to list the factors that were instrumental in supporting them in their role. They were also asked to rank order the top three factors they believed most important in supporting the parish nurse. Two further questions included ranking the top nursing interventions thought to be essential or core to the ministry of parish nursing practice. The last question asked the respondent to identify any interventions important to the practice of parish nursing but not listed in the Nursing Intervention Classi cation System. This modi ed survey tool was reviewed by an expert panel of parish nurse leaders from across the United States and piloted using three focus groups to establish readability, validity, and reliability as well as the amount of time to complete the survey. The International Parish Nurse Resource Center provided a list of nurses who completed the stan- 206 JOGNN, 39, 205-211; 2010. DOI: 10.1111/j.1552-6909.2010.01109.x http://jognn.awhonn.org

Solari-Twadell, P. A. I N F OCUS dardized core curriculum on parish nursing and were currently working in parish nurse roles in faith communities in the United States. The survey packet was mailed to the identi ed 2,330 parish nurses in the United States. The survey requested the parish nurse to identify the most frequently used and essential or core nursing interventions. The frequency of use was determined by noting on the survey whether the intervention was used several times a day, about once a day, about once a week, about once a month, or rarely if at all. Nursing interventions were identi ed as essential or core to the practice of parish nursing by the parish nurse respondent reviewing all 486 nursing interventions and writing in those 30 interventions believed to be essential or core to the ministry of parish nursing practice as those interventions that are used frequently may not necessarily be essential or core to the practice. Results The number of completed surveys returned was 1,161 (50%) with participants residing in all states except Vermont, Alaska, and RhodeIsland.Themajority of the parish nurse respondents were White (95%) and female (98%) The average age was 55, and most were married (83%). The reported educational preparation of the respondents included a Baccalaureate Degree (31.8%) or Associate A parish nurse works as staff of a faith community and directs care for the whole person with an emphasis on spirituality. Degree (13.7%), with the remainder having a diploma (24.4%) in nursing. A smaller number of respondents had a Master s Degree in nursing (12.1%) or Doctorate (3.7%). The religious denominations served by the respondents are noted in Figure 1. Other religious denominations written in and noted as being served by the respondents were Evangelical Covenant, Disciples of Christ, Pentecostal- Assembly of God, Seventh Day Adventist, Nazarene, Moravian, Evangelical Free, Greek Orthodox, Reformed Church in America, Congregational, and Foursquare. Most Frequently Used Nursing Interventions The most frequently used interventions reported as used daily or several times a day by the parish nurse respondents were in the behavioral domain and coping assistance classi cation in the nursing intervention system. The behavioral domain in the Nursing Intervention Classi cation system is de- ned as Care that supports psychosocial functioning and facilitates lifestyle change (McCloskey 30 20 Percent 10 0 11 Other 10 Nondenominational 9 Mennonite 8 United Church 7 Presbyterian 6 United Methodist 5 Roman Catholic 4 Lutheran 3 Jewish 2 Episcopal 1Baptist Missing Denominations Served Figure 1. Religious Denominations Served by Respondents. JOGNN 2010; Vol. 39, Issue 2 207

I N F OCUS Providing Coping Assistance for Women With Behavioral Interventions Table 1: Frequently Used and Essential Nursing Interventions by Parish Nurses Class Intervention Daily Week Monthly Essential Coping assistance Presence 2 3 0 5 Touch 3 11 0 15 Spiritual support 4 2 0 3 Emotional support 5 1 0 4 Spiritual growth facilitation 7 4 0 6 Humor 9 15 0 17 Hope instillation 10 10 24 9 Counseling 13 12 0 11 Decision making support 14 7 16 12 Self-esteem enhancement 15 21 29 0 Support system enhancement 16 13 13 16 Religious ritual enhancement 18 16 0 20 Self-awareness enhancement 21 25 0 0 Truth telling 22 0 0 0 Values clari cation 23 0 0 0 Coping enhancement 27 14 19 10 Grief work facilitation 0 20 4 8 Forgiveness facilitation 0 28 27 13 Support group 0 29 23 22 Anticipatory guidance 0 0 17 26 Dying care 0 0 8 18 Dochterman & Bulechek, 2004, p. 120). Coping assistance is de ned as Interventions to assist another to build on their own strengths, to adapt to a change in function or achieve a higher level of function (p. 121). Table 1 identi es the interventions that were identi ed with these interventions as most frequently used and/or essential to the ministry of parish nursing practice by the respondents. The nursing interventions noted on Table 1 are also identi ed as used daily and essential or core to the ministry of parish nursing practice. The parish nurse participants identi ed daily essential interventions as presence, touch, spiritual growth facilitation, hope, humor, and counseling. Support interventions included spiritual, emotion, and decision-making support as well as social support enhancement. Discussion The results of the current study have important implications for nurses and Advanced Practice Nurses (APN). These results documented the integration of parish nursing into all mainline religious denominations as well as some smaller religious groups. The information provided by the respondents indicated the interfaith dimension of the ministry of parish nursing practice. The selected interventions for health promotion and coping assistance can be used by many nurses in di erent settings. However, some of the interventions integral to coping assistance such as Religious Ritual Enhancement or Spiritual Growth Facilitation may be more easily addressed in the setting of a faith community. The other signi cant information related to the use of the select interventions for coping assistance is that they are most e ectively used when there is a trusting relationship with the nurse. In addition, the nurse must recognize and demonstrate sensitivity to the woman and her family when complex lifestyle or health-promotion behavior changes may be 208 JOGNN, 39, 205-211; 2010. DOI: 10.1111/j.1552-6909.2010.01109.x http://jognn.awhonn.org

Solari-Twadell, P. A. I N F OCUS required. When a nurse or APN working with a client in a hospital or clinical setting makes a referral to a parish nurse, the appropriate followup relationship building, supportive care, and encouragement can be nurtured over a long period of time. The parish nurse comes to know the women and their family in their episodes of wellness as well as their episodes of illness over a long period of time. Through the informal environment of a faith community the parish nurse can often case nd identifying those that are struggling with a loss, a high-risk pregnancy, chronic illness, or the chronic illness of a spouse or family member which they are trying to manage by themselves. In addition, the parish nurse often surveys members of the faith community to determine prevalence of illness and the health needs of the members of the faith community. Through formal and informal means the parish nurse creates an environment of receptiveness for women to discuss problems, obstacles, and discouragement that can accompany disrupted health patterns. Through meeting regularly and talking about their family history, what brings meaning and purpose in their life, and what prayers and rituals are comforting and supportive, the parish nurse can begin to encourage a woman and her family to integrate behavior change that will result in positive health outcomes and coping (Solari-Twadell, 2006). A further consideration in the results is that most of the frequently used or essential nursing interventions in coping and health promotion such as Spiritual Support, Spiritual Growth Facilitation, Counseling, Decision Making Support, Values Clari cation, Grief Work Facilitation, and Forgiveness Facilitation will be used over a undesignated length of time. Often the parish nurse can assist the client to understand presenting problems in a new light. Not all nurses are prepared or feel comfortable in providing spiritual care, and a referral to the parish nurse would be bene cial in these situations. The parish nurse, or faith community nurse as they are sometimes called, has spiritual care as a hallmark of their practice. Because parish nurses are situated in a faith community they have the freedom and additional time to dialogue. The parish nurse is specialized to use the client s faith beliefs as an avenue in providing coping assistance. For the woman and her family who are struggling, the long-term goal of the interaction with the parish nurse is improved health outcomes. The parish nurse will continually evaluate progress and refer the woman and her family for specialized medical follow-up care as needed. Opportunities for Collaboration and Referral As health care providers become more informed about the role of each team member, nurses, APNs, midwives, and parish nurses can work more closely together as consultants and provider referral sources. Each has expertise and knowledge that the other may bene t from in providing the best whole-person care for a woman and her family. Clients of any faith tradition or need such as a pregnant adolescent teen, a woman in a violent relationship, or a woman with advanced breast cancer could bene t from collaboration or a referral. In discussing the client with the parish nurse, the nurse or APN may gain insight into why the client is taking a particular stance on a signi cant health issue and better understand the impact of the client s particular faith beliefs on the client s decisions. Conversely, a parish nurse may have a wonderful resource for women s health issues in developing a consultative relationship with the nurse or APN. The ability of a parish nurse to be able to know the particular expertise of a women s health nurse or APN as well as the nature of their practice is a great bene t in providing excellent referral choices for a member of a faith community. On the other hand, for a women s health nurse or APN to know the location of congregations that have a parish nurse in the community and a little about the nature of a particular parish nursing practice may require some exploration. However, in reaching out to each other there is the possibility of providing a seamless provision of care for many women. Through collaboration an e ective plan for health promotion and coping assistance can mutually be developed for the client. The ingredients that make these professional relationships most valuable are regular communication with each other to update information about their respective professional practice, a respect for the religious context of the faith community that the parish nurse serves, and a mutual respect for each other as colleagues in the provision of health care. These professional relationships may play a much larger role in the future with health care reform, universal access, and economical alternatives for care. Educational Resource and Advocate The parish nurse plans educational opportunities available to members of the faith community and other community members in which the faith com- JOGNN 2010; Vol. 39, Issue 2 209

I N F OCUS Providing Coping Assistance for Women With Behavioral Interventions Unique collaborations between nurses and parish nurses can result in improved health outcomes for women and their families. munity is located. The development of programs for the members of the faith community is usually based on health needs of the members of the faith community. Sometimes health topics may also be recommended or provided by partnering health care systems, agencies, or vendors. Most educational programs o ered by a faith community are inclusive of members of the community at large. Educational strategies employed by a parish nurse are diverse. Frequently, faith communities o er face-to-face didactic educational programs. The church bulletin, newsletter, or other written materials as well as online communication may also be used regularly to keep members updated on diverse topics. If a selected topic is related to women s health, a nurse or APN could be invited to author the article or identify pertinent content appropriate for a newsletter, bulletin, or other format (Hickman, 2006). This option is often a very tangible way for members of the faith community to become familiar not only with services that are offered by the nurse or APN, but also the philosophy of practice and nature of the care or coping assistance provided by this particular practitioner. Advocacy means supporting or speaking for others when they cannot e ectively speak for themselves. Parish nurses, women s health nurses, and APNs are in signi cant positions to support the work of each other while mutually advocating for better health care for women of all age groups, socioeconomic status, disease state, and ethnicity. The better each provider gets to know the issues facing women of all ages in their communities, the better they can collaborate. Through advocating for clients in need the parish nurse and the women s health nurse or APN can elicit the assistance of faith community members, public authorities, and/or agencies. Appropriate agencies have the ability to network women of all ages and their families with needed assistance for nutrition, nancial planning, health resources, and support. The work of advocating for these women may be time-consuming, extending over a considerable length of time, and thus is often more appropriate for a parish nurse referral. However, nursing professionals and parish nurses can make more impact working together than if each was working in isolation of the other. Conclusion It is important to recognize the mutual bene ts that nurses, midwives, or APNs and a parish nurse can bring to women and the families they serve though collaboration. E ective collaboration can make a di erence in how women are cared for from a whole-person perspective. It is equally important to recognize the mutual respect, knowledge of each professional s practice, and the importance of nurturing the development of an ongoing collegial relationship that will facilitate bene cial care for all women in di erent settings and faith-based communities. These collaborative community relationships lay the seeds of meaningful health care reform in community-based women s health. REFERENCES Blank eld, D. F., & Holahan, C. J. (1999). Social support, coping and psychological adjustment among caregivers of head-injured patients. Psychology and Health, 14, 609-624. Buijs, R., & Olson, J. (2001). Parish nurses in uencing determinants of health. Journal of Community Health Nursing, 18(1), 13-23. Charlton, G. S., & Barrow, C. J. (2002). Coping and self help group membership in Parkinson s disease. Health and Social Care in the Community, 10(6), 472-478. Cortis, J. D., & Williams, A. (2007). Palliative and supportive needs of older adults with heart failure. 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Solari-Twadell, P. A. I N F OCUS Ptacek, J. T., Pierce, G. R., & Ptacek, J. J. (2007). Coping, distress and marital adjustment in couples with cancer; an examination of the personal and social context. Journal of Psychosocial Oncology, 25(2), 37-58. Rose, L. E., Campbell, J., & Kub, J. (2000). The role of social support and family relationships in women s response s to battering. Health Care for Women International, 21,27-39. Solari-Twadell, P. A. (2006). Uncovering the intricacies of the ministry of parish nursing practice through research. In P. A. Solari-Twadell & M. A. Mc Dermott (Eds.), Parish nursing: Development, education and administration (pp.17-35). St. Louis, MO: Elsevier. Taylor, E. J. (20 02). Spiritual care: Nursing theory, research and practice. Upper Saddle River, NJ: Prentice Hall. JOGNN 2010; Vol. 39, Issue 2 211