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TRANSFORMING CAREA Christian Vision of Nursing Practice
By Mary Molewyk Doornbos Ruth E. Groenhout Kendra G. Hotz Cheryl Brandsen Bart Cusveller Mary Flikkema Arlene Hoogewerf Clarence Joldersma Barbara Timmermans
William B. Eerdmans Publishing CompanyCopyright © 2005 Wm. B. Eerdmans Publishing Co.
All right reserved.
Chapter OneA Theological Interpretation of Nursing Practice
Observing a Nurse
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 treatment can sustain her for a time, even if it may not return her to relatively normal function.
Armed with this information, Janet puts on her gown, gloves, and mask and enters the room. She greets her charge warmly and is encouraged to note that Ann is lucid today. Janet performs her usual assessment of a client, using the stethoscope and blood pressure cuff that are reserved for this room. She takes blood pressure and blood oxygen levels, listens to heart and lung and bowel sounds, takes radial and pedal pulses, and examines Ann's skin. She asks questions: How are your bowel movements? Any pain? How would you rate your level of pain? She measures urine output, and she records all of this information meticulously in the client chart. She administers medications and prepares a syringe of saline so that she can flush Ann's heplock. She also turns Ann from one side to the other to prevent bed sores, all the while talking with her about what she might like for tomorrow's meals.
Before she leaves, Janet asks, as she does with every client, "Is there anything else I can do for you?" Clients make a variety of requests: Can I have a drink now or am I still forbidden to take anything by mouth? Do you know when the doctor will come in? When will they come to take me down for my test or surgery? Ann's request is simple: she would like to have her hair combed. Janet searches everywhere for a comb but cannot find one. She will have to leave the room to get one. This calls for an elaborate ritual. The gown and mask and gloves must be removed while Janet is still in the room, and her hands must be washed, a 30-second procedure that Janet performs dozens of times each shift. After she finds the comb, she must put on a fresh gown and mask and gloves. All of this takes up precious time that acute care nurses, who provide care for multiple clients, can ill afford. But the client does not know this, and Janet makes it seem that there is nothing in the world on her mind besides retrieving a comb for Ann. She carefully arranges Ann's hair, asking her questions about her children all the while, and then encourages her to eat and drink and rest.
There is nothing terribly out of the ordinary in this nurse-client interaction. Scores of activities are undertaken here that the average acute care nurse must perform dozens of times each shift. But the individual activities described here are out of the ordinary and only seem normal because of their context in the hospital (Chambliss 1996, 30-31). Notice what Janet does. She touches Ann: she touches her chest and back, skin and feet and hair. She listens to Ann: she listens to her voice and heart, lungs and bowels. She watches Ann: she measures her in a variety of ways, injects her with saline and medications, and washes her. All of these activities would be odd, inappropriate even, outside of the health care context. They derive their meaning from that context and from the nurse's self-understanding of her vocation as health care provider. In short, Janet cares for and attends to Ann, and she provides this care and attention by employing a range of skills, competencies, and techniques unique to her role as nurse.
Some of these skills are diagnostic: Is Ann's level of consciousness altered or is she oriented to her surroundings? Is she in discomfort and, if so, what might be causing that? Some of these skills are interpersonal, and sometimes the skill and gift of a nurse is simply to be present with a client. Think of what a gift and task it is to be present with clients as they experience the joy of childbirth, the fear and vulnerability of receiving a cancer diagnosis, or the confusion and pain of coming to terms with a mental illness. Most of these skills are so natural to the seasoned nurse that they often go unnoticed as skills. Notice, for example, how many steps it takes to assemble a syringe without contaminating it, and how much background knowledge about sterile procedure, pharmaceuticals, and human anatomy is involved in the use of that syringe for the intravenous administration of medications. Notice also how Janet's hands know what to do almost apart from her conscious supervision of them. The practice is so integral to her work as a nurse that it has become part of what it means to be Janet, to be a person with the skills, interests, and compassion of a nurse. This practice, like hundreds of others, has become part of her identity as nurse.
The interaction between Janet and Ann described here is perfectly ordinary in the course of an average acute care nurse's shift, but its very ordinariness is an indicator of the complex knot of relationships-personal, institutional, and systemic-that comprise professional nursing practice.
The interaction is not only ordinary, it is also many other things: morally good, morally ambiguous, awe-inspiring, frustrating, beautiful in its own way, and tragic. In this chapter, as we examine how faith structures nursing practice, we are seeking to tease out some of the strands that make up this knot of relationships and, in doing so, to discover the theological significance of Christian nursing practice. If faith shapes our character, perspective, and values, then to understand how that shaping takes place we need to do some thinking about the faith tradition that does the shaping. We need to tell the story of the faith that will affect so deeply who we are as persons, how we interpret our circumstances, and what principles guide our action. There are many, many ways of telling this story, and every telling will highlight some features of the tradition and obscure others. Here we offer just one way of telling the story, hoping that it will illumine some features of nursing practice and trusting that other tellings will supplement and correct this one.
The Experience of Goodness and Brokenness in Nursing
In this chapter we begin our thinking about Christian nursing by examining some of the theological dimensions of professional nursing practice. Theology is what happens when people of faith reflect on the meaning and implications of their faith. It is an exercise that depends upon a prior experience of the power and presence of God. And for Christians, it depends upon an experience of the power and presence of God as they are met in the person of Jesus Christ. Consider the everyday way you think and talk about your faith. Call to mind the images, rhythms, and language of worship that evoke in us a sense of reverence and awe: God is the holy one of Israel, the good shepherd, a woman who searches for a lost coin, a "mighty fortress," the one "from whom all blessings flow." These are part of ordinary religious experience. Theology rests on this foundation; it assumes that human beings naturally possess what the sixteenth-century Protestant reformer John Calvin called a "sense of the divine," a receptivity to and relationship with the transcendent God (Calvin 1960, 51).
We engage in theology when we ask questions about this primary religious experience and inquire into our common ways of thinking and talking about what it means to live "under the aspect of eternity." When we ask about the theological dimensions of nursing practice, we are asking where God is encountered in that practice, and we are assuming that Christian nurses are engaged in a religious activity-a ministry, an act of worship even-as they carry out their professional responsibilities. Ministry is not a calling reserved for pastors and missionaries. All Christians are called by God to live out their lives in ministry, and this "calling" in the midst of our everyday activities is the very meaning of vocation. Because of this, professionalism and ministry are not mutually exclusive. Instead, nursing as a Christian ministry requires professional preparation. Christian nurses engage in a scientific, evidence-based practice, a practice that is an act of ministry, and a ministry that could not exist without professional education. It is in and through the everyday aspects of our work that we encounter and respond faithfully to the God who has called us to this particular aspect of ministry.
Friedrich Schleiermacher, a nineteenth-century Calvinist theologian and a chaplain at the Berlin charity hospital, was thinking about this question of where and how we encounter God in our workaday lives when he explained that to be a religious person is to seek the eternal in all temporal things and to find in all finite existence the presence of the infinite (Schleiermacher 1994, 36). The religious person seeks God in and finds God through every creature, and especially in the relationships between creatures. When Schleiermacher thought of religious experience, he did not have in mind primarily the "mountain-top experience," where God is almost palpably present. He thought instead that for most people, most of the time, God comes to us in the valleys and plains of life.
What this means for nurses is that when we think about nursing as a religious activity we should not expect to find the "religious" dimension of a nurse's work confined to moments of intense and intentional "caring" interaction with individual clients, nor will it be isolated in dramatic interventions -"miracles"-that preserve a client's life. Rather, if we find God in and through all of God's creatures, then we should expect to find the presence of God permeating every aspect of nursing practice, from charting to taking vital signs, from dispensing medications to interacting with colleagues, from teaching a family about a low sodium diet to conducting a staff meeting, from preparing syringes to washing one's hands. The God whose goodness and beauty are everywhere present, whose power and purposes saturate creation, also permeates the full range of practices engaged in by the Christian nurse.
But goodness and beauty are not all that the nurse-or anyone for that matter-experiences of the power and purposes of God. We also experience profound brokenness, efforts that are frustrated, goals that are not attained, relationships that are perverted, and desires that are disordered. Our own frustrations lead us to respond badly or to fail in other ways. We see the effects of people's deeply evil choices that sometimes destroy their own lives and other times destroy the lives of those around them. We experience God, though it is no longer in vogue to admit it, as judge, as the one who stands over against all of our plans, and who sees the ways in which we plan to do what we should not do.
We also experience the God who is sovereignly other as a mystery-a mystery that is often as frustrating as it is inspiring. We don't understand why God doesn't intervene or protect those who are damaged by others' choices. We don't understand why an elderly woman dies in isolation and loneliness and pain. Nurses bring to their work a religious consciousness that is always marked by doubleness. On the one hand, we are always aware of our finitude and of the brokenness of creation. On the other hand, we are also aware of the goodness of creation and of the God who is "sovereign beauty" (Spohn 1981).
This doubleness lies near the heart of nursing practice. Nurses deal with clients whose health or lack of health determines their ability to pursue life plans and purposes. When we attend to health and its promotion we also acknowledge that it can, might, sometimes does, and eventually will fail or be destroyed. Good health always finds its definition relative to the possibility of failed health. The nurse works in an arena defined by finitude and brokenness. At the same time, attending to illness and working to overcome it acknowledges that human persons should be healthy and that health is the proper state for human lives. Our bodies and minds should reliably serve the plans and purposes for which we were made. Illness always finds its definition relative to a standard of health that allows for the pursuit of a good life. The nurse caring for ill people works in an arena circumscribed by the goodness of creation.
It is not as though the nurse's consciousness toggles back and forth between awareness of the goodness of God and God's creation, on the one hand, and awareness of the brokenness of creation, on the other; rather, the work of a nurse always calls for praise and anguish simultaneously. We give thanks for Ann's life, for the caring community that sustains her and remembers her before God, for the skilled care that she receives, for the unique and beautiful individual that she is, for the hope that health care offers, and for the hope of life eternal. But we also lament because her body is breaking down, because her once-sharp mind is losing its hold on the threads of continuity that weave a meaningful narrative out of life's events, because nurses have too little time for their clients, and because health science and all the efforts of skilled health care professionals cannot always bring relief, and sometimes cannot even provide comfort.
Awareness that caring for Ann provides the occasion for both thanksgiving and lament constitutes the doubleness of the nurse's consciousness. It is important to note, however, that both our sense of joy in the goodness of creation and our anguish at its brokenness grow out of and respond to our knowledge that God through Christ has redeemed us. This fact engenders a profound sense of hope even at the dark occasion of our most painful lament. This hope is more than just unrealistic wishful thinking because it is built on the foundation of Christ's resurrection, which assures us that God's grace cannot be defeated even by death itself. In essence, then, we may have two responses to creation-delight and lament -both of which emerge from our gratitude to God for our redemption, and indeed the redemption of all things, in Christ.
In the remainder of this chapter we explore the theological meaning of the nurse's religious experience of doubleness and awareness of the presence of God reflected in that doubleness. We begin by focusing on the nurse's experience of the goodness of God as it is met in and mediated through the nurse's clients and colleagues. Then we turn to a consideration of the role of lament in light of the nurse's awareness of human limitations and of the sometimes tragic character of life.
Excerpted from TRANSFORMING CARE by Mary Molewyk Doornbos Ruth E. Groenhout Kendra G. Hotz Cheryl Brandsen Bart Cusveller Mary Flikkema Arlene Hoogewerf Clarence Joldersma Barbara Timmermans Copyright © 2005 by Wm. B. Eerdmans Publishing Co..
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