Transforming Care: A Christian Vision of Nursing Practice (9 page)

Nursing is a learned profession - that is, it is a science
and an art.

MARTHA E. ROGERS

As is often the case, the very characteristics that are the strength and
pride of nursing can sometimes also contribute to problems in nursing. As
sociologist Daniel Chambliss notes, the knowledge and professional education of nurses makes it hard for them to be understanding toward clients
who choose to remain ignorant about their own condition and who make
choices that seem trivial and silly from the perspective of a health professional (Chambliss 1996, 124). The very virtues of professional education
can make it hard to avoid treating such a client patronizingly. It remains a
challenge for the contemporary nurse to discern when the characteristics
that are inculcated by contemporary nursing sometimes create blind spots.

No one had ever understood what the illness meant to this woman before, and the
understanding was [a] great gift, because
it moved back the walls of isolation and
suffering created by the disease. In our
strategic, instrumentally oriented culture,
we overlook the human importance of
understanding. Understanding can be
therapeutic or healing even when there
are no possible instrumental interventions,
because illness can cut the person off
from self-understanding and familiar relationships.

PATRICIA BENNER AND JUDITH WRUBEL

But the identity of a nurse is formed by more than just the education
she or he has received. It is also the case that the practice of nursing shapes
who someone is in important ways. We (the authors of this book) had an
interesting example of this as we met to begin writing. One of the philosophers in the group mentioned that health care practitioners tended to assume
automatically that physical
health is an individual's
highest priority in making
life decisions, while philosophers might sometimes be
more concerned about logical consistency than health.
The remark occasioned a
certain amount of amusement among the nurses, and
several of the nurses thought
that this showed just how irrational philosophers really
are! If this sort of assump tion is true, then becoming a nurse is likely to shape one's character in
deep and important ways. When one becomes a health care professional,
one devotes one's life to the pursuit of human health in general, and health
then becomes one of the central values of one's life. This good of health,
however, is not the only one that a person can value, and many people do
not consider it to be so central. Like the philosopher mentioned earlier,
they may have a different set of goods that structure their lives.

So in addition to encouraging the development of particular character
traits such as responsiveness, nursing also will tend to structure the basic
set of values a practitioner holds. In this way, it is a practice that shapes the
professional's life and values in central and important ways. It is important
to see this so that nurses (and other professionals) recognize that what
they value most highly may not be the central concern for others. But it is
also important to see this because it allows the nurse to examine her or his
values critically and to reflect on whether those should be values that
shape her or his life. The Christian nurse may occasionally find that she or
he needs to place the value of health in its proper perspective as a very important good, but not the ultimate meaning of life (Mohrmann 1995,15)

Up to this point we have been discussing the nature of nursing education and the relationships nurses have with clients. Nurses work in a context that shapes and structures that relationship because providing nursing
care always occurs in an institutional or organizational context. A Christian perspective does not end when one moves from personal to institutional contexts, so it is worthwhile to think about how faith shapes our understanding of the systemic and organizational aspects of nursing practice
as well. In the next section we'll focus on two features of institutional organization. The first involves the connections between central values of the
nursing profession and institutional values. The second examines connections between the nurse's professional responsibility and the professional
responsibility of the other actors in the institutional setting.

Nursing is a profession that involves the organization of certain caring
tasks in society. The social organization of these tasks is vital, since the education of nurses, their licensing, and the structure and responsibilities of
their jobs are decided collectively. Imagine the chaos society would experi ence if individuals had to find their own care givers before they entered the
hospital, negotiate wages and working conditions, evaluate competency,
and ensure compliance. Hospitalization would be an even more harrowing
experience than many find it to be now. Organizing nursing care needs to
be done at a professional level so that competent care is provided in a regular, continuing, and efficient manner. And because this is accomplished
through professional organization, nurses can monitor themselves to a
large degree. This is one of the hallmarks of professionalization, and it is
also the reason why many professional organizations require members to
take an oath or pledge, making a public promise that they will use their
knowledge and skills for the well-being of those who call on them (Koehn
1994, 56-59). The professional organization of nursing practice is built into
the contemporary health care system.

This both shapes and constrains nursing practice in important ways.
One obvious way it shapes nursing practice is by providing both the financial structure necessary to offer nursing care and the financial limitations
of providing that care. Without institutional structures, even the structures nurses complain about most (insurance companies! government
agencies!), there would be no consistent way to provide the care that makes
up the heart of nursing practice.

As Christians, we may be tempted to become cynical at this point,
mutter "render unto Caesar," and pretend that financial issues have no relevance to Christian life and thought. But ignoring the financial structures
of contemporary nursing is a mistake. Nursing practice is fundamentally
affected by economic structures, whether at basic levels of staffing and salaries or at more general levels of what treatments are funded for which clients. And because nurses are the health care professionals most constantly
involved in the day-to-day care of clients, nurses often find that they have
to explain to clients what insurance will or will not cover; they may even
negotiate with insurance companies as to what, exactly, is meant by a term
such as "life-threatening."

Given this central role for the nursing profession as a whole, then, it is
vital for nursing to be vocal in advocating for financial structures that support rather than prevent good care. But what does this mean for the Christian nurse? We will discuss issues of social justice at greater length in subsequent chapters, but it is worth noting here that an important part of
being a professional involves active participation in shaping the organizations of one's profession. Christian nurses have a responsibility to partici pate in productive ways in professional organizations, to speak out on issues on which they have expertise, and to contribute to the internal
development and growth of the profession.

Participating in professional organizations, while important, is not the
most obvious aspect of institutional structures that the nurse confronts on
a day-to-day basis, however. The organization that structures the nurse's
life in ways that can be both rewarding and frustrating is the health care
campus within which much care is given. For the acute care nurse, and
some types of mental health nursing, this may be the site of professional
practice. For the parish nurse this may be the location where clients are
sent for care, from which they come needing arrangements for home
health care, and the like, but few nurses work in contexts where their practice is not structured by the demands of the health care system.

Working in the health care system also involves working with other
health care professionals: physicians, technicians, aides, and administrators. The complexities of the nurse/physician relationship have been noted
by many researchers and cannot all be examined in detail here, but a few
aspects are worth noting in the context of considering how Christian faith
influences nursing practice. Nurses often find themselves in a frustrating
or difficult situation due to the organizational role they play as mediator
between client and physician (Engelhardt 1985, 62-79). The frustrations
that can accompany this role are described and analyzed in some of the
later chapters of this book, but a few general comments are worth making
here.

First, the Christian nurse has a sense of confidence in her or his role.
Nursing involves advocacy for the client, often the most vulnerable and
weakest individual involved in any controversy. The use of professional
status and knowledge for the benefit of the vulnerable is one important
part of the Christian life, and the nurse occupies an institutional role that
allows her or him to do this. Further, a Christian perspective can give
nurses a sense of freedom from some of the status fights that often go on in
the health care setting over who has the authority to do what. From a
Christian perspective it is clear that what is central is that good care be
provided in ways that are consistent and fair. Work that involves dealing
with the less pleasant aspects of embodiment and sickness are not, from a
Christian perspective, inherently demeaning or lower in status. In fact, Jesus specifically names caring for basic bodily needs as the service that is
proper to those who would be his followers. Recognizing this, the Chris tian nurse operates from a position of confidence in negotiating with
other professionals. What he or she does is important and worthy of respect. If others consider it less valuable because it sometimes requires getting messy, then that reflects badly on others' values.

It is important to be clear about what this does not imply. Being a
Christian nurse does not require the nurse to give up on basic claims of justice or to cheerfully accept mistreatment or abusive relationships. The
knowledge that one is a beloved child of God should always provide a sense
of confident expectation that professional relationships will be structured
fairly and in ways that protect the basic dignity of everyone involved. We
consider some of the aspects of justice with regard to institutional structures in Chapter Four and will say more on this topic later. But the point to
be made here is that when nurses are involved in work that others may be
tempted to dismiss as "mere service work" or as unimportant because it involves hands-on care, nurses can confidently reply that this work is central
to human life and well-being. It is not menial; it does not deserve disrespect; and those who do it deserve societal gratitude and a fair salary.

Noting that organizational structures sometimes treat hands-on, caring work as trivial or unimportant provides an important transition to our
next topic. What is it that allows the Christian nurse to see such labor as
valuable and worthy of respect? In part, the Christian nurse can draw on a
Christian understanding of what it is to be a person. The Western tradition
has tended to define persons in terms of independent existence and rational intellect, while downplaying or ignoring their embodied, emotional,
interrelational nature (Benner and Wrubel 1989, 29-54). It can be easy to
see caring for bodily needs as a mark of subordination in part because we
do not always value or respect our embodied nature. As Christians we have
resources for seeing persons in another way, however, and seeing them in
that way gives us better insight into what nursing itself is.

In the previous chapter we met a nurse, Janet, whose client, Ann, suffered
from congestive heart failure and edema. Being a competent nurse, Janet
took diagnostic information with practiced hands and showed genuine
concern for Ann by greeting her warmly and honoring her request to have
her hair combed despite the complications this made for Janet.

The story of Janet and Ann suggests that an adequate picture of human persons starts with the notion of embodiment: persons are bodily beings. Nursing practices, from the taking of diagnostic information to
combing hair, demonstrate the bodily character of the persons involved
and the interactions between them. Embodiment involves both independence and dependence related in interesting ways. A full understanding of
what it is to be a person requires us to go beyond embodiment and recognize that persons are created in God's image. In turn, this leads to understanding persons as characters in a narrative, co-authors of the stories in
which they are embedded. We'll deal with each of these three concepts -
embodiment, the image of God, and the narrative structure of human life
- in the sections that follow.

We'll begin with the idea of embodiment. To say that a person is embodied
implies two things about being a person. The first is subjectivity, the sense
of being a concrete, particular "I," someone who is able to consciously experience her or his life. The second is wholeness. We sometimes elaborate
this by saying that a person is an integral unity of a variety of interrelated
dimensions: physical, emotional, mental, social, moral, and spiritual.
Wholeness and subjectivity are connected to each other. The unity or
integrality of being a person is what makes it possible for someone to
speak of himself or herself in the first person, as an "I." We sometimes call
this concrete unity of being subjectivity, or being a "subject."

These two notions of unity and subjectivity are central components of
being a human person, but when we start with them we run the risk of implying that all persons have this sort of wholeness and sense of self. This
clearly isn't true. Some people lack any sense of self, perhaps because they
suffer from Alzheimer's or some other cognitive dysfunction. Others lack
physiological wholeness because their bodies have been ravaged by disease
or they've been badly burned. So how do we maintain our sense that being
a person involves wholeness and subjectivity, while recognizing that some
persons lack both of these to some degree? What we need to recognize is
that wholeness and subjectivity are part of the way humans are supposed
to be. When we recognize another as a person, we recognize that both of
these features should be attributes of his or her life. One of the aspects of health that nurses often work toward is the restoration of wholeness and
subjectivity when these have been diminished by disease or accidents. In
some cases we deal with persons who will never gain or regain these capacities, as when we work with people with severe developmental disabilities.
In such cases we recognize the capacity only in its absence, and this can be
cause for lament.