University of Illinois, Chicago, Illinois, United States
by Robert Hayes
Using your mind’s eye, imagine a painting that my husband and I bought several years ago in the Smokey Mountains. An old-fashioned, wooden, crank-type ice cream maker rests in the foreground surrounded by heaps of fresh red strawberries and lava-like streams of thick, pink, strawberry ice cream frothing out of the top. Nostalgic for when we as children made ice cream on our grandparents’ farms, both my husband and I were drawn to this painting. When we returned home, I immediately hung it over the piano and called a friend to describe my new artistic find. I was somewhat disappointed by her unenthusiastic reaction. However, when she visited a few days later, her reaction was completely different. She commented:
That’s not the painting you described to me on the phone. I pictured it as flat and all red. You didn’t describe the background: the subtle blue of the sky, the lush green of the trees, the warm sweeping brush strokes.
With this comment, I was reminded of the importance of both the background and foreground in a painting. While the foreground usually portrays the artist’s primary focus and is generally the first thing one notices, it is the background and setting which gives a piece depth, contextual perspective, and aesthetic richness.
One afternoon, as I stared at the artwork above my piano, I thought about how concepts used to describe a painting’s landscape, such as foreground and background, could also be used to describe the landscape of one’s profession. One might say that what initially attracts individuals to a profession and is foremost in their minds as they practice functions as the foreground of their career. In nursing, for instance, the basic skills of caring that students learn early in their education training could be considered the foreground of this profession. Much of the nursing practice is focused on developing and implementing these skills. As depicted in the nursing process, such skills include assessment and analytic competence, therapeutic/intervention expertise, and critical thinking to evaluate outcomes. However, the nature of these skills varies depending on which career one assumes within the profession of nursing. Nursing offers a wide variety of educational preparation programs (ADN, BSN, MSN, DNP, PhD) and specialty roles (caregiver, scientist, policymaker) with each requiring its own individual subset of expertise. Those who simplify nursing as a one-dimensional career defined by a singular set of skills only consider the foreground of the profession. Only by acknowledging its background characteristics can one understand the complexity of nursing and appreciate the overall landscape of the profession including its depth, contextual perspective, and aesthetic richness.
The scientific basis of the nursing profession, or what we might refer to as one of its background characteristics, contains elements from the natural sciences (i.e. chemistry, biology, physics) and the social sciences (i.e. psychology, sociology). In nursing, these scientific elements provide the foundation for evidence-based practice. The soundness of this profession depends on the nurse’s ability to generate research documenting new knowledge and the use of this research to positively influence an individual’s health and the healthcare system as a whole. Understanding the scientific basis behind the healthcare practices nurses and other health professionals implement in their care of patients lends credibility to the profession while offering a common reference point in relevant discussions with colleagues. Without paying close attention to its scientific foundation, nursing care skills will be considered insignificant and not trustworthy by patients and other healthcare professionals.
The socioeconomic and political environment of nursing functions as a second background characteristic. This environment serves as an important contextual perspective from which to view caring. As the U.S. struggles with healthcare reform implementation, it is essential that nurses be healthcare advocates. Nurses cannot merely understand and react to political decisions regarding healthcare, but instead must actively participate in the political decision-making process. The achievement of high-quality, safe patient care depends on nurses’ proactive involvement in the political landscape.
Just as smooth brush strokes and complementary color tones add aesthetic richness to a painting, certain background characteristics of the nursing profession provide an aesthetic richness to caring. Intellectual curiosity, cultural, spiritual, and ethical values, empathy and compassion are vital attributes that should be nurtured and rewarded in the nursing profession. Patients do not remember their nurses for their technical competence; they do, however, remember the nurses who share part of themselves, take time to relate to their patients as individuals, and who demonstrate insight into what they are experiencing. Caring is being fully present to another person to affirm personhood, relieve vulnerability, and empower growth and strength (Halldorsdottir, 1999). These aesthetic elements complement and enrich the overall profession.
Benner (2010) attributes partial responsibility for a common one-dimensional portrayal of nursing to the 1970 Lysaught Report, which stated that the nursing profession had two mutually exclusive options: to represent itself as knowledgeable and skilled in science and technology or as non-skilled nurturers. As a nursing student in the late sixties, I struggled with this dichotomy. My struggle was evident to one of my instructors who questioned my ability to care for patients:
You may get all A’s on your exams, but you are nursing the machines, not the patients. You are attending to tasks and ignoring the person in front of you.
Although her admonition was painful at the time, it was a pivotal point in my career that enabled me to fully understand the complexity of my chosen profession. An experience during my first year of practice further reinforced the lesson I had learned about caring for “the person in front of you.”
Mary was a young wife and mother with terminal cancer who was my patient for the three weeks before Christmas. She requested that I buy her husband a Christmas present:
I know this is not really part of your job, but it is my last Christmas and I want to make sure he has a special present from me to always remember our life together.
Despite what Mary thought, I realized then that it was “a part of my job” to be a caring presence, affirming personhood, relieving vulnerability, and empowering strength. When Mary died two days after Christmas, her husband was at her side holding Kahlil Gibran’s The Prophet, Mary’s last special present which I delivered to him.
The further I moved along in my career, the more I came to acknowledge, understand, and appreciate the multi-dimensional landscape of nursing that enriched my professional experiences. As a mental health nurse specialist, I intentionally endeavored to integrate scientific knowledge with interpersonal care. I enthusiastically used this biobehavioral research to offer new insights into the etiology and treatment of mental illness, aiming to enhance both my treatment plans and relationships with my patients. When it became evident that mental health care treatment was not accessible to the individuals who needed it the most, I decided I wanted to engage in policy decisions that would impact my patients’ care. In order to do so, I pursued a PhD in Public Policy Analysis with an emphasis on healthcare policy so that I would be able to serve as an effective advocate for my patients. Reflecting on the total landscape of my nursing career, I realize that competently implementing the nursing care process remains an important aspect in the foreground. However, I believe it is my experiences firmly set in the background that fully define who I am as a nurse: a research subject advocate for federally-funded studies, an activist for school policies that promote children’s mental health, and a compassionate and empathetic caretaker.
Imagine the painting once more: the wooden ice-cream maker, ripe red strawberries, and lava-like streams of ice cream still draw you immediately in. But it is the subtle blue sky resting quietly in the backdrop and the warm sweep of green bushes along the edge which gives the piece full depth and richness, enabling you to appreciate the painting’s full landscape. Similar to the painting, when a relationship between the background and foreground of one’s profession is explored, an enhanced awareness of the profession’s multidimensional character is stimulated. For a complete portrait of nursing, one must not only recognize the therapeutic skills that quality nursing care requires upfront, but also the scientific foundation and socioeconomic and political backdrop that enrich the profession and engage intellectually curious and active nurses who assume a variety of professional roles.
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: a call for radical transformation. San Francisco: Jossey-Bass.
Halldorsdottir, S. (1999). Suffering – reflection – caring. International Journal of Human Caring, 3(2), 18.
Lysaught, J.B. (1970). An abstract for action. New York: McGraw-Hill.
LYNDA SLIMMER, PhD, RN has taught mental health nursing for 29 years at Elmhurst College’s Deicke Center for Nursing Education. She currently teaches Holistic Health at the University of Illinois at Chicago’s College of Nursing and implements the Teaching Mentoring Program for the department of Biobehavioral Health Science where she currently serves as Associate Department Head. Dr. Slimmer’s research has focused on mental health promotion for children, depression in the elderly, and the scholarship of teaching. She is a commentator for the Evidence Based Nursing journal and a reviewer for the journal Education for Health.