Humanistic Nursing - Loretta T. Zderad (best books to read for knowledge TXT) 📗

that his excessive ritualistic behavior was his way of coping with his discomfort. One repetitively stated a happy illusion that he seemed to hang on to for dear life. When I asked what he would do if this illusion was not truth, he said that he had never considered {102} this possibility. I knew he had been confronted with the truth of his situation many times in many ways. One patient merely looked directly at me and walked away.

Then I again reviewed my clinical recorded data to see what kinds of knowledge nursing with an aim to comfort would infer as necessary. Fifty-two items of knowledge were extrapolated from the clinical examples selected as representative of the twelve nurse behaviors. These items were categorized under broad cognitive and affective domains. This was an arbitrary point of separation. They were teased apart simply as an aid to conceptualization and understanding. If these knowledge domains had related to one another in a simple direct manner, I would have conveyed them in a table in which each would have been across from its mate. Their relationships to one another were far too complex to be handled in any such a way. The affective domain knowledge areas were a dynamic internalized synthesis of several knowledge areas from the cognitive domain. Thus, the expression of these affective knowledge areas was evidence of the practice of nursing as an artful form of expressing cognitive knowing.

In looking directly at the discomfort of long-term hospitalized psychiatric patients, I found myself faced with behaviors that resulted possibly from a muddle of many contributories. What in the behavior resulted from lifetime environmental influences and compounded responses that deepened scars? What resulted from long-term hospitalization? How many varieties of ills superimposed like layers on the above were expressed in what I saw as discomfort in these psychiatric patients? Diagnostic classifications are necessary for statistical economic planning reasons. Still, how naively and superficially they convey the human therapeutic care needs of each person.

At this point of construct development I saw a positive relationship in my thinking about comfort as a proper aim of psychiatric nursing and Viktor Frankl's description of his aim in logotherapy toward meaning. I had struggled with the idea of aiming at comfort while with patients who possessed ability and a favorable prognosis, often purposefully and deliberately asking them to consider ideas that caused them immediate greater discomfort. Frankl's quotes from Nietzsche and Goethe supported my altruistic intention. Nietzsche said:

"He who has a why to live can bear almost any how."[4]

Goethe said:

"When we take man as he is, we make him worse; but when we take man as if he were already what he should be, we promote him to what he can be."[5]

In conclusion to this stage of development of a synthetic construct of comfort as an aim of psychiatric nursing I can say: Comfort is an aim toward {103} which persons' conditions of being move through relationship with others by internalizing freedom from painful controlling effects of the past. These effects have inhibited their self-control, realistic planning, and prevented them from being all that they could be in accordance with their potential at any particular time in any particular situation. I would project this as an aim for nursing in all situations although the data for constructing this conceptualization were gathered in a clinical psychiatric setting.

CLINICAL: HOW

As a component of my doctoral examinations I was faced with having to rewrite a clinical paper. This led to my deliberately and personally choosing to conceptualize a synthetic construct of "clinical." This was my decision. It speaks well for the value of having had the experience of conceptualizing "comfort." Often it is said that man repeats that which he finds as meaningful and good. This choice also signifies a real overcoming of my resistance and ambivalence toward synthetic construct development in a year's time.

"Clinical" was developed as a synthetic construct in 1968. It was a conceptualized response to a dialectical process within myself. If I am a clinician, then "how" I am in the health-nursing situation would equate to "clinical." In conceptualizing this construct I teased out of my lived-nursing-world the "how" of my working toward my own and others' comfort.

Confusion, over what was meant when persons casually and currently popularly attributed the term "clinical" to situations and persons, called forth this conceptualization. It grew out of comparing and contrasting two nursing consultation experiences in the psychiatric-mental health area. Beginning this conceptualization I would have referred to both these experiences as "clinical." At the termination of the conceptualization they were both "clinical." They were very different experiences for me, and yet of equal value in my advancement toward my more of being. Prior to this conceptualization because my attending emotions were so disturbing and unacceptable to me in relation to one of these experiences, automatically I repressed part of them and found reasons to suppress the rest of them. Unfortunately, all else that was of value to me in having lived this experience was integrally enmeshed with these emotions. This, too, became unavailable to my conscious awareness. Conceptualization made recall and reflection a necessity. Clinical includes inherently a process of experiencing awarely and then recalling, looking at, reflecting on, and sorting out to come to knowing.

Before knowing how to approach the rewriting of my clinical paper as a partial requirement for receiving my doctoral degree I experienced a depression. I felt frightened, angry, and inadequate. The original clinical paper had been judged as more intellectual and scholarly than clinical. I could conceive of only two alternatives. Both seemed self-defeating. One, I could revise my former clinical paper into a more intellectual and scholarly paper that still {104} would not be clinical and would still leave my "I" out. Or, two, I could revise my former clinical paper, dump all my feelings in the situational experience, blame everyone else for these feelings, and culminate at least with my clinical passions visible. Conflict resulted from my considering pursuing either of these routes. I was immobilized for a time. A time limitation and time passing pushed me to begin somewhere. I began. Choosing the second alternative in the belief that at least through writing I would better understand what I had lived in the experience.

I could support the value of dredging up these old feelings and looking at them. Authentically letting myself be aware of what I had experienced, not necessarily communicating this or acting out in accordance with these redredged feelings; just really looking at them might allow me choice in how I wanted to live with them. One support for the value of looking at these old feelings was my own past three and one-half years in psychoanalysis in which I profited through such a process. The other support was my readings of the past two years. These included works of Russell,[6] Nietzsche,[7] Plato,[8] Popper,[9] Dewey,[10] Buber,[11] Bergson,[12] Cousins,[13] and de Chardin.[14]

As this experience became in shape and meaning through my writing, I began to view this product as like an existential play filled with blatant atrocities and absurdities that had to be nonrealities. This production, also, made visible beautiful raw data. As meaning in this clinical nursing consultation experience as a graduate student became evident, comparison of it with the meaning of clinical work experiences in nursing consultation situations flowed naturally. Then joy, it was like sunshine burst forth and warmed my spirit.

Before entering school, I was, for two years, a mental health psychiatric clinical nurse consultant to a staff of forty-five visiting nurses. I had become intrigued {105} with what I had come to understand about consultation related to clinical situations. I wrote a paper for publication on the subject. Busy in the process of returning to school, and awaiting the publication of two other papers—both of these proceedings feeling unreal and out of my control, not to mention self-exposing—I merely filed in my desk the typed submittable rendition of this consultation paper. Now, I dug it out. This meant that I had two conceptualized presentations of similar type personal experiences in nursing consultation to compare and contrast. From these, my conceptualization of clinical, and the values on which my clinical practice rests, could be extrapolated.

A Student Consultation Experience Becomes Clinical

In the graduate student nurse consultation experience I felt helpless, confused, unwanted, guilty, anxious, and unimportant. It was a passion-filled experience for me. As a nurse-student consultant among interdisciplinary nonstudent-consultants I experienced dependency for my being and doing on persons I viewed as anxious, critical, nonempathetic, and inadequate. We were attempting to offer consultation to a professional group of nonpsychiatric mental health oriented consultees who were anxious and felt inadequate in this area. I felt forced into an observer rather than participant mode of being, and my recorded data support this. Impotency comes to mind when I recall this experience, as well as a racking rage and suffering that obliterates feelings of love, good-will, tenderness, or hope. About that time I was reading Nietzsche's eternal recurrence phenomenon[15] and viewed it most pessimistically—all was awful, it would continue to be awful, life was just a vicious cycle of awfulness.

Defense or health, it is questionable. Suddenly, perhaps it was having hit feelings of rock bottom, I began to view Nietzsche's eternal recurrence phenomenon optimistically. Did the polarization of my negative feelings magnetically call forth my opposite feelings? All, now, contained the new, it would continue to contain the new, life was a series of similar and yet different cycles that always contained the new.

Now my reflections let in hope, positiveness, comradeship, good feelings, and progress made by myself and others in our year and a half together as consultants. During this period we met with the consultees for an hour once or twice a week. The group had continued over this period despite its components of psychiatric mental health professionals and nonpsychiatric mental health profession culturally, professionally, and historically having been quite alienated from one another. Attendance had improved some over time. Toward the end of the year and a half, during the last three months, the focus of discussion was on patients and their worlds for longer periods of time. There was less defensive acting out in which things, fees, time, and mechanics consumed the hour.

{106}

Toward the end of these sessions the consultant chief found more acceptable space in which to meet for the consultation. Eating lunch became part of the session. Food can be looked at in many ways. In this case it seemed to be a cohesive force, rather than a distracting, socializing force. Was this because of the underlying meanings food had for these people? Or was the meaning of food in this situation concrete? Now the consultees could have their lunch served to them while receiving consultation. This latter saved their time and meant money to them. This was a giving gesture on the part of the consultants even though the lunch monies did come out of the project funding source. The meaning of food was never discussed in the group. I wonder if this feeding was done with deliberate awareness or was just serendipitous.

During the last three months of meeting I began to feel related on a deeper level with a few of the participants, consultants and consultees. Individual to individual we began to communicate collaboratively with one another as professional colleagues. We discussed both patients' lived worlds and the meaning of psychiatric mental health terms and ideas. I can conceive, now, that this may have occurred between other group members before or after sessions. Initially there were often only two to three consultees to five or six consultants. Later the total group contained fifteen to sixteen people. Now I would project that the very existence of this group could influence future groups positively.

A Clinical Work Consultation Experience

In this work consultation experience my feelings were openness, reflectiveness, pain, helpfulness, alertness, searchfulness, appreciativeness, receptiveness, responsiveness, wantedness, competence, joy, and importance. It was both a passionate and a dispassionate experience. As a working consultant I met with consultees either alone or as part of a collaborating team of consultants. Often the situations the consultees presented which they struggled with and stayed in struck me with awe. They aroused my humility while making me feel whole and fulfilled in my participation with the consultees. In my explorations of and with the consultees my presence, thereness, and authenticity were all important. Buber would say that my aim in consultation was to "imagine the real" of what the consultee and the patients and families she discussed with me "could be."[16] This was my initial disposition. I aimed to be open to and accept the potentials of these others.

In initial receptiveness, grounded in my comfort, was the "key" to the "door" of the consultant-consultee "I-Thou" relation in which I could come