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

Also, although the nurse and the patient have the same goal, that is, well-being and more-being, they have different modes of being in the shared situation. One's purpose is to nurture; the other's is to be nurtured. This difference in the perspectives from which they approach the meeting is reflected in the kind and degree of their openness to each other.

In describing their experiences nurses often have revealed that they are open to patients in a certain way. This is evident when nurse and patient meet. The nurse may have prior knowledge of the patient, perhaps even an image of him drawn from case history, charts, tour of duty reports, and so forth; or she may meet him as a total stranger. But when they come together, the nurse sees "the patient as a whole." This global apprehension is not experienced as an additive summation but rather as a gestalt. It may result in a very clear "picture" of the patient's condition with nursing action initiated almost before the picture registers in full conscious awareness. Or the perception may be imprecise yet strong that "something is wrong." From these experiences one may infer that a nurse's openness involves being open to what is and to what is not in the patient's state of being as weighed against some notion (or standard) of what "ought" to be, with the intention of doing something about the difference. Thus, the nurse is open-as-a-helper to the patient. This kind of openness is a quality that characterizes the humanistic nursing dialogue. Of course, every nurse-patient meeting differs, for each participant comes to the situation as the {26} unique individual he is, with his own expectations and capacities for giving and taking help.

When these factors are considered in terms of an actual personal nursing experience (for instance, the example recalled above by the reader), they highlight a tension in the lived nursing world. The meeting through which the nursing dialogue is initiated and consequently is possible is, to a certain extent, out of the nurse's control. She is assigned to approach or she approaches the patient in terms of her function. In this sense, "the nurse" is synonymous with the function "nursing." Yet she experiences each meeting as herself—a unique individual person, this here-and-now being in this body responding in this situation. She is at once a replaceable cog in a wheel of an incomprehensibly complex system and a unique human being sharing most intimately in another's search for the meanings of suffering, living, dying. Can these two world views be reconciled? How can they be lived in the nursing dialogue?

Relating

As a human response to a person in need, the nursing act is necessarily an intersubjective transaction. Or to put it in other words, regardless of the complexity of need and/or response, when nurse and patient meet in the event of nursing both have "to do" with each other. Since both are human, their doing with means being with. (Reflect for a moment on the personally experienced patient encounter you recalled at the beginning of this exploration. Relive it and see clearly again that the nursing dialogue involves being with and doing with the patient.)

Men can do with and be with each other because they are able to see others and things as distinct from themselves and enter into relation with them. What distinguishes the human situation is that men can enter into a dialogue with reality. They have a capacity for for internal relationships, for knowing themselves and their worlds within themselves, they can relate as subject to object (for example, as knower to thing known) and as subject to subject, that is, as person to person. Both types of relationships are essential for genuine human existence.

It is natural, in fact unavoidable, for man to relate to his world as subject to object. How could a person survive even one day without knowing and using objects? Therefore, man's abilities to abstract, objectify, conceptualize, categorize, and so forth, are necessary for everyday living. Even beyond this, the human capacity for relating to the other as object is basic to the advancement of mankind for it underlies science, art, and philosophy. It is simply one way of being human.

Another mode of relating is open to men. Whenever two persons are present to each other as human beings, the possibility of intersubjective dialogue exists. Since both are subjects with the capabilities for internal relationships, they can be open, available, and knowable to each other. They can know each other within themselves. Furthermore, they can be truly with each other in the {27} intersubjective realm because while maintaining their own unique identities, they can participate in an interior union. Intersubjective relating is also necessary for human existence. For it is through his relationships with other men that a person develops his human potential and becomes a unique individual.

Nursing, being an interhuman event, has within it possibilities for various types and degrees of relationships. Both nurse and patient can view themselves and the other as objects and as subjects or in any variation or combination of these ways. A person can view and relate to another person as an object, for instance as a mere function ("patient," "nurse," "supervisor," "medicine nurse," "admitting nurse," "administration") or as a case or type ("schizophrenic," "cardiac," "outpatient," "readmission," "bed patient," "wheelchair patient," "total care patient," "terminal patient"). Such subject-object or "I-It" relationships differ essentially from subject-subject or "I-Thou" relationships.

As the derivation of the term indicates, an object is something placed before or opposite; it is anything that can be apprehended intellectually. Through objectification the object is de-individualized and therefore made replaceable for the purpose of study by any other object with the same properties. It is indifferent to the act by which it is thought and, therefore, the subject studying the object may also be replaced by a similar subject.

Although it is possible to view a person as an object, persons and things are necessarily different kinds of objects. A thing, as object, is open to a subject's scrutiny, while a person, as object, can make himself knowable or set up barriers to objectification. He can keep his thoughts to himself, remain silent, or deliberately conceal some of his qualities.

Through the scientific objective approach, that is, subject-object relating, it is possible to gain certain knowledge about a person; through intersubjective, that is, subject-subject relating, it is possible to know a person in his unique individuality. Thus, both subject-subject and subject-object relationships are essential to the clinical nursing process. Both are integral elements of humanistic nursing.

Presence

In the nursing world, as in the world at large, human encounters may range from the trivial to the extremely significant. Within a day's work, the nurse may experience many levels of intersubjectivity from the lowest level of being called on as a function or being used as an object, to the other end of the scale of being recognized as a presence or a thou in genuine dialogue.

Nursing activities bring a nurse and patient into close physical proximity, but this in itself does not guarantee genuine intersubjectivity in which a man relates to another person as a "presence" rather than an object. A presence cannot be grasped or seized like an object. It cannot be demanded or {28} commanded; it only can be welcomed or rejected. In a sense, it lies beyond comprehension and can only be invoked or evoked.

There is a quality of unpredictableness or spontaneity about genuine dialogue. A nurse may be going through her daily activities, functioning effectively, relating humanely, when suddenly she is stopped by something in the patient, perhaps a look of fear, a tug at her sleeve, a moan, a reaching for her hand, a question, emptiness. In a suspenseful pause two persons hover between their private worlds and the realm of intersubjectivity. Two humans stand on the brink of the between for a precious moment filled with promise and fear. With my hand on the doorknob to open myself from within, I hesitate—should I, will I let me out, let him in? Time is suspended, then moves again as I move with resolve to recognize, to give testimony to the other presence.

Thus, for genuine dialogue to occur there must be a certain openness, a receptivity, readiness, or availability. The open or available person reveals himself as "present." This is not the same as being attentive; a listener may be attentive and still refuse to give himself. Visible actions do not necessarily signify presence so it cannot be proven. But it can be revealed directly and unmistakably in a glance, a touch, a tone of voice. (I can only ask you to substantiate this statement with your own experience.) Availability implies, therefore, not only being at the other's disposal but also being with him with the whole of oneself. Furthermore, it involves a reciprocity. The other is also seen as a presence, as a person rather than an object, such as a function or a case.

As was discussed earlier, the nursing dialogue occurs within the domain of health and illness and has a purpose in the minds of the participants. Nursing is a lived dialogue (a being with and doing with) aimed at nurturing well-being and more-being. This fact of goal-directedness modifies or characterizes dialogical presence. As a nurse I try to be open to the other as a person, a presence, and to be available to the other. Yet, when I reflect upon my presence, I realize that my openness is an openness to a "person-with-needs" and my availability is an "availability-in-a-helping-way." By comparison, my experiences of openness and availability in social, family, or friend relationships and in nurse-patient relationships differ. In the later, I find myself responding with a kind of "professional reserve." While it is true that what I conceive of as "professional" and the degree of "reserve" has varied over the years and from patient to patient, nevertheless, it is always a factor influencing the tone of my lived dialogue of nursing.

It is the qualitative differences in the various experiences of presence that deserve, yet almost defy, description. For instance, the presence seems to have a different quality of intimacy. It is not experienced as less intense or less deep in the nurse-patient relationship, but as somehow colored by a sense of responsibility or regard for what is seen as the patient's vulnerability. At times I am aware of a shadow of "holding back" in terms of what I consider "nurturing" {29} or "therapeutically appropriate" at a given moment. As a nurse, I find my presence flows through a filter of therapeutic tact.

Or again, the mutuality of presence may be experienced in the nurse-patient situation. At times I become consciously and acutely aware of the reciprocal flow of openness in the dialogue. It is as strong, definite, immediate, and total as in other dialogical relationships and yet it is somehow different. It is felt as a flow between two persons with different modes of being in the shared situation. My reason for being there, to nurture, and his, to be nurtured, bob into my consciousness like buoys marking the channel of openness.

Often in nursing it is necessary to focus my attention on some aspect of the patient's body or behavior. The patient may or may not have the same focus of attention. At least momentarily then, or even for a prolonged period, I place some aspect of the patient before or opposite myself (that is, objectify it). And to the extent that this detail absorbs my attention, I lose my sight of and my relatedness to the whole person who happens to be the patient. While I know this focusing on details to be a necessary step in the nursing process, sometimes I find myself abruptly refocusing my attention on the whole person with almost a twinge of guilt for having abandoned him. (Patients have described this uncomfortable intersubjective experience as feeling "looked at" or "watched" by staff.) At other times, on reflection, I find my attention was oscillating between the detail and the person, or focusing on both relating one to the other. From these experiences it is evident that dialogical presence is complicated in the nursing situation. It is inhibited when the focus of attention (of one or both participants) is on the patient's body itself or on his behavior. Yet the body is an integral part of the person and his behavior is an expression of his mode of existence or his way of being in the world. Man is an embodied being, and the nurse, in nurturing the patient's well-being and more-being, must relate to him and his body in their mysterious interrelatedness.

Call and Response

The dialogical character of nursing may be explored further by considering it in the general sense of a call and response. Nursing is a purposeful call and response, that is, it is related to some particular kind of