Nursing Ethics

I am excited to be back in classes for the Spring semester, and inspired by my reading last night which matches closely with my understanding of Buddhism.  Three paragraphs discussed the "three basic ethical principles of nursing": Respect for a persons right to self-determination, beneficence, and justice. 

Self Determination: Treat patients as autonomous individuals capable of making their own decisions.  My fiancee recently described working with a parent who was trying to get their child to stop playing with water.  I was impressed with her ability to hold the parent's point of view as well as the child's in the interaction that followed.  My reaction to hearing the situation was "I would have been like, 'it is okay if they play with water, we can clean it up later."  However, such a response would have undermined the parent's authority and potentially confused the child if there is an expectation around such play that will be enforced when the child is not in that setting.  Likewise, patients have different frames of reference from my own and it is not only counterproductive to impose my beliefs on them but also disruptive to their health and overall well being.  Buddhism takes the long-view.  The Buddha was enlightened some 2500 years ago and set out to "save all beings," however he did not exhaust himself trying to force people to accept one "way" of doing things.  In one story he sits in silence as a learned man sits and questions him, finally leaving convinced that the Buddha is a sham and has nothing to offer.  When asked why he was silent by his disciples the Buddha replied that the man didn't really want to hear he just wanted to argue.  It was not appropriate to teach what would not be heard.

Beneficence: Work for the benefit of the patient.  This includes the axiom "first, do no harm" common among doctors, and includes a wider sphere of active participation in ensuring the patient's well-being.  I can see how the art of nursing becomes important as potential conflicts exist between my personal and cultural norms and standards and the patient's right to self determination.  I am beginning to see my role as educator and advocate as potentially more fluid and dynamic than I thought.  Perhaps each patient brings a new frame of reference and boundaries within which my work to benefit a patient is somewhat constrained.  I say "somewhat" because I think it is also my role to explore these boundaries with patients and push to expand them where appropriate.

Justice: Treat all patients equally and fairly.  I referred to this in an earlier entry in which I saw the orange jumpsuit of prison patients as a kind of meditation bell.  A reminder to slow down and give the best care possible regardless of cultural learning that disregards prison populations, lower social classes, and minorities in general.  A number of readings in my program have also highlighted the role of nurses not only in their care settings but also in their communities.  This is a very Buddhist teaching.  If a problem exists in a community or nation that manifests as a recurring problem in a healthcare setting it is the nurses role to address the larger issue and not just treat the manifestation in the healthcare setting.  Cardiovascular disease among African-Americans, the obesity epidemic, low levels of health education... These are areas that can be addressed both in the microsystem of bedside or outpatient care as well as through advocacy, research, democracy, community involvement, mentoring, etc.

I am looking forward with beginners eyes and eagerness to develop my professional practice.  When I started this program I was excited by the calls from my teachers to view our profession as fluid and full of continuous learning.  I don't think that I will ever be "done" as a nurse.  That is one of the most exciting things about this profession.

New Years Wedding

“Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us. We ask ourselves, Who am I to be brilliant, gorgeous, talented, fabulous? Actually, who are you not to be? You are a child of God. Your playing small does not serve the world. There is nothing enlightened about shrinking so that other people won't feel insecure around you. We are all meant to shine, as children do. We were born to make manifest the glory of God that is within us. It's not just in some of us; it's in everyone. And as we let our own light shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others.”   - Marianne Williamson (often attributed to Nelson Mandela)

This reading was shared at a wedding I recently attended.  It has been a touchstone for me since then and I find myself returning to it for strength.  The other day I thought "it would be easier for me to do this if I had known someone else to have done it."  Then this quote popped up and I thought, "If I do this I can be that example for someone else."  That was hugely self-empowering.

Coming Full CIrcle

"In the beginner's mind there are many possibilities, but in the expert's there are few." -Shunryu Suzuki

I took advantage of my break from nursing school and headed to Joshua Tree National Park.  I had not been there in seven years, since my first ever "climbing trip."  Seven years ago I had done my first lead climb while in the park.  Lead climbing involves placing metal chockstones as you climb with the possibility that one will fall from above onto this protection.  Although I had been scrambling on rocks since childhood and had placed protection in cracks to set up top-ropes I had never taken "the sharp end."  I remember my first lead vividly.

As we set up to climb a group of three climbers on the opposite wall headed up a wandering route with a slight overhanging section at the end.  The leader looked so poised and confident.  The route looked very difficult and I couldn't tell what he would hold on to.

I focused my attention on the rock in front of me and headed up with a carabiner full of nuts, some large hexes, four tri-cams, and a single #3 Camalot.  The route was classified as very easy (5.2) by the guidebook, but I kept questioning my security, my placements.  My confidence was being challenged, but the rock looked within my ability.  I couldn't tell why it was so hard.

The route wandered over a rock slab for twenty feet and then followed a chute for another thirty before topping out over a bulge of unprotected friction climbing.  I wedged myself in the chute and fiddled with gear.  I tried to get the gear securely in the thinnest part of the crack.  The crack was the same size the whole way and I only had one of every size so I had to look ahead and plan out my protection three moves in advance.

As I neared the top I put in the cam on a long sling, I put two nuts in opposition and headed out on ten feet of rock which looked intimidating.  As I neared the top I got to a crack that would take a tri-cam and I slotted it securely.  I knew I was safe and continued on to a good stance where I built an anchor and brought up my friend.

A rush came over me.  I had done it.  I had pushed my limits and opened up a new world of opportunity and challenge.  I looked out at the other party working their way up the much more difficult wall opposite the one I stood on and thought, "That is so cool.  I hope one day I can climb that."  I was euphoric and hooked on the sport and leading. 

Seven years later I found myself back in Joshua Tree and taking the morning off from climbing to avoid the rain that seemed to be rolling in.  I wanted to go for a hike and to do some Yin Yoga, so I did.  After two hours of Yin I scrambled up a pile of roks and looked out over the desert.  It was gorgeous as only the desert can be.  Still, quiet, with everything visible.  It is like being an eagle soaring high above looking for prey.  You can see everything in the desert and everything is in stark contrast.

I picked a pile of rocks in the distance as my target and headed out cross country towards my destination.  I didn't know it, but this pile of rocks that was chosen was the same pile that contained the first lead climb I ever did.  For those of you who have not been to Joshua Tree this may seem unremarkable, however there are literally hundreds of rock piles spread out over many miles, with thousands of climbing routes.

I neared the rocks and crossed a dirt road which paralleled the rocks.  I headed down the road and came to a split between the rocks as wide as a four lane highway.  On each side a thick fin of rock arched up from the desert before dipping back into the sand.  It was like two giant rock whales breaching simultaneously and frozen in space.  I had never known the name of my first lead climb, nor the name of the rock formation it was a part of, but I never forgot how it looked.  There it was staring me in the face.  I looked across the valley for the route that I had seen the other climbers on for confirmation.  Sure enough it was there and as I remembered it.  I laughed, I smiled, I was blown away by the series of events that had brought me to this spot a second time. 

I sat at the base of each climb.  I felt the rock.  I thanked the rock for being there and for playing a role in what has been a rewarding seven years full of personal growth, challenge and change.  I just sat there and felt connected, grounded literally to that spot.

My partner and I returned that afternoon and I respectfully repeated my first climb, crossed the valley and headed up the climb that had inspired me to grow as a climber many years before.  This time I headed up with a light rack of cams and long draws.  I could tell what gear I would need from the ground.  The initial ramp was easy and I waited until I was twenty feet up to place gear at the first very secure placement.  I attached a long sling to reduce rope drag and headed up a very featured face to a ledge below the overhang.  I placed two cams in a flared crack and another cam in a beautiful constriction.  Before heading up the last twenty feet of overhanging crack I organized the three cams I had so they would be ready in order for the upcoming section.

Right finger lock, left layback, reach high with right hand.  The hold was so big that I could have hung like Stalone in Cliffhanger.  Plug in a cam.  Reach high with left hand, match with right, press feet high and reach for a finger lock, cam again, reset feet, finger locks to slopers and press myself up on top.  I felt like a kid again, like I had seven years before, like I do whenever I climb something challenging.

The route had been easy, easier than I had expected.  I had spent years making this route more difficult in my mind because of what I had seen seven years before through a different pair of eyes.  I felt like I had come full circle and was ready for new challenges.  What had looked impossible a few years before was now possible because of the work that I had put into growing in this aspect of my life.  What else is possible?  How high can I shoot?  Getting into nursing school was a process and at times I felt like my attempts were the biggest failure of my life.  Now I am in school and every semester I feel more prepared, more competent, and more confident that I have chosen a fitting path for my career.

"There is something uncomplicatedly true in the sensation of laying hands upon sun-warmed rock."  - Robert Macfarlane

Projections & Illusions: Part 2

While planning my previous entry (Projections & Illusions: Part 1) it was apparent that at first glance it seems profoundly “unbuddhist” in the sense that it is all about self.  Impermanence, nonself, and nirvana are omnipresent themes in Buddhism known as the Three Dharma Seals.  Although nonself is important, one must be aware of a sense of self before it can be given up as impermanent and illusion.  Impermanence and nonself are intimately linked and there is no understanding one without understanding the other

“When we look deeply into impermanence, we see that things change because causes and conditions change.  When we look deeply into nonself, we see that the existence of every single thing is possible only because of the existence of everything else.  We see that everything is the cause and condition for its existence.  We see that everything else is in it.” -Thich Nhat Hanh

Impermanence is the teaching that things come and go and that nothing lasts forever.  Impermanence is often taught with the analogy of a river.  One can never step in the same river twice.  Our conception that there is a real and permanent river is just a perception, an illusion, a projection.  Buddhism doesn’t teach us to reject the illusion of a river, but to recognize it as an illusion and live our life accordingly.

Nonself is the teaching that our idea of a whole and independent self is a false concept because we are all interdependent.  Nonself can be explored through the following process.  Pick something and ask “What is that?”  A chair is a chair.  Simple enough, now ask again.  A chair, after all is only a chair because that is the name we give to things we sit on.  Is it made of wood?  If so it is also a tree.  A tree is nutrients from the soil, rain from the clouds and energy from the sun.  It is all these things and our conception of it as a chair.  Every chair is also unique in the wood from a particular tree which stood in a particular spot, was cut, moved and milled by particular people and particular machines that are themselves all products of countless other interactions.  The chair is said to be interdependently co-arising because it is interdependent on all these factors for its existence.  A short story by Ram Dass also illustrates nonself:

“There are two waves drifting along in the ocean, one a bit bigger than the other.  The bigger wave suddenly becomes very sad and upset.  The smaller wave asks what's wrong.  ‘You don't want to know,’ the bigger wave says.  ‘What is it?’ the small wave asks.  ‘No - really - it's too terrible.  If you knew what I knew, you'd never be happy.’  The small wave persists.  Finally the big wave explains: ‘You can't see it, but I can see that, not too far from here, all of the waves are crashing on the shore.  We are going to disappear.’  The small wave says, ‘I can make you happy with just six words, but you have to listen very carefully to them.’  The big wave doesn't believe it -- what does the small wave know that he doesn't -- but he's desperate.  After a while of doubting and mocking the small wave, the big wave finally gives in, and asks the small wave to tell him.  And so the small wave says: ‘You're not a wave, you're water.’”

So how does impermanence and nonself relate to “Projections & Illusions: Part 1?”  I used the analogy of a private movie screening to present my insight that we are all projecting and being projected upon.  These projections are interdependently co-arisen.  My own growing sense of self is also an illusion.  Buddhism teaches me not to reject my personal truth, to recognize its impermanence and illusory nature, and to take appropriate action based on my understanding.

Here is a helpful link to more information.

Life is Hard...even for the Dalai Lama

I recently read that the Dalai Lama reminds himself every morning as he wakes that he has a precious human life and mindfully vows to use all his energies: to develop himself, to expand his heart for others, to think kind thoughts and avoid anger and unkind actions.  He vows to benefit all beings as much as he can, every day.

This passage was followed with the commentary: "If he needs to continue to cultivate his Bodhisattva Vows after fourteen lifetimes as the Dalai Lama, you and I should not be surprised that selfish thoughts arise in us from time to time."