Transforming Care: A Christian Vision of Nursing Practice (28 page)

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 low-wage 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 lice-infested
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.

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 life-threatening 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 life-threatening complications were 19 percent lower in hospitals
where baccalaureate nursing graduates (BSNs) comprised 6o percent of
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 well-being 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.

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 life-threatening 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).