Transforming Care: A Christian Vision of Nursing Practice (25 page)

In both of these instances, the nurse is working in an environment
that is fallen. Our first example demonstrates the fallenness of the health
care system. The prenatal care given to teens on Medicaid is most often not
as good as the care given to women with private insurance. Further,
women who are too "wealthy" to qualify for Medicaid but do not have private insurance may have no access to affordable prenatal care. Our second
example demonstrates the fallenness of other social structures. In the case
of lead in homes, it is well known that older homes, if they have not been
repainted in many years, will have lead-based paint on the walls. Home
owners (often landlords) are supposed to correct this problem but often
choose not to take the necessary steps. Babies and toddlers suffer the most
drastic consequences if the lead-based paint remains exposed. "Mental retardation, learning disabilities, and other neurological handicaps are the
needless results of this condition. Infants and young children are at highest risk for complications of lead toxicity because they absorb lead more
readily than do adults, and their nervous systems are more susceptible to
the effects of lead" (Clemen-Stone et al. 2002, 535).

We have said that justice is centrally a matter of equity and fairness.
Our examples show a lack of equity and fairness for two vulnerable
groups. Certainly, neither pregnant teens nor babies have much power in
our society. Justice would demand that those in power protect their rights
and advocate for them. Community focused nurses might often be in such
a position. They work with groups who lack privilege and power, they
know the issues confronting them, and the nurses have some power and
authority to be able to advocate for them. In advocating for those who may
be unable to advocate for themselves, the Christian CHN has an opportunity to bring the light of Christ into the world.

Since community focused nurses most often work with clients who
are uninsured or underinsured, and since they deal with issues that focus
on prevention rather than treating illness, frequently the nurse will identify health-related concerns within her community for which there is no
government, insurance-related, or other funding source. In these cases,
she may seek grant funding to meet these needs. Consider the following
example.

Deb is a school nurse at a city high school. A majority of her students
come to school without having eaten breakfast, and she sees what they eat
for lunch. For a lot of them, lunch is a Coke from the vending machine and
a plate full of french fries smothered in ranch dressing. Deb is concerned
about the nutritional status of these kids. She would like to be able to feed
all of them a good breakfast and teach them to choose healthy food for
lunch, but she has no budget to do these things. Therefore, Deb applies for
and receives grants from the state Dairy Association, the U.S. Department
of Agriculture, and the county health department. With the grant money,
she will pilot a school breakfast program, do additional classroom teaching related to nutrition, and work with the food service workers to provide
more appetizing, healthier choices for lunch.

Thus, Deb has found the means to meet a need within her community even though the funds were not available in the school's budget.
Again, as she works to enable her students to achieve a more healthy condition, Deb is working to restore a small part of God's creation; she is an
agent of shalom.

A community focused nurse also has the remarkable privilege of knowing
her community well. She will know and work with many of the residents
of the community, with business owners and pastors, with school principals and teachers. She will also know about community development and
community organizing in her neighborhood. She will know the various
racial, ethnic, and cultural groups within her community and how best to
gain entry into the different groups. For example, information about
breast cancer and the importance of mammograms might be needed by
most of the women in the nurse's community, but the methods for disseminating this information would likely vary greatly from one cultural group
to the next. In working with the Mexican-American women in her community, the CHN might elicit help from the currandera (the local healer)
by getting her to endorse mammograms and to teach self breast examination to her clients. For the Irish-Catholic women in her neighborhood, the
CHN could work with local parish nurses to teach their fellow parishioners and provide mammogram information. The National Cancer Institute has funded breast cancer education and screening programs in the African American community set up through neighborhood beauty shops
(Forte 1995; Browne 2004). Community health workers provide the beauticians, who are usually trusted members of the community, with the information and resources they need to educate their clients. Clients are
more likely to heed the information when the messenger is known and
trusted (Icard et al. 2003), and the effective CHN will identify and work
with those who are known and trusted within her community.

In addition to knowing the health-related issues and the means of entry into the community, the community health nurse also knows the cultural values and beliefs of the people in her community. The CHN working in New Mexico will know that type II diabetes is a serious health risk
for both her Navajo and her African American clients. She will, therefore,
focus at least some of her efforts on educating her clients regarding the importance of staying physically fit, eating a diet that is low in saturated fat
and high in fiber, and maintaining an optimal weight. In this way, some of
her clients may be able to avoid developing type II diabetes or at least minimize the serious complications associated with it. Her teaching will vary,
however, depending on the client.

In teaching the traditional Navajo client about a high fiber, low fat diet, the nurse might emphasize skimming the fat off the mutton stew,
adding fresh vegetables when possible, frying in canola oil rather than lard,
and using whole wheat flour rather than refined white flour for making fry
bread. As the CHN works with her 6o-year-old African American client
who recently moved from rural Alabama, the diet teaching looks very different. In this case, the nurse might instruct the client not to add fat to vegetables as they cook, to bake rather than fry chicken, and to choose white
rather than dark meat whenever possible. These clients would likely be different not only regarding their usual eating patterns but also with regard to
their culture and values. The nurse must know these differences and how
best to motivate her clients to make the necessary changes without simply
assuming that every African American or every member of the Navajo nation will neatly fit into certain cultural categories. In other words, she
needs to understand the cultural background that forms her clients, and
she needs to be open to the beautiful diversity of the actual, embodied individuals she encounters. Good nursing care requires that she see both the
big systems and the individuals. We see, then, that the community focused
nurse is privileged to work with persons from a wide range of backgrounds, cultures, and socioeconomic levels. She or he has a magnificent
opportunity to embrace cultural differences and learn from others. CHNs
encounter in their practice a glimpse of the kingdom of God as we will see
it one day.

This discussion has focused on the idea that community oriented
nurses know the issues and the people of their community. It is also worthwhile to point out that we have seen ways in which the nurse works with
each of the different levels of the environment. In terms of the
microsystem, the nurse does diet teaching with individual clients, but she
also works in the mesosystem as she engages the client's spouse and family
in the diet teaching. As the nurse uses the appropriate point of entry into
her various communities, she is cognizant of the exosystem of her clients,
and when she seeks to procure state funding for a needed program she is
working with the macrosystem. The nurse's role in the chronosystem is perhaps not as clearly delineated; however, the CHN is acutely aware of
changes in the health care system and how these changes affect her clients.
We will consider this more fully as we look at Bert and Lucy in the next
section.

Bert and Lucy, both in their late 70s, have been married for fifty-five years.
They have four children, all of whom are married, and ten grandchildren
whom they adore. They are both retired, are very active in their church,
and do volunteer work at various places in their neighborhood. They live
in a one-bedroom condominium that they bought when they sold their
home. Neither one receives much of a pension, so they live mostly on their
Social Security checks. The only health insurance they have is Medicare
(Part A). They live fairly simply, have few needs, and, until recently, have
both lived healthy, full, and happy lives. However, six months ago Bert was
diagnosed with pancreatic cancer.

When Bert and Lucy had their first appointment with the oncologist,
they discussed treatment options and agreed that Bert would receive a
three-month course of chemotherapy. The treatments made Bert very ill
and weak, and he lost all of his hair, but he made it through them. The
worst news came two weeks after the treatments were completed, when
they found that the cancer had not slowed its progress. The oncologist recommended a different course of chemotherapeutic agents. After much
crying, praying, and talking together, with their children, and with their
pastor, Bert and Lucy decided that Bert would not have any more treatments. Bert said the chemotherapy made him feel so awful that he couldn't
face that prospect again. Also, their very small savings had been used up
for the co-payments associated with the treatment. Bert was not willing to
make things more difficult financially for Lucy, especially since there was
no guarantee that the second set of drugs would work any better than the
first set. Finally, Bert said he had lived a long and happy life, and he was
ready to "see my Jesus."

Karen, a nurse from their neighborhood clinic, works with Bert and
Lucy. The clinic provides care to individuals and families in the community, and its overarching mission is to improve the health of area residents.
Karen has known Bert and Lucy for many years, and she knows their children and grandchildren. Her professional roles in working with this family
include counselor, teacher, advocate, and resource person (DeLaune and
Ladner 1998). As counselor, Karen assists Bert and Lucy to identify the issues they will be facing in the future, and she helps to clarify their options.
Karen's role as a teacher includes providing information on practical ways
to help Bert eat, on recipes for high protein supplements, on how to talk to family members about death, and even about the process of dying. Karen
functions as an advocate by supporting them in the difficult decision they
have made and (at the request of Bert and Lucy) by calling the oncologist
to explain to him again the reasons for refusal of further treatment. As a
resource person, Karen helps them gain access to services such as Hospice,
which they will need in the future, connects them with low-cost legal services so that their wills are in order, and (at their request) calls their pastor
to determine how their church family can help with Bert's care.

Along with her professional roles, Karen is also a friend to this family.
Karen is uniquely able to serve Bert and Lucy because of her long-term relationship with them. She can anticipate many of their needs and concerns. This relationship in some ways makes the situation more difficult
for Karen. When Bert dies, Karen will lose not only a client but also a
friend. Karen must deal with her own grief in the midst of helping the
family cope with theirs. Lament becomes an important part of Karen's experience with Bert and Lucy. She laments the fact that Bert is suffering,
that she cannot make him better, and that Lucy will be without her husband. She also grieves over a health care system that offers Bert only limited options.

How does Bert and Lucy's case help us think about the CHN's focus
on health? In our discussion of health as one of the foundation concepts in
nursing theory, we defined it as the complete physical, mental, and spiritual flourishing that allows us to fulfill our created purposes and so give
glory to our Creator and to enjoy relationships with our Creator and with
fellow creatures that are made possible by those purposes. Although we
know that Bert's physical flourishing is severely compromised, he continues to flourish both mentally and spiritually; he continues to witness to
God's faithfulness to his family and friends; he continues to glorify his
Creator; and he takes delight in his relationships. From these perspectives,
Bert is healthy. As Bert's physical condition worsens, some of these other
abilities may also be lost, but Karen will work with Bert and his family to
help him to flourish as much as possible. In short, the nurse will continue
to focus on health even while assisting a client to deal with a terminal illness.

Margaret Mohrmann, a pediatrician, writes about this in her book
Medicine as Ministry (1995). Mohrmann discusses what she calls the idolatry of health and the idolatry of life. The idolatry of health refers to both
seeing health as "better than God intends it to be" (p. 14) and assuming that health refers only to physical health. "A true and complete understanding of health includes mental and spiritual health as important ingredients in their own right, not just as promoters of physical health" (p. 15).
Karen, our community health nurse, knows that relentlessly pursuing
medical treatment is not the ultimate goal. She understands that life is
more than the physical body and that, although Bert's physical health is
important, it is not the supreme good. Even as Bert's physical health is diminished, his physical, spiritual, and relational health must continue to be
promoted. Because of her professional emphasis on health promotion, Karen is able to focus on promoting Bert's health even as he dies.