Transforming Care: A Christian Vision of Nursing Practice (31 page)

If we believe that God created us to live in community and harmony
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.

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. Care-giving 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 care-giver 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 long-term 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, short
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 they
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 long-term 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 (Spel-
lerberg 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.