Agents of Shalom: A Reformed Perspective in Nursing Care

Abstract

In many countries today, the practice of health care has become a complicated system of services. The notion of health prevalent in this system is that of catering to physical needs and functions. The role of healthcare professionals becomes a function of this system. This runs against the experience and the worldview of many that professional systems and practices can never be morally and existentially neutral. Traditionally, health care and in particular nursing care have been understood as an element of fostering human flourishing. The question arises: what is lost when health care is no longer thus understood? In this article, the ‘raison d’etre’ of nursing care is explored by highlighting the Judeo-Christian notions of health and care as elements of shalom. The meaning of this concept is illuminated by recent nursing literature. Furthermore, Alasdair MacIntyre’s analysis of ‘social practices’ explains how such a concept runs deep in the capillaries of health care practices like nursing care. It is argued how shalom permeates nursing’s professional values (what nurses aim for), norms (how nurses ought to act), and virtues (who nurses ought to be). This ‘DNA’ of nursing care can combine professional clinical language with religious-moral language, enriching its understandings of health, care, and professional identity.

1. A Light-Hearted Introduction

In jest, cartoonist Alison Bechdel once introduced the “Bechdel test” for gender bias in movies (Bechdel 1985). In one of her comic strips, the main character says she watches a movie only if it satisfies one rule: it features at least two women who talk to each other about something other than a man. Although presented tongue in cheek, the test actually caused a storm of serious debate in circles of movie critics. And when one thinks about it, it is not easy to think of many movies that satisfy the rule! (The main character in Bechdel’s comic could only come up with Alien).

In a similar vein, one could propose a test for nursing bias in movies. According to this test, a movie is nurse friendly only if it satisfies the following rule: it features at least two nurses who talk to each other about something other than a doctor. Even if only half-serious, it might prove hard to come up with many movies that satisfy this rule. The point being, if it is true that movies mirror our present culture, then this test occasions the topic of this article, which is the ‘raison d’etre’ of nursing care. And, arguably, movies do mirror the image of nursing care and its contribution to health care in our popular culture.

One way to approach this topic is to see that a concern for health and human flourishing has always been at the core of the nursing profession. In our times, when the concept of health has narrowed, as it fell victim to more reductionist interpretations in medical science, we have lost from view meaningful aspects of health as related to the much richer concept of human flourishing and well-being (Bouma et al. 1989). Hence, we reflect on the contribution of nursing care to health and well-being. Thus, our question is, how does a richer concept of health connect to the ‘DNA’, so to speak, of nursing care (Fowler 2023)?

2. A More Serious Introduction

The topic of this paper is nursing’s ‘raison d’etre’. How to approach this question? Surely, reflections on something as fundamental to being human as the meaning of health and its relationship to human flourishing will not be neutral with respect to comprehensive understandings of being human. In other words, anthropologies and worldviews, as well as moral and religious interpretations of our topic, will be inevitable. To show the present author’s own colors in this respect from the outset, these meta-ethical or philosophical-anthropological reflections will be engaged from the perspective of Judeo-Christian understandings of what it is to be human. In particular, within this broad riverbed, it will be discussed how contemporary Protestant or Reformed nursing scholars have explored nursing.

There is a deeply seated inclination in the Reformed tradition to see the whole of human life as subjected to God’s reign, and to reject claims that certain areas of human life can be religiously of morally neutral. This inclination presents them with the challenge to provide an account of the way religion enters the institutions and practices of human life. In the case of Reformed thinking about nursing care, attempts to give such an account are scarce. Interestingly, however, these scarce attempts have something in common.

Specifically, the article pulls together existing sources on the Biblical language of shalom in relation to nursing care. It is not new to point to the language of shalom in nursing (Fowler 2008). To be sure, there is nursing literature using the language of human flourishing, but because of its Aristotelian overtones it will be put to the side. Even so, there is some literature bringing to speech the relationship between nursing and shalom, as well. These sources have previously stood alone and underdeveloped but come from an intellectually robust and culturally established tradition. After letting these sources speak on their own terms and identifying their commonalities, I propose to trace their potential for bearing on the work of nurses using Alasdair MacIntyre’s concept of social practices, of which nursing care is an example (Bishop and Scudder 1990). Hence, the emphasis in this article will not be on discussion with other traditions of thought.

Nurses, to clarify, can be understood as the International Council of Nurses defines them: “A nurse is a professional who is educated in the scientific knowledge, skills and philosophy of nursing, and regulated to practice nursing based on established standards of practice and ethical codes. Nurses enhance health literacy, promote health, prevent illness, protect patient safety, alleviate suffering, facilitate recovery and adaptation, and uphold dignity throughout life and at end of life” (ICN 2025).

3. Theoretical Background: Nursing and Shalom

One notable source summarizing nursing care as “working toward shalom” is Shelly & Miller, Called to Care (1999/2006). I say “summarizing”, as publications by Whitney Miller (1997), Tazelaar (2001), and Reimer-Kirkham et al. (2013) in Journal of Christian Nursing orbit around the same discourse. To quote their definition of the term shalom: “Often translated as ‘peace’, shalom actually incorporates all the elements that go into making a God-centered community—peace, prosperity, rest, safety, security, justice, happiness, health, welfare, wholeness. Christian philosopher Nicholas Wolterstorff defines shalom as “the human being dwelling at peace in all of his or her relationships: with God, with self, with fellows, with nature”.” (Shelly and Miller 2006, p. 191)1.

Another notable source summarizing a similar discourse on the notion of shalom in nursing care is Doornbos, Groenhout & Hotz, Transforming Care (2005). They refer to a similar description of shalom: “The Old Testament word shalom […] is sometimes translated as “health”. Shalom can be defined as a dynamic state of wholeness, well-being, peace and completeness that permeates all areas of life (Plantinga 2002, p. 15). We can understand it as universal well-being, wholeness and delight—a rich state of affairs in which natural needs are satisfied and natural gifts employed, all under the arch of God’s love (Wolterstorff 1983, pp. 69–72). […] Health in the fullest sense is the complete physical, mental, and spiritual flourishing that allows us to fulfill our created purposes—and so to give glory to our Creator and enjoy the relationships with our creator and fellow creatures […]” (Doornbos et al. 2005, p. 70)2.

A last notable source to be mentioned is Swinton’s From Bedlam to Shalom (2000). His project is to locate mental health care within the context of the work of the church in the world. In this context, he posits that the idea of shalom is central. In the Old Testament, “The root meaning of the word shalom is wholeness, completeness, and well-being. It does however have several secondary meanings, encompassing health, security, friendship, prosperity, justice, righteousness and salvation, all of which are necessary if wholeness, completeness, and well-being are to come about” (Swinton 2000, p. 57)3. He adds that in the New Testament “Shalom is seen as inextricably bound up with the nature and person of Jesus […] Shalom is a personal gift from a relational God” (p. 59). He then explains how in the work of the church for those with intellectual disabilities or mental health problems—when the Gospel can barely be communicated in words—shalom is best expressed through friendship.

All three sources address the point that the notion of shalom can help us to see that current clinical standards of health have indeed narrowed, and that more meaningful aspects are involved in human well-being: not just physical, but also biographical; not only mental, but also spiritual; not only individual, but also relational; not only social, but also societal; and not only technical, but also moral. One may have perfect diagnostic results but not experience shalom because other aspects of well-being are lacking; then again, one may not have perfect diagnostic results yet experience shalom because of other aspects of well-being. These writers point out that nursing care has a wider purpose than promoting health in the narrow, physical sense. From this vantage point, nurses are to look beyond this narrow sense of well-being to what health and care mean for living a fully human life.

All of these three sources hasten to add that shalom may be taken as too lofty an ideal or an ‘eschatological horizon’ to be a practical goal of clinical nursing—meaning, harmony, fulfillment, even wholeness, are hardly achievable in practice. Thus, their use of terms like “future hope”, “distant ideal”, and such. But this ideal character does not preclude that the term shalom functions as a goal (or an attainable proximate good) of nursing care. And even if it cannot function thus, it is in the same boat as the equally lofty ideal of health as vitality, or as autonomy, or as the absence of disease—who can achieve that?

Here we will continue our exploration in this vein. However humbly these sources present shalom in relation to the goals of clinical nursing care, after all, they do present nursing care as “working toward shalom” and nurses as “agents of shalom”. Thus, they seem to presuppose that shalom is some sort of—or at least compatible with—outcomes or results, some aim or end of nursing care. We may fail to achieve them fully in this life, but we aspire to reach for these aspects and degrees of our well-being. It is as Swinton (2000) says, “both a goal and a holistic process”, “a movement”, even “a shalomic evolution” (p. 60).

4. Conceptual Background: Shalom and Care

As noted, all three sources of Reformed thought on nursing quote Nicholas Wolterstorff. This Reformed philosopher goes back to the beckoning perspective of shalom in his own writings time and again. To the usual translation of shalom as ‘peace’, he suggests, we should add justice, harmony and delight. The shalom that Jesus brings, the peace that passes all understanding (Tazelaar 2001, p. 5),4 is more than mere absence of ailment, strife and poverty. “What the Hebrew writers called shalom […] is perhaps better translated into contemporary English as ‘flourishing’ than as ‘peace’. To experience shalom is to flourish in all one’s relationships—with God, with one’s fellow human beings, with the non-human creation, with oneself. Such flourishing’ naturally presupposes peace in the usual sense, absence of hostility. But shalom goes beyond the absence of hostility, to fulfillment and enjoyment” (Wolterstorff 1995, pp. 19–20).

A few distinctions can be gleaned from Wolterstorff’s quote. We can first of all distinguish shalom as experienced by individual human beings, as well as by communities, and even by nations. Maybe the lines between those dimensions are not clear cut in the daily realities of nursing care as we are now often think of care recipients, e.g., as “patient systems”. Surely, there are relevant lessons to be learned about community health, public health and global health from thinking about health in terms of shalom. In the present context of health and nursing care, however, we will mostly have in mind the shalom of individuals or small units of individuals such as families, and for now leave extrapolations to communities to the side.

Another distinction is that shalom sometimes seems to come about by nurturing, sometimes by restoration, and sometimes by both. Suppose the fruits of nature or art are potentials of Creation, then nurturing those potentials—e.g., by watering plants, feeding animals or practicing music—may by themselves lead to shalom. If, on the other hand, well-being or even life itself is threatened or harmed by whatever results of the Fall, nurturing will not be enough, and acts of restoration may be in order (Dorman 2018). Again, in nursing’s daily realities the distinction may not always be that clear. And admittedly there are relevant lessons to be learned about prevention, health education and health promotion. In the present context of shalom and nursing practice, however, we will often have in mind the restoration of health, occasioned by illness, disease, disability, trauma, and imminent death (and leave the extrapolations to prevention and promotion be).

We should note, in any event, the mixture of nurturing and restoring suggests that shalom requires some effort on our part. We can give this effort to foster human life as it is supposed to be the name of “care,” in the general sense defined by Joan Tronto: An “activity that includes everything we do to maintain, contain, and repair our “world” so that we can live in it as well as possible. That world includes our bodies, ourselves, and our environment” (Tronto 1994, p. 126). From the point of view of shalom, we care for ourselves and for others—by nurturing and restoration—with an eye to the way our world is supposed to be, i.e., well-being, in shalom. In this sense care is close to what Reformed thinkers like to call the “cultural mandate” (Plantinga 2002, p. 32) or “responsibility” (Cusveller et al. 2004; Cusveller 2011, 2013). As creatures of God, we are called by the Creator to aim for living in shalom; it is rightly expected of us. The Bible is rife with passages of God holding us accountable to live up to the requirement of doing our part to advance the well-being of human beings—i.e., to care. Shalom requires care. Hence, the activity of caring shows itself to be an inherently moral activity. In summary, we have a responsibility to care.

5. Recap: Caring Practice and Shalom

Let us take stock and observe how care is required—according to this strand of Christian philosophy—for human well-being, for human life as it is meant to be, for human beings dwelling in right relationships as intended by God, the Creator, Provider and Redeemer. If this sense of well-being is identified with shalom, and shalom is identified with health, then it becomes clear that health is to be taken as broader than mere vitality of the body, or the autonomy of the individual.

This means the multi-faceted notion of shalom indicates that one can be fit and independent in one sense, yet impoverished, withering, not functioning well in others. Well-being in and through caring relationships is thus very practically and concretely encompassed by the notion of shalom. So, even if the writers of the sources cited hesitate to call shalom a goal of nursing, there can be situations in which it is warranted for nurses to stop and reflect: “This or that patient seems to be in good health by clinical standards, but is it shalom?”. Or, the other way around: “This patient is not in good health by clinical standards, but does she experience shalom?”.

Also, we spoke of shalom as a ‘good’ of some approximate sort, of nursing care as working toward shalom, and of nurses as agents of shalom. But we should note here that human life is meant as living in relationships and responding to a moral call. Caring takes place in and through relationships and responses to moral calls. In other words, the activity of care is not merely a means to an end, but the activity or process may itself be an expression of shalom. Care is not an activity purely for the sake of something else, we also engage in care for its own sake. This distinction too may not always be clearcut in clinical practice. But just like we only develop and enjoy friendship by engaging in friendship, in the practice of care we foster shalom by conduct that itself expresses shalom.

This explains, for instance, the experience of nurses that sometimes you do not have to do or achieve anything for a patient other than being with him or her. Think of a dying patient. Caring for him or her is often its own reward, so to speak, i.e., the caring relationship as such fosters and expresses shalom. Here too, then, there can be situations in which it is warranted for nurses to stop and reflect: “Our nursing interventions and our nursing outcomes seem acceptable by current standards, but is our mere presence a reflection of shalom?”. Or, the other way around: “Maybe our interventions and outcomes are not optimal for this patient, but maybe our efforts and attitude reflect shalom”.

6. The Core: Fostering Shalom as Professional Practice

So far, our exploration has shown that shalom in the Bible is used as a telos, a destination of sorts for our human existence, and that caring for shalom is a responsibility for each and every one of us. Now, exploring this idea further, for various reasons our responsibility may become a specific task for specific individuals. We can imagine, for instance, that someone in, say, Antiquity proved to have a knack for teaching and that the tribe or village or polis decided to send their children to such a person for tutelage. Thus, parents would transfer their own responsibility for the education of their own children to the teacher so deputized. So for nursing care, sometimes caring for a family member’s health becomes a task one decides to delegate to someone else, to someone who has an area of expertise to provide health care for others. In the course of history, some of these practices became occupations, and some of these occupations became professions.

The general human activity to care for shalom in order to nurture and restore it is familiar to us all. We know it, not just from the moment we start doing it ourselves, but not in the least because we grow up in the midst of it and because of it. Meanwhile, we have seen caring activities shape historically durable, socially extended and individually embodied fabrics of giving and receiving. Nursing literature (e.g., Bishop and Scudder 1990) refers to this as a moral practice in the sense of MacIntyre’s definition:

“By a practice I am going to mean any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence, and human conceptions of the ends and goods involved, are systematically extended.”

(MacIntyre 1983, p. 187)

To trace the bearing of Reformed thought on caring and shalom to nurses’ daily practice, let us now think along those lines. Being a social and moral practice gives nursing a certain structure. Exploring nursing as practice will help us see where and how the notion of shalom enters.

First, note a social practice in the MacIntyrian sense, such as nursing, has an intentional character: it exists to foster or advance or achieve some state of affairs, especially desirable results or valuable consequences. MacIntyre translates the Latin term for this goal of sorts, bonum or bona, as “goods”. Performing, say, a concerto well is a good of the practice of piano playing, and a harvest is a good of farming. Perhaps we can say this is the end-in-itself or the practice’s central value. In professional nursing, they might be called “clinical outcomes” or “patients’ interests”.

Depending on the lifespan or the patient category, the central value of nursing care may concern various aspects of well-being: development (for a newborn), mental stability (for a bipolar adolescent), recovery (for a surgical patient), comfort (for the dying), and so on. These are the kinds of things nurses want to see achieved or at least advanced, at the end of the day. Surely, outcomes are sometimes expressed in technical terms of, say, reduced dosage of medication, or how far a patient can walk down the hall without a crutch, or getting to grips with anxiety. But are those nursing outcomes at odds with the language the Bible uses to refer to desirable situations in the state of shalom? Take the wiping away of tears; restoring hearing and seeing; easing the effects of paralysis and leprosy; washing and feeding; restoration of friendships and family ties? Not at all.

From the perspective of shalom, then, nurses can often speak both of nursing goals in professional terms and in terms of shalom. In fact, doing so ties together what to want for a patient and the wider context of why to care for it. As a New Testament writer like St. Paul says, righteousness, godliness, faith, love, endurance and gentleness are to be pursed (1 Tim. 6:11). This does encompass nursing care.

Second, in social practices such as nursing care, some interventions and procedures prove to be preferable above others, especially with respect to bringing about the goods of the practice. Practices have a normative character. How to place one’s fingers, say, when playing an instrument, how to move the pieces in a game of chess, and so on, are sometimes called the “rules” of the art. MacIntyre calls them “standards (of excellence)”. Professional nurses, in turn, are all familiar with guidelines, regulations and protocols for their procedures (e.g., keeping records, using data), as well as codes and regulations for their conduct (e.g., keep confidential information confidential, double-check medication).

Seen from the perspective of shalom, we can think of duties, commandments or obligations holding for what we owe the vulnerable, e.g., New Testament writers suggest duty- and rule-like directives like: “Do not let any unwholesome talk come out of your mouths, but only what is helpful for building others up according to their needs, that it may benefit those who listen” instead of even a hint of sexual immorality, impurity, or greed (Eph. 4:29). This does seem to qualify as a professional norm holding for a nursing relationship or the nursing process as well. The point being, shalom is not only a value to work toward to, but also a normative quality of the work itself.

Third, what you as a nurse want to achieve for a patient and what you as a nurse aim to do for a patient, also includes certain requirements for the person who is a nurse. This often determines how she does things. In the nursing profession, these personal qualities are often called competencies, which include knowledge, skills, and attitudes. MacIntyre calls personal qualities or character traits that bring out the good of the practice virtues, e.g., courage, justice, and honesty. Usually, when nursing students are asked to name essential traits, attitudes or virtues, the first thing that they bring forward is empathy. To be sure, there is a professional language for the kind of person a nurse needs to be for a patient and her colleagues (open, careful, patient, and so on). At the same time, the language of shalom suggests personal qualities not out of place for professional nurses5. New Testament writers usually call them “talents”, “gifts” or “fruits” such as “Love, joy, peace, forbearance, kindness, goodness, faithfulness, gentleness and self-control” (Gal. 5:22). These are qualities equally relevant for contemporary nurses.

Using MacIntyre’s definition of practice, in short, helps us to see how the notion of shalom bears on professional nursing practice, not just in a lofty sense, but in a practical sense. Nurses who understand their personal identity from this perspective can understand themselves as full-fledged professionals at the same time. They can be agents of shalom who shalom in their professional conduct, foster the good of the patient as shalom, and embody shalom in their ways of being a professional. In summary, what to want (as a nurse for a patient), what to do (as a nurse for a patient), and who to be (as a nurse for a patient) can be expressed in both professional language and the language of shalom. They do not have to separate their religion from their professional identity; they can be bilingual.

7. Conclusions

We began this exploration of the comprehensive nature of health at the most general level of human existence as created by God, so that it is to be understood in the wide sense of shalom. This is where Reformed thought likes to start. Then the place of care was introduced as a commitment to nurture or restore shalom and the responsibility we have as human beings to care for ourselves and for each other. Proceeding from there, it came to light that some of us have the responsibility to care for others in a professional capacity, sometimes evolving to nursing care. Here, a distinction was made between the intentional, normative and personal sides of what can properly be expected of nurses: professional values, professional norms and professional virtues. All the while, the Biblical perspective of shalom enabled us to talk about her professional responsibilities in relation to her religious identity.

It is true no attempt has been made to define the concept of shalom very precisely. The aim was to evoke a perspective on reality in which this concept shines through in practice, as it were. This ought to enable us to look inside the realities of nursing care to see how this perspective—that we human beings are to live in shalom—relates to nurses’ professional responsibility. And given this aim, the conclusion of this article is, (1) there is a plausible sense in which to understand health in relation to well-being—as shalom points to various aspects and degrees in which we humans may flourish beyond the material, physical, or clinical. And (2) shalom bears on what to want, what to do and what to be as a nurse for a patient, even as a professional. So (3) from a Reformed perspective, it is indeed relevant, helpful, and indispensable for nurses to be able to use both professional and religious accounts of their practice.