Marie Manthey’s Nursing Salon

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

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