Transforming Care: A Christian Vision of Nursing Practice (20 page)

In the remaining three chapters, we examine three contexts in which
nurses pursue this worthwhile vocation. In each instance we point to the
ways in which we see the presence of the kingdom of God even now, to the
places where we must work against challenges to advance its ends, and to
the hope we hold out for its fulfillment in God's own time.

Jeff is 37 and lives in a house with five other men, all of whom struggle with
persistent mental illnesses. This house is located in a neighborhood setting
and is staffed by unlicensed personnel twenty-four hours a day. Beth is a
nurse case manager who has worked with Jeff for the past two years. She
visits him regularly at his home as well as in the acute care setting if he requires hospitalization.

Today, Beth has been alerted to the fact that Jeff has been very agitated
and delusional since a telephone conversation with his brother last evening
in which they became angry at one another. As Beth greets Jeff she notices
that he is disheveled and has not groomed himself. They sit down in the
corner of the living room. Jeff urgently tells Beth that the CIA has begun
tracking him again. They have "bugged" his room and are tapping the
house telephone. Jeff reports that when he leaves the house, agents, seeking
to uncover where he has hidden high-security coded information, are following him. Jeff's speech is disjointed and tangential.

Beth asks no questions but rather listens intently and patiently to
Jeff's conversation. Her nonverbal behavior indicates that she is fully
engaged in her interaction with Jeff. When asked by Jeff if she saw the
agents outside the house, Beth calmly replies, "I did not see any evidence of CIA agents outside, but I hear that you are very concerned
about that right now." Jeff nods and continues on. After a period of
time, Jeff's rate of speech begins to slow. During a pause, Beth suggests
that they might move to the table and play a favorite card game while they converse. Jeff is agreeable, and soon he is focused on attempting to
win the game.

After the card game, Beth inquires about Jeff's conversation with his
brother. They identify some beginning strategies to reduce anxiety when
conversing with Jeff's brother. Beth realizes that she will need to work with
Jeff further on this issue when his symptoms are better controlled. She
ends her interaction with Jeff by telling him that she will return in a week
to see him again.

Beth speaks with the staff, who indicate that Jeff has been isolative and
talking to himself more over the past few days. Beth enters a progress note
into Jeff's chart before she leaves the house. She identifies the need for an
interdisciplinary conversation regarding the adequacy of Jeff's medications, additional family education for Jeff's siblings, increased structure
for Jeff during the day, and increased attention to his hygiene.

Cathleen is a master's prepared nurse practitioner who serves as the director of a college counseling center at a small, religiously based, liberal arts
college. As such, Cathleen directs the efforts of two other professional staff
members and provides counseling to a caseload of students. In addition,
she periodically conducts group sessions on campus on various topics
such as "Dealing with your Parents' Divorce," offers college-wide mental
health promotion sessions on topics like assertion skills or healthy relationships, directs the screening efforts on campus for depression and eating disorders, and serves as a liaison between the college counseling center
and the college health center.

The students whom Cathleen sees individually and in group therapy
are struggling with a variety of issues: situational or maturational crises,
stress, anxiety, self-esteem, identity issues, loss and grief, or perhaps suicidal thoughts. Some may have actual psychiatric diagnoses such as major
depression, bipolar disorder, panic disorder, bulimia, anorexia, or substance abuse. Cathleen assesses, diagnoses, and treats the students who
seek help in the Counseling Center.

Cathleen has prescriptive authority and finds herself prescribing a variety of psychotropic medications to students who need them. As a nurse
practitioner, Cathleen may call colleagues from other disciplines in on
consult as necessary. She occasionally seeks consultation from a psychologist who does psychological testing of students, which provides Cathleen
with additional assessment data upon which to formulate her plan of care.

It stands to reason that the
mentally sick should be at
least as well cared for as the
physically sick.

LINDA RICHARDS

[Peplau completed her book
in 1948, but] it was not
published until four years
later because it was considered too revolutionary for a
nurse to publish a book
without a physician as coauthor.

A. W. O'TOOLE AND S. R. WELT

The practice of Beth and Cathleen as psychiatric-mental health nurses
is not necessarily the type of work that immediately comes to mind when
one speaks of nursing. This is perhaps not surprising as this specialty area
of nursing practice is relatively new. Linda
Richards is commonly recognized as the
first American psychiatric nurse for her
work in the late nineteenth century (Carson 2002, 17). However, it was not until
1913 that Johns Hopkins became the first
school of nursing to include a fully developed course on psychiatric nursing in the
curriculum (Stuart 2001, 3). In 1950, the
National League for Nursing first required
that accredited schools of nursing must provide experiences in psychiatric
nursing. In 1952, Hildegard Peplau published Interpersonal Relations in
Nursing, in which she set forth the first systematic, theoretical framework
for psychiatric nursing (Peplau 1952).

The label "psychiatric-mental health nursing" attempts to encompass
a broad spectrum of practice within this specialty area. Mental health
nursing practice is directed toward "well" individuals, families, and communities in an attempt to promote an already existing level of mental health and
to prevent the emergence of mental illness. Psychiatric nursing practice is directed toward individuals and the families
of individuals who are struggling with
identified mental illnesses. Cathleen's
groups on assertion skills and healthy relationships as well as her work with individual students experiencing crises, stress,
or self-esteem issues are examples of mental health nursing practice. Obviously,
psychiatric nursing is the focus of Beth's
practice with Jeff. Psychiatric-mental
health nurses deal with the full spectrum of these issues and with the many
areas of overlap between mental health and psychiatric nursing.

The clinical practice of psychiatric-mental health nursing occurs at
two levels: basic and advanced (www.apna.org). Beth, as a registered nurse functioning at the basic level, has worked with Jeff and his family in assessing his mental health needs and then developing, implementing, and evaluating a plan of nursing care for him. As Jeff's case manager, she monitors
the effectiveness of his medications, promotes his ability for self-care, assists him in improving his coping skills, and attempts to maximize his
functioning as he deals with a persistent mental illness. Beth also collaborates with the interdisciplinary team and educates Jeff's family about his
symptoms, medications, and strategies for interacting with him. Cathleen,
as an advanced practice psychiatric-mental health nurse, has the required
minimum of a master's degree in this specialty area and has assumed the
role of a nurse practitioner (www.apna.org; Bjorklund 2003, 78). In addition to the functions included in Beth's role, Cathleen is prepared to assess,
diagnose, and treat individuals or families with psychiatric disorders or the
potential for such disorders. She independently provides a full range of
mental health care services to the college community as an individual and
group psychotherapist, an educator, a consultant, and an administrator. In
the particular state where Cathleen resides, she has prescriptive authority
as well.

So what are the "reasons of the heart and mind" for engaging in the
work of psychiatric-mental health nursing? Where might God be encountered in the practice of psychiatric-mental health nursing? How might
Beth be expressing her Christian vocation in her work with Jeff or
Cathleen in her care for the college students that form her caseload? On
the other hand, what "reasons of the heart and mind" might make us apprehensive about taking on the work of psychiatric-mental health nursing? Why are students often so intimidated by this type of nursing practice? Why might experienced practitioners be weary and overwhelmed? To
explore these questions, let us identify some of the opportunities as well as
the challenges faced by psychiatric-mental health nurses.

Psychiatric-mental health nursing offers the nurse multiple opportunities
to care for the "least of these," the vulnerable and the marginalized. In
Beth's practice, her brief encounter with Jeff offers important opportunities
to engage in care-giving and see the care-receiving process in action
(Tronto 1994, 106). J. C. Tronto indicates that care-giving involves meeting care needs directly, which involves physical work and direct contact between care-giver and care-receiver. Care-receiving entails a response that
ideally indicates that care needs have been met. Clearly, there are many reasons why care needs may not be met, not the least of which are inaccurate
perceptions of needs or inappropriate responses to correctly perceived care
needs. Thus, as was previously noted, care involves vulnerabilities, concern,
action, and response. Jeff's vulnerability and Beth's concern and action are
evident at many junctures in this brief scenario. When Jeff is frightened by
people who do not exist and events that have never occurred, Beth responds
with a comforting and reassuring presence. When Jeff is confused about
what is reality and what is a product of his mind, Beth assists him in clarifying by sharing her sense of reality, directing him toward basic reality-based
activities, and advocating a change in his medication regime. When Jeff has
difficulty communicating, Beth has the opportunity to listen attentively
and respectfully to his verbalizations. While Jeff runs the risk of being rejected by others because of lack of understanding of his bizarre behavior,
Beth has the concrete chance to accept him as a unique creation of God
and, through education about Jeff's illness, to move those around Jeff closer
to such acceptance. Beth has daily opportunities to deliver complex care
that is rooted in the Christian obligation to serve the human need that surrounds us. But note Jeff's response to Beth's care-giving as well. Jeff's
anxiety-driven speech slows and his attention is directed toward a shared
reality that is not frightening to him. In this instance, it appears as though
Jeff's care needs have been appropriately perceived and properly responded
to. Of course, not all nurse-client interactions are characterized by such resounding success!

Nurses have often focused on delivering Christ-like care to others
(O'Brien 2001, 4; O'Brien 2003, io); but they have focused less on the inherent opportunity they have to see a reflection of the suffering, broken
Christ in the faces of those for whom they care. In the face of Jeff and his
accompanying symptoms, Beth is seeing a reflection of the suffering servant, Jesus Christ. Where exactly does one see Christ in delusions about
the CIA, tangential conversation, and inadequate hygiene? We see Christ
precisely in those verbalizations about secret agents and "bugged" rooms.
Matthew 25 assures us that even as we attend to the vulnerable, the defenseless, or the disenfranchised among us we attend to Christ himself.
Our crucified Lord was mocked and rejected. Perhaps the experience of
one with a persistent mental illness is not so far removed. Often these indi viduals suffer similarly as a result of society's lack of understanding of
their illness and its manifestations. If Jeff is, indeed, a mediator of the divine, then Beth has continuing opportunities to encounter Christ in her
interactions with Jeff. The person of Jeff provides Beth with an important
point of contact with God.

The recognition of Jeff as an agent of the divine, who gives to Beth in
important ways, brings us logically to a consideration of the reciprocity inherent in the nurse-client relationship. Psychiatric-mental health nursing
offers the practitioner numerous opportunities to learn about courage, resilience, and faith firsthand. Reflect on the following questions: How
would I manage if I had to get up each morning and wonder about the accuracy of my perceptions? Would I have the strength to battle suicidal
thoughts on a continuing basis? Would I become hopeless if I had immobilizing panic attacks weekly? Could I trust in God's good plan for my life
if I had been emotionally, physically, or sexually abused as a child? How
would I cope with the addictive pull of a binge-purge cycle? Could I find
evidence of a sovereign God as I had to deal with the mood swings associated with a bipolar disorder? How much effort might I need to devote to
managing an addiction to a substance? If the nurse is candid in answering
these questions, admiration begins to grow for those persons who live with
mental illnesses.

Many of us enjoy reading personal stories of courage and faith in
newspapers or magazines as they inspire us, encourage us, and foster a
positive outlook on life. Cathleen and Beth encounter the main characters
in such stories on a daily basis. They see living examples of persons who
bravely fight the biochemically based mental illness that threatens to overtake them. They see individuals who must surely be stronger and more resilient than most to have survived and been victorious over childhood
atrocities. They see persons whose faith remains vibrant in the face of the
difficulty and adversity of a persistent mental illness. Such encounters can
be profoundly instructive to the nurse, assuming that she or he has the
necessary humility to be open to the learning offered. These interactions
can encourage a humble sense of gratitude for that which we often take for
granted and can serve to reinforce an awareness of God's faithfulness in all
circumstances. In essence, then, the nurse is enhanced by her or his practice of psychiatric-mental health nursing.