Transforming Care: A Christian Vision of Nursing Practice (21 page)

To take this point a bit further, the clients of Beth and Cathleen may
also offer specific gifts. These gifts may come in the form of gratitude, warmth, and affirmation of their vocational calling. Jeff's appreciation
for Beth's weekly visits and his response to her care-giving efforts give
clear evidence that the giving and receiving in their relationship is certainly not unidirectional.
Similarly, the student
who stops by Cathleen's
office to thank her and
tell her that she "made it"
through the semester after the tragic and unexpected loss of her father
is giving of herself to
Cathleen in meaningful
ways. While the goods
exchanged may be different, there is, nevertheless,
reciprocity in operation
where the nurse is the recipient of the blessing.

Many people are looking for an ear that will
listen.... He who no longer listens to his
brother will soon no longer be listening to
God either.... One who cannot listen long
and patiently will presently be talking beside
the point and never be really speaking to
others albeit he be not conscious of it.

DIETRICH BONHOEFFER

The purposes of the practices of a professional nurse are more than merely helping to
heal the physical ailments of the patient, although of course this is one important activity of the nurse. The nurse, more than the
physician, must relate meaningfully to the reaction of the patient to his or her illness, including psychological and social changes that
illness forces upon the patient. The nurse
spends more time with the patient than does
the physician, and therefore has more opportunity not only to observe but also to talk
with and come to know the patient. This time
factor gives the nurse an opportunity to help
the patient become aware of and make sense
out of his or her reactions to the current
condition so that these can be more or less
understood by the patient in light of longrange personal consequences.

HILDEGARD PEPLAU

Psychiatric-mental
health nursing also offers
powerful opportunities to
understand the client as a
character in a narrative.
Through careful listening,
the nurse is able to come
to appreciate the person
as someone with a story
that preceded this encounter and that will continue on long after leaving
the nurse's care. Margaret Mohrmann (1995,
65) makes the point that
health care providers need
to learn how to pay attention and listen to the stories of those they care for. In doing so, we have the opportunity to see the client as "a person in all his
wholeness - a person with ... an intact and meaningful life story into
which the present suffering can be incorporated, and therefore comprehended" (Mohrmann 1995, 72). For Christians, these individual life stories
are always embedded in the greater narrative of creation and redemption as
told in Scripture. If we reflect upon the practice of Beth or Cathleen, each
has the potential of extended periods of time to hear the stories of and
come to see their clients as rooted in personal life narratives. Beth has seen
Jeff over the period of two years, while Cathleen may work with students intermittently over the course of their undergraduate careers. Even in instances where the luxury of extended time with a client is not available to
Beth or Cathleen, their practice of psychiatric-mental health nursing focuses very intentionally on the skillful establishment of interpersonal relationships and partnerships that are characterized by active listening, trust,
and empathy as the context for care. Such a context offers each the exciting
chance to see how God's narrative intersects with the unique narratives of
the clients to whom they are called to minister.

At a township meeting, the agenda included consideration of a proposal to
put a home for persons struggling with schizophrenia in a residential
neighborhood. Numerous speakers addressed the planning commission to
express their dismay at having "those crazy people on our block." Several
were very concerned about the "impact of maniacs on our property values."
Others spoke animatedly about the "dangerous nature of schizophrenics."

Two women were talking after church about the absence of Peter, a
member of their congregation. Peter had not been at services for several
weeks and yet there was no announcement as to his situation. The two
women concluded that "it must be his drinking again or otherwise the
pastor would have shared the information."

Two nursing students were talking about their course in mental health
nursing. One said to the other: "If I had to have an illness, I don't know
what I'd wish it to be. But I do know what I would wish it not to be - any
sort of mental illness!"

The staff of an acute care psychiatric unit was in shift change report.
Monica, the nurse manager, was sharing information about new admissions. Leslie P. was being readmitted for the third time in six months with a
diagnosis of major depression and borderline personality disorder. Each of
these diagnoses may have had its roots in a complex array of genetic and
biochemical factors as well as the childhood sexual abuse that Leslie had
suffered. Leslie was being admitted because she had been cutting herself
again. James, one of the RNs, whispered to Sandra, another RN, "We're entering the frequent flyer time of year again. The borderlines are coming
out of the woodwork!" Both laughed at the joke before turning their attention back to the report.

Chantalle, an advanced practice nurse, was leading a group session for
families with members who had a mental illness. When she asked about
the challenges that they faced, several spoke of the stigma that still exists
regarding mental illness. "People treat us as if we have the plague!" one
family member shared. Another said, "No one knows what to say to us or
how to ask about Darnell. I wonder if they'd have so much difficulty if he
had cancer?"

The general public stigmatizes those with mental illnesses as dangerous, irresponsible, unpredictable, isolated, and unlikely to improve (Emrich et al.
2003, 20). Similarly, those with substance abuse problems are viewed as
lacking in will power and morally deficient (Martinez and Murphy-Parker
2003,157). Alarmingly, such attitudes on the part of the general public have
not changed significantly in the past three decades. Perhaps even more disturbing is the fact that many health care professionals share these same
prejudices relative to those with mental illness and addictions (Emrich et
al. 2003, 2o; Martinez and Murphy-Parker 2003, 157).

So what is the impact of stigma? Or more specifically, how does stigma
affect persons created in God's image? First, stigma separates and disconnects. Being an embodied person entails openness to other persons -
openness to a relationship with another, a responsibility to care for another, an attunement to others outside of our expectations and prejudgments of them. Image-bearers, as ones who have the ability to interact with
other humans, should be in inescapable proximity with others for the purpose of serving God by attending to our neighbors. Stigmatizing statements are generally based upon prejudgments and inaccurate information. They are often used to create artificial barriers that we imagine might somehow protect us. Irrationally we hope that such distance will ensure
that "this won't happen to me." Stigmatizing language, then, is diametrically opposed to openness and neighborliness.

Persons with mental illnesses are also stigmatized when we refer to
them as "schizophrenics," "alcoholics," "anorexics," or "manic-depressives."
When we attach such labels we immediately reduce the personhood of the
individual and signal that her or his entire identity is subsumed by the illness. In our discussion of personhood, we pointed out the importance of
naming. When we substitute an illness label for a person's name, we fail to
recognize that person as the unified whole that she or he was created to be.
The stigmatized individual is seen as one-dimensional rather than as an
embodied person who is an image-bearer of God, a particular "I" with
physical, emotional, social, moral, and spiritual dimensions, characterized
by independence and dependence, and as a co-author of the story in which
she or he is embedded. In other words, to think of Peter, Leslie, or Darnell
strictly in terms of their particular mental illness misses critical aspects of
who God created them to be. It is also clearly inconsistent with the notion
of cultivating an atmosphere of reverence and awe toward them as tokens of
the divine. Stigma, then, does damage to perpetrators and recipients alike
in terms of their identity as image-bearers of God.

As demonstrated in the vignettes and documented in the literature,
nurses are not immune from perpetrating stigma. Perhaps we need to examine with greater care the expectations and preconceived notions that we
carry with us into our client encounters. The negative aspect of seeing clients as a part of a narrative may be that we have certain "set story lines"
that we impose on individuals without exploring their validity. In fiction,
if an author consistently uses such a "set story line" his or her work is often
lacking in creativity, dull, monotonous, and ultimately unsuccessful. The
parallel in nursing practice is that if we consistently approach clients with
these preconceived notions, we short-circuit the opportunity to be cocreators with God by conforming our nursing actions to what we are able
to discern of God's direction for creation. These stigmatizing attitudes distort our practice of nursing from one that has been shaped by experiencing the reality of God to one that is shaped by our brokenness.

Brian is a psychiatric-mental health nurse working on an acute care unit.
Brian's assignment today includes completing a nursing assessment on
Cheryl, a 23-year-old, newly admitted client. Brian greets Cheryl and her
parents, whom he has met on several previous admissions. Cheryl has a
four-year history of bipolar disorder as well as a history of nonadherence
to her psychotropic medications. Cheryl reports that her admission this
time was the fault of her parents, who brought her to the unit because her
apartment manager claimed that she was "too loud." Cheryl's parents report that she was talking non-stop, had not slept in three days, was too hyperactive to eat, was disturbing her neighbors by knocking on their doors
in the middle of the night, was spending money wildly, got fired from her
job for inappropriate behavior, and had recently announced her intention
to move to Paris and work as a world-renowned artist. Cheryl's parents indicate that they found her Depakote and Zyprexa prescriptions unopened,
indicating that Cheryl had not taken her medications for the past two
weeks. Brian continues his assessment by asking Cheryl about her medication regime. Cheryl repeatedly insists that she does not need either the
Depakote or the Zyprexa that have been prescribed and complains about
the fact that they "affect my creativity." Cheryl indicates that if her neighbors and parents would just "chill out" things would be fine. Brian completes the assessment and sighs as he walks back to the nursing station. He
remarks to his co-worker, "I'm so sick of these clients who can't seem to
figure out that their medication is the key to their functioning! What's the
point of stabilizing them just so they can leave and stop their meds again?"

Although psychotropic medications have been consistently shown to
be highly effective in the treatment of persistent mental illnesses, many clients are reluctant to take them (Kemppainen et al. 2003, 41; Pinikahana et
al. 2002). Cramer and Rosenheck (1998) reviewed thirty-four studies on
psychotropic adherence rates and found the mean level of client adherence
to antipsychotic medications was 58 percent with a range of 24 to 9o percent. The mean rate of adherence to antidepressant medications was
slightly better at 63 percent with a range of 40 to 90 percent. Numerous
reasons have been set forth as to why persons diagnosed with mental illnesses may not adhere to their medication regimes. These include the nature of mental illness (Weiss et al. 1998); distressing physical side effects
(Pinikahana et al. 2002; Ruscher et al. 1997); a lack of acceptance of their diagnosis and need for treatment (Pinikahana et al. 2002); a history of substance abuse (Heyscue et al. 1998; Pinikahana et al. 2002); the nature of the
therapeutic relationship (Pinikahana et al. 2002); insufficient knowledge
of medications (Tempier 1996); a lack of economic and social supports
(Kemppainen et al. 2003; Pinikahana et al. 2002); and lack of awareness of
symptoms (Kozuki and Froelicher 2003, 57). Brian maybe seeing several of
these factors in operation with Cheryl.

So how does the Christian nurse unpack the multifaceted issue of client nonadherence to a psychotropic medication regime? While there are
no easy answers to the complex questions involved, perhaps we can at least
identify some of the key issues and general directions that might assist us.
While doing so, it will be critically important that we resist the inclination
to simplify this issue and leap to a hasty conclusion prior to considering all
relevant aspects. In addition, we must recognize that any proposed direction will, of necessity, be general and may or may not be appropriate to an
individual with a unique story and set of needs.

First, might nurses be guilty of paternalism (or maternalism) as they
attempt to convince clients to take these medications? Do we really "know
best" in regard to an individual's unique sense of well-being when she or
he is on these medications? Certainly the charge of paternalism has some
validity, given that nursing rhetoric suggests that clients are experts in their
own experience. It is, no doubt, often the case that nurses do not thoroughly explore this expertise that their clients bring to the table. But that
charge should rightly be set next to the expertise that the nurses bring to
this situation given their education and clinical experience. Both clients
and nurses bring specific expertise that must be valued in order to determine a reasonable course of action relative to medication adherence.