Transforming Care: A Christian Vision of Nursing Practice (7 page)

So what should our response to this suffering be? Should we assume
the cowering posture of a slave who hopes the master will be merciful?
Should we bargain our way toward a better life, promising to be good in
hopes of reprieve? Should we lie to ourselves and say that God never gives
us more than we can handle? Or that suffering is good because it gives us a
chance to develop character? Or that we would not call it suffering if we
could see the big picture? The Bible, especially in the Psalms and Lamentations, proposes a different response: lament. The book of Lamentations
was written during a time when the Babylonian army had besieged and
then destroyed the city of Jerusalem. Thousands had been killed. Thousands more were starving. Here is part of what Jeremiah said:

The LORD has done what he purposed,
he has carried out his threat;
as he ordained long ago,
he has demolished without pity...
Cry aloud to the Lord!
O wall of daughter Zion!
Let tears stream down like a torrent
day and night!
Give yourself no rest,
your eyes no respite!
Arise, cry out in the night,
at the beginning of the watches!
Pour out your heart like water
before the presence of the Lord!
Lift your hands to him
for the lives of your children
who faint for hunger
at the head of every street.
Look, 0 LORD, and consider!
To whom have you done this?
Should women eat their offspring,
the children they have borne? Should priest and prophet be killed
in the sanctuary of the Lord?
The young and the old are lying
on the ground in the streets;
my young women and my young men
have fallen by the sword;
in the day of your anger you have killed them,
slaughtering without mercy.

(Lamentations 2:17-21)

Notice that Jeremiah addressed these laments, not to the Babylonians, but
to God. It is to God that Jeremiah says, "you have killed them, slaughtering
without mercy." He encourages the people of Jerusalem to "cry aloud" and
to "lift your hands to him for the lives of your children." Ultimately, he
held God responsible for the suffering, and he protested that suffering to
the powerful God whom he knew as the only source of hope for renewal
and restoration. The lament does, in the end, look to God for restoration
and comfort, but not before it first raises its complaint. It does not gloss
over that suffering in its recognition of God as the source of life and hope.

Most of us are unaccustomed to the lament and uncomfortable with
the idea of raising a clenched fist to the God who made us and who can
unmake us. But consider what freedom the lament offers and what is lost if
we deprive ourselves of it. Lamentation gives us space to voice the very real
pain and suffering that we experience. It does not demand that we face all
of life's trials with an unrealistic piety that expects joy at every turn. Lamentation gives us permission to lay our troubles at the feet of the One who
is powerful enough to do something about them. Lamentation tells us that
anger with God can be appropriate and that God is "big enough to take it"
if we need to shake our fists and cry out in rage. Even Jesus, while suffering
indescribable agony on the cross, lamented. His lament was directed, as
was Jeremiah's, to God the Father. He cried out, "My God, my God, why
have you forsaken me?" (Matthew 27:46). Why have you abandoned me in
my suffering? Where are you? This is the human cry of lament.

Lament does not end with anger and gall. It moves us toward peace
without offering any false or easy solutions. Jesus cried out the beginning
of Psalm 22 as he was dying on the cross, but that psalm concludes with the
confidence that God will bring deliverance. Similarly, Jesus himself, after
uttering these words of lament on Good Friday, greeted his disciples on Easter Sunday with "Peace be with you" (Luke 24:36). Deliverance had
been won. Only someone with a sense that the world is not as it should be,
only someone with faith in a God who cares about suffering, would bother
to raise the lament. It is precisely a person of faith's confidence in God's
goodness and power, in other words, that makes the protest of the lament
possible.

Nurses are witnesses to some of humanity's greatest suffering. As witnesses they are the ones who observe and who can testify to the reality
and meaning of that suffering. This is the true sense of nursing as a Christian witness. Nurses care for people who are fearful, in pain,
lonely, confused, and vulnerable.
And it is not simply individual
human suffering that affects the
nurse. The inadequacies of our
health care system, which asks
health care providers to do too
much with too little, the social
structures that make that health
care inaccessible to a significant
portion of the population, the hierarchical mindset that can relegate the nurse to the status of mere servant - all are cause for lament. It is simply inhumane to expect nurses always to offer comfort without also providing some means by which they
can vent the very natural frustration and anger that accompany this form
of work. We ask nurses to be something other than real and full persons
when we expect them to deal with suffering day in and day out without
ever raising questions about it or being hurt by it themselves. This experience of being confounded by evil forms an important part of the nurse's
religious consciousness, and we cannot ignore it if we are to develop an
adequate theological reflection on nursing practice.

A casual observer watching Janet comb Ann's hair might not see what we
have just seen: that this simple act emerges from, shapes, evokes, sustains,
and expresses certain forms of religious awareness in Janet (and perhaps in Ann, too - but an analysis of that is not our focus here). On the one hand,
experiences of working toward the restoration of health and of caring for
suffering evoke in Janet an awareness of the goodness of creation - a
sense of delight in the world God has made, confidence that we were made
for this world, and gratitude that it is the realm in which we find meaning
and purpose. On the other hand, those same experiences simultaneously
evoke in Janet anger and frustration not only with the structures of human
sinfulness but also with the very fact of our finitude and the pain and tragedy that accompany it.

0 Lord our God, we see in a mirror
darkly. But we see there the face of
your Son, who suffered for us.
Though faith fails and hearts sink,
we know that he has led the way
through suffering to a peace that
passes understanding.

CORNELIUS PLANTINGA

These forms of awareness are ultimately religious in nature because
they concern our basic orientation toward God and God's world. If we excavate the Christian nurse's concerns, we discover that beneath the layers of
thought about efficiency, technique, procedures, scheduling, and evidencebased practice rest an abiding conviction that Christians, having been
claimed by God, are called to lives of grateful service and a persistent disposition of reverence, awe, and respect. These forms of awareness, in other
words, situate us in the world as certain "sorts of persons" (Gustafson 1975).
Certain experiences, certain practices bring about particular forms of
awareness, and, over time, these settle down into a person and become
more than mere fleeting feelings or passing thoughts. They become abiding
convictions and settled dispositions. In other words, they form us as persons. These forms of awareness become the shape of who we are as Christians and as Christian nurses. Now we see our clients in a new light. Now we
interpret and respond to their suffering and joy in distinctive ways. Now we
see in them and through them the presence of the divine.

Gustafson uses the term piety to characterize this orientation toward
God and God's world. Many Christians have negative associations with the
term, but Gustafson attempts to rescue it from the misuse that causes these
associations. "Piety," he explains,

is not a transient emotion, though consciousness of piety ebbs and
flows with circumstances. It does not refer to piousness - the kind of
sanctimoniousness that lends itself to caricature in novels, films, and
drama; or to intensity of religious emotion. It is a settled disposition, a
persistent attitude toward the world and ultimately toward God. It
takes particular colorings or tones in particular circumstances, but
awe and respect are the fundamental and persisting characteristics of
piety. (Gustafson 1981, 201)

What we seek in this book is to explore the "particular colorings or tones"
that Christian piety takes on in the "particular circumstances" encountered by nurses in their professional practices. This is quite simply an exploration of what it means to be a Christian nurse. Or, as we explained in
the Introduction, it is an exploration of who the Christian nurse is, more
than it is an explanation of what Christian nurses do differently from other
nurses. What "sort of person" is the Christian nurse?

Being a Christian nurse is not only about what one does but also about
who one is. So who are nurses? How do they become the sorts of persons
who are suited to nursing practice? What kinds of contexts shape their
work? What kinds of assumptions do they make about what it means to
pursue and promote the health and well-being of their clients? In many
ways, Christian nurses will find that their assumptions about the nature of
nursing practice, or health, or the like are shared with non-Christian
nurses. We share a common created nature and should expect to find such
agreement. But there are also ways in which the perspective of the Christian nurse enriches or deepens his or her understanding of these foundational concepts, and it is important to note this as well. Christianity qualifies and shapes the people who become nurses, the ways in which they
interpret their circumstances, and the values that guide their actions. In
this chapter we examine more specifically how it does so.

It is common in introductory nursing textbooks to refer to four concepts that are foundational for understanding professional nursing practice. These are sometimes called the four defining or "metaparadigm" concepts, namely: nursing, person, health, and environment. This chapter offers
a fresh and distinctively Christian interpretation of the foundational concepts of nursing and person. These two basic concepts are then situated in
the next chapter in terms of a Christian understanding of health and environment, the second pair of metaparadigm concepts of nursing theory.

If we went out and asked most nurses what it is that they do, they would be
likely to answer in terms of specific kinds of nursing. "I'm an acute care
nurse," one might say, "with a primary specialization in ICU nursing." Or
"I'm a visiting nurse with a Hospice program. I do a combination of community nursing and end-of-life care in the context of a Hospice setting."
Or "I'm a nurse in an Ob-gyn practice where I do client education." If we
pressed a bit harder, these same nurses might go into more detail in terms
of the specific techniques and practices involved in their work, whether
monitoring client status in the ICU or working on pain management techniques with clients facing terminal illness. And of course these are all accurate descriptions of what a specific nurse might find himself or herself doing in a particular nursing role.

But we might be asking a slightly different question here when we ask
what nurses do. We might be asking less about the actual specifics of a particular aspect of nursing and more about what it means to be a nurse. That
is, we might be asking questions about what it is that makes nursing a specific profession, rather than a subset of some other profession (such as
medicine or social work). And we could also be asking questions about
what the ideals of nursing are, both in terms of the profession as a whole
and in terms of the practitioners. Every profession has some sense of what
it should be and what its practitioners should be like, and though the ideal
is generally not realized in every particular, it nonetheless shapes the way
professionals understand themselves and their identity.

When we ask questions of this sort, we are treating nursing as a social
practice. That is, we are thinking of nursing not just as a job someone
might have but as an identity in some sense. For the purposes of this book,
we will be defining nursing as a social practice, oriented toward a holistic
understanding of health, practiced by professionally educated and licensed
practitioners. As is the case with almost any profession, undergoing education and becoming licensed as a nurse involves more than just passing certain courses and being able to answer certain questions on exams. Becoming a nurse is a process of professionalization that partly defines one's identity as a person and that shapes one's character in important ways.
When I am introduced to someone and ask what he does, if he tells me that
he is a nurse I am likely to make certain assumptions about what sort of a
person he probably is, and many of those assumptions will turn out to be
correct.

This notion of a social practice is one that has been developed and analyzed by the philosopher Alasdair Maclntyre, and it has been enormously
influential in thinking about how we organize social life, how we understand identity, both of self and other, and what it means to be a particular
kind of person. Maclntyre's account of a social practice is helpful for
thinking about what nursing is and about how nursing as a profession
shapes the identities of nurses, so we will borrow certain aspects of it for
our discussion here. Maclntyre's definition of a social practice reads as follows:

By a "practice" I am going to mean any coherent and complex form of
socially established cooperative human activity through which goods
internal to that form of activity are realized in the course of trying to
achieve those standards of excellence which are appropriate to, and
partially definitive of, that form of activity, with the result that human
powers to achieve excellence, and human conceptions of the ends and
goods involved, are systematically extended. (Maclntyre 1984,187)