Humanistic Nursing Part 5

Other Human Beings

The dialogue lived between nurse and patient is affected by their numerous other interhuman relationships. For a nurse to be genuinely with a patient involves her coexperiencing his world with him. His family, friends, and significant others are a very real part of this world whether they are physically present or distant. So to be open to the patient is to be open to him as a person necessarily related to other men.

Furthermore, in caring for a patient the nurse relates to him not only as an individual patient but also as one in a group of patients. The group may be physically present (for example, in a ward, in an intensive care unit, in a {32} waiting room, in a dining room, in a therapeutic group) or they may be present in the nurse's mind (for example, while caring for one she may think "I have three more patients to visit," "so and so needs his medication in five minutes," "I promised so and so I'd get back to him," "three other patients are waiting to be fed"). Even when the nurse is responsible for only one patient, she often views him in relation to other patients she has nursed.

The nurse herself also functions within complex networks of interhuman relationships that affect the nursing dialogue. As health care becomes more specialized, more groups of health care workers arise and the various groups become more diversified. So the nurse's intersubjective transactions with her patients occur within an intra- and interdisciplinary milieu of constantly changing personnel, functions, and roles. While her own role is expanding, extending, deepening, broadening, becoming more specialized, she must relate with others undergoing similar change. And here again, as with the patients so with her colleagues, the nurse is constantly faced with the possibility and necessity of relating to others in terms of their functions and as persons.

Finally, it should be recognized that while it is easy and common to think of "the nurse" as synonymous with the function "nursing," in real life the nurse is a human being necessarily related to others. She learns to focus on those present in her here and now work situation. But she too is her history and brings to her work world all that she is and all that she is not including her past experienced and future antic.i.p.ated interhuman relationships. So each nurse affects her peopled nursing world and is affected by it in her own unique way.

>From the other side, the patient also enters into the nursing dialogue with his various networks of interhuman relationships. How he experiences his relationships with his family and significant others, with the patient groups of which he becomes a part in different degrees, with members of various disciplines and health services groups, with "the" nurse and "his" nurse, all influence the lived nursing dialogue.

It is always colored by the patient's current mode of interpersonal relating. Of course, the current mode reflects his past, for example, learned habits of response, and his future, for example, concerns about antic.i.p.ated changes in interpersonal relationships due to the effects of his illness. In some cases, the intersubjective behavior itself becomes the focus of the nursing dialogue as the area of the patient's greatest needs in attaining well-being and more-being.

Things

The nursing dialogue takes place in a real world of things, ordinary things of everyday living and all forms of health care equipment. Both types of objects affect the nurse-patient transactions and their influence varies for they may be experienced differently by nurse and patient.

Ordinary objects used everyday--eating utensils, clothes, furniture, books, television sets--are so familiar that one usually takes their use for granted. {33} However due to illness a person may be unable to manipulate a knife and fork, for example. They become frustrating objects. His tools are no longer extensions of himself but impediments and barriers. He feels handicapped. His world of things changes.

On entering a health care facility, the patient finds himself in a foreign world of strange objects. In place of his familiar possessions he is surrounded by equipment, machines, instruments, solutions, and so forth. He may experience these as bewildering, frightening, painful, supportive, soothing, life-sustaining. The nurse, on the other hand, may experience these same objects quite differently. To her they may be familiar tools, useful aids, complex machines, annoyingly defective equipment. Even in a situation that does not have special equipment, for instance in a home, the patient's world of things changes as the nurse converts ordinary objects into tools. Thus, while nurse and patient share a situation, the things in their shared world have different meanings for each. The things themselves as well as the persons'

relations to them can serve to enhance or inhibit the intersubjective transaction of nursing.

Time

To view dialogical nursing as it is actually experienced in the real world, one must conceive of it as occurring in time, not simply measured time but also time as lived by patient and nurse. Certainly both partic.i.p.ants are caught up in measured time and this influences their shared world, for example, eight-hour tours of duty, a day off, surgery scheduled at 8:00 a.m., discharge in two days, visit three times a week, clinic appointment in 30 days. Thus, to an extent, both patient and nurse must live by the clock and calendar.

However, equally important, or perhaps even more important, in the lived dialogue of nursing is the partic.i.p.ants' experience of time. Some references were made to lived time in the section on call and response where it was noted how the nursing dialogue unfolds over time from moments to years. How the involved persons experience this continuity is an individual matter.

The nurse may conceive of herself as one of many persons contributing to a continuous stream of caring for the patient. So she will give and hear and write and read reports, note observations, keep records. She will carry an image of the patient in her mind continually adding to it or changing it with each interaction or report. Sometimes, after not seeing the patient for a time, on meeting him again she will "pick up where she left off," treating him as if he were the same person, as if days, months, years of living had not intervened. "Oh, it's him again." Or she may be startled by the visible changes and resume the dialogue from that point. Or even if change is not visible, she may be aware that it may have occurred and try to fill in the gap.

These possibilities may be mirrored from the patient's standpoint, for he likewise experiences continuity or lack of it in his care. And yet, the experience must be different for him. For instance, nurses may think of continuity of care in terms of "coverage" for a planned program of care. So it has often been {34} claimed that "the nurse is with the patient 24 hours a day." From the patient's point of view this is not true. _A_ nurse may be with him but each nurse is different. The function of nursing may be continuous, but individual nurses come and go; the day nurse, the evening nurse, the night nurse are each unique individuals. And the nursing dialogue as lived, intersubjective transaction occurs between a particular nurse and a particular patient.

When we speak of a nurse and a hospitalized patient spending a day together, we usually are referring to eight hours out of a 24-hour day.

They may both experience the s.p.a.cing of this time by functions or activities such as meal time, medicine time, visiting time. Yet the measured minutes and hours are experienced differently by each in their different modes of being in the situation. Nurses often express feelings of not having enough time to give the care they want to give; of having too many demands on their time; of trying to "make time" for patients who ask "do you have a minute?" Patients live their time in relation to boredom, pain, loneliness, separation, waiting. The nursing dialogue runs its course in clock time but both nurse and patient live it in their private times.

When the nursing dialogue is genuinely intersubjective, it has a kind of _synchronicity_ that is evident in the nurse's being with and doing with the patient. This kind of timing is related to the transactional character of nursing and to its goal of nurturing the development of human potential. It is experienced in openness, availability, and presence, as well as in nursing care activities. The nurse feels in harmony with the rhythm of the dialogue and, sensing the timing of its flow, she paces her call and response to patient's ability to call and respond in that moment. So, as a nurse, you may find yourself almost unconsciously or intuitively waiting, holding back, antic.i.p.ating, urging the patient. This kind of synchronization or timing is intersubjective for the clues or reasons for encouraging or waiting are not found solely in the patient's behavior nor only in the nurse's knowledge or experience. "Good" or "right" timing somehow involves the "between." It implies that nurse and patient share not only clock time but private, lived time.

s.p.a.ce

By exploring the dialogue of nursing as it is lived in the real world the factor of s.p.a.ce becomes apparent. Here again the dialogue is influenced by s.p.a.ce as it is measured and s.p.a.ce as it is experienced by nurse and patient. When thinking of health care facilities, "s.p.a.ce" may be synonymous with such things as beds, waiting rooms, interview rooms, treatment areas, size of patient's room, visiting areas, a quiet place, a private place. Naturally, the physical setting, whether in a hospital, home, anywhere in the community, can serve to enhance or impede the nursing dialogue. However, the person's experience of the s.p.a.ce may be even more important.

s.p.a.ce is lived in terms of large and small, far and near, long and short, high and deep, above and below, before and behind, left and right, across, all {35} around, empty, crowded. These perceptions and experiences of s.p.a.ce may be influenced by the effects of illness, for example, changes in vision or locomotor ability. Thus, a patient's spatial world may change, expand or diminish, become unmanageable or manageable day by day. Furthermore, a patient's att.i.tude toward and experience of a particular place may be affected by his mental a.s.sociation to it (for example, oncology ward, psychiatric unit), his previous experience in it (for example, emergency room, operating room), or a desire to be somewhere else (for example, "This is a nice hospital but I'd rather be home").

Place is a kind of lived s.p.a.ce. It is personalized s.p.a.ce. One says, for example, "Come to my place" meaning to my home. Or even more personally, it relates to where I feel I belong or am, for instance, "he put me in my place; I felt put down." The patient may feel "out of place" in the health care setting, while it may be commonplace to the nurse. There may be areas in the setting that the patient experiences as his territory, for example, his bed, his room, his ward; while other areas are "theirs"

or "restricted to authorized personnel." So a nurse and a patient may be in a place together, yet one feels at home and the other does not. For the nurse to be really _with_ the patient involves her knowing him in _his_ lived s.p.a.ce, in his here and now.

Lived s.p.a.ce is interrelated with lived time. Patients hospitalized for a long time often express a proprietary att.i.tude toward the hospital. The same holds true for personnel. With time and familiarity a feeling of reciprocal belongingness grows. The person belongs in the place and the place belongs to the person. On the other hand, when a person finds himself in a new place he may feel the discomfort of not belonging. This is as true for the nurse in an unfamiliar setting as for the patient.

Again in this regard, the lived nursing dialogue is enhanced by the nurse's awareness of not only her own experience of s.p.a.ce but the patient's as well.

CONCLUSION

This chapter explored the basic view of humanistic nursing as a phenomenon in which human persons meet in a nurturing, intersubjective transaction. Beginning with the central intuition that nursing is lived dialogue, the examination turned to its existential source, the nursing situation as it is lived. Reflection on actual experience clarified the phenomena of meeting, relating, presence, and call and response as they occur in humanistic nursing. Dialogical nursing was then reconsidered in broader perspective as it actually evolves in the real world of men and things in time and s.p.a.ce.

As scientific advances multiply in the health field, nursing is swept along in the tide. Continuous technological changes, ever increasing specialization, emphasis in nursing education and research on scientific methodology all have marked influence on the development of nursing.

Science (with a capital S) colors the nursing world. At every turn it permeates the nurse's being with and {36} doing with the patient. It offers a certain security by providing a consistent and effective approach to some problems and questions, and, in some cases, results in general laws to guide practice. At the same time, in the lived nursing world the nurse experiences a reality that is not open to the scientific approach, a reality not always verifiable through sense perception, a reality of individuality. The uniqueness of individuality (her own as well as the patient's) pervades the nursing dialogue.

The ever-present individual differences may be regarded as intractable elements to be conquered for the sake of the efficiency of the system (for example, fit the patient to the treatment program). Or they may be valued as indicators of the inexhaustible richness of human potential to be developed. In their daily practice, nurses are drawn toward the two realities--the reality of the "objective" scientific world and the reality of the "subjective-objective" lived world. This tension is lived out in the nursing act. Doing with and being with the patient calls for a complementary synthesis by the nurse of these two forms of human dialogue, "I-It" and "I-Thou." Both are inherent in humanistic nursing for it is a dialogue lived in the objective and intersubjective realms of the real world.

In the highly complex health care system nurses experience many demands from many directions. Their clinical judgments in daily practice must be made within a continuous stream of decisions about priorities of investment of their time and efforts. Sometimes, survival in the system reduces the nurse to following the line of least resistance, that is, responding to the immediate or to the loudest demands. However, even with their total commitment this course of response does not guarantee that nurses are making their greatest possible contribution to health care. This can happen only if we are able to see demands and opportunities in relation to our reason for being--nurturing the well-being and more-being of persons in need.

Humanistic nursing, viewed as a lived dialogue, offers a frame of orientation that places the center of our universe at the nurse-patient inter subjective transaction. Insightful recognition of the lived nursing act as the point around which all our functions revolve, could require a Copernican revolution of orientation of some nurses. It does provide, for all nurses, a true sense of direction that can be actualized by each unique nurse through creative human dialogue. {37}

4

PHENOMENON OF COMMUNITY

Humanistic nursing creates, happens within, and is affected by community. This chapter will discuss the abstract term "community." To stimulate thought on a nurse's influence on community, consideration will be given to three points: (1) my angular view of community and its evolvement, (2) how man has considered community over time, (3) how a human being comes to be through community.

MY ANGULAR VIEW

One can view members of a family, a student cla.s.s, a hospital unit, a hospital staff, several related hospital staffs, health services organizations within a geographic area, a profession, a town to a world or universe as community. Man's mind, my mind, determines where I superimpose the limits or lift the limits or relate components. In _The Republic_ Plato depicted a community as a macrocosm.[1] Its nature was conditioned by the kinds of men, the microcosms, that composed it. The macrocosm was a reflection of its microcosms.

So each human person, each nurse, as a microcosm, could make a difference. Reflecting on the lived worlds of nurses, their communities, if we use Plato's philosophical a.n.a.logy of macrocosm-microcosm, despite the varieties of situation, we can make meaningful a basic concept of community. Such a concept utilized by a nurse to view her particular ongoing changing world can help her to understand more realistically, survive within, and strugglingly partic.i.p.ate as a quality force.

To be a quality force within community a nurse must open her being to the endless innovative possibilities and unattempted choices available to her. {38} The ability to thus open one's self requires our exposing our biases, the shades through which we regard the world, to the sunlight. In nursing our shades often are closed categories, labels, diagnoses, trite superficial hackneyed expressions learned by us, taught to us as fact, taken in unexamined, and left unreexamined despite other changes in ourselves and our situations. Socrates said, and it still holds, that the unexamined life is not worth living. Our shades can be cherished concepts, beliefs that guide us automatically rather than thoughtfully. Whether they are entirely myth or partial truths, they can cause us agonizing dilemma because they obscure the obviously relevant and the possibilities beyond. A concept of community, if grasped and if a nurse is truly consciously aware, can help her to understand how her nursing world has evolved, is presently, and how she can be, to shape its future in accordance with her values.

As nurses one of our shades is often the confining labels we give to ourselves as doers in service giving profession. I would like to go on record as most respectful of this aspect of my world. I regret, nonetheless, that we have not always similarly crystallized and floodlighted the discovery and creative possibilities in our communities. In our very personal, intimate, involved professional nursing relations with other man we are privileged to be included in human happenings open to no other group. As nurses, we have had and are having emphasized to us the importance of facts handed to us. Can we actuate the importance of the knowledge of man that becomes part of us through our nursing worlds? It is hard to honor the significance of the everyday, the commonplace, the intimately known? It has been said that one could know of the whole universe if one could make every possible relationship starting from a piece of bread. Think of a "simple" or "routine" nursing situation. Think of its true complexity and how it can trigger puzzlement, wonderment, and thinking. As learning situations, nurses' situations are existentially priceless. Returning now to Plato's conception of community understood through the terms macrocosm and microcosm, what can the nursing world situation reveal to us of community? What are the qualities of the partic.i.p.ants, the microcosms, and how are these qualities reflected in our nursing communities?

HISTORY: THE SHADES OF MY WORLD, BRACKETED

In years past as a public health mental health psychiatric nurse I have structured facts about man, family, and community precisely for presentation. Approaching the data sociopsychologically I framed it in the public health model of promotion of health, prevention of illness, treatment, rehabilitation, and maintenance. I thought of family sociologically as nuclear, procreative, and extended. In accordance with the psychoa.n.a.lytic model, family members were oral, a.n.a.l, oedipal, latent, h.o.m.os.e.xual, adolescent, heteros.e.xual, and/or mature. Community, like person and family, was considered according to a {39} closed paradigm, ranging from ideal to abysmal, from the smallest to the largest unit in which persons congregated for common purposes. I selected from experience nursing examples to make these sociopsychological public health constructs meaningful. I did not start from nursing experiences to come up with nursing concepts of man, family, and community. I denied my particular self as a source of knowledge of these areas. Had education programmed me to value only others' ideas gleaned in the cla.s.sroom or from books? I projected this devaluation of my own ideas onto my colleagues and until I really knew them gave them what I thought they wanted, others' ideas. Presently I prize my uncertainty about the nature of man in family and community and my striving toward an ever explorative process of being and becoming, available for surprise. Paradoxically, I believe it was these very same capacities, uncertainty and striving, that compelled my superimposing on my colleagues with certainty other persons' and other professions'

views. Actually, my certainty about the conundrums: man, family, community come only in particulars and only in fits and starts, and my certainty is at once a truth and a nontruth. I see my aim as ever striving toward certainty while constantly wrestling with the discomfort of uncertainty.

EACH NURSE: A _NOETIC LOCUS_[2]

Each nurse is a "knowing place." It feels as if my greatest talents, as a human nurse person, awaited my acceptance that came through as I related to the existentialist thinking of persons like Martin Buber, Teilhard de Chardin, Frederick Nietzsche, Karl Popper, Hermann Hesse, Wilfrid Desan, and Norman Cousins. Now when I think of the phenomena--man, family, community--Theresa G. Muller, nurse educator and clinician, who quoted Hersey from his novel, _A Single Pebble_, comes to mind.[3] He said, "I approached the river as a dry scientific problem; I found it instead an avenue along which human beings moved whom I had not the insight, even though I had the vocabulary, to understand." I consider my greatest gifts as a human being nurse my ability to relate to other man, to wonder, search, and imagine about my experience, and to create out of what I come to know. My ever developing internalized community of world thinkers dynamically interrelated with my conscious awareness of my experienced nursing realm allows my appreciation of my human gifts and the ever enrichment of myself as a "knowing place."

NURSE: EXPERIENCE INTERNALIZED