FORGOTTEN SAINTS
After a 44-year absence for school and work, it seemed like I was stepping into a time warp when I returned to my home church in Oregon. Those who had been church leaders in service and ministry when I left years earlier had aged significantly. Many were getting ready to move to, or already were living in, a retirement or healthcare center. Some were living with their children, as my mother and I had just decided to do.
During visits with homebound persons-individuals who have difficulty leaving their private residence, nursing care home, or other residential facility-I noted many were having difficulties hearing, seeing, and ambulating. As we talked, I realized most were lonely. Some told me the church community had all but forgotten about them, as only an occasional church member and the visitation pastor came to visit. They said most interactions were brief, leaving them feeling even more separated from the church community.
Recalling how much service these former spiritual pillars had given to the congregation, I felt sad that now, when they were in need, they received so little. I recognized that the few visitors who came probably didn't know how to cope with the changes due to aging and chronic illness. It was easier to send a card or occasionally take flowers. I saw ways to improve care of the homebound elders in our church.
This article addresses how we developed a ministry of volunteer visitors, coordinated by the Faith Community Nurse (FCN). By sharing how a targeted church ministry was developed to meet the needs of this deserving, yet forgotten, group of elders, I hope to encourage others to take on this needed work.
INITIATING A VISITATION PROGRAM
Homebound elders are vulnerable to decreased quality of life related to their social and emotional isolation (Musich, Wang, Hawkins, & Yeh, 2015). Consensus is that homebound elders are an understudied population and are in need of programmatic attention (Musich et al.). Indeed, there was no information in the nursing literature on visitation programs of homebound, frail elders. Reviewing allied pertinent literature, there were references advocating visiting programs for older adults but few details regarding specific ways to conduct the programs and/or visits.
Webb (1989) noted that the apostle Peter's commissioning by Jesus (John 21:15-17) was to feed both the lambs and the sheep. Interestingly, she categorized the frail elderly into the lamb group, because they could not always care for themselves. This is counterintuitive, as their wisdom and depth would not be at all lamb-like.
Webb also noted that old age is not a set period with specific needs. Rather, the needs of 65-year-olds differ from those 80 and beyond. The aging of society and the church, with retirement of the baby boomer generation, is providing younger, vibrant older adults in the church. Many of these have experienced firsthand the exclusion of their elderly parents by their long-term church communities. Many of the newly-retired can be recruited to visit the homebound.
Gallagher (2002) planned a program to organize seniors to become active in church ministry. He distinguished senior adults by their level of activity and identified 15 characteristics of this group to use in church program planning. Of these characteristics, two relate specifically to visitation: senior adults love to volunteer, serve, and give; and senior adults love to be busy. If health permits, they are on the go, filled with energy. These were helpful adjuncts; however, no information available with specific details of a visitation program.
Realizing that older seniors need support, a visitation program was initiated, composed of church members with a desire to provide compassionate visits. Emergent design was the plan: the group was put together, and as we proceeded, we modified the plan for visitation as issues arose. A few younger people volunteered, but in accordance with Gallagher's predictions, most volunteers were in their 60s and 70s.
The usual pattern was for the visitors to bring church bulletins and audio tapes/CDs of worship services to the homebound. The visitor might read the worship Scripture and pray together, or offer a conversational prayer. But that only took 10 to 15 minutes. The question surfaced as to how 30 minutes or more might be invested in pleasant interchange. Each visitor had a different idea about how to manage a visit. Those who hadn't sung songs with their visitee (the person they had selected to visit) felt they had missed something meaningful. Some who read to their visitee thought that took up too much visitation time. When visitors mentioned foods they had brought to give their visitee, I realized we needed to discuss diet issues. Visitors needed to know why a cup of unthickened coffee might cause a stroke victim to choke and why it was not good to bring sugary treats to a diabetic visitee.
We soon decided that our visitation group would meet monthly to discuss needs and pray about concerns. It became apparent that more emphasis was needed on making the visit experience enjoyable for recipients and satisfying to the visitors. Factors influencing the establishment of visitor/visitee relationships were important topics.
Many who volunteered to be visitors were newly- retired from professional work and could bring interpersonal relationship experiences from their careers to the visiting experience. However, others had less background in initiating therapeutic interpersonal relationships. Also, some volunteers had not previously met their visitees. We discovered that knowing a person over time makes a big difference in the relationship. Other significant factors that influenced rapport between visitor and visitee were changes in visitees' physical appearance, communication, and/or behaviors, resulting from the illness experience. Many of these issues were amenable to education and group support. As we addressed these issues, our Compassionate Visitation Program was born.
THE COMPASSIONATE VISITATION PROGRAM
We began to meet the hour before church services to work on the program, praying for 30 minutes and then focusing on a key point to incorporate into visits. We learned ways to discover what might interest the visitee. Exploring the person's life history, including family, work, and social history, is a starting place. We talked about how to listen for cues of things that spark the visitee's interest.
From my nursing background, I identified general focus points. An acrostic using the word HOMEBOUND was developed to help visitors remember aspects of the program (Table 1).
Humor: Humor is "a spontaneous response that promotes health" (Emblen, 2014, p. 16) and "combines funny details, as well as a certain presence of mind" (p. 15). Humor promotes positive emotions and releases negative emotions. Humor can be found if one looks for it. Using real-life events as a starting point, many situations can be viewed through this lens. Simple jokes and comics can be shared. Funny stories can make a humorous contribution to a conversation. Lightness and mirth promote well-being.
Observation of Person and Environment: For nurses, assessment of person and his or her environment is so natural, it is easy to forget that lay visitors do not have these skills. The foundation for observation of person and environment can be established by providing information about what to observe, using a checklist with structured items (Tables 2 and 3). As part of training, visitors can be accompanied by the FCN, and then debriefed as to what they did or did not observe. In addition, when to make appropriate and timely referrals as issues of concern are observed, needs to be established in the program. Emphasis is made that the visitor does not need to intervene, but that referrals will result in needed care. Thus, the referral system needs to be robust. The interventions undertaken by the referral need to be evident to the visitor to reinforce this process of observation and referral.
Music: Because visitors had asked about including music, it became a focus point for one meeting. Singing can be an important link for elders. Singing together is a good action that pleases many visitees, but is not every visitee's desire or every visitor's gift. Portable, electronic music systems can provide a full range of music in any space.
Encouragement: Discouragement about isolation and life circumstances may mar a visitee's life, and mar a visit. A visitor must recognize discouragement. Once aware that discouragement is present, deliberately seeking to provide encouragement brings a positive energy to a visiting situation. Encouragement can be fostered through words. Scripture and prayer often are sources of encouragement to elderly church folks. Simple, positive feedback, suggestions for change, and promises of prayer and personal affirmation (Emblen, 2014, p. 40) are other ways to provide encouragement.
Active listening is a nursing skill that can be taught to visitors. Visitors can listen to visitees' stories about the past and concerns about the present. Allowing visitees to share their pain validates their experience and helps decrease the loneliness of chronic pain (van Loon & Legge, 2013). Visitees also are likely experiencing loss, as they find themselves unable to engage in prior activities. Visitors can learn to be present, listen to visitees, help them process their feelings, and explore healthy responses. In the Informed Friend Program, Australian nurses Antonia van Loon and Vicky Legge encourage those supporting someone with chronic illness to be empathetic, reflective listeners. "You must practi[c]e paraphrasing the person's responses back to [him/her], reflecting the feelings and emotions behind the responses, so the person can hear/see [him/herself] and work out how to move forward with life" (p. 33). When a visitee says, "I am totally worthless; I can't do anything," the visitor might gently reflect back, "You are feeling worthless. Tell me about the things you do," and help the visitee see what activities they continue to engage in. Giving the visitee time to reminisce and review his or her life can be helpful.
Occupational Activities: Introducing activities can help visitees pass lonely time and extend the benefit of the visitation program. Carefully chosen activities can extend the impact of the visit, especially if the visitee continues working on the activity after the visitor is gone. Three examples of conversations leading up to introducing an activity are included in the sidebar, Meaningful Activities.
Understanding Impaired Communication: Speech difficulties and short-term memory impairment are common challenges. See Table 4 for visitor guidelines on how to adjust speaking and other interactions, when visitees struggle with impaired communication.
Nutritional Issues: Assessment of the visitee's health status and food preferences is needed prior to sharing food with a visitee. Note food allergies and chronic illnesses, such as diabetes. Fresh garden foods are an excellent choice, along with a favorite treat. Baking items at the visitee's home increases appetite and adds warmth. Visitors are encouraged to eat with visitees to enjoy fellowship and increase bonding.
Death of the Visitee: When visitors noticed their visitees becoming more fragile, they began asking questions about how to help their visitees and oneself cope with oncoming death. I was surprised at the profound grief and sense of loss I felt, when my first visitee died.
One of our focus times helped visitors deal with death. Our pastor provided useful suggestions for visitors to use when visitees were near death:
* Be quiet and listen in the presence of a dying person
* Express emotion sensitively
* Express joy for/with the person, who is going into the presence of God.
Our pastor also described ways visitors might develop comfort with death:
* Spend time with God
* Focus on heaven, rather than on death (1 Corinthians 15)
* Consider the joy of eternally living with God, rather than death being the ending of life
* Spend time with Christians anticipating death, who are rejoicing to go to be with God (Emblen, 2014).
We discussed having a plan for hard questions. Some homebound people need special counseling and guidance. Pastoral referral could help with questions about salvation and other faith questions, and to provide counseling for deep discouragement. Pastors can use their judgment about meeting alone with the visitee or with the visitor present. Visitors can also seek the pastor's counsel.
PROGRAM STRUCTURE AND ORGANIZATION
Over time, we developed a structure for the Compassionate Visitation Program. It is helpful to have a Visit Facilitator to coordinate the program and be someone to whom visitors report. The facilitator is typically the FCN or a church pastor. To recruit visitors to the program, we make announcements in church bulletins, newsletters, and Sunday-school classes. Visitors are encouraged to visit their visitee biweekly. A phone call is used to arrange and confirm visits. We initially planned to have visitors change visitees yearly, but some visitors wanted to keep their visitees.
In the beginning, we received a list of visitees from our senior pastor. Visitors chose one or two people they would visit. In succeeding years, we learned to pick up new visitees from announcements made about people who were ill, or discussion with other church members who knew someone had been absent from church. Sometimes family members requested visitors for a homebound family member.
Some visitors stop to interact with several people, having short conversations with visitees to whom they are not assigned. Having several people drop by during a week makes time pass more quickly for the homebound. Visitor overlaps on different days are usually a good thing, unless the visitor appears tired.
We developed these important visitation guidelines:
* Contact Visit Facilitator/FCN regarding questions or problems arising during a visit (i.e., food assistance, medical or other needs).
* Do not provide transportation for homebound person; contact church staff/FCN.
* Do not make suggestions to visitee about changing residence.
* Do not sign checks or initiate medical or legal assistance.
* Contact Visit Facilitator immediately regarding any evidence of abuse or neglect.
* Do not directly assist with medical care needs.
* Avoid lifting or manually handling the visitee, without proper training and help.
* Do not give advice about changing treatment or go into lengthy discussion of what visitor did to treat a similar problem.
* Use good hand-washing and safety precautions.
* Do not visit if you are sick or coming down with something.
Regarding record-keeping, on the initial visit, the visitor should complete a form and file it with the Visit Facilitator. Note special food needs, past and current hobbies, and other pertinent information. Following each visit, send a brief note to the Facilitator regarding the visit and the general response to activities that were part of the visit. Records are essential to provide the FCN with the number of visits and particular events that occur related to the visits.
CLOSING COMMENTS
Making homebound visits is an important part of the ministry of the church. Matthew 25:31-46 addresses our calling as Christians to visit those who are ill or in prison; certainly this means visiting our elders who, like prisoners, cannot leave their homes. A visit can encourage and lighten some of the lonely hours for those who have little to do during their long days. It takes time and planning on the part of the visitor, particularly if doing special activities. But the time pays off bountifully, as the visitor leaves with the visitee calling out, "Come back soon! I really enjoy our time together."
Meaningful Activities
Indoor Gardening. On his second visit, Ted*, a visitor, found Rives* disinterested in general conversation. Gardening had been a favorite hobby in past years, but Rives would be physically unable to do much gardening. So, Ted brought up the idea of setting up a mini flower garden near a window.
After discussing with Rives about what he'd like to watch grow, Ted purchased a pottery planter 14 in. in diameter. Rives agreed to try growing a bonsai tree and a few orchids in a sunny window. On the next visit, Ted brought garden supplies. Ted moved a table, covered it with old newspapers, and put the garden things on the table for Rives. For the next 10 minutes, Rives worked at assembling his garden. When he finished, Ted brought a watering can and opened the fertilizer bag. Rives stirred in fertilizer and carefully poured water around the plants. "I really like my little garden. I can watch it every day and check it for moisture," Rives happily told Ted. "Before you know it, I'll be giving you an orchid for your wife."
A Reminiscence Box. Liz knew Adelle pretty well, and in reviewing the hobbies Adelle enjoyed, Liz had an idea. She explored a toy and craft shop and a discount paper store to gather things to put into a reminiscence box. She recalled that Adelle had sent many cards to people over the years, so she got paper they could use to write notes to people. Adelle also had baked lots of cookies for church events, so Liz thought a miniature mixing spoon, bowl, and plate from a toy store might jog Adelle's memory of her previous activities and even help her get interested in baking cookies.
Liz dusted out an old shoebox she had in her closet and found pretty paper to cover the box. She decorated the lid with a miniature set of measuring spoons labeled "pinch, dash, and smidgen." Liz pasted a ribbon on the side of the box, tied several ball-point pens into it, and put the miniature kitchen tools and paper inside. When she carried the box into Adelle's room, Adelle was in her wheelchair with her back to the door-her usual spot. "Hi, Adelle," Liz called loudly enough to awaken Adelle, who seemed to always be asleep when she arrived. "I've brought something to show you."
"Hello," Adelle responded, a bit less than enthusiastically. She looked sleepily at the box Liz placed on her lap.
"I have made a remembrance box for you," Liz explained. "You can look at the things in it and think about how you used them, and when visitors come, you can tell us stories about using these things. Your friends and family can add to the box."
A Visitor Book. "Did you have any visitors come to see you this week?" Hazel asked Betty. "You are the only one who ever comes to see me. All I do is lie here all the time and hope that someone will come." Betty expressed her sense of being alone. Hazel talked more with Betty, and when she left, she went to the nurses' station and asked if Hazel's family or friends came to see her. "Compared to other residents, Betty holds the record for visitors," the desk clerk told Hazel. Hazel realized that Betty probably forgot a lot of the events occurring in her day. Then she remembered that she used a guest book to help her to remember who had been to her home. She decided that Betty needed a guest book.
On her way home, Hazel stopped at a stationery store but found that guest books did not have the right kinds of spaces for visitors to write much. So she bought some card stock, paper, and ribbon. At home she made a sample page with the headings "Date/time," "Visitor's Name," and "Note of Conversation or Activity." She put in five lines and repeated the heading and was able to put records for six visits on a standard sheet of typing paper. Using the church copier, she made 30 copies of the page and punched holes through the paper and the colored cardstock she chose for a cover. She tied ribbons through each hole and attached a pen so visitors could sign the book. She put a paper flower on the front of the book with a note that read: "Please sign this book when you visit, so Betty will remember and her family will know you stopped in to see her. Thank you for helping us know that you were here."
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