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Evangelism in Patient Care

An Ethical Analysis

Fowler, Marsha D.

doi: 10.1097/CNJ.0000000000000622
Feature: practice/education
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ABSTRACT: Evangelism has been present in modern nursing care from the days of Nightingale in the Crimea. Even so, there is little in the way of ethical analysis and guidance regarding evangelism in healthcare. This article examines Nightingale's concern about evangelism in nursing care; discusses the boundaries established by the 2015 American Nurses Association Code of Ethics for Nurses with Interpretive Statements; and analyzes ethical issues including vocation, power, vulnerability and voluntariness, religious diversity, spiritual care, harm, and the Great Commission. Within the context of ethical analysis, broad guidelines are provided for nurses in clinical practice.

Marsha D. Fowler, PhD, MDiv, MS, RN, FAAN, FRSA, is professor of Ethics and Spirituality, Azusa Pacific University, Azusa, California. She is past-chair of the ANA Ethics Committee and is a member of the Expert Panel on ethics, American Academy of Nursing. Dr. Fowler served as Historian and Code Scholar, and colead writer for the revision of the ANA Code of Ethics with Interpretive Statements, 2015. She authored Guide to the Code of Ethics: Development, Interpretation, and Application (ANA, 2015), and edited Religion, Religious Ethics and Nursing (Springer).

The author declares no conflict of interest.

Accepted by peer-review 07/09/2018.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of the article at journalofchristiannursing.com.

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The day after I was asked to be a speaker at a nursing conference on evangelism, I headed for the gym to do cardio. I paused at the railing on the second floor, waiting to go to an insane boot camp. A tall, slender woman was standing at the railing with her foot atop it, arm extended and arcing, as in ballet barré style. I casually nodded to acknowledge her presence. Out of the blue she asked me, “Are you a follower of Jesus?” I was startled. I had never before seen or met her. Irritated, I decided not to be confrontational, so I nodded, shrugged, and said, “I am a Presbyterian minister,” to which she responded, “But are you a follower of Jesus?” Now I found her inquiry intrusive, offensive, and utterly without license. But it got me to thinking about a topic I do not often dwell on—proselytizing. For reasons that will be elucidated shortly, I actually prefer to use the term evangelism. I do, however, use the terms mostly interchangeably.

I have spent a number of years working on the world stage and see evangelism function at several levels—those of international efforts, disciplinary focus, and individual interaction. This article focuses primarily on individual interaction. Please note that these comments pertain explicitly to evangelism and not to missions generally.

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NIGHTINGALE, NURSING, AND EVANGELISM

Florence Nightingale, the patron saint and progenitor of modern nursing in the English-speaking world, was a devout Christian in the Anglican (Church of England) tradition. A large body of her writings displays a deep and steadfast interest in theology and in the Bible; a personal devotion to God, prayer, Scripture, and service to God in the world; a difficult relationship with her church, due, in part, to her heterodox theology; and a personal embrace of nursing as a form of Christian ministry. She lived out her Christian faith in service to God both through her own personal call by God to nursing and her belief in nursing as a high calling in itself.

In developing a model for nursing education, Nightingale demanded a rigorous education for the women who would become nurses, even though she, surprisingly, sought a thoroughly secularized (and scientized) nursing education. Three principal reasons seem to account for this.

The first was her general disillusionment with Roman Catholic religious nursing orders, as well as the fact that, pragmatically, the English Anglican religious orders for women never really caught on. Second, Nightingale loathed what she termed “saving souls” in the practice of nursing. It was not proselytizing per se that offended her, but that nursing was made subservient to proselytizing, or even neglected altogether. Nurse historian Lynn Macdonald (2002) writes:

The exacting workload, character, and devotion long required of the nurse go back to Nightingale's conceptualization of nursing as a religious calling, a calling to patient care and health promotion. She abhorred nurses acting as missionaries to save the souls of the sick or dying, which prompted her to insist that her training school for nurses be non-sectarian. Crimea had given her too much experience of people neglecting their nursing duties to gain another convert to their denomination. (p. 74)

Third, Nightingale wanted to accept students into her nursing school irrespective of their religious commitment or tradition, and with no religious test. Even so, though the school was to be nonsectarian, it was nevertheless Christian in its milieu (Fowler, 2011, pp. 12-15).

There is a subtle distinction about calling to be noted: nursing is not, itself, a calling. The call resides within the person, not nursing. If (and only if) one is called to nursing, is nursing a spiritual exercise. There can be a general assumption that Christians who choose nursing and become nurses are in fact calledto nursing. Even so, nursing, in its care for others, is an intrinsically worthy occupation. Nursing ought not to be little more than a vehicle for evangelism, and yet I have seen nurses who have little commitment to the profession (in violation of the Code of Ethics for Nurses), for whom nursing is an instrumental value, solely as a vehicle for evangelism. Other fields also wrestle with this issue, such as TESOL (Teachers of English to Speakers of Other Languages). Some are called to be teachers, some preachers, some evangelists, some prophets, and some nurses. The test of a calling is threefold: it serves God's glory, our joy, and our neighbor's good. Those who are called as evangelists need to be true to their calling and not devalue the calling of nursing by using it as a means to other ends.

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EVANGELISM IN PATIENT CARE: ETHICAL ANALYSIS

In an ethical analysis of evangelism in patient care, it is easiest to begin with the conclusion, then move to its argument. The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (Code) from 2001 is the first among successive revisions of the Code to address sharing the nurse's personal opinion with patients:

In situations where the patient requests a personal opinion from the nurse, the nurse is generally free to express an informed personal opinion as long as this preserves the voluntariness of the patient and maintains appropriate professional and moral boundaries. It is essential to be aware of the potential for undue influence attached to the nurse's professional role. Assisting patients to clarify their own values in reaching informed decisions may be helpful in avoiding unintended persuasion. (Provision 5.3)

This revision went through a committee process, and the original word coercion was changed to persuasion. However, I believe coercion is actually the proper word here, as persuasion implies an argument, whereas coercion implies a power dynamic. The current 2015 Code reiterates this:

When nurses are asked for a personal opinion, they are generally free to express an informed personal opinion as long as this maintains appropriate professional and moral boundaries and preserves the voluntariness or free will of the patient. Nurses must be aware of the potential for undue influence attached to their professional role. Nurses assist others to clarify values in reaching informed decisions, always avoiding coercion, manipulation, and unintended influence. (p. 20)

This is the portion of the Code that relates to evangelism, as evangelism is seen to arise from the “personal opinion” of the nurse. This particular part of the interpretive statement is found under provision five, which deals with “duties to self.” The provision states: “The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth” (ANA, 2015, p. 23). Section 5.3 is on “wholeness of character.” (In the interest of full disclosure, I was instrumental in the inclusion of this material in the Code in the 2001 and 2015 revisions.)

The nature of the nurse–patient relationship has undergone significant change over the 150 years of modern nursing, both because relationships have changed in society, and the standing of nursing has changed, as has the social location of women (remembering that nursing is a female-predominant profession). This section of the Code is intended to allow the nurse to be a whole person, to allow the nurse to respond with integrity to patient questions such as, “Do you have a faith?” It is a false dichotomy that separates professional and personal life. If one is a Christian, or Buddhist, or naturalist in private life, one remains a Christian, Buddhist, or naturalist in professional life, even when the metaphysics of that perspective might be transparent by being couched in secular terms. So, the nurse, in today's healthcare world, needs to be free to come to the patient as she or he is—as a whole person. This section of the Code also permits the nurse to go further, if the patient invites the nurse to express the nature or content of her or his religious belief. What the section specifically does not permit is a general evangelistic intent in nurse–patient relationships. So, the question is why or why not may nurses engage in evangelism in care of patients?

Power Differential: Modern organized nursing in the United States began during the Civil War. Nursing was started by largely upper crust, philanthropic, socialites who—not unlike Nightingale in the Crimea—wished to stem the tide of deaths in military hospitals by bringing in nurses to care for the wounded. However, these wealthy women were not nurses, never wanted nor intended to be nurses, and had no identity in nursing—they simply wanted to place nurses on the battlefield. To do so, they ceded all authority to the military men and placed nurses in what became an exceptionally subservient role, devoid of power or authority, even over nursing practice itself (Sheahan, 1979, pp. 92-94). As nursing moved into modern schools of nursing in the 1870s (on a modified Nightingale model), early nursing largely took place in the patient's home, where nursing, for some years, struggled to differentiate itself from “domestic help” (Robb, 1900). Nursing did not move completely into hospitals until after WWII. It also was after WWII that nursing began to move fully into higher education, into the conduct of research, into differentiation from medicine, and into the status of a profession in its own right (ANA, 1965).

This historical note is important to understanding that as the social location of women and nursing changed, the nature of the authority of the nurse changed and grew to the degree that the nurse today is in a power position in the nurse–patient relationship. This is somewhat similar to the power relationship, or more specifically the power differential, that exists between teacher and student, pastor and parishioner, physician and patient, warden and prisoner, or with any other status individual. By analogy, coercion by the scalpel may be more subtle than conversion by the sword, but it, too, is morally illicit. Picture, if you will, the infamous Gregory House of television fame in the series House on Fox Television Network from 2004 to 2012, a physician who had no redeeming attributes, but who was a brilliant diagnostician. He was abusive, coercive, interpersonally violent, and his behavior morally repugnant. Why would anyone ever accept him as their physician, much less employ him? Because his diagnostic acumen gave him unparalleled power over patients, and people accepted abuse and more from him in hope of a cure.

Power differentials can be dangerous. The paradigm issue for power differentials, addressed by a number of professions in their ethics policies, is that of the more powerful person engaging in inappropriate sexual relationships with the less powerful person—where professional boundaries are violated. It should be asked whether evangelizing patients fits a similar power-differential violation of professional boundaries. Today, as nursing authority and power have grown, the nurse–patient relationship is intrinsically persuasive, and it intrinsically risks becoming unduly influential or coercive, providing opportunities to violate professional boundaries, particularly in the face of the existential anxiety that health crises can produce.

Vulnerability & Voluntariness: A second issue is that of patient vulnerability and voluntariness. Disease, trauma, injury, and disability lock patients into a healthcare system, often with professionals not of their own choosing, under conditions that may be threatening to life, limb, or aspiration. Patients are subject to internal constraints to voluntariness such as anxiety, pain, chemical imbalances, sepsis, suffering, and the like. In addition, the very nature and threat of health crises make patients particularly subject to external constraints to voluntariness, including pressure, undue influence, coercion (fraud, deceit), and the like. Although the emphasis here is on healthcare professionals, sometimes the perpetrators are family members. Sometimes coercion derives from a constrained view of what is a legitimate expression of Christianity, as in the case where the lone evangelical member of a Roman Catholic family pressured her father for a death bed conversion. Although internal and external constraints do not necessarily render a patient nonvoluntary, they do constrain voluntariness and can do so to the degree that the patient makes a decision inconsistent with, or perhaps even against, her or his wishes or values.

Awaiting an Invitation: Nurses must tread the fence rail between persuasion and undue influence and, even further, coercion. That is accomplished through a third consideration: awaiting a patient's invitation or a free expression of openness. One needs an authentic patient invitation or expression of openness—not one that is manufactured. The best way to arrive at that free invitation or to openness is for the nurse to model Christ, that is, to be the face of Christ to the patient. Doing so is a part of the nurse–patient relationship, a part of the process of growth in Christlikeness, in dying to self and rising again with Christ, and in growing in integration so that all aspects of life, including one's professional role, are permeated by faith and become a way of being in the world (i.e., Exodus 34:29-35; Matthew 17:1-9; Mark 9:2-8; Luke 9:28-36; 2 Peter 1:16-18).

The next question then must be, “What is it that is shared?” Caring, succor, blessing, nurture, warmth, in short, relationship—relationship—relationship, not judgment. It is to speak from the core of a relationship of love and joy with God-in-Christ. This of course alludes to the issue of motivation for evangelism. The woman in the gym was evangelizing out of a sense of command-and-response, of obligation or duty, not out of any personal or relational connection.

Nurses seek patients' health in a whole-person sense, in the sense of shalom, which means totality or completeness. The concept shalom (or salam) is often poorly translated as peace in English; it has a far richer and more capacious understanding than this. Shalom

...is one of the most significant theological terms in Scripture, [having] a wide semantic range stressing various nuances of its basic meaning: totality or completeness. These meanings include fulfillment, completion, maturity, soundness, wholeness (both individual and communal), community, harmony, tranquility, security, well-being, welfare, friendship, agreement, success, prosperity. (Youngblood, 1986, p. 732)

Here, the totality or completeness sought for the patient is relational in nature and is to be found on the patient's terms, not the nurse's. If the patient expresses an openness and an invitation, nurses may share what faith is for them—not what they think the patient needs as faith. So, what the nurse discloses is something of her or himself, in a way that the patient is free to pursue further discussion, or not. It is an offering of the nurse's own self, and with the aid of the Holy Spirit, it is a seed planted.

Theologian David Dorman (Dorman, 2019) has focused his recent theological research on human neediness in the theology of Karl Barth, who was viewed as one of the greatest Protestant theologians of the 20th century. Although Barth did not focus on evangelism itself, the issue of evangelism arises directly from any concern for human neediness. Dorman's research on Barth is groundbreaking and a critical read to understand ethical evangelism in a healthcare context. His companion piece to this article, A Theology of Neediness and Evangelism (2019), discusses Barth's perspective on human neediness. It is helpful in understanding evangelism in a healthcare context. Furthermore, the categories of blessed neediness and wretched neediness, that Dorman explicates from Barth's theology, provide a nuanced and spacious basis for a theology of nursing.

Waiting upon God: Note how much Dorman's exposition of neediness and evangelism stands in dramatic contrast to evangelism that can be seen in healthcare contexts. Too often it is, “I know what you need, and here is the solution,” rather than a more authentic, “I came to know my own neediness, and here is how it became wholeness for me.”

At times, evangelism that occurs in healthcare actually fails to trust God. One must trust God to do God's own work of salvation. Few decisions of such great moment are made on the spot. Sometimes one plants the seed and others, with God's aid, bring the seed to fruition. Pressuring patients may serve to inoculate them against further openness. Evangelism must always be good news; evangelism is and must always be the, the good news.

But to return to the invitation, Jesus came to us and called us friends (John 15:13-16). His message was one of reconciliation and (chesed, loving-kindness). If nurses approach the patient as Christ-the-friend, in relationship, they come with an offering that may be accepted freely, or may be rejected, just as freely. And if rejected, the nurse cannot know how God continues to work on the person's heart, for as Scripture notes, it is God alone who looks upon the heart.

Diverse Expressions of the Faith: Five additional considerations remain to be addressed. The first is evangelism directed toward other Christians. A tendency exists in some Christian circles to rely upon specific word combinations as a confirming test for faith. The woman in the gym would have accepted “Yes, I am born again,” “Yes, I am a follower of Jesus,” or “Yes, Jesus is my Lord and Savior.” Anything short of that would not have been definitively Christian. Nurses need to understand the wideness of the Christian faith. Those who would engage in evangelism must come to embrace the diversity of legitimate Christian expression and theology. It must be understood that one can be saved and not be evangelical, or Catholic, or Lutheran, or any other expected expression of Christianity.

Religiously Based Hospitals: Another consideration is that of evangelism within the context of a religiously based hospital. If the religious mission of the institution has been made clear and public, patients can and should expect to be exposed to the faith, in some manner. However, a hospital serves the public within its catchment area; admission to a particular hospital may be beyond the control of the patient. One tends to end up wherever the ambulance goes. So, while a religiously based hospital may have greater liberty in its expression of the faith to patients through its care professionals, and perhaps the right to more directly raise faith issues, the patient nonetheless retains the right to say no.

Spiritual Care, Spirituality, and Health: Spiritual care is not to be confused with evangelism. A spiritual care department (and nurses) must offer spiritual care asspiritual care, not as evangelism. The two must not be conflated, even within a religious institution. By the same token, patients in the institution know that spiritual care is a part of whole-person care and that spiritually related aspects of health will be explored. This implies a related issue, that of the proper domain of spiritual care. A hospital or patient care context such as home healthcare or a clinic, has a charge to deal with spiritual needs specifically as related to health. It is disingenuous to redefine salvation as health. A hospital is not the proper context for spiritual formation or spiritual development, apart from the interaction of spirituality and health. And nurses are not experts in spiritual development or formation, or in some instances, how spirituality or religion and health interact. Nursing intervention in patient spirituality must be limited to the relationship between the patient's spirituality and the patient's health and must not exceed that limit.

Evangelism That Inflicts Harm: A fourth consideration is that of nonmaleficence, the duty to not inflict harm. This is a danger that those who support patient evangelism generally fail to address. It also is an extension of the issue of nurse preparation to deal with spiritual care. Evangelism does, in fact, address core issues of life and meaning. If evangelism (even when invited) pulls the strand of the patient's belief structure, it risks going beyond unraveling the whole of the person's belief system. Because of the magnitude of the importance of belief systems, evangelism further risks unraveling the person herself or himself—to the core. This raises issues of knowledge, skill, wisdom, experience, mindfulness, and a safety net for the patient. Evangelism requires a safety net; evangelism requires aftercare. Any institution (or nurse) committed to evangelism must be scrupulous about providing follow-up care. To leave a patient unraveled is to inflict harm, and it is unloving, morally unconscionable, and sinful.

The Great Commission: Most who would evangelize in any setting take as command to do so what has been called The Great Commission, found in several passages but most notably in Matthew 28:16-20. However, the emphasis of the passage is not on an evangelistic proclamation of the gospel, but on discipleship, baptism, and teaching. In Matthew's gospel, “to be made a disciple...means above all to follow after righteousness as articulated in the teaching of Jesus” (Hagner, 1995, pp. 887-888). Evangelism without surrounding, or accessible, structures of discipleship, baptism, and teaching Jesus' commands, intrinsically violates the heart of the Great Commission.

And here is the final consideration. When faith is brought into patient care, it may only licitly be a response to the patient's invitation. Note that opening the door to sharing faith (again, when appropriately invited) is not, and cannot be, limited to Christian nurses. Nurses of any or no faith are also free to share their faith to the same degree that Christian nurses are.

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CONCLUSION

With increasing diversity comes increasing religious diversity in healthcare. Evangelical nurses benefit by developing a deeper understanding of how Christianity, as well as other faiths, interact with health, that is, that go beyond dietary restrictions and other practices to explore the actual conceptualization or theology of the faith tradition. How does Christian theology understand health and its parameters, define person, speak of stewardship of environment, and explore care of the stranger (nursing)? These are theological rather than biblical questions, as Scripture does not directly address them. But, rooted in Scripture, the theological literature offers, for example, a theology of disability, a theology of compassion, and a theology of dementia. A starting place for Christian nurses who would share their faith is to have a stronger understanding of how Christian faith and health are related (see Appendix A Place to Start Bibliography online as supplemental digital content, http://links.lww.com/NCF-JCN/A63).

After that, nurses need to know how Islam, Buddhism, Hinduism, Jainism, Sikhism, Judaism (whichever religion predominates in their geographic area), and, yes, Christianity view health, illness, healing, care of the ill, nursing, suffering, injustice, and more. The aim is for nurses to be able to speak in an informed way to patients who are religious, culturally religious, or even nonreligious—and to Christians—about the ways in which religion and health interact. Sharing one's faith in a healthcare context is still about the relationship between health and faith, but even more, it is about relationship.

American Nurses Association. (1965). Committee on Nursing Education: American Nurses Association's first position on education for nursing. The American Journal of Nursing, 65(12), 106–107.
American Nurses Association. (2001). Code of ethics for nurses with interpretative statements. Silver Spring, MD: Author.
    American Nurses Association. (2015). Code of ethics for nurses with interpretative statements. Silver Spring, MD: Author.
    Dorman D. (2019). A theology of neediness and evangelism. Journal of Christian Nursing, 36(3) doi:10.1097/CNJ.0000000000000623.
    Fowler M. (2011). Religion, religious ethics, and nursing. New York, NY: Springer.
    Hagner D. (1995). Word biblical commentary, Vol. 33b. Matthew 14-28. Dallas, TX: Word Books. pp. 887–888.
    MacDonald L. (Ed.) (2002). Florence Nightingale's theology: Essays, letters and journal notes. Collected works of Florence Nightingale, Vol. 3. Waterloo, ON: Wilfrid Laurier University Press.
    Robb I. (1900). Nursing ethics. New York, NY: Koeckert.
    Sheahan D. (1979). The social origins of American nursing and its movement into the university (Unpublished doctoral dissertation). New York University, New York, NY.
    Youngblood R. F. (1986). Peace. In G. Bromily (Ed.), The International Standard Bible Encyclopedia (Rev. ed., Vol. 3, p. 732). Grand Rapids, MI: W. B. Eerdmans.
    Keywords:

    Code of Ethics; ethics; evangelism; harm; Nightingale; nursing; power; proselytizing; religion; spiritual care; vocation; vulnerability

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