Institute for Christian Teaching

Education Department of Seventh-day Adventists

BEYOND PROFESSIONAL CARING: TEACHING NURSING

STUDENTS THE ART OF CHRISTIAN CARING

Nancy A. Fly

School of Nursing

Loma Linda University

Prepared for the

Faith and Learning Seminar

held at

Union College

Lincoln, Nebraska

June 1993

126-93 Institute for Christian Teaching

12501 Old Columbia Pike

Silver Spring, MD 20904, USA

At the core of contemporary American nursing is "the order to care in a society that refuses to value caring" (Reverby, 1987, p.1). Historically, nurses have been viewed as caregivers in both the sense of emotional contribution and clinical expertise (Benner, 1984). During the recent nursing shortage and with anticipated changes in national health care, professional nursing has become involved in developing a theory of caring that can be practical in client interactions and teachable in schools of nursing. Caring, in its broadest sense, has become the watchword in nursing practice.

The use of the word "caring" in a professional sense can be related to "three categories: attention to or concern for the patient; responsibility for or providing for the patient; and regard, fondness, or attachment to the patient" (Chipman, 1991, p.171). Caring is "the willingness to provide support for others in times of need" (Jacono, 1993, p. 93).

Caring theory is difficult to delineate concretely. The concept is illusive and seems to defy objective investigation, though nursing researchers are continually pursuing new strategies to generate data which will demonstrate the value of caring. Caring, as it relates to nursing, is predominantly a humanistic philosophy. This philosophy has enriched the profession, and yet, the Christian nurse must ask some basic questions about its underlying presuppositions (Sire, 1990). How does Christian caring differ from purely professional caring in terms of worldview, framework for practice, and teaching methodology?

The purpose of this essay is to answer these questions as well as to examine the role of Christian nursing educators in preparing students for clinical practice grounded on Christian values of caring.

Current Nursing Theory

The practice of nursing is based on a variety of nursing theories. Though some experts argue that nursing, as a social science and caring profession, should not be restricted by a particular paradigm (Robinson, 1992), present conceptual models are seemingly best understood in the context of a fundamental nursing paradigm. These models address the interrelationships among the descriptive categories of nursing, person, health, and environment (Fitzpatrick & Whall, 1989). The concept of God is not included in this metaparadigm.

Patricia Benner and Jean Watson have developed models of caring which are currently foremost in describing the essence of professional caring. Concepts of theses theories will be compared and contrasted with each other as well as with a model for Christian caring.

Benner's model places caring as a necessary component in her theory of skill acquisition "from novice to expert" (Benner, 1984). She describes nursing as an "enabling condition of connection and concern" (Marriner-Tomey, 1989, p.192) which implies a high level of emotional involvement in the nurse-client relationship (Benner, 1989). Benner's definition of person is "a self-interpreting being, that is, the person does not come into the world predefined but gets defined in the course of living life" (Marriner-Tomey, 1989, P. 192). Health is portrayed in terms of what can be assessed by the nurse and includes wholeness as a description of well-being. Environment is explained as situation which implies social significance and the interaction of people within that situation (Benner, 1984).

Patricia Benner speaks of the "power" of caring. Her description of the caring role involves the concepts of transformative power, integrative caring, advocacy, healing power, participative/affirmative power, and problem solving (1984). She emphasizes that nursing care is more than the application of mere skill; it is relational and involves the nurse's response as a human being, first, and then secondarily, in the nursing role (1988). Benner's model seems to ascribe primarily to a naturalistic worldview (Sire, 1990).

Another nursing theorist, Jean Watson, focuses on nursing care that is humanistic and individualized (Schroeder & Maeve, 1992). Her philosophy and science of caring endorses a pantheistic view of the cosmos (Carson, 1993). Watson's theory addresses ten curative factors of nursing practice. They are:

1. Formation of a humanistic-altruistic system of values.

2. Instillation of faith-hope.

3. Cultivation of sensitivity to one's self and to others.

4. Development of a helping-trust relationship.

5. Promotion and acceptance of the expression of positive and negative feelings.

6. Systematic use of the scientific problem-solving method for decision-making.

7. Promotion of interpersonal teaching-learning.

8. Provision for a supportive, protective, or corrective mental, physical, sociocultural, and spiritual environment.

9. Assistance with the gratification of human needs.

10. Allowance for existential-phenomenological forces." (Marriner-Tomey, 1989, p. 167-168)

Watson writes of the need for a knowledge of caring which would examine the moral and ethical implications involved in human caring in nursing (Watson, 1990). She views nursing as the practice of caring in which the nurse enters into a transpersonal caring relationship with the client. This caring moment promotes and restores health as well as helps to prevent illness. Watson's idea of person contains the beliefs that human have potential for what they may become and are free to make responsible choices. The environment is an open system with internal and external variables which are at one with nature and God. (Marriner-Tomey, 1989).

Both Benner and Watson have made significant contributions which enhance the value of professional caring. They have helped to create an atmosphere within the nursing profession which values the wholeness of human beings including their psychosocial and spiritual needs. Many of their beliefs can be accepted and affirmed by Christian nurses. Yet a model of Christian caring in nursing is able to go beyond these theories by basing nursing practice on a uniquely Christian philosophy.

Christian Caring

Historically, the caring ministry of Christian professionals has been of interest to various philosophers and theologians. Their insights enhance the Christian nurses's view of the healing role. E.G. White writes that nurses "can bring a ray of hope into the lives of the defeated and disheartened. Their unselfish love, manifested in acts of disinterested kindness, will make it easier for these suffering ones to believe in the love of Christ" (1912, p. 29).

Paul Tournier, in his book The Healing of Persons, emphasizes the need for "real inner transformation" as a prerequisite to health. "The source of all reformation of life is in personal fellowship with Jesus Christ. This is why I feel that the deepest meaning of medicine is still not in 'counseling lives,' but in leading the sick to this personal encounter with Jesus Christ, so that accepting it they may discover a new quality of life, discern God's will for them, and receive the supernatural strength they need in order to obey it." (1965, p.212).

Judith Shelly (1991) in her book, Values in Conflict, states: "nursing is no longer a Christian profession. Not only are nurses themselves becoming more pluralistic, but the very foundation of nursing is shifting from its Christian roots. Nursing theories are increasingly being based on New Age or secular humanistic philosophies" (p. 63). Shelly and Fish have conceptualized an approach to spiritual care which emphasizes the need for meaning and purpose, love and relatedness, and forgiveness based on faith in Jesus Christ (Shelly & Fish, 1988).

The Catholic theologian, Henry Nouwen, has written for pastors about ministry in contemporary society. In The Wounded Healer, he speaks of principles of Christian leadership in the area of human healing. Nurses are commissioned to be leaders in caring. Thus these principles can be applied in further defining the concept of Christian caring. Nouwen's beliefs are delineated as follows:

1. "Personal concern which asks one man to give his life for his fellow man." (Nouwen, 1972, p. 71). Nouwen defines this sense of compassion as involvement in which the whole person takes risk of entering into a painful situation without thought of the possible hurt that may be experienced. "The beginning and the end of all Christian leadership is to give your life for others' (p. 72). This thought offers an alternative beyond that of mere empathy which characterizes professional caring (Montgomery, 1992).

Compassionate connectedness is often displayed nonverbally by the nurse. For example, several students during clinical lab were dealing with a variety of difficult patients in painful situations. They had learned to be professional in their caring and as non-traditional, more mature students, had related empathetically with their clients. Yet they felt they were "getting nowhere". They were all visibly touched, however, as they observed their instructor become involved with the patients. "Something you do is different," they told her, as they observed the personal concern extended to the patients. They noted that the patient's responses were warmer and more positive as well. The students had used much of the same verbal communication, but their manner was much less involved.

2. "A deep-rooted faith in the value and meaning of life, even when days look dark" (Nouwen, 1972, p. 71). This belief finds meaning in human suffering even in despair and impending death. For a man or woman with this type of faith, "every experience holds a new promise, every encounter carries a new insight, and every event brings a new message. But these promises, insights, and messages have to be discovered and made visible. A Christian leader … faces the world with eyes full of expectation, with the expertise to take away the veil that covers its hidden potential" (p. 74, 75).

Christian nurses might ask themselves – What meaning can be found by the family of an Alzheimer's victim? How can I facilitate faith for the family of a brain-damaged teen-ager or find promise in the leukemia of a four-year old?

3. "Out-going hope which always looks for tomorrow, even beyond the moment of death" (p.71). "Hope prevents us from clinging to what we have and frees us to move away from the safe place and enter unknown and fearful territory. This might sound romantic, but when a man enters with his fellow man into his fear of death and is able to wait for him right there, 'leaving the safe place' might turn out to be a very difficult act of leadership" (p.77).

Hope such as this gives the Christian nurses something very unique to offer to the dying patient. This concept is illustrated beautifully in the situation of a young mother dying of breast cancer at home. The nurse sat with the client, her husband, and three small girls in the early dawn as life ebbed away. They talked of eternity, of God's care for the future of the family, of plans for the heirloom quilts which the talented young woman had nearly finished for the girls. Then they planned the funeral and spoke of future memory parties where they would eat donuts together, just "the kind that Mommy liked." Sharing this kind of hope required involvement by the nurse as she placed her hand on the husband's shoulder and held a tiny hand while a tear slipped down her cheek.

George Akers, a Seventh-day Adventist educator, identifies behaviors in Christian teachers which form a ladder of excellence going beyond the "mere professional" (Akers, 1989, p.12). Nouwen's principle can be applied to Christian caring in nursing which also goes beyond professional caring. These levels which were described in earlier text are: First, professional caring; secondly, true personal concern or compassion; thirdly, inspiration of faith; and finally, provision of hope. Each level requires progressively more involvement with the client without thought of reward or possible personal pain.

According to Nouwen, Christian caring is service which "requires the willingness to enter into a situation, with all the human vulnerabilities a man has to share with his fellow man" (1972, p.77). So, is Christian caring then a form of codependency? This issue must be briefly addressed.

The Christian's identity is found in a relationship with Jesus Christ. This enables the caregiver to serve clients in an involved manner because of conscious choice rather than out of need or shame (John, 1991). In addition to having a sure identity, the Christian nurse experiences a type of spiritual transcendence which finds a meaning in service that is not ego-centered. He/she retains a sense of Spirit-directed connectedness with the client which is neither destructive to the nurse or the patient. Also, the Christian caregiver finds energy to cope with the stress of caring through a vital relationship with God (Montgomery, 1992).

A Christian framework of caring must include the concept of God in the person of Jesus Christ. Jesus will be seen as the Creator and Redeemer who offers restoration and forgiveness through relationship with human being. Nursing will involve an altruistic, caring relationship with clients which stresses change that will restore the image of God in persons. Persons are created to reflect the image of God with individual potential for continuous growth toward becoming all that God intended for them to be. Human beings have a free will which enables them to make responsible choices. They are also of infinite value. Health exists as a state of positive well-being involving the whole person –mental, spiritual, physical, and psychosocial. It occurs on a continuum between high level wellness and illness, and is significantly improved when the client's lifestyle becomes increasingly in harmony with God's natural laws.

Environment is a combination and internal and external realities which must interact with the individual. These realities include the unseen great controversy between good and evil as well as the possibility of eternal life in a perfect setting.

This model of nursing practice will be enhanced by the uniqueness of Christian caring which impacts every nursing interaction. Christian caring emphasizes the encouragement of a spiritual transcendence which is based on a relationship with Jesus Christ rather than existential phenomena or humanistic interchange. "And truly effective spiritual care will include humbly and gently putting a person in touch with the triune of God" (Carson, 1993, p. 55).

Caring in a Christian context will include the aspects of professional caring but it will go beyond as it inspires hope in an eternal future (at Christ's second coming), finds meaning in human suffering, offers forgiveness, "goes the second-mile," and most importantly, encourages clients to find unconditional love in Jesus.

Teaching Christian Caring

Nursing education has become more committed to instructing students in the art of caring. This movement over the past few years has also provided a helpful basis for teaching caring from a Christian perspective in schools of nursing whose mission reaches beyond secular standards of professionalism.

"Care is . . . conceptualized as values and as attitudes" (Symanski, 1990, p. 138). Nursing leaders have examined caring as a value, which must be taught in the classroom and clinical setting. They see this instruction as essential to promote caring professional behavior in the next generation of nurses (Symanski, 1990). In a series of interviews with both students and faculty within small liberal arts colleges, caring was described as "a crucial dimension" of nursing education ( Miller, Haber, & Bryne, 1990, p. 132). Caring should be the thread which runs through the nursing curriculum from beginning to end.

To educate in the area of Christian caring essentially means to teach unique values which, when internalized, will affect nursing practice. Christian caring must involve moral reasoning based on these values. "Caring outcomes in practice, research, and theory depend on the teaching of a caring ideology" (Cohen, 1993, p. 662).

A few studies have been carried out which address moral reasoning in nursing education. Further research is needed, however, to evaluate the actual outcomes of learned values in terms of performance in the practice setting after graduation. Christian caring becomes real only when it is displayed in involved, caring behaviors between the nurse and the client. Most of the current literature and evaluation tools are directed toward student attitudes rather than behavioral outcomes.

Cartwright, Davson-Galle, and Holden (1992) hypothesize that humanistic existentialism is the predominant philosophy upon which most nursing curricula is based. They suggest that moral development should be encouraged in nursing education to create graduate nurses "who can exercise personal and professional autonomy and accountability for moral decisions" (p. 228) which influences their actions in the workplace. The use of Christian values in developing a moral philosophy of nursing practice is not addressed.

In a study of 79 registered nurses, Katefian (1981) used the Watson-Glaser Critical Thinking Appraisal Test and Rest's Defining Issues Test to ascertain the relationship between critical thinking and moral reasoning. She also examined the variable of educational preparation and its effect on moral reasoning. Conclusions of this study indicated that the higher the degree of critical thinking and level of education, the more advanced the moral reasoning was inclined to be. 32.9 percent of the variance in moral judgment was attributed to education and critical thinking. Consequently, the development of critical thinking in nursing students would seem to enhance the possibility for Christian caring.

Most recently, Foster and Larson of Loma Linda University and Loveless of La Sierra University (1993) discussed strategies for helping students in the development of ethical-decision making, an integral part of Christian caring.

To begin with, the student must have certain characteristics in order to make sound ethical-decisions. These are:

1. Overall physical, mental, emotional, social and spiritual health.

2. Ability to see the perspective of another individual.

3. Skill to decide whether or not an ethical problem actually exists.

4. Vision to formulate possible responses.

5. Understanding of ethical thinking in Western culture with consideration of both "individual rights and community well-being" (p. 31).

6. Courage to evaluate and modify decisions.

Specific classroom strategies to encourage the development of these characteristics are delineated by the authors. Active learning can be encouraged through "small-group discussions, role playing, case presentations, writing assignments, and debates. Specifically, faculty promote moral reasoning by listening, asking thought-provoking questions, promoting peer-to-peer interactions, and helping students reflect on how these concepts relate to themselves" and their clients (p.32).

"Caring in nursing education is conceptualized as an evolutionary, interpersonal process between a nurse educator and a nurse student" (Sheston, 1990, p. 111). First of all, the instructor must demonstrate caring behavior toward the students. As one faculty member expressed: " 'If we don't care, how can we expect them (students) to care?' " Then as student said: " 'It's like how they (faculty) are with us is how we should be with our patients.' " (Miller, et al., 1990, p. 132).

The teacher who cares will express genuine regard and empathetic understanding for the students (Sheston, 1990). "The caring teacher is professionally competent, has genuine concern for the student as a studying person, has a positive personality, and is professionally committed" (Halldorsdottir, 1990, p. 97). Beyond this, the Christian professor of nursing will apply her inner spiritual beliefs in all interactions with students in both the classroom and clinical areas. Instructions in caring requires "interpersonal demonstration and practice" (Sheston, 1990, p. 113).

Class content in Christian caring will incorporate concepts of "therapeutic communication, appropriate use of touch, and nurse-patient relationships" (Symanski, 1990, p. 138). The theories of Benner and Watson will be heavily emphasized as they are compared and contrasted with a Christian worldview. Nouwen's principles of healing will be taught and applied in various discussions of case studies and clinical situations. Students will be asked to analyze their own values and worldview especially as these apply to the care of clients.

Gelazis (1990) makes specific mention of the need for fostering creativity in nursing students. She emphasizes the desire to educate the full person as both a left and right-brained individual. In teaching care, the instructor can incorporate the creative "use of poetry, use of humor, promotion of a sense of wonder, work with other cultural groups (such as the homeless), awareness of popular culture, and use of arts such as drama" (p.156). A Christian perspective with these activities can make them especially meaningful. As the nursing educator encourages creativity in students, she/he will also become more creative in developing new strategies to transmit caring values.

Integrating faith with learning in teaching the art of Christian caring requires unique course content combined with visionary strategies of instruction. It necessitates close interpersonal relationships with students and Christ-centered role-modeling.

Summary

Students in Christian nursing programs should find that they will become nurses whose caring goes beyond the mere professional level. They will build on existing theories of caring to include an involvement with clients which supports faith, meaning, and hope. In essence, by caring in a uniquely Christian manner, nurses will inspire their patients with the love of Christ.

References

Akers, G. (1989). The ministry of teaching. Adventist Review, 166(20), 12-13.

Anderson, S.L. (1991). Do student preceptorships affect moral reasoning? Nurse Educator, 16(3), 14-17.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley Publishing Company.

Benner P. & Wrubel, J. (1989). The primacy of caring: Stress and coping in health and illness. Menlo Park, CA: Addison-Wesley Publishing Company.

Carson, V.B. (1989). Spiritual dimensions of nursing practice. Philadelphia: W.B. Saunders.

Carson, V.B. (Winter 1993). Spirituality: Generic or Christian? Journal of Christian Nursing, pp. 24-27.

Cartwright, T., Davson-Galle, P., & Holden, R.J. (1992). Moral philosophy and nursing curricula: Indoctrination of a new breed. Journal of Nursing Education, 31, 225-228.

Chipman, Y. (1991). Caring: It's meaning and place in the practice of nursing. Journal of Nursing Education, 30, 171-175.

Cohen, J.A. (1993). Caring perspectives in nursing education: Liberation, transformation, and meaning. Journal of Advanced Nursing, 18, 621-626.

Fitzpatrick, J.J. & Whall, A.L. (1984). Conceptual models of nursing: Analysis and application. Norwalk, CT: Appleton & Lange.

Foster, P.J., Larson, D., & Loveless, E.M. (1993). Helping students learn to make ethical decisions. Holistic Nursing Practice, 7(3), 28-35.

Gelazis, R. (1990). Creative strategies for teaching care. In M. Leininger & J. Watson (Eds.), The Caring Imperative in Education (pp. 155-165). New York: National League for Nursing.

Halldorsdottir, S. (1990). The essential structure of a caring and an uncaring encounter with a teacher: The perspective if the nursing student. In M. Leininger & J. Watson (Eds.), The Caring Imperative in Education (pp. 95-108). New York: National League for Nursing.

Jacono, B.J. (1993). Caring is loving. Journal of Advanced Nursing, 18, 192-194.

John S.D. (Spring 1991). Whatever happened to caring? Journal of Christian Nursing, pp. 18-22.

Katefian, S. (1981). Critical thinking, educational preparation, and development of moral judgement among select groups of practicing nurses. Nursing Research, 30, 98-103.

Marriner-Tomey, A. (1989). Nursing theorists and their work (2nd ed.). St. Louis: C.V. Mosby.

Miller, B.K., Haber, J., & Bryne, M.W. (1990). The experience of caring in the teaching-learning process of nursing education: Student and teacher perspectives. In J. Leininger & J. Watson (Eds.), The Caring Imperative in Education (pp. 125-135). New York: National League for Nursing.

Montgomery, C.L. (1992). The spiritual connection: Nurses' perceptions of the experience of caring. In D.A. Gaut (Ed.), The Presence of Caring in Nursing (pp. 39-52). New York: National League for Nursing.

Nouwen, J.M. (1972). The Wounded Healer. New York: Doubleday.

Orlick, S., & Benner, P. (March 1988). The primacy of caring. American Journal of Nursing, pp. 318-319.

Reverby, S.M. (1987). Ordered to care: The dilemma of American nursing. Cambridge: Cambridge University Press.

Robinson, J. (1992). Problems with paradigms in a caring profession. Journal of Advanced Nursing, 17, 632-638.

Schroeder, C., & Maeve, M.K. (1992). Nursing care partnerships at the Denver Nursing Project in Human Caring: an application and extension of caring theory in practice. Advances in Nursing Science, 15(2), 25-38.

Shelly, J.A., & Fish, S. (1988). Spiritual care: The nurse's role (3nd ed.). Downer's Grove, IL: Intervarsity Press.

Shelly, J.A. & Miller, A.B. (1991). Values in conflict: Christian nursing in a changing profession. Downer's Grove, IL: Intervarsity Press.

Caring Theories of Nursing Practice

Theory

Benner

Primary of Caring

Watson

Theory of human

care

Christian Caring Model

Worldview

Humanistic

Neopantheistic

Theistic

Nursing's Metaparadigm (God)

General Spirituality

Spiritual interconnectedness. One with nature. Existential phenomena.

Mysticism.

Jesus Christ

Creator

and Redeemer.

Nursing

Nurse-client relationship-- enabling condition of connectedness.

Novice to expert.

Transpersonal

caring

interaction.

Change agent to restore the image

of God in persons.

Person

Self-interpreting.

Defined in the course of living life.

Potential. Free choice.

Connectedness with others and nature.

Free-will.

Infinite value.

Created to reflect the image of God.

Health

Assessment by nurse.

Wholeness.

Well-being.

Subjective.

Holistic.

More than the absence of illness.

Wholeness.

Continuum.

Positive well-being.

Harmony with God's natural laws.

Environment

Situation.

Implies social significance.

Interaction of persons.

Open system.

Internal and external variables.

Harmony with nature.

Internal and external realities.

Great controversy between good and evil.

Future eternal life.

Caring

Responding first as a human being.

Relational.

Integrative.

More than skill.

Ten carative factors: – include: values, hope, self sensitivity, trust, expression of feelings, problem-solving, teaching, meeting human needs.

Adds to

Benner and Watson.

Person concern and compassion.

Inspiration of faith.

Provision of hope.