Chapter 4
METHODOLOGY--A PROCESS OF BEING {50} {51}
5
TOWARD A RESPONSIBLE FREE RESEARCH NURSE IN THE HEALTH ARENA
ANGULAR VIEW
Research is an inherent component of humanistic nursing. What condition of humanness is necessary in the nurse for the actualization of nursing's research potential? This chapter will attempt to share some brooding and mulling on this problem.
Nurses practice within ever-moving, changing settings where formulated plans frequently and suddenly go awry. Unexpected patient needs arise. Powerful others make both reasonable and unreasonable demands. Depended on others fail us due to human frailty or lack of dependability. The nurse's setting, her researchable area, is the extreme opposite of her colleague's, the laboratory investigator's. Her area is beyond research control measures. Too, it lacks the quiet isolated atmosphere conducive to contemplation and creative thinking associated with research.
Conversely, it is oversaturated with the "stuff" of meaningful existence. It can stimulate questions to the frenzy of immobilization. The human nurse's system can become overloaded. Such overloading reflects the humanness of the nurse; like all man she can envision possibilities beyond any human being's ability of fulfillment.
Nurses know there are events in their commonplace worlds that scream for human interpretation, understanding, and attestation. The question becomes "how." This "how" depends on more than concretes and events in the nurse's setting. This "how" depends on relevant "ifs." The meaningfulness of the nursing world will be actualized conceptually "if" this is supported by institutional economic and administrative planners, other nurses, and intradisciplinary colleagues. For knowledge available and visible to nurses in the health setting to be preserved, conceptualized for durability, it needs to be valued by the institutional health community. Still, most necessary to its duration is the appreciating of this knowledge by the nurse, herself. {52}
HUMAN CONDITION OF BEING: NURSE RESEARCHER
Initiation of a Nurse Researcher
The nurse student, recently arrived in her experiential world, is awed with the need to be cognizant of multitudinous factors. At this initial introductory phase one could say her "being" as a nurse is programmed or imprinted with: It is your responsibility to report and attend all the things that influence the response and comfort of those for whom you care. This programming supports and is supported by any already existing tendencies within the nurse student toward unrealistic, perfectionistic expectations of self.
Then in research courses, usually positivistically geared, her programming jams. Her system is fed: Select out, isolate, focus down on a single question, limit your variables, establish a protocol of operation, control for reliability and validity, tunnel your vision, and safeguard objectivity. The jamming is the result of the human nurse's capacity to see relationships between the part and the whole. Human intelligence, as a condition of humanness, demands this relating of one thing to another. Often such relating is intuitive, human, based on much thinking for purposes of understanding and solution. Yet, often it cannot be substantiated fully and conceptualized logically at specific times, therefore it is subjective.
To highlight the obvious in the above I attempted facetiousness. Many nurses acutely aware of the complexities, contradictions, and inconsistencies of their nursing worlds have struggled and used the positivistic method in research studies. Hence, they have isolated a researchable question, stated their basic assumptions, hypothesized outcomes, selected samples, established experimental and control groups, formulated methodologies, searched out and utilized appropriate findings, and have made recommendations. Usually these research efforts have advanced scientific knowing and knowledge of existents within the health-nursing situation. And yet, often these efforts have discouraged the research wonderment of the nurse interested in the nature and meaning of the nursing act and how the event of nursing is lived, experienced, and responded to by the participants. These positivistic research methods have made available answers. Still, they have not answered the questions most relevant to nursing practice and to nurses.
These nurses were certain that man generally could not be prescribed for interpersonally; he was not predictable, not yet an automaton. Faced with alternatives men often surprised. Consequently these positivistic approaches to studying human events, unless one forced one's data crowbar style, always terminated with a kind of miscellaneous category. Man's undeterminedness makes him all-at-once frustrating to study, impossible to distinctly categorize, and excitingly mysterious and the most worthy focus of nursing research. {53}
A Nurse Researcher's Presence in the Nursing-Health Setting
The existent, a nurse labeled researcher, in the health world brings a disquiet that has to be understood and endured. Necessities for scientific study in the nurse's world of the nursing event or situation are wonderment, concern, and responsibility. Open adherence to such qualities frequently startles others into speculating about the researcher. She, herself, becomes an oddity. Persons ponder the possibility of her study's having a hidden agenda that involves them. Over time these persons generally accept or reject the searcher's efforts. If rejected the searcher is often labeled a worthless nosey troublemaker. Subtly it is conveyed among those involved that she is to be interfered with often by mechanisms of ignoring or forgetting or righteously setting "patient's needs" above conforming to the study plan. For instance, how often have research nurses met with responses from staff at the time of their planned arrival on a unit to work with a patient, "Oh, he seemed to need activity, he was restless, I forgot you were coming, I sent him to the gym," or "Oh, (surprise) did you want to give the patient his morning care? That was done a while ago; we give care early." If accepted the searcher is often labeled an interested, interesting person whose efforts are to be fostered because her findings will enhance situation nursing. The distinction frequently is based in staffs' responses to the searcher's personality more than in the value of the issues of the investigation.
Significant to negative staff responses toward a nurse searcher is the necessity for her to withhold information. This withholding may be necessary to protect the study results. For example, it is necessary when a special type of patient care is being tested against usual patient care or when confidentiality is an issue. Confidentiality requires a nurse, searcher or not, to censor communications when personal knowledge of individuals make them identifiable. The need for confidentiality can be determined by the nurse's considering the knowledge gained in view of whether it will or will not influence the over-all treatment plan. If it will affect the plan, there is reason to reveal it; then it must be related in a manner that insures the patient's continued protection and, if possible, with his permission. If over-all treatment is not influenced, one must censor the knowledge gained to check one's own free communications. Would the patient want it revealed; is it knowledge of a quality that brings ridicule, is looked at negatively or nonacceptably in our particular culture generally? Is it of a sensitive nature and therefore knowledge we do not just reveal to anyone?
Other patient care givers may sense this withholding by the nurse searcher. They may reasonably accept it or unreasonably not accept it. The researcher may or may not be aware of or concern herself with her colleagues' sensitivity. This would depend on the searcher's usual modus operandi and on the importance she associates with her colleagues' sway in her investigation. The latter can be much greater than is obvious. {54}
Confidentiality--Description: Humanistic Nursing
Humanistic nursing practice theory proposes phenomenology, a descriptive approach to participants in the nursing situation as a method for studying, interpreting, and attesting the nature and meaning of the lived events. Humane nursing is not humanistic nursing within this theory unless that which becomes visible to the nurse in the nursing situation is shared in a durable form with colleagues.
Confidentiality, then, becomes an important issue in humanistic nursing. No scientific methodology of research is affixed with "ought" or "should" virtues regarding knowledge gained. In nursing, a professional helping realm, a practitioner or researcher is wed to "ought" and "should" virtues. The knowledge gained "ought" to be dispersed to colleagues for their increased understanding. It "should" enhance the constructive force of the profession. To so enhance it "must" be communicated in a manner that allows understanding while protecting distinct individuals and groups. Words and conceptualized ideas are the tools of phenomenology. Protection of distinct persons and meaningful communication can be augmented through the utilization of abstractions, metaphors, analogies, and parables. So humanistic nurses, as practitioners and researchers, are inherently responsible for their manner of being, responding, and consciously sculpturing knowledge into words.
Responsibility When Sharing: Understanding of Man
How does a nurse searcher, who wonders, notices, relates, and comes to know, become humanly responsible? Nietzsche's philosophical works would direct a nurse searcher to look at her values. The values known through looking at what determines her actual behavior considering how these values correlate with her privilege of calling herself, nurse. Empathy, knowing how another experiences, when coupled with the title, nurse, dictates a performance that encompasses no harm to others and hopefully benefits them. Despite the human excitement of discovery, disciplined effort and rigorous evaluation enter into preparing knowledge of man for dispersal. Revelation should not merely shock; rather, professionally we use shock to awaken surprise, a fundamental, for human constructive movement toward moreness. The former, mere shock, needs to be guarded against. The latter, shock to awaken surprise needs to be exactingly, uncompromisingly attended for the communicability of knowledge and the actualization of the phenomenon, nursing.
In considering confidentiality and the quality of knowledge of man available to me, as nurse, my consciousness is confronted with my former mentor, and internalized "Thou," Paul V. Lemkau, M.D., psychiatrist. He {55} emphasized repeatedly that the professional person, as he increasingly understands man, should take on increasing responsibility to man, one's self and one's others. Buber says, "As we become free ... our responsibility must become personal and solitary."[1] One can extend this and say that to help others struggle for freedom one must realize that others must responsibly decide and that although they do this through and in the authentic presence of a nurse, these others are alone in deciding. And nurses in deciding what and how to convey of their knowing must decide freely, responsibly, personally, and alone.
The nurse in deciding what and how to convey, considering the professional necessities of both confidentiality and dispersion of knowledge, can be guided by a conception of the nature of man-in-his-world. Man in humanistic nursing practice theory is viewed as a conflictual, contradictory, inconsistent dilemma. One horn of the dilemma is ideal spirituality that wrestles against the other horn, protective materialistic animalism. This "all-at-once" struggling, stretched, mixed nature of man needs recognition. Recognition of man's nature, as such, supports greater self-acceptance. Self-acceptance and this view of man-in-his-world, like a magnifying glass, unmasks for a nurse her possible responses, motivations, and alternatives. Cognizant of these, she can responsibly select what knowledge to disperse to protect individuals and to continually shape and conceptually actualize the nursing profession. Utilizing this magnifying glass on self in humanistic nursing practice theory to let one's existing mixed, varied, struggling responses, motives, and alternatives into self-awareness is an axiom referred to as authenticity with self.
Acceptance of the others' human nature or human condition of being is usually easier than acceptance of our own. Usually each man is his own severest judge. Lilyan Weymouth, R.N., clinical specialist, my past teacher and present friend, in sympathetic moments, speaking of suffering others, often says, "the poor devils." Once, feeling anxious and annoyed, I responded, "we are all poor devils." She retorted, "I am glad you recognize that." Stopped short, I found myself continuing to ponder the phrase, "poor devils." Man's dilemma is that he is neither saint nor devil. He is a "poor saint" and a "poor devil," and by his nature he is pushed and pulled in both directions, "all-at-once." Our human existence in the world calls for an enduring with our virtues and vices, our energy and our laziness, our altruism and our selfishness, in a word with our humanness.
What meaning does this conception of man have for humanistic nursing practice theory? This theory necessitates a nurse who accepts and believes in the chaos of existence as lived and experienced by each man despite the shadows he casts interpreted as poise, control, order, and joy.
Labeled mental patients in therapeutic situation, in the sun beyond the shadows, express how they set themselves apart from the rest of the community {56} of man. They express how they experience themselves. They view themselves as the worst, the noblest, the unhappiest, the most maligned, and the most afraid. It comes out as if these superlative distinctions are their only claims to fame. In my humanness I appreciate the awesome dreads they live. They need to know that they exist in their unique distinctness. And yet, the separation and loneliness with which they adorn themselves and which professionally we have fostered with fear engendering diagnostic labels seem a heavier than necessary burden. In the light of existential loneliness, a part of each human existence, often I invite them to see themselves as not so unlike other men and as suffering the turmoil of existence as part of the human community, such as it is. One usually can note their surprise and disbelief of my view. Then, momentarily at least, tension seems to visibly fall from their faces and forms. When this idea of them is heard by them, its effect corresponds to how I experienced the technique in sensitivity group of literally being allowed to dance into what felt like the circle of man, our group.
To hear opportunities for humanistic nursing acceptance and support nurses, too, need to question their self-nurse-image within the nursing and health community. Do they know that they make and have real potential for making a difference, an important difference? Do they accept themselves as nurse? To me, a nurse is a being, becoming through intersubjectively calling and responding in her suffering, joyous, struggling, chaotic humanness, always trying beyond the possible while never completely free from ignoble personal human wants. And, through her presence it is possible for other persons to be all they can be in crisis situations of their worlds. For the nurse to be humanistic it is necessary for her to live her human condition-in-her-nursing-world proudly with all its vulnerability and all its wonders. As man, the nurse can recall and reflect on her "I," on her past "I-Other" experiences, and she can come to know and accept more and more of herself, as she becomes more. In humanistically recalling and reflecting a nurse will understand and respond empathetically and sympathetically to both her own humanness and the other's. She will recognize both self and other as "poor devil" and "poor saint," all-at-once.
On the other hand, if a nurse denies her own struggling humanness, she self-righteously will be apt to accuse either self or her other. This way of being denies, suppresses, and represses one's own and the other's ability to be, to be as much as potentially possible. Understanding man through this conception of him is important to the possibility of augmenting the implementation of humanistic nursing practice theory.
Authenticity With The Self: For Actualization of Nursing's Potential
Husserl, the father of phenomenology, suggested the study of our lived worlds, our experience, a return to the study of "the thing itself." Looking at the lived worlds of nurses one is confronted with conflicts and multiple {57} values. In their nursing worlds nurses often risk themselves in their commitment to good for their patients. They come to know aspects of their own and others' unique natures. These are often different from and frequently in conflict with generally accepted cultural values and/or institutional policies and rules. If confidentiality is an issue, does this dictate a suppression of nurses' complete knowing? Or does this call for a recognition of as complete a knowing as possible followed by responsible selection and revelation of that knowing which will advance knowledge and understanding of man? Understanding of man can change a person's way of being with other man and his way of existing in and responding to his world. I suggest the latter, as complete knowing as possible followed by responsible selection and revelation, with occasional risk taking to deepen the level of accepted cultural knowledge of man. Always, the nurse would protect an individual other man. This dispersion of knowledge, then, requires not only responsible being in the nursing situation but also mulling, pondering, assessing, and judging prior to disclosure.
As complete a knowing as possible, in humanistic nursing refers to its axiom, authenticity with the self. When I, nurse, respond in the arena of my lived nursing world, I respond to a particular person in this "here and now" with all my background and all my anticipation of the future. By respond, I do not mean to indicate that I overtly deliberately communicate or verbalize my total response. Rather I mean that I strive for _awareness_ of my total response within myself to a particular person in a particular "here and now" viewed through my particular past and anticipated future. It is a struggle to grasp how I perceive and respond within all my capacity of human beingness. To attain the highest possible level of authenticity with the self requires later recollection of ongoing perceptions of the other and reciprocal responses, selected communications, and actions by the self. These recollections now become raw data available for analyzing, questioning, relating, synthesizing, hypothetically considering, and ongoing correcting. Sometimes sharing such recollections with a trustworthy confidant (clinical specialist, consultant) for purposes of reality testing is helpful. Often this can broaden the professional meaning base I attribute to both my perceptions and my responses. On return to the arena of my nursing world I then verify my perceptions. I can let the other know how I perceived his actions and be open to his further expression of how this world is for him. In professional nursing this kind of experiencing, searching, validating, utilizing of one's human potential capacity must be based in the ideals on which nursing rests. Primarily for me, I see myself, nurse, as comforter or being nurse in such a way that my other is helped to be all that he can humanly be in this particular "here and now" considering his unique potential.
So, being authentic with the self, is not an acting out of a nonthought through response or merely a doing of what one feels like doing. Rather it is the very opposite of this. It is a thought through responsible choosing of overt response based in knowledge and on nursing values. It must correspond positively with one's belief that searching and sharing in one's nursing world will promote both the nursed and the nurse to be more. If it is merely a {58} peeking in on, an exploitation of the other, for selfish learning purposes, it desecrates the very concept of nursing. One has the broad human potential of feeling like doing many things, all-at-once, that extend into all kinds of living. And this is true in, as well as outside, a nurse world. In recollecting and reflecting on perceptions and responses in all these extremes one becomes freer to select from within one's self the values to be chosen, actualized, and potentiated in one's nursing practice. Authenticity with the self calls forth confrontation of the self with one's motivations and alternatives. This permits a purposeful selection and an aware actualized overt response based on one's nursing value criteria artfully tailored to a particular situation.
I consider each nurse a scientific-artist: classical, modern, primitive, cubic, or interpretive. My inference here is that we express artfully in accordance with our uniqueness. Many nurses given the same data would accomplish with the same or a similar degree of adequacy through use of their particular distinct selves. Therefore, though the function called for might be the same, each nurse would approach the function and the patient differently. How one actualizes the result of thinking, and being authentic with one's self recalls what Jung said about art.
"Art is a kind of innate drive that seizes a human being and makes him its instrument. The artist is not a person endowed with free will that seeks his own ends, but one who allows art to realize its purpose through him. As a human being he may have moods and a will and personal aims, but as an artist he is "man" in a higher sense--he is "collective man"--one who carries and shapes the unconscious, psychic life of mankind."[2]
Through the years, over and over, I have met nurses so driven, motivated, and expressive in their nursing worlds.
I called this section "authenticity with the self: for actualization of nursing's potential." In it I have been trying to say, the more of ourselves we are able to awarely include, the more of the other we can be open to and with. A capacity for presence with others allows us to share ourselves. Through this sharing others become more. They are able to internalize us as "Thou." This happening occurs in the reverse, too, and we become more.
In a nursing situation the quality of being authentic with the self is to be striven for. It is a taking advantage of and appreciating of our human ability and spirit. It fosters our pursuit of inquiry, improves our caring for others, the contributing of our unique knowing, and it allows us to shape ever further a scientific-artistic profession of nursing.
Authenticity With the Self: Potentiated in Lived Experience
This example is offered to support the claims for authenticity with the self made in the last paragraph of the prior section.
{59}
As clinical supervisor and thesis advisor to a young graduate nursing student in her twenties the benefits of authenticity with the self were again brought home to me. She was taping her therapy sessions with two patients. These taped materials were to become her thesis data.
One of her patients was not much younger than herself. The other was a divorced woman in her forties, around my age. This young graduate nursing student was receiving clinical nursing supervision as a necessity in her particular situation not by personal choice or awareness of need.
>From the onset of her clinical supervision with me I was aware that it aroused her feelings about dependence. At her age this had meaning since she was still struggling for independence and interdependence. This is a difficult time. Her response to me was "respectful," sweetly and unawarely hostile, and she made it apparent that I was another nurse authority to be appeased, manipulated, and outsmarted. This behavior had been successful for her with past authorities. She was bright and had been able to complete intellectual requests and assignments at the last minute with little effort. During the initial phase of our relationship awareness of her struggle, her difficulties and her assets, allowed me to maintain a supportive kind of being with her.
In listening to her therapy tapes I realized that another clinical supervisory approach was called for. She was defending against relating to her older patient by behaving toward her as she probably felt toward her own mother, and often toward me. Also, she was defeating her therapeutic purpose with her younger patient by viewing her as if the patient were herself. The older suicidal, depressed patient was begging her for an understanding therapeutic relationship. She needed terribly to share her suffering. This woman did not need a "rejecting daughter" working hard to outwit her. The younger patient needed to share her angry feelings and sense of worthlessness.
Through the tapes and through weekly sessions with the graduate student, I came to know and understand her existing nursing situations. At this time neither the student's need to understand nor the patients' therapeutic needs were being met. The student, too, was aware of this in a sort of suppressed way. Indirectly, in responding to her patients, knowing I would be listening to the tape she would take a "sweet swipe" at me which placed the responsibility of all our efforts on my shoulders. So if there were no beneficial outcomes, obviously the blame could be placed.
During the initial phase of my relationship with the graduate student and during the initial phases of her relationship with her patients I came to understand. I listened, got into the rhythm of these other spirits, reflected on what I had come to know, and out of this experience assessed and planned.
Later, taking what I had come to know, as just how it was for all of us, I shared my knowing with the graduate student and budding first-rate therapist. Together we explored the implications of the above. She became invested, involved, and excited about herself becoming more. We, myself and each of her patients, become for her more whom we essentially were. Most important to her and to me, this graduate student grew in her recognition and acceptance {60} of herself and her ability as an adult nurse therapist. The thanks and meaningful praise she received from both her patients on termination of therapy made this apparent. It brought tears to both her eyes and mine. I felt joy in being with a now-respected colleague, as opposed to the earlier being with a person who felt like an unasked for "awe struck defensive daughter."
Authenticity with myself, and this graduate student's ability for authenticity with herself allowed these patients' progress to occur. It allowed a realistic articulation in this student's phenomenological master's thesis of her lived nurse experience. From such articulation will a theory and scientific-artistic profession of nursing ever mold, flow, and form.
WORDS DISTINCTLY HUMAN: LIMITING, YET HUMANIZING
Through words we humanly share the meaning to us of our behavior, experience, and profession. Words attest to and endure. Thus, a professional history is possible, accrues, and has lasting duration. The study of the nursing event itself and its conceptualization as proposed in humanistic nursing practice theory is an application of phenomenology. Articulation of our perspective, experience, and ideas is the human way of phenomenology.
Words are symbols to which man gives meaning as an outgrowth of his civilization within his culture. Through words man attempts to communicatively describe his experienced states of being-in-his-world. In describing, of necessity, he relegates his uniquely known experiences to already known word symbols or categories. Thus, the conceptualized experience is limited, or less real than the lived unique experience. So, while words prevent the loss of the wisdom of lived experience, they are both a wonder of humanness and a limitation of humanness.
In describing human experiences there are efforts that can cut back this limitation. If we truly wish to convey meaning to others, really want to share what we have experienced in living, we will put forth the effort. To put forth such effort requires going beyond "I must publish to publish." It takes writing, structuring, rewriting, and restructuring often to a point where for a period one comes to hate materials he once held dear.
Through the years many of us come to use words as a means of passing a course, or we view words as a mode for self-explosion, expression, and self-understanding. In these ways they hold much purpose. The requirement that words convey unique experiences of being to others demands much more. This necessitates one selecting words that depict one's perspective, his unique human angular view; or depict for another, this particular man as he perceives and responds to his unique experience. Such a depiction has to be unknown to the other; each one's vantage point, given his history as an existent in this time and place, is singular. Then it requires finding words and putting them {61} together in a way that best conveys the meaning the nursing event had to the nurse. An adequate dictionary and thesaurus can be useful.
The actual presentation of experience for an audience demands an ordering of data in a sequence that will be sensibly logical for them. We live experience in an order that flows from our being and history within a multiplicity of calls and responses. Presently human expression is limited to sequentiality. So again we see that the conceptualized experience is different from and lacks the reality of the uniquely lived event. Structuring a logical sequential presentation of data, deciding on those aspects that influenced meaning, and having it conform as closely as possible to the real is difficult.
Often, when it seems that one has done his very best, it is wise to have a trusted other react to conceptualizations. Another's questions can bring to the conceptualizer's awareness thought connections that moved him along and that he has failed to convey. Also, such a reader can indicate aspects of thought trips the writer took that add nothing to the issue at stake and weaken his message. Too, another's response can make apparent to a writer the need to clarify meaning. This clarification may merely entail a better choice of words or phrases, or it may suggest the use of a meaningful metaphor, analogy, or parable.
These last imaginative forms of expression we frequently use meaningfully, sometimes like a shorthand, with our intimates. A phrase, metaphor, or analogy conveys with an immediacy the quality or spirit of an event. For example, a nurse working in a psychiatric hospital unit speaking of a patient said, "He came down the hall looking like an accident about to happen." A page of technical description could not have given me as much feeling for what she and the patient were experiencing at that moment. In nurses' efforts to express objectively, scientifically, and eruditely such modes of expression are often deleted from our written professional works. It is as if we enforce the rules of medical record charting of precision, conciseness, and use of "weasel" words onto all our written works to the detriment of a theoretical and professional enduring body of nursing knowledge being actualized. It takes considerable pain and endeavor to find egress from such human programming. With it we have purified, equalized, wearied, and dehumanized supreme experiences of human existence. And, we have negated the meaning and importance of ourselves and nursing. How often have you heard, "I am _just_ a nurse"?
Phenomenology requires rigorous investment into respectfully, appreciatively, and acceptingly making evident our lived worlds and their ramifications for the now, the past, and the anticipated future. Nursing literature of this caliber would call and inspire those who attended it to further nursing practice and responsibly share the meaning they attribute to their area of specialized dedication.
The raw data of our lived nursing worlds do not easily reveal their meanings or messages. Many see their worlds only superficially, and themselves as mere functions. How often a nurse is surprised, confounded, on hearing a relative or friend speak of a nursing event in their lives that may have occurred {62} from 10 to 40 years previously. Frequently persons express appreciation for the meaning these events have had for them through the years. They remember the pleasure, anger, pain, fear, and/or joy they experienced.
It is not loose performance that allows raw data to convey its message to a nurse. New data are sucked easily and immediately into old, worn out, known theoretical frames and networks of words. Severe self-discipline enters into describing nursing experience with the vigor of how it was lived. Too easily the description is let fall to mediocre common forms. Proper grammar and plain English should suffice. This would carry the nursing message, as jargon borrowed from other disciplines in which the nurse always speaks as an alien, never will. Humanistic nursing practice theory in asking for description does not ask one to forget or deny known terms and knowledge. Rather it asks for a bracketing or holding of this knowledge to the side. The nursing experience should be given an opportunity to be seen in its pure form, rather than forcing it to conform to foreign prestigious terms borrowed from other areas of specialization, which beg the meaning of the nursing event. Prior to dispersion, of course, one should weigh one's expression in English against one's expression in one's known foreign jargon. Then one will be open to choose how one wants to express and share the meaning of her nursing world.
Phenomenology accepts categorization as a necessity of communicating. It holds, nevertheless, that this is secondary to initial aware experiencing. This study method acknowledges the unfathomable complexity of existing and knowing. It strives for as adequate conceptualization of the existential experience as possible. It honors the knowing person's continued capacity for surprise and wonderment. Phenomenology asks us to go beyond the common labels to the surprise of our own and other's unique existences-in-the-world. A nurse who had been struggling over many months with a family in their home, on the day she first experienced an "I-Thou" relationship with them said, "It was as if I had gone beyond the uncooperativeness and dirtiness of the situation." Immediacy in labeling offers us the complacency and security of a wrapped up problem. How could a nurse be held responsible for what happened to a "dirty," "uncooperative" family. The many commonly heard labels humans attribute inhumanely to others rarely relate to answers in situations or to the dreadful human suffering problems generate.
Phenomenology seeks attestation of the meaning of a situation to a participant. Positivism seeks general objective categories within the universal. Phenomenology prizes differences, variations, and struggles for their representation as parts of the whole. Rather than emphasize the majority as holding sway, it recognizes that the unique contribution can possibly be the weightiest in meaning. {63}
THE PROCESS: BECOMING A FREE RESPONSIBLE RESEARCH NURSE
For a nurse to become a free responsible research nurse in the health arena she accepts her lived nursing world as beyond the controls valued in positivistic science. She appreciates her lived nursing world as saturated with knowledge to be extracted or wrung. Then she must examine, recognize, appreciate, and unfold her history, her angular view, and her human nurse potential. In prizing her view, as nurse, she will ask relevant nursing questions. To attain her potential as nurse she will discipline herself rigorously for authenticity with the self. With the self-acceptance that comes with self-authenticity she will know the importance of the difference she and the nursing profession make and can make in the community of man. Then out of her own human social need and for the survival of nursing she will describe to propel knowledge, nursing theory, and practice forward. In this process and in its effects she will become more human as she contributes to man's humanization.
FOOTNOTES:
[1] Martin Buber, _Between Man and Man_, trans. Ronald Gregor Smith (Boston: Beacon Press, 1955), p. 93.
[2] Carl G. Jung, _Modern Man in Search of a Soul_, trans. W. S. Dell and Cary F. Baynes (New York: Harcourt, Brace and World, 1933), p. 169.
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6
THE LOGIC OF A PHENOMENOLOGICAL METHODOLOGY
PERSPECTIVE: ANGULAR VIEW
In humanistic nursing practice theory we, Dr. Zderad and myself, propose that nursing practice when studied, like any other area studied, will only become available for human conceptualization if the study methods are appropriate to its nature. Therefore, the methodology presented in this chapter is relevant to humanistic nursing practice theory.
Embraced within this chapter is a methodology for studying nursing that evolved out of the process of my nursing practice. The logic of this method and of my process of nursing are one. It is not a method of another discipline superimposed on nursing. So this method did not force nursing or change nursing to have it mold or conform. As this method unfolded it arose from and in accord with nursing process. This methodology came into being only after years in which various attempts were made to get positivistic methodology to answer relevant nursing questions and to develop a professional scientific theory of nursing.
The method presented here was used initially to creatively conceptualize nursing constructs in 1967-68. The data for the development of the constructs "comfort" and "clinical" were gathered from my clinical nursing practice and while I was deeply engrossed in existential readings. The process or method used was not conceptualized until it was called for while writing my doctoral dissertation in 1968. It had then been used to study the clinical literary works of two psychiatric mental health nurses, Theresa G. Muller and Ruth Gilbert.[1] Its conceptualization at that time was rudimentary. Gradually it has been further conceptualized. "From a Philosophy of Nursing to a Method of {66} Nursology," an article published in _Nursing Research_ in 1972, was my next attempt.[2] Graduate nursing students studied this article and repeated the process of the methodology in their studies of their clinical nursing data. Reflecting on this article and realizing how others had to study and struggle with it. I became aware that still only the bare bones of my thinking were presented. Further elaboration of this methodology was called forth to share it with the _humanistic nursing practice theory_ course participants. Since 1970 I have delved into phenomenologists' writings and at this time can say that this process of studying nursing is a phenomenological method of nursology. Interesting to me is that the initiation of this method came when I first began to read the existentialist literature. Existentialism can be viewed as the fruits of phenomenological study. The process of this method has become clearer and clearer to me over time. Phenomenologically the process or method has grown out of the reality of the "thing itself" to be studied, in this case, clinical nursing practice.
This chapter then is the result of reflecting on these past efforts and is a conceptualization of this method as I understand it now.
The following quote is offered to support and validate the efforts put into conceptualizing this method. The philosopher of science Abraham Kaplan says of methodology:
"The aim of methodology ... is to invite speculation from science and practicality from philosophy ... to help us understand in the broadest possible terms, not the products of scientific inquiry, but the process itself."[3]
The above quotation expresses the spirit in which this presentation is offered. Positivistic science aims at objectivity and its results are viewed as scientific facts. Nursing practice has been understood by many as an implementation of such theoretical facts. Considering my and other nurses' implementation of such facts it is apparent that in these endeavors nurses come to know much about human existence.
Philosophy is often viewed as man's contemplations, autobiographical revelations, and the values and belief systems that underlie man's actions, Can an explicit philosophy of nursing allow for more meaningful quality practice, be a resource for nurses, improve service, be available for reexamination, correction, and the forwarding of knowledge? If nursing practice is viewed as the implementation of scientific facts and what they call forth in the nursing situation related to man's condition of existence, is a heuristic science of nursing developed from this situation, by nurses, an appropriate practical professional aim?
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This presentation is my answer, a committed "Yes."
The method offered here, a phenomenological method of nursology, aims at the reality of man, how he experiences his world, or it aims at a subjective-objective state. It aims at description of the professional clinical nursing situation which in reality is subjective-objective world that occurs between subjective-objective beings. The description focuses on this between and preserves the complex mobile flow of the river of nursing to make apparent that superficial precise portrayals are only an overlay of its river bed, course, and eventual destinations.
The relevance of phenomenological nursology ranges from the formulation of nursing constructs to the creation of theoretical propositions. It is applicable to one's own clinical data and to others' clinical data, here and now, or in historical study of the literature.
METHODOLOGICAL STARTING POINT
This method addresses itself to the question: How can a nurse, a subjective-objective human being know self and the other and compare and complementarily synthesize these known betweens?
Basic to this method is a belief system, a philosophy about the nature of man explicitly commented on by thinkers throughout human history.
Plato said:
"I cannot be sure whether or not I see it as it really is; but we can be sure there is some such reality which it concerns us to see."[4]
Nurses are with other men in times of peak life experiences under the most intimate circumstances. We, too, can not be certain about what we come to know in our betweens. We can be sure that these realities of human experience are worthy of exploration. Our opportunities are unique, only we can describe man in the nursing situation.
In _Let Us Now Praise Famous Men_, James Agee voices a similar concern about the need to describe man-in-his-world and the adequacy of human description.[5] Aware of the wonders and complexities of man he considers not trying to describe worse than the inadequacy of description.
Thinkers have also acknowledged that we can come to know from others. A poem by Goethe expresses an attitude about this:
"Somebody says: 'Of no school I am part, Never to living master lost my heart; Nor anymore can I be said To have learned anything from the dead.' {68} That statement--subject to appeal-- Means: 'I'm a self-made imbecile.'"[6]
In nursing what better master than the nursing situation in which we become through our relations with others. Each human person has something unique to teach us if we can but hear.
About our inadequacies of expression, many things are, are true, "all-at-once." The law of contradiction does not apply in-the-lived-experienced-world. We each view the world through our unique histories. Wisdom is many sided truth. Wisdom cannot be expressed "all-at-once." Truths can be stated only in sequence or metaphorically. If I were supercritical of my human limitations to express "all-at-once" wisdom, I would say nothing. Jung points up the dangers of this, he says:
"I must prevent my critical powers from destroying my creativeness. I know well enough that every word I utter carries with it something of myself--of my special and unique self with its particular history and its particular world."[7]
Each nurse's uniqueness dictates then a responsibility to share her particular knowing with fellow struggling human beings. Only through each describing can there be correction and complementary synthesis to movement beyond.
The nurse's world is an experiential place for becoming influenced by each participant's "here and now" inclusive or origin, history, and hopes, fears, and alternatives of the confronting future. Positivistic science focuses on selected particulars. Henri Bergson says:
"... for us conscious beings, it is the units that matter, for we do not count extremities of intervals, we feel and live the intervals themselves."[8]
Each human participant in the nursing situation has a unique flow of consciousness which is intersubjectively influential.
So as human nurses we are limited in our ability to express the reality of our-lived worlds. Yet, also, this world depends on and demands that we, as human nurses, give it meaning, understand it in accordance with our {69} humanness. Will and Ariel Durant, historians, professionals who are forced to selectively present the world for other humans, say:
"The historian will not mourn because he can see no meaning in human existence except that which man puts into it: let it be our pride that we ourselves may put meaning into our lives, and sometimes a significance that transcends death."[9]
Humans are the only beings conscious of themselves. Nurses are human beings. As such we are capable of looking at our existence, choosing our values, giving our world meaning and of constantly transcending ourselves, or becoming more. If we value and prize our human nursing world and our human potential for consciousness and expression, we will actuate our potential and conceptualize our human nurse-world. This suggests questions to me. What do I want nursing to be? How can I influence the meaning of the term, nursing? How committed am I? What investment am I willing to make? Will I risk exploring and saying what I see in my nursing world? Am I open to knowing? How can I actuate my uniqueness to allow the realistic potential of my nursing profession to become, become ever more? Am I contributing my "nursing here and now" to nursing's history through a lasting form of expression? Of what importance is what I think or say; do I make any difference? Hermann Hesse says of each man's uniqueness:
"... every man is more than just himself; he also represents the unique, the very special and always significant and remarkable point at which the world's phenomena intersect, only once in this way and never again."[10]
Or, a nurse might say:
"... every nurse is more than just herself, she also represents the unique, the very special and always significant and remarkable point at which the nursing world's phenomena intersect, only once in this way and never again."
To me, human freedom means recognizing our unique potential, responsibility, and limitations. Our singularity as a nurse among nurses, then, confronts us with a responsibility that belongs to one else. Martin Buber, philosophical anthropologist says:
"As we become free ... our responsibility must become personal and solitary."[11]
Our unlikeness to other nurses is a lonely, very person conditioned state. Only each nurse can be responsible for herself. The wonders of freedom are {70} paradoxically, "all-at-once," both a delight and a burden. In nursing it is important for us to understand freedom not as opposing or agreeing: freedom is choosing--choosing and saying "yes" to one's self.
Human endeavor between man and men in their-worlds, in this instance professional clinical nursing, if explored and described is viewed as contributing to man's human evolvement and to knowledge of the human condition and how man becomes.
Integrally all the above statements are the bases and biases of this human phenomenological method of nursology. In a phrase, I suppose what all these _starting point_ statements say is: Nursing situations make available human existence events significantly worthy of description. Only human nurses can describe them. Humans' ability to describe reality adequately has its limits. We should describe since pridefully we humans are the only existing beings capable of giving meaning to, looking at, and expressing our consciousness. In the long run this effort could yield a nursing science.
PHASES OF PHENOMENOLOGIC NURSOLOGY
Phase I: Preparation of the Nurse Knower For Coming to Know
This method engages the investigator as a risk taker and as a "knowing place." Risk taking necessitates decision. Decision imposes confronting ambivalence in one's self. The ambivalence of wanting to be "all-at-once" responsible and dependent. Superimposing an already accepted and acceptable structure on data is safe feeling. Approaching the situation or data openly, letting the structure emerge from it, not deciding what to look for, being willing to be surprised, give feelings of excitement, fear, and uncertainty. There exists the possibility that our humanness may include the dilemma of our not being able to perceive the messages of our data, that we will not be able to merge with it and become more. The question arises, Are we knowing places that can relate to otherness and intuitively synthesize knowledge? This process of accepting the decision to approach the unknown openly is experienced as an internal struggle and we become consciously aware of our rigidity and satisfaction with the status quo. Conforming to the usual, in this case positivism, gives a security that is not easily relinquished despite the advantages of actualizing our unique responsible freedom.
Russell's metaphorical phrase, "windows always open to the world," depicts the sought state of mind. His elaboration on this phrase gives the flavor of the process of preparing the mind. He says, "Through one's windows one sees not only the joy and beauty of the world, but also its pain and cruelty and ugliness, and the one is as well worth seeing as the other, and one must look into hell before one has any right to speak of heaven."[12] Pain, cruelty, ugliness, hell seem appropriate words to convey seeing our {71}long-cherished ideas and values, our security blankets, as only false gods. Nietzsche in speaking of confrontation of one's values said, "And now only cometh to him the great terror, the great outlook, the great sickness, the great nausea, the great seasickness."[13] So this human methodology seeks a condition of being in the investigator. The investigator must be aware of her own angular view and democratically open to giving the angular views apparent in the data, the called for representation.
The first phase of this method of research correlates well with the struggle experienced by me in clarifying my approach to patients in public health, medical-surgical, and psychiatric mental health situations. In these situations, one truly has to struggle with democratically keeping one's windows open to the world. And this is a continual process. Having experienced this struggle in clinical nursing made this approach to research valid and meaningful to me.
Preparing the mind for knowing in clinical or research endeavors may be accomplished by several means. One means is by immersing one's self in dramatic and literary works and contemplating, reflecting on, and discussing them as they relate to the knower's already known, in this case, nursing practice. In clinical or research nursing the selection of literary works to stimulate the opening of one's human view is based on their presentation, depictions, and descriptions of man's nature. In literature authors share their thoughts as men and present possible ways men may view and relate to their worlds.
Phase II: Nurse Knowing of the Other Intuitively
Bergson conceives of man knowing through a dilatation of his imagination getting inside of, into _le durée_, into the rhythm and mobility of the other. Living the rhythm of the other he believes results in an absolute, intuitive, inexpressible, unique knowledge of the other. He says:
"... an absolute can only be given in an intuition, while all the rest has to go with analysis."
"... from intuition one can pass on to analysis, but not from analysis to intuition."
"... fixed concepts can be extracted by our thought from the mobile reality; but there is not means whatever of reconstituting with the fixity of concepts the mobility of the real."[14]
The known, clinical nursing practice, gave meaning to the above for me. Over the years in nursing conferences I had been told my grasp of nursing situations was intuitive. Most times this was offered rather disparagingly although the nursing outcomes were most times successful. Along with having {72} the attribute of intuition assigned to me persons often asked, "Why are you so fascinated with other persons' situations?" Together these relate to Dewey's view of intuition. He views intuition as a mulling over of conditions and a mental synthesis that results in true judgments since the controlling standards are intelligent selection, estimation, and problem solution.[15] In nursing practice research knowing the other and how he experiences and views his world is viewed as the problem.
Knowing intuitively, as described by Bergson, is comparable to Buber's considerations of man's necessary mode of becoming through "I-Thou" relation. The criteria Buber describes as characteristic for "I-Thou" relation are subscribed to in my approach to nursing practice and in this human or phenomenological nursology approach.[16] Buber held as prerequisite for intuitive type knowing of the other, or imagining the real of his potential for being, a knower, and "I," capable of distance from the other, able to see the other as a unique other, one who turns to the other, makes his being present to the other, and allows the other presence. The knowing, "I," in this case the nurse, responds to the other's uniqueness, does not superimpose, maintains a capacity for surprise and question, and is with the other, as opposed to "seeming to be." This kind of relating cannot be superimposed on a nurse clinician or researcher. It must be personally responsibly chosen and invested in.
The approach then of the second phase of this method and of the transactional phase of nursing when nurses are in the arena with others is the same. This method proposes that to study nursing from outside the arena for purposes of objectivity bursts asunder the very nature of nursing practice. The studier is a part of that which is being studied. Observations interpreted from outside the situation could be classified only as projections.
Phase III: Nurse Knowing the Other Scientifically
Bergson believes man knows incompletely through standing outside the thing to be known, metaphorically walking around it, and observing it. This analytical process, this viewing of a thing's many aspects, he conceives as the habitual function of positive science. This is the third phase of this phenomenological nursology method. Bergson says:
"... analysis multiplies endlessly the points of view ... to complete the ever incomplete representation."
"All analysis is thus a translation, a development into symbols, a representation taken from successive points of view."
"Analysis ... is the operation which reduces the object to elements already known, that is, common to that object and to others."[17]
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So phenomenological nursology proposes that after the studier has experienced the other intuitively and absolutely, the experience be conceptualized and expressed in accordance with the nurse's human potential. Humanly we can express only sequentially while our actual experienced lived worlds flow in an "all-at-once" fashion. Our words are known symbols and categories used to convey the experience and thus deny the uniqueness of each realized experience.
Buber's description of man's "I-It" way of relating to the world is in agreement with Bergson. He conveys the necessity of this kind of relating by man to his world; and despite its lacks proposes that man prize his analytical ability. Like Bergson, Buber views knowing as a movement from intuition to analysis, and not the other way around. Buber sees knowledge expressed or science created through the knowing "I" transcending itself, recollecting, reflecting on, and experiencing its past "I-Thou" relation as an "It." This is man being conscious of, looking at, himself and that which he has taken in, merged with, made part of himself. This is the time when he mulls over, analyzes, sorts out, compares, contrasts, relates, interprets, gives a name to, and categorizes.
The third phase of this methodology is the same as that phase of clinical nursing practice in which the nurse, removed from the nursing arena, replays and reflects on this area and transcribes her angular view of it. In this reflective state the nurse analyzes, considers relationships between components, synthesizes themes or patterns, and then conceptualizes or symbolically interprets a sequential view of this past lived reality. The challenge of communicating a lived nursing reality demands authenticity with the self and rigorous effort in the selection of words, phrases, and precise grammar.
Phase IV: Nurse Complementarily Synthesizing Known Others
In this phase of the methodology the nurse researcher, the knower, compares and synthesizes multiple known realities. Buber says of comparison:
"The act of contrasting, carried out properly and adequately, leads to the grasp of the principle."[18]
In this comparison and synthesis the "I" of the researcher assumes the position of the knowing place. The knower, like an interpreter, allows dialogue between the multiple known realities. These realities are unknowable to each other directly. The knower interprets, sorts, and classifies.
In the human knowing place discovered differences in similar realities do not compete, one does not negate the other. Each can be true, present, "all-at-once." Differences can make visible the greater realities of each. Desan, the philosopher, says of this kind of synthesis:
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"... a synthetic view where two or more positions are seen to illuminate and to transfigure one another through their mutual presence."[19]
The knower alert to an aspect present in a single reality can question the other reality on this aspect. This aspect may be present in both, more blatant in one than in another. Its forms may be different or modified in each. It may be totally absent in one. Differences found may arouse or bring to consciousness other questions to ask of the data. This oscillating, dialectical process continues throughout reflection on the multiple realities. This indirect dialogue is recorded by the investigator as the complementary synthesis.
This synthesis is more than additive because it allows mutual representation and the illumination of one reality by another.
The fourth phase of this research methodology is like that phase of clinical nursing in which a nurse compares and synthesizes the similarities and differences of like nursing situations and arrives at an expanded view.
Phase V: Succession Within the Nurse From the Many to the Paradoxical One
This phase of phenomenological nursology is highly probable if not absolutely necessary. Desan says:
"Truth emerges in and through the relational operation. For the way of paradox is the way of truth."[20]
The investigator may struggle with the multiplicity of views now consciously part of and within herself. Again Desan:
"... this unrest "is" the mind of man, reaching its center.... From this center the splendor of multiplicity is visible."[21]
The researcher, mulling over and considering the relationships between the multiple views, insightfully corrects and expands her own angular view. This is not a right-wrong type of correction. Such correction would amount only to an ongoing eternal recurrence of a frustrating nature. Rather this correction takes the form of ever more inclusiveness. Struggling with the communion of the different ideas the knower takes an intuitive leap, through and yet beyond these ideas, into a greater understanding. She then may come up with a conception or abstraction that is inclusive of and beyond the multiplicities and contradictions.
This inclusive conception or abstraction is an expression of the investigator in her here and now, with the old truths and the novel truths, none obliterated.
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The fifth phase of this phenomenological nursology method can be equated to that phase of clinical professional nursing in which the nurse propels nursing knowledge forward. In this phase a nurse struggling with the mutual communion of multiple nursing situations arrives at a conception that is meaningful to the many or to all. From the specific concrete ideas of the many situations she moves through dilemma to resolution which is nursing expressed abstractly in units or as a whole, as one.
Experiential knowledge of nursing, years in which I came to know self and the other while implementing scientific facts, allowed me as a knower to recognize the relevance of this philosophical nursology method. This method does not aim at conventionality. Rather it strives to meaningfully augment and share conceptualized nurse-world realities.
FOOTNOTES:
[1] Josephine G. Paterson, "Echo into Tomorrow: A Mental Health Psychiatric Philosophical Conceptualization of Nursing" D.N.Sc. dissertation, Boston University, 1969.
[2] Josephine G. Paterson "From a Philosophy of Clinical Nursing to a Method of Nursology," _Nursing Research_, Vol. XX (March-April, 1971), pp. 143-146.
[3] Abraham Kaplan, _Conduct of Inquiry_ (San Francisco: Chandler Publishing Co., 1964), p. 23.
[4] Plato, _The Republic_, trans. Francis MacDonald Cornford (New York: Oxford University Press, 1945), p. 45.
[5] James Agee, _Let Us Now Praise Famous Men_ (New York: Ballantine Books, 1939), pp. 91-102.
[6] Johann Wolfgang von Goethe, "On Originality." In _Great Writings of Goethe_, ed. Stephen Spender (New York: Mentor Press, 1958), p. 45.
[7] C. G. Jung, _Modern Man in Search of a Soul_, trans. W. S. Dell and Cary F. Baynes (New York: Harcourt, Brace and World, 1933), p. 118.
[8] Henri Bergson, "Time in the History of Western Philosophy," in _Philosophy in the Twentieth Century_, ed. William Barrett and Henry D. Aiken (New York: Random House, 1962), p. 252.
[9] Will Durant and Ariel Durant, _Lessons of History_ (New York: Simon and Schuster, 1968), p. 102.
[10] Hermann Hesse, _Demian_, trans. Michael Roloff and Michael Lebeck (New York: Harper & Row, 1965), p. 4.
[11] Martin Buber, _Between Man and Man_, trans. Ronald Gregor Smith (Boston: Beacon Press, 1955), p. 93.
[12] Bertrand Russell, _The Autobiography of Bertrand Russell, 1914-1944_ (Boston: Little, Brown and Co., 1968), p. 97.
[13] Frederick Nietzsche "Thus Spake Zarathustra," trans. Thomas Common, in _The Philosophy of Nietzsche_ (New York: Random House, 1927), p. 239.
[14] Henri Bergson, "An Introduction to Metaphysics," in _Philosophy in the Twentieth Century_, ed. William Barrett and Henry D. Aiken (New York: Random House, 1962), pp. 303-331.
[15] John Dewey, _How We Think_ (Boston: D. C. Heath & Co., Publishers, 1910), p. 105.
[16] Martin Buber, "Distance and Relation," trans. Ronald Gregor Smith, in _The Knowledge of Man_, ed. Maurice Friedman. (New York: Harper & Row, Publishers, 1965), pp. 60-82.
[17] Bergson, "_An Introduction to Metaphysics_," pp. 303-331.
[18] Martin Buber, _I and Thou_, 2nd ed., trans. Ronald Gregor Smith, (New York: Charles Scribner's Sons, 1958). pp. 3-34.
[19] W. D. Desan, _Planetary Man_ (New York: The Macmillan Company, 1972), p. 77.
[20] _Ibid._
[21] _Ibid._, p. 80.
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7
A PHENOMENOLOGICAL APPROACH TO HUMANISTIC NURSING THEORY
Humanistic nursing is dialogical in the theoretical as well as the practical realm. Just as the meaning of humanistic nursing is found in the existential intersubjective act, that is, in the dialogue as it is lived out by nurse and patient in the real world, so the theory of humanistic nursing is formed, in the dialogical interplay of articulated experiences shared by searching, abstracting, conceptualizing nurses.
The theory of humanistic nursing originates from and is continually revitalized and refined by actual nursing experience. But each nurse, as a unique human being, necessarily experiences the nursing dialogue and her nursing world in a unique way. So the development of humanistic nursing theory rests on the sharing of individual unique angular views. And the theory as a totality will become richer, more consonant with reality, as it represents more and more nurses' views.
So often nurses, even nurses who know that their clinical expertise grew out of their practice, hesitate to share their nursing experiences. They are apt to say deprecatingly, "Oh, that's _only_ my _personal_ experience." Yet that is precisely where the value lies, in the uniqueness of human experience. Since each nurse's description of her nursing experience is a glimpse of a real nursing world, the views cannot justifiably be judged as right or wrong; they simply are. Once the various views are expressed, they can be compared and contrasted, not for the purpose of accepting some and rejecting others but rather in the interest of clarifying each in relation to the other. Such a dialogue of experientially based conceptualizations can result in a complementary synthesis. The process calls for not only a true appreciation of personal experience by each nurse but also commitment to a collaborative effort of open sharing by a genuine community of nurses.
This view, that the development of humanistic nursing practice theory is a dialogical process, has led to our valuing (in fact, insisting on) the description {78} of nursing phenomena. We see phenomenological description as a basic and essential step in theory building. Indeed, considering the "state-of-the-art" of nursing theory development, it is the most crucial and immediate need.
Looking back at the historical evolvement of our humanistic nursing approach, it is obvious that we had been using and developing a phenomenological approach for a number of years before we graced our efforts with the impressive label, "Phenomenological Psychiatric Mental Health Nursing," in a course offered to a group of nurses at Northport Veterans Administration Hospital in April 1972. Although we were aware much earlier that our interests and work were flowing in the general stream of phenomenology, we usually refrained from using the label because it did little to clarify our position.[1] The term has grown less precise with the extension of its use in different disciplines and with variations in methodology.
When we began applying the term "phenomenological" to our work, we learned that to many persons it sounds strange, unpronounceable, foreign; to some forbidding; to others enticing. We later coined the title "humanistic nursing" as being more suitable for it encompasses our general existential bent. However, this change in title does not imply any abandonment of our phenomenological approach. The description of nursing phenomena is as highly prized now as ever. In humanistic nursing, phenomenological and existential currents interrelate. Having an existential view of nursing as a living dialogue influences which phenomena one becomes aware of, experiences, values, studies, and describes. Reciprocally, as one discovers and struggles to describe and develop meaningful ways of describing nursing phenomena, the lived nursing dialogue itself will be continually perfected.
It is more precise to speak of phenomenological methods (in the plural) rather than phenomenological method (in the singular), for, since Edmund Husserl's original work, the approach has been used by different disciplines. With its spread there has developed a corresponding variation in methodology. This, in a sense, is the beauty of phenomenology: it thrives on variety of perspective; it allows, perhaps requires, individual creativeness; it is always open. In this spirit, ideas are offered here with the hope of stimulating imaginative, critical response, and further development of methodology.
This chapter considers some of the more concrete details of phenomenological methodology as they relate to humanistic nursing. The general approach and procedures discussed below have been used, individually {79} and collaboratively, by Dr. Josephine Paterson and myself with individual and groups of nurses to explore and describe their nursing experiences. They have helped nurses in various levels and types of nursing service to take a fresh look at their practice and make desirable changes. We have lived through the process with graduate students in nursing, and it has led both the students and us to new conceptualizations and reconceptualizations of nursing phenomena. We have found this to be a fruitful research method when applied to clinical nursing phenomena personally experienced and/or reported in the literature. And we are currently exploring its potentials with interested nurses at Northport Veterans Administration Hospital.
A PHENOMENOLOGICAL APPROACH
The method may be characterized generally as descriptive but it is not a simple cataloguing of qualities or counting of elements. Basically, it involves an openness to nursing phenomena, a spirit of receptivity, readiness for surprise, the courage to experience the unknown. Equally important is awareness of one's own perspective and of personal biases. The methodological process is subjective-objective and intuitive-analytic. Besides subjective knowing or personal experiencing of the phenomenon, rigorous analysis also is required. This being-with (subjective, intuitive knowing and experiencing) and looking at (objective analyzing) the phenomenon all at once sparks a creative synthesis, a conceptualization from which emanates insightful description.
More specifically, the method entails _an intuitive grasp of the phenomenon, analytic examination of its occurrences, synthesis, and description_. In actuality, as the method is carried out, one does not necessarily recognize or focus on these processes as distinct phases or steps. In the flow of the experience, at times, some seem to occur simultaneously or in oscillation. Bearing this in mind, the processes will be considered in more detail.
Intuitive Grasp of the Phenomenon
Phenomenology is grounded in experience. It values the raw data of immediate experience. ("To the things themselves," was the slogan that inspired and guided Husserl and his followers.) So this approach requires, in the first place, attitudes of openness and awareness. It involves learning to become conscious of spontaneous perceptions, or in other words, getting in touch with one's sensations and feelings. It means capturing prereflective experience, that is, becoming aware of one's immediate impression or response to reality before labeling, categorizing, or judging it.
In this kind of a state of readiness to receive what appears, a phenomenon may be grasped intuitively. It is as if a particular bit of reality, a happening, flashes _impressively_ into one's awareness. The intensity of the experience and the absorption of one's attention in the phenomenon vary over a wide range. There may be only a fleeting recognition of a phenomenon accompanied by {80} a half-formulated thought or judgment, such as, "hmm, that's interesting," with immediate dismissal from or replacement of it by something else in one's consciousness. The impression may, of course, be stored in memory and pop out again at a later time. Or the phenomenon may strike on one's consciousness more forcefully causing further pondering and wonder. Or the impression of the phenomenon may be so startling that it fills one's consciousness to the point of pushing all else out; a person is momentarily "stopped in his tracks."
In the intuitive grasp, regardless of its intensity or duration, the phenomenon appears clear and distinct. The intuitive grasp is an insight into reality that bears the certainty of immediate experience. No discursive process intervenes; one simply knows the phenomenon as it is experienced. Furthermore, the intuitive grasp provides a kind of definite and whole understanding, a gestalt, that allows recognition of the phenomenon in other situations. So when the person is faced with another event he can say, "Yes, that is the phenomenon under consideration," or "No, that is not it."
In order to be open to the data of experience in using a phenomenological approach, one strives to eliminate "the _a priori_" (that which exists in his mind prior to and independent of the experience). This is done by attempting to "bracket" (hold in abeyance) theoretical presuppositions, interpretations, labels, categories, judgments, and so forth. Granted, a person cannot be completely perspectiveless. Man is an individual; he is a unique here and now person. So naturally, _necessarily_, he has an "angular" view for he experiences reality from the angle of his own particular "here" and his own particular "now." Or, stated differently, as a knowing, experiencing subject, each man must have _some_ perspective of the phenomenon being experienced. However, by recognizing and considering the particular perspective from which he is experiencing it, a person may become more open to the thing itself.
Furthermore, this kind of openness to one's own perspective can be developed through deliberate practice. Several approaches may be used. To begin with, a person can develop the habit of recognizing and exposing his own biases. This could involve something as basic as stating the actual physical situation or circumstance in which the phenomenon was experienced. For example: the phenomenon could be something seen from above or below, at a distance or nearby; something heard in a quiet room or above the din of background noise; a patient's behavior in a large group or in a small group, with his family, with on particular nurse, with his doctor; a patient's response while being fed, bathed, monitored.
Beyond this unavoidable bias of the angle of perception, the nurse's experience of her lived world may be dulled by habituation. It is necessary to break through the tunnel vision of routine. For instance, a nurse new to a situation may notice a patient's response to her and remark about it to another nurse. The second nurse, to whom the patient's behavior is familiar, may respond, "Oh, he's done that for years." Often this is the end of the dialogue; it should be the beginning, for the duration of a phenomenon is not {81} equal to its description or meaning, but rather, is an indication of its significance.
The mystery of the commonplace is hidden by veils of the obvious. To recognize one's biases means to put one's beliefs, one's cherished notions, out on the table. A helpful aid in reflecting on and articulating an experience is the question, "What am I taking for granted?" Commonly used terms, such as, "psychiatric patient," "orthopedic patient," "oncology unit," "uncooperative," "emotional," "chronic," "terminal," "hopeless," "outpatient," "ambulatory," "visitors," "family," "doctor," "nurse," "administration," "front office" have an aura of connotations that may correspond to or differ greatly from the actual immediate experience. It may be a case where believing is seeing. The habit of premature labeling may close a person to the full savoring of experience.
Another means of increasing openness to one's own perspective is to consciously note whether the phenomenon is being experienced actively or passively. For example, the phenomenon may be the motion of changing a patient's position in bed. Both experience the motion, but it is a different experience for the nurse who actively moves the patient and for the patient who is moved passively. Or again, many studies of the phenomenon of empathy have been reported in the literature. Almost exclusively, these are descriptions of empathizing with someone; only rarely are they concerned with the experience of being empathized with. Yet obviously, the active and passive experiences of the phenomenon of empathy are different. The same holds true for touching and being touched, bathing and being bathed, feeding and being fed, supporting and being supported, reassuring and being reassured, and many other phenomena in nursing.
Similarly, awareness of one's perspective may be increased by consciously realizing whether the phenomenon is being viewed objectively or subjectively. Consider for example, phenomena such as pain, anxiety, sleep, restlessness, boredom. Seeing evidence of pain in another person is not the same as feeling pain within myself. Recognizing objective signs of anxiety in another person differs from the subjective experience of feeling anxious myself. Sleeping and observing someone sleeping are two different experiences. The same hold true for restlessness, boredom, and so forth.
In view of nursing's dialogical character it may be assumed that many phenomena of major concern would be intersubjective or transactional. It is important then for nurses, attempting to develop openness to their own perspectives, to consider whether the phenomenon involves two subjects and their between. Does the action go both ways? Are both persons calling and responding to each other simultaneously? Take the phenomenon of "timing" for example. The nurse's verbal response to a patient depends not only on her perception of her own here-and-now and his perception of his here-and-now but rather it also involves their perceptions of their shared here-and-now situation. The nursing world is filled with intersubjective phenomena such as, eye {82} contact, touch, silence. To describe these fully the nurse must be open to her perspective, the patient's perspective, and their between.
Analysis, Synthesis, and Description
After a nursing phenomenon is grasped intuitively, it is desirable to find as many instances of it as possible for the sake of description. Keeping the phenomenon in mind and reflecting on it from time to time, the nurse becomes more alert to its occurrence in her lived world. The phenomenon may be experienced directly. In which case, it is described and reflected on and descriptions, reflections, and questions are recorded. When she observes the phenomenon in others, the nurse may ask them to describe it and verify her own observations. Some nurses have involved other staff members in discovering and describing instances of the phenomenon being studied. Similarly, one becomes more open to descriptions of it in the literature--any literature--or in any form of human expression, for example, poetry, drama, art, science. As many descriptions of the phenomenon are gathered from as many angles as possible, these are the data to be analytically examined, synthesized, and described.
The three processes of analysis, synthesis, and description are so interrelated and so intertwined in reality that it is simpler to discuss techniques in relation to all three. Some techniques are equally useful in the analytic examination and the description of phenomena. In a sense, a person does both at once. And often, it is during this process of shifting back and forth, analyzing and describing an experience that synthesis occurs. A person gets a sudden insight, "everything falls into place," "it clicks." One gets a gestalt, a whole, not necessarily a whole in the sense of complete and entire, but a whole frame, form, or structure that allows for further developing and filling in of details.
There are many ways of going about the analysis and description. The following are some that have been found useful in the explication of nursing phenomena.
Comparing and contrasting instances of the phenomenon lead to the discovery of similarities and differences. For instance, in studying patients' crying it was found that their crying was with or without tears; loud or silent; expressing pain, anger, fear, sorrow. Or again, silence may be defined simply as absence of sound. But silence as experienced in the real nursing world has other characteristics. It may convey anger, fear, peacefulness, and so forth. It is these nuances or qualities of silence that are significant cues for the nursing dialogue. They could be brought to light by comparing and contrasting descriptions of silence.
Various instances of the phenomenon being studied may be examined to discover common elements. Characteristics or elements seen in one instance are sought in the others. For example, when descriptions of interpersonal empathy were scrutinized, it became evident that in all cases there were physiological, psychological, and social components. Examining experiences {83} of reassurance revealed they had elements such as empathy, sympathy, reality orientation, feelings of hope and comfort.
One may determine which elements are essential to the phenomenon by imaginative variation, that is, by trying to imagine the phenomenon without a particular element. For instance, reassurance without empathy or sympathy would be false reassurance or, in other words, would not reassure.
The elements of the phenomenon can be studied to determine how they are interrelated. One may ask, is there a priority in time? Does one element develop from another? Consider the phenomenon of reassurance; does empathy precede sympathy? Or, to take another example, in the empathic experience, an openness to the other and an imaginative projection into his place lead to the vicarious experiencing of his situation.
For further clarification of its distinctive qualities the phenomenon may be related to and distinguished from other similar phenomena. For example, empathy is similar to and also different from identification, projection, compassion, sympathy, love, and encounter.
By considering what it has in common with other phenomena, the phenomenon being described may be classified as being subsumed in a broader category. Thus, empathy is a human response, a coalescent movement, a form of relating.
The phenomenon may be described by selecting its central or decisive characteristics and abstracting its accidentals. For instance, interpersonal empathy always involves movement into another's perspective and as a form of movement it has directions, dimensions, and degrees. It can occur between persons of difference age, education, experience, sex; these latter characteristics are accidental.
Some descriptions make use of negation. A phenomenon cannot be described completely by negation but it may be clarified to some extent by saying what it is not. For instance, empathy is not sympathy; it is not projection; it is not identification.
Analogy may be used to promote analytic examination and description. This involves a comparison based on partial similarity between like features of two things. For example, the movement of empathy is like the currents in the sea; the heart is like a pump. The advantage of using analogy is that the comparison raises questions about the nature of the phenomenon under consideration. However, since the similarity between the analogues is always partial, one must guard against overextending the comparison to unwarranted conclusions. The description must always be consonant with the phenomenon as it occurs in reality.
The use of a metaphor also may enhance description and analysis. A metaphor suggests comparison of the phenomenon with another by the nonliteral application of a word. For example, "the between is a secret place." The use of metaphor may be criticized in regard to its lack of precision. On the other hand, there are some (for example, Marcel, Buber) who hold that the intersubjective realm can be described only metaphorically because it is {84} beyond the level of objectivity. And to attempt to describe intersubjective phenomena in precise terms related to the physical world would tend to distort rather than clarify. Many of the nursing phenomena requiring description occur within the intersubjective realm. Metaphors could cast some light on these.
CONCLUSION
As a theory of practice, humanistic nursing is derived from individual nurses' actual experiences in their uniquely perceived but commonly shared nursing world. Its development, therefore, depends on the articulation of their angular views and also on the truly collaborative effort of a genuine community of nurses struggling together to describe humanistic nursing practice.
Since the description of nursing phenomena is recognized as a basic and essential step in theory development, this chapter presented an approach and detailed some techniques used by nurses to describe phenomena. It is hoped that these would be viewed critically and creatively; that they would be used, varied, combined adapted, and lead to new methods suited to the description of nursing phenomena. And if they are developed, it is hoped that they will be shared for the growth of humanistic nursing depends not only on using and sharing what we learn but also on describing how we come to know. Then humanistic nursing theory will grow in dialogue.
FOOTNOTES:
[1] Loretta T. Zderad, "A Concept of Empathy" (Ph.D. dissertation, Georgetown University, 1968). Josephine G. Paterson, "Echo into Tomorrow: A Mental Health Psychiatric Philosophical Conceptualization of Nursing" (D.N.Sc. dissertation, Boston University, 1969). Loretta T. Zderad, "Empathy--From Cliche to Construct," _Proceedings of the Third Nursing Theory Conference_ (University of Kansas Medical Center Department of Nursing Education, 1970), pp. 46-75. Josephine G. Paterson, "From a Philosophy of Clinical Nursing to a Method of Nursology," _Nursing Research_, Vol. XX (March-April, 1972), pp. 143-146. Josephine G. Paterson and Loretta T. Zderad, "All Together Through Complementary Synthesis," _Image_, Vol. IV, No. 3 (1970-71), pp. 13-16.
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8
HUMANISTIC NURSING AND ART
The term "humanistic nursing" often is interpreted as implying humaneness. Logically, humane caring must be one aspect (a major aspect) or a natural expression of humanistic nursing practice theory. But the term means more. According to the position being taken here, nursing may be described appropriately as humanistic since at its very base it is an inter-human event. As an intersubjective transaction, its meaning is found in the human situation in which it occurs. As an existential act, it involves all the participants' capacities and aims at the development of human potential, that is, at well-being and more-being. Our approach qualifies, then, as a form of humanism, according to the dictionary definition, being "a system or mode of thought or action in which human interests, values, and dignity are taken to be of primary importance."
In another sense of the word, our theoretical stance is humanistic by virtue of its regard for the humanities and arts. Philosophy, literature, poetry, drama, and other forms of art are valued as resources for enriching our knowledge of man and the human situation. They also are seen as suitable means for expressing or describing the lived realities of the nurse's world.
Contemporary nursing, being a true child of its time, reflects American society's high regard for "Science." Values of science are easily discernible in nursing and affect the character of its research, education, and practice. Consider, for instance, how the nursing dialogue is influenced by the prizing of objectivity, precision of language, operational definitions, scientific jargon, development of constructs and theories, methodology of scientific inquiry, emphasis on quantification and measurement.
There is much more written in our current literature about nursing as a science than about nursing as an art. Although slighted, the humanities have not been rejected. In fact, some nurses and educators are urging that the role {86} of the humanities and arts be recognized in nursing and that they be used more effectively in undergraduate and graduate nursing education.[1]
Turning to my own personal experience, I recall that one of the first definitions I had to learn in my basic nursing program began with the statement, "Nursing is an art and science...." (It is interesting that now, years later, this is all I can recall of the definition!) At that time, I accepted the statement at face value. I did not question it. Perhaps I had not thought enough about art and science and certainly I did not know enough about nursing to question the description. Yet over the years many experiences and insights have turned into questions that challenge this adopted cherished notion.
In the beginning I merely accepted the view that nursing is an art in the sense of being a skillful or aesthetic application of scientific principles. After all, we had a course in nursing arts (later called fundamentals of nursing). This had to do with bathing, feeding, making beds, and hundreds of other nursing procedures that were presented as "nursing arts," the doing of nursing. At the time I also had courses in the humanities and liberal arts. These courses were not related directly to nursing by either the teachers or myself, as I recall. I did not ask: In what way is nursing an art? What kind of art is nursing? Or, how does the art of nursing differ from other arts?
The notion (perhaps "conviction" would be more accurate) that nursing is an art in some sense other than an artful application of scientific principles has been with me for a long time. I do not know its origin nor even the form in which the view first appealed to me. I do recall having difficulty on several occasions in trying to express let alone explain, my idea. At these times, what I experienced subjectively as an intuitive flash of insight would end up objectified in an amorphous blob of words. Yet the theme returns over and over in a variety of questions and issues that demand response if not resolution. This chapter offers some further reflections on the relatedness of humanistic nursing and art.
USE OF ARTS
One of the most obvious ways in which nursing and art are related is in nursing's use of the arts. This may be seen in nursing education as well as in nursing practice.
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Liberalization
Usually, when arts and humanities are included in nursing education programs, it is for their humanizing effects. Traditionally they have been recognized as having a civilizing influence. So in nursing they are seen as supporting the elements of humaneness and humanitarianism. Furthermore, they are a necessary antidote for the depersonalization that accompanies scientific technology and mechanization.
The arts are valued also for their liberalizing effect. They stimulate imaginative creativity. They broaden a person's perspective of the human situation, of man in his world. For instance, depictions of suffering man or of other aspects of the human condition that are found in poetry, drama, or literature are far more descriptive and much closer to reality than those given in typical textbooks.
Current nursing practice reflects the educational preparation of nurses that is weighted heavily with scientific courses and the methodology of positivistic science. Arts and humanities are a necessary complement. Science aims at universals and the discovery of general laws; art reveals the uniqueness of the individual. While science strives for quantification, art is more concerned with quality. Strict conformance to methodology and replicability are prized in scientific studies, whereas freedom and uniqueness of style reign in art. Science, forever updating itself, opens the nurse's eyes to constant change and innovation; the classics promote a sense of the unchanging and lasting in man's world. Science may provide the nurse with knowledge on which to base her decision, but it remains for the arts and humanities to direct the nurse toward examination of values underlying her practice. Thus, humanistic nursing has both scientific and artistic dimensions.
Expression
Humanistic nursing and art are interrelated in another way. Some nurses who are also artists use their respective arts to express their nursing experience. Poetry is a good example.
In an article, "Nurses as Poets," Trautman notes that since the 1940s progressively greater numbers of poems about nursing have been published and since the 1960s the quality of these poems has improved considerably.[2] She believes that nurses' ability to express their feelings about nursing in poetry cannot be attributed entirely to a change in times. Rather, it is a reflection of change in nursing practice. For one thing, contemporary nursing requires a great deal of abstract thinking. It calls for an understanding involving mental and emotional investment, and imaginative feeling _with_ the patient. The {88} nurse-poet puts aside technical terms, looks at her patient in a fresh and creative way and shares her view in a poem.
A second reason offered by Trautman is the increased emphasis in nursing education on communication and verbal skills. A nurse with a talent for writing may be moved by a particular experience to share it. Thus, "the sensitive nurse-writer may use poetic expression to work through a problem, to muse about a detail, or to record a profound experience."[3]
Finally, she states that some nurses write poetry about aspects of their work that defy scientific analysis and cannot be easily contained in technical papers. In this, then, nurses' poetry goes beyond the personal satisfaction accompanying expression; it preserves a unique angular view of nursing's lived world and adds to our store of clinical wisdom. As Trautman concludes:
"Poetry has trailed the profession for many years, probably because nurses were not encouraged in creative writing of any kind. Today, however, I think that poetry leads the profession because most of it never loses sight of human needs--both nurses' and patients'. Our poets lend a clear and vital voice to our profession. They cite their experiences, emotions, beliefs, and awareness in lieu of a science-oriented bibliography. They appeal to our common sense but, more importantly to our hearts. They tell us to observe honestly and to feel. Above all, our poets tell us to believe in our observations and to trust in our feelings--for patients, for ourselves."[4]
Some elements or aspects of nursing lend themselves to scientific exploration and discovery while others, equally important and likewise deserving expression, reveal themselves only through the artist's vision. So what has been said of poetry, therefore, may hold true in other arts. Each art has its own form of dialogue with reality. The painter, for example, feels with his eyes; he feels lines, points, planes, texture, and color.[5] What could the nurse-painter share? Or as Garner, a nurse-musician, suggests, nursing could be conceptualized along the schema of tones, texture, rhythm, meter, intensity, temperament.[6]
What nursing content would accrue if the various nurse-artists used their forms of knowledge, skill, and vision to explore nursing as the various nurse-scientists do? What can our poets, painters, musicians and dancers see, hear, feel in the nursing dialogue?
Therapeutics
There is a third way in which humanistic nursing and art are related. For many years, the arts have been used in nursing for their therapeutic effects, especially with psychiatric, geriatric, and pediatric patients. The nurse and a patient or a group of patients participate in an artistic experience together. These may be passive activities, such as, attending a concert or play or visiting {89} an art exhibit; or they may be active ones in which nurse and patients are involved in artistic expression or creation.
Music, poetry, painting, drama, and dance have been used effectively in various nursing situations. For instance, Christoffers, a nurse and dancer, emphasizes the importance of body language as communication and supports her view with clinical evidence. She urges nurses to become "physically literate--to develop an understanding and appreciation of the part played by body language in human relationships."[7] Or again, according to Garner, "Music, when carefully planned, can be used as a source of culture, nurturance, communication, socialization, and therapeusis."[8]
A major therapeutic value of art lies in the fact that it confronts one with reality. "Art is a lie which makes us realize the truth."[9] In his novel, _The Conspiracy_, Hersey has Lucan, a poet, write to Seneca:
"To me the ideal of a work of art is that each man should be able, in contemplating it, to see himself as he really is. Thus art and reality meet. This is the great healing strength of art, this is the power of art, ... Art's power which nothing can challenge, is the blinding light of recognition."[10]
By using various art forms the nurse helps the patient experience, become aware of, and express his feelings. When the activity occurs in a group, the members have the additional advantage of sharing in others' expressions and of developing fellow-feeling. Increased socialization is another important therapeutic effect nurse-artists/art appreciators seek in the use of art. A corollary benefit is improved communication between the patient and the nurse or between the patient and others.
Obviously, self-knowledge and fellow-feeling are consistent with the aim of humanistic nursing to nurture well-being and more-being. A person develops his human potential and becomes the unique individual he is through his relationships with other men.
NURSING AS ART
Thus far, this chapter has been concerned with the relatedness of nursing and art. It was seen that nurses may study arts and humanities for a broader understanding of the human situation, may express their nursing worlds through various art forms, and may use the arts therapeutically. Now the question is raised whether nursing is an art, and if so, what kind of art.
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Artful Application
Even the most scientific nurses do not deny that nursing is, in some way, an art. But precisely how the art and science of nursing are interrelated is not clear. For example, Abdellah writes:
"The art of nursing must not be confused with the science of nursing. The former concerns itself with intuitive and technical skills (often ritualistic), and also the more supportive aspects of nursing; the latter concerns itself with scientific truths. Both are important. They are interwoven and complement each other."[11]
However, Abdellah gives no further elaboration of this point. Usually, when nurses are asked about the relatedness of the art and the science of nursing, the view expressed is that science has to do with general principles and laws that govern nursing and art has to do with the particular application of principles in individual cases. Furthermore, when a nurse describes some event as "beautiful nursing" and is pressed to elaborate, she usually describes nursing actions that were performed "artfully," "skillfully," "harmoniously." Thus, in some way, the art of nursing has to do with the nurse's response to human needs through actions that are purposeful and aesthetic.
Useful Art
In current usage, the term "art" is most commonly associated with the beautiful, that is, with aesthetics or the fine arts. Frequently, it is restricted even more to signify one group of the fine arts, namely, painting and sculpture. For instance, one refers simply to an "art exhibit" or an "art" museum but specifies further "a center for the performing arts."
However, historically the word "art" was related to utility and knowledge, and its traditional meanings still exist today. For example, we speak of "industrial arts" and "arts and crafts" through which useful things are produced. On the other hand, "liberal arts" (work befitting a free man) are those related to skills of the mind. We also refer to the art of medicine, of teaching, of nursing, of politics, of navigation, of military strategy, and so forth.
The word "art" can refer to both the effect of human work (works of art) and the cause of things produced by human work (the knowledge and skill of the artist). It is obvious that not only knowledge but also some form of work and skill are involved in all art, useful or fine. "Art" is the root of "artisan" as well as of "artist."[12]
Some arts, such as nursing, medicine, and teaching, may be considered useful, yet they differ from other useful arts, such as industrial arts, for they {91} do not result in tangible products. Nursing for instance, aims purposively for well-being, more-being, health, comfort, growth. These are the results of the art of nursing. As an artist, therefore, the nurse must know how to obtain desired effects and must work skillfully to get them. The nurse cannot make well-being or comfort or health as one can make a shoe or a painting or a speech. The art of nursing involves a skillful doing rather than a making. Furthermore, nursing is concerned with changes in human persons not merely with the transformation of physical objects. It is intersubjective and transactional, so the art of nursing must involve a doing with and a being with.
Performing Art
Along this vein, nursing may be viewed as a kind of performing art. Fahy, nurse-educator-actress, draws an interesting comparison between the process of nursing and acting in a drama.
"In a play the actors know certain things, there are a certain number of given circumstances: plot, events, epoch, time, and plan of action, conditions of life, director's interpretation. The technical things are also there: setting, props, lights, sound effects, and so forth. But it remains at the time of curtain for the actors to go on alone and produce. In the act of nursing there are some known facts that the nursing student or the nurse can pick up: name, age, religion, ethnic background, medical diagnosis, and plan of care (sometimes), her own background knowledge and experience, and her own unique personality. However, when she encounters other patients--watch it! The same thing happens in the teaching-learning process."
"Edward A. Wright in _Understanding Today's Theater_ says about the actor and acting something which I believe about the nurse and nursing.
'... the actor ... is his own instrument. His tools are himself, his talent, and his ability. Unlike other creative artists, he must work through and with his own body, voice, emotions, appearance, and his own elusive personal quality.... He uses his intelligence, his memory of emotions, his experiences, and his knowledge of himself and his fellow men--but always he is his own instrument.'"[13]
Here is another example of viewing nursing as a performing art. Once a nurse was trying to describe the nursing care she received from another nurse when she had been ill. She struggled with some details of finer points and then summed it up by saying, "I felt her nursing care was just like a symphony. That's the only way I can describe it."
These comparisons bring many aesthetic qualities to mind, for instance, harmony, rhythm, tone, feeling. Nursing is like music and drama in other ways. The nursing procedure, like a musical score or a play script, allows for individual interpretations, adaptations, and embellishments. Although nurses follow the same general principles, each can develop her own unique style. {92} If nursing really is viewed as a performing art, there are opportunities for creative exploration and development of the art of nursing. And furthermore, these individualized styles of nursing are worthy of description and sharing.
Another similarity is the ephemeral character of nursing, music, and drama. A particular nursing transaction, like a concert or play, is transitory, short-lived. Yet the effects may be long-lasting and remembered. There is this difference in nursing, I believe. Each nursing transaction may flow into a stream of nursing care extending continuously over 24 hours a day for weeks, months, years. And many individual nurses "get into the act." How does this affect the art of nursing? How is nursing like and unlike the other performing arts? The answers to these and similar questions must come from the nurse-artists.
HUMANISTIC NURSING AS CLINICAL ART
The relatedness of nursing and art, viewed existentially, is more basic, more fundamental than mere similarity of qualities and characteristics as discussed above. Both art and nursing are kinds of lived dialogue. In both, man responds to his world of men and things through distance and relation. They affect him and he affects them with the creative force of his relation.
In fact, one may say further that humanistic nursing is _itself_ an art--a clinical art--creative and existential. This is evident when one returns again to the thing itself, to the nursing dialogue as it is lived in the everyday world.
In genuine meeting the nurse recognizes the patient as distinct from herself and turns to him as a presence. She is fully present to him, authentically with her whole being and is open to him, not as an object, but as a presence, a human being with potentials. In such a genuine lived dialogue, the nurse sees within the patient a form (that is, a possibility) of well-being or more-being (or comfort or health or growth, and so forth). Like a beautiful landscape inspiring a painter or poet, the form in the patient addresses itself to the nurse, a call for help demanding recognition and response. The form is clearer than experienced objects; it is not an image of her fancy; it exists in the present although it is not "objective." The relation in which the nurse (artist) stands to the form is real for it affects her and she affects it. If she enters into genuine relation with the patient (I-Thou) her effective power (caring, nursing skills, hope) brings forth the form (well-being, more-being, comfort, growth), just as the painter's or poet's power and skill create a painting or a poem.
Of course, there is this difference. The art of nursing, being goal-directed and intersubjective, is more complex than the arts of painting and poetry, for example. As a clinical art, it involves _being with_ and _doing with_. For the patient must participate as an active subject to actualize the possibility (form) within himself. Perhaps the art of nursing could be described as transactional. Not only does the nurse see the possibilities in the patient but the patient also sees a form in the nurse (for example, possibility of help, of comfort, of support), and he responds in relation to bring it forth. {93}
Then the question logically may be raised: Is the patient's responses in relation (I-Thou) a necessary condition for the art of nursing? Or to state it differently: can there be any art of nursing the infant, the unresponsive, the comatose, the dying? I would answer that the art of nursing can exist even if the relation is not mutual. For as Buber writes,
"Even if the man to whom I say _Thou_ is not aware of it in the midst of his experience, yet relation may exist. For _Thou_ is more than _It_ realises. No deception penetrates here; here is the cradle of Real Life."[14]
DIALOGICAL NURSING: ART-SCIENCE
Art and science, like nursing, represent angular views. Each is a view with a particular purpose. They are human responses to the everyday world in which man lives. Existentially speaking, each is a form of living dialogue between man and his human situation.
It is possible that there is in nursing a kind of human response to reality that is a combination, a true synthesis of art and science? The more one focuses on nursing as it is lived, on the intersubjective transaction as it is experienced in the everyday world, the more questions arise about it as art and science. Elements of both art and science are evident in nursing. The practicing nurse must integrate them in her mode of being in the situation.
While Dr. Josephine Paterson was developing a methodology of inquiry from a clinical nursing process and describing her construct of the "all-at-once," she was so intent on communicating the interrelated reality of the art and science elements in nursing, that she welded them together with a hyphen into one word, "art-science." And even then there is some dissatisfaction when the weld is interpreted merely as a seam. For the combination is more than additive; it is a new synthetic whole.
I experienced a similar difficulty in trying to describe the synthesis of art and science that takes place in the nursing process. The nursing dialogue reflects the orientations of art and science for it involves both the patient's and the nurse's subjective and objective worlds. I believe the synthesis of art and science is _lived_ by the nurse in the nursing act. This is a phenomenon more readily experienced than described.
Yet if we truly experience nursing as a kind of art-science, as a particular kind of flowing, synthesizing, subjective-objective intersubjective dialogue, then nursing offers a unique path to human knowledge and it is our responsibility to try to describe and share it.
FOOTNOTES:
[1] New England Council on Higher Education for Nursing, _Humanities and the Arts as Bases for Nursing:_ Implications for Newer Dimensions in Generic Nursing Education, Proceedings of the Fifth Inter-University Work Conference (Lennox, Mass: New England Council on Higher Education for Nursing, June, 1968). "Humanities, Humaneness, Humanitarianism," Editorial in _Nursing Outlook_, Vol. 18, No. 9 (September, 1970), p. 21. Charles E. Berry and E. J. Drummond, "The Place of the Humanities in Nursing Education," _Nursing Outlook_, Vol. 18, No. 9 (September, 1970), pp. 30-31. Marion E. Kalkman, "The Role of the Humanities in Graduate Programs in Nursing," in _Doctoral Preparation for Nurses_, ed. Esther A. Garrison (San Francisco: University of California, 1973), pp. 138-155.
[2] Mary Jane Trautman, "Nurses as Poets," _American Journal of Nursing_, Vol. 71, No. 4 (April, 1971), p. 727.
[3] _Ibid._, p. 728.
[4] _Ibid._
[5] Chaim Potok, _My Name Is Asher Lev_ (Greenwich, Conn.: Fawcett Publications, 1972), p. 105.
[6] Grayce C. Scott Garner, "Qualitative and Quantitative Analyses of Schizophrenic Verbal and Non-Verbal Acts Related to Selected Kinds of Music," _Humanities and the Arts_, p. 49.
[7] Carol Ann Christoffers, "Movigenic Nursing: An Expanded Dimension," _Humanities and the Arts_, p. 95.
[8] Garner, p. 40.
[9] Picasso as quoted in _My Name Is Asher Lev_.
[10] John Hersey, _The Conspiracy_ (New York: Alfred A. Knopf, 1972), p. 82.
[11] Faye G. Abdellah, "The Nature of Nursing Science," _Nursing Research_, Vol. XVIII (September-October, 1969), p. 393.
[12] "Art," _The Great Ideas_: A Syntopicon of Great Books of the Western World I, Vol. 2, 1952, pp. 64-65.
[13] Ellen T. Fahy, "Nursing Process as a Performing Art," _Humanities and the Arts_, p. 124.
[14] Martin Buber, _I and Thou_, 2nd ed., trans. Ronald Gregor Smith (New York: Charles Scribner's Sons, 1958), p. 9.
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9
A HEURISTIC CULMINATION
This chapter presents an application of the humanistic nursing practice theory over time and an outcome. The outcome represents my present conscious conceptualization of my personal theory of nursing. It has grown out of my nursing practice experience, my reflecting, relating, describing, and synthesizing. This is heuristic culmination of much mulling over my lived world of nursing.
ANGULAR VIEW: PRESENT PERSPECTIVE
In 1971 after a presentation on concept development I heard myself in a chatty response to the audience declare my unique theory of nursing. It was based in constructs that I had developed and conceptualized. Previously I had viewed these constructs only as distinct entities. My synthesis of them surprised me. This was the first time I conveyed them as my why, how, and what of nursing. This synthesis may have emerged as a sequence to my reexamination and reflection on each of these constructs in preparation for this 1971 presentation.[1] Now it became evident that their sequential evolvement had a logic that had come from my being without my awareness.
Since 1971 I have planned to reflect on these synthetic constructs to better understand how they relate to one another complementarily. Why? To further the development of these constructs and to state them as propositions. Statements of propositions are movement toward nursing theory. Theory is considered here as a conceptualized vision teased out of my knowing from my nursing experience.
{96}
Like Elie Wiesel, the novelist and literary artist, I write to better understand and to attest to happenings. This chapter is the fruit of this endeavor.
The first term, "comfort," was developed as a construct in 1967. After recording and exploring my clinical experiential data, a conceptualized response emerged to my question: "Why, as a nurse, am I in the clinical health-nursing situation?" The second term, "clinical," was developed as a construct in 1968. It was a conceptualized response to a dialectical process within myself. I asked, "What is clinical?" I answered, "I am a clinician." I asked, "As a nurse clinician what do I do; what is the condition of my being in the nursing situation?" I answered, "This described would equate to clinical." Consequently I compared and contrasted two nursing experiences similarly labeled to properly grasp the principle of "clinical" for conceptualization. The third term or phrase, "all-at-once," arose intuitively within me as a construct in 1969 and was partially conceptualized. It arose after mulling over other nurses' published clinical data and asking, "What can you tell me of the clinical nursing situation?" "What do you perceive as the nature of nursing?" Therese G. Muller's, Ruth Gilbert's and my thought on the nursing situation merged into a view of these as multifariously loaded with all levels of incomparable data, the "all-at-once." Incommensurables relate to the nature of nursing and its concerns. How can one study unrelated appearances? Muller often used an historical approach while Gilbert emphasized individualization. In humanistic nursing practice theory a descriptive, intersubjective, phenomenological approach is proposed for greater understanding and attestation of the events and process of the nursing situation. The construction of "comfort, clinical, and all-at-once" I would now label as conceptualized phenomenologically. I view them as relevant phenomena to any nurse and this nurse-in-her-nursing-world.
Theory: Unrest, Beginning Involvement
This desire to develop nursing theory goes back to my years (1959-64) as a faculty member in a graduate nursing program. I fussed with the idea, did not know exactly what I was fussing about, and expressed my desire, interest, and concern poorly. Much, I am sure now, to others' dismay. Teaching in nursing was an offering of multitudinous theories developed in and for other disciplines using nursing examples. There were both similarities and differences in the many nursing examples in which attempts were made to describe the qualities of the participants' beings. Emphasis was placed on the observations by the nurse of the others' responses in the nursing situation. Nursing education was rife with lengthy repetitive examples utilized to focus on particular variations. I desired a unifying base applicable to all nursing situations. This was not a seeking for conformity nor an attempt to negate individuality. Certainly I did not want such a base to exclude individual nurses' talents. Rather this base, foundation of nursing indicative of the nature of nursing, would heuristically promote endless variations to flow, blossom, cross-pollinate, and evolve. {97}
In these observations and thinkings I was attempting to understand, sort out, and clarify the questions that underlay my puzzlement. This puzzlement arose out of my 18 years in nursing practice and education. In a theory course and a philosophy of science course, while in doctoral study, I recognized and learned to label my unrest and puzzlement as a recognition of the need for nursing theory.
In 1966 in discussing my purposes for doctoral study, I expressed this unrest and puzzlement. I viewed my varied past experiences in nursing as excellent. I sought time to reflect on the past 24 years of living nursing to see what it could tell me, and to come to better understand its meaning to the profession of nursing. The philosophical nature of these questions and what they express of myself is evident. Such personal revelation at this time is no risk, and withholding would only deprive myself and others of the answers that might be brought forth.
As in most school situations initially responding to class assignments and involvement in new clinical situations consumed my time and thwarted my personal, professional interests. When I commented on this my interests were interpreted to me as a desire to live in the past. Living in the present was recommended and terms like "up-to-date" and "progressive" were employed. I felt stopped cold. I had never viewed myself as old fashioned or non-progressive. Many of my past nursing experiences were still avant-garde as compared with general current practices.
There was something different though in recalling and reflecting on the past as opposed to current experiences. One's past would be visible in view of how one approached and experienced the present. Self-confrontation moved me beyond confining myself either to the past or to the present. In my writings one could detect a comparison of what had been known with what was coming to be known. It was as if a light of a different hue lit up the whole--past and present--as a different scene. Similarly I viewed and experienced my clinical experience differently. I gained awareness of a quality of my being that always had been there, but which I hid. Now I valued this part, struggled with it, and expressed it directly with courage, integrity, and pride. The power with which this self-actualization imbued me has been sculpturing my "I" into a form of my choosing ever more acceptable to me, and accepting of others.
Concept Development
In a nursing theory course the final assignment was: develop a concept relevant to nursing. Again I found myself struggling. The didactically stated importance of investing precious time and energy into constructing a synthetic conceptualization of a term eluded me. Time and energy spent to better understand man as he was known to me in the nursing situation seemed so limited. In these situations persons were expressing so many things at one time, how could the conceptualization of one term be relevant. Finally I understood: no one was saying that any one term could equate any particular or group of {98} nursing situations. They were saying that to communicate the nature or experience of nursing with words, to develop nursing theory, relevant terms needed clarification as to the meaning they conveyed and delineation as to their inclusiveness and exclusiveness.
As this struggle subsided I could hear, "a term could be developed as a concept or synthetic construct if one conceptualized its why, what, how, when, and where and how these interrelated." In approaching concept development the last but not least hurdle was, what term did I consider relevant enough in nursing to expend this precious time and energy on considering the many possibilities. The first term I began to intellectually play with was "ambivalence." Now, I would attribute my selection of "ambivalence" to my then existing ambivalence about conceptualizing a synthetic construct. Then, I based its selection only on its existence in my clinical nursing world. I was working therapeutically on a regular, individual basis with an ambivalent adolescent male labeled diagnostically as a paranoid schizophrenic. I began to consider my clinically recorded data of my sessions with Bob through ambivalence. What were the relationships between why, how, what, when, and where Bob expressed ambivalence?
Struggling with the term "ambivalence" involved and interested me in concept development. During this phase I overcame my fear of exposing my thoughts, I took the risk, and my courage had the upper hand. Nevertheless, another choice had to be made since now I was not willing to invest this much time on conceptualizing "ambivalence" as so relevant to nursing. Perhaps this signified that my own ambivalence had dissipated. And again, I faced the question, what term would I want to develop as a synthetic construct?
The next question that occurred to me was, what term would indicate why, as a nurse, I am in the clinical health-nursing situation? Did I view my value mainly as growth, health, freedom, or openness promotion? I worked for a while with each of these terms and eventually discarded them. Some long-hospitalized persons with whom I was working on a demonstration psychiatric unit to prepare them for a more independent and appropriate form of community living would never be stably balanced in health, growing, freedom or openness. For many, these could be only flitting memorable beautiful moments. Still I believed I was very much there in the nursing situation for these persons, as well as for those who moved into the community and found work and social satisfactions. Something occurred between all of these 15 patients and myself--and that was nursing.
COMFORT: WHY
While considering what construct to conceptualize, I was in the process of recording my three-hour, twice a week interactions in the demonstration unit. I reflected on these interactions and waited for the data to reveal to me the major value underlying my nursing practice. Then the term "comfort" came {99} to mind. Perhaps at this point I became comfortable in this unit, or perhaps the unit, itself, became a more comfortable setting. When I had first begun my experience with this demonstration unit, it was still being planned and the hospital was new to me. However, the term "comfort" has long been associated with nursing. One can find it as a historical constant throughout the professional nursing literature. The term had been used recently in an ANA publication.[2] When I considered the idea of comforting in nursing practice I felt such experiences had fulfilled and satisfied me, made me feel adequate. I could recall specific experiences that went back to my initial nursing practice settings. I could conceive of comfort as an umbrella under which all the other terms--growth, health, freedom, and openness--could be sheltered. Some of my contemporaries scoffed and viewed this term as much too trivial.
Now, again reviewing my months of gathered clinical data, I sorted out 12 nurse behaviors that I viewed as aiming toward patient comfort. They were:
1. I focused on recognizing patients by name, being certain I was correct about their names, and using their names often and appropriately. I also introduced myself. Names were viewed as supportive to the internalization of personal identification, dignity, and worth.
2. I interpreted, taught, and gave as much honest information as I could about patients' situations when it was sought or when puzzlement was apparent. This was based in the belief that it was their life, and choice was their prerogative as they were their own projects.
3. I verbalized my acceptance of patients' expressions of feeling with explanations of why I experienced these feelings of acceptance when I could do this authentically and appropriately.
4. When verbalizations of acceptance were not appropriate, I acted out this acceptance by staying with or doing for when appropriate.
5. I expressed purposely, to burst asunder negative self-concepts, my authentic human tender feelings for patients when appropriate and acceptable.
6. I supported patients' rights to agape-type love relationships with others: families, other staff, and other patients.
7. I showed respect for patients as persons with the right to make as many choices for themselves as their current capabilities allowed.
8. I attempted to help patients consider their currently expressed feelings and behaviors in light of past life experiences and patterns, like and unlike their current ones. {100}
9. I encouraged patients' expression to better understand their behavioral messages and to enable me to respond overtly as therapeutically as possible.
10. I verified my intuitive grasp of how patients were experiencing events by questions and comments and being alert to their responses.
11. I attempted to encourage hope realistically through discussing individual therapeutic gains that could be derived from patients' investment in therapeutic opportunities available to them.
12. I supported appropriate patient self-images with as many concrete "hard to denies" as possible.
Each of these nurse behaviors was repeatedly evident in the months of recording patient-nurse interactions. For the conceptualization of the term "comfort," a representative clinical example was given to enhance the meaning of the behavior cited (see Appendix). When compiling materials for the conceptualization of this term, I found 12 assumptions about psychiatric nursing that I had written for the theory course in one of the first class sessions. Although these assumptions were expressed in different words, their congruence with my 12 selected behaviors made me believe that these behaviors were somehow verified both in my conceptualized philosophy of psychiatric nursing and in my behavior while being a psychiatric nurse.
Next I struggled with an idealistic conception of comfort as opposed to a continuum of behavior which would indicate a person's degree or state of discomfort-comfort. Again, reflecting on and teasing out aspects of my data, I set up four behaviorally recognizable criteria for estimating a person's discomfort-comfort state:
1. Relationships with other persons which confirm one as an existent important person.
2. Affective adaptation to the environment in accord with knowledge, potential, and values.
3. Awareness of and response to the reality of the now with understanding of the influence of and separation from the past.
4. Appreciation and recognition of both powers and limitations which enlighten the alternatives of the future.
These behavioral criteria, too, could each be spread on a continuum to evaluate the effects of this aim of nursing on a patient's actual comfort status at any particular point in time.
Considering the concept of comfort as a proper aim of psychiatric nursing brought forth the necessity of considering its opposite, discomfort, as a concept. Evidence for the existence of discomfort could be inferred in the absence of the above behavioral criteria. {101}
The basic foundation to justify the concept of comfort as a proper aim of psychiatric nursing would be both organic and environmental. In our culture, among the species man, we are moving toward being able to effect some organic conditions by genetic controls and surgical and chemical means. The professions have struggled long years to influence environmental deterrents to comfort. If an individual as a fetus, or as an infant, or young child never internalizes comfort of any kind from his environs, the probability of initiating a continuum within himself as an adult that is propelled toward comfort seems unlikely. Such individuals, lacking any potential capacity for comfort, I suspect are rare. There is evidence for the existence of this dormant seed of comfort in persons with schizophrenia in the hospital setting. Consider how repetitively and ambivalently they "reach out" to authority figures. This dormant comfort seed requires nourishment of a high quality for testing whether it can develop and bear the fruits of health, growth, freedom, and openness.
When the development of this synthetic construct of comfort was discussed in the theory course a question was raised: Is a person who denies all feeling, presents himself as emotionally dead, comfortable? If feelings are not relegated to the mind alone, as the effects of a peptic ulcer cannot be relegated to the stomach, if feelings are an essential of the nature of humanness, a human who denies this essential of his nature would not fit into this concept as comfortable. This synthetic construct of comfort, like its synonym contentment, described by Plutarch A.D. 46-120, does not imply passivity, resignation, retirement, or a simple avoiding of trouble. Plutarch said, "Contentment comes very dear if its price is inactivity."[3] I would perceive of comfort or contentment as implying that a human being was all he could be in accordance with his potential at any particular time in any particular situation.
Continuing the aforementioned twelve nurse behaviors, observing behavior through the four established criteria and conceptualizing the construct of comfort, I began to wonder. Was I seeing what I had decided was the state of psychiatric patients' conditions of being? Was I projecting discomfort onto patients? I did not expect straight answers. Nonetheless, I decided to ask patients about their discomfort-comfort states to verify my perception of the condition of their beings. All fourteen patients I asked assured me by their responses that I was not projecting or seeing discomfort where it did not exist.
Some described physical discomfort and sought the cause within and outside themselves (either another caused it, or another could cure it, pills would cure it), negatively viewed self-images, guilt based in their behaviors or thoughts. One patient defined comfort by analogy and stated directly to my surprise that he seldom felt comfortable and 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.
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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 to know intuitively the experience of this particular other nurse-in-her-lived-nursing-world. The consultees offered their lived-nursing-worlds each in their unique ways. Some discussed directly their pains, joys, adequacies, and inadequacies. Some discussed indirectly their panic, success, action, and immobilization. Some beyond being able to discuss their lived-worlds {107} spontaneously acted out their lived-worlds. For example, these often behaved toward me as their patients and families behaved toward them. These kinds of acted out lived-worlds I had to sense my way into to understand. When I began to wonder what it was that they wanted from consultation to take back to their lived-nursing-worlds, I would pull out of the "I-Thou" form of relating. This wonderment became my conscious clue. It was time to reflect and look at what my explorations had uncovered.
At this point transcending this "I-Thou" relation, I would look at "It." Seeing, now, what was within me, what the condition of my being was that I had intuitively taken on from the consultee, I would set it apart from myself, and see it as an empathic response. I knew that these feelings I experienced which I received existentially, globally through the compound of the consultee's words, tone inflection, volume, facial expression, posture, and positioning to me were what she experienced in her-nursing world. Verbalization of this empathized understanding fulfilled several purposes: (1) it conveyed my sympathy or joy with, and always my caring, (2) it validated that I saw it as it was for this nurse, and (3) it opened the door to our working through the possible meanings of the nurse's experience and to speculating about outcomes of alternative future nurse actions and behaviors.
Cognitively the range of these consultation discussions was broad. Some common themes were social and health histories of families, pertinent psychological growth and development factors of persons in the families of concern to the consultees, relationships between persons within the situations, resources available to the families, ways the consultees could relate with the parents and patients' families, friends, and other professionals in the situation, and the meaning of all these themes to the particular consultee.
This clinical consultation experience necessitated my being certain ways. It necessitated my being authentic with myself with regard to what responses were called forth in me in relating with a particular consultee. I viewed honesty with the consultee as a value necessary to the consultation process. In approaching the consultation I needed to be open to the consultee's angular view and predisposed toward an "I-Thou" relationship. The "I-Thou" relating necessitated subsequent scientific understanding extrapolated from it through reflection on it as "I-It." My hope in consultation was to offer both a cognitive, as well as, an ontic experience in which a mutual feeling apart from and toward the other would exist. This latter seemed most important to me. If the consultee experienced my being authentically present with her, she then would be apt to offer this type of relationship to the patients and families of concern to her.
Results of Comparison
The two clinical consultation experiences were juxtaposed, contrasted, questioned, related, and synthesized to envision their unified contribution to the construct of "clinical." The synthetic construct of "clinical" is not viewed as a mere juxtaposing, a disintegrating, or reconstructing of the contributions {108} to my knowing from either of these experiences. This comparison is viewed as a facing of the multiplicities they both present. The synthesis is an illumination of both experiences with each transfigured through their mutual presence in the "knowing place" of the comparer.[17]
In this comparison my appreciation grew of how I had uniquely implemented and conceptualized clinical consultation in my work experience. I recognized through the comparison that adequate clinical consultation demands both a passionate and dispassionate phase of "I-Thou" and "I-It" relating. Without either of these forms of consultant being-in-the-situation we degrade the term "clinical" if we employ it. Consultation lends itself naturally to a collaborative cooperative relationship. The consultant is dependent on the consultee for presentation of the specifics of particular situations. The consultee is dependent on the consultant for the tailoring of general knowledge to the consultees' particular situations. The relationship if appropriately called consultation is then of necessity interdependent. In being separate from the other while feeling with the other the consultant does not lose the ability to question. Passion undealt with or identification with the consultee inhibits the clinical purpose of the consultant and of the consultation. In identification one feels as if he were the other, rather than turning to the other and feeling with him. The degree of anxiety this provokes in the consultant can prevent looking at the consultation situation and issues in an "I-It" manner. The consultant loses the ability to question.
Through this comparison I was able to reflect on the graduate student nursing consultation experience in an "I-It" way. At this time it became a "clinical" experience for me. The lack of this reflective phase in this experience highlighted the reflective phase already existent in the working clinical consultation experience. The existence of this phase in the working clinical consultation experience highlighted its absence in the graduate student nursing consultation experience. My commonplace nursing world through this comparison became awarely meaningful and availed itself for conceptualization. A situation is not a "clinical" experience until the "would be" clinician can reflect, analyze, categorize, and synthesize it.
Clinical Is
A potentially clinical psychiatric mental health situation becomes "clinical" if the clinician relates to the helpee to awaken his unique potential or ontic wholeness, and noetically transcending this relating conceptualizes its meaning.
Clinician signifies a particular mode of being and a particular kind of cognitive knowledge. With all his human capacity the clinician relates with his clinical-world consciously and deliberately in "I-Thou," and "I-It."
Relating in "I-Thou" with the other in-his-clinical-world the clinician gives himself and receives back the other and himself in the sphere of "the between." {109} He knows the other and the more of himself in this relating. He is confirmed and confirms the other through the other's presence with him. Thus, he calls forth the other's actualizing of self through the clinical relationship. In accepting the other as he is the clinician imagines and responds to the reality of his potential for becoming, becoming according to his unique capacity for humanness.
Relating in "I-It" with his clinical world the clinician noetically transcends himself, objectifies himself, and studies his "I-Thou" knowing. He teases it apart. He classifies and studies it. He asks it questions. He compares and contrasts it to other clinical experiences. He discusses its many aspects in dialogue with his "inward," and possibly "outward" "Thous." He reorders its parts. He shapes, creates, plans from and for its clinical existence. Thus, he ever augments a world of heuristic knowing.
This "how" allows the clinical fulfillment of my nursing "why." Comfort is "why" I, as a nurse, am in the health-nursing situation. As conceptualized "comfort" is being able to freely control and plan for one's self, being fully in accord at a particular time, in a particular situation, with one's unique potential. Now, "what" is the nature of the nurse's world, the health-nursing situation?
ALL-AT-ONCE: WHAT
The term "all-at-once," arose within me as a construct that would metaphorically describe the multifarious multiplicities that exist within nursing situations. Completing my comparison of Gilbert's and Muller's written works to grasp how they viewed the nature of psychiatric mental health nursing I found myself mulling over and fussing.[18] Your question is probably, mulling and fussing over what? While I mulled over and fussed I believe I, too, was perplexed. Why was I unsatisfied?
I had compared Gilbert's and Muller's writing styles, their conceptions of man, approaches to nursing, nursing education, supervision, and consultation. Their similarities and differences were noted, and how each presented herself predominantly. Then I cited the nursing communities they sought to influence and those in which they were while writing. Through reviewing their bibliographies and biographies I indicated the sources that had influenced them.
Still I mulled over, fussed, and was perplexed. I awakened in the middle of one night in 1969 understanding what had been causing my struggle. The "all-at-once" was my answer.
The description of single constructs and single examples originally had felt unrelated to the reality of the nurse's world. They oversimplified its complexity. The nature of nursing was complex. It seemed to me that we needed, as a profession, constructs that simplified and allowed clear communications. We, also, needed constructs that conveyed the reality and complexity of the {110} worlds in which nurses nursed. Perhaps a description of what "all-at-once" expressed for me would convey to others the lived-unobservable-worlds of nurses.
Nurses relate to other man in situations of "all-at-once." The "all-at-once" is equated by me to Buber's "I-Thou" and "I-It" occurring simultaneously and not only in sequence as he expressed it. These two ways that man can relate to and come to know his world and himself demand sequential expression for clear communication. However, the responsible authentic nurse in the nursing arena lives them "all-at-once." Aware of the multifarious multiplicities of her responses to another and at once to the surrounding field of action, the nurse selects and overtly expresses her responses that actualize the purpose, values, and potential of the artful science of professional nursing.
Awareness of the multifarious multiplicities affecting the other and the self in the nursing arena is a component of "I-Thou" relating. Selectively overtly expressing concordantly with the purpose, values, and potential of nursing necessitates a looking at, which is a component of "I-It" relating, while acting and being. Therefore both "I-Thou and I-It" modes of being are "all-at-once."
This necessity for a nurse's duality in her mode of being came to my awareness through comparing Gilbert' and Muller's works, studying Buber's conceptions of man, and considering them in relation to my current and past lived-experiences in the nursing-arena. In my nursing world of "I-Thou" relating reflection is called forth prior to my overt response to allow response selection concordant with my nursing purpose. The very character of multifarious multiplicities of the nursing world undoubtedly has called for nurses to develop their human capacity for duality in their mode of being.
To make these "multifarious multiplicities" explicit I would like to offer a description of a recent, personal nursing experience. In a community psychiatric mental health psychosocial clinic, I sat across from and focused on relating with a psychiatric client. After long years of hospitalization he was now living in a community foster home and visiting the clinic three days a week. When there was no special clinic activity in progress and often even when there was, he sat by himself and played poker. He told me about his game many times, over weeks and months. He dealt out five poker hands. Each hand was dealt to a member of his family, long dead. He did not accept their deadness. One day while describing the poker games and his relatives, he intermittently expressed his fantasies which he projected on to a sweet cheerful 65-year-old community volunteer. She was somewhat deaf. His fantasies were angry. When he gestured toward her, she in a motherly way came over to him, put her arm around him, and her ear down to his mouth. It was a moment of possible client explosion. With my eyes I attempted to communicate with her. This, and the tone of the patient's voice warned her to move away. While this was occurring another patient jealous of my attentions to this patient walked up and down, and in passing negatively commented on the religious background of the man I was sitting with. In the rear of the room a dietician was conducting a group on obesity. And all of this was set to the {111} melodious, sanguine strains of "If I Loved You" being poorly beat out on a piano about ten feet away by another volunteer accompanied in song by a few clients. Meanwhile two staff nurses were observing my part in all this since I was labeled "expert." The client did support me that day and responded to my staying with him. Much to my surprise he began playing poker with me. He dealt me out a hand. This was, at this time, a new behavior on his part. It was movement toward his potential for relating to live persons in his current world. This, again, is just one example of the multifarious multiplicities of one very common type of nursing situation.
The inference from the above is that professional artistic-scientific nurses relate in "I-Thou, I-It, all-at-once" to the specific general, critical nonconsequential, and the healthy ill. This presents a paradoxical dilemma. Nurses, as human beings, have a highly developed capacity for living "all-at-once" in and with the flow of the multifarious multiplicities of their worlds. Nurses, as human beings, like all other human beings, are limited to thinking, interpreting, and expressing conceptually only in succession.
This metaphoric synthetic construct, "all-at-once," has allowed me to better convey how I experience the health nursing situation. It also has aided my understanding of the multifarious multiplicity of angular views expressed by several professionals in responding to and describing a similar situation. I can accept each description as truth for each responder. Each responds with his uniqueness in the situation. Comparing, contrasting, and complementarily synthesizing these multiple views inclusive of their inconsistencies and contradictions, none negating the other, allows a better understanding of man-in-his-world in the health situation than the so frequently presented oversimplifications. These oversimplified presentations usually deal only with what is occurring that is important to the particular interests of the reporter. And they are offered only after the selected material has been put through a process of interpretation and logical sequencing to emphasize the reporter's particular point. In such reporting the existent in the situation labeled unimportant, unacceptable, or unrelated is not considered. Such existents, nonetheless, may control the patients, the families, the nurses and health professionals generally. Their control may well be more powerful than any erudite oversimplification or its presentation.
Humanistic nursing practice theory in asking for phenomenological descriptions of the nurse's lived-world of experiencing proposes authentic awareness with the self of what is existent in the situation prior to conceptualization for dispersal. Unless nurses appreciate and give recognition to the dynamic meaningful breadth, depth, and future influence of their worlds the actualization of the potential thrust of the nursing professional will never be or become.
A THEORY OF NURSING
A human nurse nurses through a clinical process of "I-Thou, I-It, all-at-once to comfort." {112}
"I-Thou" is a coming to know the other and the self in relation, intuitively.
"I-It" is an authentic analyzing, synthesizing, and interpreting of the "I-Thou" relation through reflection.
The "all-at-once" symbolizes the multifarious multiplicities of extremes (incommensurables, criticals, nonconsequentials, contradictions, and inconsistencies) as metaphorically representative of what exists in the nurse's world.
"Comfort" is a state valued by a nurse as an aim in which a person is free to be and become, controlling and planning his own destiny, in accordance with his potential at a particular time in a particular situation.
FOOTNOTES:
[1] Josephine G. Paterson, "A Perspective on Teaching Nursing: How Concepts Become," in _A Conceptual Approach to the Teaching of Nursing in Baccalaureate Programs_, a report of a project directed by Rose M. Herrera (Washington, D.C.: The Catholic University of America, School of Nursing, 1973), pp. 17-27.
[2] American Nurses' Association, Division on Psychiatric-Mental Health Nursing, _Statement on Psychiatric Nursing Practice_ (New York: American Nurses' Association, 1967), p. IV.
[3] Plutarch, "Contentment," in _Gateway to the Great Books_, Vol. 10, _Philosophical Essays_ (Chicago: Encyclopaedia Britannica, 1963), p. 265.
[4] Viktor E. Frankl, _From Death-Camp to Existentialism_ (Boston: Beacon Press, 1961), p. 103.
[5] _Ibid._, p. 110.
[6] Bertrand Russell, _The Autobiography of Bertrand Russell_ (Boston: Little, Brown and Company, 1968) and _An Outline of Philosophy_ (Cleveland: The World Publishing Company, 1967).
[7] Frederick Nietzsche, "Beyond Good and Evil," trans. Helen Zimmern, in _The Philosophy of Nietzsche_ (New York: The Modern Library, 1927) and "Thus Spake Zarathustra," trans. Thomas Common, in _The Philosophy of Nietzsche_ (New York: The Modern Library, 1927).
[8] Plato, _The Republic_, trans. Francis MacDonald Cornford (New York, Oxford University Press, 1945).
[9] Karl Popper, _Conjectures and Refutations_ (New York: Basic Books, Publishers, 1963).
[10] John Dewey, _The Knowing and the Known_ (Boston: The Beacon Press, 1949) and "The Process of Thought from How We Think," in _Gateway to the Great Books_, ed. Robert W. Hutchins, et al. (Chicago: Encyclopaedia Britannica, 1963).
[11] Martin Buber, _Between Man and Man_, trans. Ronald Gregor Smith (Boston: Beacon Press, 1955); _I and Thou_, 2nd ed., trans. Ronald Gregor Smith (New York: Charles Scribner's Sons, 1958); _The Knowledge of Man_, ed. Maurice Friedman (New York: Harper & Row, Publishers, 1965).
[12] Henri Bergson, "Introduction to Metaphysics," in _Philosophy in the Twentieth Century_, Vol. III, ed. William Barrett and Henry D. Aiken (New York: Random House, 1962) and "Time in the History of Western Philosophy," in _Philosophy in the Twentieth Century_, Vol. III, ed. William Barrett and Henry D. Aiken (New York: Random House, 1962).
[13] Norman Cousins, _Who Speaks for Man_ (New York: The Macmillan Company, 1953).
[14] Pierre Teilhard de Chardin, _Letters from a Traveler_, (New York: Harper & Row, Publishers, 1962) and _The Phenomenon of Man_ (New York: Harper Torchbooks, Harper & Row, Publishers, 1961).
[15] Nietzsche, _The Philosophy of Nietzsche_, p. 441.
[16] Buber, _The Knowledge of Man_, Appendix, p. 168.
[17] Wilfrid Desan, _Planetary Man_ (New York: The Macmillan Company, 1972), p. 77.
[18] Josephine G. Paterson, "Echo into Tomorrow: A Mental Health Psychiatric Philosophical Conceptualization of Nursing" (D.N.Sc. dissertation, Boston University, 1969).
{113}
APPENDIX
NURSE BEHAVIORS EXTRACTED FROM CLINICAL DATA
In pursuing the idea of conceptualizing comfort as a proper aim of psychiatric nursing I extracted 12 nurse behaviors from my clinical data that were used repeatedly to increase patient comfort. I quantified these behaviors for two months. The following are a list of these behaviors with a representative example of all but the first. The first was too general and continuous for example.
1. I focused on recognizing patients by name, being certain I was correct about their names, and using their names often and appropriately. I also introduced myself. Names were viewed as supportive to the internalization of personal feelings of dignity and worth.
2. I interpreted, taught, and gave as much honest information as I could about patients' situations when it was sought or when puzzlement was apparent. This was based on the belief that it was their life, and choice was their prerogative since they were their own projects.
_Examples_
(a) While drinking coffee with a few patients at the dining room table suddenly we could hear Sidney, in his customary way, wailing, moaning, and muttering in another room. It is a sad sound. I was about to get up and go to him as I often do, when Arthur, who was sitting next to me, face working, and tense posture-wise, aggravatedly said, "Sidney doesn't have to do that, he should control himself, the rest of us control ourselves." I said, "When others express how miserable they feel, it sometimes arouses our own feelings about our misery." This was an attempt to provoke 32-year-old Arthur to work on his own {114} feelings of misery and to deter his projection of anger at himself out onto Sidney. Arthur looked at me sharply, like he had gotten the message, and agreed by relaxedly nodding his head.
(b) Alice, diagnosed as manic depressive, has been depressed. This depression dates from her going out to a department store and asking for a job. She was hired for a five-day-a-week job. This was done on her own. Later her readiness for a five-day-a-week job and her participation in the unit were questioned. Then Alice became depressed.
Alice was sitting in the dayroom. I sat down next to her. She looked very sad, her eyelids as well as her mouth, drooped. Her mouth worked as if she wanted to talk, but she was quiet. I asked her about her job decision. She said that she had not taken it. I said, "You look so sad that I feel like holding your hand." Her hands were in her coat pockets, but she looked at me and smiled weakly. I said, "Sometimes a conflict of wanting to do two things at once in the present and not being able to can bring up the feelings of a past very much more important similar experience." Alice just shook her head up and down and looked at me. Alice is in her mid-forties. Later I was walking down the hall to leave saying goodbyes to various people. Alice came out of a side room, put both her hands out to me, and said, "goodbye and thank you." In a previous contact Alice had discussed her suicidal thoughts with me.
3. I verbalized my acceptance of patients' expressions of feelings with explanations of why I experienced these feelings of acceptance when I could do this authentically and appropriately.
_Example_
I met a new patient at coffee. Later she was the only patient in the dayroom when I went in. She had not spoken at coffee. Now she sat very stiffly in her chair. I sat down next to her and reintroduced myself. She looked scared but told me her name. Her shifting eyes reminded me of a cornered animal. She blurted out, "I don't believe I've met you." It was like she had said, "go away." I smiled at her and said, "We were introduced at coffee, but with so many new people it's hard to remember." Conversation continued to be tense. At one point Marion bolted from her chair toward the door. I thought she was going to leave. I stayed in my chair. She went to the fish bowl in the corner. We continued to talk about the fish. Marion came back and sat down a few seats away from me. I said that I felt I'd been asking her an awful lot of questions but that I was only trying to get to know her. Marion seemed to relax in her chair and gave a great deal of information about herself in a strange stiff sort of way often inserting a word that did not have meaning for me. I encouraged, supported and showed my interest. Finally she said that she {115} had been admitted to McLean in her third year of nurses' training just before her psychiatric experience. She had been in therapy there, one-to-one for a couple of years. I teased her about knowing the ropes, yet giving me a difficult time. This was an attempt to increase her feelings of adequacy by bringing out the similarities of the old situation which she knew and this new situation. For the first time she really grinned at me, almost laughed. Marion is in her early thirties.
4. When verbalizations of acceptance were not appropriate, I acted out this acceptance by my behavior of staying with or doing for when appropriate.
_Example_
Mary is a middle-aged patient who, on her first days in the unit, was liberally gobbling her food with alertness for only more to be had. Her only rather loud, irrelevant, smiling expression was about her daughter who was a go-go dancer, had three children, and whom she had visited twice by bus in California. This day she approached me and asked if I would file her nails. I said that I would but asked if she knew if there was a file in the unit. Another patient offered his. We sat down and I filed. The patient poured out a life story full of misery. This was a side of this patient that I had not perceived. I listened, nodded, and filed. The story started in the 1930s about her husband and mother-in-law's behavior; their marital separation; his being killed in World War II; their two children; their son, now thirty, was born with cerebral palsy, is blind and mute, and has been institutionalized since eleven months old; their daughter's husband left her with three children after fourteen years of marriage. I silently wondered what old feeling might have been aroused in her by her daughter's marital separation. Her daughter is so busy that she is unable to write regularly. She has told Mary not to worry if she doesn't hear from her. Mary then expressed concern over not receiving her usual letter this week from her mother, whom she visits. Mary had tried to reach her by phone and would again. I inquired if her mother lived alone. Yes, but next to relatives. She then related the drastic physical problems of a relative. I felt the sadness of this woman as she talked and empathized with the tough time she had had.
5. I expressed purposely, to burst asunder negative self concepts, my authentic human tender feelings for patients when appropriate and acceptable.
_Example_
I was sitting in a rather large group of patients in the dayroom. A casual conversation ensued about Thanksgiving as it had been and Christmas as it might be. There was talk of having been at home and plans for being at home. I supported and encouraged the discussion because of the meaningfulness of holidays, past and present. Snow was initiated as a {116} topic. I said, "It would be nice to have a white Christmas, but not too white." Vincent, a stiff, exact, ritualistic person who avoids stepping in an obvious fashion on thresholds, does little jiggle-like dance steps before sitting down, and again before settling in his chair, suddenly spoke. "Josephine, I beg your pardon, but I must take issue with you." I encouraged his unusual behavioral expression. He went on and on about the importance of a white Christmas. I let my mind flow with his jumbled discourse trying to decipher what he was getting at rather than each specific rapidly mentioned issue. He went from white to black, day to night, goodness to badness, love to hate, this side of the world to the other side of the world (Vietnam). I expressed that he seemed to keep mentioning two sides of things and that for some reason I could not help thinking of boys and girls. I said that he was over on that side of the world (room) and that I was over on this side of the world. I asked why he did not come over to my side, paused a minute, felt this was asking too much of this patient, and said, "Well I'll come over to your side then." When I sat down next to Vincent, he giggled as he does. Arthur, a younger patient, made a critical jealous type comment about Vincent's age (50ish). Arthur has done this before when I give attention to Vincent. Has Arthur a stereotype of father images and perhaps mother images? I said to Vincent "you have beautiful white hair, and big, brown, smiling Italian eyes." Vincent sat back smiling shyly but comfortably and the discussion of the group continued.
6. I supported patients' rights to loving relationships with others: families, other staff, and other patients.
_Example_
Alice M. said that she was sad to be back at the hospital after her weekend at home. Alice is a quiet, bland, soft-spoken person about fifty. She wears a worried expression even when she smiles and strikes me like she is "turned inside" herself. I encouraged her to talk about her time at home. She told me about how they had painted the living room with what for her was a show of real excitement. I said that her wish to be at home was very understandable. I did this because this patient almost whispers her wish to be at home and, generally, no one responds to it. Alice talked on with encouragement about the single sister whom she visits and the pleasure it gives her to be with this sister.
[I have other examples of this nurse behavior that indicate supporting of relationships between patients and between patients and other personnel.]
7. I showed respect for patients as persons with the rights to make as many choices for themselves as their current capabilities allowed.
_Example_
Discussion of group at coffee revolved around Carolyn's needing a new pair of shoes. The issues were where these might be gotten (Carolyn has {117} money), what kind she should get, and who and when someone would take her for them. It struck me as if Carolyn might not have been present. I asked Carolyn what kind of shoes she would like. Carolyn responded that she did not know whether she should buy regular shoes, or sneakers, or canvas shoes like Marilyn had gotten. She beamed. Since, she has come up to me several times and discussed the two pairs of different kinds of shoes she bought and why. Carolyn is a sweet, simple, retarded, deaf sixty year old whose behavior resembles an eight year old.
8. I attempted to help patients consider their currently expressed feelings and behaviors in light of past life experiences and patterns, like and unlike their current ones.
_Example_
On my arrival after Christmas, Irene expressed anger at me in a laughing way for having been away. Then she moved from a seat in the corner of the room to a chair behind me at the coffee table. I moved to allow her to move up to the table, but she did not. After coffee Irene nonverbally with eyes and body movements told me to follow her. She led me into a small beauty parlor room and we both sat down. She closed her eyes. I said, "You seem to have some feelings about us all having been away." First she blurted, "I missed you," then in a quieter voice denied this, "It wasn't important that you weren't here." I said, "It could be helpful to you to talk about your present missing feelings as you had some very important losses of people when you were younger." Her eyes literally popped open and she again blurted, "You mean my parents?" I said, "Yes and your therapist could help you with this." I then asked if she ever had the opportunity to talk with anyone about such things. She replied, "No, well I had a social worker when I was a little girl." I tried at this point to transfer feelings of the past to the present. "Oh, for how long? What was she like?" "I don't remember," and Irene closed her eyes. In a few minutes Irene requested that I set her hair. She is capable of doing this herself. I set her hair, but discussed the question of what she was really asking for. I believe she was asking for concrete attention to test my ability to care for her. I was trying to say, concretely, by setting her hair, that people could care about her.
9. I encouraged patients' expression to come to understand better their behavioral messages to enable me to respond overtly as appropriately and therapeutically as possible.
_Example_
The previous time I was at the hospital Alice had not come to the unit. I was told that she felt too depressed to come down. I went to see her. She had looked surprised and impressed by my visit. She talked on at some length about her suicidal thoughts. I supported this on the basis that {118} verbal expression might make active expression unnecessary if she experienced empathy regarding how dreadful she felt. Then with little encouragement she had come down to the unit with me. Today, Alice was always near me, but nonverbal except for concise responses to questions that were offered with effort. I verbalized my reflections on her behavior and said that I was wondering about it. She said, "I like having you around; it takes me away from my thoughts." "How are your thoughts?" "The same, I wonder if I'll ever get better?" "You've gotten better before. I wonder if you're not more concerned about whether you can stay well." Alice, eyes watery, agreed with a nod. Irene, another patient, interrupted, "Don't expect too much from me, I've been here twelve years." I responded to them both, "But, I do expect a lot of you; things don't always have to be the same."
10. I verified my intuitive grasp of how patients were experiencing events by questions and comments, and being alert to their responses.
_Example_
Vincent's ritualistic behavior is associated in my mind with his exaggerated conscious expression of only the true, the good, and the beautiful. On this occasion we had just had a long talk about his weekend at home, his concerns about his family, and his food likes and dislikes. As we left a room he took his usual long step over the threshold. I noted this aloud and asked him if he knew why he did this. His expression became wide-eyed and smiling which indicates to me he consciously or unconsciously is selecting what he is going to say. We came to the next threshold. He stopped me by touching my arm and said, "Josephine, I almost grabbed you to prevent your bumping into that patient." In relation to my last question I focused on the "grabbed you" and said, "Vincent, to think about grabbing me is a pretty natural thought, and no reason to take a wide step over a threshold." He put his foot very deliberately if rather testily, right in the middle of this threshold. He stopped, looked at me with his hands together and giggled. Then he had to go to the bathroom.
11. I attempted to encourage hope realistically through discussing individual therapeutic gains that could be derived from patients' investment in therapeutic opportunities available to them.
_Example_
My impression of Arthur, a thirty-two year old, is that he works at responding to me agreeably as he thinks I want him to, he frequently goes out of his way to make cutting comments to me about middle-aged men patients, and he responds with anger or teasing to a female patient his age. Arthur has a mother, father, and two older sisters. He obviously let me win at Ping-pong several times. I discussed this with him and asked if {119} he had ever talked with anyone about his responses to older women, people in general, or if he understood them. He said, "No, I have not been able to exactly figure this out yet." I repeated the talking it over. He said, "I haven't had much chance for that." Then staring at me he asked seriously, "Do you think talking it over would help?" I said, "I think that it would take a great deal of effort on your part, but I believe that it could help."
12. I supported appropriate patient self-images with as many concrete "hard to denies" as possible.
_Example_
Alice, a middle-aged woman, in the midst of a discussion of the difficulties of living outside the hospital, past relationships with nursing personnel, and her past practical nurse jobs suddenly said, "I worry about being sexually OK." This was kind of blurted out and she observed me closely. I said, "I thought that you had some concerns about this in relation to how you responded to my cutting the hairs on your face. I guess everyone worries at times about their adequacy in this area." She said, "I've never been able to have intercourse; I can just go as far as heavy petting. People say you can get a lot expressed if you have intercourse." I said, "Some people can, but if you have other standards that you've grown up with, (I suspect a rather religious, rigid Jewish background) it might cause difficulties to go against those standards." (Alice first became ill at sixteen, left school, and had some treatment in the community.) "It's pretty responsible not to be willing to bring a fatherless baby into the world, and I'm sure you'd have feelings about how your family might have responded to this sort of thing." Alice nodded and said "It's just that I don't know how womanly I am." I said with gestures and emphatically, "Well, Alice, if you have two things up here and no thing down here, then the fact is that you are a woman." Discussion pursued about her further talking about this topic with her therapist and the value of her working through her feelings in this area. This was a lengthy discussion and the first talking I had experienced Alice doing since her depression. {120} {121}
GLOSSARY
~angular view.~ An individual's unique vision of reality necessarily restricted by the angle of his particular here and now.
~authenticity.~ Genuineness; congruence with the self.
~(the) between.~ The realm of the intersubjective.
~bracket.~ Hold in abeyance.
~community.~ Two or more persons struggling together toward a center.
~existential.~ Of, relating to, or affirming existence; grounded in existence or the experience of living.
~existential dialogue.~ A unique individual person with the wholeness of his being is present, open to, and relates to the other seen in his unique individual wholeness; an exchange in which two persons transcend themselves and participate in the other's being; an interior unification; a mutual common union in being.
~existential experience.~ Contact with reality with the whole of one's being; involves all that a man _is_ as opposed to experiencing through one or several faculties.
~existentialism.~ Philosophy based on phenomenological studies of reality; centers on the analysis of existence particularly of the individual human being, stresses the freedom and responsibility of the individual, regards human existence as not completely describable or understandable in idealistic or scientific terms.
~here and now.~ An individual's unique experience of his present spatial and temporal reality including his past experiences and expectations of the future.
~humanistic nursing.~ A theory and practice that rest on an existential philosophy, value experiencing and the evolving of the "new," and aim at phenomenological description of the art-science of nursing viewed as a lived intersubjective transactional experience; nursing seen within its human context.
~intersubjective.~ Pertaining to two or more human persons and their shared between; a relationship of two or more human beings in which each is the originator of human acts and responses. {122}
~lived dialogue.~ A form of existential intersubjective relating expressed in being with and doing with the other who is regarded as a presence (as opposed to an object); a lived call and response.
~lived world.~ The everyday world as it is experienced in the here and now.
~metanursing.~ A discipline designed to deal critically with nursing, ontological study of nursing; study of the phenomenon of nursing; a critical study of nursing within its human context.
~metatheoretical.~ Transcending theory; ontological inquiry from which theory may be derived.
~nursology.~ Study of the phenomenon of nursing aimed toward the development of nursing theory.
~phenomenology.~ The descriptive study of phenomena.
~phenomenon.~ An observable fact, event, occurrence or circumstance; an appearance or immediate object of awareness in experience. A phenomenon may be objective (that is, external to the person aware of it) or subjective (for example, a thought or feeling).
~prereflective experience.~ Primary awareness or perception of reality not yet thought about; spontaneous experience; immediate experience or perception.
~presence.~ A mode of being available or open in a situation with the wholeness of one's unique individual being; a gift of the self which can only be given freely, invoked, or evoked.
~transactional.~ An aware knowing of one's effect in a situation of which one is a part; an action that goes both ways between persons. {123}
SELECTED BIBLIOGRAPHY
In addition to the extensive discussions that have been generated since the initial publication of Paterson and Zderad's _Humanistic Nursing_, the work has been formally cited and or discussed in the nursing literature. This selected bibliography was compiled by Helen Streubert, MSN, RN doctoral candidate and research assistant in the Department of Nursing Education, Teachers College/Columbia University, New York.
BOOKS
Chenitz, W. C. (1986). _From practice to grounded theory._ Menlo Park, California: Addison-Wesley.
Chinn, P. O., & Jacobs, M. K. (1983). _Theory and nursing._ St. Louis: Mosby Company.
Duldt, B. W. (1985). _Theoretical perspectives for nursing._ Boston: Little-Brown & Company.
Ellis, R. (1984). Philosophic inquiry. In H. H. Werley & J. J. Fitzpatrick (Eds.), _Annual review of nursing research_ (pp. 211-228). New York: Springer Publishing Company.
Fitzpatrick, J., & Whall, A. (1983). _Conceptual models of nursing: Analysis application._ Bowie, Maryland: Brady Company.
Kleiman, S. (1986). Humanistic nursing: The phenomenological theory of Paterson and Zderad. In P. Winstead-Fry (Ed.), _Case studies in nursing theory_ (pp. 167-195). New York: National League for Nursing.
Leininger, M. (1985). Ethnography and ethnonursing models and modes of qualitative data analysis. In M. Leininger (Ed.), _Qualitative research methods in nursing_. Orlando, Florida: Grune & Stratton.
Meleis, A. I. (1985). Theoretical nursing: Development and progress. Philadelphia: Lippincott. {124}
Moccia, P. (Ed.). (1986). _New approaches to theory development._ New York: National League for Nursing.
Munhall, P. L., & Oiler, C. J. (1986), _Nursing research: A qualitative perspective_. Norwalk, Connecticut: Appleton-Century-Crofts.
Paterson, J. G. (1978). The tortuous way toward nursing theory. In _Theory development: What, why, how?_ (pp. 49-65). New York: National League for Nursing.
Phipps, W. J., Long, B. C., & Woods, N. F. (1987). _Medical-surgical nursing: Concepts and clinical practice_ (3rd ed.). St. Louis: Mosby Company.
Roy, C. (1984). _Introduction to nursing: An adaptation model_ (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall, Inc.
Stevens, B. J. (1984). _Nursing theory: Analysis, application, evaluation_ (2nd ed.). Boston: Little Brown Co.
Suppe, F., & Jacox, A. (1985). Philosophy of science and the development of nursing theory. In H. H. Werley & J. J. Fitzpatrick (Eds.), _Annual review of nursing research_ (pp. 241-267). New York: Springer Publishing Company.
Zderad, L. T. (1978). From here-and-now to theory: Reflections on "how". In _Theory development: What, why, how (pp. 35-48). New York: National League for Nursing_.
ARTICLES
Bael, E. D., & Lowry, B. J. (1987). Patient and situational factors that affect nursing students' like or dislike of caring for patient. _Nursing Research, 36_ (5), 298-302.
Beckstrand, J. (1980). A critique of several conceptions of practice theory in nursing. _Research in Nursing and Health, 3_, 69-79.
Bottorff, J. L., & D'cruz, J. V. (1984). Towards inclusive notions of patient and nurse. _Journal of Advanced Nursing, 9_ (6), 549-553.
Braun J. L., Baines, S. L., Olson, N. G., & Scruby, L. S. (1984). _Health Values, 8_ (3), 12-15.
Brown, L. (1986). The experience of care: Patient perspectives. _Topics in Clinical Nursing, 8_ (2), 56-62.
Chenitz, W. C., & Swanson, J. M. (1984). Surfacing nursing process--A method for generating nursing theory from practice. _Journal of Advanced Nursing, 9_ (2), 205-215.
Drew, N. (1986). Exclusion and confirmation: A phenomenology of patients' experiences with caregivers. _Image, 18_ (2), 39-43.
Flaskerud, J. H. (1986). On toward a theory of nursing action skills and competency in nurse-patient interaction. _Nursing Research, 35_ (4), 250-252. {125}
King, E. C. (1984). Humanistic education: Theory and teaching strategies. _Nurse Education 8_ (4), 39-42.
Nahon, N. E. (1982). The relationship of self-disclosure, interpersonal dependency, and life changes to loneliness in young adults. _Nursing Research, 31_ (6), 343-347.
Oiler, C. (1982). The phenomenological approach in nursing research. _Nursing Research, 31_ (3) 178-181.
Rigdon, I. S., Clayton, B. C., & Dimond, M. (1987). Toward a theory of helpfulness for the elderly bereaved: An invitation to a new life. _Advances in Nursing Science, 9_ (2), 32-43.
Sarter, B. (1987). Evolutionary idealism: A philosophical foundation for holistic nursing theory. _Advances in Nursing Science, 9_ (2), 1-9.
Taylor, S. G. (1985). Rights and responsibilities: Nurse patient relationships. _Image, 17_ (1), 9-16. {126} {127}
INDEX
Abdellah, Faye G., 90
Agee, James, 8, 67
All-at-once, 4, 8, 44, 52, 55, 56, 68, 70, 73, 93, 96, 109-111
Analogy, 37, 54, 61, 83
Analysis, 72, 79, 82-84
Angular view, 5, 20, 37-38, 51, 65-67, 71, 74, 80-82, 84, 88, 95-98, 111
Art, 3, 7-8, 14, 17, 58, 60, 85-93, 111
Authenticity, 4-5, 14-15, 55, 56-60, 63, 104, 106, 111
Being and doing, 13-14, 17, 19, 26, 92
Bergson, Henri, 6, 68, 71, 72, 73, 104
Between, (the), 4, 7, 13, 21-22, 31, 44, 67, 82, 108. _See also_ Dialogue; Intersubjective; Presence; and Transaction
Bracket, 38, 62, 80
Buber, Martin, 4, 6, 16, 23, 39, 44, 45, 47, 55, 69, 72, 73, 93, 104, 106, 110
Call and Response, 3, 5, 7, 24, 29-31
Choice, 4-6, 15-17, 20, 24, 37, 57, 69, 72. _See also_ Confidentiality; Responsibility
Christoffers, Carol Ann, 89
Clinical, 65, 67, 92-93, 96, 103-109
Comfort, 65, 96, 98-103, 106, 111-112
Community, 7, 14, 37-48, 63, 84
Complementary synthesis, 3, 8, 36, 68, 73-74, 111. _See also_ Synthesis
Confidentiality, 53-56. _See also_ Choice; Responsibility
Cousins, Norman, 39, 47, 104
Cross-clinical, 20
de Chardin, Pierre Teilhard, 6, 39, 41, 104
Desan, Wilfrid, 16, 39, 73, 74, 108
Description, _see_ Phenomenological description
Dewey, John, 72, 104
Dialogue, 21-36, 73, 77, 92-93. _See also_ Between (the); Intersubjective; Presence; and Transaction
Durant, Ariel, 69
Durant, Will, 69
Existential, existentialism, 4-9, 14, 15, 23, 38, 47, 65-66. _See also_ Phenomenology; Philosophy
Fahy, Ellen T., 91
Family, 38-45
Frankl, Viktor E., 6, 102
Garner, Grayce C. Scott, 88, 89
Gilbert, Ruth, 65, 96, 109, 110
Goethe, Johann Wolfgang von, 6, 67, 102 {128}
Heinlein, Robert A., 45
Here and now, 40, 41, 57, 68, 69, 80, 81
Hersey, John, 39, 89
Hesse, Herman, 6, 39, 40, 45, 69
Humanistic nursing, 3, 5, 14-20, 21, 85, 92-93
Humanistic nursing practice theory, 3, 6-7, 8, 17-20, 21, 55, 60, 62, 65, 70, 77-84, 95-112
Human situation, 11, 18-20, 87, 89
Husserl, Edmund, 56, 78, 79
Intersubjective, 13, 15-17, 21-22, 26-27, 31-32, 35-36, 68, 81, 90, 93. _See also_ Between, (the); Dialogue; Presence; and Transaction
Intuition, intuitive, 19, 23, 52, 71-72, 73, 79-82, 96, 109
I-It, 27, 36, 44-45, 73, 106-112
I-Thou, 6, 27, 36, 44-45, 62, 72, 73, 92, 106-112
Jung, Carl G., 6, 58, 68
Kaplan, Abraham, 66
Kiell, Norman, 43
Laing, R. D., 17
Lemkau, Paul V., 54-55
Man, concept of, 5, 15-16, 18-19, 26, 38-45, 51, 52, 54-56, 67-71
Marcel, Gabriel, 6, 16, 23, 41
May, Rollo, 6
Meeting, 18, 24-26
Metanursing, 20
Metaphor, 54, 61, 84
Methodology, 65-75, 77-84, 95-112
Microcosm-macrocosm, 37-38, 40, 48
More-being, moreness, 4-6, 12, 16-17, 19, 29, 32, 36, 44-45, 48, 63, 69, 89, 92
Muller, Theresa G., 39, 65, 96, 109, 110
Nietzsche, Frederick, 6, 39, 40, 41, 46, 47, 54, 71, 102, 104, 105
Nursing, 3, 5, 7, 11-17, 21, 45-48, 57-58, 65, 69, 71, 72, 73, 74, 75, 90-92, 95-112. _See also_ Humanistic nursing
Nursology, 65, 67, 70, 72, 73, 74
Nurture, 13, 18-19, 25
Objective, _see_ Subjective-objective
Paradox, 4, 39, 70
Phenomenological description, 3, 6-8, 13-14, 54, 60-62, 70, 77-84, 96, 111
Phenomenology, 6, 9, 60-62, 66, 67, 72, 78, 79
Phillips, Gene, 4
Philosophy, 17, 40, 66, 67, 75, 97. _See also_ Existentialism; Phenomenology
Plato, 6, 37, 45, 67, 104
Plutarch, 101
Popper, Karl, 39, 104
Practice, _see_ Humanistic nursing practice theory
Presence, 3, 5, 6, 13, 15, 16, 27-29, 47, 56, 58, 72, 106. _See also_ Between, (the); Dialogue; Intersubjective; and Transaction
Proust, Marcel, 6
Research, 51-63
Responsibility, 3, 6, 16-17, 20, 28, 41, 53-55, 57, 63, 69, 70, 72, 110. _See also_ Choice; Confidentiality
Rousseau, Jean-Jacques, 6
Russell, Bertrand, 70, 104
Science, scientific, 3, 6, 7, 8, 15, 17, 35, 45, 52, 53, 58, 60, 66, 68, 70, 72, 85-87, 88, 90, 93, 111 {129}
Socrates, 38
Space, 18-20, 34-35
Subjective-objective, 27, 35-36, 52, 67, 79, 81, 93
Synthesis, 72-74, 79, 82-84, 93, 95, 102, 103, 108, 111. _See also_ Complementary synthesis
Theory, _see_ Humanistic nursing practice theory
Time, 18-20, 29, 33-34
Transactions, 11, 12-13, 16-20, 21, 35-36. _See also_ Between, (the); Dialogue; Intersubjective; and Presence
Trautman, Mary Jane, 87, 88
Uniqueness, 4, 7, 15, 23, 25, 26, 27, 32, 34, 35-36, 40, 45, 56, 68, 69, 72, 77, 111
Value, 6, 16, 17, 18, 30, 39, 46-48, 54, 56-57, 69, 71, 77, 79, 85, 97, 98, 104, 105
Well-being, 12, 16, 36, 89, 92
Whitehead, Alfred North, 6
Wiesel, Elie, 7, 96
Weymouth, Lilyan, 55
Words, 8, 60-62, 73, 81, 98
Wright, Edward A., 91
[Transcriber's Note: The following corrections have been made in this version.]
Page iv 'exhilirating' corrected to 'exhilarating': same exhilarating feeling 'evalute' corrected to'evaluate': and evaluate.
Page 11 'sitution' corrected to 'situation': the human situation 'appers' corrected to 'appears': nursing appears in
Page 12 'limtations' corrected to 'limitations': and limitations of
Page 14 'siuation' corrected to 'situation': now shared situation
Page 15 'wothout' corrected to 'without': goes without saying 'echos' corrected to 'echoes': process echoes existential
Page 18 'wiscom' corrected to 'wisdom': of clinical wisdom 'wourlds' corrected to 'worlds': lived nursing worlds
Page 20 'appraoch' corrected to 'approach': nursing approach is 'cross-clincal' corrected to 'cross-clinical': genuine cross-clinical
Page 21 'clairty' corrected to 'clarity': gained in clarity 'nusing' corrected to 'nursing': runs through nursing 'conveyting' corrected to 'conveying': stream conveying the
Page 22 'languge' corrected to 'language': with our language 'consitituent' corrected to 'constituent': component or constituent 'relfecting' corrected to 'reflecting': Once while reflecting
Page 23 'dicionary' corrected to 'dictionary': the typical dictionary
Page 25 'ot' corrected to 'to': expects to give 'reflectd' corrected to 'reflected': meeting is reflected
Page 26 'for for' corrected to 'for': have a capacity for 'tor' corrected to 'for': necessary for everyday
Page 27 'objectivication' corrected to 'objectification': Through objectification 'his' corrected to 'this': but this in
Page 28 'availbility' corrected to 'availability': and availability in
Page 29 'begin' corrected to 'being': modes of being 'purposefull' corrected to 'purposeful': a purposeful call
Page 30 'communicaion' corrected to 'communication': nurse-patient communication
Page 31 'expecially' corrected to 'especially': staggering, especially so 'Futhermore' corrected to 'Furthermore': Furthermore, in caring
Page 33 'occured' corrected to 'occurred': may have occurred 'possiblities' corrected to 'possibilities': These possibilities may
Page 35 'exmination' corrected to 'examination': the examination turned
Page 40 'echos' corrected to 'echoes': world echoes its
Page 41 'childrens'' corrected to 'children's': their children's worlds 'intial' corrected to 'initial': this initial home
Page 42 'errupt' corrected to 'erupt': it might erupt? 'Ofen' corrected to 'Often': Often one saw
Page 43 'long-rememberd' corrected to 'long-remembered': long-remembered events 'of of' corrected to 'of': times of feeling 'there' correct to 'there are': there are multiple 'give' corrected to 'gives': it gives satisfaction
Page 47 'contemporaires' corrected to 'contemporaries': with my contemporaries
Page 51 'necesssary' corrected to 'necessary': is necessary in 'reasonbale' corrected to 'reasonable': both reasonable and
Page 52 'substanitated' corrected to 'substantiated': be substantiated fully
Page 53 'of' corrected to 'or': care or when
Page 55 'viewd' correct to 'viewed': is viewed as 'profesion' corrected to 'profession': nursing profession. Utilizing 'reponses' corrected to 'responses': struggling responses
Page 57 'knowlege' corrected to 'knowledge': dispersion of knowledge
Page 59 'clincial' corrected to 'clinical': As clinical supervisor 'theapeutic' corrected to 'therapeutic': patients' therapeutic needs
Page 60 'civilzation' corrected to 'civilization': his civilization within
Page 61 'somethimes' corrected to 'sometimes': sometimes like a 'us' corrected to 'use': and use of "weasel"
Page 62 'presitigious' corrected to 'prestigious': foreign prestigious terms 'intial' corrected to 'initial': to initial aware
Page 66 'mehtodology' corrected to 'methodology': the methodology in 'reexemaination' corrected to 'reexamination': available for reexamination, 'phenomenologic' corrected to 'phenomenological': a phenomenological method
Page 68 'citical' corrected to 'critical': my critical powers
Page 70 'excietment' corrected to 'excitement': feelings of excitement 'easilty' corrected to 'easily': not easily relinquished
Page 71 'clincal' corrected to 'clinical': struggle in clinical 'reconsituting' corrected to 'reconstituting': of reconstituting with
Page 72 'assunder' corrected to 'asunder': bursts asunder
Page 74 'oscilating' corrected to 'oscillating': This oscillating, dialectical
Page 78 'the the' corrected to 'the': the approach has been 'desciplines' corrected to 'disciplines': by different disciplines 'deatils' corrected to 'details': more concrete details
Page 81 'perpectives' corrected to 'perspectives': their own perspectives 'aslo' corrected to 'also': rather it also
Page 82 'a' corrected to 'as': angles as possible 'expliction' corrected to 'explication': the explication of 'chracteristics' corrected to 'characteristics': has other characteristics 'convy' corrected to 'convey': may convey anger
Page 83 'empahty' corrected to 'empathy': Thus, empathy is
Page 85 'othe' corrected to 'other': and other forms
Page 87 'peparation' corrected to 'preparation': educational preparation 'sceintific' corrected to 'scientific': with scientific courses 'quanitification' corrected to 'quantification': strives for quantification
Page 90 - footnote 11 'Sceince' corrected to 'Science': Nursing Science
Page 91 'physcial' corrected to 'physical': of physical objects
Page 93 'responsses' corrected to 'responses': human responses to 'it' corrected to 'is': It is possible
Page 97 'nusring' corrected to 'nursing': for nursing theory 'veiwed' corrected to 'viewed': never viewed myself
Page 100 'opportunties' corrected to 'opportunities': therapeutic opportunities available
Page 102 'necesary' corrected to 'necessary': are necessary for 'contributaries' corrected to 'contributories': of many contributories 'Geothe' corrected to 'Goethe': Nietzsche and Goethe
Page 104 'comparision' corrected to 'comparison': comparison of it Footnote 9 'Pbulishers' corrected to 'Publishers': Basic Books, Publishers
Page 106 'containted' corrected to 'contained': total group contained
Page 110 'nurse'' corrected to 'nurse's': a nurse's duality
Page 111 'nusing' corrected to 'nursing': Humanistic nursing practice
Page 114 ''Sometimes' corrected to '"Sometimes': I said, "Sometimes
Page 115 'know' corrected to 'knew': if she knew 'assunder' corrected to 'asunder': to burst asunder
Page 117 'encourged' corrected to 'encouraged': I encouraged patients'
Page 118 'therapeautic' corrected to 'therapeutic': individual therapeutic gains 'aggreeably' corrected to 'agreeably': to me agreeably
Page 121 'mure' corrected to 'more': two or more
Page 123 'Hursing' corrected to 'Nursing': Zderad's _Humanistic Nursing_
Page 124 'Refelections' corrected to 'Reflections': Reflections on "how" 'Dcruz' corrected to 'D'cruz': & D'cruz, J. V.
Page 128 'Nietzche' corrected to 'Nietzsche': Nietzsche, Frederick,]