Transforming Care: A Christian Vision of Nursing Practice (32 page)

In a fallen world, many nurses will find themselves working in institutions that are not so bad that they feel they must leave, nor so good that
they love to stay. Instead, many nurses find themselves working in institutions that do a great deal of good but do it in maddeningly inefficient ways,
or that provide a generally decent working environment with occasional
flashes of pure misery. Under those conditions, it is wise for nurses to remember that part of the Christian life involves spiritual self-care. Nurses
can experience chronic emotional suffering because of the context within
which they work. Johanna Selles notes that "perceiving a vocation is only
one part of the professional task - developing the spiritual self-care that
allows for the pursuit of that vocation over time and with compassion is
the real challenge" (Selles 2002, 17).

The importance of self-care for nurses may be compared to the instructions that one receives with a preflight safety review prior to takeoff
in an aircraft. Individuals are instructed to place the oxygen mask over
their own face first and then assist others who may need help. Nurses need
the oxygen of emotional and spiritual strength to face the challenges of
providing compassionate care to those in their charge in today's health
care environment, as well as to continue to grow themselves as professionals and as children of God. Selles identifies the hope that allows us to look
beyond the suffering that the nurse might see and experience. "God's
promises in history are the source of this hope. Thus, in order for the self
to be securely anchored in relation to God, one must examine and reexamine and cling to this hope. We must continually make clear the tie between our faith and our work and this task is what is meant by spiritual
self-care" (Selles 2002, 5). In recognizing the ways that nursing brings
about healing and relief of suffering, and in naming these as God's work,
the nurse can gain strength for continuing to work. But more than this, the
nurse has a responsibility to find resources for spiritual growth and renewal, and to protect the time and space for receiving these gifts, in order
to continue to function in her or his vocation.

Mrs. Sanchez is a Mexican migrant worker who came to the area for the
summer with her large family to pick apples and other produce. A few
months ago, Mrs. Sanchez had severe pain in her jaw and went to the
nurse-run clinic near the farm where she was working. Sister Rosemary, a
nurse supervising the clinic, immediately referred her to a local dentist,
who extracted a severely infected tooth. The dentist provided her with two
prescriptions, one for pain control, and one for an antibiotic to fight infection. Mrs. Sanchez did not have transportation, nor did she know where a
pharmacy might be located, nor could she afford to fill the prescriptions
for the medications. Any money the family had was needed for basic survival. Because the extraction had provided quite a bit of pain relief, she assumed that the problem was solved and returned to her work in the fields,
feeling a great deal better than she had been feeling.

A few months later Mrs. Sanchez had to be admitted to the cardiovascular unit of the local hospital for open-heart surgery. An untreated infection from the abscessed tooth had traveled through Mrs. Sanchez's
bloodstream and settled on her heart valves. The resulting damage produced heart failure. The heart valves had to be replaced or Mrs. Sanchez
would not survive. After surgery, Mrs. Sanchez needed to spend time on
the cardiovascular unit to recuperate. Because she did not speak English,
her large and loving family made certain that one of the children was always available, day or night, to translate for her, despite the fact that this
meant one less worker in the fields to earn money for food. Mrs. Sanchez
spent most of her first night crying, begging to go home. Her condition
was not stable enough for her to be discharged, however, and complications from the surgery required that she stay in the hospital for several
days.

Claire is the day nurse in charge of Mrs. Sanchez's care. As she listens
to the history and report that the night nurse provides, Claire finds herself
grateful that Mrs. Sanchez received the surgery she needed to save her life,
despite the fact that without health insurance she cannot pay for the surgery. Claire finds herself grateful to the technological powers of modern
health care. Mrs. Sanchez received state-of-the-art heart valves to replace
her diseased valves, making it likely that she would be able to resume her
usual activities with little difficulty. Claire also rejoices in the fact that Mrs.
Sanchez has a devoted family who, despite a lack of resources, consistently demonstrates both their ability and their motivation to carefully and effectively provide care for Mrs. Sanchez.

But at the same time Claire is frustrated by the fact that Mrs. Sanchez
wouldn't have needed the surgery if she had had access to the antibiotics
she needed originally. She is frustrated
by the fact that we live in a world where
the huge costs of valve replacement
surgery can be absorbed by the health
care system, but the provision of inexpensive, effective care at the basic level
is not provided. She is angry that Mrs.
Sanchez is going through pain, confusion, and a frightening experience because no one explained to her what the result of not treating her tooth abscess might be. And she finds herself frustrated more generally at the
inequities and disparities of health care delivery in a country like the
United States that has such great wealth and resources.

Claire is a Christian nurse. She seeks to use her highly developed skills
and abilities to provide healing, when possible, and comfort and compassion to the dying. She sees her job as one that glorifies the God who has
made us as complex and wondrous creatures. Part of what drew Claire to a
large, acute care, teaching hospital was the excitement of seeing how dramatic healing can occur with state-of-the-art interventions. Claire and
many other nurses enter acute care with a sense of nursing as service to
God, a calling, and an opportunity to serve others. They wish to show
Christ's love and compassion to those with whom they come in contact.
Nurses often provide a voice for those who cannot speak for themselves,
particularly for those who are most acutely ill, perhaps even unresponsive.

But many nurses like Claire find themselves frustrated in their calling
because of the inequities and roadblocks built into the health care system.
Many find themselves wondering what they can do in the context of a system that can make it so difficult to provide care for the clients who are entrusted to them. The previous scenario depicts a client who arrives in the
acute care setting because she was unable to have basic health-related
needs met. The cost of her treatment is high in terms of dollars and cents
and even higher in terms of human suffering. Nurses in acute care see the
inevitable results of poor health promotion and preventive measures
among those who are unable to afford appropriate health care in our soci ety. As health care increases in technological sophistication it also increases
in cost. At the same time, public money available for health care is diminishing, leading to calls for rationing and the limitation of care. As Laurie
Zoloth notes, "The real struggle for health care reform is going on daily,
even hourly, in the American clinical encounter. There is not a gesture, not
an order, not a touch, that is not painfully rationed" (Zoloth 1999, 221).

A world in which health care
access is defined by a market
metaphor is inevitably unstable,
to say nothing of immoral.

LAURIE ZOLOTH

In our previous discussion of the environment, the idea of the nurse
bringing justice into the health care system was emphasized. Given the
nurse's strategic position in the health care environment, his or her influence is appropriate at many levels within the system. The nurse has intimate knowledge of the health care system and environment at the
microsystem level, the client's bedside. Evidence of the broken system is
apparent in the lack of time the nurse has to spend at the bedside, the limited resources available, the stressful, rushed environment where care may
be delivered quickly and with less quality than the nurse might desire for
the client. At the mesosystem level, the unit or institutional level, nurses
see short staffing, mandatory overtime, peers who are exhausted, burned
out, and hopeless, perhaps in the process of leaving the nursing profession
altogether. The macrosystem level may include the national and/or international influence of the nursing profession. Until recently nurses were
not included in health care policy development on a national level (Curtin
2003), despite the fact that they are often the members of the health team
most directly involved in client care.

Nurses may be called to build shalom in many ways and at many levels
in the environment: at the client's bedside, in unit meetings, participating
in decision-making discussions, and perhaps advocating for the nursing
profession at the national or international level. While caring and power
create tension for nurses, it is essential that those who understand this tension are responsive and faithful to God's call in building shalom. God calls
us to be faithful in advocating for others, both clients and nurses, at whatever level of the environment God calls us to redeem.

If we believe nursing is a holy calling, then we should seek meaning
not only in what we do for and with hospitalized clients but also in what
we do in and for God's kingdom. Both nursing practice in general and the
specific practice of nursing in the fast-paced, highly technical world of
acute care are settings within which the Christian nurse is called to bring
shalom. Nurses in acute care management roles, in particular, are a critical
link to the larger health care environment. They can assist staff members who are attempting to survive the turmoil of cost cutting or who are working with more numerous and sicker clients in the acute care setting. Laurie
Zoloth points out that nursing always faces the problem of limits. "As long
as rationing focuses on the limitation of care and not the limitation of
profits," she writes, "it will continue to burden the most vulnerable disproportionately, shifting the cost of the solution onto those individuals least
able to bear it" (Zoloth 1999, 233).

We know that the world is a fallen world and that limits and frustrations face us each day. But we also have another vision of a world where
power is used to protect and sustain the
most vulnerable, where wealth meets people's needs, and where we meet and respond to each other as image-bearers of
God. This alternate reality can be seen, occasionally, peeking through the cracks in
the present world. We see it when health
care reform really does produce more
funds for emergency care for the indigent,
when a health care system is organized to recognize and respect nursing
expertise, or when the client everyone thought was dying surprises everyone by walking out of the hospital under her own power.

Mrs. Williams, an 82-year-old mother, grandmother, and great-grandmother, was admitted to the critical care unit with a diagnosis of septic
shock, following a rigorous round of chemotherapy for liver cancer. The
chemotherapy had depleted her white blood cell count, and she was unable to fight the infection that was ravaging her body. Mrs. Williams's condition quickly deteriorated, and she was placed on the ventilator for respiratory support and given multiple potent antibiotics, as well as powerful
vasopressor drugs to support her blood pressure. The shock continued to
progress.

After all of the treatment that was appropriate for Mrs. Williams had
been implemented, it became clear that very little progress was being made
in fighting the infection or in stabilizing her condition. The prolonged
state of shock had led to poor circulation to many body organs, and it was evident by her unresponsive state and her beginning kidney failure that
she was able to maintain only minimal circulation to the brain and kidneys.

Shalom gathers all aspects of
wholeness that result from
God's will being completed
in us.

EUGENE PETERSON

The physician approached Mrs. Williams's family to discuss the possibility of placing a "Do Not Resuscitate" order in Mrs. Williams's record.
The physician explained to the family that while Mrs. Williams's condition
was theoretically reversible, the septic shock had progressed to the point
where nothing more could be added to the treatment regimen. He explained that the treatments could be continued to see if Mrs. Williams
would be able to respond, but if her heart were to stop the hospital staff
would let her die. After much discussion and prayer, the family reluctantly
agreed.

Susan Griggs, the nurse assigned to care for Mrs. Williams, had accompanied the physician to the conference room to provide support and
to answer questions for the family after the physician left the unit. She had
worked closely with the Williams family since their wife and mother was
admitted to the critical care unit and had developed a close relationship
with the family. The waiting room was crowded to overflowing with family
members: husband, children, grandchildren, and great-grandchildren. Everyone who came to the unit had a story about their mother or grandmother, a woman of strong faith. Her frail 85-year-old husband had told
every nurse on the unit that he was praying Mrs. Williams would recover
so they could celebrate their 55th wedding anniversary. A large party had
been planned to celebrate not only the anniversary but also the remission
of her cancer. But now the family, especially Mr. Williams, faced a funeral
rather than a celebration.

Susan saw the goodness of creation in this strong and loving family.
Their constant faith and legacy of trust in the Lord were obvious. After the
physician left, and as Susan entered Mrs. Williams's room again, she found
herself in tears at the sight of this elderly woman with tubes and monitors
everywhere. Another nurse passing by at that moment said, "Get a grip
here! It's not like we don't see this everyday." But Susan didn't see this client, or her family, as simply an everyday occurrence. Because of the relationship that she had developed with Mrs. Williams and her family, Susan
was able to see precisely the beautiful and painful particularity of this
event for this family. Mrs. Williams became more than "the liver cancer
down the hall." Susan was able to see her as a particular, embodied, vulnerable "I."