Loss of job for faith community nurses (FCNs) has been anecdotally relayed by FCNs for many years while research on termination of FCNs has been nonexistent. In the only published article examining FCN termination, Ziebarth (2018) explored FCNs' voluntary and involuntary termination through a national survey. Questions were asked pertaining to why termination occurred, resources used during termination, post-termination behaviors, and feelings related to termination. Findings were reported in Ziebarth's 2018 publication; however, respondents' feelings in relation to termination were not discussed. The purpose of this article is to further explore FCN feelings following termination as reported in a national survey and to incorporate an evidence-based practice translation of this research into FCN practice.
FAITH COMMUNITY NURSING: A UNIQUE SERVICE
With increased knowledge of faith community nursing as a specialty, a fuller understanding of the context in which termination of FCNs occurs is possible. All nursing specialties practice under the legal authority of each state's nurse practice acts and policies. In addition, all specialties are guided by the general Nursing: Scope and Standards of Practice (American Nurses Association [ANA], 2016), and by individualized specialty scope and standards of practice. Faith community nursing is guided by the Faith Community Nursing Scope and Standards of Practice which states that,
Faith community nursing is a specialized practice of professional nursing that focuses on the intentional care of the spirit as the promotion of whole-person health and the prevention or minimization of illness within the context of a faith community and the wider community. (ANA & Health Ministries Association [HMA], 2017, p. 1)
Two well-noted theoretical definitions of faith community nursing are
1. Care that supports and facilitates physical functioning; psychological functioning and lifestyle change, with particular emphasis on coping assistance and spiritual care; protection against harm; the family unit; effective use of the health system; and health of the congregation and community. (Solari-Twadell & Hackbarth, 2010, p. 74)
2. A method of health care delivery that is centered in a relationship between the nurse and client (person, family, group, or community). The relationship occurs in an iterative motion over time when the client seeks or is targeted for wholistic health care with the goal of optimal wholistic health functioning. Faith integrating is a continuous occurring attribute. Health promoting, disease managing, coordinating, empowering and accessing health care are other essential attributes. All essential attributes occur with intentionality in a faith community, home, health institution and other community settings with fluidity as part of a community, national, or global health initiative. (Ziebarth, 2014, p. 1829)
Although professional nursing uses nursing interventions and the Nursing Interventions Classification system (Butcher et al., 2018) to describe practice, in the early faith community nursing movement, role functions were frequently used. Initially, the role was conceptualized into five functions (Solari-Twadell & Westberg, 1991), and later seven functions (Jacobs, 2019; Solari-Twadell & McDermott, 1999). The seven roles include integrator of faith and health, personal health advisor, health educator, trainer of volunteers, developer of support groups, referral agent, and health advocate. It was subsequently recommended that the seven roles be regarded as nursing interventions in describing what FCNs do (Solari-Twadell & Hackbarth, 2010).
Based on a literature review of 124 articles, Ziebarth (2014) found that FCNs perform additional routine nursing interventions. These interventions include (a) intentional spiritual care, spiritual leadership/practices, and integration of health and faith; (b) coordination, implementation, and sustentation of ongoing activities; (c) utilization and application of survey results; (d) training and utilization of volunteers; (e) multidisciplinary and interdisciplinary resourcing and referring; and (f) the goal of wholistic health functioning. However the practice is described, this nursing specialty is unique in that the FCN is a registered nurse who has additional training to work in/with a faith community and to provide spiritual care.
FCNs provide a unique service. The Joint Commission (2010) states that patients have specific characteristics and nonclinical needs that can affect the way they view, receive, and participate in healthcare. Patients who have services rendered by an FCN may experience a range of assessments and interventions that promote an adaptive process of attaining or maintaining wholistic health functioning (Solari-Twadell & Hackbarth, 2010; Wolf et al., 2008; Ziebarth, 2015, 2016).
TERMINATION IN FAITH COMMUNITY NURSING
Voluntary termination is when employees decide to leave a job of their own accord because of a change in personal circumstances, dissatisfaction with working conditions, or the search for a better job. Voluntary termination can occur when FCNs are not successful in assuming the FCN role. Ziebarth and Miller (2010) found that certain role-transition interventions had an impact on successfully assuming an FCN role. Some role-transition deterrents were insufficient time to practice, inadequate knowledge, lack of support, and lack of program value perceived by the faith community. Some positive perceptions of role-transition support were peer support groups, orientation, mentors or role models, and continuing education.
Involuntary termination is when an employee is asked to leave a job and most often occurs in faith community nursing when a program is eliminated. Programs are eliminated at both hospitals and faith communities for different reasons. Many hospitals fund faith community nursing programs in a missional environment. The FCN programs are a non-revenue-producing department and are "most at-risk for elimination when margin is threatened" (Ziebarth, 2015, p. 89). Revenue-producing activities are the core business of most hospitals. Margin means having excess money to do missional activities. Unless additional altruistic reasons exist, most hospitals support faith community nursing through Community Benefit status where nonprofit hospitals obtain tax-exempt status by offering initiatives to improve health in the communities they serve (Community Benefit Connect, 2020). If revenue-producing activities ineffectively support non-revenue-producing programs or if priorities change, the hospital may eliminate faith community nursing activities.
In faith communities, most think the core purpose is interpreting Scripture, worship, making disciples, and doing good deeds, not promoting health or preventing illness. Chase-Ziolek (2015) argued that the Church needs to reclaim its biblical and historic foundations for ministries of health, healing, and wholeness through health ministry. Many faith communities support FCN programs for altruistic reasons linked to Scripture, but unless there is economic support, an FCN program may be at risk for closure.
Related to FCN termination, faith community leadership termination is the termination of pastors and other faith community leaders. Three earlier studies (Blackmon, 2011; Fuller et al., 2003; Krejcir, 2007) identified stress, low income, low self-esteem, isolation, conflict, and lack of skills as contributing to faith community leadership termination. The studies also revealed environmental stressors exist unique to faith communities. As FCNs work in or with faith communities and are perceived as leaders, understanding aspects of FCN termination is important to supporting practice and retaining FCNs and their leadership in the faith community.
FCN TERMINATION SURVEY
A survey exploring FCN termination seeking a representative sample of the larger FCN population in the United States was conducted in 2017. Survey Monkey online was used to collect data. A link to the survey was available through the regularly published Westberg Institute e-newsletter. A total of 264 FCNs responded to the survey's first question, "Were you ever voluntarily or involuntarily terminated from your position as a faith community nurse or faith community nurse coordinator?" Eighty-seven (n = 87, 33%) of the FCNs self-identified as having experienced termination and answered the remaining questions. Out of the 87 who were terminated, 23.69% (n = 59) were voluntarily or involuntarily terminated as an FCN and 12.73% (n = 28) as an FCN coordinator; 46.58% were in unpaid FCN positions and 53.42% were in paid positions. Table 1 relays responses to the question, "What was the reason(s) for the termination?" Table 2 shows responses to the next three survey questions regarding resources used after termination (Ziebarth, 2018).
Many of the FCNs returned to the role in another setting. Those who did not return relayed continuing aspects of FCN practice such as doing grief support groups and grief counseling, organizing blood drives, maintaining a bulletin board in the faith community, and serving on the advisory board for their local FCN organization or on the board of the state-led FCN organization.
Issues unique to FCN termination found in Ziebarth's study (2018) were (a) the high percentage of involuntary FCN terminations due to program closure in both hospitals and faith communities; (b) the search for both a new job and a new faith community home after involuntary termination; (c) the high percentage of FCNs returning to unpaid FCN positions after termination; and (d) the lack of resources for FCNs experiencing termination (Ziebarth, 2018).
FEELINGS RELATED TO TERMINATION
In an effort to understand the experience of FCN termination, Ziebarth (2018) asked, "When you lost your position as a FCN, describe your feelings." The FCNs who experienced involuntary termination relayed anger, sadness, devastation, and mourning the lost position. The responses in Table 3 illustrate the intense pain of the FCNs. The responses were divided into five categories of normal grief: denial, anger, bargaining, depression, and acceptance, as first proposed by Elisabeth Kubler-Ross (1969).
Some responses to the feelings question suggested voluntary termination. Although sadness was relayed, other feelings were gratitude and acceptance:
* "I retired and still take calls when the two who replaced me are not available."
* "It was my choice." "I was getting married and moving out of state."
* "I didn't think about the situation very much, because I had already been transitioning out of my usual role in the ministry so that I could go back to school."
* "I retired, and another person is serving in the coordinator position."
* "I was already in discussion with another group to become an educational partner and begin teaching at the new organization."
* "Grateful for the blessings of being an FCN and happy to retire."
* "Sad that I had to make the change but was happy to be a stay-at-home mom."
* "I was able to find another person to take my position at the parish."
* "I retired to spend time with my husband who was having health problems."
* "Acceptance, as it was mutually agreed upon."
TRANSLATION OF RESEARCH INTO PRACTICE
Research produces new findings, results, and outcomes, contributing to the body of knowledge from which nursing draws. Research has significant value; however, translation of research into practice when utilized to improve nursing practice, is where the true worth of research lies. The Westberg Institute's Position Statement (Knighten, 2019, p. 1) states "the faith community nurse supports, applies, and engages in evidence-based practice."
When FCNs terminate their positions, either voluntarily or involuntarily, and/or FCN and health ministry programs are eliminated, deep losses are felt. The primary role of the FCN-intentional care of the spirit in a whole-person context: caring for the mind, body, and spirit of individuals, congregations, and communities-is a very intimate role, so the impact of loss is extreme. Respondents relayed that it is as if "a hole is ripped in the heart and soul of the church." Hinton (2016) describes the practice of faith community nursing as not simply a job, but a calling and a ministry. Losing any job is painful, but the loss of one's ministry can shake one to the core.
Although FCNs who were terminated involuntarily described negative feelings (Table 3), FCNs who leave voluntarily may also experience mourning. In his classic text, Noer (1993) posits that those who are left behind after a position has been eliminated or vacated experience the same feelings as those who left-anger, fear, sadness, hurt, and guilt-with alarmingly more intensity than the person who left.
Many FCNs shared caring for their congregation's wounds while trying to look after themselves in their wounded state. Theologian Henri Nouwen (1979) describes wounded healers as individuals who must attend to their own wounds while simultaneously healing the wounds of others. Putting Nouwen's observations in the context of the FCN who vacates a position, a paradox exists in which the FCN may feel compelled to care for the congregation's wounds while trying to look after himself or herself in the wounded state. This perceived need may result in moral distress.
Dirksen (1993) identified that involuntarily imposed work cessation is a very stressful event that represents the loss of a central role and life function. In addition, involuntary termination, or the antipation of termination, can lead to pyschological and physical health consequences and maladaptive behavioral responses that may manifest immediately or over time. The effect of prolonged anticipation of job loss has been found to be associated with increased psychosomatic complaints, resentment toward both the organization and the world in general, and a diminished sense of security in the future (Dirksen, 1993). Although it is possible for the recently terminated FCN to perceive job loss as positive, it is far more likely that it may be the most stressful life event ever experienced.
Farley (2006) described a survey of mental health professionals who experienced job layoffs. Their responses were similar to those of FCNs, including anger, shock, disbelief, and sadness that progressed to depression, anxiety, and feelings of being betrayed and devalued. The two primary coping mechanisms expressed were processing these feelings by talking to others who were laid-off and focusing on job-seeking (Farley, 2006).
Bland (2015) reviewed global trends and risk factors associated with job loss in the United States, indicating that most Americans perceive decreased employment stability and job displacement as common in the labor market. Bland found that worker displacement is associated with subsequent unemployment, long-term earnings loss, lower job quality, decline in physical and psychological well-being, loss of psychosocial assets, social withdrawal, family disruption, and lower levels of children's well-being. The sequelae reach well beyond the individual to touch the family, impact the social network, and bleed into the community.
In discussing the FCN termination survey, Solari-Twadell and Ziebarth (2020) identified that terminations occurred as a result of leadership change, organizational restructuring, and the role not being considered a strategic or financial priority. Each time there is a new pastor, change in reporting structure, financial hardship, or personal crisis, the FCN position may be at risk for elimination.
PREVENTING TERMINATION
Preemptive strategies may be useful to prevent loss of the FCN position or ministry (Solari-Twadell & Ziebarth, 2020). For example, FCNs should meet with new pastors to educate them on what a health ministry is and what the role of the FCN entails. Bagley (2011) examined the opportunities and barriers of FCN practice implementation, identifying that the majority of pastors would support a health ministry program to address health needs in their congregations. Presenting outcomes achieved to sustain health and wellness in the congregation and community is important. Connecting health ministry to evangelization through providing service to God's people integrates health and faith concepts, aligning with the faith community's mission. The FCN may ask for support, offer assistance, and demonstrate collaboration. It is imperative that both the faith leader and the FCN understand her/his individual roles and how the roles are enhanced by collaboration, discussing what skills and knowledge each contributes. The nurse should be aware the faith leader may not have worked with a faith community nursing program before and might feel threatened (Catholic Health Association of the United States, 2016).
Another important strategy is to create an environment and infrastructure where the health ministry can be financially self-sustaining. This reduces the burden on the church's general budget and allows allocation of resources when church finances may be strapped.
Succession planning is important when the FCN anticipates personal reasons for why the role may become vacant. Planning involves praying for guidance and discernment, identifying and developing a successor, and preparing the congregation using a change/transition model. A well-developed health cabinet may carry forward health ministry goals while the search for a new FCN occurs.
RECOMMENDATIONS FOLLOWING TERMINATION
In Ziebarth's 2018 survey, FCNs who were terminated self-identified interventions used, actions taken, and resources that were or would have been helpful. These included friends and family, peers, spiritual resources, professional therapists, and books/literature when in transition. The FCNs' recommendations are listed in Table 2.
It is clear that resources need to be developed to assist FCNs in transition after termination as a significant gap exists between what is needed and what is available. FCNs may use their professional association for support. It also could be helpful to use a transition model. Transition is a three-prong psychological reorientation process used as people come to terms with a change, focusing on letting go of and grieving for what was while anticipating a new beginning or what will be. A transition model can impact the potentially chaotic, negative, anxious period between letting go of the termination and old position (called the neutral zone) into a time of creativity, innovation, and hope as a new beginning is anticipated (Bridges & Bridges, 2017).
The Model for Healthy Living (Model) is an evidence-based framework used to assess wholistic wellness and the interconnectedness of body and spirit (Church Health, n.d.). The Model recognizes the particular challenges of balancing life while fulfilling a call to ministry against the backdrop of vocation (Church Health Reader, 2018). As the FCN works through the termination process, the seven dimensions of wellness may be used to guide questions, reflect on healing Scriptures, and create actionable goals to regain whole person health and wellness. One FCN's experience following termination involved seeking spiritual direction for help identifying her ministry calling.
Finally, Hinton (2016) provides comfort in the life-altering situation that is termination of employment:
* Our job is not where our value lies; value is in God's eyes and has nothing to do with the ministry.
* God's plan is bigger than ours and he is at work no matter how painful the situation.
* Our emotions and feelings are only one perception of the situation; owning our emotions allows God to help us learn and grow spiritually.
* Take the high road. Pray, conduct self-examination, speak to someone for spiritual support and direction; do not take responsibility for others' choices, behaviors, or actions.
* Pray for those who persecute us and cause pain and suffering (Matthew 5:44). Prayer changes our perspective and removes others' power to hurt us.
* Prepare for the next step God has chosen specifically for us. He is already at work preparing our future.
Losing an FCN position or having one's ministry eliminated is a stressful, painful life-altering event. There is hope in God's plan for us, that our gift of service will be used as we lean into him and use available resources.
TEST INSTRUCTIONS
* Read the article. The test for this nursing continuing professional development (NCPD) activity is to be taken online at http://www.NursingCenter.com/CE/CNJ. Tests can no longer be mailed or faxed.
* You'll need to create an account (it's free!) and log in to access My Planner before taking online tests. Your planner will keep track of all your Lippincott Professional Development online NCPD activities for you.
* There's only one correct answer for each question. A passing score for this test is 7 correct answers. If you pass, you can print your certificate of earned contact hours and access the answer key. If you fail, you have the option of taking the test again at no additional cost.
* For questions, contact Lippincott Professional Development: 1-800-787-8985.
* Registration deadline is June 2, 2023.
PROVIDER ACCREDITATION
Lippincott Professional Development will award 2.5 contact hours for this nursing continuing professional development activity.
Lippincott Professional Development is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.
This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.5 contact hours. Lippincott Professional Development is also an approved provider of continuing nursing education by the District of Columbia, Georgia, and Florida, CE Broker #50-1223. Your certificate is valid in all states.
Payment: The registration fee for this test is $24.95 for nonmembers, $17.95 for NCF members.