CHAPTER III -- NURSING SITUATION AS THE LOCUS OF NURSING

The concept of nursing situation is central to every aspect of the theory of Nursing as Caring. We have claimed that all nursing knowledge resides within the nursing situation (Boykin & Schoenhofer, 1991). The nursing situation is both the repository of nursing knowledge and the context for knowing nursing. The nursing situation is known as shared lived experience in which the caring between the nurse and the one nursed enhances personhood.

It is to the nursing situation that the nurse brings self as caring person. It is within the nursing situation that the nurse comes to know the other as caring person, expressing unique ways of living and growing in caring. And it is in the nursing situation that the nurse attends to calls for caring, creating caring responses that nurture personhood. It is within the nursing situation that the nurse comes to know nursing, in the fullness of aesthetic knowing.

The nursing situation comes into being when the nurse actualizes a personal and professional commitment to the belief that all persons are caring. It should be recognized that a nurse can engage in many activities in an occupational role that are not necessarily expressions of nursing. When a nurse practices nursing thoughtfully, that nurse is guided by his or her conception of nursing. The concept of nursing formalized in the Nursing as Caring theory is at the very heart of nursing, extending back into the unrecorded beginnings of nursing and forward into the future. Acknowledgement of caring as the core of nursing implies that any nurse practicing nursing thoughtfully is creating and living nursing situations because, whether explicit or tacit, the caring intent of nursing is present.

Remember that the nursing situation is a construct held by the nurse, any interpersonal experience contains the potential to become a nursing situation. In the formal sense of professional nursing, the nursing situation develops when one person presents self in the role of offering the professional service of nursing and the other presents self in the role of seeking, wanting, or accepting nursing service.

The nurse intentionally enters the situation for the purpose of coming to know the other as caring person. The nurse is also allowing self to be known as caring person. Authentic presence, like most human capacities, is inherent and can be more fully developed through intention and deliberate effort. Authentic presence may be understood simply as one's intentionally being there with another in the fullness of one's personhood. Caring communicated through authentic presence is the initiating and sustaining medium of nursing within the nursing situation.

The nurse, with developed authentic presence and open to knowing the other as caring, begins to understand the other's call for nursing. A call for nursing is a call for specific forms of caring that acknowledge, affirm, and sustain the other as they strive to live caring uniquely. We must remember as well that calls for nursing originate within the unique relationship of the nursing situation. As the situation ensues, the call for nursing clarifies. The nurse comes to know the one nursed more and more deeply and to understand more fully the unique meaning of the person's caring ways and aspirations for growing in caring. It is in this understanding that the call for nursing is known as a specific situated expression of caring and a call for explicit caring response.

The nursing response of caring is also uniquely lived within each nursing situation. In the nursing situation, the call of the nursed is a personal "reaching out" to a hoped-for other. The nursed calls forth the nurse's personal caring response. While the range and scope of human caring expression can and must be studied, the caring response called forth in each nursing situation is created for that moment. The nurse responds to each call for nursing in a way that uniquely represents the fullness (wholeness) of the nurse. How I might respond to such a call would and should reflect my unique living of caring as person and nurse. Each response to a particular nursing situation would be slightly different and would portray the beauty of the nurse as person.

The nursing situation is a shared lived experience. The nurse joins in the life process of the person nursed and brings his or her life process to the relationship as well. In the nursing situation, there is caring between the participants. Further, the experience of the caring within the nursing situation enhances personhood, the process of living grounded in caring. Each of these components of the construct of the nursing situation raises questions for immediate and continuing discussion.

How can an unconscious patient be a participant in a nursing situation? Can "postmortem care" be considered nursing? How can the nurse know that the other is truly open to nursing--can the nurse impose self into the world of the other? What about an unrepentant child rapist or a person responsible for genocide, can we say that person is caring, and if not, can we nurse them? Does the nurse have to like the person being nursed? Does the nurse seek enhancement of personhood in the nursing situation? If so, might the goals of the nurse be imposed on the one nursed? If the nurse gains from the nursing situation, isn't that unprofessional?

In part, these legitimate questions raise larger issues about the uniqueness and scope of nursing as a discipline and professional service in society. Certainly the study of these questions adds clarity to the purpose of nursing actions. To nurse, situations in a general sense are transcended and transformed When they are conceptualized as nursing situations. From the perspective of the Nursing as Caring theory, the study of these questions would require that the nurse transcend social or other situational contexts and live out a commitment to nurture the person in the nursing situation as they live and grow in caring.

Persons with altered levels of consciousness, measured on normative scales developed for medical science purposes, can and do participate in nursing situations. Nurses committed to knowing the unconscious as caring person can and do describe their ways of expressing caring and aspirations for growing in caring. Nurses speak of the post-anesthesia patient as living hope in their struggle to emerge from the deadening effects of the anesthesia; as living honestly in fretful, fearful thrashing. Nurses help these persons sustain hope and extend honesty through their care. The profoundly mentally disabled child lives humility moment-to-moment and calls forth caring responses to validate and nurture that beautiful humility. Nurses speak of caring for their deceased patients as nursing those who have gone and are still in some way present. The nurse, connected in oneness with the one known and nursed, holds hope for the other as the other's expression of hopefulness lives on in the consciousness of the nurse. Thus, a sense of connectedness does not dissipate when physical presence ends, but remains an active part of the nurse's experience.

Nursing another is a service of caring, communicated through authentic presence. Nursing another means living out a commitment to knowing the other as caring person and responding to the caring other as someone of value (Boykin & Schoenhofer, 1990, 1991). In its fullest sense, nursing cannot be rendered impersonally, but must be offered in a spirit of being connected in oneness. "To care for" seems to require that the caregiver see oneself as caring person reflected in the other (Watson, 1987). The theoretical perspective of Nursing as Caring is grounded in the belief that caring is the human mode of being (Roach, 1984). When a person is judged by social standards to be deviant and even evil, however, it is difficult to summon caring. This points to the contribution nursing is called upon to make in society. When we speak of nursing's contribution here, we are invoking earlier discussions of discipline and profession. Each discipline and profession illuminates a special aspect of person--in effect, what it means to be human. The light that nursing shines on the world of person is knowledge of person as caring, so that the particular contribution of nursing is to illuminate the person as caring, living caring uniquely in situation and growing in caring. In nursing, practiced within the context of Nursing as Caring, the person is taken at face value as caring and never needs to prove him or herself as caring. The nurse, practicing within the context of Nursing as Caring, is skilled at recognizing and affirming caring in self and others. Being caring, that is, living one's commitment to this value "important-in-self" (Roach, 1984), fuels the nurse's growing in caring and enables the nurse I turn to nurture others in their living and growing in caring. The values and assumptions of nursing as caring can assist the nurse to engage fully in nursing situations with persons in whom caring is difficult to discover.

Nursing knowledge is discovered and tested in the ongoing nursing situations. Once experienced, nursing situations can be made available for living anew, with new discovery and testing. Aesthetic representation of nursing situations brings the lived experience into the realm of new experience. Thus, the knowledge of nursing can be made available for further study. Re-presentation of nursing situations can occur through the medium of nursing stories, poetry, painting, sculpture, and other art forms (Schoenhofer, 1989). Aesthetic re-presentation conserves the epistemic integrity of nursing while permitting full appreciation of the singularity of any one nursing situation (Boykin & Schoenhofer, 1991). Here, then, is one nurse's story of a shared lived experience in which the caring between nurse and the one nursed enhanced personhood. This story is offered as an example of nursing situation, re-presented as an open text, available for continuing participation by all who wish to enter into this shared lived experience of nursing. In fact, we invite the reader to enter into this nursing situation, which may then be used in classroom or conference settings to stimulate general or specific inquiry and dialogue.

CONNECTIONS

One night as I listened to the change of shift report, I remember the strange feeling in the pit of my stomach when the evening nurse reviewed the lab tests on Tracy P Tall, strawberry-blonde and freckle-faced, Tracy was struggling with the everyday problems of adolescence and fighting a losing battle against leukemia. Tracy rarely had visitors. As I talked with Tracy this night I felt resentment from her toward her mother, and I experienced a sense of urgency that her mother be with her. With Tracy's permission I called her mother and told her that Tracy needed her that night. I learned that she was a single mother with two other small children, and that she lived several hours from the hospital. When she arrived at the hospital, distance and silence prevailed. With encouragement, the mother sat close to Tracy and I sat on the other side, stroking Tracy's arm. I left the room to make rounds and upon return found Mrs. P. still sitting on the edge of the bed fighting to stay awake. I gently asked Tracy if we could lie on the bed with her. She nodded. The three of us lay there for a period of time and I then left the room. Later, when I returned, I found Tracy wrapped in her mothers arms. Her mothers eyes met mine as she whispered "she's gone." And then, "please don't take her yet." I left the room and closed the door quietly behind me. It was just after 6 o'clock when I slipped back into the room just as the early morning light was coming through the window. "Mrs. P," I reached out and touched her arm. She raised her tear-streaked face to look at me. "It's time," I said and waited. When she was ready, I helped her off the bed and held her in my arms for a few moments. We cried together. "Thank you, nurse," she said as she looked into my eyes and pressed my hand between hers. Then she turned and walked away. The tears continued down my cheeks as I followed her to the door and watched her disappear down the hall.

Gayle Maxwell (1990)

This nursing situation is replete with possibilities for nurses, and others, to understand nursing as nurturing persons living caring and growing in caring. A dialogue ensues on the nursing situation that allows participants an opportunity to experience both resonance and uniqueness as personal and shared understandings emerge. As the reader enters into the text, the nursing situation is experienced anew, now within the presence of two nurses, not one. Though intentionally entering the situation, the second nurse experiences d affirms being connected in oneness with both nurse and nursed as caring lived in the moment.

Gayle entered into Tracy's world that night open to hearing a special call. Gayle's openness was partly a reflection of her use of the empirical pathway of knowing, the data given in report, the comparison of empirical observations against biological, psychological, developmental, and social norms. Before discussing our understanding of Gayle's response from the theoretical per-perspective represented, it might be helpful to compare how the call for nursing may have been interpreted if approached, for example, from a psychological framework. If the nurse responded from a psychological framework, the problem identified would perhaps be conceptualized as denial on the part of Tracy's mother. It could be assumed that Tracy's mother was avoiding the reality of the impending death of her daughter. Here, the nursing goal would be assist the mother in dealing with her denial by facilitating grieving. Denial is only one psychological concept that could be applied in this situation; avoidance, anxiety, and loss are others. When nursing care is based on a psychological framework, however, the central theme of care is likely to be deemphasized in favor of a problem-oriented approach. The perspective offered by a normative discipline requires a reliance on empirical knowing. Using only the empirical pathway of knowing, the richness of nursing is lost.

Gayle's personal knowing, her intuition, however, was the pathway that illuminated the appreciation of this situation and prompted her acknowledgement of a call. She heard Tracy's call for intimacy, comfort, and protection of her mother's presence as she (Tracy) summoned courage and hope for her journey. Gayle intuitively knew that the specific caring being called forth was the caring of a mother. Gayle's caring response also took the form of the courageous acknowledgement of a call for nursing that would be difficult to sub-stantiate empirically. Beyond telephoning Tracy's mother, Gayle continued her nursing effort to answer Tracy's call for the presence of a mother as she supported Mrs. P. living her interconnectedness, in being with Tracy. Gayle heard Mrs. P.'s calls for knowing, knowing what to do and knowing that it would be right to do it, for the courage to be with her daughter in this new difficult passage. Her response of showing the way reflects hope and humility. The caring between the nurse and the ones nursed enhanced the personhood of all three, as each grew in caring ways. It is possible that the caring between the original participants in the nursing situation and those of us who are participating through engagement with the text continues to enhance personhood.

REFERENCES

Boykin, A., & Schoenhofer, S. (1991). Story as link between nursing practice, ontology, epistemology. Image, 23, 245-248. Boykin, A., & Schoenhofer, S. (1990). Caring in nursing: Analysis of extant theory. Nursing Science Quarterly, 4, 149-155. Maxwell, G. (1990). Connections. Nightingale Songs, 1 (1). P.O. Box 057563, West Palm Beach, FL 33405. Paterson, J., & Zderad, L. (1988). Humanistic nursing. New York: National League for Nursing Press. Roach, S. (1984). Caring: The human mode of being, implications for nursing. Toronto: Faculty of Nursing, University of Toronto. (Perspectives in Caring Monograph 1). Schoenhofer, S. (1989). Love, beauty and truth: Fundamental nursing values. Journal of Nursing Education, 28 (8), 382-384. Watson, J. (1987). Nursing on the caring edge; Metaphorical vignettes. Advances in Nursing Science, 10, 10-18.