Transforming Care: A Christian Vision of Nursing Practice (29 page)

All of this explains why some people would find acute care nursing to
be an exciting, challenging, and rewarding career, but in what way do we see the advanced practice opportunities, the high level of excitement, and
the importance of the acute care nurse's role to be shaped by Christian
faith? Nursing is often defined in terms of care, and acute care nurses provide the face of care in the hospital setting.
Physicians are generally not able to remain actively involved in client care once
any surgical interventions are completed.
But nurses, who remain on the unit with
the client, provide continuity of care; they
are expected to provide continual and
knowledgeable oversight of the client's
condition and to attend as well to the human side of healing or comfort care. We
spoke earlier of the vulnerability that marks the human condition, and
acute care nurses are involved every day in ministering to that vulnerability in the lives of their clients and the clients' families.

When the spirit does not
work with the hand, there is
no art.

LEONARDO DA VINCI

For the Christian acute care nurse, it is natural to see much of the dayto-day routine of work as a natural ministry of service to the suffering,
hurting, and dying. Nurses rejoice with clients when they are healed; they
mourn with clients and their families when they are not healed, or when
they confront death; and in all of these roles the nurse can both bring
God's care and peace to others and reach out to others in recognition of
the image of God that they bear. This aspect of nursing is both clear and
commonly recognized; it is one of the defining characteristics of many
nurses' experience. But the acute care nurse also faces very specific difficulties in living out her or his calling, and these need to be noted as well.

Because the acute care setting is fast-paced and exciting, it is also stressful
and exhausting. Burnout rates are high in acute care, and nurses in that
context often feel overwhelmed, frustrated, and unable to focus on the specific needs of clients because there is so much that needs to be done. Pressure to be efficient, to move quickly from client to client and never slow
down, can add to the stress of the acute care nurse's life. Hospitals resort to
minimal staffing levels as a way of keeping down costs; more of the clients
admitted to hospitals have serious conditions and the length of their stays is shorter because of insurance regulations; and acute care can be enormously tiring and demanding. In that context nurses may find that they
are unable to respond to clients in ethically and religiously appropriate
ways. Today a nurse's practice in an acute care institution is profoundly affected by the nursing shortage.

Jesus never approached from
on high but always in the
midst of people, in the midst
of real life and the questions
that real life asks.

FREDERICK BUECHNER

A nursing shortage affects the acute care hospital more than other
health care settings since prolonged orientation and specialty education
are needed to prepare nurses in their specialty area. Specific education is
needed to monitor clients and support them in difficult circumstances,
handle advanced technology safely, administer medications or treatments
effectively, and follow hospital policies and procedures. Fewer nurses are
choosing to go into acute care given the current health care environment
and stress of hospital nursing. Experienced nurses in midlife are opting to
resign from hospitals (despite accrued retirement benefits) and work in
other settings. Little incentive exists for nurses to continue a career in such
a stressful environment. Many nurses have left the profession completely.
It is estimated that if all of the currently licensed nurses were to return to
practice, there would be no nursing shortage (Hilton 2003). Shortages often lead to mandatory overtime: nurses are not given a choice about working overtime, they are scheduled for it and expected to complete that extra
work. This in turn leads to resentment and higher levels of burnout among
the nurses who remain in the system, and it generates a destructive spiral
of more nurses leaving. It is a short-term fix that exacerbates the long-term
problem.

During the early to mid 198os, serious cost-cutting measures were implemented in anticipation of rising health care costs. One such measure that
was attempted was using nursing aides and assistants as replacements for
RNs at the bedside. The following example, recounted by Mary Mallison,
demonstrates the dangers of shifting client care away from nurses:

A nurse's aide came from a client's room and was heading for the linen
closet when the RN met up with her in the hallway. The RN asked how
things were going for the client and the aide replied, "Mrs. B is fine,
but she is shivering and cold. I'm on my way to bring her some blankets." The RN, knowing that Mrs. B was receiving a blood transfusion,
recognized that shivering or chilling may indicate a serious, allergic
transfusion reaction in response to the blood that was infusing. The
RN immediately examined the client and found Mrs. B was indeed ex periencing a serious reaction. He discontinued the blood transfusion
and notified the physician to obtain orders for emergency medication.
With early intervention the nurse was able to reverse the allergic response. (Mallison 2000, 39)

When nurses are not able to monitor clients directly, the chances of missing serious complications of this sort are increased.

Because acute care nursing involves a high degree of stress, it is very
natural for nurses to respond by trying to limit their responsibilities, and
among the responsibilities that the acute care nurse faces are the constant
demands of clients, of clients' families, and of other members of the health
care team. We see this dynamic in cases where a client is receiving care that
the health care team feels to be inappropriate, especially excessive and aggressive treatment provided for a client who is at the end of life. Such care
often is more of an imposition than care; it fills the last days and moments
of the client's life with terror and agony without providing any particular
benefit. When families are not able to accept the approaching death of a
loved one, however, they often resort to demanding that "everything be
done" for that loved one, feeling that somehow demanding more and more
care will prevent the death or at least prove their love.

One of the techniques used by acute care nurses to deal with these demands is humor. While caring for clients whom they perceive to be receiving futile care, nurses and other health team members use dark humor, humor that mocks the situation while still recognizing the tragedy of the
experience. They may joke, for example, that a client has joined the 40-4040 club, meaning that her systolic blood pressure was 40, her heart rate was
40, and her urine output was 4occ for the last twenty-four hours. Nurses
know that few clients recover from such a condition, and the label allows
them to convey this knowledge in coded language so that their bleak prognosis for the client is not imposed as a burden on family members. Some
team members refer to clients in this condition as "train wrecks." They are
such a mess, physically, that one does not know where to begin to provide
care. In such an instance, dark humor may point to the need for lament.

Is such humor acceptable for the Christian nurse? Much of this dark humor helps staff members to distance themselves from an intensely emotional situation, assisting them to function amid the most difficult of circumstances. When is this type of coping mechanism inappropriate and
when does it serve as a way for staff members to continue on with care? We
might worry that referring to a client as a train wreck obscures the person
whose life has become so difficult, and if the humor denies the
personhood of the client then it does become something that the Christian
nurse should avoid. Consider another example for comparison. A nurse labels one of her clients a "Clampett Queen," a name that designates someone as poor, white, and "trashy," uneducated and unwilling to comply with
health care directives. Labeling someone a "Clampett Queen" relieves
stress by the use of humor in much the same way that referring to someone
as a train wreck does, but there are differences in how these labels are used.
The term "Clampett Queen" demeans a person created in the image of
God based on that person's social status. Using the term depends upon the
nurse's willingness to accept society's conventions about who is and is not
worthy of our time and attention, but those conventions are based in
deeply materialistic values that are antithetical to Christian faith. The label
may imply that the client does not deserve quality care and that her lack of
education, lack of social status, and general unwillingness to do as directed
place her outside the community to which others belong. After all, the assumption often goes, she will be discharged to home and continue her destructive lifestyle patterns such as smoking, eating a poor diet, and failing
to exercise. When someone is called a "train wreck," perhaps we are recognizing the overwhelming nature of the care that needs to be provided. The
label of "Clampett Queen" denies the client's personhood, however, and
makes it easier to provide less than excellent care. It is critical that we as
nurses who seek to follow God's command to love our neighbor as ourselves attempt to discern the purpose and consequences of dark humor. As
professional nurses working for shalom, we are in an excellent position to
construct the boundaries of what is acceptable humor and what is destructive to the person and to the nurse-client relationship.

This does not mean that the Christian nurse should place herself or
himself on a self-righteous pedestal, earnestly policing the language used
by colleagues and other staff. What it means is that the Christian nurse
should enter the acute care setting knowing that humor is an indispensable technique for dealing with issues that otherwise would be overwhelming. The level of suffering, death, and bodily fluids the nurse confronts ev ery day requires the development of a rather bleak sense of humor. While
this humor is essential to survival, however, it also represents a danger
when it crosses over the line from releasing the nurse's pressure and frustration to diminishing the personhood of the client. In those cases the
Christian nurse can offer an alternative way of acting, showing respect to
the difficult clients, perhaps even joking with them rather than about
them, and making sure that the general tone of a unit remains professional.

Another issue that frequently confronts those in acute care nursing relates
to the question of responding to clients who are dying. Some clients enter
the acute care setting with a clear and strong Christian faith, and this may
be noted on the chart in the nursing assessment area. They may have family members and church friends who pray with them and support them
during their stay. In these cases it is easier for the Christian nurse to assume that members of the client's community are offering appropriate
spiritual care. But how is a nurse to care for a client who is dying and who
appears to have no sources of spiritual support? Or, in another case that is
often difficult for the Christian nurse, how ought one to care for dying clients who are not Christian? Nurses may or may not know the spiritual
state of their clients, of course, because clients may not choose to share
their spirituality with the nurse.

Because death is such an awesome and frightening experience, it is
natural for both family members and care-givers to try to manage or control the process. One way of feeling that one has gained control over the
process is to try to determine the outcome, and for Christian nurses it can
be tempting to take control of the client's life by ensuring that she or he is
saved. We need to acknowledge that the impulse to proselytize a client who
is dying is a good one and is evidence of care and concern for that client.
But it is also wrongly expressed and grossly manipulative to intrude on the
dying process of a client with urgent pleas that they pray the right prayer
or somehow do something so that the nurse can feel like a savior. Forcing a
death-bed conversion on an already vulnerable individual provides more
comfort for the forcer than for the one who is forced, and it suggests that a
nurse is trying to control matters that are not within his or her power.

God is, ultimately, in charge of our living and dying. This is true for
every client the nurse faces in the acute care setting, Christian and nonChristian alike. We cannot know what God has planned for these various
people, though we can know that God is both just and merciful and that
God's love for those created in God's image is deep and everlasting. Within
the context of a secure trust in God's providential care for people, nurses
can respond to the spiritual needs of their clients in ways that meet those
clients' needs, not the nurses' anxieties. It is appropriate, for example, for
nurses to ask questions of a spiritual nature to get a sense of client's life
narrative and the ways in which her or his impending death does or does
not make sense in that context. When an acute care nurse has time to get to
know a client, it makes sense to ask what the client is feeling and whether
she or he needs to talk about fears or hopes for life after death, and possibly
to contact the hospital's pastoral care office. Each client approaches death
in an individual way, and part of providing good holistic care involves an
openness on the nurse's part to the specific needs and vulnerabilities of
this particular client.

The most difficult and frightening cases for the Christian nurse may
be those cases where the client has refused to see someone from the clergy
and has stated, "I don't believe in religion. When you die that's the end." In
such a case the nurse can still place this client in God's hands and pray for
grace and guidance. But in these cases, too, we need to remember that clients' lives are held in God's hands, not ours. Adequate holistic nursing
care, including spiritual care, is never a matter of taking over someone
else's life. The calling of an acute care nurse is a calling to care and provide
support to clients as they make the decisions that determine the shape of
their lives.