Transforming Care: A Christian Vision of Nursing Practice (14 page)

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.

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 its
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 well-being
is short-sighted, 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.

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 well-being 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 often
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 and
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.

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 well-being. We know, from a
vast literature on health care outcomes, that meso-, exo-, macro-, and
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
well-being.

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 well-being. 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.

To make explicit what is implicit in our discussion of James and his care for
Rita, attentive and competent nurses, in addition to the hands-on 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 well-being: "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 on-site 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.