Transforming Care: A Christian Vision of Nursing Practice (26 page)

The settings in which community health nurses work necessitate a certain
attitude toward clients. One important aspect of the nurse's attitude is recognizing that the nurse and the client are on an equal (or nearly equal)
power level. The nurse and the client are both experts in their own experience, and they must work together. To be sure, the nurse brings professional expertise, but the client brings essential information about what will
and will not work in his or her own situation. Nursing authorities agree
that nurses should work with clients to establish mutual goals for care, but
in a hospital setting the nurse is still largely in control of the situation. The
acute care nurse administers medications at specified times, completes client assessments according to the nurse's schedule, orders meals and therapies to occur at certain times, etc.

Nurses working in the community, however, are clearly not in control
of what their clients do. The nurse can encourage the newly diagnosed diabetic client to eat three meals and two snacks at regular intervals every day,
but she has little or no control over whether or not this actually happens.
Because of this obvious lack of control, the nurse must work in partnership with her clients to an even greater degree than acute care nurses do.
The concept of partnership is essential for the nurse who believes in persons as image-bearers of God with inherent dignity and worth. Partnership has been defined as "a close mutual cooperation between parties
having common interests, responsibilities, privileges and power" (Community Campus Partnerships for Health 2001). "Such mutual cooperation
characterizes the nurse-client relationship as together the two pursue the goal of promoting and protecting health" (Calvin College Department of Nursing Conceptual Framework). The CHN will
need to "come alongside" the
client and determine how best
to empower him or her to make
necessary changes. At times, the
nurse is the salesperson trying
to convince the client of the necessity of a new diet plan. At
other times, the nurse becomes
the coach who encourages the
client to stick to the plan even when it is difficult. Unlike an acute care
nurse, the CHN has some assurance that whatever changes were made will
continue even after the nurse is out of the picture, because the changes
were under the client's control.

The substance of any hope for
change can come only from some
"community of faith" which has the
perseverance to return constantly to
the places where suffering is to be
found and to bring that suffering to
the awareness of the whole society.

A. CAMPBELL

To serve the poor effectively means
surrendering the power of the health
professional, willingness to live with
chaos, tolerance of racial and cultural
differences, acceptance of lack of trust
in health professionals, and attitudes
of attention, care, hope, and listening
often neglected in conventional medical training and practice.

C. E. COCHRAN

One aspect of community health nursing that is especially exciting and challenging is the opportunity to work primarily with vulnerable population
groups. It is true that community health nurses work with the full range of
people within their communities; however, they usually tend to concentrate
on the groups that have the most health-related issues but the fewest means
to be able to deal with them. One CHN textbook defines a vulnerable population as "A population or aggregate susceptible to injury, illness,
or premature death" (Smith and
Mauer 2000, 342). Vulnerable
population groups include those
living in poverty, the homeless,
migrant workers, refugees, those
with chronic illness, pregnant
teens, and those who are addicted
to drugs or alcohol. In our society,
these are the people who tend to have the least, in terms of both resources and power. Jesus exercises a positive
preference for "the least of these." "Has not God chosen the poor in the
world to be rich in faith and to be heirs of the kingdom that he has promised
to those who love him?" (James 2:5). Community health nurses are privileged to work primarily with those who will "inherit the kingdom."

One final and very practical benefit to working as a community health
nurse is the variety of practice. A nurse who works in a hospital on a
postpartum unit will always be caring for women who have just given
birth. While this can be a very rewarding and stimulating place to fulfill
one's calling as a nurse, it offers a rather narrow range of clients. Consider,
on the other hand, all of the examples of clients and all of the practice settings described thus far in this chapter. Any one community health nurse
may have all of these clients within her caseload. Indeed, she may encounter them all within a single day! The nurse needs a broad background to
work with people of all ages, cultures, socioeconomic levels, and diagnoses
and with those who are at varying degrees of health and illness. The CHN
will also have ample opportunity to use her creativity and her critical
thinking skills. She may at times become discouraged and frustrated, but
she will never be bored.

While community health nursing has many valuable and rewarding aspects, it also presents significant challenges. The cultural differences encountered bring richness and learning opportunities to one's practice, but
they can also bring challenges, frustration, and lack of understanding. Because the CHN has a clear understanding of the partnership nature of her
relationship with her clients, she knows the importance of motivating
them to make health-related changes rather than mandating the changes.
It can be very difficult, however, to discover the motivator for each client.

One reason for the difficulty in motivating people may lie in people's differing definitions of health and illness. To a great extent, our definitions
are culturally determined. For example, it is common for Dutch farmers in
Iowa to define wellness as the ability to work. If a farmer has type II diabetes, he may not view himself as having an illness because he is still able to
do his work. He may not see the need to make any modifications to improve his health. Thus, the nurse, knowing his cultural values, will approach the Dutch Iowa farmer differently than, for example, a single African American mother. She may motivate the farmer by helping him to
understand the nature of his disease and its long-term consequences (including the inability to work) and by encouraging him to take his medications and change his diet so that he can remain healthy enough to continue
to work.

The CHN working in a rural community knows that Mr. Vanden
Hoek's view of illness is a rather typical cultural belief in rural communities (Clark 2003). Our nurse is also aware that "Rural residents are characterized by a strong desire to do and care for themselves. This may result in
reluctance to seek help from others, reliance on informal support networks when care is sought, and resistance to seeking care from `outsiders.'
Rural residents prefer to receive services from people well known to them"
(Clark 2003, 588). Because the nurse knows that these characteristics are
indeed true of Mr. Vanden Hoek, this will shape her approach toward him
as she discusses his diabetes. First and most importantly, the nurse knows
the importance of developing a relationship with Mr. Vanden Hoek and
gaining his trust so that he does not view her as an "outsider." In her teaching, she will emphasize the fact that he will continue to feel well and continue to be able to work only if he regularly takes his medication. Further,
as she discusses possible complications that occur when diabetes is not
well controlled, she will highlight how these can limit one's ability to care
for oneself.

On the other hand, the nurse might encourage Darlene Williams, a
single African American mother, a bit differently. She may advocate dietary change and medication adherence by helping her understand the relationship between doing these things and avoiding serious complications
in the future so that she will be able to see her children and grandchildren
grow up. The nurse may also link Darlene with a group of women in her
area who also have diabetes. We see, then, that the CHN must know
enough about each of her clients, their views on health and illness, their
values, and their life circumstances to discern how best to motivate each individual. To be sure, the nurse shows equal respect to each of these clients because each is an image-bearer of God. But she treats them individually, according to their own particular backgrounds, cultures, and values,
because each has his or her own situation and story.

The nurse may experience particular difficulty working with clients
when her own definitions of health and illness clash with those of the client.
It is so obvious to the nurse that our Iowa farmer, Mr. Vanden Hoek, has an
illness that can be controlled if only he will
take his oral hypoglycemic medication and
modify his diet. It is equally obvious to Mr.
Vanden Hoek that he does not have an illness because he feels fine and he is able to
work every day. Their values and beliefs
about health and illness are very different.
In order to be effective, the nurse will need
to work within Mr. Vanden Hoek's frame
of reference. Although the cultural differences can be challenging, the gaps
can often be bridged if the nurse is knowledgeable, caring, and creative.

The differences can seem almost insurmountable, however, when the
nurse has no previous experience with a certain culture, when there is a
language difference, or when the values and beliefs of the client are in direct opposition to those of the nurse.

All three of these issues are exemplified in a rather well known book,
The Spirit Catches You and You Fall Down (1998). In this story we see how
the medical community's lack of knowledge about the Hmong culture, the
language barrier, and the "dramatically clashing worldviews" combined to
result in disastrous consequences for a little girl. We see evidence of the
fallenness of our world and of the great divisions between people and cultures. Would the outcome have been different if the doctors and nurses
had known more about the Hmong culture? Would it have been different
if they had used a translator who knew both the Hmong culture and the
American medical culture? Would it have been different if there had been
an attempt to combine the approaches to treatment? We cannot know the
answers to these questions, but it is obvious that each of these areas should
have been explored. However, even with abundant knowledge, creativity,
understanding, and an open attitude, the nurse will not always be able to
bridge every cultural gap she encounters. Herein lies one of the great challenges of community health nursing.

Goals of health professionals
and goals of recipients of
health care may be incongruent.

IMOGENE KING

Let us return for a moment to Bert and Lucy, our couple in their 70s. We remember that one of the reasons Bert cited for refusing to continue his cancer treatment had to do with a lack of adequate health insurance and an unwillingness to place a large financial burden on Lucy. The health care
"system" in the United States operates according to the free market system.
In general, services are available to those who can pay. It is not a system that
provides equally (or even somewhat equally) to all. Bert and Lucy, because
their only insurance is Medicare Part A, have no coverage for physician bills,
outpatient diagnostic tests, medical equipment, or prescription drugs. The
services that are covered require significant co-payments. The financial
considerations for this couple are very real. The problem has to do with a
fallen environment. It is a health care system issue and also a justice issue.

Need is the proper principle for distributing health care. Health is necessary for a community's proper functioning. Good health facilitates social
interaction and economic enterprise.
Medical care is one of the principal
means to preserve and restore physical, mental, and emotional functioning. Therefore, all societies (except
the United States) that value health
and that have the financial and technical means to develop modern systems of medical care recognize that
health care for all citizens is a matter
of public justice.

C. E. COCHRAN

Let us consider how Karen might actually promote justice and "reform" her particular corner of the health care system as she works with
Bert and Lucy. Karen will offer to connect them with free or reduced-rate
prescription resources, to contact their pastor to discuss support for them,
to connect them with Hospice, to anticipate the need for a legal-aid lawyer
for making a will, and to give
them information on how to
reach such a lawyer. In short, Karen will find all possible resources
and offer them to Bert and Lucy.
She will also be an advocate for
them whenever necessary. In all
her interactions with Bert and
Lucy, Karen will continue to
maintain their autonomy and to
treat them with dignity and respect. In these small ways, Karen
will "humanize" the health care
system for Bert and Lucy. Although she does not "reform the
system" through these actions,
she does manage to promote justice in her individual interactions
with clients.

As important as it is for Karen to be caring and just in her own practice, political action and community organization on the part of the nurse
may sometimes be called for. One of the most basic justice-related questions we must ask is, How fairly are benefits and burdens distributed? In
the case of Bert and Lucy, they are not receiving adequate health care benefits. A community health nurse like Karen has intimate and daily encounters with injustice in our health care system. She would be uniquely qualified to provide expert testimony to community leaders or to be a member
of a task force looking to provide better health care services to the
underserved within her community. Any nurse in Karen's situation might
feel some desire to change the system, but, as we stated earlier, being a
Christian nurse means answering the call to become an agent of renewal in
society.