Transforming Care: A Christian Vision of Nursing Practice (16 page)

This is hard and demanding work. Conscientious nurses run the risk
of compassion fatigue, but they also run the risk of becoming cynical and
perhaps leaving the profession for good. Certainly the job of bringing justice into health care does not belong to nurses alone; yet, given their close
location to client care, they are in a unique
and particularly critical position to advocate
for justice. Such a task is part of the calling
faithful nurses recognize. They are not, however, called to change all aspects of their
world single-handedly. Part of our recognition of the nature of persons as interdependent involves recognizing that when we act as
agents of renewal, we act as members of a
community.

And so attentiveness to the various aspects of environmental features
of nursing practice brings the Christian nurse to an awareness of responsibilities that go beyond competent care for particular clients, requiring more
broadly based advocacy and political activism. These responsibilities are
not always recognized as a part of the nurse's vocation, but a concern for client well-being makes it impossible to ignore them. Nursing associations
have gained a more powerful and respected voice in public affairs in part
because they are in a position to speak to these environmental issues with
clarity and specialized knowledge. Recognition that environmental factors
are human constructs and that they have a history of development provides
a measure of hope for the Christian nurse, because what has been constructed can be reshaped in ways that make it better and more in line with
how things ought to be. Further, the compassion fatigue we mentioned earlier is often a result of social structures that make the provision of adequate
care impossible. When we shift our attention from the impossible circumstances in which people try to function, focusing instead on how the sys tems within which they live create those circumstances, we can sometimes
see solutions that were not apparent from the individual perspective.

Respect for life ... necessarily includes responsibility for the standard of
living conditions.

KARL BARTH

This discussion of large-scale social change may still seem to demand
too much of a nurse, however. "I'm working too many hours on an understaffed floor, and you want me to be a political activist, too?" a nurse might
say. "Give me a break!" And the nurse could very well be right. It is important to remember that as Christians we understand our lives in terms of
vocation, in terms of being created by God for good works, called to participate in the works of God's kingdom in some specific ways. This notion
of vocation is an important one for understanding our roles in bringing
about social change.

My vocation is the job I am called to do. In order to do it, however, I
have to recognize that there are lots of other things, important and worthwhile things, that I cannot do. I have to trust that God will provide others
whose vocations call them to work in those areas. Not all nurses are called
to be involved in bringing about social change. Many nurses are called to
be God's representatives in very specific locations, bringing warmth and
respect into the context of a psychiatric unit, for example. As Christians we
need to recognize and respect the limitations each of us faces in trying to
carry out what God has called each of us, specifically, to do.

This notion of a limited vocation can be a double-edged sword, however. We may be tempted to exploit it when challenging problems appear
in front of us. We see the need for social transformation, but it is a daunting task, and it's much easier to turn away and focus only on the job immediately in front of us. This can be a real recipe for compassion fatigue:
knowing that the system needs to be changed, but refusing to do anything
about it, we then find ourselves frustrated and overwhelmed and are
tempted to take out those frustrations on the people in front of us. But
then the clients, who are already burdened with their own health needs
and overwhelmed with their own struggles with a difficult institutional
system, are likely to bear the brunt of our frustration as well.

If a nurse cannot help but see how the system is badly structured and
cannot escape the frustrations and anger this can cause, that may be an indication that God is calling that nurse to action. The call to a vocation very
often comes through exactly this sort of inability to turn away. We need to
recognize our own limitations of time, energy, and capacities. But we also
need to keep our ears open for the call of God when it comes through our
ability to see what needs to be changed and how to change it.

Each of the metaparadigm concepts that structure an understanding of
what nursing is - nursing, health, environment, and person - is dependent on the others. We cannot define nursing without making reference to
health, since nursing is a practice whose identity is constituted, in part, by
its goal of providing health care. Further, the nature of nursing practice is
determined in part by the social structures that make up the environment
within which nurses practice. Making an assessment of health requires an
understanding of the environment within which a client functions (or is
unable to function), and it requires some sense of the stories in which the
client plays a role so as to judge how a given condition affects that client's
well-being.

For the Christian nurse, each of these concepts reflects some aspect of
the theological framework that structures her or his understanding of human life. The nature of nursing is focused by an understanding of the client as a bearer of the image of God. Our understanding of the concepts of
health and environment are partly structured by the notion of shalom and
partly structured by an awareness of sin and brokenness. In all of these
ways, the Christian nurse can experience nursing as a practice structured
by, and responsive to, a relationship with a loving Creator. But we have also
noted that some of these concepts, particularly the concept of person, have
an in-built orientation toward certain ethical issues. In the next chapter we
will turn to an examination of those ethical issues, focusing on the two
concepts that appear in this chapter with regularity: care and justice.

When Sheryl walked into the staff lounge she knew it wouldn't be a relaxing place to take a break. Annette, one of the older nurses on the floor, was
arguing heatedly with Tanisha about recent administration decisions.
"They can't just change our hours!" Tanisha was saying. "We have a contract that says if we agreed to work four twelve-hour shifts every week,
then we get weekends off. I signed it, and so did you. If the administration
wants to start requiring weekends, then we should go on strike. It isn't fair
for them to just dismiss the contract they agreed to!"

"But we can't go on strike," Annette responded. "That's going to hurt
the clients more than the administration. Besides, we're nurses. We got
into this profession because we care about sick and hurting people. I don't
mind starting to work weekends again - I've done it before, and I suppose
I can start doing it again."

"I can't," Sheryl said flatly. "I've made arrangements for child care during after-school hours, and I can't just change those. And I can't afford to
start paying $4 an hour per child for three children on weekends for
twelve-hour shifts. It's not as if my pay has been going up fast enough to
cover extra costs, and I can't just change my schedule."

"Well, you may not have any choice," Annette said sharply. "We're
nurses, not doctors or administrators. We don't make the rules around
here, and we don't have much say about who does make them. Besides, if
we don't fall into line, it isn't the administration that suffers, it's the clients.
They're the ones who will pay if we try to organize any sort of protest. We
have responsibilities to them to make sure their care isn't compromised,
and we can't do that if we act as though this is just another job."

Tanisha rolled her eyes. "Yep, we should just roll over and let people
walk all over us, 'cause we're nice girls. It's slavery all over again," she said
sarcastically. "Come on! We're professionals, and we deserve to be treated
with respect. And we also have other responsibilities - kids, elderly parents who depend on us. It would be wrong to let the administration think
it can treat us this way. We need to defend our dignity."

Sheryl sat down and sighed. She'd just heard a sermon in church on
the responsibility of Christians to be servants of all and to treat others with
self-giving love. But it seemed wrong to equate accepting unfair labor
practices with Christian service. At the same time she knew that a strike
would affect client care. She wondered how hard it would be to switch
jobs.

When Sheryl asks herself what she ought to do, what choice she should
make, she is doing ethics. How she makes that choice - what principles
she acts on, what good she strives to realize - will depend in part on what
sort of person she is and how she interprets her circumstances. As we have
seen in previous chapters, her Christian faith will qualify and shape both
her personhood and her perspective. But it will also shape her values.
Christian faith qualifies the very principles on which we act. Throughout
this chapter we will look at two values that guide our action and that
emerge from within the Christian faith.

Before we turn to an examination of how Christian faith shapes our
values, though, we need to think a bit about what it means to do ethics. We
sometimes think that ethics is solely a matter of major, controversial issues: abortion, euthanasia, and cloning, for example, tend to be the big
items in many ethics textbooks. But much of ethics is a matter of day-today interactions, lower-level choices, and conflicts that can add up to cumulatively important issues. The issue of staffing in our case study is a central moral concern for many nurses today. And it is an important issue, as a
researcher at Michigan State University recently showed. She discovered
that many nurses' understanding of their jobs is marked by what this researcher calls "moral distress." The term refers to the feeling many nurses
experience of being unable to give adequate care to their clients because of
staffing cuts, an increase in the severity of the conditions in the clients they care for, and a constant increase in the number of clients they are assigned.
The nurses feel they can't give adequate care, and they feel trapped in a situation of moral complicity with a system that is morally problematic, or
even morally evil. But the situation can't be solved by working harder or
more efficiently, so the nurses feel that they have no solution. They can offer substandard care, or they can leave nursing, a career they have been educated for and worked at for a significant portion of their lives (Andre
2002). Moral distress seems an appropriate name for this feeling of being
trapped in a no-win situation.

This problem is a systemic one, not an issue of inadequate moral resolve on the part of the nurses involved. In a similar way, the dilemma that
faces the nurses in the dialogue with which we began is a dilemma about
how individuals should understand their roles in the context of a larger
system that seems to place unacceptable burdens on them. We need a way
of thinking about ethical problems that allows us to recognize, understand, and respond to the full range of problems nurses face, and that is the
goal of this chapter. The chapter will not spend much time on the standard
ethical cases that fill so many ethics textbooks. Abortion has been well analyzed by countless scholars, and nurses do not need one more rehashing of
an already over-discussed issue. This chapter instead is aimed at offering
tools for thinking through what an ethical issue is, how one can analyze it,
and how to respond to it in ways that are effective and not self-destructive.

We normally think of needing ethics (at least, in this narrow sense of
needing to make a choice) only when a disagreement arises, or when consensus about what is good or right has broken down, or when multiple desirable outcomes conflict with one another, or when one senses the wrongness of a situation. If everyone agrees and the right thing to do is clear,
then there is no quandary that prompts us to "do ethics" in this narrow
sense. This is true of standard ethical problems such as abortion and euthanasia, and it is equally true of the ethics of the everyday.

Nurses know when something is wrong with the system of which they
are a part (Chambliss 1996, 117). That wrongness sometimes manifests itself in the difficulty they experience offering adequate care and in the tension they feel between their responsibility to be client advocates and their
need to get through their work in a reasonable amount of time. They
sometimes find themselves feeling like one very small and impotent gear in
a huge machine that slowly grinds up the people and things they value.
And although almost all nurses have a deep sense of responsibility, they of ten have no clear sense of how the situation could be changed. This seems
to leave nurses with only two options: either work in the system and risk
becoming complicit in the destruction it causes, or leave nursing altogether. It is not surprising that a researcher discovers moral distress.

But neither complicity nor giving up the work that one is called to do
is really a satisfactory answer. In this chapter we will think about whether
there might be an ethical framework that can help us think through such
situations and come to more satisfactory solutions to them. We've already
begun to develop such a framework by offering an analysis of the foundational concepts in Chapters Two and Three: nursing, the person, health,
and environment are crucial for understanding the practice of nursing itself. But by themselves they cannot offer full-blown moral guidance in
thinking through the sorts of moral dilemmas nurses face on a regular basis. Each of these concepts deals with a central and important part of nursing practice and life, but none, by itself, can tell us how to balance conflicts
between, say, a concern for health and the need for a strong professional
organization.