Transforming Care: A Christian Vision of Nursing Practice (3 page)

The focus of this book is on how Christian faith commitments inform the
practice of nursing. We want to understand what it means to be a Christian nurse as one engages in all of the various activities that constitute professional nursing practice.

There are two approaches we will not adopt, and both are common
enough that a word of explanation as to why we will not adopt them is in order. Some accounts of Christian nursing focus on what Christians
should do when they find themselves in the midst of ethical dilemmas
such as abortion, euthanasia, or conflicts of confidentiality. Other accounts focus on whether and when it is appropriate for nurses to share
their faith with clients. But neither of these approaches really addresses the
heart of nursing practice. Both skim past the day-in and day-out work of
being a nurse. By doing so, both approaches undervalue that which is common and everyday in nursing practice.

It is precisely this everyday way of being a nurse that we want to explore, and we want to do so because we find nursing in its everydayness to
be an enormously valuable and worthwhile way to express one's Christian
vocation. Could Loretta understand her response to Mr. White, for example, from the perspective of a Christian who recognizes the image of God
in another person? Is it possible to respond to a frightened and confused
client as if to Christ, and if so, what does that mean? This book, then, in
some ways is a project in moral theology - that is, it describes and analyzes the theological grounding and significance of the moral life of professional nursing practice. These two broad themes, theology and nursing,
provide the structure for our discussion. We have already noted how important it is to think about the theological context within which the Christian nurse functions. It is also important to think through how the practice
of contemporary nursing shapes the life and character of a Christian
nurse. To think this through, we need to start with a broad vision of what
nursing is and what its aim is. With a clear sense of what the goal of nursing practice is we will be in a better position to think about how we can
achieve that goal in particular cases and also how that goal fits into the life
of a committed Christian.

This explains, then, why we don't make quandaries and dilemmas the
central focus of our discussion. Hard cases will always exist in health care,
but they aren't the place to start an ethical analysis. We are much better off
beginning with the central goals and practices of nursing. Then, when we
do need to think through hard cases, we will have a framework within
which such cases can be considered. Likewise, issues specific to the Christian nurse's concerns, such as questions about whether and how to pray
with a client, are best considered within the context of a clear sense of what
nursing is and how it fits into the structure of a committed and joyful
Christian life.

Any adequate answer to questions about how Christian faith commit ments inform or qualify professional nursing practice must incorporate
theological, ethical, structural, and practical analyses of nursing practice.
To think comprehensively about nursing practice, then, we need to provide
both a theoretical reconstruction of nursing and an analysis of the concrete
practices that nurses undertake. Our goal is to offer a normative vision for
nursing, grounded in Christian commitments, and practical guidance that
offers a paradigm of the actual practices of nursing. Rather than an ethic
that functions only in the extreme cases, then, we offer a comprehensive
understanding of what it means to be a Christian nurse. In order to develop both the theoretical and the practical aspects of Christian nursing,
we have divided this book into two parts. The first part articulates the relationship between Christian faith and nursing practice, and the second relies on that articulation to describe and examine three specific areas of
nursing practice.

The first half of the book offers an analysis of the ways in which Christian faith qualifies the character, perspective, and values of the Christian
nurse, and it is divided into four chapters. The first chapter highlights certain features of the Christian tradition that are active in shaping Christian
character, perspective, and values. This, in other words, is one way of telling the story of the faith that will do the shaping and qualifying of nursing
practice. We explore how a commitment to the sovereignty of God and to
the goodness and revelatory character of creation implies that we can discern some of God's purposes from the ordering of creation and that we
ought to conform to those purposes through consent to that ordering. We
also explore how these commitments lead to a deeply theocentric piety,
not a piety that results in the rather inhuman mandate that one always be
cheerful, but a piety that respects God's will even when tragedy strikes,
thus leaving room for lament, and an acknowledgment that human life is
sometimes tragic. We pay special attention to the way in which God's presence is mediated to individuals and communities through others and a
corresponding orientation toward others that respects them as mediators
of the divine.

Literature in nursing theory frequently treats four concepts that are
foundational for understanding the professional practice of nursing. These
concepts are nursing, person, environment, and health, and we examine
these four concepts in the second and third chapters. In the second chapter
we examine the concepts of nursing and person, and we indicate how the
Christian story shapes our interpretation of them. In the next chapter we consider how health and environment might be altered, expanded, or reworked in light of our faith commitments and how our understanding of
these foundational concepts might be reconceived from the perspective of
a fundamental responsiveness to God's creative and redemptive ordering
of human life. We consider how understanding nursing as a practice that
involves care for the health of persons who are embedded in particular environments fits into a Christian perspective and how that perspective
shapes our understanding of nursing.

Thus in these two chapters we begin with an interpretation of the concept of nursing that views it as a form of social practice. We explore the
concept of personhood in light of the Christian affirmation that we are
made in the image of God, and we offer an analysis of the pleasure and suffering, the joy and vulnerability that accompany our embodied care-giving
and care-receiving. We draw on the biblical image of shalom to assess the
meaning of health and disease. And we explore how the environment
within which nursing is practiced, the social structures and physical context, are largely human constructions, constructions that participate in the
goodness of our creatureliness but are also bearers of our sinfulness and so
in need of critical examination and, sometimes, reformation. An evaluation of these four concepts indicates how Christian faith qualifies the character and perspective of the Christian nurse.

Reinterpreting the foundational concepts of nursing theory from a
Christian perspective has the effect of highlighting the need for a clarification of the ethical aspects of nursing practice. We provide this analysis in
our fourth chapter, where we turn to an account of how the Christian faith
qualifies the values and principles on which we rely when we consider how
we should act. What are the foundational ethical considerations pertinent
to the ordinary practice of nursing? And when the difficult or exceptional
cases arise, how might these foundational considerations provide a basis
for responding? Our interpretation of the foundational concept of
personhood, for example, should have some bearing on how nurses evaluate their personal interactions and institutional settings.

Thus in the fourth chapter we offer some guidance to nurses in identifying and analyzing the ethical dimensions of their work. We argue that
the standard four principles of biomedical ethics - beneficence, nonmaleficence, autonomy (or respect for persons), and justice - need to be
qualified in light of the Christian story. Here we take up Chapter Two's discussion of how "respect for persons" must be understood as more than mere autonomy and develop these considerations further, considering
how care and justice function in the reasoning of the Christian nurse. We
focus on these two basic components of ethical reasoning, rather than the
four standard principles, for several reasons. One is that the distinctions between
the four principles are often difficult to
make - non-maleficence and beneficence, though relatively clear in theory,
are almost impossible to tell apart in practice. However, a more important reason is
that the two principles of care and justice
seem particularly apt for a Christian context. God is both just and merciful, righteous and loving. These two aspects of God's character are not separable,
but an overemphasis on either one without the other distorts our understanding of what it means to say that God is good. In a similar way, much
of our ethical life can be understood as the effort to live lives and structure
systems that are both caring and just. These two principles, then, provide
the context for thinking about what we should do, and why, and when.

Care is essential for wellbeing, health, healing,
growth, survival, and facing
handicaps or death.

MADELEINE M. LEININGER

One hour of justice is worth
a hundred of prayer.

ARAB PROVERB

The first half of the book focuses on how the Christian story shapes
nursing practice, how it qualifies the "sorts of persons" who act as Christian
nurses, the ways in which they interpret their circumstances, and the principles that guide their actions. But the theoretical work involved in elucidating
a Christian, theological framework, rethinking the foundational concepts of
nursing theory, and assessing the ethical dimensions of nursing practice
needs to be fleshed out in terms of concrete
practices. How does such a perspective on
nursing incarnate itself as nurses carry out
their work with clients in different stages of
life and from differing social, economic,
and cultural backgrounds? Working toward health takes on very different meanings for infants, adolescents, middle-life adults, older adults, and those at the
end of life. It also involves different challenges in the context of acute care
nursing, community health nursing, or psychiatric-mental health nursing.

In the second part of the book we describe and evaluate three different
kinds of nursing practice: acute care, psychiatric-mental health nursing,
and community health nursing. For each kind of nursing practice we iden tify the kinds of caring activities associated with the practice, some of the
opportunities associated with the work, and some of the challenges the
work presents. In each case we are seeking out the "reasons of the mind
and heart" that prompt nurses to enter this type of practice and that sustain them in that practice. Clearly these three areas are not representative
of every facet of nursing practice, but they offer a context for examining a
wide variety of human experiences, a range of health care issues, and the
social structure of nursing practice in contemporary society. They offer a
concrete way to think through how the identity of a Christian nurse is expressed in a representative range of nursing contexts.

If we return, then, to Loretta's dilemma with Mr. White, we'll recognize that faith commitments ground and shape her identity as a Christian
nurse, and that her understanding of the meaning of her response to her
clients will occur within the framework of central theological commitments. Unfortunately, this does not always make life simple or provide
quick answers to the difficult questions and ethical challenges that fill
nursing practice. Faithful Christian nurses sometimes respond badly to
difficult clients. But they also know that the ultimate course of creation is
in the hands of a loving Creator, a Creator who weeps at the brokenness of
human lives and who understands what it means to be human, tired, and
in pain. They can continue to work toward healing and restoration, even
when both seem far distant, because of the hope that accompanies faith in
a sovereign, creative, and loving God.

A bright orange sheet of paper taped to the door of room 2487 cautions
anyone who enters to maintain contact isolation with its occupant. No one
may come into the room without first donning a yellow gown, latex gloves,
and a disposable mask, and no one may leave the room without first removing these items and placing them in the correct receptacles. No one
may touch this client directly, without the presence of these fabric and latex barriers, in order to avoid spreading to others on this cardiac unit the
old, antibiotic-resistant staph infection that plagues her.

Before she enters the room, Janet, the 24-year-old registered nurse
who will care for Ann today, carefully reads the chart that records all relevant information about the client. Ann is 74 years old, suffers from congestive heart failure, and has presented with intermittently altered consciousness over the past several shifts. Sometimes she does not know where she is
or simply cannot respond coherently to questions put to her. Janet is concerned about this confusion, but what concerns her even more today is the
edema. Ann is retaining fluids; her body is hugely swollen and bruised, her
skin pulled taut by the fluid. Although she has a Foley catheter inserted
into her bladder, the fluids that she takes in are not making their way
through her system to her bladder so that they can be drained. Janet fears
the worst: organ failure. Ann's weakened heart can no longer push blood
through the kidneys; as the kidneys fail, fluids and toxins begin to build
up, which can fill the lungs with fluid and lead to their failure, too. Ann is
dying, but it is unclear whether she is actively dying or whether some treat ment can sustain her for a time, even if it may not return her to relatively
normal function.