Transforming Care: A Christian Vision of Nursing Practice (11 page)

Because being a person is always a matter of reciprocal interrelatedness, the giving and receiving of care flows in both directions. In our example, despite Janet's role as care-giver, she not only gives but also receives
from Ann. Conversely, despite Ann's need for care, she not only receives
but also gives to Janet. The reciprocity is not an economic exchange of
equal and comparable goods. What is given and received may well be quite
different for each person in the relationship and will depend in part on
what each needs. Nurses receive gifts of all sorts from the clients they care
for, from the gift of service as a "guinea pig" that a client gives to a nursing
student as he learns to start an IV to the gift of respect that a client gives to
a practiced, professional nurse for her expertise and experience. It would
be a mistake to think that in giving care nothing is traveling in the reverse
direction. In fact, without the reciprocal gifts of respect, gratitude,
warmth, and humanity that clients can offer, nursing would be an unattractive profession. And as scheduling pressures and lack of funds have
made this reciprocity harder and harder to maintain in acute care settings,
nursing has become more stressful and less rewarding. The problem of
mid-career burnout has clear connections to the structures that prevent
reciprocity in the nurse/client relationship.

We have described embodiment as enjoyment and vulnerability, freedom
and responsibility, all drawn together in the image of God; but this still
leaves something unsaid because it treats persons as if they were complete
at any given instant. Such a description omits the ways in which identity
involves being a character in a narrative with a past, present, and future
plot (Maclntyre 1984, 206). Ann and Janet are not abstract embodied
agents. Each of them also has a history that has determined the shape of
her character and makes sense of her choices and actions. Part of this story
is composed of the social roles into which we are born. None of us enters
society as a generic human being. We begin our lives as someone's son or
daughter, as a citizen of a nation and a member of a particular society and
civilization. Each of these roles involves expectations and responsibilities.
We enter the world as members of ethnic groups with particular languages, concepts, assumptions, rules for the proper use of humor, and so
forth, all of which constrain the shape that the story of our lives can take, while providing the necessary context within which those stories can be
told. Without membership in those larger social groupings I would have
no particular identity - which is to say, no identity at all, for identity is always particular.

To be a person is to be historically and socially situated. Each person
has a character informed by social expectations about gender, social class,
nation, race, and ethnicity as well as by assumptions about duties, rights,
goods, dangers, temptations, evils, and obligations. Both Janet and Ann
enter their interactions with each other from the midst of such social presuppositions about identity and roles. Their identities as characters, including their social roles as nurse and client, only make sense against the
backdrop of the narratives of the communities - family, society, nation,
civilization - in which they are embedded. Most of the time we simply assume that these identities exist, without paying them much attention, but
when we find ourselves working in a context where groups with critical
cultural differences must interact, we suddenly become aware of how
deeply our assumptions of identity structure our lives.

Culturally congruent nursing
care can only occur when
culture care values, expressions, or patterns are known
and used appropriately and
meaningfully by the nurse
with individuals or groups.

MADELEINE M. LEININGER

However, the social situation in which one is a character is not the
only feature that marks personal identity. One is always a character in a
narrative in two ways: first, passively, to the extent that one's life is scripted
by historical and social conditions; and second, actively, to the extent that
one affirms or rejects those conditions.
Just as independence is always relative to
vulnerability and dependence, so active
determination of the direction and meaning of one's life always takes place against
the background of social and historical
possibilities. Both Janet and Ann exhibit
this mixture of activity and passivity, albeit in different ways. Janet, we might
think at first glance, is largely the agent in
this narrative fragment, the one who has
the freedom to come into the room, actively checking diagnostic information, initiating conversation, deciding
to get the comb, and so forth. Yet she is also constrained in at least two
ways. First of all, she is constrained by the setting - namely, the institutional procedures and her workload, as well as currently accepted nursing
practices, including expectations of efficiency and thoroughness. Second, she is constrained by the person of Ann, to whom she attends, listens, and
complies. Janet's sense of herself as a nurse will be partly determined by
the response she receives from Ann. Being a nurse is an important part of
Janet's identity, so Ann's response can be quite powerful.

Ann, we might also think at first glance, is (literally) the patient, the
passive one who suffers, who receives the care that Janet gives her, who is
constrained by the rules and expectations of the particular institution she
is in, and who acquiesces to the health care system of which she is part. Yet
her request to have her hair combed shows agency, a continuing expression
of freedom. And her expression of freedom gains its meaning from the
part it plays in the continuing story of her life. We can imagine that she has
always been careful of her personal appearance, and the request then fits
into a story of continued care for propriety in the context of a world that
feels in disarray. On the other hand, Ann may be the sort of person who
goes through life with a cheerful disregard for the finer points of personal
hygiene. In that case her request has a different sort of meaning, and it may
prompt Janet to inquire whether she is expecting visitors or some special
event.

This indicates why we speak of persons as characters in a narrative.
The meaning of their actions and of the events that occur in their lives always relates back to the particular narrative structures that make sense of
what they do. For Christians, individual life stories are always embedded in
the greater narrative of God's creative and redemptive activity, a story we
learn in Scripture. And just as we come to knowledge and relationship
with God through the stories of Scripture, we also come to a knowledge
and relationship with other persons through the stories those persons tell
us of their lives.

Because people are agents, they have some control over how the story
of their life goes. Sometimes we might speak of this as being the author of
one's life, or determining how the plot will play out. But simply to speak of
authorship is too one-sided. An author of a book has total control over the
story's path or trajectory. But the person writing her or his life has only
partial control. Because she or he is constrained by circumstances and by
other people who are not under her or his control, we need to speak of the
individual as the co-author rather than the author of her or his life. A person is a character who co-authors the narrative.

Furthermore, it is as a character in a particular story that an agent
finds herself with the obligation to act in particular ways and not others. Janet's recognition that she needs to respond to Ann with respect and care,
and her understanding that part of that respect requires her to go through
the cumbersome process of leaving and then reentering Ann's room without burdening Ann with a sense of having asked too much, are shaped by
the context in which she provides nursing care. The context of a narrative
gives the actions chosen by an agent their meaning and their moral status.
Actions are judged right or wrong, wise or foolish, in or out of character
against a background composed of social practices and roles, professional
and personal life plans, and the narrative unity of a whole life (Ricoeur
1992,157; Maclntyre 1984, 205). We can evaluate how and when actions are
to be approved or disapproved, or how and when characters are to be
praised or blamed for their actions, only in the context of the stories, including the story of God's self-revelation through Scripture, of which
those actions are a part.

Very few stories are written with only one character. We've already noted
that being a person involves interdependence and openness to others, and
this is true of the stories of our lives as well. Every story has multiple characters made up of the other people in the communities of which one is a
member. We have already noted how a person's identity is shaped by the
societal and communal stories of which she or he is a part. But the fact of
communal existence brings us to another aspect of personhood as well.
Whenever there are multiple members of a community, we face the issue
of determining how the benefits, resources, and burdens of that community will be distributed among them. This points our attention forward to
Chapter Four, in which we will discuss ethical principles in more detail,
but it warrants some mention here as well.

To return to our example, Janet's competent interaction with Ann is
shaped not only by the structure of nursing practice but also, more concretely, by clients in other rooms who also are under her care. While Ann
as an image-bearer of God deserves to be treated with dignity and respect,
Janet has other clients who also are image-bearers and who also deserve to
be treated with dignity and respect. These other clients are tacitly present
in the room as Janet competently cares for Ann in her decisions about how
long to stay, whether she has time to fetch the comb, and so forth. Further more, Janet's fellow nurses on the unit also are tacitly present, as a team of
care-givers of which she is a member, in which she has to carry out a fair
share of the workload. Part of her competence in responsibly nursing Ann
is her tacit responsibility to her fellow workers to "pull her weight" on the
entire unit. The reverse is true as well. Janet must be tacitly present in the
work of the other nurses on the unit, and they must do their part so that
Janet is treated fairly and given the space to do her work well. Each of the
members of this small and fluid community deserves to be treated as a
neighbor, to be offered respect, to receive care that permits her or his life to
go well, and to experience her or his membership as a matter of equality
and fairness. What we are dealing with here, then, is a question of justice.
Justice involves structuring responsibilities and practices in ways that
make it possible to treat all members of the community fairly, with equity,
giving each her or his due.

Justice, absolute fairness, is never fully realized, of course, and decisions about equitable sharing of resources are always contestable. Even
when a care facility has rules and regulations that are intended to be equitable, to treat both clients and care-givers fairly, we might find that they
lack effectiveness or have imperfections or limitations. As we will note
when we discuss environmental factors such as the Medicare system, even
when a system is designed to contribute to justice and fairness for all the
members of that society, we might still find that it falls short in important
ways. Concrete social practices, plans, and policies are always limited, fallible, and reflective of their makers' self-deception and sinfulness.

That is not to say that all rules or regulations or practices are equally
unjust. On the contrary, the recognition that no regulations embody perfect justice does not rule out the simultaneous recognition that some regulations fall much farther short of justice than others. For example, nursing
practice is better structured when it makes care its central concern than
when it instead makes efficiency or profit its central goal. This is not to
suggest that a nurse should be inefficient or that an institution ought to finance itself into bankruptcy. However, a health care system that aims to remain solvent to facilitate care is a very different system from one that aims
for profit as a primary motive, just as being efficient in caring for others
and aiming at efficiency as one's primary goal are two different things.
And, we might say, the call to justice in the area of health care is precisely
the call to aim not at profit or efficiency, but at an equitable distribution of
competent care - money, time, staffing, equipment - so that all within the reach of the community can flourish. We will return to this question of
justice in Chapter Four, but for now we can note that being a person always
places one into the context of moral relationships that require judgments
about justice and fairness and about how we respond to the weak and vulnerable among us. For the Christian nurse, this moral dimension of
personhood is what we would expect to find, given our understanding of
persons as created by, loved by, and imaging a God of justice.

From a Christian perspective we might say that justice forms the communal horizon for particular characters whose social roles include being
health-care providers. Here we can return briefly to the discussion of embodiment, one that we have never quite left. Embodiment, as it turns out,
means many things. It means
being in a location, here and
now, being a character in a narrative. Embodiment means having relative freedom with respect
to one's surroundings, being
both an agent in the story and a
co-author of the narrative. It
means enjoyment of life, being
oriented toward well-being and
flourishing. Embodiment means
being vulnerable, not only to suffering but also to being informed by the
expectations of the community into which one is born. And it means
openness, the ethical call to responsibility in the context of community.
Justice is the shape that the ethical call takes in a communal context, as we
together engage in the social practices that allow embodied persons to care
for other embodied persons.