Transforming Care: A Christian Vision of Nursing Practice (24 page)

Alongside situations like Lydia's, other taxing issues surround psychiatric-mental health nurses in practice. Many health care professionals experience "vicarious trauma" resulting from their work with trauma clients
(McCann and Perlman 1990). Some health care professionals may endure
pervasive and cumulative psychological consequences due to their exposure to the traumatic experiences of their clients (Robinson et al. 2003, 34).
Some of these psychological consequences include a diminished sense of
safety, trust, control, and connection with others as well as disillusionment
and despair (McCann and Perlman 199o). Another fear of most psychiatric-mental health nurses is that of the suicide of one of their clients. Joyce
and Wallbridge describe the effects of client suicidal behavior on nurses as
stress, sadness, shock, fear, anger, guilt, devastation, physical and emotional exhaustion, and a sense of failure (2003,18-19). Still other nurses are
involved in the treatment of clients who engage in acts of deliberate selfharm without suicidal intent. These clients typically cut and burn themselves as a method of managing their intense emotions. Nurses frequently
respond to these clients with a sense of unease as well as irritation and anger at what is often considered to be manipulative behavior (Perseius et al.
2003, 218). Any one of these situations might be considered overwhelming
for those in another type of work. And yet, the nurse may encounter clients with persistent mental illness, trauma, suicide, and self-harm issues all
in the course of one day in practice. How does one survive this emotional
onslaught?

We have spoken of illness as an occasion for individual and communal
lament. Psychiatric-mental health nursing involves constant encounters
with brokenness and mental illnesses that are certainly compelling occasions for such lament. Lament offers the Christian nurse freedom to voice
the pain and suffering that are encountered in practice. While this catharsis is critical, perhaps the larger question becomes: Is the concept of lament sufficient to enable these nurses to continue their care-giving efforts
despite the intense psychological burden? In order to explore this question,
we must consider both this freedom to voice our pain before God and the
aspect of lamentation that allows us to lay our troubles at the feet of the
One who is powerful enough to do something about them. Having resisted
the temptation to gloss over the suffering that is so evident in the lives of
her or his clients, the nurse can still find peace. While not offering a "quick
fix," lament can move us toward reflection on the fact that God's hand is in
the lives of these individuals. It can allow us simultaneously to grieve about the devastation that persistent mental illness or trauma brought
about and also to be convicted that God is a God of goodness and power
who will, in God's own time, make all things new. Lamentation allows
nurses to be fully human as they engage in their practice. Nurses need not
detach themselves from clients and their pain in some sort of artificial attempt to maintain objectivity or to protect themselves. On the other hand,
the pain of human suffering encountered by nurses on a daily basis need
not be immobilizing. Rather, lamentation offers nurses the opportunity to
engage, to feel, and ultimately to give the pain that surrounds them to the
sovereign Creator who can sustain and renew them.

Thus, lamentation in essence moves us toward hope. And this hope is
more than mere wishful thinking. Where might we find ground for hope
in the practice of the psychiatric-mental health nurse? Of course, we embrace the hope that is inherent in client improvement. Consider Lydia's
hope-filled story as told by her mother:

Lydia now has a full time job at the Clubhouse. What a blessing after
SSI and monthly disability forms! Lydia has had many responsibilities
at the Clubhouse including driving the van, managing the kitchen, and
now serving as the receptionist. Lydia's job includes medical benefits
- such a victory after Medicaid and hunting all over for doctors that
would accept this - and provides the opportunity to put money into
an annuity for her future. She applied and was accepted into a Masters
program in social rehabilitation where she will take evening courses.
Lydia received a scholarship from the University to support her studies. Lydia has never given up! Our dream was that she would rise above
her illness and live a full and productive life and she is doing just that! I
am so very proud of my daughter Lydia! God has kept her in his sight
all these years and she has a faith in the Lord that never wavers.

What about people whose outcomes are not so glowing? In the cases
where there are only small, almost imperceptible victories, we can still find
hope. Lament allows us to acknowledge the suffering and pain but also to
recognize the sovereignty of our God over our fragile practice of nursing
and the clients whose lives we touch. We can find reassurance and hope in
the fact that it is not ours to "fix" these individuals, but rather it is ours to
be faithful to the work to which we have been called.

Perhaps the Christian community has a role to play in supporting nurses in their expressions of lament as well as their efforts to be faithful to
the work that constitutes their calling. Fostering faithfulness may occur
more naturally in community than in isolation, and it may well be a communal responsibility rather than simply something that the individual
nurse needs to work toward alone. If this is the case, the issue then becomes whether or not there is space in the Christian community for nurses
to go, share their stories, and be fortified for a return to their practice. The
contours of this space may be numerous and varied. Christian professional
nursing organizations may play a vital role as well as the institutional
church.

So what are the reasons of the heart and mind for engaging in the practice
of psychiatric-mental health nursing? This practice offers very clear opportunities to address the business of the kingdom and to engage in a life
of Christian service. On an ongoing basis we are given specific and concrete opportunities and challenges in which we might work for shalom -
the pursuit of justice, harmony, and delight among God, human beings,
and all creation (Plantinga 2002,139). We are privileged to serve those who
are marginalized and disenfranchised, but who in their marginality give to
us far more than we give to them. We have daily opportunities to touch individuals, families, and communities as well as entire systems with an eye
to moving them closer to that which God intended. In other words, psychiatric-mental health nurses need waste little time in identifying kingdom work - it awaits them each day in their practice.

John and Joyce are two nurses who often work at the same retirement village. John, a home health nurse, is employed by a local hospital in their
home health division. Although his clients are drawn from all over the city,
he often finds himself caring for people at the Oakcrest Retirement Village,
which is located near the hospital. His job includes changing dressings, administering intravenous medications or fluids, coordinating discharge
plans for residents who are returning from the hospital or a rehabilitation
facility, and assessing whether or not clients are making a good adjustment
to living on their own after their hospitalization. John must frequently
make decisions regarding clients' physical status and will collaborate with
clients' physicians to determine treatment needs. In residents with congestive heart failure, John listens to lungs and checks for edema; in clients
with diabetes he looks at insulin dosages and blood sugar levels. Based on
his assessments, he will decide whether or not the physician should be contacted to suggest a change in medications or other treatments. John works
with his clients and their families to ensure they receive "comprehensive,
coordinated, and continuous care" (Stanhope and Lancaster 2000).

Joyce also provides nursing care at Oakcrest Retirement Village. She was
hired by Retirement Villages, Inc., the owners of Oakcrest and three other retirement villages, for the primary purpose of improving the overall health of
each of the retirement villages. Her first task at each village was to conduct
an assessment of health-related needs within each community. At Oakcrest,
she found that many of the residents were not getting regular exercise; they were interested in a group activity, so she started a daily exercise class. Information from the health assessment also showed that many of the seniors had
lost weight since their last check-ups and had low hemoglobin levels. Simply
put, they were undernourished. As she got to know the residents better and
began working with residents on the board of Oakcrest, she found that many
did not have the money for adequate nutrition, so she worked to open a food
pantry in the village and began to teach a class about how to cook nutritious
meals using commodities (government surplus) foods. Joyce's efforts at
Oakcrest are directed by the findings of the health assessment, and her overarching goal is to improve the health of the population at Oakcrest.

Community based nursing is a philosophy of nursing practice in
which care is designed to meet the needs of people where they live, work,
attend school, or worship and as they might move between and among
their community and various health care settings (Hunt and Zurek 1997).
According to this definition, both John and Joyce are practicing community based nursing. Furthermore, both are providing care in a community
setting (not a hospital) - indeed, in the same location. So how would we
make a distinction between what the two nurses do? As a home health
nurse, John's primary focus is on individuals and families, and his primary
purpose is to care for persons who are ill. Joyce's primary focus is on an aggregate or population, and her primary purpose is health promotion.

One label for Joyce's type of nursing is "community focused nursing."
"Community focused nursing views the community as the client. Care is
provided within the context of promoting and protecting the health of the
community as a whole" (from the Calvin College Department of Nursing
glossary, adapted from Stanhope and Lancaster 2000). Confusion in terminology exists because there are at least three labels for this type of nursing, and not all the professional nursing literature gives exactly the same
definitions. For the purposes of this chapter, "community focused nursing," "community health nursing," and "public health nursing" will be
considered synonymous.

Community health nursing represents a systematic process of delivering nursing care to improve the health of an entire community. Although community health nursing may deliver care to individuals and
groups, it is primarily responsible for the health of the population as a
whole, with special emphasis on identification of high-risk aggregates.
Community health nursing practice synthesizes nursing theory and public health science and places priority on prevention, protection,
and promotion. (Zotti et al. 2000, 7)

We may thus characterize Joyce as a community focused nurse (or a community health nurse, or a public health nurse) because, although she
works with individuals within the retirement community, her primary focus is on promoting and improving the overall health of the senior citizens
living in the village. In other words, Joyce has a population focus, and the
entire retirement village is her client.

One additional note regarding community health nursing is warranted. While all nurses value health promotion and disease prevention,
the community health nurse is primarily concerned with these aspects of
nursing. Health is a central value of nursing, and although community
health nurses may at times work with persons who are ill, this is the specialty within nursing that focuses most clearly on health rather than on illness. This aspect of community health nursing will be further explored as
we examine what a community health nurse (CHN) does.

To many of us, Joyce's job as a CHN might not seem like a "traditional"
nursing role. She is not working in a hospital. She is not primarily seeking
to help ill people get better. Why would a nurse choose this less common
career path? In other words, what is exciting about being a community
health nurse? First, community focused nurses have the opportunity (indeed, the mandate) to work to improve the overall health of the community in which they work. Rather than working with clients only after they
have had a stroke, the CHN will work with her population group to prevent strokes by encouraging regular exercise, a low salt diet, regular blood
pressure monitoring, and adherence to medications. Although the nurse
may often deal with illness and its effects, her primary focus is on promoting wellness. Thus, the CHN has a very clear occasion for joyous and redemptive work within her community. She also is in a position to identify
some of the elements within her community that are the result of our
fallenness: polluted water that is resulting in high cancer rates, lead-based paint in homes that causes lead poisoning in toddlers, a high rate of obesity in the community that is leading to diabetes and heart disease. She sees
these problems, and she works with those in her community to deal with
them. The community focused nurse identifies those issues which might
cause greater health-related problems in the future and works to prevent
those problems from happening. As she works to enable people in her
community to achieve a more healthy state, she is working to restore a
small part of God's creation and is functioning as an agent of shalom.

Some of the work a community health nurse engages in may be broad,
community initiatives. For example, she may be a member of a countywide taskforce that is working to address an infant mortality rate that is
higher than the state rate. As part of the task force, the nurse could be instrumental in designing a program intended to reduce the number of teen
pregnancies within the county, or she could be the expert who lobbies the
state legislature to provide funding for the program. She might also be a
part of implementing existing state or federal public health programs. An
effort called "Get the Lead Out" is an example of such a program. It provides funding for areas with a known high incidence of lead-based paint in
homes. Community health nurses identify children who are at risk for lead
poisoning; they test children for lead poisoning and teach parents how to
deal with the problem. These nurses also partner with local housing and
government officials to help parents "Get the Lead Out" of their homes or
to advocate for better housing conditions if they are living in rental property.