Transforming Care: A Christian Vision of Nursing Practice (27 page)

Jennifer, a public health nurse working for a county health department, returns to the office after a particularly frustrating client visit. She shares
with her co-workers her dismay about Stacy, a client who "is too lazy to
take her kids in for their shots." The situation has reached a crisis, since
Haley, the 5-year-old little girl, is not allowed to start kindergarten because
she has not received her immunizations. Jennifer has repeatedly told the
client the hours of the immunization clinic and that the shots are free, but
still Stacy "just won't follow through. I know it's not politically correct to
label someone `noncompliant,' but that's just what Stacy is!"

Scenarios like this are everyday experiences for nurses working in
community health. Clients often seem to make bad choices even when the
right choice seems easy and obvious to the nurse. How hard could it be to
get to the health department so Haley could receive the necessary immunizations? Jennifer is so frustrated with this situation! She feels as though she
has done all she can do (or all she should need to do) to get Stacy to follow
through. Jennifer is also angry at Stacy and what she sees as Stacy's unwillingness or inability to set her priorities correctly. Jennifer's values would
dictate that Haley must be able to start school on time, but apparently
Stacy has different values. In circumstances such as these, what can be
done to build shalom? One important part of the answer often involves
learning more about the client's situation. Frequently, there are variables that the nurse, because of her own frame of reference, has never even considered. Let us learn a bit more about Stacy and her family.

Stacy, age 21, is a single mother with three children. She moved to this
area about a year ago to escape her abusive boyfriend. She left her family
and friends behind because she needed to get away to protect herself and
her children. Stacy was just i6 when she gave birth to Haley; she was i8
when Justin was born and 20 when she gave birth to Vanessa, her youngest.
She has not completed high school, but has recently been attending a high
school completion program in her neighborhood. This program works for
Stacy, since on-site child care is offered. She has been looking for part-time
work, but because she has few marketable skills and will need to earn more
than the cost of child care it is proving difficult to find a job.

When Stacy left home, she had to get out quickly, so she took only a
few clothes and their old car, which has since broken down. Since she was
not married and her name was not on the bank account, she has no access
to the account she shared with her boyfriend. Currently, her only sources
of income are the money her mom occasionally sends and the monthly
check she receives from Family Assistance. Thankfully, she will soon begin
to receive Food Stamps also. Stacy has known for a few months that she
needs to get Haley immunized, and she meant to do it.

If the nurse knows more about Stacy's circumstances, what barriers to
compliance might she anticipate? Stacy has no car. Since it is likely that
Stacy cannot afford cab fare, is she able to get to the health department using public transportation? If so, how long will it take her to get there? Will
it require a transfer or two? What if the weather is rainy or very cold? Since
Stacy is new to the area, perhaps she has no friend who could watch her
younger children while she and Haley make the trip. She would then need
to bring (and pay bus fare for) the whole family. Maybe the children have
been passing the flu to each other for the past month, so she has been unable to get out with them.

Stacy might also have some less obvious reasons for her "noncompliance." Suppose the cover story in last month's women's magazine was
about children who became very ill as a result of immunizations, and this
frightened Stacy. Perhaps Stacy has cultural or religious reasons for refusing to obtain the immunizations. The point is, Jennifer must be able to anticipate these barriers, ask Stacy about them, and work with her to overcome the barriers.

Being a person involves being a character in a narrative with a past, present, and future plot. All nurses must listen closely to their clients' narratives. This is especially true in community health settings where the client's life experiences are often so very different from the nurse's. Jennifer
cannot and must not use her own frame of reference to judge her client's
actions. She needs to "stand in Stacy's shoes" in order to have an understanding of her behavior. We have also said that to be a person means, in
part, to be the co-author of our own narratives. But being the co-author is
not the same as being a sole author. We never single-handedly write the
stories of our lives because we are constrained by circumstances and by
persons who are not under our control. We can judge how and when actions are to be approved or disapproved, how and when characters are to
be praised or blamed for their actions, only in the context of the stories of
which those actions are a part. Thus, Jennifer must carefully listen to Stacy
as she explains what has happened and then assess all aspects of the situation with a view toward understanding those aspects which are not under
Stacy's control.

Having discussed the importance of listening and working to achieve
understanding of client circumstances, we must still acknowledge that no
matter how well the nurse listens and anticipates, people will still make
choices that the nurse considers wrong, choices that are bad for their
health. Consider the following.

Bob and Cheryl are a couple in their late 50s. Although they are not
married, they have been together for seven years. They have no children,
but do have five large dogs living in the house with them. The house is
dirty and run down, but it is a large step up for Bob and Cheryl. Until two
years ago, they were homeless.

They became homeless when they both lost their jobs and fell behind
in their rent and other debts. Bob, a Vietnam veteran, was fired when his
post-traumatic stress disorder caused him to be incapable of doing his
factory job. Cheryl had to quit work because her chronic obstructive pulmonary disease (COPD) and diabetes made her unable to bus tables anymore. After the unemployment benefits ran out, they had no source of income and began living on the streets and in shelters. Bob and Cheryl now
have a home because Bob was finally able to obtain some veteran's pay
and Cheryl to qualify for disability pay. Currently, they are focused on
buying a car.

Ray, a public health nurse who works with homeless and formerly
homeless clients, is Bob and Cheryl's nurse. Ray knows this couple well. He has helped Bob obtain a referral to a psychiatrist so he can get a prescription for anti-anxiety medication. He has assisted Cheryl to get the inhome oxygen she needs to help her manage her COPD. Ray and Cheryl
frequently discuss the fact that Cheryl's COPD might be significantly improved if she quit or even cut down on her smoking. Now, with oxygen in
the house, Ray knows that the smoking poses an even more significant
health risk since the lit cigarettes could ignite the oxygen and blow up the
house. Ray's greatest frustration in caring for Cheryl is that Cheryl continues to smoke cigarettes in the house even with the oxygen present. Ray
feels that he made a little headway at his last home visit when Cheryl
agreed to smoke only in the living room and to leave the oxygen tank in the
kitchen. Ray knows, however, that the television is in the living room, and
Cheryl likes to use the oxygen when she watches TV.

Clearly, Cheryl's decision to continue smoking is a bad choice. From a
health perspective, both of her chronic conditions would be easier to manage and would likely improve if she quit. Her choice to continue smoking
also affects Bob. Not only is he exposed to her secondhand smoke, he also
faces the risk of being blown up! Indirectly, Cheryl's choice also affects the
rest of society. Scarce health resources are being spent to enable an addicted smoker to continue life-threatening behaviors, thus limiting health
care funding in other areas.

How does the Christian nurse deal with these issues? How should he
treat Cheryl in this situation? First of all, Ray must keep in mind that he
and Cheryl are partners. He is not in charge of what Cheryl does. He must
give Cheryl information, anticipate potential barriers, work to motivate
and encourage her, and provide her with resources. The difficulty for Ray
will be to avoid dealing with Cheryl in a paternalistic way. He must remember, as we stated earlier, that clients may have central values other
than health, and they often do not care as much about health as nurses
wish they would. For some clients, the very real needs of food and shelter
take precedence over the more abstract and distant idea of health. For
Cheryl, the enjoyment she derives from smoking the cigarettes may well
outweigh the value she places on her own improved health. Her capacity to
experience enjoyment and delight may be so constrained by poverty and
illness that depriving herself of even this admittedly misplaced enjoyment
represents a greater sacrifice than she is currently able to handle.

Second, Ray must continue to work with Cheryl even when he sees little change in Cheryl's behavior. Ray needs to "walk with" Cheryl, and Cheryl needs to know that Ray sees her as a valuable person even if she does
not follow Ray's advice. From a practical standpoint, Ray also needs to
know the process of smoking cessation for most people. It is rare that someone would quit on their first attempt, so he should not expect this of
Cheryl. He also needs to understand the pleasure she derives from smoking
and perhaps find alternative sources of
enjoyment for her that would also bring
her delight, but without the negative
health consequences. However, even if
Ray is perfectly helpful and supportive,
in the end the choice still belongs to
Cheryl. Cheryl, as a person, has agency,
and as such she has a certain amount of
control over what she does and what
she decides. This can be frustrating to
the nurse, but it can also be freeing. It is good news that the nurse is not ultimately responsible for the behavior of his clients.

Earlier we discussed the nurse's attitude toward his or her clients, and we
must remember that even with (perhaps especially with) Cheryl, Ray's attitude must be one that reflects the awe and respect that he owes to God as Creator and, derivatively, to God's creatures. Ray's attitude may well be helped if
he remembers that "all have sinned and fallen short of the glory of God"
(Romans 3:23). None of us can begin to achieve the perfection that God demands. We are all equally in need of God's grace, Ray just as much as Cheryl.

One who has been touched by grace will no longer look on those who
stray as "those evil people" or "those poor people who need our help."
Nor must we search for signs of "loveworthiness." Grace teaches us
that God loves because of who God is, not because of who we are. Categories of worthiness do not apply. In his autobiography, the German
philosopher Friedrich Nietzsche told of his ability to "smell" the inmost parts of every soul, especially the "abundant hidden dirt at the
bottom of many a character." Nietzsche was a master of ungrace. We
are called to do the opposite, to smell the residue of hidden worth.
(Yancey 1997, 280)

As a way to help shape his attitude, Ray could spend time in prayer before
he visits Cheryl and Bob. He might ask to see this family as Jesus would see them, or to see them as God intended them to be. Ray could also reflect on
his thoughts and actions and consider the sin in his own life, so that he
walks into this situation with a clear notion of his own fallibility and his
need for grace and with a thankful heart for the grace he has received.

Grace means there is nothing
we can do to make God love us
more. And grace means there is
nothing we can do to make
God love us less.

PHILIP YANCEY

We have examined many roles of the community health nurse and have
looked at what ought to characterize the posture of a Christian nurse as he
or she practices in this realm. One final component is necessary. The
Christian community health nurse also needs an attitude of humility and
servanthood. How might this attitude be portrayed in the work of the
community health nurse? Let us look at a real-life and very complex situation.

The Miller family consists of Grandma Clara; her daughter, Cindy;
Cindy's husband, Rick; their children, Missy, Tanner, and Mandy; Rick's
daughter, Ashley, from his previous marriage; and Suzie, Clara's 24-yearold daughter who is developmentally disabled. These eight people live together in a small, three-bedroom home. Grandma Clara has her own bedroom, as do Cindy and Rick. The other five people share the remaining
bedroom and the other sleeping space in the small house. The first three to
bed get the beds in the bedroom, and the last two people take the living
room couch and a mat on the floor.

Ashley, age 8, and Missy, age 6, have been sent home from school five
times in the past month because they have head lice. The first time,
Juanita, the school nurse, sent home an information sheet on how to get
rid of lice. The second time, she sent a more detailed pamphlet that outlined how Cindy should clean her house to get rid of the lice. The third
time, she called Cindy and gave her step-by-step instructions on exactly
what she needed to do. When she contacted Cindy the fourth time, Juanita
discovered that Cindy could not afford again to buy the shampoo to treat
the lice, so Juanita obtained some from the health department and
brought it to the Millers' home. In doing so, she determined that the two
previous times, Cindy had treated only the two girls, and not Tanner,
Mandy, or Suzie, who share the same sleeping space and were also infected
with lice. Juanita instructed Cindy to treat all five people and again discussed how to clean the home properly. When the lice were discovered a fifth time, Juanita scheduled a home visit with Cindy to discuss the problem. Juanita asked if Rick could be present for the meeting, but she was
told, "Rick works two jobs, so he's never home."