Transforming Care: A Christian Vision of Nursing Practice

TRANSFORMING CARE

TRANSFORMING CARE A Christian Vision of Nursing Practice By Mary Molewyk Doornbos Ruth E. Groenhout Kendra G. Hotz with Cheryl Brandsen Bart Cusveller Mary Flikkema Arlene Hoogewerf Clarence Joldersma Barbara Timmermans

Contents Acknowledgments vi Introduction i Part One: Christian Faith and Nursing Theory i. A Theological Interpretation of Nursing Practice 17 2. A Christian Vision of Nursing and Persons 40 3. A Christian Vision of Health and Environment 67 4. How Christian Faith Shapes Nursing Values: Care and justice 93 Part Two: Christian Faith and Nursing Practice 5. Psychiatric-Mental Health Nursing 117 6. Community Health Nursing 143 7. Acute Care Nursing 167

Works Cited 198 Index 207

Acknowledgments This project has truly been a journey. It began in the fall of 2000 with a letter of inquiry from Bart Cusveller of the Lindeboom Instituut, Ede, The Netherlands, to James Bratt, Director of the Calvin Center for Christian Scholarship, regarding a project on Christian nursing. We gratefully acknowledge Bart's initiative and Jim's supportive response for providing the impetus for this project. In the intervening years, the project has spanned several grants, consultations, and a reading group. It has been a model of collaborative endeavor in which the knowledge, expertise, and wisdom of many have been essential to its development and completion. First, we wish to acknowledge the Governing Board of the Calvin Center for Christian Scholarship for its financial support of this undertaking. In addition, we are particularly indebted to James Bratt, Director, and Donna Romanowski, Program Coordinator, for their encouragement and wise council. We are also grateful to Eerdmans Publishing Company for their faith in this project. Specifically, we wish to thank Jon Pott for his formative feedback, Linda Bieze for her assistance as

managing editor, and Jennifer Hoffman for her editorial work. There were several consultants whose insights were essential to the development and revision of this manuscript. We especially wish to thank Allen Verhey, formerly at Hope College, now at Duke Divinity School, for reading a draft of the first half of the book and for offering thoughtful critique and advice. We are also grateful for the efforts of Rebecca Pruitt, then Vice President for Mission and Ethics of Mercy Health Systems in Oklahoma; Johanna Selles of Emmanuel College; and Marilyn Vander Esch of St. Clair County Community College. Dan Harlow and Helen Sterk, colleagues from Calvin College, graciously offered their insights on the nature of collaborative research. The input of the Calvin College Nursing Class of 2004 was particularly helpful to us as we completed the final revisions of the book. Two expert nurse clinicians were invaluable in acquainting one of us with the scope of professional nursing practice. Sarah Douma Boomstra, of Spectrum Health, and Gail Koel, of Forest View Psychiatric Hospital, generously gave of their time by consenting to a shadowing experience over a period of several months. Writing this book was truly a collaborative project, and all of the chapters have been written and rewritten numerous times by various members of the team. Nevertheless, we would like to recognize the members of the writing team and the portions of the book that they contributed as primary authors. Kendra G. Hotz served as primary author of the Introduction and Chapter One. Ruth E. Groenhout contributed the section of Chapter

Two on the concept of nursing and Chapter Four. Bart Cus veller of the Lindeboom Instituut contributed to the development of the concept of nursing. Several of our Calvin College colleagues developed sections on the remaining three metaparadigm concepts of nursing: environment by Cheryl Brandsen, Department of Sociology and Social Work; person b y Clarence Joldersma, Department of Education; and health by Arlene Hoogewerf, Department of Biology. Our Calvin College nursing colleagues, Barbara Timmermans and Mary Flikkema, lent their expertise in the areas of community health nursing and acute care nursing, respectively, and are responsible for those chapters. Mary Molewyk Doornbos served as primary author of Chapter Five on psychiatric-mental health nursing. We are most grateful to the writing team for the hard work, good humor, and generosity of spirit that made the entire process a positive experience. A mere word of thanks to those who have contributed seems inadequate. Perhaps the vision that countless nurses and other health care providers may be assisted in their efforts to articulate the relationship between their Christian faith and their vocation will suffice. MARY MOLEWYK DOORNBOS RUTH E. GROENHOUT KENDRA G. HOTZ

Introduction Loretta is taking ice chips to the client in room 5723 when she realizes that something has gone wrong. A loud, frightened voice is coming from room 5719, Mr. White's room. From her brief encounters with Mr. White - whom she knows instinctively not to call by his first name - she knows that he is a recently widowed 78-year-old client who was admitted with chest pain and shortness of breath. His home is in one of the farming communities settled in the vast rural areas that surround this urban center, and he is very much out of his element, not only in the hospital but in the city itself. Everything seems too busy and too fast, and Mr. White always seems suspicious - or, rather, worried - that things are being done to him in the hospital that he does not understand and that may not be in his best interest. His wife, Loretta supposes, had always taken charge of Mr. White's health. He wishes his wife were with him now, and so does Loretta. The cardiologist who visited with Mr. White yesterday, shortly after he arrived on the unit, had explained to him that she suspected that the arteries leading into his heart had become blocked. She had ordered a test - a heart catheterization - that would determine whether this was the cas e. At the time Mr. White seemed to understand what the test would entail and what his options would be if a blockage were found. But now Loretta enters the room to find the 78year-old in a state of panic and confusion. He is holding the technicians from the cardiac studies lab at bay by shouting at them: "I'm not going anywhere with you! Where is my son? I

need to talk to my son! He'll know what to do. Go away!" After twenty-five years as an acute care nurse, Loretta has seen this scene before and has a good idea of how to intervene. Even though she spends most of her time in supervisory roles now, she still enjoys an occasional shift as a staff nurse. She gently asks the technicians if they might give her a moment with Mr. White, and they oblige. Loretta asks a passing aide to bring the ice to the client who requested it. She pulls the curtain between Mr. White's bed and that of his roommate, sits down, and asks Mr. White calmly, "Tell me what's happening." After listening to his concerns, she reminds him of the conversation he had with the cardiologist yesterday. Yes, he remembers, but he thought his son would be here by now and doesn't want to go until they have a chance to talk. He is almost in tears. "Your concerns make sense," Loretta assures him, even though she knows that rearranging the cardiac studies lab schedule will be difficult. Just as Mr. White is calming down, his son arrives. He's a big man who wears khaki pants, an oxford shirt, and too much aftershave. He is in a rush and looks like someone who always is. He assesses the situation quickly and announces, "Dad, you have to go now. These good people are all waiting on you. You have to do what the doctor tells you to do. Tell him, nurse, he has to go. Doesn't he?" It would be so easy just to say, "Yes, you have to do what the doctor says." But Loretta cannot do that if she is to maintain her integrity as a nurse. Even after twenty-five years, there is no simple way for a nurse to balance all of her

responsibilities. Her role as a nurse calls for Loretta to be a care-giver in multiple ways. She must be a teacher, an advocate for the client, a steward of the resources of the hospital and of her colleagues, a coordinator of care, and a manager. She needs to respect Mr. White, to educate him, to help him make the best choices he can for his own health, and to value his autonomy. In order to do all of those things, she needs to understand not only his physical condition but also his social location and psychological state. She also needs to attend to her other clients, who have similar, if not more urgent needs. But how do you do all of those things when time and energy are short, and a client is scared, confused, and under pressure from family members? And what do you do when one obligation seems to conflict with another? This is a book both for and about nurses, Christian nurses specifically. It is about how faith structures nursing practice. Our goal is to offer a resource that will provide practicing nurses and nursing students with a way to think about these tough questions and begin to formulate some answers. We do not want to provide a set of pat answers that nurses can memorize and repeat by rote, nor do we wish to leave our audience of thoughtful practitioners and students with the sense that there are no answers. Instead, we hope to point to some resources from within the Christian tradition that can guide us as we seek to live out our vocations faithfully. Can Nursing Be Christian? Loretta faces the sort of situation every nurse faces in the course of her or his work. But because Loretta is a Christian,

she also has a sense that her faith in and relationship with a loving Lord should have some bearing on how she acts and reacts in this sort of context. Thinking through how one's Christian faith is lived out in the complex world of contemporary nursing is not an easy task, but it is a rewarding one. It is also a task that can be greatly assisted by turning to some of the resources that the Christian tradition has to offer. In the mid-1970s, James Gustafson, a leading figure in Christian theological ethics, published a book that posed the question Can Ethics Be Christian? To many people the question seems absurd and the answer obvious: Of course ethics can be Christian. Christians are ethical people, and their faith calls them, among other things, to live moral lives. But Gustafson points out that what Christians take to be the right thing to do, or what they identify as a good way to live, looks pretty much like what is generally accepted by nonChristians. And, in fact, Christians do not claim that only Christians can be moral. Any Christian nurse has colleagues of other faiths, as well as nonreligious colleagues, who carry out their responsibilities in ways that are clearly moral. Loretta is likely to respond to her encounter with Mr. White in similar ways, whether or not she is Christian. Both a Christian Loretta and a nonChristian Loretta would maintain professional standards, treat clients with respect, and show concern for the good of the client. If ethical actions are based on principles that are shared by Chris tian and nonChristian alike, then what makes Christian ethics Christian? Does a "Christian life" refer simply to whatever is left over when we subtract from the realm of

morality anything that could be justified on nonChristian grounds? That leaves us with a very small realm of Christian life! In the realm of nursing this would mean that only the portion of nursing practice that is unique to the way Christians act would really be Christian nursing. This slim remainder, however, is not all that there is of Christian ethics, nor is the broad agreement on ethical actions Christians can reach with nonChristians something to ignore or find problematic. After all, we Christians affirm that all things have been created through Christ who is the Lord of all. Since the God of redemption is also the God of creation, we should expect that what is broadly acknowledged as moral - what Hindus and Muslims and even atheists would agree to - squares with much o f what Christians should endorse. We should expect that what is revealed through creation and is, therefore, accessible to all will not be substantively different from what is revealed through the redemption available in Christ. When we turn to professional nursing practice, we find, then, as we would expect, that in the vast majority of cases what the Christian nurse does and refrains from doing is identical to what the nonChristian nurse would do. One does not need to be a Christian to be a good nurse. A syringe is assembled in precisely the same way whether one is Christian o r not. The same is true for the administration of CPR, distribution of medications, charting, completing a health history, teaching a client about a new diagnosis, conducting a community assessment, and so forth. And this is true as well of the nursing practices that are more clearly moral in nature. Nurses, Christian and nonChristian alike, care deeply about the wellbeing of the clients they encounter in all of the contexts in

which nursing is carried out. The ethical principles found in any nursing textbook and foundational to nursing profession and practice are ones that Christian nurses can generally endorse. Christians and nonChristians alike wrestle with the difficulties of mediating between clients, their families and significant others, and other health care professionals. But when we note these large areas of overlap, we might be led to ask, Can nursing be Christian? Is there anything distinctive about the Christian nurse? If there is something distinctive and if Christian ethics does refer to something other than the slim remainder that is not shared with nonChristians, then what is that distinctive "something"? Gustafson proposes that when we are speaking of Christian ethics, we are speaking of the ways in which our faith qualifies our moral lives. By "qualify" he means the ways i n which the life of faith shapes, informs, and modifies our morality. There are several ways in which faith qualifies morality, three of which are particularly relevant to nursing practice. First, faith shapes and qualifies our character as moral agents. Second, faith shapes our perspective as moral agents. Third, faith shapes our values as moral agents. Let's examine each of these briefly. Characte r

When we say that faith shapes our character as moral agents, we mean that Christian ethics is concerned not only with what we do but also with who we are. "The experience of the reality of God," Gustafson argues, "evokes, sustains, and renews certain `sensibilities' or `senses,' certain sorts of awareness,

certain qualities of the human spirit. These in turn evoke, s u s tain , and renew moral seriousness and thus provide reasons of the mind and heart for moral life, indeed for a moral life of a qualitatively distinctive sort" (Gustafson 1975, 92). Awareness of God as our loving Creator, in other words, evokes in us senses of dependence and gratitude, and these senses shape the "sorts of persons" we become and the "reasons of the mind and heart" for being moral. Christian nurses may engage in the same moral activities as nonChristians, but those actions emerge from a different center o f personhood for the Christian, a personhood that has been fundamentally shaped by the experience of God's creating and redeeming grace. Having been shaped as a certain "sort of person" makes the Christian nurse attentive to the structures of creation and to the distortions of sin in ways that are distinctive. As persons formed by senses of remorse and obligation, Christian nurses are especially aware of our tendency to be biased in favor of our own interests. As persons formed by senses of possibility and direction, Christian nurses are attentive to God's continuing creative activity and seek ways to become co-creators with God, conforming our actions and intentions to what we are able to discern of God's direction for creation. Perspective

Faith also qualifies our perspective as moral agents so that we interpret our circumstances in terms of their religious significance. For Christians, this interpretation is always framed by the story of God's creating and redeeming work in human

history as it is revealed to us in Scripture. H. Richard Niebuhr, an important twentieth-century theologian, explained that Scripture helps us to see that our lives do not consist merely in individual episodes disconnected from one another. Instead, all of the moments of our lives are bound together in a narrative that is meaningful. For Chris tians the narrative coherence of our lives exists within and is shaped by God's self-revelation in Christ. Niebuhr explains that whatever else revelation means it does mean an event in our history that brings rationality and wholeness into the confused joys and sorrows of personal existence and allows us to discern order in the brawl of communal histories.... Through it a pattern of dramatic unity becomes apparent with the aid of which the heart can understand what has happened, is happening, and will happen. (Niebuhr 1941, 109) What this means concretely is that we find the meaning and importance of our own life events interpreted through the meaning and importance of the stories of the Bible. We interpret the significance of our circumstances in light of the story of Scripture. Interpreted through the cross and resurrection, for instance, human suffering and death bear a different meaning and significance than they would apart from them. Christians naturally grieve over the loss of loved ones, "but not as those who have no hope" (1 Thessalonians 4:13). For faith to qualify our perspective in this way means not only that we must be attentive to the story of Scripture so that it can illumine our experience, but also that we must be attentive to the context and details of our circumstances.

The facts of existence are like so much loose type which can be set up into many meanings. One man leaves these facts in chaotic disarrangement, or sets them into cynical affirmations, and he exists. But another man takes the same facts and by spiritual insight makes them mean glorious things and he lives indeed. HARRY EMERSON FOSDICK This notion of attentiveness is sometimes captured by using the word discernment. If we are going to be faithful interpreters of the world around us, and faithful hearers of God's call both in Scripture and in the suffering of those to whom we are called to minister, then we need to learn to see and hear the specific characteristics of the world around us. There is a reason why Jesus describes the kingdom of God as a search for hidden details (a lost lamb, a lost coin), and the reason is that God's kingdom is a kingdom where the little things matter. Nurses know this, of course. Care for a client can be good care only when the little things are taken care of. a client who is bedridden is turned regularly to prevent bed sores; the parish nurse remembers details of the lives of people in the neighborhood; the mental health nurse notices when a client is having a good day rather than seeing only the crises. This aspect of care reflects the way God is shown in the Gospels: when Jesus tells us that God cares for sparrows and wildflowers, when Jesus welcomes children or notices

Zacchaeus up a tree. Christian nurses, then, need to be careful, attentive observers of the details of their world, shaped by the stories of Scripture, and able to see life from the perspective of beloved and redeemed children of God. The moment of grace comes to us in the dynamics of any situation we walk into. It is an opportunity that God sews into the fabric of a routine situation. It is a chance to do something creative, something helpful, something healing, something that makes one unmarked spot in the world better off for our having been there. We catch it if we are people of discernment. LEWIS SMEDES Values

Finally, faith qualifies our values and shapes the principles on which we act. For example, Christian and nonChristian nurses alike will strive to respect client autonomy. But the Christian tradition will qualify the meaning of that autonomy for the Christian nurse. As Christians, we know that we are always dependent for our very existence, and for every good gift, on a God of love. So for the Christian, autonomy occurs within the context of a human life that is embedded within a broader context of interdependence. From this perspective, the Christian nurse can see how important other human

relationships are to any expression of autonomy, and in cases such as that faced by Loretta they can work to educate other family members in what they can do to support a client's ability to understand and make good decisions. Likewise, the Christian nurse will strive to enhance and sustain client health but will also recognize that health on its own is not the ultimate goal of human life. We are given the gift of health so that we can live in ways that bring glory to God. While this is a value that the Christian nurse cannot impose on a client who holds different values, it does provide a helpful perspective for seeing how health fits into, but is not the only purpose for, a meaningful human life. This book offers an interpretation of nursing practice that identifies the ways in which faith shapes practice. Because of this focus, we do not spend much time worrying about what the nonChristian would do that would be different from what the Christian nurse is called to do, nor do we try to find actions that are unique to Christian nurses and never performed by nonChristians. Since Christian nursing does not consist of the "remainder" that is left after we subtract all that is common to the way Christians and nonChristians practice nursing, the actions and practices of Christian nurses need not always be different from those of nonChristian nurses. In fact, we are grateful for the conscientious work of the nonChristian nurse and believe that it can glorify God, serve the good of the client, and contribute to the building of the kingdom of God. From the perspective of this book, the question is not, How do Christian nursing practices differ from nonChristian practices? but rather, Who is the Christian nurse? Why is

nursing a noble calling that Christians should be encouraged to undertake? How does the Christian nurse understand her or his relationship to God and how does that relationship shape her or his identity as a nurse? Developing a Christian perspective on nursing practice is a matter of describing what "reasons of the mind and heart" there are for engaging in this work. We are describing the "sort of person" the Christian nurse is and the perspective and values that shape the practice of nursing for Christians. Nothing in this task requires us to reject or belittle the good actions of nonChristians. The identity of the Christian nurse flows from membership in the community of believers, from a relationship with a covenanting God, not from proving that nonChristians are never ethical. Our task is to develop a normative vision of nursing practice for Christians, a vision that acknowledges it as a holy calling and that locates its activities within a broader Christian duty to be responsive to human need and divine providence. The Organization of the Book 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 Go d 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 comprehens ive 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. W e 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 s o 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 - nonmaleficence 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 t h e 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.

PART ONE Christian Faith and Nursing Theory

CHAPTER ONE

A 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 nurs e 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. 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 selfunderstanding 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 b a c k g r o u n d 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 i96o, 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, evidencebased 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. There is a beautiful portion of the gospel that speaks of consecration and I think it is as pertinent to you in health care as it is to priests and bishops. JOHN CARDINAL O'CONNOR 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 i98i). 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 sci ence 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 o f 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. The Goodness of Creation

Theology reflects on religious experience, so a theological consideration of nursing practice must seek the experience of

God in that practice. But where do we encounter God in nursing? As we mentioned earlier, Schleiermacher describes a religious person as one who seeks God in all things. A s overeign and creative God is present to us in all of our experiences, if we can learn to attend to that presence. When we return to the case of Ann, where do we encounter God? We recognize the presence of God, in a very basic sense, in our recognition that Ann's suffering and weakness are conditions to be ameliorated, not celebrated. In the nurse's double consciousness, the awareness of the goodness of creation and of its Creator takes priority over the awareness of tragedy. It is only because of the expectation of goodness and the assumption that the world is well and beautifully made that the recognition of tragedy and the protest of the lament make sense. The Westminster Catechism, a seventeenth-century tool for Chris tian education, captures this sense of the priority of goodness with its deceptively simple first question and answer. It begins by asking, "What is the chief end of humanity?" Why are we here? The catechism provides an equally simple answer, one that any child can learn and understand, but also one that can sustain a lifetime of inquiry. Our purpose is to "glorify God and enjoy him forever." The purpose of human existence is to glorify God, to bring delight to the divine, and this is the same as to enjoy God and bring delight to ourselves. We were meant for happiness, for delight. And in the context of health care that means that health, the goodness of a body and mind functioning as they were made to function, is part of the way the world should be. But how can this be expressed and experienced in the context of nursing

practice? Enjoyment specifies a kind of affective response to the experience of divine goodness. An affection is a kind of emotion that does not simply come and go. It is deeply rooted in the core of our personalities. An affection, then, is like a basic disposition toward God and God's world. Calvin describes the world as the "theatre of God's glory," and he describes our human role as that of spectators who take delight in the display of divine majesty on the stage of creation before us (Lane 2001). In our role as spectators, we discern in the ordering of creation some of the intentions of its Orderer; we sense in the powers that sustain us and bear down on us the presence of the Power that creates and sustains the whole. James Gustafson explains how our affections are formed by our awareness of the creation's capacity to mediate the presence of its Creator. He describes how our affections are formed in gratitude so that we become thankful people: As with the sense of dependence, so in the sense of gratitude the goodness provided by the natural world, by cultures and societies, by other persons, is the glass through which religious persons perceive the goodness of God. The occasions of thankfulness to others for what they have done for us are at the same time the occasions for thankfulness to God.... For all the anxieties and struggles of living, we are grateful to be, to exist. In certain moments of experience we recognize that we have been loved by others beyond our deserving, we have been forgiven when we dared not believe it was possible, we have been sustained by the patience of others when they have had sufficient reasons to reject us, we

have benefited from nature and society more than we have contributed to them. We have received more than we have earned or deserved, and we are thankful. In the religious consciousness these are experiences that open the possibility of affirming the goodness of God; they confirm his goodness which we only dimly and in part apprehend. (Gustafson 1975,101-2) Gustafson goes on to explain that our senses of dependence, gratitude, obligation, remorse, possibility, and direction all originate from our experience of God in creation. Our enjoyment of God, in other words, comes from our sense of the creation as a place of delight. Our ability to be loving and thankful people and to know God as the source of love and the one to whom we owe gratitude rests on our experience of having been loved "beyond our deserving." The priority of the goodness of the creation and its Creator leads theologian Herb Richardson to emphasize our experience of rightness and wellbeing (Richardson 1967, 57-59). Our thinking begins from a foundation in the rightness of creation. This is particularly clear in the practice of nursing. When nurses care for the ill, they do so with a vision of what normal human functioning, what good health, looks like. This is because we have a basic sense of rightness about the world. We observe the structure of the world and affirm that all of its various parts work together in ways that are discernibly good. We also, according to Richardson, have a sense of wellbeing, an awareness that these structures of the world make for human flourishing, that reality is not fundamentally hostile to the human good. We were made for this world, not for some

spiritual, heavenly realm to which we can escape after death. We find in this world the proper context for human life and human work. We see that view of healing in Jesus' ministry. He didn't radically transform those he healed into something other than what they were made and intended to be. Christ's miracles of healing were numerous: the man with leprosy, the centurion's paralyzed and suffering servant, Peter's mother-in-law afflicted with a fever, those possessed by demons, the woman with a bleeding disorder, Jairus's dead daughter, the blind, and on the list goes. The Gospel writer Matthew simply tells us, "Many crowds followed him, and he cured all of them" (Matthew 12:15). In each instance, it is apparent that Jesus was restoring normal function and good health. Extremities could now bear weight; arms could once again extend and perform a full range of motion; skin was intact; platelets facilitated proper clotting; eyes could see; minds could comprehend the world around them - in each instance Jesus restored what was intended to be in the goodness of creation. Jesus' healing ministry affirms that this world is the right and proper context for human life. We have, then, a sense of rightness and wellbeing about the world, a sense that we fit here. Nurses assume this rightness as they seek to promote, enhance, and restore their clients' sense of wellbeing. Nurses attempt, in other words, to conform the is, the current situation, to the ought. For the Christian nurse, the theological framework of a creative, loving God provides the background for the recognition and pursuit of health. In his famous work The Nature of True Virtue, written in the e a r l y eighteenth century, Jonathan Edwards likewise

acknowledges this sense of rightness and wellbeing. If one believes that the world is well and beautifully made, he argues, then ethical action does not aim, first and foremost, to transform the world fundamentally. Rather, we consent to God's ordering of the world. We might call this an ethic of consent. "True virtue most essentially consists," he explains, "in benevolence to being in general" (Edwards 1991, 3). This doesn't mean that Christians adopt a fatalistic acceptance of whatever happens to occur. It means, instead, that virtue begins with recognition of the underlying goodness of the whole and aims to bring parts of that whole back into reconciliation with that goodness. Christians sometimes become so busy trying to transform the world and claim it for Christ that we forget that God's declaration in Genesis that "it is good" means that the world is a hospitable place for us. It means that it has already been claimed by Christ who, as the Word of God, formed the creation and is still reforming it. For the nurse this ethic of consent functions at many levels. It means that, as Margaret Mohrmann points out, the human body is reliable and can be trusted. The body needs restoration at times and even occasionally extreme interventions such as surgery. At the same time, however, we should not treat its most basic functions as if they were pathological or fundamentally flawed. Bodies work, much of the time, the way they are supposed to work, and health care should work with them. An overemphasis on the power of science and new technologies can lead us to believe that we can improve on nature in a number of ways, from advocating caesarean sections even when a pregnancy is progressing normally to putting small children on diets because their bodies are

chubby. As we know in retrospect, these are problematic interventions, generated by misunderstand ings of the nature of a healthy body. But they also represent a failure of trust in the goodness of our bodies, in the goodness of creation, and ultimately in the goodness of its Creator (Mohrmann 1995, i6). The ethic of consent also means that, insofar as human institutions participate in the goodness of creation, Christian nurses need not assume that they will be in conflict with the institutions in which they work, even though those institutions may not be explicitly Christian. All creatures experience, at some level, this sense of rightness and wellbeing. There is no one, in other words, who utterly lacks a "sense of the divine," and because of this we should expect that Christians will find large areas of common interest with those of other faith traditions (and even with those who hold to no faith at all!). Given that these common interests are part of our created nature, we should also expect them to be evident in our organizational structures. When institutions are structured to promote physical and psychological health, when they operate in ways that protect the wellbeing and dignity of the clients who use their facilities, then the Christian nurse can participate in them and affirm their goals. These institutions can surely embody our sinfulness (think, for example, of how racism and sexism take on institutional lives of their own), but they also manifest the fundamental goodness of creation. The gratitude, enjoyment, rightness, and wellbeing that are rooted in the first part of the nurse's double consciousness mean that we are called to respond to those who evoke gratitude and enjoyment as those who belong to God.

Gustafson characterizes the task of theological ethics as one of seeking to "relate to all things in a manner appropriate to their relations to God" (Gustafson 1981, 158). If our lives are to be lived for the glory of God, are to be fitted to the divine purposes, then we must relate to those around us in ways that acknowledge their role as mediators of the divine. Our basic posture toward God, which Gustafson characterizes as one of "reverence, awe, and respect," is reflected in our posture toward God's creatures, for they are tokens of the divine (Gustafson 1981, 201). Though we must never confuse God and creation, we do seek God in and through God's creatures. The goal of organizations that provide health care services is helping individuals maintain their health, regain it if they have had some disturbance in their health, prevent reoccurrence of illness and disease, if possible, and learn to cope with chronic illness or disease. IMOGENE KING Nurses find in their colleagues and clients persons who prompt them to live in gratitude and delight, who move them to enjoy the creation and to enjoy and glorify God through that creation. It is perhaps easiest to see how nurses show respect to their clients as those who belong to God. This respect is everywhere present in Janet's interaction with Ann. She greets Ann and speaks with her as one worthy of her time and energies. Even when Ann is disoriented and incoherent, Janet

owes this respect to her. Likewise, Janet never touches Ann or carries out any kind of intervention without first explaining what she is going to do. No matter how badly deteriorated her body is and no matter how uncomprehending her mind, Ann's body and mind must be respected as tokens of the divine. Janet offers a ministry to Ann that shows the love of God, and this is an entirely appropriate way for the Christian nurse to understand what she or he does. After all, Christ said, "just as you did it to one of the least of these who are members of my family, you did it to me" (Matthew 25:40). Ann - in her current condition - certainly qualifies as one of the least of these. The simple act of combing Ann's hair is transformed into a theophany, an experience of the presence of God, when one approaches it as a religious event. Janet, in other words, can manifest the comforting love of God to Ann through her interventions. But we cannot stop there, or we will miss an important aspect of Christ's words. The one who offers aid to one of the least among us encounters Christ in that "least" person. Jesus' emphasis was not on the Christ-like character of the one offering food, clothing, or shelter, but on the Christ-mediating presence of the one receiving care. The God of sovereign beauty is manifest in the bloated, confused person of Ann; she mediates the presence of God to Janet. We are used to thinking of God as manifest in gracious service, but we need to remember that God is seen in the vulnerabilities and neediness of those we are called to serve. If we forget this important truth, then we not only fail to take in the breathtaking depth and diversity of divine being, but we also deny the client as an image-bearer of the God who comes to humanity in the person

of Christ, the suffering servant. Ann's circumstances offer us the opportunity to encounter vividly the suffering Jesus. In her infirmity, we see images of the beaten, broken, and dying Christ. When the nurse refuses to receive Christ in the client, then the nurse deprives the client of dignity and deprives herself or himself of an important point of contact with God, a source of renewal and refreshment (Mohrmann 1995, 41). Perhaps no scriptural theme so well models the spiritual posture of nursing practice as the Old Testament depiction of Moses and the burning bush.... The nurse's spiritual posture [is as one] "standing on holy ground." ... We will respond to our patients as we would wish to respond to God in the burning bush. MARY ELIZABETH O'BRIEN When the nurse clinician ... stands before a patient .... God is also present.... For it is here, in the act of serving a brother or sister in need, that the nurse truly encounters God. MARY ELIZABETH O'BRIEN Jesus himself modeled how we are to engage appropriately with "the least of these" as image-bearers of God. In Luke 7:1117 we are told a story of Jesus' response to a woman's

paralyzing grief. Jesus encountered a funeral procession at the gate of the town of Nain. He learned that the man who had died was his mother's only son and that she was a widow. The author of Luke tells us that Jesus "had compassion for her," and so he raised the son from the dead. Jesus recognized the p articu lar grief that this woman experienced: she had previously lost her husband and now her only son. This would be a devastating set of losses for anyone, but especially for a woman in an ancient society. Jesus felt compassion for her in her fragile and vulnerable state. Likewise, Christ's empathy permeated and literally touched the multitudes of other suffering, vulnerable, and outcast persons that he healed. Jesus often identified himself with social outcasts. He ate and drank with sinners and tax collectors. He considered women to be worthwhile conversation partners. He treated with respect those who were considered beneath contempt. In short, he upset social expectations about respectability, righteousness, and purity, and he calls us to do the same. When nurses, mindful of the grace that has been extended to them in their unworthiness, model themselves on Christ, they approach the vulnerable as mediators of the divine, they respect the dignity of those whom our society would cast aside, and they treat with respect even those, especially those, whom they consider to be sinners. Because we recognize God's presence in the vulnerable and weak, both reverence and awe are appropriate attitudes for the Christian nurse as well. To treat clients with reverence is to honor them as image-bearers of God who escort us into the presence of what Rudolf Otto was fond of calling the "mysterium tremendum," the overwhelming mystery of the

Holy One who binds all of reality together (Otto 1950). Just as we quake in wonder before the majesty of God, so we ought to hold in reverence those who bear God's image. This means that the task of nursing must be approached with fear and trembling, for the ones the nurse cares for are the fragile vessels of the God who weaves a meaningful cosmos out of the chaos of nothing. This is cause for awe, for we are participants in God's creative work as we engage others in the task of seeking meaning. Nurses undertake this wondrous and awe-full task as they promote the health and welfare of their clients, enabling them to pursue their life's plans and purposes. The web of relationships that call for us to reflect reverence, awe, and respect includes not only the nurse and the client but also the nurse's colleagues, health care institutions, and the health care delivery "system" such as it is. The nurse works together with lab technicians, nurse's aides, physicians, social workers, chaplains, clients' families, and administrators. In all of these relationships, the nurse seeks the presence of God and cultivates reverence, awe, and respect. It is important to note that the nurse herself or himself likewise deserves to be treated as one who belongs to the God whom we approach with reverence, awe, and respect. Consciousness of the sacredness of human life and awareness of the way we encounter Christ in those around us generate a commitment to create, maintain, and preserve structures that ensure that everyone is treated with concern and respect. This consciousness will be important in Chapter Four when we consider the ways in which Christian faith shapes the values and principles that guide ethical action in nursing practice.

Sin, Tragedy, and Lament

If the majesty of God shines through the created order, evoking in the nurse gratitude and a sense of wellbeing, then that same light, as it strikes the objects of creation, also casts a long shadow over the nurse's experience. We cannot be honest about the human relationship with God if we fail to acknowledge this "shadow side" of religious experience. The experience of God as it is found in nursing practice prompts an awareness of the goodness of creation that takes priority in the nurse's consciousness, but this awareness does not eclipse the experience of brokenness and tragedy. This other side of the nurse's double consciousness, the shadow side of religious experience, includes two aspects pertinent to our discussion of Christian nursing practice. The first is the experience of selfdeception; the second is the experience of tragedy. The first of these is rooted in our sinfulness, the second in our finitude. When we considered the ethic of consent earlier, we noted that it is grounded in a sense of rightness and wellbeing that reflects a recognition and enjoyment of God's sovereign power over all creation. But this recognition of God's sovereign power, which allows us to discern some of God's purposes from the patterning of creation, also brings forth a different set of affections: bewilderment rather than awe, anger rather than gratitude, lament rather than enjoyment. Consenting to the divine ordering of the world requires an honest assessment of our place in it, and that assessment does not always prompt joy. Imagine the whole creation bound together the way the

points of a cobweb are related to one another. Every point derives its existence and significance from its relationship to the central point, and each point relates to other points on the web on the basis of their relationship to the central point. If we think of God as occupying that central point, then we have the image of a theocentric creation - that is, a creation focused on and oriented toward the glory of God. Each creature comes into exis tence and derives its meaning and purpose for being through its relationship to its Creator. All things exist for the glory of God. Creatures may serve each other's purposes, too, but this is not their primary identity. No creature is merely a means to another creature's end. Every creature is intrinsically valuable. The exacting client who makes constant, inconsequential demands on an overworked nurse and treats her as nothing but a servant has probably forgotten this important truth. The efficient nurse who moves through her client assessments as though those individuals were widgets on an assembly line has also forgotten it. One of the things that happens when we forget that we are to "relate to all things in a manner appropriate to their relations to God" is that we become self-deceived. Rather than living our lives out of a theocentric orientation, we become anthropocentric or egocentric in our orientation. We think, in other words, of the human species and its good, or of ourselves as individuals, as the central purpose for the creation. In that perspective, all things exist to serve our purposes; all things derive their meaning and value from our priorities. Plants, animals, even other people are seen as valuable only if they suit our plans. Even God is moved to the periphery and given a minor role that serves our good - God

becomes the heavenly sugar-daddy who doles out blessings at our prayerful request and who ultimately exists to save our immortal souls and provide them with a happy afterlife. In short, we put ourselves in the place of God. But this is all an elaborate self-deception rooted in our unwillingness to acknowledge that we are not God and that all things do not exist for our sake. This can happen in subtle ways. Nursing is a practice oriented toward the preservation of life, and this is a good thing; but it is not an absolute end in itself. If, for example, Janet can find her work meaningful and worthwhile only when its goal is the preservation of life at all costs, then she cannot care effectively for Ann because she is fundamentally deceived about the nature and limitations of human life. Such a view of health care demonstrates a refusal to accept the reality of death and to acknowledge that we will not live indefinitely. At bottom this refusal, this self-deception, is an effort to transfer divine infinitude to the finite and fragile h u ma n frame. It is a form of self-deification wherein the continuation of physical existence becomes the highest good. And if we operate with such a distorted picture of human life as the absolute good, we cause destruction to the very lives we should be treating with care and respect. There comes a time in some lives when death is a gracious relief from inconceivable suffering, and if we arrogantly insist on using every resource to stave off death, which ultimately only prolongs suffering, we do so out of a mistaken desire to pretend that human life is not finite. To preclude misunderstanding, it is worth noting that this is not intended to be an argument for active euthanasia. It is,

instead, an argument for recognizing that the attempt to use interventions to stave off death should come to an end at some point, in recognition that human lives, on this side of the general resurrection, do not continue indefinitely. We are finite creatures, and respect for that finitude includes the recognition that at some point we should no longer attempt to prolong life at whatever cost. The unbounded fight to prevent physical death represents an idolatry of physical human life that is generated by self-deception about our place in creation. One of the great strengths of the Christian faith is that it takes our capacity for self-deception - our ability to confuse ourselves with God - as a central theme for theology. Christianity acknowledges that even religion can be associated with self-deception and self-deification. Because of this, Christians must always be self-critical. We must always seek out the hidden idolatries in all of our activities. When we begin to assume that all things exist for our sake, we also begin to feel the weight and responsibility of being God. Suddenly the salvation of individuals falls to us! But this is an illusion, for salvation is a gift from God. God claims us before we are ever capable of claiming God. Confusion about our role can lead Christian nurses to forget this central affirmation of the faith. They come to believe that they are acting as Christian nurses only when they are "witnessing" to their clients, when they are being explicit about their faith and trying to convert the client. Or, worse, they can think of their vocation as a nurse as merely a pretense to get at vulnerable clients and convert them. But because we are not God, and because salvation is the work of God, it is not our

responsibility to save anyone. This is not to say that there is never a time when Christian nurses should speak of their faith with clients. The spiritual dimensions of nursing care are central and important, and nurses who are open about their own faith commitments are better nurses for it. But acknowledging one's faith and being open to the spiritual needs of the client are not the same thing as confusing nursing with evangelization. Nursing itself is a valid Christian ministry, responding to Christ's call to care for the least of these, and should be treated as such. Sinful self-deception sometimes operates subtly - for example, when we value human life as if it were the absolute good or when we are led by genuine concern to ignore the constraints of respect and manipulate clients' vulnerability in order to feel that we have saved their souls. But we also need to have a clear vision of the ways in which self-deception operates in more obvious ways. When we label a client "noncompliant" or ignore the call light and repeated requests of a demanding client, we probably have some justification, but we run the risk of justifying too much. When we simply give the medication ordered by a cantankerous physician, rather than calling to check on a dosage that looks wrong, we may be choosing not to see what we should see. Self-deception also plays a deep and abiding role in the many ways in which we fall short of living a life that brings glory to God and contributes to the wellbeing of those we are responsible for. We need to learn to see the workings of this self-deception and self-deification in our own lives, as we can so often see it in the lives of others. The awareness of our sinfulness forms one part of the

"shadow side" of the nurse's religious consciousness. But another important dimension is rooted in the simple fact of our finitude. Even if Janet recognizes that human life comes to an end, her recognition does not cancel out Ann's misery, because the suffering itself is not a result of our self-deception. It is real. The Gospel accounts of Jesus' life give ample evidence that he understood the reality and full range of human suffering as he took on human form and appearance for the sake of our salvation. Jesus, the Messiah, was betrayed, mocked, taunted, spat upon, flogged, and nailed to the cross, where he endured a slow and tortuous death. Jesus' death likely entailed some of the same horrible elements of physical suffering that nurses often see in their dying clients exhaustion, searing pain, gasping for breath. Christ's experience with suffering validates the reality of human suffering in general and offers the assurance that our particular suffering is not foreign to him. Ann suffers as her body is failing, and Janet suffers as she struggles with a sense of futility that her care cannot reverse Ann's deterioration and pain. Ann is dying, and therefore she needs a different kind of care than she would if she were suffering from a reversible condition. Even if Janet acknowledges this fact and comes to enjoy the work of palliative care as a way of consenting to human finitude, she will still, no doubt, be confounded by the reality of suffering. A careful examination of the structure of creation reveals that not all of God's purposes are to do with us, and not all of them conform to our immediate good, or at least to our perception of it (Gustafson i98i, 202). It is far easier for the zebra to consent to the divine ordering as it munches on the

grasses of the savannah than to do so in the mouth of the lion. And we should expect that, even as the zebra struggles against the lion's jaw, so Janet will protest the raw evil that decimates Ann's body and unravels her mind. But we prefer to imagine that there is never a time in the proper ordering of things when we belong in the lion's mouth, or its equivalent in human experience. This happens in part because we are deceived about our place in the world, deceived into believing that we are the ultimate reason for its existence and that the rest of creation derives its meaning and purpose from its relationship to humanity. But there is more to it than that. We can certainly recognize that there is something wrong with asking the zebra to take delight in being devoured by the lion even if it is part of how God has ordered the world. We expect the zebra to put up a fight. Likewise, an ethic of consent could be nothing but perverse if it called for human beings to submit gleefully to the process of degradation that ultimately ends in our deaths. So what should our response to this suffering be? Should we assume the cowering posture of a slave who hopes the master will be merciful? Should we bargain our way toward a better life, promising to be good in hopes of reprieve? Should we lie to ourselves and say that God never gives us more than we can handle? Or that suffering is good because it gives us a chance to develop character? Or that we would not call it suffering if we could see the big picture? The Bible, especially in the Psalms and Lamentations, proposes a different response: lament. The book of Lamentations was written during a time when the Babylonian army had besieged and then destroyed the city of Jerusalem. Thousands had been killed. Thousands more were starving. Here is part of what Jeremiah said:

The LORD has done what he purposed, he has carried out his threat; as he ordained long ago, he has demolished without pity... Cry aloud to the Lord! O wall of daughter Zion! Let tears stream down like a torrent day and night! Give yourself no rest, your eyes no respite! Arise, cry out in the night, at the beginning of the watches! Pour out your heart like water before the presence of the Lord! Lift your hands to him for the lives of your children who faint for hunger at the head of every street. Look, 0 LORD, and consider! To whom have you done this? Should women eat their offspring, the children they have borne? Should priest and prophet be killed in the sanctuary of the Lord? The young and the old are lying on the ground in the streets; my young women and my young men have fallen by the sword; in the day of your anger you have killed them, slaughtering without mercy. (Lamentations 2:17-21) Notice that Jeremiah addressed these laments, not to the Babylonians, but to God. It is to God that Jeremiah says, "you have killed them, slaughtering without mercy." He encourages the people of Jerusalem to "cry aloud" and to "lift your hands to him for the lives of your children." Ultimately, he held God responsible for the suffering, and he protested that suffering to the powerful God whom he knew as the only source of hope for renewal and restoration. The lament does, in the end, look to God for restoration and comfort, but not before it first raises its complaint. It does not gloss over that suffering in its recognition of God as the source of life and hope. Most of us are unaccustomed to the lament and

uncomfortable with the idea of raising a clenched fist to the God who made us and who can unmake us. But consider what freedom the lament offers and what is lost if we deprive ourselves of it. Lamentation gives us space to voice the very real pain and suffering that we experience. It does not demand that we face all of life's trials with an unrealistic piety that expects joy at every turn. Lamentation gives us permission to lay our troubles at the feet of the One who is powerful enough to do something about them. Lamentation tells us that anger with God can be appropriate and that God is "big enough to take it" if we need to shake our fists and cry out in rage. Even Jesus, while suffering indescribable agony on the cross, lamented. His lament was directed, as was Jeremiah's, to God the Father. He cried out, "My God, my God, why have you forsaken me?" (Matthew 27:46). Why have you abandoned me i n my suffering? Where are you? This is the human cry of lament. Lament does not end with anger and gall. It moves us toward peace without offering any false or easy solutions. Jesus cried out the beginning of Psalm 22 as he was dying on the cross, but that psalm concludes with the confidence that God will bring deliverance. Similarly, Jesus himself, after uttering these words of lament on Good Friday, greeted his disciples on Easter Sunday with "Peace be with you" (Luke 24:36). Deliverance had been won. Only someone with a sense that the world is not as it should be, only someone with faith in a God who cares about suffering, would bother to raise the lament. It is precisely a person of faith's confidence in God's goodness and power, in other words, that makes the protest of the lament possible.

Nurses are witnesses to some of humanity's greatest suffering. As witnesses they are the ones who observe and who can testify to the reality and meaning of that suffering. This is the true sense of nursing as a Christian witness. Nurses care for people who are fearful, in pain, lonely, confused, and vulnerable. And it is not simply individual human suffering that affects the nurse. The inadequacies of our health care system, which asks health care providers to do too much with too little, the social structures that make that health care inaccessible to a significant portion of the population, the hierarchical mindset that can relegate the nurse to the status of mere servant - all are cause for lament. It is simply inhumane to expect nurses always to offer comfort without also providing some means by which t h e y can vent the very natural frustration and anger that accompany this form of work. We ask nurses to be something other than real and full persons when we expect them to deal with suffering day in and day out without ever raising questions about it or being hurt by it themselves. This experience of being confounded by evil forms an important part of the nurse's religious consciousness, and we cannot ignore it if we are to develop an adequate theological reflection on nursing practice. Being a Nurse, Being a Christian A casual observer watching Janet comb Ann's hair might not see what we have just seen: that this simple act emerges from, shapes, evokes, sustains, and expresses certain forms of religious awareness in Janet (and perhaps in Ann, too - but an analysis of that is not our focus here). On the one hand, experiences of working toward the restoration of health and of

caring for suffering evoke in Janet an awareness of the goodness of creation - a sense of delight in the world God has made, confidence that we were made for this world, and gratitude that it is the realm in which we find meaning and purpose. On the other hand, those same experiences simultaneously evoke in Janet anger and frustration not only with the structures of human sinfulness but also with the very fact of our finitude and the pain and tragedy that accompany it. 0 Lord our God, we see in a mirror darkly. But we see there the face of your Son, who suffered for us. Though faith fails and hearts sink, we know that he has led the way through suffering to a peace that passes understanding. CORNELIUS PLANTINGA These forms of awareness are ultimately religious in nature because they concern our basic orientation toward God and God's world. If we excavate the Christian nurse's concerns, we discover that beneath the layers of thought about efficiency, technique, procedures, scheduling, and evidencebased practice rest an abiding conviction that Christians, having been claimed by God, are called to lives of grateful service and a persistent disposition of reverence, awe, and respect. These forms of awareness, in other words, situate us in the world as certain "sorts of persons" (Gustafson 1975). Certain experiences, certain practices bring about particular forms of awareness, and, over time, these settle down into a person and

become more than mere fleeting feelings or passing thoughts. They become abiding convictions and settled dispositions. In other words, they form us as persons. These forms of awareness become the shape of who we are as Christians and as Christian nurses. Now we see our clients in a new light. Now w e interpret and respond to their suffering and joy in distinctive ways. Now we see in them and through them the presence of the divine. Gustafson uses the term piety to characterize this orientation toward God and God's world. Many Christians have negative associations with the term, but Gustafson attempts to rescue it from the misuse that causes these associations. "Piety," he explains, is not a transient emotion, though consciousness of piety ebbs and flows with circumstances. It does not refer to piousness the kind of sanctimoniousness that lends itself to caricature in novels, films, and drama; or to intensity of religious emotion. It is a settled disposition, a persistent attitude toward the world and ultimately toward God. It takes particular colorings or tones in particular circumstances, but awe and respect are the fundamental and persisting characteristics of piety. (Gustafson 1981, 201) What we seek in this book is to explore the "particular colorings or tones" that Christian piety takes on in the "particular circumstances" encountered by nurses in their professional practices. This is quite simply an exploration of what it means to be a Christian nurse. Or, as we explained in the Introduction, it is an exploration of who the Christian nurse is,

mo re than it is an explanation of what Christian nurses do differently from other nurses. What "sort of person" is the Christian nurse?

CHAPTER TWO

A Christian Vision of Nursing and Persons Being a Christian nurse is not only about what one does but also about who one is. So who are nurses? How do they become the sorts of persons who are suited to nursing practice? What kinds of contexts shape their work? What kinds of assumptions do they make about what it means to pursue and promote the health and wellbeing of their clients? In many ways, Christian nurses will find that their assumptions about the nature of nursing practice, or health, or the like are shared with nonChristian nurses. We share a common created nature and should expect to find such agreement. But there are also ways in which the perspective of the Christian nurse enriches or deepens his or her understanding of these foundational concepts, and it is important to note this as well. Christianity qualifies and shapes the people who become nurses, the ways in which they interpret their circumstances, and the values that guide their actions. In this chapter we examine more specifically how it does so. It is common in introductory nursing textbooks to refer to four concepts that are foundational for understanding professional nursing practice. These are sometimes called the four defining or "metaparadigm" concepts, namely: nursing, person, health, and environment. This chapter offers a fresh

and distinctively Christian interpretation of the foundational concepts of nursing and person. These two basic concepts are then situated in the next chapter in terms of a Christian understanding of health and environment, the second pair of metaparadigm concepts of nursing theory. Nursing: Practitioners and Their Institutions If we went out and asked most nurses what it is that they do, they would be likely to answer in terms of specific kinds of nursing. "I'm an acute care nurse," one might say, "with a primary specialization in ICU nursing." Or "I'm a visiting nurse with a Hospice program. I do a combination of community nursing and end-of-life care in the context of a Hospice setting." Or "I'm a nurse in an Ob-gyn practice where I do client education." If we pressed a bit harder, these same nurses might go into more detail in terms of the specific techniques and practices involved in their work, whether monitoring client status in the ICU or working on pain management techniques with clients facing terminal illness. And of course these are all accurate descriptions of what a specific nurse might find himself or herself doing in a particular nursing role. But we might be asking a slightly different question here when we ask what nurses do. We might be asking less about the actual specifics of a particular aspect of nursing and more about what it means to be a nurse. That is, we might be asking questions about what it is that makes nursing a specific profession, rather than a subset of some other profession (such as medicine or social work). And we could also be asking questions about what the ideals of nursing are, both in terms of

the profession as a whole and in terms of the practitioners. Every profession has some sense of what it should be and what its practitioners should be like, and though the ideal is generally not realized in every particular, it nonetheless shapes the way professionals understand themselves and their identity.

Nursing as a Social Practice

When we ask questions of this sort, we are treating nursing as a social practice. That is, we are thinking of nursing not just as a job someone might have but as an identity in some sense. For the purposes of this book, we will be defining nursing as a social practice, oriented toward a holistic understanding of health, practiced by professionally educated and licensed practitioners. As is the case with almost any profession, undergoing education and becoming licensed as a nurse involves more than just passing certain courses and being able to answer certain questions on exams. Becoming a nurse is a process of professionalization that partly defines one's identity as a person and that shapes one's character in important ways. When I am introduced to someone and ask what he does, if he tells me that he is a nurse I am likely to make certain assumptions about what sort of a person he probably is, and many of those assumptions will turn out to be correct. This notion of a social practice is one that has been developed and analyzed by the philosopher Alasdair Maclntyre, and it has been enormously influential in thinking about how we organize social life, how we understand identity, both of self and other, and what it means to be a particular kind of person. Maclntyre's account of a social practice is helpful for thinking about what nursing is and about how nursing as a profession shapes the identities of nurses, so we will borrow certain aspects of it for our discussion here. Maclntyre's definition of a social practice reads as follows: By a "practice" I am going to mean any coherent and complex

form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence, and human conceptions of the ends and goods involved, are systematically extended. (Maclntyre 1984,187) 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 midi6oos 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 s ys tem 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 wellbeing. 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 selfdefinition of nurses, and it involves a shift in the central goods of nursing from a more servicebased model to a sciencebased 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 d o 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 levelheaded 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 wellbeing of others. This overlap is due in part to the fact that nursing as a practice w a s 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 sciencebased 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 profes s ional 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 nurs e 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 bestcase scenario the gap is a minor one.

Nursing is a learned profession that is, it is a science and an art. MARTHA E. ROGERS As is often the case, the very characteristics that are the strength and pride of nursing can sometimes also contribute to problems in nursing. As sociologist Daniel Chambliss notes, the knowledge and professional education of nurses makes it hard for them to be understanding toward clients who choose to remain ignorant about their own condition and who make choices that seem trivial and silly from the perspective of a health professional (Chambliss 1996, 124). The very virtues of professional education can make it hard to avoid treating such a client patronizingly. It remains a challenge for the contemporary nurse to discern when the characteristics that are inculcated by contemporary nursing sometimes create blind spots. No one had ever understood what the illness meant to this woman before, and the understanding was [a] great gift, because it moved back the walls of isolation and suffering created by the disease. In our strategic, instrumentally oriented culture, we overlook the human importance of understanding. Understanding can be therapeutic or healing even when there are no possible instrumental interventions,

because illness can cut the person off from self-understanding and familiar relationships. PATRICIA BENNER AND JUDITH WRUBEL But the identity of a nurse is formed by more than just the education she or he has received. It is also the case that the practice of nursing shapes who someone is in important ways. We (the authors of this book) had an interesting example of this as we met to begin writing. One of the philosophers in the group mentioned that health care practitioners tended to as s ume automatically that physical health is an individual's highest priority in making life decisions, while philosophers might sometimes be more concerned about logical consistency than health. The remark occasioned a certain amount of amusement among the nurses, and several of the nurses thought that this showed just how irrational philosophers really are! If this sort of assump tion is true, then becoming a nurse is likely to shape one's character in deep and important ways. When one becomes a health care professional, one devotes one's life to the pursuit of human health in general, and health then becomes one of the central values of one's life. This good of health, however, is not the only one that a person can value, and many people do not consider it to be so central. Like the philosopher mentioned earlier, they may have a different set of goods that structure their lives. So in addition to encouraging the development of particular character traits such as responsiveness, nursing also will tend

to structure the basic set of values a practitioner holds. In this way, it is a practice that shapes the professional's life and values in central and important ways. It is important to see this so that nurses (and other professionals) recognize that what they value most highly may not be the central concern for others. But it is also important to see this because it allows the nurse to examine her or his values critically and to reflect on whether those should be values that shape her or his life. The Christian nurse may occasionally find that she or he needs to place the value of health in its proper perspective as a very important good, but not the ultimate meaning of life (Mohrmann 1995,15) Up to this point we have been discussing the nature of nursing education and the relationships nurses have with clients. Nurses work in a context that shapes and structures that relationship because providing nursing care always occurs in an institutional or organizational context. A Christian perspective does not end when one moves from personal to institutional contexts, so it is worthwhile to think about how faith shapes our understanding of the systemic and organizational aspects of nursing practice as well. In the next section we'll focus on two features of institutional organization. The first involves the connections between central values of t h e nursing profession and institutional values. The second examines connections between the nurse's professional responsibility and the professional responsibility of the other actors in the institutional setting. Nursing and Institutional Context

Nursing is a profession that involves the organization of certain caring tasks in society. The social organization of these tasks is vital, since the education of nurses, their licensing, and the structure and responsibilities of their jobs are decided collectively. Imagine the chaos society would experi ence if individuals had to find their own care givers before they entered the hospital, negotiate wages and working conditions, evaluate competency, and ensure compliance. Hospitalization would be an even more harrowing experience than many find it to be now. Organizing nursing care needs to be done at a professional level so that competent care is provided in a regular, continuing, and efficient manner. And because this is accomplished through professional organization, nurses can monitor themselves to a large degree. This is one of the hallmarks of professionalization, and it is also the reason why many professional organizations require members to take an oath or pledge, making a public promise that they will use their knowledge and skills for the wellbeing of those who call on them (Koehn 1994, 56-59). The professional organization of nursing practice is built into the contemporary health care system. This both shapes and constrains nursing practice in important ways. One obvious way it shapes nursing practice is by providing both the financial structure necessary to offer nursing care and the financial limitations of providing that care. Without institutional structures, even the structures nurses complain about most (insurance companies! government agencies!), there would be no consistent way to provide the care that makes up the heart of nursing practice.

As Christians, we may be tempted to become cynical at this point, mutter "render unto Caesar," and pretend that financial issues have no relevance to Christian life and thought. But ignoring the financial structures of contemporary nursing is a mistake. Nursing practice is fundamentally affected by economic structures, whether at basic levels of staffing and salaries or at more general levels of what treatments are funded for which clients. And because nurses are the health care professionals most constantly involved in the day-to-day care of clients, nurses often find that they have to explain to clients what insurance will or will not cover; they may even negotiate with insurance companies as to what, exactly, is meant by a term such as "life-threatening." Given this central role for the nursing profession as a whole, then, it is vital for nursing to be vocal in advocating for financial structures that support rather than prevent good care. But what does this mean for the Christian nurse? We will discuss issues of social justice at greater length in subsequent chapters, but it is worth noting here that an important part of being a professional involves active participation in shaping the organizations of one's profession. Christian nurses have a responsibility to partici pate in productive ways in professional organizations, to speak out on issues on which they have expertise, and to contribute to the internal development and growth of the profession. Participating in professional organizations, while important, is not the most obvious aspect of institutional structures that the nurse confronts on a day-to-day basis, however. The organization that structures the nurse's life in ways that can be

both rewarding and frustrating is the health care campus within which much care is given. For the acute care nurse, and some types of mental health nursing, this may be the site of professional practice. For the parish nurse this may be the location where clients are sent for care, from which they come needing arrangements for home health care, and the like, but few nurses work in contexts where their practice is not structured by the demands of the health care system. Working in the health care system also involves working with other health care professionals: physicians, technicians, aides, and administrators. The complexities of the nurse/physician relationship have been noted by many researchers and cannot all be examined in detail here, but a few aspects are worth noting in the context of considering how Christian faith influences nursing practice. Nurses often find themselves in a frustrating or difficult situation due to the organizational role they play as mediator between client and physician (Engelhardt 1985, 62-79). The frustrations that can accompany this role are described and analyzed in some of the later chapters of this book, but a few general comments are worth making here. First, the Christian nurse has a sense of confidence in her or his role. Nursing involves advocacy for the client, often the most vulnerable and weakest individual involved in any controversy. The use of professional status and knowledge for the benefit of the vulnerable is one important part of the Christian life, and the nurse occupies an institutional role that allows her or him to do this. Further, a Christian perspective can give nurses a sense of freedom from some of the status

fights that often go on in the health care setting over who has the authority to do what. From a Christian perspective it is clear that what is central is that good care be provided in ways that are consistent and fair. Work that involves dealing with the less pleasant aspects of embodiment and sickness are not, from a Christian perspective, inherently demeaning or lower in status. In fact, Jesus specifically names caring for basic bodily needs as the service that is proper to those who would be his followers. Recognizing this, the Chris tian nurse operates from a position of confidence in negotiating with other professionals. What he or she does is important and worthy of respect. If others consider it less valuable because it sometimes requires getting messy, then that reflects badly on others' values. It is important to be clear about what this does not imply. Being a Christian nurse does not require the nurse to give up on basic claims of justice or to cheerfully accept mistreatment or abusive relationships. The knowledge that one is a beloved child of God should always provide a sense of confident expectation that professional relationships will be structured fairly and in ways that protect the basic dignity of everyone involved. We consider some of the aspects of justice with regard to institutional structures in Chapter Four and will say more on this topic later. But the point to be made here is that when nurses are involved in work that others may be tempted to dismiss as "mere service work" or as unimportant because it involves handson care, nurses can confidently reply that this work is central to human life and wellbeing. It is not menial; it does not deserve disrespect; and those who do it deserve societal gratitude and a fair salary.

Noting that organizational structures sometimes treat handson, caring work as trivial or unimportant provides an important transition to our next topic. What is it that allows the Christian nurse to see such labor as valuable and worthy of respect? In part, the Christian nurse can draw on a Christian understanding of what it is to be a person. The Western tradition has tended to define persons in terms of independent existence and rational intellect, while downplaying or ignoring their embodied, emotional, interrelational nature (Benner and Wrubel 1989, 29-54). It can be easy to see caring for bodily needs as a mark of subordination in part because we do not always value or respect our embodied nature. As Christians we have resources for seeing persons in another way, however, and seeing them in that way gives us better insight into what nursing itself is. Persons: Embodied and Made in the Image of God In the previous chapter we met a nurse, Janet, whose client, Ann, suffered from congestive heart failure and edema. Being a competent nurse, Janet took diagnostic information with practiced hands and showed genuine concern for Ann by greeting her warmly and honoring her request to have her hair combed despite the complications this made for Janet. The story of Janet and Ann suggests that an adequate picture of human persons starts with the notion of embodiment: persons are bodily beings. Nursing practices, from the taking of diagnostic information to combing hair, demonstrate the bodily character of the persons involved and the interactions between them. Embodiment involves both

independence and dependence related in interesting ways. A full understanding of what it is to be a person requires us to go beyond embodiment and recognize that persons are created in God's image. In turn, this leads to understanding persons as characters in a narrative, co-authors of the stories in which they are embedded. We'll deal with each of these three concepts - embodiment, the image of God, and the narrative structure of human life - in the sections that follow. Embodiment and Independence

We'll begin with the idea of embodiment. To say that a person is embodied implies two things about being a person. The first is subjectivity, the sense of being a concrete, particular "I," someone who is able to consciously experience her or his life. The second is wholeness. We sometimes elaborate this by saying that a person is an integral unity of a variety of interrelated dimensions: physical, emotional, mental, social, moral, and spiritual. Wholeness and subjectivity are connected to each other. The unity or integrality of being a person is what makes it possible for someone to speak of himself or herself in the first person, as an "I." We sometimes call this concrete unity of being subjectivity, or being a "subject." These two notions of unity and subjectivity are central components of being a human person, but when we start with them we run the risk of implying that all persons have this sort of wholeness and sense of self. This clearly isn't true. Some people lack any sense of self, perhaps because they suffer from Alzheimer's or some other cognitive dysfunction. Others lack physiological wholeness because their bodies have been

ravaged by disease or they've been badly burned. So how do we maintain our sense that being a person involves wholeness and subjectivity, while recognizing that some persons lack both of these to some degree? What we need to recognize is that wholeness and subjectivity are part of the way humans are supposed to be. When we recognize another as a person, we recognize that both of these features should be attributes of his or her life. One of the aspects of health that nurses often work toward is the restoration of wholeness and subjectivity when these have been diminished by disease or accidents. In some cases we deal with persons who will never gain or regain these capacities, as when we work with people with severe developmental disabilities. In such cases we recognize the capacity only in its absence, and this can be cause for lament. There is another danger in starting our discussion of personhood with the notion of embodiment. When we think of embodiment we often first think of the body as it is portrayed in anatomy and physiology textbooks: as a system of cells organized into tissues, organs, and organ systems that function together as a body. The body is portrayed as a physical something that can be operated on, studied by science, and so forth. This picture of the body is extremely useful and important for nursing practice, and it produces what we might call an objective account of the body, an account that is the result of focusing on the body as an object of study. The result of such study is a picture of the body as a sophisticated but purely physical mechanism. We need to recognize, however, that this picture of the body as an object is an abstraction. Our first experience of the

body is our own lived experience of being embodied, of seeing the world from this particular location, reaching out for a cup of coffee, waking up and stretching in the morning. To begin to see bodies as objects rather than people requires us to abstract the body from its immediate context of the concrete, living person and to focus solely on its physical (physiological, biological) aspects, as an object. This process of abstraction is part of the process of education as a nurse, and although it feels natural once one has been socialized into nursing, it is worth remembering that it is not natural for those outside the health care context (Chambliss 1996, 26-28). Although this abstraction is both important and necessary for scientific study of health and disease processes, we should keep in mind that abstractions are always partial and that the concrete person is more than physiological processes. Keeping this cautionary note in mind, we will use the term embodied to refer to the concrete person: the embodied subject. Embodiment does not refer to only one aspect of the person, namely his or her physical dimension, abstracted from the other dimensions (emotional, social, moral, spiritual, and so forth) or abstracted from the fact that such a person is an "I," a subject. Instead, embodiment refers to a unified, integral someone who can say "I," an embodied subject, the concrete person before any ab straction occurs. Embodiment is, first of all, the person as a unified, particular "I." Part of the character of embodiment involves the occupation of a location, here and now. This means that as a creature I am not just any old where, nowhere in particular; certainly I am not, more fancifully, everywhere in general. Thinking back to

our example, Janet was in a particular location, Ann's room, standing beside her, with the early morning sun shining on the floor and wall. Being finite, being creatures, means that we are always located in a particular place and time. Spatial and temporal location is what makes being a human "I" possible at all. And it is also a central aspect of the recognition of another person as an "I" in her own right. Janet recognizes this particularity when she addresses Ann by name. To call another by name is tacitly to recognize that person as an "I," a concrete person, rather than as an abstraction or a role. When we refer to someone as "the congestive heart failure in room 3574" or "the complainer down the hall" we diminish that person's subjectivity. Names are important precisely because they recognize our embodied specificity, the particular person that we are rather than the interchangeable occupants of a hospital bed. In addition to location in space and time, embodiment also implies that I have some independence from my surroundings and can interact with them in ways that are satisfying and meaningful for me. Enjoying the taste of freshly baked bread or the warmth of a cozy house on a cold winter's evening offers evidence of my relative independence and ability to interact with my environment in ways that are satisfying and pleasurable (Levinas 1961, 11o). The senses of rightness and wellbeing that we discussed in the last chapter are related to enjoyment. Enjoyment is one way in which we feel those senses in our everyday lived experience. In other words, we become aware of our sense of rightness in moments when we experience enjoyment.

When we are not able to interact in satisfying ways, we experience this as a lack of independence and find it frustrating and sometimes painful. Enjoyment, then, is an integral, interior aspect of the subjectivity of embodiment. We see this even in situations where one might not expect to see much joy. Ann's desire to have her hair combed is a small request, but it touches the core of her subjectivity and offers evidence of her ability to experience some of the basic physical pleasures of life. The caring nurse, in fact, notices when such requests diminish or disappear. This is a bad sign, an indicator that a client is losing a sense of self. In these cases the client has a diminished sense of subjectivity, manifest in the lack of enjoyment of minor bodily processes. Enjoyment is a delight that comes with wellbeing, and its absence is always a danger signal. Even when wellbeing is no longer robust enough to sustain much independence as we normally think of independence, in terms of directing the course of one's life and activities, it is still possible for an individual to experience the small physical activities of the day as a source of satisfaction. The enjoyment of embodiment constitutes the standing possibility for thanksgiving: a heartfelt thanks for goodness, delight, and life. And so we return to themes developed in our first chapter, as we see that for the Christian nurse even the most mundane activities can be experienced as participating in worship and gratitude and delight. But there is more to our relative independence than enjoyment. Separation from our environment as bodily creatures makes us beings that can have certain amounts of control over what we do, where we go, what we will eat, who

we will talk to, what we will say, and what we will decide. Janet's activities in the hospital room were actions, the activity of a being with agency, as was Ann's request. Being an embodied person, an "I," means to be a point of origin of deliberate, voluntary, particular actions; in other words, it means having agency (Merleau-Ponty 1962, 137). To be an "I" is to have agency with respect to my surroundings. Again, of course, we need to recognize that this is a description that begins with how things ought to be. Too often in life we experience a frustrating lack of agency in our own case or that of others. Sometimes this is merely temporary, other times it is lifelong, and always it is cause for a certain level of frustration and lament. This brings us to a second aspect of being an embodied person, namely dependency. Embodiment and Dependence

Ann's situation indicates ways in which she is capable of acting as an embodied agent, but it also points to the other side of embodiment - dependence. Dependence is universal. We are dependent on the ground on which we walk and on the air we breathe. These universal dependencies remind us of our constant dependence on God's continuing creative and sustaining work. We also depend on the other people and the social institutions that provide the context within which we act and live. Human life makes sense only within an interdependent web of relationships. As embodied, dependent, and interdependent creatures, then, we are vulnerable. Embodiment is a fragile state; enjoyment is always precarious. And because we are embodied and vulnerable, we cannot ignore the environment within which we function. When we

discuss health and environment in the next chapter we will see how dependent we are on environmental factors, but for now it is important to note that embodiment always involves a tension between agency and dependency. We are always vulnerable because we are always dependent. In fact, part of embodiment involves our knowledge that there will come a time when each of us ceases to be an "I," when the elements out of which we are composed no longer make up a person. The vulnerability of embodiment constitutes the standing possibility for lament: an anguished cry against suffering, degradation, and untimely death. Health is not only to be well, but to be able to use well every power we have to use. FLORENCE NIGHTINGALE There is yet another side to being an embodied person, related to both vulnerability and agency - namely, openness (Levinas 1987, 146). Embodiment means permanent exposure to incoming disruptions. Because we are located in space and time and in relations of interdependence with other people, we are always in a position to be interrupted by other things and, more importantly, other people. This is not something we have any choice about. Right from the start of life we find ourselves constantly in relationships where others make decisions that affect us. As we grow and gain some relative independence we have more control over some of these mutual interactions, but especially in occupations such as nursing that involve constant attentiveness to others' needs we are never free from

the demands of others. And though a bit more time away from others' demands generally sounds attractive, none of us really wants to be isolated and completely alone; there are few things more damaging to selfhood than extended solitary confinement. A basic part of embodied personhood is this openness to other selves. Openness means that persons are always formed by reciprocal interdependence. Janet competently took information from an objective body - blood pressure, oxygen levels, pulse, urine output - but while she was doing that she also attended to Ann as a whole person. Janet greeted her warmly, asked an open-ended question, listened for the answer, complied with the request, and didn't draw attention to its complications. This sug gests a fundamental openness, an attunement to others. It also requires that we set aside expectations and prejudgments so that we can be open to others as the vulnerable, enjoying, embodied beings that they are (Olthuis 2002, 128). Openness thus also points to the responsibility we have to and for the other person. While we generally begin with an assumption of our own freedom and agency, part of being an interdependent person is to feel the need to relativize one's own freedom because of responsibility to another person. To be a person is to be called to put one's agency to work for the good of the other person, to care for that other person. We experience our own openness when we recognize that we have a responsibility, here and now, in this relationship, to care. Being a person involves having a responsibility to care for others, and this responsibility is a part of the interdependence

that marks the human condition. Most nurses, of course, have no trouble remembering that they have a responsibility to care for others, particularly clients, since that is built into their professional identity. But this relationship of responsibility is a reciprocal one, not a one-way street. At the same time that the nurs e cares for his or her client, we frequently find that the client responds by trying to take care of the nurse. The client denies her pain because she doesn't want her caregiver to feel distress. Or the client makes sure he asks about the nurse's life and family. These gestures can be awkward, but they indicate that the client feels a need to be in a reciprocal relationship. Sometimes it is tempting for the nurse to brush these gestures aside as impertinent, and they can be inappropriate and intrusive. But at the same time, recognition that the client is not an entirely passive object of the nurse's care is an important part of the relationship between these two embodied persons. It is a relationship of interdependence, though not of equal dependency. Failure to recognize this interdependence and reciprocity of the nurse-client relationship can result in what William May has described as the "conceit of philanthropy," which assumes that the world can be neatly divided into caregivers and care-receivers, which lends an air of superiority to the caregiver (May 1975, 37). Persons as Image-Bearers

This recognition that being a person always involves interdependence and responsibility naturally brings the discussion for Christians to the notion of persons as bearers of the image of God. One way we bear the image of God is in being God's stewards - representatives, co-workers, co-

authors, signs of God's reign - here on earth. To be an imagebearer is also to be oriented toward our neighbor (Berkouwer 1959,151). In discipleship, life becomes a truly human life, lived in service of God through attending to one's neighbor. This means, of course, that there are at least two imagebearers in any relationship: the one who is being neighborly and the person to whom one is neighborly. Recalling our discussion earlier about location, we can say that the term neighbor involves a closeness that includes openness and care for the other. So the call to be a neighbor is the call to image God in caring action. Using our freedom to respond to others' vulnerability in responsible action shows us to be imagebearers. In our example, Janet shows God's image by her attunement to Ann, by showing her respect and care. And Ann, reciprocally, images God to Janet, so that Janet finds herself in the presence of the sacred as she ministers to Ann's physical, emotional, and social needs. The call from God that I experience when I see another's vulnerability and need is a fundamental part of what it is for me to be a subject (Bloechl 2000, 46). Who would think himself unhappy if he had only one mouth, and who would not if he had only one eye? It has probably never occurred to anyone to be distressed at not having three eyes, but those who have none are inconsolable. BLAISE PASCAL

Thus the other person also bears God's image. In fact, the very suffering and pain of another reflect the image of God in that person. The reason we call it suffering is related to the dignity and sacredness of life and the recognition that concrete, individual lives ought to exhibit wellbeing. We can recognize the absence of something as tragic only when we know that its presence is part of the proper ordering of a good creation. This recognition of sacredness is not a respect for "dignity of life" generally, as an abstract principle, but recognition of the concrete dignity of this particular person, here and now. The dignity of Ann's particular, individual life bears the image of God, the Provider and Sustainer of life, and her suffering is painful precisely because it is a breakdown of the rightful wellbeing of the other as a living person. The task of neighborliness is not blindly or abstractly directed at humanity in general. It is directed to the other person precisely because the other bears God's image in his or her vulnerability and need. Because being a person is always a matter of reciprocal interrelatedness, the giving and receiving of care flows in both directions. In our example, despite Janet's role as caregiver, she not only gives but also receives from Ann. Conversely, despite Ann's need for care, she not only receives but also gives to Janet. The reciprocity is not an economic exchange of equal and comparable goods. What is given and received may well be quite different for each person in the relationship and will depend in part on what each needs. Nurses receive gifts of all sorts from the clients they care for, from the gift of service as a "guinea pig" that a client gives to a nursing student as he learns to start an IV to the gift of respect that a client gives to a

practiced, professional nurse for her expertise and experience. It would be a mistake to think that in giving care nothing is traveling in the reverse direction. In fact, without the reciprocal gifts of respect, gratitude, warmth, and humanity that clients can offer, nursing would be an unattractive profession. And as scheduling pressures and lack of funds have made this reciprocity harder and harder to maintain in acute care settings, nursing has become more stressful and less rewarding. The problem of mid-career burnout has clear connections to the structures that prevent reciprocity in the nurse/client relationship. Persons as Co-authors

We have described embodiment as enjoyment and vulnerability, freedom and responsibility, all drawn together in the image of God; but this still leaves something unsaid because it treats persons as if they were complete at any given instant. Such a description omits the ways in which identity involves being a character in a narrative with a past, present, and future plot (Maclntyre 1984, 206). Ann and Janet are not abstract embodied agents. Each of them also has a history that has determined the shape of her character and makes sense of her choices and actions. Part of this story is composed of the social roles into which we are born. None of us enters society as a generic human being. We begin our lives as someone's son or daughter, as a citizen of a nation and a member of a particular society and civilization. Each of these roles involves expectations and responsibilities. We enter the world as members of ethnic groups with particular languages, concepts, assumptions, rules for the proper use of humor, and so forth,

all of which constrain the shape that the story of our lives can take, while providing the necessary context within which those stories can be told. Without membership in those larger social groupings I would have no particular identity - which is to say, no identity at all, for identity is always particular. To be a person is to be historically and socially situated. Each person has a character informed by social expectations about gender, social class, nation, race, and ethnicity as well as by assumptions about duties, rights, goods, dangers, temptations, evils, and obligations. Both Janet and Ann enter their interactions with each other from the midst of such social presuppositions about identity and roles. Their identities as characters, including their social roles as nurse and client, only make sense against the backdrop of the narratives of the communities - family, society, nation, civilization - in which they are embedded. Most of the time we simply assume that these identities exist, without paying them much attention, but when we find ourselves working in a context where groups with critical cultural differences must interact, we suddenly become aware of how deeply our assumptions of identity structure our lives. Culturally congruent nursing care can only occur when culture care values, expressions, or patterns are known and used appropriately and meaningfully by the nurse with individuals or groups. MADELEINE M. LEININGER

However, the social situation in which one is a character is not the only feature that marks personal identity. One is always a character in a narrative in two ways: first, passively, to the extent that one's life is scripted by historical and social conditions; and second, actively, to the extent that one affirms or rejects those conditions. Just as independence is always relative to vulnerability and dependence, so active determination of the direction and meaning of one's life always takes place against the background of social and historical possibilities. Both Janet and Ann exhibit this mixture of activity and passivity, albeit in different ways. Janet, we might think at first glance, is largely the agent in this narrative fragment, the one who has the freedom to come into the room, actively checking diagnostic information, initiating conversation, deciding to get the comb, and so forth. Yet she is also constrained in at least two ways. First of all, she is constrained by the setting - namely, the institutional procedures and her workload, as well as currently accepted nursing practices, including expectations of efficiency and thoroughness. Second, she is constrained by the person of Ann, to whom she attends, listens, and complies. Janet's sense of herself as a nurse will be partly determined by the response she receives from Ann. Being a nurse is an important part of Janet's identity, so Ann's response can be quite powerful. Ann, we might also think at first glance, is (literally) the patient, the passive one who suffers, who receives the care that Janet gives her, who is constrained by the rules and expectations of the particular institution she is in, and who acquiesces to the health care system of which she is part. Yet her request to have her hair combed shows agency, a

continuing expression of freedom. And her expression of freedom gains its meaning from the part it plays in the continuing story of her life. We can imagine that she has always been careful of her personal appearance, and the request then fits into a story of continued care for propriety in the context of a world that feels in disarray. On the other hand, Ann may be the sort of person who goes through life with a cheerful disregard for the finer points of personal hygiene. In that case her request has a different sort of meaning, and it may prompt Janet to inquire whether she is expecting visitors or some special event. This indicates why we speak of persons as characters in a narrative. The meaning of their actions and of the events that occur in their lives always relates back to the particular narrative structures that make sense of what they do. For Christians, individual life stories are always embedded in the greater narrative of God's creative and redemptive activity, a story we learn in Scripture. And just as we come to knowledge and relationship with God through the stories of Scripture, we also come to a knowledge and relationship with other persons through the stories those persons tell us of their lives. Because people are agents, they have some control over how the story of their life goes. Sometimes we might speak of this as being the author of one's life, or determining how the plot will play out. But simply to speak of authorship is too onesided. An author of a book has total control over the story's path or trajectory. But the person writing her or his life has o n ly partial control. Because she or he is constrained by circumstances and by other people who are not under her or

his control, we need to speak of the individual as the co-author rather than the author of her or his life. A person is a character who co-authors the narrative. Furthermore, it is as a character in a particular story that an agent finds herself with the obligation to act in particular ways and not others. Janet's recognition that she needs to respond to Ann with respect and care, and her understanding that part of that respect requires her to go through the cumbersome process of leaving and then reentering Ann's room without burdening Ann with a sense of having asked too much, are shaped by the context in which she provides nursing care. The context of a narrative gives the actions chosen by an agent their meaning and their moral status. Actions are judged right or wrong, wise or foolish, in or out of character against a background composed of social practices and roles, professional and personal life plans, and the narrative unity of a whole life (Ricoeur 1992,157; Maclntyre 1984, 205). We can evaluate how and when actions are to be approved or disapproved, or how and when characters are to be praised or blamed for their actions, only in the context of the stories, including the story of God's self-revelation through Scripture, of which those actions are a part. Pe rsons in Community

Very few stories are written with only one character. We've already noted that being a person involves interdependence and openness to others, and this is true of the stories of our lives as well. Every story has multiple characters made up of the other people in the communities of which one is a member.

We have already noted how a person's identity is shaped by the societal and communal stories of which she or he is a part. But the fact of communal existence brings us to another aspect of personhood as well. Whenever there are multiple members of a community, we face the issue of determining how the benefits, resources, and burdens of that community will be distributed among them. This points our attention forward to Chapter Four, in which we will discuss ethical principles in more detail, but it warrants some mention here as well. To return to our example, Janet's competent interaction with Ann is shaped not only by the structure of nursing practice but also, more concretely, by clients in other rooms who also are under her care. While Ann as an image-bearer of God deserves to be treated with dignity and respect, Janet has other clients who also are image-bearers and who also deserve to be treated with dignity and respect. These other clients are tacitly present in the room as Janet competently cares for Ann in her decisions about how long to stay, whether she has time to fetch the comb, and so forth. Further more, Janet's fellow nurses on the unit also are tacitly present, as a team of caregivers of which she is a member, in which she has to carry out a fair share of the workload. Part of her competence in responsibly nursing Ann is her tacit responsibility to her fellow workers to "pull her weight" on the entire unit. The reverse is true as well. Janet must be tacitly present in the work of the other nurses on the unit, and they must do their part so that Janet is treated fairly and given the space to do her work well. Each of the members of this small and fluid community deserves to be treated as a neighbor, to be offered respect, to receive care that permits her or his life to go well, and to

experience her or his membership as a matter of equality and fairness. What we are dealing with here, then, is a question of ju s t ic e . Justice involves structuring responsibilities and practices in ways that make it possible to treat all members of the community fairly, with equity, giving each her or his due. Justice, absolute fairness, is never fully realized, of course, and decisions about equitable sharing of resources are always contestable. Even when a care facility has rules and regulations that are intended to be equitable, to treat both clients and caregivers fairly, we might find that they lack effectiveness or have imperfections or limitations. As we will note when we discuss environmental factors such as the Medicare system, even when a system is designed to contribute to justice and fairness for all the members of that society, we might still find that it falls short in important ways. Concrete social practices, plans, and policies are always limited, fallible, and reflective of their makers' self-deception and sinfulness. That is not to say that all rules or regulations or practices are equally unjust. On the contrary, the recognition that no regulations embody perfect justice does not rule out the simultaneous recognition that some regulations fall much farther short of justice than others. For example, nursing practice is better structured when it makes care its central concern than when it instead makes efficiency or profit its central goal. This is not to suggest that a nurse should be inefficient or that an institution ought to finance itself into bankruptcy. However, a health care system that aims to remain solvent to facilitate care is a very different system from one that aims for profit as a primary motive, just as being efficient in

caring for others and aiming at efficiency as one's primary goal are two different things. And, we might say, the call to justice in the area of health care is precisely the call to aim not at profit or efficiency, but at an equitable distribution of competent care - money, time, staffing, equipment - so that all within the reach of the community can flourish. We will return to this question of justice in Chapter Four, but for now we can note that being a person always places one into the context of moral relationships that require judgments about justice and fairness and about how we respond to the weak and vulnerable among us. For the Christian nurse, this moral dimension of personhood is what we would expect to find, given our understanding of persons as created by, loved by, and imaging a God of justice. From a Christian perspective we might say that justice forms the communal horizon for particular characters whose social roles include being health-care providers. Here we can return briefly to the discussion of embodiment, one that we have never quite left. Embodiment, as it turns out, means many things. It means being in a location, here and now, being a character in a narrative. Embodiment means having relative freedom with respect to one's surroundings, being both an agent in the story and a co-author of the narrative. It means enjoyment of life, being oriented toward wellbeing and flourishing. Embodiment means being vulnerable, not only to suffering but also to being informed by the expectations of the community into which one is born. And it means openness, the ethical call to responsibility in the context of community. Justice is the shape that the ethical call takes in a communal context, as we together engage in the social practices that

allow embodied persons to care for other embodied persons. Conclusion Because nursing is a profession in the fullest sense of the word, it is a practice oriented toward important human goods, and it is a practice that shapes the lives of its practitioners in important ways. It is a moral practice, carrying within it certain values and encouraging the development of certain character traits in its practitioners. The identity of nurses is shaped by the education they receive and by the institutions within which they practice. The identity of nursing is also shaped by assumptions about the nature of the persons who become nurses and the clients for whom they care. As we have seen, both the nature of nursing and the identity of persons are shaped and qualified in important ways by the Christian n u rs e's faith commitments. This does not mean that the Christian nurse and the non-Christian nurse disagree about what nursing involves; it means instead that although there is broad agreement about what nursing is, the Christian nurse comes to that practice shaped by her or his faith and seeing the privileges and responsibilities of that role in terms of the grand story of God's creating, sustaining, and redeeming activity. Five elements of personhood: • image-bearer of God • physical, mental, social, moral, and spiritual dimensions •independent and dependent

• co-author of his or her own story 0 part of a community The very elements of what constitute good nursing are as little understood for the well as for the sick. The same laws of health or nursing, for they are in reality the same, obtain among the well as among the sick. FLORENCE NIGHTINGALE In the same way that Christian faith shapes one's understanding of the practice of nursing and the meaning of personhood, it also shapes the fundamental orientation nursing has toward the good of health. It is fairly commonplace to define nursing as a practice oriented toward health. This orientation is a part of the very earliest history of nursing. The health in question is not an abstract idea of health, however, but the health and wellbeing of concrete people with whom the nurse works. And these people live, work, and sometimes suffer in the midst of particular environments. Because all of these concepts are so inescapably interconnected with nursing practice, they are often called the metaparadigm concepts of nursing. The next chapter examines the two concepts we have not yet discussed - health and environment - from the perspective of an understanding of nursing and personhood shaped by Christian faith.

CHAPTER THREE

A Christian Vision of Health and Environment The Christian faith shapes nursing practice by shaping the character, perspective, and values of the nurse. In the previous chapter we began a process of reinterpreting the defining concepts of nursing theory. We saw there how the concepts of nursing and of personhood are understood in distinctive ways from a Christian perspective. Nursing is not simply a profession; it is a practice whose internal goods such as health and care fit wonderfully well with a Christian vision of service to God. We argued that the concept of personhood cannot be understood rightly if we reduce personhood to autonomy. The resources of the Christian tradition reveal to us that persons are embodied, vulnerable, and interdependent. In this chapter we turn to a reinterpretation of the defining co n cep ts of health and environment. Here our focus is primarily upon how our perspective is shaped by our faith. When we think about how faith qualifies perspective, we are thinking of how we interpret our circumstances in light of their religious significance, and we identify this significance in light o f the testimony of Scripture. As we assess the meaning of health and the environment from a Christian perspective, then, certain central biblical themes frame our discussion. We return again and again in this chapter and the chapters that follow to

ideas such as shalom, "the least of these," justice, idolatry, and so forth as we reassess the meaning and significance of these defining concepts. Nursing is a practice that is fundamentally oriented toward health. Because health is such a central notion for the definition of nursing as a practice, it plays a central role in every account of what nursing is. Imogene King, for example, argues that the goal of nursing is "to help individuals and groups attain, maintain, and restore health" (King i98i, 13). But while health is central to nursing practice, it is not an easy concept to define. The next section looks in more detail at what health is, the various aspects of it that make it a complex and difficult notion, and how these aspects are shaped and qualified by Christian faith. Health: Wholeness and Wellbeing Rita is the kind of woman who makes others want to be around her. Just over five feet tall, with short gray hair, and dressed in attractive slacks and tennis shoes, she heads out on her daily two-mile walk. Before she walks she stops to say hello to friends who are sitting outside, enjoying the fall colors at the retirement home. Rita enjoys life and communicates that enjoyment to others. She is 95 years old, and although she is one or two generations older than many others who also live at the retirement home, she never gives the impression of living in the past. She listens attentively to her adult grandnieces talk about their lives, and her interest in their activities, made possible by her own zest for life, is unmistakable.

To the external observer, Rita would appear to be an elderly woman in perfect health. But her life is not without disease. Rita suffers from diverticulitis, an inflammation of the intestine that can result in blockages and severe abdominal pain. She also has hypertension and type II diabetes. Rita has been to the hospital three times in the last five years because of her diverticulitis, and each time the surgeons have needed to remove the blocked and damaged portion of the intestine. The last time she suffered from abdominal pain, she asked friends to help her, and while they were communicating with her doctor concerning her symptoms, she still managed to eke out a smile, even through the pain. The way she handled the situation made everyone else in the room feel a little bit less awkward. When she gets back to her apartment after her walk, Rita meets with her nurse, James, from the Area Agency on Aging, assigned to help her remain independent and to promote her health. "How have you been feeling since I saw you last month?" James asks. "And how are those grandnieces? Still coming by for regular visits?" He waits carefully for Rita to respond before continuing on to talk about her diet and inquire about any recent abdominal pain. Rita reports triumphantly that she has been able to get the medica tions she needs through the prescription assistance program he helped her apply for last month, and they share a laugh over the complexities of government programs while he checks her blood pressure and blood glucose level. James also takes a quick look in the bathroom to be sure that the shower bars he brought for Rita last month have been properly installed in her bathtub. Rita and James work together as a team

to help Rita stay as healthy as possible. But what exactly do we mean by healthy? Since Rita is not without some disease, can she still be healthy? And how should our understanding of both aging and the disease process affect how we think of health in this particular case? Initially we are tempted to consider Rita healthy because she is physically fit enough to walk two miles each day. When we focus on her diverticulitis, hypertension, and diabetes, however, we are likely to think of her as chronically unhealthy. This indicates that we need a definition of health that is nuanced enough to capture various aspects of a person's life. I n many ways Rita is healthy. In spite of her disease she is joyfully connected to her community and environment in very healthy ways. Human beings were meant to live with others in relationships of mutuality, hospitality, and reciprocity, and when we see these relationships we should recognize that they reflect a healthy life. However, health also involves the proper functioning of our bodies and minds, and that proper functioning is important for the bodily, mental, and spiritual integrity we need to engage God's world and God's children in healthful ways. Hence, a concept of health must be broad enough to include the physical, psychological, social, and spiritual dimensions of being human, and it must be deep enough to reveal the integral connection between of all of these. Sometimes a client's physical need, such as dangerously elevated glucose levels, requires that a nurse focus more heavily on just one aspect of health. But the nurse must always be cognizant of how all dimensions of health intersect. When

the physical crisis has been handled, the psychological, social, and spiritual aspects of the client's health must still be addressed. Suppose Rita had experienced dangerously high glucose levels, a condition caused, in this case, by missed insulin injections. When James inquires, he might discover that there were delays with the prescription program application process that caused Rita to be without needed medications for a day. The nurse functions as a coordinator of care so that all aspects of an individual's health can be addressed, and this requires the nurse to discover the story of someone's life - to ask about why the insu lin injection was missed, to recognize how the need for daily insulin injections affects the client's social calendar or makes her feel depressed because she will be burdened with a need for pharmaceutical intervention all of her life. Perhaps Rita had a close friend who had a leg amputated because of diabetic complications, and this affects her commitment to maintaining her own treatment schedule. Discovering the client's story can help the nurse be an effective coordinator of all aspects of his client's health. The Old Testament word shalom, which can mean many things, is sometimes translated as "health." Shalom can be defined as a dynamic state of wholeness, wellbeing, peace, and completeness that permeates all areas of life (Plantinga 2002, 15). We can understand it as universal flourishing, wholeness, and delight - a rich state of affairs in which natural needs are satisfied and natural gifts fruitfully employed, all under the arch of God's love (Wolterstorff 1983, 69-72). If we define health in terms of this concept of shalom, or in the terms we developed in Chapter One of creational goodness, it becomes clear that health is not merely the absence of sickness or pain. Health in

the fullest sense is the complete physical, mental, and spiritual flourishing that allows us to fulfill our created purposes - and so give glory to our Creator and enjoy the relationships with our Creator and fellow creatures that are made possible by those purposes. But while this ideal of full flourishing may be part of our definition of health, it cannot be the definition we normally work with in the context of nursing. It sets the standard so high that no one is healthy, and surely our ordinary use of the term healthy implies that many people, much of the time, experience health. This does not mean that we need to dismiss the ideal of full flourishing completely; as Christians, the ideal of all things being made new forms the horizon of our thinking at some level. But in terms of the ideal of health that functions in the context of nursing practice, we need a much more modest definition. The concept of shalom as an ideal of health is significant because it makes clear how health is connected to functionality, to flourishing, and to a fruitful employment of gifts. If disease, which could be described as an anatomic, physiologic, or biochemical malfunctioning, interferes with our ability to perform normal human functions or to employ our talents, then our health has been compromised. When we think of physical accidents such as a small cut with a scissors, or surgical procedures such as the removal of the tonsils, we usually don't speak of them as making us unhealthy because they have such a small influence on functioning. But dia betes has a greater health impact because the disease can cause further physical damage or incapacitate a person if not treated,

and it requires the client to extend a fair amount of effort in coping with the disease; both the disease's physical damage and the effort to cope with it can negatively affect the ability of the person to flourish. In acknowledging the multidimensional nature of health, we note that insofar as physical diseases, p o o r social conditions such as poverty and illiteracy, psychological conditions such as stress and depression, and conditions of spiritual emptiness interfere with our ability to function and flourish, they affect our health. The ability of a physical disease such as diverticulitis or diabetes to influence health negatively is well noted. However, the overall health outcome in these disease situations may not be so negative that we evaluate the person with the disease as unhealthy. Some individuals who have a physical ailment can actually be healthier than those whose bodies are whole and functioning well. In Rita's case, even when she is in the midst of a painful episode of diverticulitis, she still describes herself as quite healthy, and James, her nurse, would agree with that description. She understands the nature of her physical disease, she knows what to expect and how to handle an episode, and she is at peace with her condition. She works with her nurse and physician and follows their advice and instructions. She also has the support of her friends and family to help her function well. When James compares her total health to other clients at the retirement home, several of whom are younger and are without chronic or episodic physical dis eas e, Rita's hope for the future and her delight and involvement in other people's lives makes her shine as the healthier individual.

Health means capability, vigour, and freedom. It is strength for human life. KARL BARTH Paradoxically, there are even cases when the diagnosis of a physical disease can actually be the stimulus for a person to lead a healthier life. When a middle-aged man receives a diagnosis of heart disease, the realization that he could die sooner than anticipated can prompt him to move toward health in many dimensions in his life, including the physical dimensions. He may examine the meaning of his life, his relationships, and his habits, and he may reorder his priorities in ways that lead to greater health. He may change his eating habits so that he consumes fewer calories and less fat, and he may come to consider mealtime as a time when relationships with family and friends can be strengthened. He may think about ways to exercise more, whether that means going to a health club regularly or choosing to climb stairs instead of using the elevator. He may determine that his life has more meaning and satisfaction when he serves the needs of others rather than pursuing career success exclusively, and he may choose to find the time to help second graders at his daughter's school learn to read. He may think about the possibility of his own death and thereby seek to strengthen his spiritual life. If this man is a Christian, the sudden awareness of his own finitude may make him rely upon the peace and strength of Christ in ways that he never knew were possible. Six months or a year after his initial diagnosis with heart disease, he may see that he understands his humanity more fully and is healthier than before the diagnosis of physical

disease. To call him healthier, however, is to evaluate his life along one particular axis, that of his awareness of and responsibility for central aspects of his life. If we are speaking specifically of his physical state of health, we still need to recognize that he lacks a crucial part of physical health. This alerts us to the fact that health is always evaluated in relation to background assumptions about context and social situation. We evaluate a 95-year-old woman who walks two miles a day as healthy because many 95-year-old individuals are significantly less mobile. A physically able i8-year-old, however, will hardly be evaluated as healthy merely because she is capable of a two-mile stroll. Any time we use a term such as health we assume a set of conditions that serve as our standard of normal health, and as those background assumptions change, so does our assessment of health. This is an important component of nursing practice, since it reminds us that when we speak of health or wellness (or illness, pain, or suffering) we need to be clear what aspects of an individual's life are being evaluated, against what standards, and the like. Further, although we can acknowledge that good may come in the midst of pain, that health may grow in the midst of disease, this acknowledgment should not eclipse from our view the very real suffering that accompanies disease. Others in the room may feel less awkward because Rita bravely smiles in spite of her pain, but if Rita feels that she must produce such a smile, something in the situation could be quite wrong. Sometimes people do deal better with suffering when they are able to focus on others and generate a certain level of stoic acceptance of physical pain. We should recognize that

different people use different methods to deal with crises. But we should be careful not to expect every Christian to show a brave face, to smile in the midst of suffering, to deny the lamentable condition in which she finds herself, or to worry about whether others feel awkward to be in the presence of her suffering. Here is a place where a Christian nurse could gently attend to this client's spiritual needs by assuring Rita that she does not need to concern herself with putting others at ease. She does not need to deny her pain or pretend that all is well. Her body is not functioning as it was designed to. She can lean on the strength of others in this time of weakness. In the midst of this painful experience, Rita has the opportunity to confront her own finitude and to ask what constitutes a beautiful and meaningful life. The nurses in the Emergency Department may not have the time or resources to engage Rita in asking these questions, but there is another who may fill this role. As a nurse who is comfortable enough with Rita to ask about her grandnieces and to know about what she needs in the bathtub, James surely knows Rita well enough to engage her in conversation about the meaning of her suffering. He may refer her to a pastor or counselor, but he may also be available simply to listen when she needs to talk. Christian nurses, in other words, need not shield their clients from asking tough questions or from the difficulty of seeking answers. In Chapter One we noted that the Christian nurse should not see his or her spiritual role as one of trying to make sure every client has a conversion experience. But we most surely do not want to rule out the Christian nurse's responsibility to be aware of spiritual suffering in a client, to ask if the client needs to talk about struggles and questions,

and to offer to be a Christian presence in the client's life when that is appropriate. This is good nursing, and it is part of the nurse's professional responsibility to be concerned with the holistic aspects of the health of the client. We have noted that human life involves a process through which we strive toward health and shalom, seek our place in God's world, and recognize our limitations and dependence. But what does it mean for individuals to recognize their place in God's world, and how is this tied to health? We acknowledge that God is Creator, Sustainer, and Redeemer and that the purpose of life is joyful service to God. This context is what gives health its meaning. We rob health of its meaning when we fail to recognize that it is only a means, an instrument, by which we can joyfully serve God. Health is not an ultimate good. Margaret Mohrmann, a reflective Christian and a pediatrician, suggests that our society tends to idolize both health and life as ends in themselves, thereby denying the real source from which health and life derive their meaning and import. She writes of this idolatry: Reinhold Niebuhr has said that evil in its most developed form is always a good pretending or imagining itself to be better than it is. The idolatry of health is a good example of this process, of pretending or imagining that the relative, subordinate good of health is better than God intends it to be. Evidence of the idolatry of health in our society is clear, manifesting itself in our fickle, shifting obsessions with diets and exercise machines and with jogging down every primrose path to perfect health, whether it is the path of vitamin C or brewer's yeast or no yeast at all or oat bran or whatever the

latest "cure du jour." (Mohrmann 1995, 14) Mohrmann goes on to critique our society's obsession with health, especially in our over-valuation of a healthy, youthful body. This obsession reveals that we do not really understand the true, multidimensional nature of health or humanity. She notes that even when we focus on establishing and maintaining good mental health, we often do so because it will contribute to better physical health. "We try to be calm so we can avoid ulcers and heart attacks," she argues, and "we try to think positive thoughts so our immune systems will be stimulated to do their jobs more enthusiastically. A true and complete understanding of health includes mental and spiritual health as important ingredients in their own right, not just as promoters of physical health" (Mohrmann 1995, 15). Understanding health as an instrument that allows us to live joyful, complete lives of service to God allows us to put the good of health in its proper relationship to the other good things in human lives. It also helps us to find some peace when wrestling with issues of health and disability, aging, and dying. We acknowledge that we live in a fallen world and that this fallen nature keeps us from attaining perfect health. Yet striving toward health means that we find ways to cure and accommodate where possible, as well as to accept our limitations where accommodation is not possible. Henrik Blum writes, "Health is the state of being in which an individual does the best with the capacities he has, and acts in ways that maximize his capacities" (Blum 1983, 93). Christians with diminis hed physical and mental capacities, whether due to disability or to aging, can strive toward health when finding

ways to live joyfully and to serve God with the capacities they have. We cannot speak about health without also addressing issues of disability. Disabilities of one sort or another are so common as to be almost universal. Some people have chronic dry skin, others are lactose intolerant, others have the farsightedness that often accompanies aging. These disabilities are relatively easy to cope with. One can use lotions, avoid milk o r add the missing enzyme to the diet, or wear glasses. Other disabilities interfere more significantly with the ability to perform important functions or require social intervention in order for the individual to flourish. Some theorists limit the definition of disability to conditions that fall under one or the other of these categories, in fact, so that the conditions mentioned earlier would not even count as disabilities (Bouma et al. 1989, 56). Because health is multifaceted, we can recognize that those with a disability in one physical or mental dimension can nonetheless experience health in other physical or mental dimensions, as well as in the social and spiritual dimensions of their lives. The recognition that health is not a single value and that it must be evaluated against a background of assumptions about context and social settings allows us to celebrate whatever aspects of health are possible in an individual's life, without losing sight of the difficulties the lack of health in other areas may create. At the same time, the holistic sense of the human person that is at work in nursing allows us to be aware of the ways in which diminished health in one area of life can also have a serious impact on other parts of an individual's life. As George

Agich writes, "When the illness and symptoms are severe, the orientation to the world of everyday life, if not loosened, is altered in various ways and so the energies of the self are unders tandably directed away from routine activities and toward the general task of constituting new structures of meaning" (Agich 1996, 146). Part of a healthy response to disability or chronic illness is a redirection of energies, a reordering of life in general so that necessary adjustments can be made to the ongoing changes in one's life. It is important for nurses, who generally experience relatively good health, to be aware of the many ways in which a chronic illness or disability may require turning away from normal aspects of life. In many ways Rita is an easy client to deal with because she is cheerful and self-motivated. This makes it easy to recognize the healthy as p ect s of her life. A client dealing with chronic and debilitating arthritis pain, however, may not always be cheerful, and her admission of pain and planning ahead to avoid overexertion may be just as healthy a response to the conditions of her life as are Rita's cheerfulness and activity. It is also important, when thinking about health, to recognize the extent to which health is not simply a matter of an individual's condition. It is often the conjunction of a condition with the presence or absence of various social goods that determine whether someone is disabled or not. Our society sometimes responds in positive ways to help individuals flourish in spite of disabilities: providing Braille lettering on doors and elevators, curb cut-outs on sidewalks for wheelchair access, voice-recognition software for word processing, and even playground equipment like swings with specially shaped seats and straps that allow physically disabled individuals to

enjoy the thrill of having the wind blow through their hair. It is important for society to continue to use and find new technological, social, and pharmaceutical interventions that allow people to flourish even when they have limited functions of various sorts. The holistic account of health that nursing has adopted is an important reminder that health is not simply a matter of an individual's condition but is also a communal issue. As we noted when we spoke about the nature of persons in Chapter Two, persons are fundamentally interdependent, and we see what this means when we think about health. Our society sometimes tends to fall into an idolatry of health. This idolatry is evident when we fail to respect those with disabilities, or when we act as if lives that involve disabilities are lives that are not worth living or not worth investing health care dollars in. We can fail to recognize that physical disabilities are compatible with full decision-making capacities and treat an adult with quadriplegia as if she were a small child. The idolatry of health can also indicate a fear of death and a denial of death's inevitability, both of which indicate a lack of hope. Our society tends to seek salvation through medical intervention, and in the context of health care we frequently encounter language that suggests that the avoidance of death might be possible. Evidence abounds: hospital advertisements on billboards read, "Saving Lives Every Day," and "Partners in Saving Lives." But only God can save, and health care workers who try are doomed to failure. Life and health are given to us by God so that we can live joyful lives of service in community, and as long as we seek health and life for that end, we seek them rightly (Mohrmann

1995, 20). Within that context it is possible to pursue health without making it an idol. The pursuit of health, even when it is properly contextualized by Christian values, can never be completely successful because human lives always come to an end at some point, because accidents happen, and because diseases and suffering are part of the human condition. When we discussed the nature of persons earlier, we noted that embodiment implies vulnerability, and we return to this point when we think about health. We care so much about health because we know we are always vulnerable to the loss of some aspect of health. In spite of the best efforts of nurses and other health care workers, individuals with disabilities will struggle with the difficulties they face, people will die, individuals will suffer painful diseases, and babies will be born with dreadful genetic disorders. Nurses know better than almost anyone the depth of sadness and tragedy caused by the lack of health in our world and our need for lament in the face of that sadness. But lament is not despair. We know what health is because we see the marks of a loving Creator in the health of those around us, and we hope for the eventual restoration of all of creation by a God whose love is never failing. There is a "double vision" quality to the notion of shalom. It allows us to see what is not yet, while at the same time we see what we are called to at this time. Even though the full incursion of shalom into our history will be divine gift and not merely human achievement, even though its

episodic incursion into our lives now also has a dimension of divine gift, nonetheless it is shalom that we are to work and struggle for. We are not to stand around, hands folded, waiting for shalom to arrive. NICHOLAS WOLTERSTORFF The Christian nurse's double vision is rarely so apparent as it is in the case of health. We see what health is as we celebrate the ability of a child's body to heal and regain function and the ability of a 95-year-old to live a full and satisfying life even in the face of chronic disease. But we also lament the many ways in which health is disrupted and diminished, and we recognize that human sin frequently destroys even the possibility of health for some. But we remember that health is never a single valence. The lack of health in one aspect of human life does not make it unachievable in another, and this gives us grounds for hope. And, more importantly, we remember that health is not the ultimate meaning or focus of life. Health exists for the sake of service to God, and not vice versa, and this allows us to place it in its proper relationship in human life, as a central good, but not the absolute good. In our discussion of health we noted that whether or not a condition limits a person's ability to function is not simply a matter of the individual in question, but also a matter of the social environment in which she or he lives. This brings us to the fourth metaparadigm concept of nursing, environment, and the way our understanding of it is shaped by our Christian

faith. Environment: The World as We Make It When we were introduced to Rita, a 95-year-old woman living in a retirement community, we also met James, the nurse who cares for her, and we began to consider the kinds of practices nurses engage in that constitute good care. What is perhaps less apparent in our reflections thus far is the attentiveness James gives to environmental variables that influence Rita's health. Why should Christians, and in this case Christian nurses, care about environmental aspects of nursing? Why not focus exclusively on concrete practices of care - taking blood pressures, giving injections, attending to monitors, charting, and so forth? Christians take a wide and high view of creation. Through creation, God brought into being a wonderfully complex and intricate universe that sustains human life, fosters i t s flourishing, and engages our hearts and minds. God declared creation very good, and God also invited human beings to participate in the continuing process of creation by naming creatures, bearing children, organizing society, and caring for the earth - an astounding invitation when we stop to consider it. In short, God invited us to be partners in furthering shalom - in co-constructing a world of universal flourishing, wholeness, and delight (Plantinga 2002). Sin, of course, destroyed shalom's perfect order. Human beings as individuals sinned and were affected by sin and evil; the entire created order suffered and continues to suffer from sin as well, including relationships humans have with other creatures and the material, social, and physical world. We know, however, that when God's redemptive work is complete, not only will

human beings be restored to a right relationship with God, but the whole of creation will also be restored. As Christian nurses, then, we recognize that we care about environmental aspects of nursing because the environment is part of God's good creation intended for universal flourishing. We care because we also know that the environment will be the target of restoration when indeed all things are made new. We care because God has issued an invitation to us to be partners in the work of making all things news. Finally, we care because, without broad understandings of the physical and social environment, the tendency to judge clients prematurely and unfairly for their problems is very strong. To ignore environmental dimensions of health and wellbeing is shortsighted, something akin to the church that cares only whether a member's soul "is saved;" while ignoring the fact that such a person might be poor, lonely, abusive or abused, or struggling with addictions. De fining Environme nt

Nursing theorists offer a number of definitions of the notion of environment, but the most common definition understands environment as those factors, influences, or conditions outside of the client that influence the health and wellbeing of the client (George 1995, 230, 260, 286). These factors can be physical dimensions of the environment, such as clean air and water, or socially constructed aspects, such as how health care is organized and delivered. Obviously these are not unrelated, since access to clean water, for example, is determined in part by social decisions. Because our focus is on the environment

within which nursing practice takes place, in this section we focus mainly on the more obviously socially constructed dimensions of the environment. For the purposes of assessment, the external environment is o ft e n conceptualized at several levels. Betty Neuman, for instance, identifies interpersonal and extrapersonal environmental factors (discussed in George 1995, 286-87). Interpersonal influences include family, friends, and caregiver relationships and resources, while extrapersonal influences focus on larger, more distant arrangements such as the community, county, state, or nation, each with its attending services, resources, and policies. Employment opportunities, public or private welfare services, public policies, affordable housing, and availability of public transportation are examples of extrapersonal influences that shape health outcomes. Urie Bronfenbrenner (1994) has developed an ecological model that provides a more fine-grained method of analysis for environmental assessment. His approach was initially developed to understand how people shape and are shaped by their environment, and it works well in the context of nursing practice. Bronfenbrenner identifies five levels of analysis, ranging from the immediate to distant. The microsystem identifies the client and significant individuals in that client's life. With respect to the client, nurses assess not only physiological variables but also psychological, spiritual, social, and cultural dimensions. Such assessment focuses not only on need and vulnerability but also on strengths, resources, coping abilities, and the client's efforts to construct a narrative that imbues his or her life with meaning and purpose. The

mesosystem assesses interactions between these key players. Family, friends, and health care providers, for instance, might be subjects of assessment. The exosystem assesses local geographic and cultural influences. Assessment variables here might include quality of care standards, access to health care via insurance, access to health care in local neighborhoods, and the nature of the physical environment in which the client lives. The macrosystem assesses national and cultural influences. Possible assessment factors include state and federal public policies that determine eligibility for services, delineate client rights, or set ethical and practice standards for practitioners. Finally, the chronosystem assesses the dynamics of change in systems over time. Here nurses might consider, for instance, how Prospective Payment Systems (PPS) and Diagnostic-Related Groups (DRGs) have shortened stays in acute care settings and expanded the need for nursing home a n d community-based care. Regardless of terminology, the intent of such a framework is to move the nurse beyond a narrow assessment of environment to a more holistic, dynamic, and systemic understanding of the environment, the person in the environment, and the relationships of these to health outcomes. Five Levels of Environmental Assessment: • Microsystem: the client and significant individuals in that client's life • Mesosystem: interactions between these key players

• Exosystem: local geographic and cultural influences • Macrosystem: national and cultural influences • Chronosystem: the dynamics of change in systems over time This richer assessment of the environment moves the nurse to a fuller awareness of the complexity of God's creation. It serves as a reminder of the interrelated nature of human lives and practices. At the same time, Christian faith shapes perceptions of the environment at all its different levels. Christians do not expect that all of life is acceptable just the way it is; Christians expect to see some evidence of fallenness at every level of the environment. Nor do Christians assume that sin operates only at the level of individual action. Sin pervades human life and affects all these levels, from the microsystem to the chronosystem, producing the need to work toward shalom at every level of the nursing environment. But Christian faith also allows us to see the hope and goodness at each level as well, the ways in which individuals and their families work together and support each other in mutual love, the ways in which social structures of care are developed in society over time, and the ways in which practices such as parish nursing can influence the environment in ways that promote health. Analyz ing Environme nt

We can see how all these aspects of environment would shape the analysis of a client's situation if we return to Rita and see how James's assessment might take shape when paying

attention to environmental variables. Some additional details about Rita's life are included. For clarity, we use a chart to organize these environmental variables (see table i, p. 82). As James charts environmental influences and resources, we can begin to visualize the whole of Rita's life beyond her diverticulitis, type II diabetes, and hypertension. But beyond recognizing what environments and persons bring to a health care encounter (which is what the chart sets forth), an adequate understanding of the environment includes the recognition that persons are in constant interaction with their environment. In fact, it is impossible for us not to be in interaction with our environment. It follows then, first of all, that the environment influences human behavior and, for our purposes here, health and wellbeing. We know, from a vast literature on health care outcomes, that meso-, exo-, macro-, a n d chronosystem environmental influences are important variables in predicting Rita's health. Living in chronic poverty, lack of access to health care, relentless stress, or being exposed to violence daily, for instance, takes a horrific toll on health. In contrast, adequate income, access to health care, sturdy mental health, and adequate nutrition furthers health and wellbeing. Second, it is also the case that we are human beings with agency, and subsequently we are able to act on our environment and shape it, in part, for better or worse. We are not entirely passive victims of what comes our way. We see evidence of this, for example, when individuals make decisions to exercise regularly, eat nutritiously, seek help for depression or addiction, or manage their diabetes in a way that promotes

wellbeing. Influencing the environment, however, is not only an individual enterprise. Communally, we see evidence of constructive human agency in promoting health outcomes, for instance, when collective efforts are made to clean up air and water, reduce the risk of exposure to second-hand smoke in public and private spaces, provide needle exchange programs, or pass legislation that will provide access to basic health care for uninsured children. The idea of human beings shaping the environment in particular ways is an important one, and we will return to it shortly.

Environme nt and Nursing Practice

To make explicit what is implicit in our discussion of James and his care for Rita, attentive and competent nurses, in addition to the handson care they provide, must attend to environmental variables. James, for instance, notices that Rita needs shower bars and puts in place a process whereby these can be secured and installed for Rita. In this way, he hopes to avoid a fall that would in turn prevent Rita from walking. James notices that Rita is without adequate prescription drug coverage and links her to a resource that can meet her needs. Here James hopes to reduce the risk of complications from diabetes or a possible stroke. James notices that Rita has an extensive and supportive network of friends and relatives and that she enjoys staying connected to events larger than her apartment at the retirement community. We can imagine James asking Rita questions that uncover the importance of these environmental resources in furthering her wellbeing: "Rita, not all people your age enjoy life as much as you seem to. What keeps you going?" We can imagine Rita responding by telling James about her two-mile walk each day, her grandnieces, the young couple who live onsite and play pinochle with her, her religious practices, and how she tries to be helpful to others. We can imagine James asking further questions about each of these behaviors, trying to understand how these are useful to Rita and what he might do additionally to insure that Rita is able to continue taking her walk and staying alert enough to enjoy interactions with her friends. James surely needs to be competent in delivering handson care to Rita by way of monitoring blood pressure and blood

glucose levels, taking temperatures, controlling infections, giving injections, charting accurately, and all the other tasks involved in patient care. However, James's professional responsibilities extend beyond this to include a thorough and accurate understanding of the environment in which his clients live out their lives. These are very large responsibilities for any profession, and yet such responsibilities still are not the whole of what nurses must bring into their practice. We consider the "what more" next. Re de e ming the Environme nt

Let's consider another woman similar to Rita in many respects: Delores. Like Rita, Delores has diverticulitis, hypertension, and type II diabetes. She also has a network of family and friends in which support is exchanged and lives are richer because of such relationships. Delores, like Rita, enjoys good mental health, has no cognitive impairments, and finds her faith to be an integral source of meaning and comfort. Unlike Rita, Delores does not live in a retirement community but with her adult granddaughter and three great-grandchildren in a tiny, third-floor apartment in a poor urban area. In the winter months, the apartment is difficult to heat; consequently, Delores struggles with bronchitis during most of the cold months. Her life's work has been informal cleaning jobs and unpaid care work, caring for her four children while they were young, her grandchildren at intermittent points in their lives, her great-grandchildren, as well as her father before he died. Her husband of twelve years was seldom able to find steady employment, and when he did, it seldom paid a living wage.

Subsequently, instead of a pension to supplement her income from Social Security, Delores depends solely on her Social Security check for income. Instead of being able to walk two miles a day, Delores is confined to a wheelchair, having had a leg amputated from diabetic complications. Instead of having a nurse like James who helps to coordinate care, Delores is on her own. Somehow she must make arrangements to get to the diabetes clinic monthly. She must navigate a public welfare system that provides her with Medicare benefits (Part A only) but gives no assistance with needed prescriptions, glucose test strips, purchasing a wheelchair, or paying for specialized transportation to clinic visits. Although she is wheelchairbound, somehow she must get from her third-story apartment to the diabetes clinic, located some forty minutes away, and back. In some months, through a spend-down process that makes little sense to her, her adult granddaughter, or the health care staff at the clinic, Delores is eligible for Medicaid funds if she completes the required paperwork on time and correctly. We can see that an assessment of Delores's life looks quite different from Rita's in a number of significant areas. We'll use the same environmental assessment chart to highlight the differences. Note how Delores and Rita are very similar at the individual level. They both enjoy close and supportive family relationships, a strong faith, and a generally positive outlook on life. But environmental factors affect them very differently (see table 2, p. 86). To be sure, the nurses at the diabetes clinic work hard to give Delores the best care they can. They provide her with the same quality of care they give to other clients who might be

younger, less frail, or better insured. They extend her visit as long as possible so that they might nurture her with a few extras: a warm meal; foot care; a break from the dark, cramped, stale apartment; and warmth on cold days. They give her free medications and glucose test strips when available. They make phone calls to the appropriate public offices to try to sort out her patchwork health care coverage. In short, they give competent care to Delores, with respect to both handson care and attentiveness to environmental variables that influence Delores's health. At the end of the day, when Delores's ambulance picks her up to take her home from the clinic, the nurses talk among themselves about their frustrations with not being able to do more for her. One nurse, Helena, ends the conversation with an angry shrug: "What else can we do? That's just the way the system is and there is nothing more we can do. Some people are winners and some are losers. Delores, poor thing, is a loser." What do we, as Christian nurses, make of Helena's comment? Do Helena's professional responsibilities end here? Can anything more be expected of Helena and her nursing colleagues with respect to making "the system" or the environment more useful to Delores? A charitable reading of Helena's remark is that she is weary and weighed down by a relentless stream of clients who move through the clinic doors daily with great human need. Helena's own capacity as one nurse to respond to more than immediate needs is limited. She simply cannot find a way to respond effectively to all of the brokenness in Delores's life, much less the brokenness in all

the lives she sees each week in the clinic. She is painfully aware that when she supplies Delores with free prescription drugs or glucose strips, someone else goes without. Even small and hospitable gestures such as serving a simple meal cannot be given to all. So perhaps Helena's words, harsh as they sound, are a lament. While Helena and her colleagues can do some good things for Delores, actions that acknowledge and honor her dignity, they lament because they cannot do enough for her, and for all of the others like her they meet daily. This situation can lead to a condition often spoken of as "compassion fatigue," the sense that if one allowed oneself to feel compassion for the broken lives in one's midst, the feeling and the actions it might require would be overwhelming.

We would be neglectful, however, if we understood Helena's comment only as lament. Her comment, "That's just the way the system is and there is nothing more we can do," should cause thoughtful Christians to bristle. "Systems" or social structures as part of the environment are human constructions and as much in need of redemption as human beings. Plantinga makes the point this way: God isn't content to save souls; God wants to save bodies too. God isn't content to save human beings in their individual activities; God wants to save social systems and economic structures too. If the management/labor structure contains built-in antagonism, then it needs to be redeemed. If the health care delivery system reaches only the well-todo, then it needs to be reformed. (Plantinga 2002, 97) It is sometimes difficult to see social structures, such as health care or public welfare, as human constructions amenable to reform. The systems are large and bureaucratically complex, and the rules appear quite intractable. Furthermore, it is difficult to understand how "sin burrows into the bowels of institutions and makes a home there," particularly when such institutions and structures may well begin with just and good intentions (Plantinga 2002, 63). In cases where a person's situation looks hopeless and we are tempted to turn away to prevent compassion fatigue, our Christian perspective reminds us that we are not called to turn away from suffering. We are called, however, throughout Scripture, to develop wisdom, and a large part of wisdom is learning to look at systems in terms of their social and institutional structure.

We'll use the example of the Social Security system and the s tructure of Medicare as examples to help clarify how an institutional structure that is intended for good purposes can nonetheless be structured in ways that are desperately in need of reform. In the case of Social Security, we need to look back to the formation of the institution to see how its original struc ture sowed the seeds that today grow into intractable problems. In the case of Medicare we find a different set of problems. Most of us, even if we are not yet eligible, see Social Security (SS) benefits for older adults as a good thing. About 95 percent of older Americans receive some amount of financial assistance each month that supports them when they are no longer able to work at previous levels of employment. Millions of elderly people, including parents and grandparents of the authors and readers of this text, are kept from falling below the poverty line with their SS benefits. Yet, when we examine the historical and political context of the passage of the 1935 Social Security Old Age and Survivors Insurance program, we find that it was a compromise piece of legislation, designed to accommodate the needs of some people more than others. Only people who participate in the formal labor market can participate in earning Social Security benefits. If Delores had not been married to someone who earned such credits, she would not have been eligible for Social Security because her work consisted "only" of caregiving and child care. We see here a policy decision to value certain kinds of work - paid work in the formal labor market - and to exclude other kinds of work. This did not happen by accident but was a result of

deliberate debate among policymakers. In the 1935 discussions, the elderly poor deemed ineligible for Social Security included agricultural and domestic workers (the latter applies to Delores). This was a major concern for the National Association for the Advancement of Colored People (NAACP). Charles Houston, then board member of the NAACP, argued against Social Security before the Senate Finance Committee, asserting that while the NAACP had been inclined to testify in favor of the bill, the more it studied the bill, the more it "looked like a sieve with holes just big enough for the majority of Negroes to fall through" (Hamilton 1994,495). Although race was not an explicit variable in defining policy, the exclusion of domestic and agricultural workers, overrepresented among African Americans, effectively excluded them. Someone like Rita, on the other hand, given her years of work in the paid labor market, was fully eligible for Social Security benefits. Another interesting window into the social construction of environmental variables that shape health outcomes is afforded by Medicare. When we examine the assumptions embedded in the funding provisions of Medicare, we find that it focuses on acute care, with the goal of returning older adults to previous levels of health care functioning. While this is truly a worthy goal, it is not accurately targeted to the maintenance needs of many older adults. Rita and Delores, for instance, had they needed a transplant of some sort at their advanced ages, could have received one. Yet items necessary for daily wellbeing prescription medications, a wheelchair, glucose test strips, eyeglasses or hearing aids, and so forth - are not provided by Medicare. Access to this type of item comes at a high financial cost or requires extensive negotiations with assorted

community services. Rita, because she is able to purchase supplementary insurance for Medicare, is able to secure many needed items. Delores is not so fortunate. In fact, her inability to pay for glucose strips to monitor her diabetes resulted in yet another serious harm to her, the loss of her leg. In short, Medicare policy, like Social Security, is shaped by certain assumptions and results in specific practices that can further or constrain health outcomes. When we realize that massive social institutions such as Medicare and Social Security are human constructions and that they bear the marks of human sin and brokenness, then we can also analyze how they might be constructed differently. If social systems as aspects of the environment that affect human health and nursing practice are human constructions, in other words, then they are also susceptible to human reform. This does not mean that any one individual can single-handedly change "the system," but it does mean that individuals bear some obligation to organize for change and to advocate for justice. Being a Christian nurse means answering the call to become an agent of renewal in society. Doing Justice, Being Faithful

The vocation of Christian nursing includes a call to redeem the environment. But how? Discerning the direction of redeeming the environment, in all of its various dimensions, to better support health and wellbeing is not an easy task for Christians. However, honest and clear deliberations within the community, thoughtful exegesis of Scripture, and prayer are important and useful resources. The contours of biblical justice include

meeting the sustenance needs of widows, orphans, aliens, poor, and (as we have suggested earlier) the uninsured or underinsured. Wolterstorff argues that a just society "must bring into community all its weak and defenseless ones, its marginal ones, giving them voice and a fair share in the goods of the community" (Wolterstorff 1995, 18). The call for justice extends to all Christians, including Chris tian nurses. Effective nurses are competent in the handson care they give and in their attentive assessments of the intersections between client health and the environment. And they also are attentive and responsive to redeem particularly those parts of life that have to do with their calling - patterns and practices of thinking and operating that intentionally or not prevent human beings from being able to secure their fair share of health care goods. This is hard and demanding work. Conscientious nurses run the risk of compassion fatigue, but they also run the risk of becoming cynical and perhaps leaving the profession for good. Certainly the job of bringing justice into health care does not belong to nurses alone; yet, given their close location to client care, they are in a unique and particularly critical position to advocate for justice. Such a task is part of the calling faithful nurses recognize. They are not, however, called to change all aspects of their world single-handedly. Part of our recognition of the nature of persons as interdependent involves recognizing that when we act as agents of renewal, we act as members of a community. And

so

attentiveness

to

the

various

aspects

of

environmental features of nursing practice brings the Christian nurse to an awareness of responsibilities that go beyond competent care for particular clients, requiring more broadly based advocacy and political activism. These responsibilities are not always recognized as a part of the nurse's vocation, but a concern for client wellbeing makes it impossible to ignore them. Nursing associations have gained a more powerful and respected voice in public affairs in part because they are in a position to speak to these environmental issues with clarity and specialized knowledge. Recognition that environmental factors are human constructs and that they have a history of development provides a measure of hope for the Christian nurse, because what has been constructed can be reshaped in ways that make it better and more in line with how things ought to be. Further, the compassion fatigue we mentioned earlier is often a result of social structures that make the provision of adequate care impossible. When we shift our attention from the impossible circumstances in which people try to function, focusing instead on how the sys tems within which they live create those circumstances, we can sometimes see solutions that were not apparent from the individual perspective. Respect for life ... necessarily includes responsibility for the standard of living conditions. KARL BARTH This discussion of large-scale social change may still seem to demand too much of a nurse, however. "I'm working too many hours on an understaffed floor, and you want me to be a

political activist, too?" a nurse might say. "Give me a break!" And the nurse could very well be right. It is important to remember that as Christians we understand our lives in terms of vocation, in terms of being created by God for good works, called to participate in the works of God's kingdom in some specific ways. This notion of vocation is an important one for understanding our roles in bringing about social change. My vocation is the job I am called to do. In order to do it, however, I have to recognize that there are lots of other things, important and worthwhile things, that I cannot do. I have to trust that God will provide others whose vocations call them to work in those areas. Not all nurses are called to be involved in bringing about social change. Many nurses are called to be God's representatives in very specific locations, bringing warmth and respect into the context of a psychiatric unit, for example. As Christians we need to recognize and respect the limitations each of us faces in trying to carry out what God has called each of us, specifically, to do. This notion of a limited vocation can be a double-edged sword, however. We may be tempted to exploit it when challenging problems appear in front of us. We see the need for social transformation, but it is a daunting task, and it's much easier to turn away and focus only on the job immediately in front of us. This can be a real recipe for compassion fatigue: knowing that the system needs to be changed, but refusing to do anything about it, we then find ourselves frustrated and overwhelmed and are tempted to take out those frustrations on the people in front of us. But then the clients, who are already burdened with their own health needs and overwhelmed with

their own struggles with a difficult institutional system, are likely to bear the brunt of our frustration as well. If a nurse cannot help but see how the system is badly structured and cannot escape the frustrations and anger this can cause, that may be an indication that God is calling that nurse to action. The call to a vocation very often comes through exactly this sort of inability to turn away. We need to recognize our own limitations of time, energy, and capacities. But we also need to keep our ears open for the call of God when it comes through our ability to see what needs to be changed and how to change it. Conclusion Each of the metaparadigm concepts that structure an understanding of what nursing is - nursing, health, environment, and person - is dependent on the others. We cannot define nursing without making reference to health, since nursing is a practice whose identity is constituted, in part, by its goal of providing health care. Further, the nature of nursing practice is determined in part by the social structures that make up the environment within which nurses practice. Making an assessment of health requires an understanding of the environment within which a client functions (or is unable to function), and it requires some sense of the stories in which the client plays a role so as to judge how a given condition affects that client's wellbeing. For the Christian nurse, each of these concepts reflects some aspect of the theological framework that structures her or

his understanding of human life. The nature of nursing is focused by an understanding of the client as a bearer of the image of God. Our understanding of the concepts of health and environment are partly structured by the notion of shalom and partly structured by an awareness of sin and brokenness. In all of these ways, the Christian nurse can experience nursing as a practice structured by, and responsive to, a relationship with a loving Creator. But we have also noted that some of these concepts, particularly the concept of person, have an in-built orientation toward certain ethical issues. In the next chapter we will turn to an examination of those ethical issues, focusing on the two concepts that appear in this chapter with regularity: care and justice.

CHAPTER FOUR

How Christian Faith Shapes Nursing Values: Care and Justice When Sheryl walked into the staff lounge she knew it wouldn't be a relaxing place to take a break. Annette, one of the older nurses on the floor, was arguing heatedly with Tanisha about recent administration decisions. "They can't just change our hours!" Tanisha was saying. "We have a contract that says if we agreed to work four twelve-hour shifts every week, then we get weekends off. I signed it, and so did you. If the administration wants to start requiring weekends, then we should go on strike. It isn't fair for them to just dismiss the contract they agreed to!" "But we can't go on strike," Annette responded. "That's going to hurt the clients more than the administration. Besides, we're nurses. We got into this profession because we care about sick and hurting people. I don't mind starting to work weekends again - I've done it before, and I suppose I can start doing it again." "I can't," Sheryl said flatly. "I've made arrangements for child care during after-school hours, and I can't just change those. And I can't afford to start paying $4 an hour per child for

three children on weekends for twelve-hour shifts. It's not as if my pay has been going up fast enough to cover extra costs, and I can't just change my schedule." "Well, you may not have any choice," Annette said sharply. "We're nurses, not doctors or administrators. We don't make the rules around here, and we don't have much say about who does make them. Besides, if we don't fall into line, it isn't the administration that suffers, it's the clients. They're the ones who will pay if we try to organize any sort of protest. We have responsibilities to them to make sure their care isn't compromised, and we can't do that if we act as though this is just another job." Tanisha rolled her eyes. "Yep, we should just roll over and let people walk all over us, 'cause we're nice girls. It's slavery all over again," she said sarcastically. "Come on! We're professionals, and we deserve to be treated with respect. And we also have other responsibilities - kids, elderly parents who depend on us. It would be wrong to let the administration think it can treat us this way. We need to defend our dignity." Sheryl sat down and sighed. She'd just heard a sermon in church on the responsibility of Christians to be servants of all and to treat others with self-giving love. But it seemed wrong to equate accepting unfair labor practices with Christian service. At the same time she knew that a strike would affect client care. She wondered how hard it would be to switch jobs. Ethics and the Everyday

When Sheryl asks herself what she ought to do, what choice she should make, she is doing ethics. How she makes that choice - what principles she acts on, what good she strives to realize - will depend in part on what sort of person she is and how she interprets her circumstances. As we have seen in previous chapters, her Christian faith will qualify and shape both her personhood and her perspective. But it will also shape her values. Christian faith qualifies the very principles on which we act. Throughout this chapter we will look at two values that guide our action and that emerge from within the Christian faith. Before we turn to an examination of how Christian faith shapes our values, though, we need to think a bit about what it means to do ethics. We sometimes think that ethics is solely a matter of major, controversial issues: abortion, euthanasia, and cloning, for example, tend to be the big items in many ethics textbooks. But much of ethics is a matter of day-today interactions, lower-level choices, and conflicts that can add up to cumulatively important issues. The issue of staffing in our case study is a central moral concern for many nurses today. And it is an important issue, as a researcher at Michigan State University recently showed. She discovered that many nurses' understanding of their jobs is marked by what this researcher calls "moral distress." The term refers to the feeling many nurs es experience of being unable to give adequate care to their clients because of staffing cuts, an increase in the severity of the conditions in the clients they care for, and a constant increase in the number of clients they are assigned. The nurses feel they can't give adequate care, and they feel trapped in a situation of moral complicity with a system that is

morally problematic, or even morally evil. But the situation can't be solved by working harder or more efficiently, so the nurses feel that they have no solution. They can offer substandard care, or they can leave nursing, a career they have been educated for and worked at for a significant portion of their lives (Andre 2002). Moral distress seems an appropriate name for this feeling of being trapped in a no-win situation. This problem is a systemic one, not an issue of inadequate moral resolve on the part of the nurses involved. In a similar way, the dilemma that faces the nurses in the dialogue with which we began is a dilemma about how individuals should understand their roles in the context of a larger system that seems to place unacceptable burdens on them. We need a way of thinking about ethical problems that allows us to recognize, understand, and respond to the full range of problems nurses face, and that is the goal of this chapter. The chapter will not spend much time on the standard ethical cases that fill so many ethics textbooks. Abortion has been well analyzed by countless scholars, and nurses do not need one more rehashing of an already over-discussed issue. This chapter instead is aimed at offering tools for thinking through what an ethical issue is, how one can analyze it, and how to respond to it in ways that are effective and not self-destructive. We normally think of needing ethics (at least, in this narrow sense of needing to make a choice) only when a disagreement arises, or when consensus about what is good or right has broken down, or when multiple desirable outcomes conflict with one another, or when one senses the wrongness of a situation. If everyone agrees and the right thing to do is clear,

then there is no quandary that prompts us to "do ethics" in this narrow sense. This is true of standard ethical problems such as abortion and euthanasia, and it is equally true of the ethics of the everyday. Nurses know when something is wrong with the system of which they are a part (Chambliss 1996, 117). That wrongness sometimes manifests itself in the difficulty they experience offering adequate care and in the tension they feel between their responsibility to be client advocates and their need to get through their work in a reasonable amount of time. They sometimes find themselves feeling like one very small and impotent gear in a huge machine that slowly grinds up the people and things they value. And although almost all nurses have a deep sense of responsibility, they of ten have no clear sense of how the situation could be changed. This seems to leave nurses with only two options: either work in the system and risk becoming complicit in the destruction it causes, or leave nursing altogether. It is not surprising that a researcher discovers moral distress. But neither complicity nor giving up the work that one is called to do is really a satisfactory answer. In this chapter we will think about whether there might be an ethical framework that can help us think through such situations and come to more satisfactory solutions to them. We've already begun to develop such a framework by offering an analysis of the foundational concepts in Chapters Two and Three: nursing, the person, health, and environment are crucial for understanding the practice of nursing itself. But by themselves they cannot offer full-blown moral guidance in thinking

through the sorts of moral dilemmas nurses face on a regular basis. Each of these concepts deals with a central and important part of nursing practice and life, but none, by itself, can tell us how to balance conflicts between, say, a concern for health and the need for a strong professional organization. In this chapter we will develop two central values that are shaped by the Christian faith and discuss their relevance to a Christian understanding of nursing practice. The two values we will be focusing on are deeply rooted in the Christian tradition: care and justice. The way in which we develop these values, moreover, varies from the way in which principles of biomedical ethics are often articulated. This difference is due in part to our attention to how the Christian faith qualifies our values, but it is also due to our attention to the nursing context. Biomedical ethics often focuses on four principles: respect for autonomy, nonmaleficence, beneficence, and justice (Beauchamp and Childress 1994, 38). Autonomy often functions as the premier value of the four, and its application, therefore, concerns primarily issues such as informed consent. But, as we have already seen in the second chapter, the Christian faith prompts us to acknowledge that our personhood is deeply interdependent. Respect for autonomy, for the Christian, needs to be grounded in respect for persons as image-bearers of God and as vulnerable and interdependent members of the human community. Christian faith offers a similar qualification of the principles of nonmaleficence and beneficence, which we develop in this chapter in terms of care. Finally, the principle of justice needs to be reconceived in light of our knowledge of God's character and with attention to particular issues in nursing practice.

Both care and justice are central issues in nursing practice, and they are also crucial for thinking about nursing from a Christian perspective because they reflect two central ethical concerns that we are consistently shown in Scripture - God's concern that justice be done, and God's loving-kindness and mercy. We need both concepts to have an accurate sense of who God is and of how to structure our own lives, and if we lose sight of either we end up with distortions in our thinking. Without a clear sense of God's love and care for creation we are likely to envision a God who is just but cruel, a harsh and unloving God who delights in dealing out punishments whenever possible. Without a clear sense of God's justice we are likely to end up with a picture of a God who is mushy and sentimental, one who is unable to distinguish between right and wrong at all, or who can distinguish but can't really do anything about it. As we try to think about our own moral life, we will find the same situation. We need a proper balance between a strong opposition to evil and a readiness to reach out in loving care. When we think about the dilemma that faced the nurses in our example at the beginning of the chapter, we can see that Annette offers a response that reflects caring. She wants to make sure that client care doesn't suffer. But, as Tanisha reminds her, there are issues of justice here as well, signified by the contracts the nurses signed. This tension is one that has marked the practice of nursing since its inception, but it is not one that can (or should be) resolved by giving up on either principle (Andolsen 2001). We need both concepts, justice and care, to make sense of our moral experiences, and though we will treat them separately, neither can be fully expressed

without the other (Bubeck 1995, 220; Baier 1995, 53). Care We will begin with care, because it is a term that is used widely and naturally in the nursing context. What exactly is meant by the term care? Care, first and foremost, connotes concern for the wellbeing and flourishing of someone or something. When we care for clients, we are concerned that their health care needs be met, that they are enabled to understand their own situation and to make decisions that will allow their lives to go well within the limitations they may face. So the most basic sense of care involves an active concern for the preservation and (where possible) the growth or development of someone or something (Carse 1996, 96; Noddings 1984, 31). Care also necessarily involves both attitudes and actions. If I care about something, my attitude toward it must be one of concern, but concern by itself is not enough to count as care. Concern must be active. If I say I care about something but fail to act in any way, then I cannot really be said to care unless there are extenuating circumstances. For the Christian nurse, this connection between care and action is grounded in the recognition of the goodness of creation and its Creator and gratitude for redemption that we noted in the first chapter. Love for God never exists as simply an inner feeling; love for God expresses itself in how we respond to those people around us in whom we see God's image. If we are not responding to them with love and care, our claim to love God is cast in doubt (1 John). Likewise, when we think about how God responds to us, we recognize that God's love is active, in the continued

creative activity of sustaining creation and in the incarnate presence of Christ with us. Further, because Christians recognize that creation is a good gift from God, it is appropriate to reach out in care and love to others. There is something good in the other that care responds to, and should respond to. But more than this, faith in the basic goodness of God allows the Christian to respond with care even when that may seem a bit foolish or even misguided. We don't have to limit caring responses only to those we think will care for us in return, since care offered to another is also always offered to God. Care begins, then, with response to another. Theorists such as Joan Tronto have called this basic sense of care "caringgiving" (Tronto 1994, 107). It involves the handson, active response to someone who is in a situation of vulnerability or need. We've noted, then, three of the fundamental aspects of care: care is called for when someone has needs or vulnerabilities; an agent must recognize and be concerned about those needs; and the agent's concern must be active. But we need a fourth component for an adequate account of care, and that involves the response of the person receiv ing the care (Noddings 1984, 73). In the ordinary case, the person cared for must recognize the action as one that aims at her or his good and respond appropriately in order for the complete action to be one of care. This response is crucial because it prevents care from becoming control. Of course there will be cases where no deliberate response is possible - when caring for comatose individuals, for example. But whenever care is given appropriately, the caregiver watches to see that it is

having the proper effect, so that, even in cases where the cared-for cannot respond, the caregiver should see a response. The response may be as simple as a bedsore that begins to heal, or as complex as a client who begins to challenge the authority of caregivers because she is regaining a sense of autonomy; in either case, the care and the response to it are appropriate. Caring is directed toward persons in their full individuality, motivated in part by a concern for their wellbeing and tending with any luck to produce good consequences. MIKE MARTIN Four components, then, are necessary for care: vulnerability, concern, action, and response. Failures of care can occur at any one of these points. Right from the start an individual may fail to, or refuse to, see another's need or vulnerability. Jodi Halpern notes that health care workers often turn away from clients who are in strong states of hopelessness and fear. The caregivers find the emotional states so disturbing that they tune them out and cut the client off from emotional attentiveness (Halpern 2001, 9). While the response is understandable, Halpern argues, a better response is to allow oneself to understand the emotional states, because such empathy can provide better knowledge of the client's condition and better responses to the client's needs. If someone does see the need, she or he may be wrong

about what an appropriate response might be. Daniel Chambliss notes that nurses sometimes estimate that as many as 50 percent of clients are noncompliant in some way, and he argues that this suggests something other than ignorance or self-destructiveness on the part of the client. Instead, he suggests, the client may have goals other than those of the caregivers. "From the patient's point of view," he writes, "the staff may be boldly noncompliant with the patient's own wishes. But `noncompliance' in the hospital means `noncompliance with medical authority.' The very term defines medical reality as the dominant one" (Chambliss 1996, 138). What we have here is a failure to communicate, of course, but we also have a disagreement about what the appropriate response is to clients who want to make their own decisions. Four Components of Care: • need or vulnerability • perception and concern • appropriate action • response Paternalism - that is, acting against the client's wishes for the (perceived) good of the client (Beauchamp and Childress 1994, 274) - is a constant temptation for health care workers. As we noted in our discussion of nursing as a social practice, the nurse is highly educated, and health forms the central value of her or his professional role. But clients may have other central values, and often they do not care as much about health as

nurses wish they would. In such cases the very characteristics that make someone a good nurse will also tempt him or her to paternalism. But good care requires an involved stance of care for the client in ways that allow the nurse to act as advocate for the client, not for him-or herself (Tanner et al. 1996, 211.) Even in cases where the need is seen and the action taken is appropriate, the person who receives the care may not recognize it as caring and may reject it or experience it as an unwarranted intrusion. Caregivers are not the only people who can be wrong or confused about what is appropriate care in a variety of situations. Clients can also fail. Since this is a discussion of nursing ethics, we will not focus on client responsibilities, but it is worth noting that clients sometimes make caregiving very difficult. All of these are points at which care can fail. But it is also important to note that in many cases care does occur, is appropriate, and is experienced as care by the one who receives it. We can recognize the way care is supposed to be and use that picture to understand where care goes wrong or fails. Caregiving, however, though it is the most basic sense of care, is not the only sense that is important for our purposes here. There are many needs and vulnerabilities in our world that we cannot address directly. When I walk past an elderly man sleeping on the street, I may not be in a situation to respond to his needs or to offer him any assistance. But I may still recognize that he has needs that are clearly unmet, that his humanity calls out to me to respond to him in some way. In

these situations an individual may find herself or himself caring about something rather than directly giving care (Tronto 1994, 106). When we care about something, we recognize that there is a need or a vulnerability that should be addressed. We will not always be in a situation to address that need completely on our own. The recognition of needs that leads to caring about is properly connected to political action because there are so many needs that no one person can respond to all of them (Tronto 1994,139). If we care about homelessness, for example, we need to think about how mental illness, lack of access to prescription drug plans, and homelessness all fit together. On March 6, 2003, The New York Times reported that the state of Oregon had managed to cut rates of homelessness by offering prescription coverage under its Medicare program. Unfortunately budget cuts at the national level threatened to make it impossible to continue to cover prescriptions for the poor, and the state foresaw an increase in homelessness as a result. North Americans confuse care with control. PATRICIA BENNER Four Kinds of Care: • caregiving • care-receiving • caring about

• taking care of Care is a central aspect of our ethical framework from a Christian perspective because of the centrality of care in the picture of God we are given in Scripture. The God who is revealed to us is a God who creates and sustains all that is, who cares for the needs of songbirds and wildflowers, who even counts the hairs on each human head. This is a God who is portrayed as weeping over the destructive nature of human choices, as mourning with those who have lost loved ones, and as incensed at the destructive nature of so many of our choices. Further, this is a God who loved so deeply that, in the person of Jesus Christ, he became incarnate and walked among us, suffering what we suffer, even enduring an ignominious death for the sake of sinners. As followers of this Christ we are likewise called to reflect the sort of love he offered us and to respond to our neighbors (even our neighbors who are enemies) with love. In one of the most memorable passages of the New Testament, we see Jesus explaining to us how this lo v e should be expressed. In the discussion recounted in Matthew 25, Jesus describes the sheep and the goats, and he distinguishes them in terms of the care they have offered to others. The sheep are those who fed the hungry, offered a drink to the thirsty, or provided clothing to the naked, and the goats are those who failed to offer such care. Care, then, should be a central focus of the Christian life, and the fact that it is also a central concern of ethical analyses of nursing practice is a welcome feature of contemporary analysis. But things are not always as they should be; because we care, this also leads us, with God, to lament the brokenness

of creation. Care would always be an appropriate response; even in a world that was not broken by sin it would be appropriate to see others' needs and meet them. But the brokenness of our world means that the care we are required to give is often needed because of sinful and destructive choices we and others have made, and it means that the care we give will never, ultimately, be enough. It also means that when we care, we can do it wrongly and in ways that are not going to lead to the good of the other. Our caring can be paternalistic, might evidence the "conceit of philanthropy," or might lead to "compassion fatigue" when we are confronted with the reality of too much need in the face of too few resources. Acknowledging the pervasiveness of sin leads to a chastened notion of what care can accomplish and the dangers it poses as well as the need for it. Justice This leads us, in fact, to the second big ethical principle we need to keep in mind as we think about nursing and ethics, that of justice. Care is central and important, but if we focus only on care we are likely to miss important features of many situations. People have needs and vulnerabilities that need to be met. Care encourages us to see these needs and vulnerabilities and to respond to them. But other questions need to be asked, such as how these needs and vulnerabilities arose, and why, and sometimes these questions shift the way we think about a caring response. We do need to be attentive to others' needs and vulnerabilities, but when we begin to ask ourselves why they are vulnerable or needy in those particular ways, we sometimes begin to see that there are issues of power and the

abuse of power that contribute to the brokenness of our world. We began this chapter with three nurses talking about their contractual relationship with the hospital administration. They noted that it is unjust to ignore contractual issues. But the injustice of the situation may go deeper than this. Nursing as a profession has had a long and complicated relationship with hospital administrations, physician groups, and (more recently) managed care administrations precisely because these groups have wanted to define nursing as a subordinate profession (Group and Roberts 2oo1; Baer and Gordon 1996). When we focus on issues of this sort we face a different set of issues than those we've talked about in terms of care. These are not questions about whether or not there are needs and vulnerabilities; rather, these are questions about how we should arrange to distribute benefits and burdens in society, how we should organize our communal life fairly, and how various distributions of power create or maintain vulnerabilities. In a word, these are issues of justice. Justice and care converge at some point, since it is not possible to care adequately under conditions of grave injustice, nor can a situation be called just in which people are not able to develop and maintain relationships of care for each other. But convergence is not identity - we need both concepts for an adequate account of how human ethical life should be structured. And we see in Scripture that both are invoked when God's character is described. God is a God of love and mercy, surely, but God is also a God of justice, described as being as dangerous as a mother bear whose cubs have been threatened and as being full of wrath at those who perpetrate evil. And in

Jesus we again see this aspect of God's nature. Jesus did not shy away from calling people to repent. His ministry was one of healing, certainly, but it also included driving the money lenders out of the temple, calling people to an awareness of the holiness of God and to an awareness of the many ways in which we fail to worship God or respect his image in the other people we see around us. In his Confessions Augustine notes how blind we can be to the true value of things. He offers the example of a lawyer arguing in court, noting that the lawyer is likely to be centrally concerned with whether or not he argues well and effectively, all the while ignoring the fact that a person's life is at stake. The death of a person made in the image of God is far more important than whether one's rhetoric is carefully polished, and yet we are unconcerned with the very image of God who is in front of us, Augustine says, while we focus on whether or not we put our words in the right order (Augustine 1998, 21). Justice is centrally a matter of equity and fairness. We very often speak in the language of rights when we are concerned about justice matters because rights allow us to recognize inequities in treatment. The basic human rights - rights to life, rights to freedom of religion and conscience, rights to be free from unwarranted arrest or confinement - are all designed to prevent the grossest infringements against fairness. So when we turn to issues of justice, we find ourselves concerned with questions about how practices are organized, whether or not social structures respect the rights of the people affected by them, and how fairly benefits and burdens are distributed by those structures.

Some aspects of justice issues are more easily seen in the health care context than others. The last thirty years have seen a careful articulation of the notion of patients' rights, autonomy, informed consent, and the like. All of these are justice issues because they all involve attempts to build into the structure of health care delivery a basic respect for the rights of clients. But other issues are often not as central to considerations of justice in health care. Take, for example, the issue of nurse practitioners and physician control of health care. Physicians' groups such as the AMA (American Medical Association) have regularly lobbied hard against nurse practitioners providing primary health care, even though there are insufficient primarycare physicians to provide such care, and even though several studies have shown that the care provided by nurse practitioners is equivalent to or better than that offered by physicians (Group and Roberts 2001, 418). This is clearly not a struggle about the provision of adequate care but a struggle over privilege and power. Those who have power rarely give it up without a fight, and those who want to change power relationships need to expect such a fight. It is high time to take our bearings from the orientation toward a justice that fits good news to the poor. ALLEN VERHEY So this brings us to Sheryl's question at the beginning of the chapter. Can Christian nurses be involved in fights for

justice, or should they instead think of their role as one of exemplifying Christ-like, sacrificial service? This is a pertinent question for nurses in particular because nursing, in its historical development, has been defined in terms of care rather t h a n justice (Nelson 2001, 51). But Christianity is wrongly understood if it is made to serve the cause of injustice. We have historical examples of this misuse of Christianity apartheid in South Africa, American slavery and racism, violent opposition to women's rights, and the Crusades - and they still bring dishonor to the church. Christians do need to strive for sacrificial service, but that service needs to be directed to God, not to the powerful of this earth. Jesus' own sacrifice was on behalf of broken and vulnerable humanity. He always seemed to prefer the poor, the outcast, the marginalized and powerless. It is appropriate for Christian nurses to fight for justice, to speak up when human rights are trampled on, and to call those in power to ac countability. Scripture is full of prophetic voices who remind those in power that they are responsible to God for their decisions, and when we are given the opportunity to work for justice we should not shrink back out of a misplaced worry about lack of humility. Humility, properly speaking, is exemplified when we do not consider ourselves too good to s erve the weak, not when we are too scared to resist the injustice of the powerful. Care and justice are both central to any understanding of the structure of ethical issues. But care and justice function differently at different levels of moral analysis. Care can involve empathetic understanding of another when we are in a personal relationship with her or him; but when we are thinking

about the structure of health care delivery, empathetic understanding is less important than a clear grasp of how lack of access to primary care generates over-use of acute care facilities. So in the next section we add another set of parameters to our framework: the parameters of different levels of analysis.

Levels of Analysis Ethical analysis and action shift as we consider different levels of social organization. For our purposes here we will divide ethical analysis into three levels, though in our everyday experience these levels are always interpenetrating. The first is the level of personal morality. As an individual, what do I believe, what should I be held responsible for, and what sorts of relationships are mandatory, acceptable, or unacceptable for me? The second level is that of institutional morality. This level looks at how the nurse fits into the institution of which she or he is a part. Finally, we have the level of nursing as a practice and the social structures of which it is a part. It is important to separate these three levels of ethical analysis, in part because t h e moral responsibilities of individuals differ at different levels. At the level of personal ethical decision making, I need to make sure that my own beliefs, responses, actions, and relationships are in line with the set of values I hold and the values I see portrayed in Scripture. These responsibilities fall squarely on me, and I cannot evade them by pointing to choices others make. But at the level of institutional analysis, we are not focused so much on individual responsibility as on corporate responsibility; there will be a need for cooperative action and consensus building in addition to the individual decision making that goes on at the personal level. Of course, in practice we do not leave our personal responsibility behind, but in the analysis of institutional morality our focus is elsewhere. Finally, at the level of social structures we are focused to an even greater extent on the need for collective action. When we

think about the place of nursing as a practice in the contemporary Western world, our analysis needs to go far beyond the question of what moral values an individual should try to live out. We need instead to think about what sort of a society we are and what sort of society we ought to be. As Christians, we are convinced that there will always be a gap between these two, until God's action renews creation, which means that there will always be a need for critical thought and collective action to work toward rectifying the injustices and destructive aspects of the institutional structures. Personal Morality

Are there central features of the individual Christian's moral life that should be structured in terms of particular values? And how can we think about living out these values in our relationships and careers? Clearly Christians are called to a life that embodies the sorts of concerns God portrays to us in Scripture. We are called to act in ways that model God's care for us to a world in dire need of care and love. We are also called to act in ways that reflect the holiness and justice of God and that demonstrate a concern for justice, for a full recognition of the image of God in all people. And (though we haven't made this an ethical principle) we are called to live joyously, celebrating the gift of life and the goodness of creation in the company of God and other people. This gives us a starting point for thinking about personal ethics and how we should think about our lives in the context of nursing as a practice and as a vocation. One of the first things to note is that nursing is an

inherently ethical and dignified vocation, as was noted earlier in our discussion of the nature of nursing as a practice and of health as the focus of nursing. To be a nurse is to choose to have, as a part of one's identity, a central focus on healing and the maintenance of health and appropriate care for those whose health is failing. This is a fundamentally moral goal and one to which Christians are called to contribute. So nursing is an honorable practice, one that can legitimately be the vocation to which a Christian is called. This is not true of all careers. There are some "careers" in our society that no Christian should participate in (slum lords, pornographers, prostitution) and others that are structured in such a way that it is difficult to engage in them in any honorable way (certain types of advertising, businesses that deliberately subvert moral concerns in the interest of profit). While we respect the many callings Christians can have as they seek to glorify God and serve others, we are also called to discernment in terms of which careers can be legitimate places for us to live out those vocations. It is thus important to note the essential moral core of nursing. And because nursing is a fundamentally good calling, and the nurse's job such an important one, an essential part of the good nurse's life involves self-care. That is, it is appropriate, even mandatory for a nurse to care for herself or himself in ways that allow for a full and satisfying human life and that prevent the burnout that is appearing among nurses at an alarming rate (Selles 2002). This self-care should not just be a matter of physical care, though obviously that is important; rather, in keeping with nursing's holistic perspective, it needs to be care for all the dimensions of the self: physical, emotional,

spiritual, and psychological. Beyond this, the Christian nurse is called to live out the two values of care and justice and thus to allow God to shine through her or his life to the world. In terms of basic practice, then, the Christian nurse has the responsibility to meet the requirements of competency in practice and efficiency in action, since both of these are central ways in which one's actions affect others. Without competency, the nurse runs the risk of harming clients. Without efficiency, the nurse runs the risk of creating unfair burdens on others. Both of these responsibilities are central aspects of the nurse's internalized education, and both are legitimate ethical concerns. Both, in fact, are part of the notion of stewardship, of making good use of the resources and gifts God provides for use. Before leaving them, however, it is worth thinking about whether these responsibilities might also become, in certain cases, legalistic stumbling blocks. Rules and laws, remember, are good things, but never ends in themselves. Without giving them up, we need to recognize that applying them unthinkingly may be problematic. The first principle can sometimes get in the way of asking for needed help or admitting that one is overwhelmed with responsibility. Competency is a good thing an essential thing - but we should never let our goal of competency make it impossible to ask for help or guidance. The second principle, efficiency, can sometimes function to make the nurse willing to do too much. As hospitals increasingly try to cut costs by making cuts in nursing staffing, the internalized value of efficiency may make it difficult for nurses to recognize when too much is being demanded of them. Or, as some nurses

discover, the demands of ever-increasing efficiency in the context of managed care lead to nurses functioning like machines, performing mechanical functions on the bodies who pass under their care. Seeing a client as an individual, worthwhile person becomes impossible in such a context, and one of the central internal goods of nursing practice is then lost (Baer and Gordon 1996, 228.) To the extent that the nurses blame themselves for any jobs left undone they will be unable to see that perhaps it is the structure of the job itself that is placing demands on them that simply cannot be met. These are just two of the central moral concerns that structure the nurse's individual life. There are so many other concerns that we cannot discuss all of them here, though many will certainly arise in later discussions of particular aspects of nursing. But the general approach that this section offers - that of recognizing the value of the principle, while also recognizing when it can lead to problems - is one that is valuable in all aspects of personal reflections on moral character. Institutional Morality

It is sometimes tempting to assume that institutional morality is nothing more than personal morality writ large, that all one really is responsible for is to make sure that one's personal values are enshrined in the institution of which one is a part. But things are never this simple, unfortunately. First of all, values that can be held at the personal level without serious conflict become far more difficult to balance at the institutional level. As an individual, for example, I have no difficulty recognizing the importance of the principle that I should limit

my actions as a nurse to those areas in which I have knowledge. If I try to claim expertise in areas that I don't know about, I am acting in a clearly immoral (and dangerous) way. At the purely personal level this is a fairly easy assessment to make. Unfortunately, I may find that the institution of which I am a part does not respect my own understanding of my limits. The practice of "pulling nurses" has always been widespread in various hospital settings, and it is becoming more problematic as nurses require increasingly spe cialized education to function in certain units. "Pulling" means that a nurse who works in Labor and Delivery and knows himself to be competent in that setting may find that his unit is overstaffed so that he is sent to a Pediatric Intensive Care Unit. He may not have the necessary expertise to function properly in that context, but what is he to do? If he agrees to serve in the PICU, he puts his clients at risk, and himself as well; but if he does not agree, he may endanger clients by leaving the PICU understaffed and may even lose his job. This is not an issue that can be resolved by careful ethical reflection and individual fortitude because it is an issue that is generated by the institution of which one is a part. Further, the rankings of values may change as we move from the level of personal values to the level of institutional values. When I am concerned about my own responsibilities and relationships, my moral reasoning will be different than in cases where I am concerned about how an institution should be structured and how the various members of that institution will be required or expected to contribute. It makes sense, for

example, to hold myself responsible to place the needs of my children high on my list of priorities, but I can't expect a health care institution to do the same. Having noted these difficulties, we can also note that, from a Christian perspective, the institutions designed to meet health care needs are fundamentally morally good. The fact that so many hospitals in the United States are still named after their religious founding organizations (Jewish Hospital, St. John's Health Care System, Methodist General) reflects the fact that religious groups have seen providing systems of health care as a central part of their mission, and they were absolutely correct in that perception. As Christians, we are called to participate in healing ministries. Thus, just as we noted in the case of the nurse's personal vocation, so in the case of institutions we are dealing with institutions that have a morally good purpose (though this claim becomes more complex and problematic in the instance of for-profit hospitals). But, as is the case with individuals, institutions do not always live up to appropriate standards. Because of the enormous amounts of money that flow through the health care system, the system has vast potential for exploitation and abuse. And because of the power health care institutions wield, they can also be used to control or oppress individuals. In both of these cases the individuals who work within the system are faced with a difficult problem. If they stay in the system and try to change it, they may become complicit with its problems. If they leave, they cannot change anything, and so they permit the problems to continue unabated.

There is no easy answer to problems of this sort, but it should be noted that institutional problems generally require institutional answers. One cannot address issues of inadequate staffing as an individual. But nurse administrators, with the weight of their staff nurses behind them, can challenge unacceptable practices and call for change. Action as a member of a group takes different skills and poses different challenges than action as an individual, but such collective action is an important part of functioning as a professional body. In the case of the nurse pulled from Labor and Delivery, for example, individual action is more likely to get him fired than to solve the problem. But collective action by all the nurses in a hospital system may be able to make some adjustments to protect both clients and nurses in such a case, either by limiting the units between which nurses can be pulled or by requiring some sort of mentorship for nurses brought into areas outside their expertise. Likewise, the case with which we began this chapter is a case of institutional ethics, not a case of purely personal responsibility. Tanisha is right to note that when a hospital system has a contract with a group of nurses, it is fundamentally unjust for that contract to be discarded simply because the administration finds it inconvenient. Because this is an institutional issue, however, it requires an institutional response, not a personal one. Annette is rightly concerned that the clients not be the ones who suffer while it is being resolved, but it needs to be resolved fairly so that, in the long run, client care can be provided adequately and competently. Social Structures

Institutions do not exist in a vacuum, however. The hospital system that is causing problems for Sheryl, Tanisha, and Annette is itself facing increasing pressure from managed care systems and insurance providers to cut costs. This means that we need to consider a third level of ethical analysis, that of social structures. When we move to social structures, we are not dealing with particular institutions any longer. Instead, we are dealing with the social organization of health care - the insurance providers and political forces that determine how health care will be structured. The level of social structures is the most abstract and the most recalcitrant to change. At the same time, however, it is an area of human life in which changes have the greatest effect. I can be as concerned as I like about whether or not the poor have access to basic health care, and I can (at the personal level) perhaps make it possible for some individuals to get health care by paying for it myself. But if I can work with others in the community to set up a system of neighborhood clinics to provide basic care I will have made it possible for far more people to gain access to health care, and I may even enable the continuation of this care beyond the span of my own lifetime. So it is crucial that we think clearly and carefully about social structures and how they affect people's lives. Nursing as a profession has become more vocal at this level in recent years, though the advice of the American Nurses Association does not carry the weight of an organization such as the American Medical Association. This is an important aspect of nursing, though one that does not receive as much attention as it perhaps should. Nurses, especially Christian

nurses, have the capacity to provide important insights into problems in health care and solutions to recalcitrant dilemmas. But those insights will not be heard unless nurses see themselves as having the responsibility to speak out and to organize venues for bringing political and legal pressure to bear. This is an issue that makes nurses uncomfortable, and sometimes Christian nurses in particular think that they should not be involved in policy-level decisions. As we heard Annette say at the beginning of the chapter, some nurses think of themselves as subservient, not political activists, and some define their Christian identity in terms of obedience to authority. But Christians are never called to offer unthinking obedience to political authority. When authorities act in ways that are not acceptable, we are not justified in sitting passively on the sidelines. Sometimes we are called to mitigate harm; sometimes we are called to speak prophetically to challenge the authorities. Both care and justice are central aspects of our concern here. Unless we care about clients and their needs, we will not see the ways in which the system of health care fails them. And if we cannot articulate the ways in which rights are being infringed or power is being used unjustly, we cannot challenge the system to change. Limits of Ethical Analysis We have a basic framework for ethical reflection in hand at this point, one that contains the two principles of care and justice and the three levels of analysis: personal, institutional, and social. Is this all we need, and what can we expect from such a

picture? Any answer to this question has to adopt a sort of good news/bad news structure. The bad news is that no one can produce a neat ethical system that will always produce the right answer for every ethical problem. But the good news is much the same. As H. Richard Niebuhr put it, we are "responsible selves," mature and loving responders to the God who creates, redeems, and sustains us (Niebuhr 1963, 52). This means that there can be no substitute for careful critical thought about difficult ethical issues, and it means that we cannot always get ethics right simply by finding the proper ethical authority and obeying it, or him, or her. So what we are aiming for here is not an easy answer, or even an absolute right or good action. Instead, we seek a "fitting" response, one that "fits" with who we are, what we are able to understand of our circumstances, and what flows from and is guided by our central values. As moral agents, we can never expect to be able to hand over our conscience to another. To be a moral agent is to be responsible for making judgments and choosing to act under conditions where it is not always clear what the right thing is to do. As Christians we are sometimes tempted to pretend that this is not our situation. Christians are often encouraged to set aside the need for moral reflection and instead to try to set up a list of rules, which, if followed, will result in righteousness. Unfortunately, we see in the New Testament that this leads to legalism, not righteousness. Christ's constant call to see the intent of legal rules and to act to support that intent, rather than adhering to the rule even when that adherence is destructive of the rule's very purpose, is instructive here. When Jesus addressed the issue of Sabbath laws, his constant

refrain, whether when healing a man with a crippled arm or discussing his disciples' eating grain picked from a field, was that the Sabbath laws were created to enrich and protect human life. Humans are not made to obey Sabbath laws, he reminds us; rather, the Sabbath laws are to function for the preservation and enrichment of human life. This is true of all moral rules: they exist to enrich and protect human life. Whenever we elevate a particular rule above any concern for how it affects people we begin to act in ways that are both unjust and contrary to the example Christ sets for us. And this is a real danger for Christians, who often are concerned about righteousness and can, by that very concern, become vulnerable to a particular sort of unrighteousness based on legalism. An example from the past is easy to find. When Christians defended slav ery on the basis of scriptural codes of behavior for slaves, they used legalism to avoid seeing the destructiveness of the practice of slavery in people's lives. But we can also sometimes see this same tendency today. When some Christians are concerned with sniffing out the least trace of anything that can be called "idolatry" (no Halloween costumes! no Christmas trees! no Harry Potter!) while remaining entirely blind to the ways in which they bring dishonor to the name of God by portraying the Christian life as one of joyless, cramped legalism, we see a contemporary version of that same tendency. Moral rules must always be applied in the context of loving concern for particular individuals. When they are applied for the sake of the rule itself and nothing else, they can become evil. But as we noted at the beginning of this chapter, the same is

true of the opposite error. We cannot dispense with rules, principles, and laws and "just love everybody." Active moral engagement with the world requires us to make firm judgments about right and wrong and to be clear about what is and what is not morally acceptable. Concern for particular individuals should never blind us to the many ways in which individuals may choose to do things that are simply wrong or the many ways in which we ourselves may be tempted to choose easy nonjudgmentalism rather than the difficult choice of confronting evil. Nurses do not face an easy task in trying to discern the proper moral response to the many ethical issues that confront them in their profession. We live in a complicated world, and one in which the voices of the weak have a hard time being heard. Nurses have the responsibility, as part of their vocation, to speak for the importance of health care for all and to work to make that a reality. We may never see that goal accomplished in its fullness, but in striving for it we are working with the God who heals the sick and lifts up the fallen, and that is a worthwhile way to spend one's life. The kingdom of God is in our midst now but has not yet fully come. And so we find ourselves looking for its presence, anticipating its fullness, and working toward its ends. In the remaining three chapters, we examine three contexts in wh ic h nurses pursue this worthwhile vocation. In each instance we point to the ways in which we see the presence of the kingdom of God even now, to the places where we must work against challenges to advance its ends, and to the hope we hold out for its fulfillment in God's own time.

PART TWO Christian Faith and Nursing Practice

CHAPTER FIVE

Psychiatric-Mental Health Nursing Two Case Studies Jeff is 37 and lives in a house with five other men, all of whom struggle with persistent mental illnesses. This house is located in a neighborhood setting and is staffed by unlicensed personnel twenty-four hours a day. Beth is a nurse case manager who has worked with Jeff for the past two years. She visits him regularly at his home as well as in the acute care setting if he requires hospitalization. Today, Beth has been alerted to the fact that Jeff has been very agitated and delusional since a telephone conversation with his brother last evening in which they became angry at one another. As Beth greets Jeff she notices that he is disheveled and has not groomed himself. They sit down in the corner of the living room. Jeff urgently tells Beth that the CIA has begun tracking him again. They have "bugged" his room and are tapping the house telephone. Jeff reports that when he leaves the house, agents, seeking to uncover where he has hidden high-security coded information, are following him. Jeff's speech is disjointed and tangential. Beth asks no questions but rather listens intently and

patiently to Jeff's conversation. Her nonverbal behavior indicates that she is fully engaged in her interaction with Jeff. When asked by Jeff if she saw the agents outside the house, Beth calmly replies, "I did not see any evidence of CIA agents outside, but I hear that you are very concerned about that right now." Jeff nods and continues on. After a period of time, Jeff's rate of speech begins to slow. During a pause, Beth suggests that they might move to the table and play a favorite card game while they converse. Jeff is agreeable, and soon he is focused on attempting to win the game. After the card game, Beth inquires about Jeff's conversation with his brother. They identify some beginning strategies to reduce anxiety when conversing with Jeff's brother. Beth realizes that she will need to work with Jeff further on this issue when his symptoms are better controlled. She ends her interaction with Jeff by telling him that she will return in a week to see him again. Beth speaks with the staff, who indicate that Jeff has been isolative and talking to himself more over the past few days. Beth enters a progress note into Jeff's chart before she leaves the house. She identifies the need for an interdisciplinary conversation regarding the adequacy of Jeff's medications, additional family education for Jeff's siblings, increased structure for Jeff during the day, and increased attention to his hygiene. Cathleen is a master's prepared nurse practitioner who serves as the director of a college counseling center at a small, religiously based, liberal arts college. As such, Cathleen directs

the efforts of two other professional staff members and provides counseling to a caseload of students. In addition, she periodically conducts group sessions on campus on various topics such as "Dealing with your Parents' Divorce," offers college-wide mental health promotion sessions on topics like assertion skills or healthy relationships, directs the screening efforts on campus for depression and eating disorders, and serves as a liaison between the college counseling center and the college health center. The students whom Cathleen sees individually and in group therapy are struggling with a variety of issues: situational or maturational crises, stress, anxiety, self-esteem, identity issues, loss and grief, or perhaps suicidal thoughts. Some may have actual psychiatric diagnoses such as major depression, bipolar disorder, panic disorder, bulimia, anorexia, or substance abuse. Cathleen assesses, diagnoses, and treats the students who seek help in the Counseling Center. Cathleen has prescriptive authority and finds herself prescribing a variety of psychotropic medications to students who need them. As a nurse practitioner, Cathleen may call colleagues from other disciplines in on consult as necessary. She occasionally seeks consultation from a psychologist who does psychological testing of students, which provides Cathleen with additional assessment data upon which to formulate her plan of care. It stands to reason that the mentally sick should be at least as well cared for as the physically sick.

LINDA RICHARDS [Peplau completed her book in 1948, but] it was not published until four years later because it was considered too revolutionary for a nurse to publish a book without a physician as coauthor. A. W. O'TOOLE AND S. R. WELT The practice of Beth and Cathleen as psychiatric-mental health nurses is not necessarily the type of work that immediately comes to mind when one speaks of nursing. This is perhaps not surprising as this specialty area of nursing practice is relatively new. Linda Richards is commonly recognized as the first American psychiatric nurse for her work in the late nineteenth century (Carson 2002, 17). However, it was not until 1913 that Johns Hopkins became the first school of nursing to include a fully developed course on psychiatric nursing in the curriculum (Stuart 2001, 3). In 1950, the National League for Nursing first required that accredited schools of nursing must provide experiences in psychiatric nursing. In 1952, Hildegard Peplau published Interpersonal Relations in Nursing, in which she set forth the first systematic, theoretical framework for psychiatric nursing (Peplau 1952). The label "psychiatric-mental health nursing" attempts to encompass a broad spectrum of practice within this specialty area. Mental health nursing practice is directed toward "well" individuals, families, and communities in an attempt to promote an already existing level of mental health and to prevent the emergence of mental illness. Psychiatric nursing practice is

directed toward individuals and the families of individuals who are struggling with identified mental illnesses. Cathleen's groups on assertion skills and healthy relationships as well as her work with individual students experiencing crises, stress, or self-esteem issues are examples of mental health nursing practice. Obviously, psychiatric nursing is the focus of Beth's practice with Jeff. Psychiatric-mental health nurses deal with the full spectrum of these issues and with the many areas of overlap between mental health and psychiatric nursing. The clinical practice of psychiatric-mental health nursing occurs at two levels: basic and advanced (www.apna.org). Beth, as a registered nurse functioning at the basic level, has worked with Jeff and his family in assessing his mental health needs and then developing, implementing, and evaluating a plan of nursing care for him. As Jeff's case manager, she monitors the effectiveness of his medications, promotes his ability for self-care, assists him in improving his coping skills, and attempts to maximize his functioning as he deals with a persistent mental illness. Beth also collaborates with the interdisciplinary team and educates Jeff's family about his symptoms, medications, and strategies for interacting with him. Cathleen, as an advanced practice psychiatric-mental health nurse, has the required minimum of a master's degree in this specialty area and has assumed the role of a nurse practitioner (www.apna.org; Bjorklund 2003, 78). In addition to the functions included in Beth's role, Cathleen is prepared to as s es s , diagnose, and treat individuals or families with psychiatric disorders or the potential for such disorders. She independently provides a full range of mental health care services to the college community as an individual and group

psychotherapist, an educator, a consultant, and an administrator. In the particular state where Cathleen resides, she has prescriptive authority as well. So what are the "reasons of the heart and mind" for engaging in the work of psychiatric-mental health nursing? Where might God be encountered in the practice of psychiatric-mental health nursing? How might Beth be expressing her Christian vocation in her work with Jeff or Cathleen in her care for the college students that form her caseload? On the other hand, what "reasons of the heart and mind" might make us apprehensive about taking on the work of psychiatric-mental health nursing? Why are students often so intimidated by this type of nursing practice? Why might experienced practitioners be weary and overwhelmed? To explore these questions, let us identify some of the opportunities as well as the challenges faced by psychiatricmental health nurses. Opportunities in Psychiatric-Mental Health Nursing Psychiatric-mental health nursing offers the nurse multiple opportunities to care for the "least of these," the vulnerable and the marginalized. In Beth's practice, her brief encounter with Jeff offers important opportunities to engage in caregiving and see the carereceiving process in action (Tronto 1994, 106). J. C. Tronto indicates that caregiving involves meeting care needs directly, which involves physical work and direct contact between caregiver and carereceiver. Carereceiving entails a response that ideally indicates that care needs have been met. Clearly, there are many reasons why care needs may

not be met, not the least of which are inaccurate perceptions of needs or inappropriate responses to correctly perceived care needs. Thus, as was previously noted, care involves vulnerabilities, concern, action, and response. Jeff's vulnerability and Beth's concern and action are evident at many junctures in this brief scenario. When Jeff is frightened b y people who do not exist and events that have never occurred, Beth responds with a comforting and reassuring presence. When Jeff is confused about what is reality and what is a product of his mind, Beth assists him in clarifying by sharing her sense of reality, directing him toward basic realitybas ed activities, and advocating a change in his medication regime. When Jeff has difficulty communicating, Beth has the opportunity to listen attentively and respectfully to his verbalizations. While Jeff runs the risk of being rejected by others because of lack of understanding of his bizarre behavior, Beth has the concrete chance to accept him as a unique creation of God and, through education about Jeff's illness, to move those around Jeff closer to such acceptance. Beth has daily opportunities to deliver complex care that is rooted in the Christian obligation to serve the human need that surrounds us. But note Jeff's response to Beth's caregiving as well. Jeff's anxiety-driven speech slows and his attention is directed toward a shared reality that is not frightening to him. In this instance, it appears as though Jeff's care needs have been appropriately perceived and properly responded to. Of course, not all nurseclient interactions are characterized by such resounding success! Nurses have often focused on delivering Christ-like care to others (O'Brien 2001, 4; O'Brien 2003, io); but they have

focused less on the inherent opportunity they have to see a reflection of the suffering, broken Christ in the faces of those for whom they care. In the face of Jeff and his accompanying symptoms, Beth is seeing a reflection of the suffering servant, Jesus Christ. Where exactly does one see Christ in delusions a b o u t the CIA, tangential conversation, and inadequate hygiene? We see Christ precisely in those verbalizations about secret agents and "bugged" rooms. Matthew 25 assures us that even as we attend to the vulnerable, the defenseless, or the disenfranchised among us we attend to Christ himself. Our crucified Lord was mocked and rejected. Perhaps the experience of one with a persistent mental illness is not so far removed. Often these indi viduals suffer similarly as a result of society's lack of understanding of their illness and its manifestations. If Jeff is, indeed, a mediator of the divine, then Beth has continuing opportunities to encounter Christ in her interactions with Jeff. The person of Jeff provides Beth with an important point of contact with God. The recognition of Jeff as an agent of the divine, who gives to Beth in important ways, brings us logically to a consideration of the reciprocity inherent in the nurseclient relationship. Psychiatric-mental health nursing offers the practitioner numerous opportunities to learn about courage, resilience, and faith firsthand. Reflect on the following questions: How would I manage if I had to get up each morning and wonder about the accuracy of my perceptions? Would I have the strength to battle suicidal thoughts on a continuing basis? Would I become hopeless if I had immobilizing panic attacks weekly? Could I trust in God's good plan for my life if I had been emotionally, physically, or sexually abused as a

child? How would I cope with the addictive pull of a bingepurge cycle? Could I find evidence of a sovereign God as I had to deal with the mood swings associated with a bipolar disorder? How much effort might I need to devote to managing an addiction to a substance? If the nurse is candid in ans wering these questions, admiration begins to grow for those persons who live with mental illnesses. Many of us enjoy reading personal stories of courage and faith in newspapers or magazines as they inspire us, encourage us, and foster a positive outlook on life. Cathleen and Beth encounter the main characters in such stories on a daily basis. They see living examples of persons who bravely fight the biochemically based mental illness that threatens to overtake them. They see individuals who must surely be stronger and more resilient than most to have survived and been victorious over childhood atrocities. They see persons whose faith remains vibrant in the face of the difficulty and adversity of a persistent mental illness. Such encounters can be profoundly instructive to the nurse, assuming that she or he has the necessary humility to be open to the learning offered. These interactions can encourage a humble sense of gratitude for that which we often take for granted and can serve to reinforce an awareness of God's faithfulness in all circumstances. In essence, then, the nurse is enhanced by her or his practice of psychiatric-mental health nursing. To take this point a bit further, the clients of Beth and Cathleen may also offer specific gifts. These gifts may come in the form of gratitude, warmth, and affirmation of their vocational calling. Jeff's appreciation for Beth's weekly visits

and his response to her caregiving efforts give clear evidence that the giving and receiving in their relationship is certainly not unidirectional. Similarly, the student who stops by Cathleen's office to thank her and tell her that she "made it" through the semester after the tragic and unexpected loss of her father is giving of herself to Cathleen in meaningful ways. While the goods exchanged may be different, there is, nevertheless, reciprocity in operation where the nurse is the recipient of the blessing. Many people are looking for an ear that will listen.... He who no longer listens to his brother will soon no longer be listening to God either.... One who cannot listen long and patiently will presently be talking beside the point and never be really speaking to others albeit he be not conscious of it. DIETRICH BONHOEFFER The purposes of the practices of a professional nurse are more than merely helping to heal the physical ailments of the patient, although of course this is one important activity of the nurse. The nurse, more than the physician, must relate meaningfully to the reaction of the patient to his or her illness, including psychological and social changes that illness forces upon the patient. The nurse spends more time with the patient than does the physician, and therefore has more opportunity not only to observe but also to talk with and come to know the patient. This time factor gives the nurse an opportunity to help the patient become aware of and make sense out of his or her reactions to the current condition so that these can be more or less understood by the patient in light of longrange personal

consequences. HILDEGARD PEPLAU Ps ychiatric-mental health nursing also offers powerful opportunities to understand the client as a character in a narrative. Through careful listening, the nurse is able to come to appreciate the person as someone with a story that preceded this encounter and that will continue on long after leaving the nurse's care. Margaret Mohrmann (1995, 65) makes the point that health care providers need to learn how to pay attention and listen to the stories of those they care for. In doing so, we have the opportunity to see the client as "a person in all his wholeness - a person with ... an intact and meaningful life story in t o which the present suffering can be incorporated, and therefore comprehended" (Mohrmann 1995, 72). For Christians, these individual life stories are always embedded in the greater narrative of creation and redemption as told in Scripture. If we reflect upon the practice of Beth or Cathleen, each has the potential of extended periods of time to hear the stories of and come to see their clients as rooted in personal life narratives. Beth has seen Jeff over the period of two years, while Cathleen may work with students intermittently over the course of their undergraduate careers. Even in instances where the luxury of extended time with a client is not available to Beth or Cathleen, their practice of psychiatric-mental health nursing focuses very intentionally on the skillful establishment of interpersonal relationships and partnerships that are characterized by active listening, trust, and empathy as the context for care. Such a context offers each the exciting chance to see how God's narrative intersects with the unique narratives of the clients to

whom they are called to minister. Challenges in Psychiatric-Mental Health Nursing Stigma

At a township meeting, the agenda included consideration of a proposal to put a home for persons struggling with schizophrenia in a residential neighborhood. Numerous speakers addressed the planning commission to express their dismay at having "those crazy people on our block." Several were very concerned about the "impact of maniacs on our property values." Others spoke animatedly about the "dangerous nature of schizophrenics." Two women were talking after church about the absence of Peter, a member of their congregation. Peter had not been at services for several weeks and yet there was no announcement as to his situation. The two women concluded that "it must be his drinking again or otherwise the pastor would have shared the information." Two nursing students were talking about their course in mental health nursing. One said to the other: "If I had to have an illness, I don't know what I'd wish it to be. But I do know what I would wish it not to be - any sort of mental illness!" The staff of an acute care psychiatric unit was in shift change report. Monica, the nurse manager, was sharing information about new admissions. Leslie P. was being readmitted for the third time in six months with a diagnosis of

major depression and borderline personality disorder. Each of these diagnoses may have had its roots in a complex array of genetic and biochemical factors as well as the childhood sexual abuse that Leslie had suffered. Leslie was being admitted because she had been cutting herself again. James, one of the RNs, whispered to Sandra, another RN, "We're entering the frequent flyer time of year again. The borderlines are coming out of the woodwork!" Both laughed at the joke before turning their attention back to the report. Chantalle, an advanced practice nurse, was leading a group session for families with members who had a mental illness. When she asked about the challenges that they faced, several spoke of the stigma that still exists regarding mental illness. "People treat us as if we have the plague!" one family member shared. Another said, "No one knows what to say to us or how to ask about Darnell. I wonder if they'd have so much difficulty if he had cancer?" The general public stigmatizes those with mental illnesses as dangerous, irresponsible, unpredictable, isolated, and unlikely to improve (Emrich et al. 2003, 20). Similarly, those with substance abuse problems are viewed as lacking in will power and morally deficient (Martinez and Murphy-Parker 2003,157). Alarmingly, such attitudes on the part of the general public h a v e not changed significantly in the past three decades. Perhaps even more disturbing is the fact that many health care professionals share these same prejudices relative to those with mental illness and addictions (Emrich et al. 2003, 2o; Martinez and Murphy-Parker 2003, 157).

So what is the impact of stigma? Or more specifically, how does stigma affect persons created in God's image? First, stigma separates and disconnects. Being an embodied person entails openness to other persons - openness to a relationship with another, a responsibility to care for another, an attunement to others outside of our expectations and prejudgments of them. Image-bearers, as ones who have the ability to interact with other humans, should be in inescapable proximity with others for the purpose of serving God by attending to our neighbors. Stigmatizing statements are generally based upon prejudgments and inaccurate information. They are often used to create artificial barriers that we imagine might somehow protect us. Irrationally we hope that such distance will ensure that "this won't happen to me." Stigmatizing language, then, is diametrically opposed to openness and neighborliness. Persons with mental illnesses are also stigmatized when we refer to them as "schizophrenics," "alcoholics," "anorexics," or "manic-depres s ives ." When we attach such labels we immediately reduce the personhood of the individual and signal that her or his entire identity is subsumed by the illness. In our discussion of personhood, we pointed out the importance of naming. When we substitute an illness label for a person's name, we fail to recognize that person as the unified whole that she or he was created to be. The stigmatized individual is seen as one-dimensional rather than as an embodied person who is an image-bearer of God, a particular "I" with physical, emotional, social, moral, and spiritual dimensions, characterized by independence and dependence, and as a coauthor of the story in which she or he is embedded.

In other words, to think of Peter, Leslie, or Darnell strictly in terms of their particular mental illness misses critical aspects of who God created them to be. It is also clearly inconsistent with the notion of cultivating an atmosphere of reverence and awe toward them as tokens of the divine. Stigma, then, does damage to perpetrators and recipients alike in terms of their identity as image-bearers of God. As demonstrated in the vignettes and documented in the literature, nurses are not immune from perpetrating stigma. Perhaps we need to examine with greater care the expectations and preconceived notions that we carry with us into our client encounters. The negative aspect of seeing clients as a part of a narrative may be that we have certain "set story lines" that we impose on individuals without exploring their validity. In fiction, if an author consistently uses such a "set story line" his or her work is often lacking in creativity, dull, monotonous, and ultimately unsuccessful. The parallel in nursing practice is that if we consistently approach clients with these preconceived notions, we short-circuit the opportunity to be cocreators with God by conforming our nursing actions to what we are able to discern of God's direction for creation. These stigmatizing attitudes distort our practice of nursing from one that has been shaped by experiencing the reality of God to one that is shaped by our brokenness. Me dication Nonadhe re nce

Brian is a psychiatric-mental health nurse working on an acute care unit. Brian's assignment today includes completing a nursing assessment on Cheryl, a 23-year-old, newly admitted

client. Brian greets Cheryl and her parents, whom he has met on several previous admissions. Cheryl has a four-year history of bipolar disorder as well as a history of nonadherence to her psychotropic medications. Cheryl reports that her admission this time was the fault of her parents, who brought her to the unit because her apartment manager claimed that she was "too loud." Cheryl's parents report that she was talking non-stop, had not slept in three days, was too hyperactive to eat, was disturbing her neighbors by knocking on their doors in the middle of the night, was spending money wildly, got fired from her job for inappropriate behavior, and had recently announced her intention to move to Paris and work as a world-renowned artist. Cheryl's parents indicate that they found her Depakote and Zyprexa prescriptions unopened, indicating that Cheryl had not taken her medications for the past two weeks. Brian continues his assessment by asking Cheryl about her medication regime. Cheryl repeatedly insists that she does not need either the Depakote or the Zyprexa that have been prescribed and complains about the fact that they "affect my creativity." Cheryl indicates that if her neighbors and parents would just "chill out" things would be fine. Brian completes the assessment and sighs as he walks back to the nursing station. He remarks to his coworker, "I'm so sick of these clients who can't seem to figure out that their medication is the key to their functioning! What's the point of stabilizing them just so they can leave and stop their meds again?" Although psychotropic medications have been consistently shown to be highly effective in the treatment of persistent mental illnesses, many clients are reluctant to take them (Kemppainen et al. 2003, 41; Pinikahana et al. 2002). Cramer and

Rosenheck (1998) reviewed thirty-four studies on psychotropic adherence rates and found the mean level of client adherence to antipsychotic medications was 58 percent with a range of 24 to 9o percent. The mean rate of adherence to antidepressant medications was slightly better at 63 percent with a range of 40 to 90 percent. Numerous reasons have been set forth as to why persons diagnosed with mental illnesses may not adhere to their medication regimes. These include the nature of mental illness (Weiss et al. 1998); distressing physical side effects (Pinikahana et al. 2002; Ruscher et al. 1997); a lack of acceptance of their diagnosis and need for treatment (Pinikahana et al. 2002); a history of substance abuse (Heyscue et al. 1998; Pinikahana et al. 2002); the nature of the therapeutic relationship (Pinikahana et al. 2002); insufficient knowledge of medications (Tempier 1996); a lack of economic and social supports (Kemppainen et al. 2003; Pinikahana et al. 2002); and lack of awareness of symptoms (Kozuki and Froelicher 2003, 57). Brian maybe seeing several of these factors in operation with Cheryl. So how does the Christian nurse unpack the multifaceted issue of client nonadherence to a psychotropic medication regime? While there are no easy answers to the complex questions involved, perhaps we can at least identify some of the key issues and general directions that might assist us. While doing so, it will be critically important that we resist the inclination to simplify this issue and leap to a hasty conclusion prior to considering all relevant aspects. In addition, we must recognize that any proposed direction will, of necessity, be general and may or may not be appropriate to an individual with a unique story and set of needs.

First, might nurses be guilty of paternalism (or maternalism) as they attempt to convince clients to take these medications? Do we really "know best" in regard to an individual's unique sense of wellbeing when she or he is on these medications? Certainly the charge of paternalism has some validity, given that nursing rhetoric suggests that clients are experts in their own experience. It is, no doubt, often the case that nurses do not thoroughly explore this expertise that their clients bring to the table. But that charge should rightly be set next to the expertise that the nurses bring to this situation given their education and clinical experience. Both clients and nurses bring specific expertise that must be valued in order to determine a reasonable course of action relative to medication adherence. What about enjoyment, the ability to interact with one's surroundings in ways that bring satisfaction to embodiment? What if individuals espouse a sense of a high level of wellbeing when they are not battling the difficult side effects of psychotropic medications? What about the bipolar client who likes the "highs" associated with mania? What if a client "enjoys" the voices that actually constitute a part of her "social network"? In short, what if their symptoms bother us more than them? Of course, there are many times when people will report the frightening and disturbing nature of their symptoms, but there are also the cases where an individual is not particularly bothered by delusions. In this situation, we need to determine if the principle of enjoyment is compelling enough to justify nonadherence. In addition, it may be necessary to reflect on whether this is the only viable source of enjoyment for the individual.

Although we have argued that "respect for persons" can never be reduced to mere autonomy, we do still need to think carefully about client autonomy and agency when we attempt to require adherence. Several nursing authors have identified the potential for issues of control, domination, and coercion to be central to dialogue about medication compliance rather than issues of emancipation or empowerment (Marland and Cash 2001; Murphy and Canales 2001), which might be more consistent with notions of agency. Although we believe that the concept of autonomy needs to be qualified by a Christian view of interdependence, we also affirm that agency is a critical element of being the embodied image-bearer of God. Possession of such agency allows us to have some control over our lives in terms of what we do and how we make our decisions - a key issue for some who feel as though their agency has already been lessened by a persistent mental illness. Perhaps we need to consider, however, the fact that few persons have totally unconstrained agency and autonomy. Generally, we do not have the option, in the name of autonomy, to engage in behavior that might be harmful to others, for example. So notions of autonomy and agency need to be set alongside valid reasons for restraint. In that case, a key issue to be addressed is what actually constitutes a valid reason for the constraint of one's autonomy relative to medication adherence. While concerns about serious harm to a client or another provide valid and important limits on the range of autonomous choice, we still need to think carefully about enhancing and respecting client agency in cases where such harm is not the central issue. Chambliss (1996) has suggested that if large numbers of

clients are resistant to a particular treatment regime, the problem may not be the nonadherence of these individuals; rather, perhaps the problem is that "the staff may be boldly noncompliant with the patient's own wishes" (138). Does the challenge of nonadherence actually belong to health care professionals rather than clients? Clearly, there is likely to be some truth in this assertion. It seems obvious that far more attention needs to be devoted to the development of true partnering relationships, where there is a sharing of information, perspectives, power, and decision making between clients and health care professionals in regard to medication adherence issues. One of the components of self-care agency is the ability to make decisions about the care of self and to operationalize these decisions. DOROTHEA OREM On the other hand, we cannot discount the reality that psychotropic medication has proven to be highly effective in the treatment of mental illness (Kemppainen et al. 2003, 41). Advocating for something that has been shown, through research, to be effective is consistent with nursing's commitment to deliver evidence-based practice to its clients. Nurses are not only advocates for their clients; they are also advocates to their clients. Since adherence to psychotropic medications has also been shown to maximize the functioning of persons with mental illness, allowing them to live independent and productive lives in the community (Kozuki

and Froelicher 2003, 57), then encouraging medication adherence becomes critically important to independence. And relative independence is central to the notion of a person as an embodied image-bearer of God. Further, how should we regard the cyclical relapse and rehospitalization that so often occur with nonadherence (Jarboe 2002; Kozuki and Froelicher 2003, 57)? Such a phenomenon consumes a large portion of our limited health care dollars. This surely must compel us to consider the broad issues of justice and stewardship. If justice concerns equity and fairness, how equitable and fair is it to consume enormous amounts of our health care dollars on a few whose rehospitalizations may have been preventable, via medication adherence, when these same expenditures may preclude many from accessing necessary, but less expensive, mental health services? A note should be included here that it is certainly not the case that all relapse and rehospitalizations are due to a lack of medication adherence. While some cases might clearly be a result of nonadherence, others occur in spite of valiant efforts at managing a complex illness. The argument that is being explored here pertains only to those cases where nonadherence decisions appear to have directly resulted in hospitalization. Along these same lines, if stewardship is focused on the wise use of the finite resources that we have, might these goals be more appropriately addressed by preventing frequent rehospitalizations and devoting increased amounts of funding to mental health promotion and mental illness prevention? Might we not, in essence, get more mileage from our funds in this manner?

Health professionals have a responsibility to share information that helps individuals make informed decisions about their health care. IMOGENE KING Clearly, the issues raised by medication nonadherence are co mp lex, indeed. They present ethical challenges at the personal, institutional, and social structure levels. Nurses need to examine all of the facets of this issue in a careful and thoughtful manner. They also need to deal with the emotional responses they experience themselves, responses we saw in Brian as he returned to the nursing station after assessing Cheryl. Disparities in Insurance Coverage

Juan is a 28-year-old father of three children. He and his wife, Maria, are both employed at a local cable service provider. Juan is a field technician while Maria works in the office. Together Juan and Maria have employerprovided group health insurance for themselves and their children. They are grateful for insurance coverage in this day and age when so many are without jobs, let alone insurance benefits. Recently, Juan has been diagnosed with major depression. He has a strong family history of mood disorders. As Juan begins to seek treatment for his depression, he and Maria become aware of limitations in their employerprovided health insurance. Juan discovers that he has coverage for only ten

outpatient visits per year. Given this rather sparse coverage, he tries to spread out his outpatient visits, only to find himself inadequately treated, functioning marginally at work, and unable to participate in necessary household and childcare activities with Maria. He has been reprimanded at work and is irritable and argumentative with Maria and the children at home. Juan finds himself getting worse. He now needs inpatient hospitalization for depression and suicidal ideation. At this point Maria finds herself relieved that Juan will finally get intensive treatment for his depression while hospitalized. She anticipates that the hospitalization period will be stressful, however, as she attempts to maintain her job, get the children t o childcare, visit Juan in the hospital, and manage the household. Maria's stress is multiplied exponentially when she learns that their insurance policy limits inpatient treatment to twelve days per year. Given that it is only the first of February, the treatment team suggests a brief hospitalization focused on ensuring that Juan is able to be safe outside the structured inpatient unit. Within three days, Juan is back at home again. Juan is exhibiting apathy, an inability to get out of bed in the morning, poor grooming, insomnia, hopelessness, difficulty with decision making, and tearfulness. He needs to take a leave from work, as he is still unable to function safely in his role as a field technician. He continues to talk about suicide, and after a long and difficult month Maria brings him back to the hospital for a second inpatient hospitalization. By this time, Juan feels estranged from both Maria and his children and it seems likely

that he will lose his job. Juan's second hospitalization spans six days, after which he is discharged home again. The treatment team suggests that Juan take advantage of the Partial Hospitalization Program, in which he would be engaged in therapy and classes from 9 AM to 4 PM but return home in the evening for several weeks, to ensure continuity of care. Juan and Maria discover that their insurance will not cover this type of treatment. With three days of inpatient treatment and four outpatient visits remaining in his insurance coverage for this year, Juan is determined to attempt to return to work. He does so, but soon he loses his job because of his inability to concentrate well enough to complete his work safely. Juan slips further into depression and is hospitalized for a third time this year in the middle of April. Maria is aware that this hospitalization will probably not be fully covered by their insurance plan. She tries to figure out how she can manage parenting responsibilities, her job, caring for Juan, and now the financial implications of his treatment. Maria is clearly overwhelmed and perhaps at risk herself. The children's behavior shows signs of the effects of disruption in their home. Interestingly enough, as Maria shares her circumstances with a coworker, the woman tells her about a mutual acquaintance who had recently been diagnosed with diabetes and found the company health insurance to be very adequate for her numerous visits to her primary health care provider as well as several hospitalizations to stabilize her blood sugar and determine an appropriate insulin regime. This leaves Maria

wondering why diabetes is well covered by the company insurance plan and depression is so clearly not. Health insurance coverage for mental health presents the Christian nurse with a glaring challenge that has far-reaching practice implications. It is common practice that health insurance coverage for mental health and substance abuse services, if offered at all to beneficiaries, is regularly provided at different levels than coverage for all other medical and surgical services. The number of covered outpatient visits and hospital days are often less for mental health and substance abuse. In addition, there is generally the imposition of higher co-payments and deductibles as well as lower annual and lifetime spending caps. Thus, millions of Americans with mental disorders do not have equal access to health care. Mental health parity first appeared on the Congressional agenda in 1993. In 1996, Congress passed the first ever Mental Health Parity Act, whose basic premise was that all health care insurance plans should offer the same degree of coverage or parity for mental health benefits as provided for medical and surgical benefits. It did not require employers to offer mental health care benefits, but if such benefits were provided they had to be equal to those offered for medical and surgical care. While this legislation was welcomed as "beginning the process of ending" long-standing unfair insurance practices (www.nami.org), there is still much work to be done. There are many loopholes in this legislation, it is rather limited in scope, and it allows many to skirt the spirit of the law. Therefore, the reality is that many employers and health insurers still continue to limit mental health benefits more severely than those for

medical and surgical care by placing new restrictions on outpatient office visits and number of days of inpatient care or by imposing higher co-payments and deductibles (www.nmha.org). The 1996 Act was designed to remain in effect for six years. With that deadline approaching, Congress tried to pass a new law, the Paul Wellstone Mental Health Equitable Treatment Act, by the end of 2002. In spite of widespread support for the bill, Congress failed to pass the bill in time. Instead, they voted to keep the 1996 law in effect for an additional year (www.nmha.org). At the end of 2003, a similar extension strategy was utilized (http://edworkforce.gov/press) with the intention of considering a mental health parity bill in early 2004 (www.apna.org). But the question still looms: what is the future relative to mental health parity? What of all this is of particular concern to the Christian nurse? First, psychiatric-mental health nurses have issued a call for action relative to mental health parity (Thomas and Leavitt 2002). In addition, it is apparent that the lack of full mental health parity bears the marks of human sin and brokenness. How can we rationalize acceptance of a system that excludes those with particular types of illnesses from the insurance coverage that will allow them to get access to treatment so that they can function at a maximal level? While many nurses conceptualize their practice as concerned primarily with the microsystem, as Christians we need to move beyond that narrow focus toward a systemic understanding of the environment so as to recognize its role in

the lives of individuals as well as its relationship to health outcomes for population groups. The case of Juan and Maria demonstrates this especially well. The macrosystem in which Juan and Maria live affects them negatively as it does thousands of others in like circumstances. The lack of mental health parity represents a social structure, a human construction, that is as much in need of redemption as are individual human beings. The vocation of Christian nursing includes a call to redeem such an aspect of the environment just as surely as it includes the call to attend to the suffering of a single person in the care of the nurse. Environment is all conditions, circumstances, and influences that surround and affect the development and behavior of the person. CALLISTA ROY Nursing practice that encompasses "caring about" and "taking care of" (Tronto 1994, io6) would likely also put this issue on our radar screen. "Caring about" involves recognizing t h e needs inherent in a lack of mental health parity, while "taking care of" would move the nurse subsequently to assume some responsibility for responding to this inequity. For nurses to ignore the macrosystem issues inherent in Juan and M a r ia ' s situation could be construed as "privileged irresponsibility" (Tronto 1994, 121). Tronto suggests that "those who are relatively privileged are granted by that privilege the opportunity simply to ignore certain forms of

hardships that they do not face" (1994, 120-21). In Tronto's discussion of "privileged irresponsibility" she suggests that generally these persons are also able to avoid providing direct care. Is it possible, then, that the Christian nurse, who does indeed provide direct care for individuals like Juan and Maria and sees the unmet needs daily in her practice, could still be guilty of such irresponsibility? Certainly this sort of fallenness is possible for each one of us. But as Christian nurses, we must recommit ourselves to bearing some larger obligation for "system" issues such as mental health parity and to answering the call to become agents of renewal in society. Providing a Full Continuum of Me ntal He alth Care

Kristin, a 20-year-old nursing major, is in a practicum experience in mental health nursing. One of her course requirements is to attend a support group session of the local National Alliance for the Mentally Ill (NAMI). The discussion this evening is animated and centers on the lack of housing, jobs, and opportunities for socialization for persons with persistent mental illnesses as well as the lack of supports for their families. As Kristin listens to their concerns, she begins to try to imagine her life as the family members are describing the lives of their loved ones. Instead of the excitement she feels about her promising career, Kristin tries to imagine days filled with little else besides television, smoking, and boredom. Instead of the anticipation she feels about someday purchasing a home of her own, Kristin attempts to envision a lifetime of dingy, substandard adult foster care homes where she will never have the chance to choose her housemates. Instead of her network of accepting friends, she tries to step

into the shoes of those who have few friends who really understand them and their illness. Kristin also begins to think about the 24-year-old client with a schizoaffective disorder that she cared for on the acute care unit this week. She wonders where this client went after her brief hospitalization and what her quality of life will be. Kristin is shocked to hear the story of one woman who had four children - two with graduate degrees and two with schizophrenia. This woman had raised these children essentially alone because her husband had left the family. The woman told of a time when she had no choice but to tell her 19year-old daughter to get out of her home, since "it was either her or me and I had three other children to care for." The woman shared her anguish about this decision but indicated that there were no supports for families trying to provide care for mentally ill members: "we were on our own." This daughter spent nearly two years homeless, on the streets, and mentally ill. As Kristin leaves the meeting, she feels overwhelmed, sad, and uncertain about what, if anything, a nurse can do about situations such as these. Our previous discussions about macrosystem issues, "caring about," "taking care of," and justice provide an excellent framework for us to consider seriously how our current mental health care system might be redeemed. How might the mental health care system be structured in such a way that necessary services to promote and protect the health of individu als are in place? How could the particular needs of those with persistent mental illnesses be addressed? The current American mental health care system is crisis driven.

Individuals are admitted to acute care facilities when they are exhibiting suicidal or psychotic behavior, for example. But, as one family member put it, once this crisis passes, discharge occurs "immediately and prematurely, services drop off dramatically, and this lack of support soon leads to a new crisis" (Doornbos 2002, 42). In between crises, the family struggles to provide the majority of the care without the support of a system that might promote health as well as create structure, purpose, and meaning in the lives of individuals. Families of those with persistent mental illnesses speak eloquently of the need for a continuum of care that is comprehensive, multifaceted, and aimed at assisting one to function at a maximal level of wellness (Doornbos 2002, 42). They say such a system would include not only crisis care but also continuity of care, perhaps via a strong case management model, a full range of necessary rehabilitation services, including decent housing options both supervised and unsupervised - education or vocational training, job opportunities, life skills training (i.e., money management, self-care, use of public transportation, social skills), and communities of support for clients and families alike. In short, the system would promote health rather than simply providing episodic treatment for mental illness. It is not surprising to find that clients are concerned about these same issues. One analysis of the literature (Horsfall 2003) notes that clients are primarily worried about unemployment, poverty, insecure accommodations, and stigma. The same study notes that these concerns have been marginalized, perhaps because they fall outside the purview of contemporary

psychiatry. The author suggests, however, that because nursing has traditionally focused on activities of daily living that are impeded by illness, the discipline has a responsibility to assist consumers with difficulties that arise from such structural constraints. Superimposed upon the concerns of the individuals and families struggling with persistent mental illnesses are the conclusions of the New Freedom Commission on Mental Health, which was convened in the spring of 2002. In its final report, issued July 22, 2003, the commission bluntly asserted that the American mental health care system is in shambles. The report cited the fragmentation of services and programs t h a t pervades the delivery system and creates significant obstacles to quality care. It outlined the consequences of our failure to help this vulnerable population. Many persons with serious mental illnesses are homeless, unemployed, dependent on alcohol and drugs, jailed inappropriately, or go without any treatment at all (http://www.mentalhealthcommission.gov/ reports/interim_report.htm; http://www.mentalhealthcommission.gov/ reports/finalreport/fullreport-o2.htm). It seems obvious that our fallen mental health care system presents an occasion for hope, longing, and alternative imagination (Plantinga 2002, 8). We long for and imagine a world - and, in fact, a mental health care system - that more closely resembles a caring and just system that would be pleasing to God. Unconstrained by history and previous "solutions," the Christian nurse may be freed to use an alternative imagination to work toward novel solutions that

seek to enact both caring and justice as they might pertain to those with mental illnesses. Perhaps this alternative imagination might move us toward a more functional mental health care system. Phillips and Benner suggest not just a simple reform of the health care system but rather a transformation of it: If we were able to replace our disease care system with caring practices that foster illness prevention and health promotion so that clinical wisdom could be fostered for caregivers and care receivers alike, we would alter dramatically how we are spending our health care dollar. If health care workers challenged their preoccupation with pathology and deficits and focused on wholeness, and on what creates wholeness, our therapies and structures for health care would change. As we more closely see what we have created we can free ourselves to create new visions for our health care systems. (Phillips and Benner 1994, 59) Similarly, the Freedom Commission on Mental Health concluded that the United States should fundamentally transform its system for treating people with mental illnesses such that services actively facilitate recovery and build resilience to face the challenges of life. This report serves as the clarion call to pursue a transformed system that would strive to provide the opportunity for those with serious mental illnesses to live, work, learn, and participate fully in their communities (Executive Order 13263 of April 29, 2002; Iglehart 2004, 507). Such a task is formidable but worthy of our efforts. Perhaps we can be encouraged by a "promising glimpse" of

what a transformed system might look like. Consider again our initial case involv ing Jeff, who lives in a residential setting with five other men. The staff is kind, motivated, and invested. There is minimal staff turnover at Jeff's home; in fact, each staff member has worked there at least four years and thus has established meaningful relationships with both Jeff and his family. A sense of hospitality and community has been created among the residents, too, as each attempts to respond with supportive and caring gestures toward their housemates as they struggle with particular symptoms or issues. The staff and residents are currently planning a party for Jeff's home as well as three other similar homes in their system. The residents may invite a date, if they choose, for an evening of dancing, games, pictures, and food. The party will be held at the Clubhouse of Montgomery County. The Clubhouse is supported by tax dollars and is a place run by and for those with persistent mental illnesses. Jeff and his housemates often go there to have coffee, to play cards or pool, to receive job counseling, to take courses, to do volunteer work, or simply to socialize with others in similar circumstances. Jeff is planning to leave an hour early from his part-time job at Goodwill Industries to get ready. Jeff's parents have offered to decorate the Clubhouse prior to the event and will assist that evening with music and food. In this scenario, we can identify several elements of shalom relating to the goal of a full continuum of mental health care. The availability of a variety of quality housing options that are pleasant, safe, and clean as well as nurturing and supportive is critical. In the cases where persons with mental illness require staff supervision in their living environment, minimal staff

turnover and obvious investment in the clients and the work of promoting health even in the face of serious mental illness is crucial. Meaningful employment, properly fitted to the individual's gifts, cognizant of the particularities of mental illness, and engendering a sense of purpose and fulfillment is a key element in fostering shalom as well. Such a proposal may require vocational testing or counseling as well as further formal education. Opportunities and places to socialize with others in similar circumstances is a universal need that is certainly shared by those with mental illnesses. Each of these initiatives will require tax dollars directed at stabilization and rehabilitation of those with persistent mental illnesses rather than simply crisis management for their acute episodes. Further, partnering with families who provide a sense of constancy, stability, and love to this vulnerable group is vital. In essence, Jeff's case allows us to envision the goal of using tax dollars to create locations of shalom for those with mental illnesses in housing, occupational, and social settings while actively collaborating with their families. Surviving in the Practice of Psychiatric-Me ntal He alth Nursing

Lydia is a bright, attractive, and popular young woman who was active in high school athletics. She was elected a class officer and voted homecoming queen during her senior year in high school. Lydia went on to college and majored in communications. Even as things were beginning to unravel for Lydia during her later years in college, she struggled to complete her studies. As Lydia battled racing thoughts, hyperactivity, interrupted sleep, and disturbing voices, she was able to graduate with a 3.5 grade point average. Several

years later Lydia's family found a college notebook in which she had scribbled over and over, every line, every page, from cover to cover: "I am not going crazy! I am not going crazy!" Lydia's functioning deteriorated to the point where numerous hospitalizations were necessary; underemployment was a chronic situation, and, in fact, any sort of employment was nearly impossible to maintain; independent living was not feasible; and her social network had dwindled to consist only of her family. Consider the nurses who care for Lydia. What of their raised fists at the God who created Lydia and now seemingly has allowed a debilitating illness to overtake her in the prime of her life? What about their sense of injustice concerning a beautiful young woman for whom the rules have changed twenty-some years into her life? How should they navigate their dismay at the symptoms that daily present a challenge for Lydia? How do they continue their work in the face of their nearly immobilizing sadness at the suffering that they see in Lydia's life? What of the nurses' weeping over the difficulty that Lydia faces in finding meaningful work? How should the nurses reconcile their keen sense that we were created to be relational and yet that Lydia's illness directly impacts her ability to be in community with others? What about the nurses' overwhelming sense of powerlessness in the face of a formidable adversary such as a bipolar disorder? How should these nurses go about keeping the hopelessness that continually threatens to creep into their consciousness in check, given the current state of the mental health care system and its "managed care" for clients such as Lydia?

Alongside situations like Lydia's, other taxing issues surround psychiatric-mental health nurses in practice. Many health care professionals experience "vicarious trauma" resulting from their work with trauma clients (McCann and Perlman 1990). Some health care professionals may endure pervasive and cumulative psychological consequences due to their exposure to the traumatic experiences of their clients (Robins on et al. 2003, 34). Some of these psychological consequences include a diminished sense of safety, trust, control, and connection with others as well as disillusionment and despair (McCann and Perlman 199o). Another fear of most psychiatric-mental health nurses is that of the suicide of one of their clients. Joyce and Wallbridge describe the effects of client suicidal behavior on nurses as stress, sadness, shock, fear, anger, guilt, devastation, physical and emotional exhaustion, and a sense of failure (2003,18-19). Still other nurses are involved in the treatment of clients who engage in acts of deliberate selfharm without suicidal intent. These clients typically cut and burn themselves as a method of managing their intense emotions. Nurses frequently respond to these clients with a sense of unease as well as irritation and anger at what is often considered to be manipulative behavior (Perseius et al. 2003, 218). Any one of these situations might be considered overwhelming for those in another type of work. And yet, the nurse may encounter clients with persistent mental illness, trauma, suicide, and selfharm issues all in the course of one day in practice. How does one survive this emotional onslaught? We have spoken of illness as an occasion for individual and communal lament. Psychiatric-mental health nursing involves

constant encounters with brokenness and mental illnesses that are certainly compelling occasions for such lament. Lament offers the Christian nurse freedom to voice the pain and suffering that are encountered in practice. While this catharsis is critical, perhaps the larger question becomes: Is the concept of lament sufficient to enable these nurses to continue their caregiving efforts despite the intense psychological burden? In order to explore this question, we must consider both this freedom to voice our pain before God and the aspect of lamentation that allows us to lay our troubles at the feet of the One who is powerful enough to do something about them. Having resisted the temptation to gloss over the suffering that is so evident in the lives of her or his clients, the nurse can still find peace. While not offering a "quick fix," lament can move us toward reflection on the fact that God's hand is in the lives of these individuals. It can allow us simultaneously to grieve about the devastation that persistent mental illness or trauma brought about and also to be convicted that God is a God of goodness and power who will, in God's own time, make all things new. Lamentation allows nurses to be fully human as they engage in their practice. Nurses need not detach themselves from clients and their pain in some sort of artificial attempt to maintain objectivity or to protect themselves. On the other hand, the pain of human suffering encountered by nurses on a daily basis need not be immobilizing. Rather, lamentation offers nurses the opportunity to engage, to feel, and ultimately to give the pain that surrounds them to the sovereign Creator who can sustain and renew them. Thus, lamentation in essence moves us toward hope. And this hope is more than mere wishful thinking. Where might we

find ground for hope in the practice of the psychiatric-mental health nurse? Of course, we embrace the hope that is inherent in client improvement. Consider Lydia's hope-filled story as told by her mother: Lydia now has a full time job at the Clubhouse. What a blessing after SSI and monthly disability forms! Lydia has had many responsibilities at the Clubhouse including driving the van, managing the kitchen, and now serving as the receptionist. Lydia's job includes medical benefits - such a victory after Medicaid and hunting all over for doctors that would accept this - and provides the opportunity to put money into an annuity for her future. She applied and was accepted into a Masters program in social rehabilitation where she will take evening courses. Lydia received a scholarship from the University to support her studies. Lydia has never given up! Our dream was that she would rise above her illness and live a full and productive life and she is doing just that! I am so very proud of my daughter Lydia! God has kept her in his sight all these years and she has a faith in the Lord that never wavers. What about people whose outcomes are not so glowing? In the cases where there are only small, almost imperceptible victories, we can still find hope. Lament allows us to acknowledge the suffering and pain but also to recognize the sovereignty of our God over our fragile practice of nursing and the clients whose lives we touch. We can find reassurance and hope in the fact that it is not ours to "fix" these individuals, but rather it is ours to be faithful to the work to which we have been called.

Perhaps the Christian community has a role to play in supporting nurses in their expressions of lament as well as their efforts to be faithful to the work that constitutes their calling. Fostering faithfulness may occur more naturally in community than in isolation, and it may well be a communal responsibility rather than simply something that the individual nurse needs to work toward alone. If this is the case, the issue then becomes whether or not there is space in the Christian community for nurses to go, share their stories, and be fortified for a return to their practice. The contours of this space may be numerous and varied. Christian professional nursing organizations may play a vital role as well as the institutional church. Conclusion So what are the reasons of the heart and mind for engaging in the practice of psychiatric-mental health nursing? This practice offers very clear opportunities to address the business of the kingdom and to engage in a life of Christian service. On an ongoing basis we are given specific and concrete opportunities and challenges in which we might work for shalom - the pursuit of justice, harmony, and delight among God, human beings, and all creation (Plantinga 2002,139). We are privileged to serve those who are marginalized and disenfranchised, but who in their marginality give to us far more than we give to them. We have daily opportunities to touch individuals, families, and communities as well as entire systems with an eye to moving them closer to that which God intended. In other words, psychiatric-mental health nurses need waste little time in identifying kingdom work - it awaits them each day in their practice.

CHAPTER SIX

Community Health Nursing Introduction John and Joyce are two nurses who often work at the same retirement village. John, a home health nurse, is employed by a local hospital in their home health division. Although his clients are drawn from all over the city, he often finds himself caring for people at the Oakcrest Retirement Village, which is located near the hospital. His job includes changing dressings, administering intravenous medications or fluids, coordinating dis charge plans for residents who are returning from the hospital or a rehabilitation facility, and assessing whether or not clients are making a good adjustment to living on their own after their hospitalization. John must frequently make decisions regarding clients' physical status and will collaborate with clients' physicians to determine treatment needs. In residents with congestive heart failure, John listens to lungs and checks for edema; in clients with diabetes he looks at insulin dosages and blood sugar levels. Based on his assessments, he will decide whether or not the physician should be contacted to suggest a change in medications or other treatments. John works with his clients and their families to ensure they receive "comprehensive, coordinated, and continuous care" (Stanhope and Lancaster 2000).

Joyce also provides nursing care at Oakcrest Retirement Village. She was hired by Retirement Villages, Inc., the owners of Oakcrest and three other retirement villages, for the primary purpose of improving the overall health of each of the retirement villages. Her first task at each village was to conduct an assessment of health-related needs within each community. At Oakcrest, she found that many of the residents were not getting regular exercise; they were interested in a group activity, so she started a daily exercise class. Information from the health assessment also showed that many of the seniors h a d lost weight since their last check-ups and had low hemoglobin levels. Simply put, they were undernourished. As she got to know the residents better and began working with residents on the board of Oakcrest, she found that many did not have the money for adequate nutrition, so she worked to open a food pantry in the village and began to teach a class about how to cook nutritious meals using commodities (government surplus) foods. Joyce's efforts at Oakcrest are directed by the findings of the health assessment, and her overarching goal is to improve the health of the population at Oakcrest. Community based nursing is a philosophy of nursing practice in which care is designed to meet the needs of people where they live, work, attend school, or worship and as they might move between and among their community and various health care settings (Hunt and Zurek 1997). According to this definition, both John and Joyce are practicing community based nursing. Furthermore, both are providing care in a community setting (not a hospital) - indeed, in the same location. So how would we make a distinction between what

the two nurses do? As a home health nurse, John's primary focus is on individuals and families, and his primary purpose is to care for persons who are ill. Joyce's primary focus is on an aggregate or population, and her primary purpose is health promotion. One label for Joyce's type of nursing is "community focused nursing." "Community focused nursing views the community as the client. Care is provided within the context of promoting and protecting the health of the community as a whole" (from the Calvin College Department of Nursing glossary, adapted from Stanhope and Lancaster 2000). Confusion in terminology exists because there are at least three labels for this type of nursing, and not all the professional nursing literature gives exactly the same definitions. For the purposes of this chapter, "community focused nursing," "community health nursing," and "public health nursing" will be considered synonymous. Community health nursing represents a systematic process of delivering nursing care to improve the health of an entire community. Although community health nursing may deliver care to individuals and groups, it is primarily responsible for the health of the population as a whole, with special emphasis on identification of high-risk aggregates. Community health nursing practice synthesizes nursing theory and public health science and places priority on prevention, protection, and promotion. (Zotti et al. 2000, 7) We may thus characterize Joyce as a community focused nurse (or a community health nurse, or a public health nurse) because, although she works with individuals within the

retirement community, her primary focus is on promoting and improving the overall health of the senior citizens living in the village. In other words, Joyce has a population focus, and the entire retirement village is her client. One additional note regarding community health nursing is warranted. While all nurses value health promotion and disease prevention, the community health nurse is primarily concerned with these aspects of nursing. Health is a central value of nursing, and although community health nurses may at times work with persons who are ill, this is the specialty within nursing that focuses most clearly on health rather than on illness. This aspect of community health nursing will be further explored as we examine what a community health nurse (CHN) does. Opportunities in Community Health Nursing Caring for the Entire Community

To many of us, Joyce's job as a CHN might not seem like a "traditional" nursing role. She is not working in a hospital. She is not primarily seeking to help ill people get better. Why would a nurse choose this less common career path? In other words, what is exciting about being a community health nurse? First, community focused nurses have the opportunity (indeed, the mandate) to work to improve the overall health of the community in which they work. Rather than working with clients only after they have had a stroke, the CHN will work with her population group to prevent strokes by encouraging regular exercise, a low salt diet, regular blood pressure

monitoring, and adherence to medications. Although the nurse may often deal with illness and its effects, her primary focus is on promoting wellness. Thus, the CHN has a very clear occasion for joyous and redemptive work within her community. She also is in a position to identify some of the elements within her community that are the result of our fallenness: polluted water that is resulting in high cancer rates, lead-based paint in homes that causes lead poisoning in toddlers, a high rate of obesity in the community that is leading to diabetes and heart disease. She sees these problems, and she works with those in her community to deal with them. The community focused nurse identifies those issues which might cause greater health-related problems in the future and works to prevent those problems from happening. As she works to enable people in her community to achieve a more healthy state, she is working to restore a small part of God's creation and is functioning as an agent of shalom. Some of the work a community health nurse engages in may be broad, community initiatives. For example, she may be a member of a countywide taskforce that is working to address an infant mortality rate that is higher than the state rate. As part of the task force, the nurse could be instrumental in designing a program intended to reduce the number of teen pregnancies within the county, or she could be the expert who lobbies the state legislature to provide funding for the program. She might also be a part of implementing existing state or federal public health programs. An effort called "Get the Lead Out" is an example of such a program. It provides funding for areas with a known high incidence of lead-based paint in homes. Community health nurses identify children who are at

risk for lead poisoning; they test children for lead poisoning and teach parents how to deal with the problem. These nurses also partner with local housing and government officials to help parents "Get the Lead Out" of their homes or to advocate for better housing conditions if they are living in rental property. In both of these instances, the nurse is working in an environment that is fallen. Our first example demonstrates the fallenness of the health care system. The prenatal care given to teens on Medicaid is most often not as good as the care given to women with private insurance. Further, women who are too "wealthy" to qualify for Medicaid but do not have private insurance may have no access to affordable prenatal care. Our s econd example demonstrates the fallenness of other social structures. In the case of lead in homes, it is well known that older homes, if they have not been repainted in many years, will have lead-based paint on the walls. Home owners (often landlords) are supposed to correct this problem but often choose not to take the necessary steps. Babies and toddlers suffer the most drastic consequences if the lead-based paint remains exposed. "Mental retardation, learning disabilities, and other neurological handicaps are the needless results of this condition. Infants and young children are at highest risk for complications of lead toxicity because they absorb lead more readily than do adults, and their nervous systems are more susceptible to the effects of lead" (Clemen-Stone et al. 2002, 535). We have said that justice is centrally a matter of equity and fairness. Our examples show a lack of equity and fairness for

two vulnerable groups. Certainly, neither pregnant teens nor babies have much power in our society. Justice would demand that those in power protect their rights and advocate for them. Community focused nurses might often be in such a position. They work with groups who lack privilege and power, they know the issues confronting them, and the nurses have some power and authority to be able to advocate for them. In advocating for those who may be unable to advocate for themselves, the Christian CHN has an opportunity to bring the light of Christ into the world. Since community focused nurses most often work with clients who are uninsured or underinsured, and since they deal with issues that focus on prevention rather than treating illness, frequently the nurse will identify health-related concerns within her community for which there is no government, insurance-related, or other funding source. In these cases, she may seek grant funding to meet these needs. Consider the following example. Deb is a school nurse at a city high school. A majority of her students come to school without having eaten breakfast, and she sees what they eat for lunch. For a lot of them, lunch is a Coke from the vending machine and a plate full of french fries smothered in ranch dressing. Deb is concerned about the nutritional status of these kids. She would like to be able to feed all of them a good breakfast and teach them to choose healthy food for lunch, but she has no budget to do these things. Therefore, Deb applies for and receives grants from the state Dairy Association, the U.S. Department of Agriculture, and the county health department. With the grant money, she

will pilot a school breakfast program, do additional classroom teaching related to nutrition, and work with the food service workers to provide more appetizing, healthier choices for lunch. Thus, Deb has found the means to meet a need within her community even though the funds were not available in the school's budget. Again, as she works to enable her students to achieve a more healthy condition, Deb is working to restore a small part of God's creation; she is an agent of shalom. Knowing a Community We ll

A community focused nurse also has the remarkable privilege of knowing her community well. She will know and work with many of the residents of the community, with business owners and pastors, with school principals and teachers. She will also know about community development and community organizing in her neighborhood. She will know the various racial, ethnic, and cultural groups within her community and how best to gain entry into the different groups. For example, information about breast cancer and the importance of mammograms might be needed by most of the women in the nurse's community, but the methods for disseminating this information would likely vary greatly from one cultural group to the next. In working with the Mexican-American women in her community, the CHN might elicit help from the currandera (the local healer) by getting her to endorse mammograms and to teach self breast examination to her clients. For the IrishCatholic women in her neighborhood, the CHN could work with local parish nurses to teach their fellow parishioners and provide mammogram information. The National Cancer Institute

has funded breast cancer education and screening programs in the African American community set up through neighborhood beauty shops (Forte 1995; Browne 2004). Community health workers provide the beauticians, who are usually trusted members of the community, with the information and resources they need to educate their clients. Clients are more likely to heed the information when the messenger is known and trusted (Icard et al. 2003), and the effective CHN will identify and work with those who are known and trusted within her community. In addition to knowing the health-related issues and the means of entry into the community, the community health nurse also knows the cultural values and beliefs of the people in her community. The CHN working in New Mexico will know that type II diabetes is a serious health risk for both her Navajo and her African American clients. She will, therefore, focus at least some of her efforts on educating her clients regarding the importance of staying physically fit, eating a diet that is low in saturated fat and high in fiber, and maintaining an optimal weight. In this way, some of her clients may be able to avoid developing type II diabetes or at least minimize the serious complications associated with it. Her teaching will vary, however, depending on the client. In teaching the traditional Navajo client about a high fiber, low fat diet, the nurse might emphasize skimming the fat off the mutton stew, adding fresh vegetables when possible, frying in canola oil rather than lard, and using whole wheat flour rather than refined white flour for making fry bread. As the CHN works with her 6o-year-old African American client who recently moved from rural Alabama, the diet teaching looks

very different. In this case, the nurse might instruct the client not to add fat to vegetables as they cook, to bake rather than fry chicken, and to choose white rather than dark meat whenever possible. These clients would likely be different not only regarding their usual eating patterns but also with regard t o their culture and values. The nurse must know these differences and how best to motivate her clients to make the necessary changes without simply assuming that every African American or every member of the Navajo nation will neatly fit into certain cultural categories. In other words, she needs to understand the cultural background that forms her clients, and she needs to be open to the beautiful diversity of the actual, embodied individuals she encounters. Good nursing care requires that she see both the big systems and the individuals. We see, then, that the community focused nurse is privileged to work with persons from a wide range of backgrounds, cultures, and socioeconomic levels. She or he has a magnificent opportunity to embrace cultural differences and learn from others. CHNs encounter in their practice a glimpse of the kingdom of God as we will see it one day. This discussion has focused on the idea that community oriented nurses know the issues and the people of their community. It is also worthwhile to point out that we have seen ways in which the nurse works with each of the different levels of the environment. In terms of the microsystem, the nurse does diet teaching with individual clients, but she also works in the mesosystem as she engages the client's spouse and family in the diet teaching. As the nurse uses the appropriate point of entry into her various communities, she is cognizant of the exosystem of her clients, and when she seeks to procure state

funding for a needed program she is working with the macrosystem. The nurse's role in the chronosystem is perhaps not as clearly delineated; however, the CHN is acutely aware of changes in the health care system and how these changes affect her clients. We will consider this more fully as we look at Bert and Lucy in the next section. Focus on He alth

Bert and Lucy, both in their late 70s, have been married for fifty-five years. They have four children, all of whom are married, and ten grandchildren whom they adore. They are both retired, are very active in their church, and do volunteer work at various places in their neighborhood. They live in a one-bedroom condominium that they bought when they sold their home. Neither one receives much of a pension, so they live mostly on their Social Security checks. The only health insurance they have is Medicare (Part A). They live fairly simply, have few needs, and, until recently, have both lived healthy, full, and happy lives. However, six months ago Bert was diagnosed with pancreatic cancer. When Bert and Lucy had their first appointment with the oncologist, they discussed treatment options and agreed that Bert would receive a three-month course of chemotherapy. The treatments made Bert very ill and weak, and he lost all of his hair, but he made it through them. The worst news came two weeks after the treatments were completed, when they found that the cancer had not slowed its progress. The oncologist recommended a different course of chemotherapeutic agents. After much crying, praying, and talking together, with their

children, and with their pastor, Bert and Lucy decided that Bert would not have any more treatments. Bert said the chemotherapy made him feel so awful that he couldn't face that prospect again. Also, their very small savings had been used up for the co-payments associated with the treatment. Bert was not willing to make things more difficult financially for Lucy, especially since there was no guarantee that the second set of drugs would work any better than the first set. Finally, Bert said he had lived a long and happy life, and he was ready to "see my Jesus." Karen, a nurse from their neighborhood clinic, works with Bert and Lucy. The clinic provides care to individuals and families in the community, and its overarching mission is to improve the health of area residents. Karen has known Bert and Lucy for many years, and she knows their children and grandchildren. Her professional roles in working with this family include counselor, teacher, advocate, and resource person (DeLaune and Ladner 1998). As counselor, Karen assists Bert and Lucy to identify the issues they will be facing in the future, and she helps to clarify their options. Karen's role as a teacher includes providing information on practical ways to help Bert eat, on recipes for high protein supplements, on how to talk to family members about death, and even about the process of dying. Karen functions as an advocate by supporting them in the difficult decision they have made and (at the request of Bert and Lucy) by calling the oncologist to explain to him again the reasons for refusal of further treatment. As a resource person, Karen helps them gain access to services such as Hospice, which they will need in the future, connects them with low-cost legal services so that their wills

are in order, and (at their request) calls their pastor to determine how their church family can help with Bert's care. Along with her professional roles, Karen is also a friend to this family. Karen is uniquely able to serve Bert and Lucy because of her longterm relationship with them. She can anticipate many of their needs and concerns. This relationship in some ways makes the situation more difficult for Karen. When Bert dies, Karen will lose not only a client but also a friend. Karen must deal with her own grief in the midst of helping the family cope with theirs. Lament becomes an important part of Karen's experience with Bert and Lucy. She laments the fact that Bert is suffering, that she cannot make him better, and that Lucy will be without her husband. She also grieves over a health care system that offers Bert only limited options. How does Bert and Lucy's case help us think about the CHN's focus on health? In our discussion of health as one of the foundation concepts in nursing theory, we defined it as the complete physical, mental, and spiritual flourishing that allows us to fulfill our created purposes and so give glory to our Creator and to enjoy relationships with our Creator and with fellow creatures that are made possible by those purposes. Although we know that Bert's physical flourishing is severely compromised, he continues to flourish both mentally and spiritually; he continues to witness to God's faithfulness to his family and friends; he continues to glorify his Creator; and he takes delight in his relationships. From these perspectives, Bert is healthy. As Bert's physical condition worsens, some of these other abilities may also be lost, but Karen will work with Bert

and his family to help him to flourish as much as possible. In short, the nurse will continue to focus on health even while assisting a client to deal with a terminal illness. Margaret Mohrmann, a pediatrician, writes about this in her book Medicine as Ministry (1995). Mohrmann discusses what she calls the idolatry of health and the idolatry of life. The idolatry of health refers to both seeing health as "better than God intends it to be" (p. 14) and assuming that health refers only to physical health. "A true and complete understanding of health includes mental and spiritual health as important ingredients in their own right, not just as promoters of physical health" (p. 15). Karen, our community health nurse, knows that relentlessly pursuing medical treatment is not the ultimate goal. She understands that life is more than the physical body and that, although Bert's physical health is important, it is not the supreme good. Even as Bert's physical health is diminished, his physical, spiritual, and relational health must continue to be promoted. Because of her professional emphasis on health promotion, Karen is able to focus on promoting Bert's health even as he dies. Working in Partne rship

The settings in which community health nurses work necessitate a certain attitude toward clients. One important aspect of the nurse's attitude is recognizing that the nurse and the client are on an equal (or nearly equal) power level. The nurse and the client are both experts in their own experience, and they must work together. To be sure, the nurse brings professional expertise, but the client brings essential

information about what will and will not work in his or her own situation. Nursing authorities agree that nurses should work with clients to establish mutual goals for care, but in a hospital setting the nurse is still largely in control of the situation. The acute care nurse administers medications at specified times, completes client assessments according to the nurse's schedule, orders meals and therapies to occur at certain times, etc. Nurses working in the community, however, are clearly not in control of what their clients do. The nurse can encourage the newly diagnosed diabetic client to eat three meals and two snacks at regular intervals every day, but she has little or no control over whether or not this actually happens. Because of this obvious lack of control, the nurse must work in partnership with her clients to an even greater degree than acute care nurses do. The concept of partnership is essential for the nurse who believes in persons as image-bearers of God with inherent dignity and worth. Partnership has been defined as "a close mutual cooperation between parties having common interests, responsibilities, privileges and power" (Community Campus Partnerships for Health 2001). "Such mutual cooperation characterizes the nurseclient relationship as together the two pursue the goal of promoting and protecting health" (Calvin College Department of Nursing Conceptual Framework). The CHN will need to "come alongside" the client and determine how best to empower him or her to make necessary changes. At times, the nurse is the salesperson trying to convince the client of the necessity of a new diet plan. At other times, the nurse becomes the coach who encourages the client to stick to the plan even when it is difficult. Unlike an acute care nurse,

the CHN has some assurance that whatever changes were made will continue even after the nurse is out of the picture, because the changes were under the client's control. Vulne rable Groups as Clie nts

The substance of any hope for change can come only from some "community of faith" which has the perseverance to return constantly to the places where suffering is to be found and to bring that suffering to the awareness of the whole society. A. CAMPBELL To serve the poor effectively means surrendering the power of the health professional, willingness to live with chaos, tolerance of racial and cultural differences, acceptance of lack of trust in health professionals, and attitudes of attention, care, hope, and listening often neglected in conventional medical training and practice. C. E. COCHRAN One aspect of community health nursing that is especially exciting and challenging is the opportunity to work primarily with vulnerable population groups. It is true that community health nurses work with the full range of people within their communities; however, they usually tend to concentrate on the groups that have the most health-related issues but the fewest means to be able to deal with them. One CHN textbook defines a vulnerable population as "A population or aggregate

susceptible to injury, illness, or premature death" (Smith and Mauer 2000, 342). Vulnerable population groups include those living in poverty, the homeless, migrant workers, refugees, those with chronic illness, pregnant teens, and those who are addicted to drugs or alcohol. In our society, these are the people who tend to have the least, in terms of both resources and power. Jesus exercises a positive preference for "the least of these." "Has not God chosen the poor in the world to be rich in faith and to be heirs of the kingdom that he has promised to those who love him?" (James 2:5). Community health nurses are privileged to work primarily with those who will "inherit the kingdom." Varie ty of Practice

One final and very practical benefit to working as a community health nurse is the variety of practice. A nurse who works in a hospital on a postpartum unit will always be caring for women who have just given birth. While this can be a very rewarding and stimulating place to fulfill one's calling as a nurse, it offers a rather narrow range of clients. Consider, on the other hand, all of the examples of clients and all of the practice settings described thus far in this chapter. Any one community health nurse may have all of these clients within her caseload. Indeed, she may encounter them all within a single day! The nurse needs a broad background to work with people of all ages, cultures, socioeconomic levels, and diagnoses and with those who are at varying degrees of health and illness. The CHN will also have ample opportunity to use her creativity and her critical thinking skills. She may at times become discouraged and frustrated, but she will never be bored.

Challenges in Community Health Nursing Cultural Differences

While community health nursing has many valuable and rewarding aspects, it also presents significant challenges. The cultural differences encountered bring richness and learning opportunities to one's practice, but they can also bring challenges, frustration, and lack of understanding. Because the CHN has a clear understanding of the partnership nature of her relationship with her clients, she knows the importance of motivating them to make health-related changes rather than mandating the changes. It can be very difficult, however, to discover the motivator for each client. One reason for the difficulty in motivating people may lie in people's differing definitions of health and illness. To a great extent, our definitions are culturally determined. For example, it is common for Dutch farmers in Iowa to define wellness as the ability to work. If a farmer has type II diabetes, he may not view himself as having an illness because he is still able to do his work. He may not see the need to make any modifications to improve his health. Thus, the nurse, knowing his cultural values, will approach the Dutch Iowa farmer differently than, for example, a single African American mother. She may motivate the farmer by helping him to understand the nature of his disease and its longterm consequences (including the inability to work) and by encouraging him to take his medications and change his diet so that he can remain healthy enough to continue to work.

The CHN working in a rural community knows that Mr. Vanden Hoek's view of illness is a rather typical cultural belief in rural communities (Clark 2003). Our nurse is also aware that "Rural residents are characterized by a strong desire to do and care for themselves. This may result in reluctance to seek help from others, reliance on informal support networks when care is sought, and resistance to seeking care from `outsiders.' Rural residents prefer to receive services from people well known to them" (Clark 2003, 588). Because the nurse knows that these characteristics are indeed true of Mr. Vanden Hoek, this will shape her approach toward him as she discusses his diabetes. First and most importantly, the nurse knows the importance of developing a relationship with Mr. Vanden Hoek and gaining his trust so that he does not view her as an "outsider." In her teaching, she will emphasize the fact that he will continue to feel well and continue to be able to work only if he regularly takes his medication. Further, as she discusses possible complications that occur when diabetes is not well controlled, she will highlight how these can limit one's ability to care for oneself. On the other hand, the nurse might encourage Darlene Williams, a single African American mother, a bit differently. She may advocate dietary change and medication adherence by helping her understand the relationship between doing these things and avoiding serious complications in the future so that she will be able to see her children and grandchildren grow up. The nurse may also link Darlene with a group of women in her area who also have diabetes. We see, then, that the CHN must know enough about each of her clients, their views on health and illness, their values, and their life

circumstances to discern how best to motivate each individual. To be sure, the nurse shows equal respect to each of these clients because each is an image-bearer of God. But she treats them individually, according to their own particular backgrounds, cultures, and values, because each has his or her own situation and story. The nurse may experience particular difficulty working with clients when her own definitions of health and illness clash with those of the client. It is so obvious to the nurse that our Iowa farmer, Mr. Vanden Hoek, has an illness that can be controlled if only he will take his oral hypoglycemic medication and modify his diet. It is equally obvious to Mr. Vanden Hoek that he does not have an illness because he feels fine and he is able to work every day. Their values and beliefs about health and illness are very different. In order to be effective, the nurse will need to work within Mr. Vanden Hoek's frame of reference. Although the cultural differences can be challenging, the gaps can often be bridged if the nurse is knowledgeable, caring, and creative. The differences can seem almost insurmountable, however, when the nurse has no previous experience with a certain culture, when there is a language difference, or when the values and beliefs of the client are in direct opposition to those of the nurse. All three of these issues are exemplified in a rather well known book, The Spirit Catches You and You Fall Down (1998). In this story we see how the medical community's lack of knowledge about the Hmong culture, the language barrier,

and the "dramatically clashing worldviews" combined to result in disastrous consequences for a little girl. We see evidence of the fallenness of our world and of the great divisions between people and cultures. Would the outcome have been different if the doctors and nurses had known more about the Hmong culture? Would it have been different if they had used a translator who knew both the Hmong culture and the American medical culture? Would it have been different if there had been an attempt to combine the approaches to treatment? We cannot know the answers to these questions, but it is obvious that each of these areas should have been explored. However, even with abundant knowledge, creativity, understanding, and an open attitude, the nurse will not always be able to bridge every cultural gap she encounters. Herein lies one of the great challenges of community health nursing. Goals of health professionals and goals of recipients of health care may be incongruent. IMOGENE KING Funding Issue s

Let us return for a moment to Bert and Lucy, our couple in their 70s. We remember that one of the reasons Bert cited for refusing to continue his cancer treatment had to do with a lack of adequate health insurance and an unwillingness to place a large financial burden on Lucy. The health care "system" in the United States operates according to the free market system. In general, services are available to those who can pay. It is not a

system that provides equally (or even somewhat equally) to all. Bert and Lucy, because their only insurance is Medicare Part A, have no coverage for physician bills, outpatient diagnostic tests, medical equipment, or prescription drugs. The services that are covered require significant co-payments. The financial considerations for this couple are very real. The problem has to do with a fallen environment. It is a health care system issue and also a justice issue. Need is the proper principle for distributing health care. Health is necessary for a community's proper functioning. Good health facilitates social interaction and economic enterprise. Medical care is one of the principal means to preserve and restore physical, mental, and emotional functioning. Therefore, all societies (except the United States) that value health and that have the financial and technical means to develop modern systems of medical care recognize that health care for all citizens is a matter of public justice. C. E. COCHRAN Let us consider how Karen might actually promote justice and "reform" her particular corner of the health care system as she works with Bert and Lucy. Karen will offer to connect them with free or reduced-rate prescription resources, to contact

their pastor to discuss support for them, to connect them with Hospice, to anticipate the need for a legal-aid lawyer for making a will, and to give them information on how to reach such a lawyer. In short, Karen will find all possible resources and offer them to Bert and Lucy. She will also be an advocate for them whenever necessary. In all her interactions with Bert and Lucy, Karen will continue to maintain their autonomy and to treat them with dignity and respect. In these small ways, Karen will "humanize" the health care system for Bert and Lucy. Although she does not "reform the system" through these actions, she does manage to promote justice in her individual interactions with clients. As important as it is for Karen to be caring and just in her own practice, political action and community organization on the part of the nurse may sometimes be called for. One of the most basic justice-related questions we must ask is, How fairly are benefits and burdens distributed? In the case of Bert and Lucy, they are not receiving adequate health care benefits. A community health nurse like Karen has intimate and daily encounters with injustice in our health care system. She would be uniquely qualified to provide expert testimony to community leaders or to be a member of a task force looking to provide better health care services to the underserved within her community. Any nurse in Karen's situation might feel some desire to change the system, but, as we stated earlier, being a Christian nurse means answering the call to become an agent of renewal in society. Compliance, Adherence, and the Difficulties

Jennifer, a public health nurse working for a county health department, returns to the office after a particularly frustrating client visit. She shares with her coworkers her dismay about Stacy, a client who "is too lazy to take her kids in for their shots." The situation has reached a crisis, since Haley, the 5year-old little girl, is not allowed to start kindergarten because she has not received her immunizations. Jennifer has repeatedly told the client the hours of the immunization clinic and that the shots are free, but still Stacy "just won't follow through. I know it's not politically correct to label someone `noncompliant,' but that's just what Stacy is!" Scenarios like this are everyday experiences for nurses working in community health. Clients often seem to make bad choices even when the right choice seems easy and obvious to the nurse. How hard could it be to get to the health department so Haley could receive the necessary immunizations? Jennifer is so frustrated with this situation! She feels as though she has done all she can do (or all she should need to do) to get Stacy to follow through. Jennifer is also angry at Stacy and what she sees as Stacy's unwillingness or inability to set her priorities correctly. Jennifer's values would dictate that Haley must be able to start school on time, but apparently Stacy has different values. In circumstances such as these, what can be done to build shalom? One important part of the answer often involves learning more about the client's situation. Frequently, there are variables that the nurse, because of her own frame of reference, has never even considered. Let us learn a bit more about Stacy and her family. Stacy, age 21, is a single mother with three children. She

moved to this area about a year ago to escape her abusive boyfriend. She left her family and friends behind because she needed to get away to protect herself and her children. Stacy was just i6 when she gave birth to Haley; she was i8 when Justin was born and 20 when she gave birth to Vanessa, her youngest. She has not completed high school, but has recently been attending a high school completion program in her neighborhood. This program works for Stacy, since on-site child care is offered. She has been looking for part-time work, but because she has few marketable skills and will need to earn more than the cost of child care it is proving difficult to find a job. When Stacy left home, she had to get out quickly, so she took only a few clothes and their old car, which has since broken down. Since she was not married and her name was not on the bank account, she has no access to the account she shared with her boyfriend. Currently, her only sources of income are the money her mom occasionally sends and the mo n t h ly check she receives from Family Assistance. Thankfully, she will soon begin to receive Food Stamps also. Stacy has known for a few months that she needs to get Haley immunized, and she meant to do it. If the nurse knows more about Stacy's circumstances, what barriers to compliance might she anticipate? Stacy has no car. Since it is likely that Stacy cannot afford cab fare, is she able to get to the health department using public transportation? If so, how long will it take her to get there? Will it require a transfer or two? What if the weather is rainy or very cold? Since Stacy is new to the area, perhaps she has no friend who could watch

her younger children while she and Haley make the trip. She would then need to bring (and pay bus fare for) the whole family. Maybe the children have been passing the flu to each other for the past month, so she has been unable to get out with them. Stacy might also have some less obvious reasons for her "noncompliance." Suppose the cover story in last month's women's magazine was about children who became very ill as a result of immunizations, and this frightened Stacy. Perhaps Stacy has cultural or religious reasons for refusing to obtain the immunizations. The point is, Jennifer must be able to anticipate these barriers, ask Stacy about them, and work with her to overcome the barriers. Being a person involves being a character in a narrative with a past, present, and future plot. All nurses must listen closely to their clients' narratives. This is especially true in community health settings where the client's life experiences are often so very different from the nurse's. Jennifer cannot and must not use her own frame of reference to judge her client's actions. She needs to "stand in Stacy's shoes" in order to have an understanding of her behavior. We have also said that to be a person means, in part, to be the coauthor of our own narratives. But being the coauthor is not the same as being a sole author. We never single-handedly write the stories of our lives because we are constrained by circumstances and by persons who are not under our control. We can judge how and when actions are to be approved or disapproved, how and when characters are to be praised or blamed for their actions, only in the context of the stories of which those actions are a

part. Thus, Jennifer must carefully listen to Stacy as she explains what has happened and then assess all aspects of the situation with a view toward understanding those aspects which are not under Stacy's control. Having discussed the importance of listening and working to achieve understanding of client circumstances, we must still acknowledge that no matter how well the nurse listens and anticipates, people will still make choices that the nurse considers wrong, choices that are bad for their health. Consider the following. Bob and Cheryl are a couple in their late 50s. Although they are not married, they have been together for seven years. They have no children, but do have five large dogs living in the house with them. The house is dirty and run down, but it is a large step up for Bob and Cheryl. Until two years ago, they were homeless. They became homeless when they both lost their jobs and fell behind in their rent and other debts. Bob, a Vietnam veteran, was fired when his post-traumatic stress disorder caused him to be incapable of doing his factory job. Cheryl had to quit work because her chronic obstructive pulmonary disease (COPD) and diabetes made her unable to bus tables anymore. After the unemployment benefits ran out, they had no source of income and began living on the streets and in shelters. Bob and Cheryl now have a home because Bob was finally able to obtain some veteran's pay and Cheryl to qualify for disability pay. Currently, they are focused on buying a car.

Ray, a public health nurse who works with homeless and formerly homeless clients, is Bob and Cheryl's nurse. Ray knows this couple well. He has helped Bob obtain a referral to a psychiatrist so he can get a prescription for anti-anxiety medication. He has assisted Cheryl to get the inhome oxygen she needs to help her manage her COPD. Ray and Cheryl frequently discuss the fact that Cheryl's COPD might be significantly improved if she quit or even cut down on her smoking. Now, with oxygen in the house, Ray knows that the smoking poses an even more significant health risk since the lit cigarettes could ignite the oxygen and blow up the house. Ray's greatest frustration in caring for Cheryl is that Cheryl continues to smoke cigarettes in the house even with the oxygen present. Ray feels that he made a little headway at his last home visit when Cheryl agreed to smoke only in the living room and to leave the oxygen tank in the kitchen. Ray knows, however, that the television is in the living room, and Cheryl likes to use the oxygen when she watches TV. Clearly, Cheryl's decision to continue smoking is a bad choice. From a health perspective, both of her chronic conditions would be easier to manage and would likely improve if she quit. Her choice to continue smoking also affects Bob. Not only is he exposed to her secondhand smoke, he also faces the risk of being blown up! Indirectly, Cheryl's choice also affects the rest of society. Scarce health resources are being spent to enable an addicted smoker to continue lifethreatening behaviors, thus limiting health care funding in other areas. How does the Christian nurse deal with these issues? How should he treat Cheryl in this situation? First of all, Ray must

keep in mind that he and Cheryl are partners. He is not in charge of what Cheryl does. He must give Cheryl information, anticipate potential barriers, work to motivate and encourage her, and provide her with resources. The difficulty for Ray will be to avoid dealing with Cheryl in a paternalistic way. He must remember, as we stated earlier, that clients may have central values other than health, and they often do not care as much about health as nurses wish they would. For some clients, the very real needs of food and shelter take precedence over the more abstract and distant idea of health. For Cheryl, the enjoyment she derives from smoking the cigarettes may well outweigh the value she places on her own improved health. Her capacity to experience enjoyment and delight may be so constrained by poverty and illness that depriving herself of even this admittedly misplaced enjoyment represents a greater sacrifice than she is currently able to handle. Second, Ray must continue to work with Cheryl even when he sees little change in Cheryl's behavior. Ray needs to "walk with" Cheryl, and Cheryl needs to know that Ray sees her as a valuable person even if she does not follow Ray's advice. From a practical standpoint, Ray also needs to know the process of smoking cessation for most people. It is rare that someone would quit on their first attempt, so he should not expect this o f Cheryl. He also needs to understand the pleasure she derives from smoking and perhaps find alternative sources of enjoyment for her that would also bring her delight, but without the negative health consequences. However, even if Ray is perfectly helpful and supportive, in the end the choice still belongs to Cheryl. Cheryl, as a person, has agency, and as such she has a certain amount of control over what she does

and what she decides. This can be frustrating to the nurse, but it can also be freeing. It is good news that the nurse is not ultimately responsible for the behavior of his clients. Earlier we discussed the nurse's attitude toward his or her clients, and we must remember that even with (perhaps especially with) Cheryl, Ray's attitude must be one that reflects the awe and respect that he owes to God as Creator and, derivatively, to God's creatures. Ray's attitude may well be helped if he remembers that "all have sinned and fallen short of the glory of God" (Romans 3:23). None of us can begin to achieve the perfection that God demands. We are all equally in need of God's grace, Ray just as much as Cheryl. One who has been touched by grace will no longer look on those who stray as "those evil people" or "those poor people who need our help." Nor must we search for signs of "loveworthiness." Grace teaches us that God loves because of who God is, not because of who we are. Categories of worthiness do not apply. In his autobiography, the German philosopher Friedrich Nietzsche told of his ability to "smell" the inmost parts of every soul, especially the "abundant hidden dirt at the bottom of many a character." Nietzsche was a master of ungrace. We are called to do the opposite, to smell the residue of hidden worth. (Yancey 1997, 280) As a way to help shape his attitude, Ray could spend time in prayer before he visits Cheryl and Bob. He might ask to see this family as Jesus would see them, or to see them as God intended them to be. Ray could also reflect on his thoughts and actions and consider the sin in his own life, so that he

walks into this situation with a clear notion of his own fallibility and his need for grace and with a thankful heart for the grace he has received. Grace means there is nothing we can do to make God love us more. And grace means there is nothing we can do to make God love us less. PHILIP YANCEY Conclusion: One Last Story We have examined many roles of the community health nurse and have looked at what ought to characterize the posture of a Christian nurse as he or she practices in this realm. One final component is necessary. The Christian community health nurse also needs an attitude of humility and servanthood. How might this attitude be portrayed in the work of the community health nurse? Let us look at a real-life and very complex situation. The Miller family consists of Grandma Clara; her daughter, Cindy; Cindy's husband, Rick; their children, Missy, Tanner, and Mandy; Rick's daughter, Ashley, from his previous marriage; and Suzie, Clara's 24-yearold daughter who is developmentally disabled. These eight people live together in a small, three-bedroom home. Grandma Clara has her own bedroom, as do Cindy and Rick. The other five people share the remaining bedroom and the other sleeping space in the small house. The first three to bed get the beds in the bedroom,

and the last two people take the living room couch and a mat on the floor. Ashley, age 8, and Missy, age 6, have been sent home from school five times in the past month because they have head lice. The first time, Juanita, the school nurse, sent home an information sheet on how to get rid of lice. The second time, she sent a more detailed pamphlet that outlined how Cindy should clean her house to get rid of the lice. The third time, she called Cindy and gave her step-by-step instructions on exactly what she needed to do. When she contacted Cindy the fourth time, Juanita discovered that Cindy could not afford again to buy the shampoo to treat the lice, so Juanita obtained some from the health department and brought it to the Millers' home. In doing so, she determined that the two previous times, Cindy had treated only the two girls, and not Tanner, Mandy, or Suzie, who share the same sleeping space and were also infected with lice. Juanita instructed Cindy to treat all five people and again discussed how to clean the home properly. When the lice were discovered a fifth time, Juanita scheduled a home visit with Cindy to discuss the problem. Juanita asked if Rick could be present for the meeting, but she was told, "Rick works two jobs, so he's never home." The poor and near-poor do not get the health care they need to become productive members of the economy because they lack health insurance. The problem is particularly acute for the "working poor" and their children. These are persons who

work full-or part-time, but in lowwage jobs that do not provide health insurance benefits. The percentage of workers covered by private employment-based insurance has declined in the last 15 years. Moreover, the costs of health care take a higher proportion of income the lower one's income. This means that low income workers with family health problems have less money available for decent food, shelter, additional education, job training, or other requisites of social advance. It means also that the poor go through life sicker than the non-poor and die earlier. C. E. COCHRAN As Juanita talked with Cindy and Clara in their living room and tried to review written instructions with them, Juanita became convinced of something she had suspected since she first had phone contact with Cindy. Neither woman was able to read the instructions, and they were totally overwhelmed with all of the tasks they were being asked to do. Juanita asked the women if they would be willing to let a group of nursing students that

were working at the school come into their home to help them do laundry, clean the house, shampoo heads, and comb nits out of hair. The two women readily agreed. It took the group of eight students and their instructor five hours to complete all of the necessary work. It was especially challenging to handle the laundry, since the Millers had no washer or dryer and the students had to take the laundry to a local shelter and use their appliances. In working with the Miller family, Juanita found it difficult not to take on an air of superiority. After all, getting rid of lice may be time consuming, "but it's not rocket science." "If the family would only get their act together in terms of sleeping arrangements, the problem would be so much easier to deal with." Juanita has no previous experience with a situation in which people don't have their own bed, let alone their own bedroom. She knows that if each person slept in the same place every night, they would not continue to reinfect each other, and this makes her feel frustrated and helpless to make an impact on this family. Juanita really wants to get rid of the lice so the girls can stay in school, but she also wants to get out of this lice-infested, cramped, chaotic house and be done with this family once and for all. This attitude may not characterize the Christian nurse. Christians have Christ as their example. Jesus is the perfect picture of humility and servanthood. We see him touching

lepers, talking with women of ill repute, washing the feet of his disciples. Do you suppose there might have been bugs on some of those feet? As Jesus was finishing with the feet washing, he said, "So if I, your Lord and Teacher, have washed your feet, you also ought to wash one another's feet. For I have set you an example, that you also should do as I have done to you" (John 13:14-15). Our Lord tells us and shows us what our attitude must be, and he promises a blessing if we follow his command. As important as it is to see the nurse as serving God's liceinfested children, it is equally necessary to remember that the nurse is also "served" by those same people. In working with this family, the nurses see that love and caring exist even in places where people are poor and circumstances are difficult. Although they know it in theory, sometimes persons who have grown up in middle-class homes forget this important fact. Most families care for each other, even if the house they live in is run-down and cramped. Most parents love their children and want what is best for them, even if they have a hard time feeding them every day. Of course, this is not always the case, but community health nurses would do well to operate with this as their assumption rather than assuming that a parent is unloving or uncaring when there is a health-related issue with the child. Assuming the best about the motives of parents and family members will help to shape the nurse's practice. Clients tend to respond more positively to a nurse who looks for the good in them than to one who expects the worst. We must always look for the Christ-mediating presence of the one receiving care. Each member of the Miller family brings

Christ to the nurses that work with them. As such, they are to be treated with reverence and awe. Although this family may seem totally disorganized and chaotic, if we look more closely we see that they have many strengths. They are living together as a family. Rick is working two jobs to provide for the family. They are caring for a disabled family member. Clara and Cindy care enough about the girls' education that they are willing to go through the embarrassment of having nine strangers invade their home. These family members love each other, and in that way they are agents of the divine. In his book about his journeys to churches in Latin America, Henri Nouwen says, The mystery of ministry is that the Lord is to be found where we minister. That is what Jesus tells us when he says: "Insofar as you did this to one of the least of these brothers of mine, you did it to me" (Matt 25:40). Our care for people thus becomes the way to meet the Lord. The more we give, help, support, guide, counsel, and visit, the more we receive, not just similar gifts, but the Lord himself. To go to the poor is to go to the Lord. Living this truth in our daily life makes it possible to care for people without conditions, without hesitation, without suspicion, or without the need for immediate rewards. (1983, 20) Those who choose to fulfill God's calling by working as a community health nurse will have daily opportunities to work with the poor, with "the least of these," and so will have abundant opportunities to "meet the Lord." And this is perhaps the most powerful reason of heart and mind for engaging in community health nursing practice.

CHAPTER SEVEN

Acute Care Nursing Introduction When people enter acute care hospitals, they need the care of a nurse. Almost every other need for health care can be, and often is, provided through outpatient services. Physician care, surgery, diagnostics, and physical and rehabilitation therapies are examples of care that do not require hospitalization. But all of the conditions that require in-hospital care - major surgery, complicated birth, or lifethreatening illness - require nursing care at many different levels. Nurses provide a critical link in improved client outcomes. Nursing assessment and judgment are crucial in monitoring seriously ill individuals for the presence of complications. Current research demonstrates that effective nursing care decreases the number of hospital days, prevents complications, and decreases the mortality rate of surgical clients (Kovner and Gergen 1998). And acute care nursing tends to be the sort of nursing most people think of when they think of the nurse's role. Acute care nursing, care for those who are acutely ill or injured, requires specialized education and experience. In general, the more advanced the nurse's education, the better the quality of care that he or she provides. Researchers have found that mortality and the failure to recognize lifethreatening

complications were 19 percent lower in hospitals where baccalaureate nursing graduates (BSNs) comprised 6o percent o f the nursing staff as compared to hospitals where only 20 percent of the nurses were educated at the BSN level (Aiken et al. 2002). Professional, acute care nursing makes a great contribution to the lives and wellbeing of people in our society; and because nurses see that their care truly makes a difference, acute care nursing is an enormously rewarding career. In this chapter we'll describe some of the central features of the life of an acute care nurse, think about how those features are shaped and qualified by Christian faith, and consider how they fit into our earlier analysis of ethical nursing practice. In the two previous chapters we have carefully separated out the opportunities and challenges that each kind of nursing practice entails. But in real life, of course, these things always come to us at the same time. The things that make the work meaningful and enjoyable and the things that make it frustrating are inseparable in everyday experience. For this reason, in this last chapter we present case studies that reflect this tangled reality and invite readers to look for the sources of delight and of anguish for themselves. High-Tech Excitement and Specialized Education Nursing in the acute care setting is fast-paced, and hospitals are exciting places to be. Nurses who work in this setting are constantly learning about new advances in health care: pharmacology, procedures, protocols, research, quality improvement, and more effective means of delivering nursing

care. They have the satisfaction of seeing extremely ill clients recover and knowing that their nursing care played a prominent role in that recovery. Many nursing journals refer to acute care today as "high tech" requiring "high touch." Clients can be very frightened, and it is the nurse, present with them, who explains, supports, and reassures clients and families in this confusing place. It is gratifying to receive appreciation for the care and human touch nurses provide, the care that has been the historical essence of nursing (Leininger 1981; Roach 1992). Nurses today bring multiple skills and abilities to the bedside. Graduate nurses who enter the profession are educated to be generalists, able to begin functioning in any setting where they might be needed. As their career unfolds, many nurses specialize, just as physicians do, with continuing education in a specific area of nursing practice. A higher quality of care is given when nurses are working with clients in a particular specialty. Education in that specialty area and the ability to work in that specialty are critical. Nurses should not be "pulled" from one unit to another unless they have specific education in caring for the clients in the second unit; sit uations in which their specializations are not recognized and they are assumed to be substitutable are situations that cause nurses a great deal of stress. Specialization has led to better, more efficient and cost effective care for clients (Curtin 2003). Nurses experience much greater satisfaction with their work when they are able to provide the expert, quality care they wish to provide. Some nurses particularly enjoy the challenges of caring for those who are most critically ill or injured and may become

certified in that specialty. Critical care nurses and emergency department nurses have been called "adrenalin junkies" because they thrive on the rush of adrenalin experienced with the rapid fire assessment and interventions needed to care for those with lifethreatening circumstances. The popular television program ER at one point showed a client arresting on the elevator. The nurses and physicians with the client performed CPR immediately while on the elevator and then stopped at the next floor to page a code. Some hospital visitors who had been on the elevator and witnessed the dramatic event were left pale and visibly shaken. Several college students were watching the television program, and one said, "They expect us to believe that? That doesn't happen in the elevator! How fake is that?!" A nursing student who was with them replied, "Actually, that happened to one of my classmates last semester" The life of an acute care nurse is likely to involve enough excitement and drama to justify making a television show out of it. There is something gratifying about knowing how to function in the context of an emergency and something rewarding about having the knowledge and the education to remain calm and to be able to work effectively in that context as well. Acute care nurses often pursue graduate degrees and become advanced practitioners in a variety of settings and specialty areas. This requires advanced training and certification by a professional board and can be a particularly challenging and rewarding part of a nursing career (Zeimer 1994, 7). Nurses who want to function with more independence and autonomy than is sometimes a part of a traditional nursing role can become advanced practice nurses. There are several

types of advanced practice nurses in the acute care setting: nurse practitioners, clinical nurse specialists, nurse midwives, nurse anesthetists, nurse researchers, and nurse administrators. All of these areas of specialization require a minimum of a master's degree, while some, such as a nurse researcher, will require a doctoral degree. Nurse practitioners also need to have graduated from a certified nurse practitioner program, and they need to be highly skilled in psychosocial and physical assessment, counseling, and teaching (Craven and Hirnle 2003). A clinical nurse specialist functions in a clinical setting as an expert consultant on the best nursing practices in a given specialty area, while nurse midwives, anesthetists, researchers, and administrators function in the role that each title suggests. The development of nursing as a distinct profession has opened up all of these routes for professional advancement, making nursing not only an exciting profession but also a profession that can be highly specialized and can require extensive additional education. Nursing care is based upon scientific principles, but the application of those principles for each unique client is an art. Finding the right balance of pain medications and comfort measures to relieve a postsurgical client's excruciating pain or maximizing a client's cardiac output by adjusting several potent intravenous drips requires specialized skills and abilities, expert knowledge, and creative thinking. Monitoring a client's progress for complications and providing appropriate interventions to prevent lifethreatening circumstances are central parts of the acute care nurse's job (Unruh 2003; U.S. DHHS 2001). Acute care nurses literally save lives every day (Kovner and Gergen 1998). Combining interventions in ways

that meet clients' unique and individual needs is both a science and an art. Acute care nurses find a great deal of satisfaction in creating the most appropriate, effective, personal, and comfortable combination of nursing care for each client they meet. They know how to use the available resources effectively to provide comfort and healing and to assist clients in preparing for self-care when they leave the hospital. Nurses draw from a variety of disciplines and apply that knowledge to each unique person in their care. Nurses see how illness, suffering, and stress affect the client and family on a daily basis. They are present to provide care and support, a human face and connection. Nurses quickly become aware of the very deepest of human needs and indeed are privileged to spend those sacred moments with clients and their families (O'Brien 2001). 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 o n ce 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 o f 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. The Shortage of Acute Care Nurses 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 o t h er 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 longterm 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. Dark Humor 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 nurseclient 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. Spiritual Care 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 caregivers 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, nurs es 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. Professional and Interpersonal Relationships Acute care nurses are highly educated professionals, and their practice in the acute care setting involves extensive amounts of responsibility and leadership. Registered nurses have legal and professional responsibility for providing care and evaluating the client's status. On a given hospital unit the decision-making authority with respect to nursing care rests with the RN. Licensed practical nurses (LPN), unit assistants such as secretaries and supply managers (UA), and nursing assistants (NA) are under the direct supervision of the nurse and report all care information to the RN. As Patricia Yoder-Wise notes, "Today, virtually every professional nurse leads and manages regardless of title or position" (Yoder-Wise 2003, x). Effective leaders have the capability of assisting and empowering other staff members. Nurses in a leader/manager role work to advocate for excellence not only in client care but also for fellow staff members. The nurse leader holds a unit in trust, and the decisions he or she makes may affect the health and wellbeing of many people. Improved client care as well as improved staff morale and wellbeing can be truly rewarding.

Nurse managers derive a great deal of satisfaction in planning for resources and nursing care delivery systems that enable nurses to work more closely with their clients and to provide the highest possible quality of care. All nurses, whether administrators or not, have positions with heavy responsibilities. While administrative nurses have responsibility for the operation of the unit and hospital departments, the ultimate responsibility for care of the client is with the staff RN assigned to that client. An RN is indispensable within a hospital and is often expected to fill many roles. Legally an RN must be present to supervise, deliver, and/or give care. Evaluation of nursing care is also a part of the staff nurse's responsibility. He or she must determine whether the projected outcomes of care have been met. Nurses are a central part of hospital care because the hospital cannot function without them. Other staff members may be cut for budgetary reasons, but nurses cannot be cut since the care they provide is the reason for the hospital's existence. One result of this is that staffing cuts tend to result in extra work for the nursing staff. If the unit does not have a secretary scheduled for the shift, a nurse will fill that role and provide the clerical support needed - noting physicians' orders, answering the telephone, filing routine reports and documents - all in addition to the nursing care that he or she is assigned. Under these conditions nurses are required to complete tasks that do not require nursing judgment or expertise. The expectation that some administrations have that nurses are appropriately used in this way indicates the confusion people sometimes have about the nurse's education and proper

role. This confusion is not limited to the administration. Many clients do not know the difference between aides and nurses, or between the different types of nurses that are involved in their care. Based on outmoded models of hospital organization, many see any woman in a uniform as a nurse - and as a subordinate. Blurring of the nurse's role can be a common problem. Clients are not the only ones who have trouble with a clear understanding of the nurse's role. Physicians do as well, and when others do not understand what the nurse's role is, it creates difficult issues for the nurse. Cassandra Novak is the nurse in charge of caring for a young man named Rick who has a serious head injury. She is on the telephone, attempting to contact a respiratory therapist who is urgently needed for another client, when Dr. Johnson, a physician known for his lack of interpersonal skills, approaches. Ignoring the fact that Ms. Novak is on the phone, he begins quizzing her about Rick's status, asking for information that has been documented in detail on Rick's chart and is readily available. Ms. Novak covers the mouthpiece of the phone with her hand and says, "Dr. Johnson, I have a serious situation here with another client. That information is documented, in detail. Couldn't you take a look at the chart?" "How do you expect me to find what I need in that computerized mess?" Dr. Johnson asks. "I'm expected to read your progress notes," Ms. Novak responds with an edge to her voice. "Couldn't you take the

time to read mine?" Dr. Johnson is now very angry. "Nurse, I can ask you any questions I want and you are obligated to answer! Do you want me to report you for insubordination?" "That would be impossible," Ms. Novak shoots back, in a voice devoid of any respect, and with a slight smirk on her face. "And why would that be?" "I'm not subordinate to you, so how can I be insubordinate?" Dr. Johnson's face is red, and his voice is not steady. "Oh yes, you are subordinate to me!" Ms. Novak's voice has gone up a notch as well, but she holds her ground. "No, I work for the hospital, not for you!" Dr. Johnson ends the interaction by stalking from the unit. He did not get the information he needed about Rick, and so he did not enter the needed care directives in the chart. Nurse Novak's response to him was true and her irritation at his behavior understandable, but the tangled lines of interpersonal communication result in diminished client care. As Dr. Johnson and Nurse Novak interact with one another, we recognize the fragile emotional state they may be in. The acute care context is highly stressful, and health care workers deal with devastating difficult is sues on a daily basis. We've

already noted how this can affect the individual professional, but it also has important consequences for relationships between professionals. Both of these individuals come to this interaction with a narrative, stories that make sense of their work and their lives. Physicians often have a great deal of personal identity invested in the respect that their job generally brings. Challenges to their professional status are felt to be attacks on their worth as a person. Nurses, likewise, are highly educated professionals who hold positions of power and authority in the health care system. To make the situation more complicated, the relationship between nurses and physicians has been redefined over the past few decades, and though most physicians have adjusted to this redefinition, there are a few who see these changing roles as threats to their own prestige. By claiming that the nurse was subordinate to him, Dr. Johnson attempted to assert h is own authority and control over his nurse colleague and fellow professional. Ms. Novak's response did nothing to defuse the situation, in part because her own sense of prestige and identity were at stake. We can understand how both parties to this dispute felt badly used and disrespected; we can also recognize that the breakdown in professional relationships posed more of a risk for the client than for either of the two caregivers. For the sake of the client's wellbeing and for the sake of their o wn ability to do their jobs well, both Nurse Novak and Dr. Johnson need to work on developing a working relationship that includes a clear sense of personal boundaries and appropriate professional interaction. Mutual recognition of the

skills and abilities that each of them brings to client care would help this process. Physicians bring an extensive educational background and current medical research to the client. The nurse has a similar yet different body of knowledge from her or his training in the nursing profession. The nurse brings knowledge of different cultural practices with regard to health and strong interpersonal skills in providing support and comfort to those who are suffering (Sledz 1997). Nurses and physicians may learn a great deal from each other if they are willing to demonstrate an interest and to listen. In the stressful, acute care environment, tempers may flare quickly in interpersonal relationships, particularly when the client is doing poorly and not responding to treatment. Again, the Christian nurse has resources for thinking about the challenges of interprofessional relationships. No matter how flawed other professionals maybe, they, like clients, are bearers of the image of God and de serve to be treated with courtesy and respect. Because others are made in the image of God, however, it is also appropriate to hold them responsible for the ways in which they use their power and authority. Nurses may at times be required to adopt a prophetic stance in dealing with those in power in the acute care setting, responding to abuses of power with a word of rebuke or warning. When physicians run roughshod over the nursing staff it is detrimental to all aspects of hospital functioning, and such physicians can properly be held to account for their choices. Gender issues have colored nurse-physician relationships since the beginning of modern health care. Some of the

traditional stereotypes of masculine, authoritative physicians and feminine, subordinate nurses still linger in people's minds. Of course, it's no longer true that all doctors are male and all nurses are female. But apart from that obvious fact, the reality is that nursing is not a subordinate profession in medicine, and nurses are skilled professionals who play a leadership role on the health care team. Most caregivers, physicians and nurses both, would not have it any other way, but some feel threatened by relationships that are more a matter of equal partners than that of dominant and subordinate. In cases such as these, our earlier discussion of care and justice may provide helpful tools for thinking about how to respond to difficult interpersonal conflicts. The importance of care reminds us that we need to focus on the most needy and vulnerable in a situation. In the case of Ms. Novak and Dr. Johnson, it is the client, Rick, who may end up paying the price for the breakdown in communications. If we are striving to become caring people, we will recognize that sometimes our justified annoyance at another's obnoxious behavior needs to be set aside so that those who are dependent on us are not harmed or put at risk. If Ms. Novak was not at the end of a shift, tired and frazzled, she might even find it possible to feel some compassion for the physician whose sense of self is so easily threatened. However, if Ms. Novak worries only about care, she might make not take the steps that are needed to bring about change in nurse/physician relationships in her hospital. If Dr. Johnson is treating her this way, there is a good chance he treats nursing students, aides, and perhaps even clients just as badly if not worse. Those who use power abusively often do so in many different situations. Ms. Novak

may need to consult with her supervisor, or discuss the situation with the hospital administration, to make sure that Dr. Johnson's behavior does not cause worse problems in other cases. Justice reminds us that ignoring the misuse of power is just as wrong as failing to care for the vulnerable and dependent. In fact, failing to do justice may make it difficult to provide care. Interprofessional relationships can be sources of frustration and difficulty even when both professionals are nurses. Take the example of Kathy, a nurse who had worked over several days with a family to accept the fact that their brain-injured son would not recover from his automobile accident. The parents trusted Kathy and responded affirmatively when she brought up the possibility of notifying the organ donation team to see if their son's organs were viable for donation. They experienced some comfort in the fact that their tragedy might at least provide hope for someone else, but they wanted to spend time in the room to say good-bye prior to the termination of life support. In the middle of this event, the charge nurse approached Kathy and told her that she must leave and go to another unit immediately to take a new admission. Kathy explained about the relationship she had developed with the parents and what was taking place, and she asked if another nurse could go to receive the admission. Saying "That boy is dead, we need to get on with things," the charge nurse told Kathy that if she did not go now, she would be terminated. Kathy was a single mother and dared not risk her job, at least until she could find another. She went to take the new admission. And she did find a new job, eventually, but not in nursing.

The charge nurse could have used her authority and power in this situation to enhance the quality of care and support that Kathy wished to provide to the family. She used it, instead, to force compliance with her orders. When we are put in a position of authority, it can be very tempting to use that authority for our own benefit, rather than for the benefit of others. Presumably the charge nurse's life was made easier by not having to find another nurse to take care of the new admission, even though her use of authority caused suffering to the family whose son was dying. Misuse of power in professional relationships can increase the suffering of those who are vulnerable. In the context of acute care, the vulnerable are extremely vulnerable, and so misuses of power can have devastating effects. But Kathy's response can be challenged as well. She chose not to confront her supervisor, and later she chose to leave nursing without fighting for change. Sometimes this is appropriate, of course, but other times the Christian nurse should recognize that she or he may have a responsibility to speak the truth to power. When a supervisor is using power in ways that are harmful to the functioning of the health care team as a whole, concern for clients and for the other members of the team gives us reason to think about whether the supervisor needs to be challenged. The challenge should not take the form of personal attacks or anonymous letters, obviously. As Christians we are called to be creatures of the light. Part of our responsibility as members of the kingdom of God is to be willing to speak the truth openly. At the same time, we need not do so in ways that are guaranteed to be ineffective. An obstreperous supervisor will not be restrained by one person's

complaint. But when the whole unit reports to the administration that a charge nurse is abusing her authority, the administration is more likely to take the charges seriously and to respond productively. If we believe that God created us to live in community and h armo n y with one another, consideration of relationships among professionals in the health care system is important. Previously, we discussed the concepts of embodiment and dependence related to vulnerability, openness, and responsibility. We know that clients are vulnerable, particularly in the acute care setting. But we must not forget that the members of the health team are also vulnerable human persons. When we forget this and assign vulnerability only to the clients, we run the risk of the "conceit of philanthropy" with regard to the clients, and we run the risk of dehumanizing our colleagues. Nurses, physicians, aides, technicians, and therapists all come together with different narratives, different joys and sorrows, differing perspectives on life and the meaning of life. We are all dependent upon one another in the greater sense of the world community, but also in the community of the acute care hospital. And we are all vulnerable. Nurses often state that they entered the profession of nursing because they enjoy working with people. The relationships that develop in the acute care setting are often based on necessity. The coordinated effort of many individuals is required to provide the complex, highly specialized care that is provided in the acute care setting. A group of individuals, sometimes strangers, works as a team to analyze problems, to provide interventions, and to evaluate the effectiveness of those interventions.

While we can easily identify the ways in which relationships among professionals can go wrong, we should not lose sight of the ways in which such relationships can go right. Many nurses will say that the assistance of their peers and the relationships developed with other health team members are what carry them through the difficult times. Usually, nurses support and care for one another. Respectful and caring interactions between nurses and physicians strengthen both. Likewise the gratitude and love that clients sometimes offer can be an important source of renewal for the nurse facing the rigors of the acute care field. In all of these healthy relationships we see glimpses of the proper ordering of creation. God has made us to be mutually supportive, to encourage each other to good works, and to see our interdependence as an important blessing. But interpersonal relationships are not the final determinant of the shape of acute care nursing. The nurse who chooses to specialize in some area of acute care will find that much of his or her life is structured by the institutional organization within which care is offered and by the organization of health care delivery of the country to which he or she belongs. As health care has become increasingly complex in recent years, the organizational structures that deliver health care have also become more complex, and this complexity is reflected in the nursing profession as a whole. In the next two sections we turn to the ways in which acute care nurses work within particular institutional contexts and within the broader social context of American health care delivery. Institutional Organization

The institution in which the nurse is employed determines much of what the nurse does in his or her daily client care. Nurses often raise concerns about issues such as staffing, mandatory overtime, or the practice of pulling a nurse from one area of the hospital to another, forcing him or her to practice in a context in which he or she may lack the needed education. When these concerns are raised, the administration may respond that this is the way things are and may imply that not much can be done to change things. Sometimes nurses may be given the more covert message that those who are not willing to go along should look for employment elsewhere. Historically, some institutions have had what might be called a "throwaway" mentality. If nurses are unhappy and leave, there will be others to take their place. Further, the tendency for some in administrative positions to be confused about what nurses do may contribute to an inability to see how crucial it is for a hospital to hire and retain good nursing staff. The situation has changed somewhat in recent years due to the nursing shortage. Most administrators now realize that retention of nurses is critical, something that has not previously been high on the list of priorities in hospital administration (Gelinas and Bohlen 2002; Cromer 2003). When practicing within an institution, the nurse must abide by the policies, procedures, and nursing care standards of that institution. Nurses must also meet many other standards of care. The nurse must meet professional standards of care, including the legal and ethical parameters of care defined by the State Board of Nursing and the nursing profession. Within a given institution, the nurse must meet the expectations of administrators, physicians, fellow nurses, and other health

team members. And, obviously, the nurse's priority is to meet the needs of, and advocate for, clients and their families. Christian nurses are subject to yet another standard, that of growing in Christian character and identity. Nurses who see their role, in part, as that of building shalom and integrating Christian values in the care they give may find that this aim fits better or worse with different institutions. Many Roman Catholic or other denominational hospitals articulate a clearly Christian mission statement with institutional values described from a Christian perspective (National Conference of Catholic Bishops 1995). Many other institutions are not faith-based, though they may have a mission and a set of values that are easily compatible with the Christian nurse's own values. Some hospitals are for-profit institutions whose primary mission is to make money. The priorities that drive such an institution may be in conflict with Christian nurses' personal philosophy of nursing care and with their Christian commitment. Joan Tronto analyzes the ways in which caring work tends to be allocated in organizations and in society at large. She notes that "caring about, and taking care of, are the duties of the powerful. Caregiving and carereceiving are left to the less powerful" (Tronto 1994,114). Hospital systems certainly demonstrate this division of responsibility. The roles in the organization that are most prestigious, most powerful, and best paid are those that involve the least amount of hands-on care of the clients. High pay and prestige are awarded to the organization members who have responsibility for "caring about" (identifying the institution's mission) and "taking care

of" (keeping the institution running, organizing the way care will be provided). Those who engage in the specific practices of care - nurses, technicians, and aides - receive far less authority and lower pay. The interrelationship of caring and power creates tension in the nurse's role as caregiver to clients and as a member of an institution. Nurse managers are particularly vulnerable to this tension. As middle managers they must attempt to meet the organization's needs as well as those of the staff nurses they support. Both the nurse and the administrators of the institution should aim at providing quality care to clients. But they stand in different positions when it comes to deciding how care will be given, and even whether care is the highest priority for a health care system. Because the nurse is in a less powerful position, she or he must practice and provide care, to a large extent, when and where the administration determines. When the administration's goals and values coincide with those of the nurse this can be a good situation, but when they conflict it causes serious tension for the nurse. In the most difficult cases, the conflict may become so serious that nurses feel that their license is on the line because they work in a health care environment that forces them to provide care they perceive to be substandard, putting them at risk of causing a catastrophic error (Curtin 2000; Garvis 2003). When the tension becomes too much to live with, nurses are forced to think of alternatives to working with a system that seems designed to make good care impossible. Some nurses have opted to become travel nurses. These nurses sign up for a period of time, usually about three months,

at a hospital in a desirable (and often warm!) location. If the nurse is satisfied with the hospital and the location, he or she might extend the contract. If the nurse is not satisfied, he or she can move on to another location and continue to travel. In this way the nurse is not committed to a particular unit or institution and has very little responsibility in terms of working to improve the unit environment or to participate in unit decision making. Travel nurses can remain detached from the politics of the institutional setting. From the travel nurse's perspective, he or she may be able to "throw away" the institution and move on to a more desirable one in a new location. Such an approach does little in terms of longterm solutions to the issues that nurses face in the acute care setting, however, and it is not terribly practical for nurses who are raising small children or who have a working spouse. It can be a temporary solution for some individuals, but is certainly not a longterm solution to conflicts with institutional organization. A more productive response to organizational problems would seem to be collective engagement with the organization, but historically, nurses have been poorly organized in their efforts to effect change. Many nurses say they do not wish to become involved in politics or a power struggle. They ask to be left alone, to just take care of clients. The consequences of being left alone, however, can be detrimental to clients and to the wellbeing of the nurse. The provision of quality care requires an adequate number of nurses to provide that care. If potential nursing students perceive nursing to be a career marked by short staffing, high stress, and poor compensation for difficult work, and if they hear the frustration that nurses

experience due to lack of respect, not many will wish to choose a career in nursing (Andrews 2003). Courage is being scared to death and saddling up anyway. JOHN WAYNE So some nurses have addressed problems in the organizational structure of their health care system through collective action. Collective bargaining has not been popular with nurses, however, because many think that collective bargaining always involves striking. Most nurses do not wish to force or even threaten a work stoppage, given ethical concerns about leaving clients without nursing care. When nurses do elect to strike, the issues that generate the strike are usually not low wages or limited benefits. A recent review of the literature on nursing strikes found that the most common issues that prompted nurses to strike were concerns with client care: no procedures for reporting unsafe or poor nursing care, s h o r t staffing, working in areas in which nurses were inexperienced or lacked skills, overwork, mandatory overtime assignments, and performance of non-nursing tasks. The authors cited over thirty-three issues leading to strikes, very few having to do with remuneration (Swanburg and Swanburg 2002,169-70). Nurses often cite this material to demonstrate that t h e y are not self-interested in asking for better working conditions. This does raise the question, however, of when it is appropriate to demand fair treatment. Presumably nursing

professionals should be assigned reasonable workloads and should receive reasonable compensation considering their level of expertise. Again we can see that there are connections here to both care and justice. Client care should be important, and it reflects well on nurses that they do not want to put that care at risk by striking. But it is also important for the nurse to work in an environment in which he or she may flourish as a person and as a professional. Further, the provision of good care depends, in part, on the nurse being given the needed resources and time to provide that care. Research indicates that client outcomes improve when nurses have more control and autonomy in providing care (Spellerberg 2004). If nurses wish to be professional and to be treated with respect, they must participate within the profession to improve circumstances. Every profession requires that members advocate for quality outcomes. It is part of the definition of being a professional. Christian nurses in particular may find collective bargaining contentious, especially when they think about abandoning clients and walking the picket line. After all, Christ commands us to love others as we love ourselves, and the Good Samaritan has served as the model of Christian virtue throughout the history of the church. So the question of whether Christians can allow client care to suffer in order to benefit themselves does seem a difficult issue. In the best cases, we can see how these two coincide. When nurses work under fair conditions, client care is better, too. It can be the nurses' ethical, moral, and Christian responsibility to work for justice within the institutional setting and the greater health care community as well. For Christian nurses who are answering the call to work within God's kingdom, the need to advocate for the profession

becomes more than just good professional practice. But Christian nurses do face difficult cases of discernment when it seems that the only way to bring about longterm improvement is to diminish client care in the short run. For such cases there is no simple rubric of decision making, but only prayerful consideration of all the difficult details of the situation. We may not be able to arrive at a perfectly "right" or "good" response. In this case, as in so many others, discernment may, at best, lead us to a response that is "fitting" (Niebuhr 1963). It is also worth noting that collective bargaining is not identical with striking. Collective action that does not involve withdrawing from client care is a possibility that nursing groups can and should explore. The issue of collective bargaining points to the effects of living in a world marked by sin and conflict. But we also need to see the ways in which health care systems can actively work to solve organizational problems. Some hospitals have been designated as magnet hospitals by the American Nurses' Credentialing Center. These are institutions that are able to attract and retain nurses even during times of nursing shortage, in part because they give nurses a great deal of respect and power (Spellerberg 2004). Magnet hospitals have to demonstrate that administrators facilitate professional nursing practice and positive client outcomes and that the organization's structure is decentralized, with participative management and influential nurse executives. Professional autonomy, development, and education are valued and encouraged (Scott et al. 1999; Gold smith 2003). Magnet hospitals have unit-focused care, and hierarchical structure is deemphasized. Nurses are given as much control as possible

over their own practice, and this in turn improves client outcomes (Aiken et al. 2000; Curtin 2003). Nurses might indeed consider magnet hospitals an example of shalom within a chaotic health care system. 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, t h e 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. Acute Care Nursing in Social Context 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-ofthe-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. Conclusion: "The reason I do this job" Mrs. Williams, an 82-year-old mother, grandmother, and greatgrandmother, 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 greatgrandchildren. 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 remis s ion 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." The amount of care needed to sustain Mrs. Williams kept Susan moving constantly for the next several days. She was receiving eight intravenous drips, tube feedings, suctioning, positioning and repositioning, sedation, and hygienic care, as well as needing to have her oxygen, cardiac respiratory and fluid status monitored. During the first day of care Susan spoke with Mrs. Williams, orienting her, interpreting her environment, t h e sounds of the ventilator alarming, monitors beeping, and the constant noise created in a busy critical care unit. She provided reassurance when Mrs. Williams suddenly became restless and stroked her hands and arms to let her know someone was with her. She called family members in to sit and hold her hands to provide comfort and to prevent Mrs. Williams from accidentally dislodging her airway tube or intravenous therapies. Although Mrs. Williams gave no indication of a response, Susan stimulated her as much as possible, talking with her about anything and everything: the weather, her grandchildren, recalling those who had come to look in on her. As she ran out of these topics of conversation, Susan told Mrs. Williams about her own family, her two children, the family dog, and then moved on to what was on the news. On the second day, Mrs. Williams was able to squeeze Susan's hand in response to commands. Her blood pressure

gradually rose, and it appeared that the infection was reversing. Mr. Williams was elated. Even while the nurses continued to remind him that his wife was still critically ill, he kept repeating, "praise the Lord, praise the Lord!" Later that day it appeared that Mrs. Williams was attempting to talk around her endotracheal tube. Susan offered her a pad of paper and pencil and was astounded when Mrs. Williams wrote, "How are your children today?" We can see a number of the critical components of acute care nursing in the case of Mrs. Williams. The care Susan provided was not a detached, robotic response to purely physical symptoms. Good acute care nursing requires involvement with the whole person of the client and with the client's family. This includes spiritual care. Susan rejoiced with Mr. Williams as his wife improved and echoed his joyous praise to God. Good care also comes from the whole person of the nurse. At one point, Susan had strong feelings and was unable to maintain her composure when she saw Mrs. Williams. Nurses do not have to deny their own human feelings to provide competent care. Many health care professionals are frightened of emotional communication with their clients. Clients report that physicians, especially, are cold or seem detached from their situa tion, but many other health care professions share this demeanor. Perhaps they fear that they will lose objectivity or lose sight of the client's autonomy if they identify too closely with the client's emotional situation. But some contemporary research suggests that becoming emotionally involved in client situations brings an essential depth of

informed decision making rather than a loss of objectivity. According to Jodi Halpern, for example, Empathy involves discerning aspects of a patient's emotional experiences that might otherwise go unrecognized. Empathic communication enables patients to talk about stigmatized issues that relate to their health that might otherwise never be disclosed, thus leading to a fuller understanding of patients' illness experiences, health habits, psychological needs, and social situations. As for accuracy, to the extent that emotions focus attention, training physicians to be aware of the ways their emotions determine salience can also help them notice potential blind spots and biases. Empathy supplements objective knowledge and the use of technology, and other tools for making accurate diagnoses. (Halpern 2001, 94) God asks us to bear one another's burdens and sorrows. If we seek to walk with our clients through sad and joyful circumstances, we may become emotional as we experience the situation with them. Nurses or other health team members do not have to deny their own human responses to suffering. The nurse is a whole person who experiences the joys and sorrows of others while providing care to the whole person of the client. "Interestingly, however, it is seldom inferred that a nurse herself is a `whole person', who therefore ought to be viewed holistically," one theorist notes. "Does not a nurse's physical, mental, social and spiritual functioning mean anything to her practice of patient care? Why are nursing theories and models predominantly silent about this aspect of nursing practice?" (Cusveller 1998, 266). Part of the spiritual care we mentioned earlier involves recognizing that one is affected by clients in

emotional and spiritual ways and responding to this influence rather than denying it. The acute care nurse is also the one who is constantly present at the bedside, providing support to the family on a regular basis. Many nurses have difficulty coping with numerous questions from family members. Mr. Williams, for example, was always at the bedside, where he would just stand and look at his wife. Whenever the nursing staff was attempting to complete assessment and all of Mrs. Williams's required treatments, he would try to engage the nurses in conversation. Susan sometimes found his neediness overwhelming, coming as it did in addition to the daunting job of providing care for a seriously ill client. She also knew that it was essential to respond to questions with realistic answers and not offer Mr. Williams false hope. We have discussed the concept of health as idolatry. There is another type of idolatry in acute care, a worship of the latest technology. Cost cutting comes at the expense of human interaction with clients. No one proposes that the budget for new technology be cut to permit more nursing time at the bedside. Funding new technology is a given. Advertising focuses on new technologies or treatments, and constantly escalating technology is assumed to be a fiscal necessity to attract clients. The technology is valuable. Without it Mrs. Williams would have died. But the technology is not an end in itself. It exists for the sake of good client care, and when it gets in the way of that care it needs to be set aside. In reviewing the case of Mrs. Williams, we note again that

the nurseclient relationship is a reciprocal relationship. The nurse sees Mrs. Williams as a mediator of the divine, not only because the suffering Christ can be seen in her frail body, but also because her strong and vibrant Christian faith and the legacy she is leaving her large, loving family radiate God's presence. As she improved, Mrs. Williams described her own experience as the work of God. "My Jesus brought me through. I heard all those prayers and I knew He would see me through," she told her family and the nurses. Caring for Mrs. Williams became an experience of God's grace for Susan. Mrs. Williams was able to go home and celebrate her 55th wedding anniversary. Susan knew this because Mr. Williams remained a fairly regular visitor to the unit for a while, even after his wife moved to the oncology unit, and he kept the nurses informed about the family. Before Mrs. Williams left the hospital she asked to see Susan. She was dressed in her own colorful clothing and jewelry, sitting up in a chair, looking like a "regular person," as Mr. Williams said. She lived another eight months before she succumbed to her cancer, and her family was able to have the big celebration that they had planned. Acute care nurses share joys and sorrows of the most profound kind with their clients. Their lives are marked by the opportunity to provide care in the fullest sense to the people with whom they work, and to experience the wonders and terrors of God's good creation of the human body. It is a vocation that can make its practitioners both proud and humble at the same time - proud that they can participate in the healing process and in providing comfort when healing is not possible, humble when they realize how much of human life is not under

our control but is sustained by the power of God. But always it is a profession in which the nurse needs to remain rooted in her or his faith so that strength can be drawn from the loving Creator and Sustainer of the universe.

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Index