Transforming Care: A Christian Vision of Nursing Practice (8 page)

This definition begins with the notion that a social practice is a coherent
and complex form of socially established cooperative human activity, and
nursing certainly exemplifies this aspect of a practice. The contemporary
practice of nursing is a coherent whole (otherwise it couldn't be taught as a
specialized area of study), but it is also enormously complex (as anyone involved in developing a nursing curriculum will tell you!). These two aspects of a practice do tend to generate a certain internal tension in most
practices, since any definition of the practice that emphasizes the coherence will tend to deemphasize the complexity and vice versa.

But it is not enough to note that nursing is both internally coherent
and complex. It is also, as Maclntyre's definition suggests, a socially established cooperative human activity. Nursing exists as a particular sort of activity, engaged in by practitioners whose right to call themselves nurses is
not a matter of (merely) individual choice, but a matter of meeting the
standards of the profession and engaging in the right sorts of education and activities to meet standards for licensing and the like. No one could
have been a nurse (for example) in the mid-i6oos in Mexico, though there
were certainly people in that setting who performed some of the tasks that
are associated with contemporary nursing. In the absence of a social system of health care, a body of knowledge about human health, and a system
of determining who can legitimately call herself or himself a nurse, there
aren't nurses in the sense in which we use the term today. This means that
nursing as a practice has a history. What counted as "nursing" a century
ago is no longer what counts as nursing today; but at the same time, contemporary nursing would not be what it is without those practitioners
who set the standards in former times.

These characteristics establish that nursing fits the general schema
Maclntyre offers of a practice, but clearly more specific characteristics are
required to make it nursing. What is it that identifies nursing as the specific sort of practice that it is? Maclntyre notes that a practice is defined in
part by the goods that are "internal to that practice." There are certain central values or goods or aims that are the main focus of nursing and that define it as a practice. Health is the most central of these, since nursing is a
health care practice that aims at the alleviation of pain; at restoring physical, psychological, and emotional functioning; at attending to the wellbeing of the whole person; and so on. While these latter aims may coincide
with physical health, they also may diverge in certain cases. A terminally ill
client, for example, is unable to achieve full physical health, but she can
certainly look to her caregivers for the alleviation of pain and for concern
for her emotional well-being.

Care is essential to curing
and healing, for there can be
no curing without caring.

MADELEINE M. LEININGER

These central goods can be redefined over time. In the past, nursing
tended to think of itself as a matter of service work. Training as a nurse involved learning to change dressings and
bedpans in the hospital setting, and nursing education involved learning to carry
out physician's orders (McKenna 1997, 87).
But nursing no longer defines itself in this
way. It now defines itself as a sciencebased practice and as an independent profession, and it requires practitioners to
master knowledge of the scientific basis of
nursing practice and to internalize professional standards of behavior that
include responsibility and client advocacy (Group and Roberts 2001, 344). This is an important change in the professional self-definition of nurses,
and it involves a shift in the central goods of nursing from a more servicebased model to a science-based model of nursing, though historical studies demonstrate that nursing has never been entirely service based (Nelson
2001, 31; Lewenson 1993, 5).

These goods, or central values, are what Maclntyre calls "internal"
goods of a practice. He calls them internal for two reasons. The first is that
they define the central identity of nursing as a practice, so that without
them it would not be nursing. The second is that they are distinctive from
other goods that might be incidentally connected to the practice but do
not define it. So nursing is a job, and it involves a salary, various benefits,
and often certain schedules for working. These are good things, and important things, but by themselves they don't identify what nursing is all
about. A nurse's salary may change as she moves from one health care system to the next, but her goals as a nurse remain focused on health. Further,
we can envision changing, say, the normal schedule nurses work without
changing their identity as nurses. But if we ask nurses to focus on the profitability of the health care system rather than on the promotion of health,
we are making a change in the nature of nursing itself and in the nature of
what it is to identify oneself as a nurse.

This notion of the internal goods of a practice becomes more complex
when we combine it with the notion, discussed earlier, that practices have a
history. The definition of nursing that we find in Florence Nightingale is
significantly different from the definition of nursing that we find in contemporary textbooks in some ways, though her definition clearly sets the
tone for the later development of nursing (McKenna 1997, 86). This is not
so much because Nightingale somehow got nursing wrong, but rather because nursing as a practice has developed and refined its notion of what
nursing is all about to the point where it now defines itself differently than
it did, as a practice, many years ago. Presumably, as health care continues
to develop and change, nursing will continue to develop and refine the notion of what it means to be a nurse. Part of what makes it a practice (rather
than just a job) is that these revised understandings come from inside the
practice itself as those who engage in it gain a better understanding of
what its goals are. This is what Maclntyre means by his claim that in engaging in a practice the goods of that practice are systematically extended.

But let's shift our focus now, from nursing as a profession to the professionals who engage in nursing. Earlier the claim was made that when someone identifies himself or herself as a nurse, we are likely to make certain assumptions about that person's character and identity. For example,
if I meet a new member of my church, and
he introduces himself to me as a nurse, I
am likely to assume that he will be a reliable and level-headed individual and one
who will not panic in an emergency. Is
this legitimate? Maclntyre would argue
that it is. We noted that a practice such as
nursing involves collective activity. One
can't just decide to be a nurse. One has to have had the right education,
one's grasp of that education needs to be validated by licensing, and certain social structures must be in place before one can be a nurse in the contemporary sense of the word. How does this affect the individual's character and identity?

At the most basic level, the internal goods of nursing shape the character of the nurse because they shape the goals and structure of nursing education. Imagine, for a moment, that we see a faculty member teaching students how to draw blood. Instead of teaching them the proper techniques
for assuring sterile conditions and for causing the minimum of pain, however, our professor teaches them how to draw blood from several clients
with the same needle because that saves money, and she endorses a certain
amount of pain because that ensures that clients will be taught to fear the
students and be properly submissive to them. What such a horrible professor is teaching is not nursing, but another practice that shares some techniques with nursing. This is quite different from saying that this professor
is a bad nurse. Instead, the point here is that she is not teaching nursing at
all, but some quite different practice, organized around internal goods of
control and power. It isn't nursing because its internal goods are not those
of nursing. The standards of this alternative practice are quite different because the internal goods of the practice are different, so that what makes
someone a bad nurse would actually make them good at whatever this
professor is teaching.

But now think as well of how this professor is shaping the character of
the students she teaches. What she inculcates in them is quite different
from the traits that a nursing professor should try to inculcate in students.
The internal goods of the practice of nursing are not just external goals
that people educated as nurses happen to go along with. Instead, education as a nurse develops the whole person and shapes one's character in some
obvious ways and in others that aren't so obvious. Nurses learn to deal
with crises in a calm and rational manner; they learn to be tremendously
efficient in their use of time and energy; and they learn to provide emotional support and care while maintaining healthy boundaries (Chambliss
1996,30-41). Further, nurses internalize the values of the health care system
of which they are a part, placing a high value on health, on economic efficiency, and on protecting human life.

People don't become nurses
to avoid seeing suffering or
to have a quiet day.

DANIEL CHAMBLISS

From the earliest days of the church, liturgical practices of healing have belonged to an entire family of "corporal
works of mercy" through which Christians have offered care of various sorts
to both members and strangers with
various physical and material needs. The
inclusion of these liturgical practices
within a broad understanding of care
suggests that there should exist no
sharp distinction between divine healing and medical healing.

JOEL JAMES SHUMAN

Both of these aspects of nursing practice, then, coincide with the role
that Christian faith plays in an individual's life. Nursing qualifies and
shapes a person's character and values. And there is a natural overlap between some of the ways Christian commitments and nursing training
shape character and values, since both are focused on the well-being of
others. This overlap is due in part to the fact that nursing as a practice was
originally developed by women who were deeply motivated by their Christian faith. In fact, though the profession now distances itself from this history, Christian faith has qualified and shaped nursing practice from its inception. Nursing, then, is not a practice that is somehow intrinsically alien
to Christian faith, and that makes the task of identifying the ways in which
Christian faith shapes and qualifies it much simpler. For example, the
Christian nurse's character is shaped in part by her or his commitment to
the good of the other because the other is seen as bearing the image of
God, and this adds a depth to
her or his response to the other
that is an important part of the
Christian nurse's character.
Further, the Christian nurse
acts out of a hope that is
grounded in faith in the Creator and Sustainer of all that
exists. This means that, both in
terms of character and in terms
of what he or she values, the
Christian nurse knows that the
suffering, pain, and dying that
call for care are not the end of
the story. They are an occasion
for grief and lament, surely, when they cannot be cured or mitigated, but our grief is not absolute because we live in a world where death is not final.

Character and values are not the only things shaped by a nursing education, however. Becoming a nurse is clearly a matter of knowledge.
Nursing is a science-based practice, and to be educated as a nurse requires
learning the content and practices of that science. But nursing is more
than this knowledge, and that "more" involves becoming the sort of person
who can respond to clients in the right way, the sort of person who recognizes pain as needing alleviation, or who
respects and encourages a client's attempts at self-care. Developing the character of a nurse involves developing habits
of action (efficiency, prioritization),
skilled knowledge or "knowing how"
(knowing how to start an IV, recognizing
an unusual level of confusion in a client
with Alzheimer's), and theoretical knowledge (understanding the physiology of blood gases). In addition to these,
the nurse develops personal characteristics that permit him or her to respond empathetically to a client, without trying to take over the client's life
(Halpern 2001, 113). Because nursing, like other professions, requires character formation in addition to knowledge and skills, it is more than a science; it is an art as well.

All of these patterns of character formation shape the identity of the
practitioners in a profession. Some practitioners will lack certain aspects
of this character, of course; but taken as a group, practitioners will show a
definite pattern of character. Those who are educated and licensed as
nurses will have been inducted into a profession that encourages and even
requires certain characteristics in its practitioners. These characteristics
are certainly not those that sometimes have been associated with nursing
in the past (being a "nice girl," for example); rather, they are characteristics
such as having an aptitude for science, having a quick intellectual grasp of
theories and being able to see how they apply in real world conditions, and
being capable of self-control when faced with an obstreperous client.

It is also worth noting that tensions can arise between professional
standards of behavior and socialized patterns developed in the context of
particular health care systems. Because a significant part of the education
of nurses takes place in particular hospital or clinic settings, the social con text of those settings can either support or subvert the education a nurse
receives in school. If a school had high professional standards, but the unit
has a history of practices that are less professional, it is difficult for students to maintain the standards of the education. A gap of this sort, between the ideal standards of the profession and the actual behavior of
practitioners, is not unusual in the professions, but in the best-case scenario the gap is a minor one.