Transforming Care: A Christian Vision of Nursing Practice (15 page)

James surely needs to be competent in delivering hands-on 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.

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 wheelchair-bound, 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 structure
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 care-giving 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 well-being - 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.

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 well-being 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 Christian
nurses. Effective nurses are competent in the hands-on 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.