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The Choice of Every Nurse Every Day…an excerpt of my introduction to this new book….. June 24, 2013

Posted by mariemanthey in Creative Health Care Management, History, Inspiration, Professional Practice, Values.
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A painting is not created by a free floating hand making marks with oils on canvas. The hand belongs to an artist connecting with his or her mind, body, and spirit, not only to the process of creating a painting, but to those who will one day see the painting. The hands of the artist are not where the skill lies. Without the whole person showing up in the creation of the painting, there is no art; there is just painting.

The art of nursing can be thought of in much the same way. The nurse can show up as little more than a pair of hands doing tasks, but this is not nursing; this is just doing tasks.

The art of nursing (as is perhaps true of any art) is about connection. In the art of nursing, the nurse connects to the patient, and the nurse also connects to the profession of nursing. Advancing Professional Nursing Practice is about the art of both of those connections. It is a book in which the ANA standards are named and explained, connecting nurses to the practice and performance standards of their profession. It is also a book about Relationship-Based Care, which is a care delivery model that connects nurses to patients and families by removing barriers to the nurse-patient/family relationship and improving relationships throughout the organization.

I’m always happy for nurses who get to work in cultures that support healthy relationships throughout the organization, and I share the distress of those who work in environments that seem to be fueled by chaos and competition. It is the choice of the nurse, however, whether to show up in either environment as a whole person, fully invested in the care of patients and families; or simply as a technically competent task doer.

In 1966, the way I viewed nursing was changed forever by an article I read in the American Journal of Nursing. It was written by Sister Madeleine Clemence, and it was called “Existentialism: A Philosophy of Commitment.” The way I saw it, this learned nun, a woman far ahead of her time, was challenging me, a young nurse leader, to show up as a whole person in my work. Her article challenged me to change my own practice and to mentor others to do the same:

“Commitment can mean many things: a promise to keep, a sense of dedication that transcends all other considerations, an unswerving allegiance to a given point of view. In existentialism, commitment means even more: a willingness to live fully one’s own life, to make that life meaningful through acceptance of, rather than detachment from, all that it may hold of both joy and sorrow.”[1]

It was no accident that Sister Madeleine was talking about “acceptance of, rather than detachment from, all that life may hold” in the context of the nurse’s work. As a nurse herself, she could see that the work of the nurse is secular for all, but sacred for only those who commit themselves to making it so. As we go about the work of nursing, are we solving problems or are we entering into the mystery of what it means to be with a person who is suffering, vulnerable, and afraid? She quotes philosopher Gabriel Marcel, writing, “A mystery is a reality in which I find myself involved…whereas a problem is [merely] in front of me.”

It raises a provocative question for nurses: Am I involved with my patients, or are they merely in front of me?

Over a century-and-a-half ago, Florence Nightingale helped to make nursing an art through bringing compassion into her own practice and then writing about it so that others might see that when the basic relational needs of the patient are tended to, there is a healing that takes place whether cure is possible or not. She famously encouraged the soldiers of the Crimean War to write to their loved ones. She understood the simple human truth that connection is healing—connection with loved ones (be they near or far), connection with one’s own thoughts and feelings, connection with the realities of one’s current situation.

The compassionate focus on connection that Florence Nightingale brought to nursing is still there, but it has gotten lost in the shuffle over and over; throughout history every time there was a major change in the world of health care. Here is some historical background:

Prior to the Great Depression, private duty nursing was the main avenue of employment for the nation’s RNs. As the Depression eliminated this avenue for many, RNs returned to their home hospitals as temporary workers, often on a volunteer basis, sometimes working for their room and board. As such, they found themselves working in a highly regimented, task-based, time-focused system of care that was designed to control practice and teach student nurses. This eventually became the main avenue for employment of RNs and remained so until fairly recently.  This move from more autonomy for RNs to less autonomy is a pattern that has repeated itself throughout modern history.

After WWII, the proliferation of new hospital beds coupled with the baby boom (which greatly reduced the nursing workforce), resulted in team nursing, a delivery system designed to maximally utilize technical expertise and assistive support staff under the direction and supervision of an RN. Again, the focus was on assigning and supervising the performance of tasks, since the only person educated to provide a therapeutic relationship was nearly always consumed with supervision and the performance of tasks requiring a higher skill level than that of her staff.

The system upheaval that characterized the last 30 years of the twentieth century, which was driven by finance, technology, and regulation, resulted in most health care organizations dealing with higher patient acuity coupled with severe cost cutting, which again resulted in a focus on managing the tasks of care rather than managing therapeutic relationships. The resulting dehumanization within the care system drove a spiral of regulations and system constraints that further complicated (and continue to complicate) an already intensely complex adaptive system.

The age we live in is no different. As we deal with the myriad changes of health care reform, we’re seeing, once again, a return to task-based practice. This time, however, it feels different to me in various ways. I’m heartened by the numbers of organizations that are embracing Relationship-Based Care. The publication of See Me as a Person is another example – it addresses the need for nurses and other caregivers to be “in it” with their patients rather than merely ministering to their bodies. As the next major societal shift in health care advances, whatever it is, the profession of nursing must continue to define itself. Society trusts us to do so, and our covenant requires it.

Nurses must ask themselves some important questions: What exactly is it that must always be present in order for nursing to really be nursing? What is the actual core of nursing? What strengthens that core? And what must be present in order for that core to even exist? In short, what is the nursing imperative?

I would ask you to mount your own inquiry, and come up with your own answers. Here are mine:

The nursing imperative is a two sided coin. On one side there is the imperative to be clinically competent in both technical skills and clinical judgment. The other side is the willingness to step into being with the human being for whom the nurse is caring. In health care, people experience vulnerability at every level of their being: mental, emotional, physical, and spiritual. The privilege of nursing is having the knowledge and skill, the position and relationship, to interact with a vulnerable human being in a way that alleviates pain and increases mental, emotional, physical, and spiritual comfort. This is the privilege of nursing—the being with a vulnerable human being. If this privilege is ignored or overlooked, nursing isn’t happening. No matter what is happening in a care environment, authentic human connection with the vulnerable human beings in our care can and must happen. That, to my mind, is the nursing imperative.

It’s clear that half of the nursing imperative is that we have a mastery of the technical aspects of nursing, but the other half of the nursing imperative—and it truly is no less than half—is staying present to the vulnerability of others. This book seeks to address the dual nature of the nurse’s work, both the instrumental and relational. If you are a nurse (or about to become one), I’d ask you to keep this dual nature in mind as you read this book.

Marie Manthey, MNA, FRCN, FAAN, PhD (hon.)

March 8, 2013

[1] Clemence, M. (1966). Existentialism: A philosophy of commitment. American Journal of Nursing, 66(3), 500-5.


1. mkoloroutis - June 24, 2013

Love this! Mary

Sent from my iPad

mariemanthey - June 24, 2013


Sent from my iPhone

On Jun 24, 2013, at 11:35 AM, “Marie Manthey’s Nursing Salon”

2. Charmain Diver - June 26, 2013

What a beautifully written passage … I’m so pleased I took the time to read this today – I have been searching for some inspiration for my task based crew … That search has not been in vain. Thank you … This is heading for the staff room notice board.

mariemanthey - June 26, 2013

Thanks so much for this comment. Inspiration is so important! It is one of the surest ways to improve the work experience for both the patient and the nurse.

3. Christina Nyirati, PhD, FNP-BC - September 15, 2013

Like you, I was deeply touched when I read Sister Madeleine Clemence’s article. It had been assigned to me in 1969 as a sophomore nursing student, and became my foundational credo. Now I am using that same article to develop faculty to teach in a new BSN program. I also will use your work in our faculty development. Thank you so very much.

mariemanthey - November 12, 2013

I continue to be amazed at how much truth that little French woman wisely packed into that article. I am delighted to say my colleagues and I continue to be inspired by her wisdom. I’m delighted you are able to use our work in faculty development….as that is a leverage point for professional advancement that is often overlooked.

4. Heidi Orstad - November 19, 2014

So well said, Marie!

” On one side there is the imperative to be clinically competent in both technical skills and clinical judgment. The other side is the willingness to step into being with the human being for whom the nurse is caring.”

can think of countless relationships as a nurse (and leader) where these parallel strategies were key to the development of strong health and relationship outcomes.

One story stands out. Anne was a patient of mine for over five years as she journeyed from an independent life in her own home through assisted living to hospice. I partnered with her through her transitions, helping set up meds, home care, housing adaptations, lifeline, PT, OT, all of the details that come with case managing. Along the way, I was fortunate to be part of Anne sharing her legacy and heart to heart talks about her life, her goals for the end of her life, and what was important for her.

In all of those conversations, Anne often repeated her recollection of our first meeting, a meeting that followed a discharge to home alone at age 88. She said, “Heidi, you may not remember our first meeting but I do. I was so sick that you came to my house the first time and found a mess on the floor in my bedroom and bathroom, I was horribly sick and embarrassed but you thought nothing of it. You cleaned the mess up, you cleaned me up, you got me food and drink, and sat with me, You had people come thereafter to care for me until I was strong. You made me feel safe and unashamed and befriended me. I knew then that you were special.”


5. mariemanthey - November 21, 2014

Heidi…..your contributions to the blog….and much more importantly to nursing are truly invaluable. I treasure your contribution and your passion. Keep them coming! We are going to try to jazz up the blog and make entries more accessible…….See you at the next Salon?

Heidi Orstad - January 3, 2015

Thanks for your kind words! Will see you Jan. 8! Can’t wait. So grateful to be part of these conversations!

As I was cleaning out my desk over a nice, long, Christmas Break, I was gifted to find a set of bundled letters from a family whom I partnered with during their mother’s hospice journey. I am a nurse leader, but do miss my hands on care often times. The words in the letters from each of the children reminded me of what a gift this profession called “nursing” is to all of us (I am but one of a million!).

—“I have so much gratitude that you of pall possible people were the one to take so much responsibility and care for mother in the last several months of her life…..

…”You were so good to her, and had everything to do with her feeling comfortable…”

….”We could’t have managed mother’s last month without your kindness and care.”

–“You were a guardian angel nurse for mom. I will never forget you and have a heart full of thanks for tand love for you and the work that you do.”

Nursing….what a gift!

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