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Biblical CARING Comes Full Circle: Identifying what constitutes caring in the 21st century remains imperative to defining nursing.

TRAFECANTY, LISA

Journal of Christian Nursing: July 2006 - Volume 23 - Issue 3 - p 6–11
What Distinguishes Christian Caring?
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In nursing, caring evolved from being based on Christ's command to care for the needy, to science-based to holistic caring. What is biblical caring today?

Lisa Trafecanty, BSN, RN, is anticipating completing her graduate studies (MSN, FNP) at UCLA in June 2006. She has nursing experience in telemetry and on a step-down unit. She has witnessed firsthand how postmodern thinking influences caring. Lisa is involved at Calvary Chapel at the L.A. International Airport.

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As a profession, nursing has always been characterized by caring. Caring is considered the central concept of nursing—it's what we do. Some say it's what nursing is. But caring, like many aspects of nursing, has gone through significant changes since our historical beginnings. Consider these nurses' ideas of caring and ask yourself, What is caring?

  • Knowing Mrs. Riley is fighting a losing battle with recurrent breast cancer, Joyce believes the most important caring she can do for her patient is to be emotionally present and available.
  • As Sue cares for seventy-three-year-old Mrs. Swain, she knows caring means doing for her patient what she cannot do for herself.
  • Jean takes great satisfaction in knowing the caring she does for her patients influences the eternal now, that because everything is connected on some level, her simple acts of caring impact universal energy and make a difference in the world.

Is “caring” how we relate to our patients or is it what we do for our patients? Does caring for a patient have universal consequences? Is caring all of these? Although such questions may seem like academic hair-splitting, nurses are being bombarded with ideas about caring. A central question for Christians is, do these caring perspectives coincide or collide with a biblical Christian perspective, or has the concept of care been hijacked by postmodern philosophy?

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ROOTS OF CARING

A place to begin understanding different caring perspectives is to ask, how did we get where we are today? Nursing traces its caring roots back to the idea of a mother nursing her child, but began its formal roots through Christianity. Nursing grew out of a call to fulfill God's command to love one another and minister to the needy and outcast of society (Mt 25:31-46; Heb 13:1-3;Jas 1:27). The deaconess Phoebe often is recognized as the first public health nurse (Rom 16:1-2). As Christianity grew, organized groups of deaconesses cared for the sick. By the 4th century, churches began to establish hospitals. In these early centuries, caring was following Christ's example and living out his command to love and care for others.1

During the Middle Ages (5th century), organized nursing groups evolved into Catholic religious orders, but around the 14th century, the Renaissance began a time of religious upheaval. During the Protestant Reformation (16th century), countries dominated by Protestants disbanded Catholic nursing orders. Nursing as a vocation survived through establishment of a few religious orders, but for the most part it was disorganized and corrupt. During that time nursing care often was provided by women who were uncaring, immoral and even alcoholic and prostitutes.2 This period is considered the pre-modern or early modern era.

The Age of Reason or Enlightenment occurred between the 17th and 19th centuries. Modernism, characterized by revolutions in science, politics and industry, correlates with the Age o Reason. This period emphasized rationality and superiority of the mind over emotion. Revolutions occurred throughout Europe, Russia and America; utilitarianism and individualism were born. Women began to assert their equality. Growing frustration between the Catholic and Protestant churches reflected upon the image of God. The acquisition of knowledge and supremacy of human reason led people to believe they could understand, and therefore control, the workings of nature and the universe; they assumed that God was no longer needed. Scientific discovery focused on disease process, infection and treatments. In Western medicine, the human body became understood as “the physiological mechanical body composed of organ systems, tissues, cells and biochemistry.”3 In this world-view caring was characterized as an irrational act in growing opposition to the more rational, science-based professionalism.4

The Christian church eventually revived formal nursing when Catholics formed the Sisters of Charity and the Sisters of Mercy, and Protestants established the Kaiserswerth Institute, through which Florence Nightingale (1820–1910) trained. Nightingale placed importance on environmental stimulation, such as fresh air and hygiene, and emphasized the need for formal nursing education.5 Western medicine began to develop hospitals and schools of nursing in accordance with the rationalist, scientific philosophy. As the 20th century began, conflict between Christianity and the modern worldview erupted into the world of nursing, sparking a separation between Christian nursing (as a ministry of the church) and professional nursing (those who worked in secular employment for a salary).6

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Postmodernism is the term for the present generations who have come out of the age of modernism, which ended around 1950. With Postmodernism, everything became “historically situated.” Ideas now are suspect because everything is subjective. Truth is relative, meaning what is true for you, constructed out of your own experiences and realities. In postmodern relativism, Christianity does not have universal truth and should not impress its world-view on others. Religion has become a vehicle for enhancing an individual's spirituality and may be good for you, but may not be for another, yet we should be tolerant of all.

Nursing became concerned with “redefining itself” around the 1960s, centering its function at the “interpersonal level. “This evolved into giving holistic care, recognizing people as individuals with specific wants and needs.7 Holistic care requires the nurse to go beyond the modern worldview of the separation of mind and body to incorporate postmodern ideas such as the client's culture and beliefs. Efforts in the postmodern nursing environment are to unite the science from the modern age with the art of caring.8

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POSTMODERN CARING

Identifying what constitutes caring in the 21st century is necessary to define nursing. Unfortunately, no single definition is accepted because in accordance with relativism, care is different from one individual to another. Obviously, care includes technological aspects and physically providing for a patient what he/she cannot provide for him/herself (modern era, hands-on approach). Postmodern caring entails looking holistically at the patient, including social, psychological and spiritual aspects, combining science with other forms of “care.” Postmodern nurse theorist and philosopher Jean Watson, explains: “An expanding worldview is upon us, whereby we must treat ethical, philosophical, non-measurable aspects of our work, such as values, deep beliefs, intentions, and the caring consciousness, which informs our humanity, with the same attention we have given to physical disease, hospital-medical oriented tasks, and institutional demands in the past.”9

But caring in postmodern nursing goes beyond caring for the “whole” patient. In Caring Science, Watson explains, “Caring forces us as individuals and professionals to face our relation of infinite responsibility of Belonging to other human beings as well as to a unitary field of all-our-relations. Such an orientation becomes non-dualistic, relational and unified, wherein there is a connectedness of all.”10 Caring is now a metaphysical event that impacts humanity and the universe. Bodies are “manifestations of universal energy” and caring is transpersonal, that is, it transcends time, space and the physical realm, grounded in the “eternal now.”11

It is important for Christian nurses to note that the postmodern, holistic view of caring involves more than integrated bio-psycho-social-spiritual care. The holistic perspective, additionally entails a “nonlocal” space-time and matter-energy view of persons and healing. The mind is not localized to any particular point in space (i.e., your brain or body) or time (the present moment or even your lifetime). We are now “unbounded” and infinite in space and time, being omnipresent (present everywhere at the same time), eternal and ultimately, “unitary or one.” According to postmodern nursing theorists, persons are unbounded and infinite in space/time and matter/energy because we exist as manifestations of universal energy. In this view, healing can be “rational” (medication, surgery, counseling) or “paradoxical” (placebo effects, prayer, miracles).12

While the Bible teaches and Christianity embraces rational and paradoxical healing, the source and power of healing, of life itself, is God, not human beings. God is the one who is omnipresent and eternal; God is the one who is omnipotent (all powerful). Rather than God being the created world (i.e., created “things” literally are god), God made and sustains creation, both what is seen and unseen.13 People can have a personal relationship with God because of Jesus Christ. In fact, God himself dwells within true believers in the person of the Holy Spirit.14 But God is the one who is not bound by space-time and energy-matter, not people. A critical difference between holistic and Christian perspectives is, Who or what is God–some universal energy or the God of the Bible? And, who gets to be God–God Almighty or us human beings?

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@ a glance

  • Caring in nursinghas Christian roots that grew out of Christ's call to care.
  • Caring modifiedwith evolving worldviews:
    • Premodern - to 16th century, church-based nursing
    • Modern - 17th–20th centuries, rationalism, science, physical care
    • Postmodern - late 20th–21st century, relativism, holistic care
  • Biblical caringis a response of faith to God's grace
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CAN CARING BE MAINTAINED?

Another challenge to caring in a postmodern society is that patients demand “genuine concern” from the nurse. This entails emotional involvement, which isn't always neat or safe and cannot be easily controlled by the mind.15 In analyzing the well-known work of nurse-theorist Hildegard Peplau, biomedical ethicist Chris Gastmans states that the aim of caring described by Peplau “cannot be a merely neutral, technical matter, which might be evaluated in terms of efficiency alone. The provision of care arises in a particular context, specifically in the relationship between the nurse and patient.… Therefore, empathy as a receptive, intuitive approach is a vital aspect of ‘caring involvement’ in the nurse-patient relationship.”16 Noted nurse and philosopher Patricia Benner argues that nurses are not fully able to “perceive,” “assess” and “know” their patient and his/her needs if the nurse does not experience emotion in the “care” of a patient. Emotions, in turn, shape “rational thought and knowing,”17 and moral agency of the nurse.18 All of these experts point to the critical importance of authentic emotional involvement as a key element of nurse caring.

But how do nurses maintain emotional sensitivity and caring attitudes? It has been argued that nurses cannot conjure up the “feelings” asked for in a caring relationship, that this type of care involves “emotional attachment” that can be dangerous for a nurse. Furthermore, health care literature abounds with accusations of inferior caring. Watson argues that nursing still relies on the modern era scientific view of health care and has forgotten its “humanity.”19 Others agree with her. Prominent nurse leader Luther Christ-man describes studies reporting that even though “tender loving care” is emphasized in nursing literature, patients and other staff say they do not experience or observe it in nurses. Christman concludes that although “care” that involves emotions of compassion and love in the envelope of genuine concern is an idea backed by nurses, it is not being put into practice.20 Even lay publications such as Reader's Digest and Newsweek report that while caring is a highly beneficial characteristic of nursing, it is often missing.21

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An article in the British Medical Journal, “Doctors Have Become More Caring Than Nurses,” illustrates the difference between “ideal” and real-world caring. The author, a nurse manager who had been hospitalized, writes, “As a patient, I looked to nurses to make me comfortable and to restore my independence. I believed that they would help maintain my hygiene, tend to my nutritional needs, and keep me free from pain. Sadly, all this was lacking. On the other hand, my cannula was well positioned and my antibiotics were given intraveneously with great regularity, and my cardiac monitor was interrogated and monitored regularly. But caring seemed to be viewed as subordinate or perhaps it was not seen as important at all.” She concludes, “We (nursing) seem to have lost fundamental values, in particular a concern for patients.”22

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GODLY CARING

The Christian nurse finds him/herself in the midst of this mesh of modernism, postmodernism and the huge demands of real-world practice. The Christian perspective agrees with modernism and science-based care (after all, science is the study of God's handiwork!), and holistic, integrated care for the whole person as modeled by Jesus. Christianity also affirms the reality of an unseen, spiritual world that science cannot explain.23 But modern and postmodern philosophies conflict with the theological core of Christianity in the area of absolute, unchanging truth. Christianity may have changed its theological presence in society, but the core beliefs as described in the Bible have not changed for thousands of years. The challenge to the Christian nurse is to be more like Christ, to be the active presence of the absolute truth of Jesus Christ in society and to continue in the command to love one another, even our enemies, as Jesus Christ loves us (Lk 6:27-36). How, then, can a Christian nurse care?

The Bible provides the best place to examine and understand caring. Scripture teaches that we are made in the image of God (Gen 1:26). As beings made in God's image, we have aspects of God's caring nature imprinted within us. Thus we are capable of caring in ways like God cares. But Scripture also teaches we have an inherent tendency toward wrong, known as a “sin nature” (Gal 5:19-26;Tit 3:3-7). We naturally turn away from God (Is 53:6; Rom 3:23), and fail to do what is right (Rom 3:10-18,23). A beginning mindset for caring in a way that is both comprehensive and enduring, is to realize we need God's help. This is in contrast to secular theories of caring that state nurses are always caring by virtue of our humanness; that we naturally live out caring moment-to-moment as we exist, 24 or that we care because we are naturally moral, feeling, therapeutic individuals.25

We need to consider that God's ways are higher than our ways (Is 55:8-9), that he is wise and knows how to care when we don't, or feel we cannot care. We can look at how God cares to understand consistent, quality caring. His caring is loving, compassionate, empathetic, patient, forgiving, generous, persistent, powerful and limitless. As Christian nurses we have this primary, unchanging source of caring within us–the Holy Spirit (Rom 5:5; 1 Cor 2:12). The Bible shows us that while we struggle with a sin nature, the Christian has the potential to be controlled and empowered by the Spirit of God (Rom 8:9). The biblical references in table one are only a fraction of the Scriptures that reveal the nature of God's caring and the ways he empowers caring in his people.

Table 1

Table 1

Summarizing the idea of biblical caring, Christian nursing theorists Judy Shelly and Arlene Miller explain that caring is a response of faith. We can care because God cares for us and lives within us. Shelly and Miller write, “Caring is … not just an emotional tug, an intellectual concept or a metaphysical event. It is hands-on, patient-centered, physical, psychosocial and spiritual intervention to meet the needs of a patient regardless of how the nurse feels. … Caring is an act of faith, for it involves the risk of opening ourselves to another who may not want to care or be cared for.”26 This definition of care is an outpouring of love in response to God's grace to us and his command through Jesus Christ to us. Like the Good Samaritan, Shelly and Miller point out, we must “compassionately care for anyone in need, regardless of ethnic identity, race, gender, age, status, diagnosis or ability to pay (Is 61:1-3; Mt 25:35-36; Lk 4:18-19,16:19-25; Gal 3:28).”27

How does godly caring happen? For Christian nurses, caring can begin with acknowledging God and who he is. Because we have a personal relationship with God, he can empower us to care more like he cares. Our caring does not have to be dependent on how we feel, who we are caring for, or our job situation; godly caring is dependent on God himself, the unchanging one who never leaves us or forsakes us (Deut 31:6-8;Heb 13:5-6). We care for others out of a sense of gratitude for what God has done for us. And because our lives are to be about bringing glory to God, the purpose of our caring becomes glorifying him. Table two outlines these core components of godly caring, derived from Shelly and Miller's work.

Table 2

Table 2

Christian nurses represent God, his saving power and his love for humanity. We are called to a ministry of reconciling people to God (2 Cor 5:11-21). Not only do we have an opportunity to spread the absolute love of Jesus Christ to our patients and coworkers who are searching for spiritual fulfillment, but we have the opportunity to help restore nursing to its core values. How can we do this? Shelly and Miller offer the answer in their definition of Christian nursing: “Christian nursing is a ministry of compassionate care for the whole person, in response to God's grace toward a sinful world, which aims to foster optimum health (shalom) and bring comfort in suffering and death, for anyone in need.”28

Caring as a Christian nurse requires much from us, but Jesus Christ promises to be with us and give us the strength to go on (Phil 4:13). Historically, caring in nursing began as a call to live out Christ's command to love and care for others as we would treat Jesus Christ himself (Mk 12:29-31; Lk 6:27-36). Sadly, nursing lost its Christian foundation for care with the evolution of modernism and postmodernism. However, the call of the Christian nurse remains the same: caring in Christ's love.

1 Judith Allen Shelly and Arlene B. Miller, “Caring and the Christian Story,” in Called to Care: A Christian World-view of Nursing, 2nd ed. (Downers Grove, IL: InterVarsity Press, 2006): 13–26.
3 Patricia Benner, “The Roles of Embodiment, Emotion and Lifeworld for Rationality and Agency in Nursing Practice,” Nursing Philosophy 1, no. 1 (July 2000): 6.
4 Joakim Ohlen and Kerstin Segesten, “The Professional Identity of the Nurse: Concept Analysis and Development,” Journal of Advanced Nursing 28, no. 4 (October 1998): 720–27.
5 Benner.
6 Shelly and Miller, 21.
7 Philip Lister, “The Art of Nursing in a ‘Postmodern’ Context,” Journal of Advanced Nursing 25, no. 1 (Jan 1997): 38–44.
    8 American Nurses Association, “What Is Nursing?” Accessed February 8, 2006, at
    9 Jean Watson, “Nursing: Seeking Its Source and Survival,” ICUs and Nursing Web Journal 9 (January-March 2002): 2. Accessed February 17,2006, at
    10 Jean Watson, Caring Science as Sacred Science (Philadelphia: F.A. Davis, 2005): 63.
    11 Ibid.,6–9.
    12 Ibid.; Barbara Montgomery Dossey, Lynn Keegan and Cathie E. Guzzetta, “Holistic Nursing Practice” in Holistic Nursing: A Handbook for Practice, 4th ed. (Boston: Jones and Bartlett, 2005): 5–30.
    13 See Gen 1:1;Jn 1:1-4; Col 1:16-18; 2 Cor 4:18; Eph 6:12.
    14 See Jn 14:6; Col 1:19-20; 1 Cor 1:20-21, 6:19; and Eph 1:13.
    15 David B. Morris, “How to Speak Postmodern: Medicine, Illness, and Cultural Change,” Hastings Center Report 30 (Nov-Dec 2000): 7–16.
    16 Chris Gastmans, “Interpersonal Relations in Nursing: A Philosophical-Ethical Analysis of the Work of Hildegard E. Peplau,” Journal of Advanced Nursing 28, no. 6 (December 1998): 1312–19.
    17 Benner.
    18 P. Anne Scott, “Emotion, Moral Perception, and Nursing Practice.” Nursing Philosophy 1, no. 2 (October 2000): 123–33.
    19 Watson, “Nursing: Seeking Its Source,” p. 4.
    20 Luther Christman, “Who Is a Nurse?” Journal of Nursing Scholarship 30, no. 2 (April 1998): 211–14.
    21 Sarah Glazer, “Postmodern Nursing,” Public Interest 140 (Summer 2000): 3–16;John Pekkanen, “Condition: Critical,” Reader's Digest (September 2003): 84–93; Paul Duke, “If ER Nurses Crash, Will Patients Follow?” Newsweek (February 2,2004): 12.
    22 M. Fletcher, “Doctors Have Become More Caring Than Nurses,” British Medical Journal 320 (April 15,2000): 1083.
    23 Shelly and Miller, “A Christian Worldview for Nursing,” in Called to Care: 42–71.
    24 Anne Boykin and Savina Schoenhofer, Nursing as Caring: A Model for Transforming Practice (Boston: Jones and Bartlett; New York: National League for Nursing, 2001).
    25 Janice Morse, Joan Bottorf, Wendy Neander and Shirley Solberg, “Comparative Analysis of Conceptualizations and Theories of Caring,” Image (Summer 1991): 119–26.
    26 Shelly and Miller, 250.
    27 Ibid.,68.
    28 Ibid.,244.
    Copyright © 2006 InterVarsity Christian Fellowship