I am a Faith Community Nurse (FCN) for TriHealth Good Samaritan Hospital in Cincinnati Ohio and have worked in this role for the past 20 years. Across time, the roles and responsibilities have changed almost as often as the title. First I was a Parish Nurse, and then Faith Community Nurse and most recently am known as an Outreach Nurse. Regardless of what I am called, in its purest sense, my role is to journey with clients across time, addressing any and all factors that affect their mental, physical, spiritual and social wellbeing.
Inherent in this role is the understanding that FCN’s do intentional care of the spirit, which translates into having conversations with the client about their faith, their faith practices, and their beliefs as well as how all of these factors interplay with their health and wellbeing. We use compassionate listening and reflective open conversations to help the individual express their understanding of how healing happens for them and how they can be best supported. We use prayer, touch and active listening but our biggest and most powerful intervention is the use of presence.
To be present seems like one of those fluffy things; an overused word that might equate to an image of a cross-legged person sitting serenely meditating and chanting an ohm in a field of flowers. What it really means is simply being there inside the moment that is right before you with the person or experience that is there with you. Being present means dealing with anything and everything that might be with you there in that moment, in that space and time. This includes all feelings, emotions, pasts and present offerings that need tending. We stay there, in that space accepting what is there, partnering with who it belongs to, trusting in the process of life and all that it holds. It is through these intangible tools that we do our work of tending the spirit.
You might be saying to yourself, ok now what do all of these words really mean and what does a day look like in the role of a FCN. How does one put these concepts into real life actions? Here are some vignettes of client’s stories to help bridge the gap between concepts and practice. It is my hope that the sharing of some encounters with current clients will help bridge the gap between verbiage and action so that this highly specialized role is more clearly understood. I will use initials only as client descriptive in order to protect their identities.
T and M have been married for 35 years and are refugees from Burundi Africa. They have been here almost 10 years. T had a stroke a couple of years back and M is his caregiver. They live in subsidized housing, are on Medicaid and share a monthly income of $733.00. T was granted citizenship this past year after I helped him complete the application for medical waiver. I see them weekly to monitor their use of medication bubble packs that are made and delivered by the pharmacy. In addition I manage all of the medical and social service appointments that keep them in compliance so they can continue to receive much needed financial and medical support.
At a recent visit, M was intoxicated. There have been numerous times she has been tipsy at our visits but recently she has been on a bender. This particular day she was so severely drunk that I had to call 911 for emergency care. Upon arrival at the hospital her blood alcohol level was 485, which in a normal person could have been lethal. She is also a diabetic, which added danger to the issue. With M as T’s primary care giver and knowing the fragile state of her husband due to his stroke, drastic measures had to be taken to communicate the importance of her sobriety. T was moved to a safe place for a few days and Adult Protective Services was consulted since there were unknowable safety concerns due to M’s substance abuse.
While visiting with T after sending his wife to the hospital, I asked him through an interpreter how he is doing with all the changes of the past few days. He replied, “It is too much for me.” I told him I was concerned about him and wanted to make sure I was giving him the help he needed. He told me, “you are my mother now; you are all that I have.” I turned to the Community Health Worker who also is a certified translator for understanding of this statement. He explained to me that in Africa, it is a great honor to be someone’s parent and that T perceived that I was caring for him in that capacity. I was deeply touched by this gesture and felt fortunate that in this tangle of dysfunction T had felt the care of a loving parent.
Recently M has slowed down with her drinking. She admits that she has a problem and she would like to stop drinking but she humbly reports that drinking has been her life. She started when she was a child in Africa and it didn’t have the same consequences there as it does here in America. She shared with me her shame around having never been to school and her inability to grasp concepts needed to learn to read and write. She agreed to have visits with a local seminarian who also was from Africa and knows the language. He prayed with her and spoke to her with respect. We tried to create an AA style program of sponsored group support with other African’s who have quit drinking. This was not embraced by M probably due the incongruence with their culture. We continue to recognize and compliment M on the visits that she is sober hoping that affirmation will speak to her spirit. On days she is not sober we make sure everyone is safe and wait until another day to revisit the concept of sobriety.
E is another complicated client. He has impaired vision due to diabetes and as a result he is anxious about homecare services. He has enough vision to function but not enough to manage his medications. While filling his medisets he listens to the sound of the pills as they drop into the medication compartment. He can hear if you have missed a compartment with one of the pills. I was called to see him because of his lapsed Medicaid. He was not notified of the disruption and the fall out was that he could no longer access health care. He had a new diabetic foot ulcer that was open and weeping. He had attempted to make the calls to rectify the problem but was not successful. It was then I was called to help.
I began making calls to get E back in the system. Calls were made to the seven agencies who were involved in his care. This took monumental patience and time wading through automated phone systems at each discipline. After many calls his insurance and homecare was re-established, medical appointments were made and medications could now be delivered. At the completion of getting him back up and running E wondered out loud why he wasn’t able to accomplish this on his own. I wondered this too but was grateful he was back in the system. He was misty eyed as he professed his gratitude and said it was comforting knowing that somehow God was watching out for him through me.
Recently I shopped for new housing with a refugee family who was displaced from their original subsidized housing unit. There were structural issues in their original unit that made it unsafe for occupancy. The family kept a spotless home and were used to clean and safe conditions. They were moved hastily into an adjacent unit in order to meet the housing authority’s deadlines. The new unit was not properly prepared and immediately after moving in they began to notice bed bug bites on their two small children. They contacted management for help and were ignored after their maintenance workers could not validate any problem. They even accused the client of bringing bugs into the new location and were set to charge them a fine for the infestation that they were now being accused of causing. Over the course of weeks the client aggressively looked for the source of the bed bugs. After a tireless search they discovered the infestation was hidden behind the baseboards in one of their bedrooms. The client filmed the discovery with her phone and sent the evidence to me. They asked me for help with their problem.
Part of our work is to advocate and help clients overcome barriers and sometimes these barriers lie within agencies themselves. It is essential in this work that the FCN develops respectful collaborative relationships with any and all community service providers. I quickly got busy tapping our department’s social worker and the housing authority agent with whom I have a strong respectful relationship. Because of these relationships I was able to advocate on the client’s behalf and negotiate agreeable maintenance repairs and extermination schedules to assist in gaining satisfying, safe and healthy living conditions that reduce environmental health detriments. It took filing a grievance with the housing authority and working within their allowed timelines to resolve this problem. After months of aggravating bug bites the family finally was moved into yet another unit. They will continue to need inspections and extermination until the professionals deem their residence is cleared of the nuisance.
I also saw DK who is pregnant and lives in the same subsidized housing. She is 20 weeks into a pregnancy and has complicated social issues. She also has severe depression. She initially asked me to see her weekly to offer her support and listening as she navigated the legal system. Today’s visit was especially difficult. DK was to make an appointment to see her OB and in the past two weeks she had not done so. When I questioned her about this she became especially sullen and quiet. After waiting for several minutes she began to cry and then explained that her father had suddenly died. She began to sob heavily and hung her head in her hands. We sat in quiet until it seemed like the right time to offer my condolences. I sat with her loss as well and listened to any feelings she might offer. She was already depressed and additionally she was dealing with sudden unexpected grief. Their relationship was strained so this complicated her feelings of grief. There was all of this emotion, grief and sorrow, and at the same time there was an unborn child that needed to be monitored.
After some time and supportive listening I explored what would be helpful for her in this moment. Typically I like the client to own the responsibility of making their own appointments but today with her overwhelming grief, it seemed best to offer my help for this task. Sometimes our clients do not have the capacity to act in their own best interest and that is when it is necessary to take action for them in order to prevent further decline. Today this client received support and presence during her suffering and grief while also getting a much needed nudge to get medication and a medical appointment that both she and her unborn baby needed.
Some visits are laced with frustration after learning that clients sometimes make up their own system for taking medications. The pharmacy currently delivers prefilled bubble packs, which is safer and eliminates mistakes that could happen with using the individual bottle system. This service is needed since many clients, especially the refugee population I serve have limited English and do not read or write well. This next story demonstrates how culture and literacy intersect and effect health care choices.
M and S are two who dabbled with diverting from the safe bubble pack system. M showed me an OTC medication someone bought for her because her stomach was upset. What she showed me was Prilosec. She also showed me her bottle of prescribed Ibuprofen that she can take for her occasional pain. When I saw the OTC Prilosec I was immediately concerned because I knew that Zantac was already in her bubble pack of meds, so in essence she was overmedicating. Of course, I showed her the meds in the bubble pack and reviewed what she is taking and why, something that has been done numerous times. It was at this time she admitted she no longer wants to take her blood pressure medications because she didn’t have to take them in Africa and she does not feel any pressure. Again I taught her about high blood pressure and what can happen if left untreated. She begrudgingly agreed to continue taking the meds until her next visit with the doctor.
At this visit M also told me that she has gone to the hospital before and they did things to her that she did not want done. When I asked her to tell me about one of those occasions she began gesturing back and forth to each of her breast and then she said that once they did something to her and now one was smaller than the other. I fought off giggling because M has enormous, pendulous breasts and does not wear a bra. To anyone’s naked eye, it would be very hard to tell of any size discrepancies. Of course she could not tell me what was done to her as she pointed to two pin sized markings on her skin that she presented as proof of what had happened. I told her I would have to research her chart to understand what she might have had done and then I would explain more to her about what had happened.
As she continued sharing her displeasure of having medical procedures done to her that she did not want, it seemed like a good time to discuss advanced directives. It became instantly clear that this was not going to be an easy concept for low literacy, non-English speaking refugees from Africa to understand. I took a deep breath and gave it my best shot. She interrupted me to say that many times the “Muganga’s” (doctors in Kirundi) have talked with her about these papers and that she did not die and because of this she would never sign the forms. It was then I realized that she believed talking about death would invite it to come and that she believed she had dodged a very near bullet after past conversations.
The conversation became quite lengthy and complicated as we brushed against primitive philosophical, religious and spiritual concepts relating to life and death and unspoken tribal taboos that urged one not to speak of such things. Mind you, this was all being discussed through an interpreter! Not an easy conversation to have with anyone let alone when it is loaded with what one brings with them as a refugee from another continent, layered with trauma and fixed understandings about the world, God and all of humanity.
This next client, W has been my most challenging. W is diabetic with chronic gastroparesis. She was diagnosed with diabetes when she was 10 and has not been well managed since diagnosis. She was raised by her grandmother who was also diabetic and of low literacy. W’s own mother struggled with substance abuse and died at an early age. W shared memories of how she used to look out her granny’s window to see her mom “working” the corner and at bedtime and would yell out the door to her to tell her good night. W is also a depressed and bipolar, with a personality disorder. At 15 she suffered a stillborn, two years later her mom died and since that time W has been on a steady course of self-destruction. She continues in this spiral and all of our best efforts are seemingly ineffective.
Recently she was homeless. She chronically visits someone’s ED every day for the same symptoms: DKA, nausea, vomiting, diarrhea and pain, the cluster of symptoms cause from her chronically mismanaged diabetes. She has received every resource known to man and for reasons beyond understanding, she is incapable of turning her life around. We have had “come to Jesus” conversations that result in a promise of changed behavior that time again fall short. It is here that I turn to the wisdom of the 12 Step program and admit my own powerlessness over someone else’s disease, choices and habits that result in their suffering. I sit with my own feelings of helplessness and inadequacies that make me question my effectiveness. It is then that I remember this work is mysterious and dynamic and that I have agreed to journey with this client no matter where it takes her, maybe even to her grave. Clients have the right to make really bad decisions; they lose everything, housing, employment, health, family, children and even their life. But this is the call. We move with them and honor their path and trust that the Divine Mystery holds it all. Today I will accompany her to yet another doctor’s appointment and listen to her spirit as she discovers the healing only she can give to herself.
Another refugee was in an automobile accident in early August and suffered a severe fracture of her wrist. I accompanied her to the orthopedic visit where she learned surgery is required to have it re-aligned. A is 77 years old and has never had surgery or been hospitalized. After the NP left the office A asked me, “Will I be able to make fufu again?” Fufu is a staple of the African diet. It is made from the cassava root. It is something like a big ball of undercooked dough that is cooked in a pot of sauce. To eat it one would roll it into small balls and dip it into sauces flavored by broth of fish, meat and vegetables. To make the fufu she has to sit before a very large wooden bowl that is the size of a medium tree trunk, and mix the ingredients with an equally large wooden stick. I explained to her that it probably will take several months for her recovery and that she will have to ask her family for help with making fufu. A looked at me with sad, heavy eyes and then said, “Today I have been visited by Lucifer!” Knowing many details of the suffering she has faced I responded, “Again? Lucifer has visited you again?” She said, “Yes, yes, yes, again.” We smile and then I remind her, “And God visits you every day!”
This last statement referring to Lucifer gives insight into the beliefs of A as she faces yet another hard time. She has already survived life in a refugee camp for over 28 years, was sent to a foreign country for assimilation, has suffered many obstacles related to the incorrect recording of her birthday, been hit by a car and now this. As she tries to understand all of these difficulties the only plausible explanation is Lucifer…Satan.
This is a small glimpse into the ministry of a FCN. In addition to these individual visits we do community screenings, wholistic wellness retreats, communal services, attend funerals, medical and social service agency appointments along with staying current with all requirements of our employers annual certifications and renewals. We belong to professional organizations, sit on hospital and church counsels, and have active nursing licenses in our perspective states. We are a small but mighty band of nurses who go into impoverished, sometimes dangerous neighborhoods delivering the good news that they are valued and loved by us, our institutions and by th