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Title: Humanistic Nursing
Author: Paterson, Josephine G., Zderad, Loretta T.
Language: English
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Copyright Status: Not copyrighted in the United States. If you live elsewhere check the laws of your country before downloading this ebook. See comments about copyright issues at end of book.

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Copyright (C) 2007 by Josephine Paterson and Loretta Zderad.



Humanistic Nursing

(Meta-theoretical Essays on Practice)

by Josephine Paterson and Loretta Zderad

Copyright (C) 2007 by Josephine Paterson and sLoretta Zderad all rights
reserved except as follows.  This e-text may be freely copied for
academic and scholarly work with the copyright notice clearly affixed to
all copies.  No commercial use may be made of any part of the text
without the express permission of the copyright holders.

This e-text version of the classic text "Humanistic Nursing" is
made available with the kind permission of the authors and copyright
holders, Josephine Paterson and Loretta Zderad. The book was originally
written to define the Humanistic Nursing Theory which presented a way
for each nurse to become-more as a person and to extend that
becoming-more to the community of nurses in which he or she
practices. The offering of this book in the "free" e-text format
reiterates the continuing contribution of these two nurses long after
their retirement from practice. It is their hope that nurses everywhere
will take their vision for nursing and expand on it and integrate it
into their nursing practice.  At the request of the authors this e-text
version is complete with the original 1976 Front Matter.

Susan Kleiman

For more information or questions about the subject of Humanistic
nursing or this e-text you may contact Professor Susan Kleiman, PhD, RN,
CS, NPP at: susank@humanistic-nursing.com.  Alternatively you may visit
the web site: www.humanistic-nursing.com.  The Humanistic Nursing
Inquiry web site provides context for the major initiatives of
humanistic nursing, which celebrate the enduring and immutable ideals of
Humanism that give us insight into the fundamental truths of being in
the world of nurses, patients, families, colleagues, and students.


FOREWORD to the 1976 Edition

These essays will evoke different reactions from different
readers. "Well, I know that," for example, may be the reaction of a
beginner in nursing; "I wouldn't have said it that way but I knew that
is really nursing." "Since they've given us a methodology," perhaps from
one more experienced in nursing; "I'll give it a try." Others with still
more or different kinds of experience may respond, "It's about time
nurses put that into words; it's about time."

Timely as these essays are I would prefer not to use up the foreword
with a listing of the crises, the "eco-spasms," and scientific triumphs
that would document their timeliness. It is my pleasure, rather, to use
this opportunity to relate the six elements of my own reaction:

Nursing has a solitariness until we find it has many companions in
philosophy, science, and art.  It has a steadiness about its pace yet
holds a potential for flights to higher elevations.  It is constantly
changing yet has an enduring component of permanence.  Good is the word
we use every day; our vision, however, is of excellence.  Its tasks
often have the appearance of homeliness until we glimpse that kind of
beauty that is humanness.  Nursing even sings very softly because our
ears are attuned to "a different drummer."

Lilyan Weymouth, R.N., M.S.  Northampton, Massachusetts October 1975


PREFACE to the 1976 Edition

Out of necessity nursing, as a profession, reflects the qualities of the
culture in which it exists. In our culture for the past quarter of a
century nursing has been assailed with rapid economic, technological,
shortage- abundance, changing scenes' vicissitudes. In the individual
nurse these arouse turmoil and uncertainty. These cultural stirrings
inflame that part of the nurse's spirit capable of chaotic conflict and
doubt. Often she questions her professional identity. ''Just what is a
nurse?" Her nurse colleagues, other professionals, and nonprofessionals
freely, directly and indirectly-on television, in the theater, through
the news media and the literature-pummel her with their multitudinous
varied views.

As searching, wondering, reflecting, relating microcosms within this
perplexing health nursing world for longer than a quarter of a century,
we present this book. Descriptively we view the chapters as hard-wrung,
philosophical foundations, synthesized extracts from our lived
experiences.  These metatheoretical essays on practice present an
existential alternative approach for a professional nurse's knowing and
becoming.

These conceptualized existents are available because Miss Marguerite
L. Burt, formerly Chief of Nursing Service, Northport, N.Y. Veterans
Administration Hospital called them forth from us. These chapters are
our response to her call. In 1972 Miss Burt requested us to develop a
course for the professional nursing staff at Northport V.A.H. This book
has evolved from the original presentations offered to the ten
participants in the first course. While we taught and worked with five
subsequent groups, we learned and continually revised and clarified our
conceptualizations.  The course is entitled Humanistic Nursing.

Fifty-three nurses have been involved in this course. Interest,
appreciation, wonderment, effort, and investment characteristically
depict their response. They convey that the humanistic nursing practice
theory reflects what nursing means to them. Their hungry approach to the
suggested readings has both surprised and pleased us. Our amazement
persists over the participants' ability to concentratedly discuss
abstract theory and concrete nursing practice for weekly day-long
sessions over six-to nine-month periods. Presently requests to
participate in the next humanistic nursing course are mounting from
nurses both within and outside the Northport complex.

The course, the theory, and this book are the fruits of our individual
and collaborative efforts. While sharing seminar responsibility for
graduate students in 1960, we began to dialogically and -dialectically
struggle with professional and /clinical nursing issues. Discussing and
searchingly questioning ourselves and our students became a
value. Through conveying, struggling for clarification, openness to
honest argument, we grew in our awareness that each was moved beyond her
beginning thoughts.  Through reflection we have come to view, describe,
and distinguish our dialogues as struggles with, and not against,
others' ideas. Differences in response are valued for what they can tell
us of our chosen area-nursing.  So dialectical dialogue has gradually
become our predominant teaching method. We convey our ideas, are open to
others' questions, struggle to clarify and really communicate, and
question ourselves, and others. In the process of the humanistic nursing
course, using this methodology, which is deliberate and, yet, natural
and authentic for us, we and our professional nursing staff students
have learned and become more human, more questioning, more clinical, and
just, more.

We value our moreness. Appreciating and valuing the effects of our
actualizing selves as human beings, we must attest to our existential
modes of nurse being; our inner mandate is: share. Hence, Humanistic
Nursing has come into being.

To find the meaning of nursing we have returned "to the thing itself,"
to the phenomenon of nursing as it occurs in the everyday world. Our
reflections on nursing as a lived experience flowed into the realm of
metanursing. Obviously, these thoughts are only a beginning. They are
offered in the hope of stimulating response and further development.
Dialogue may be difficult at first because humanistic nursing represents
one of our discipline's less articulated streams. Yet, it is a stream
traceable to nursing's foundation and, as such, is related to nursing's
artistic, scientific, and technological currents. It is not being,
cannot be, developed in opposition to them.

Science and art are forms of human responses to the human situation.
They are valued in genuine humanism. Thus, the humanistic nursing
approach does not reject advances in nursing technology, but rather it
tries to increase their value by viewing their use within the
perspective of the development of human potential. The same holds true
for scientific, artistic, and clinical developments in nursing
practice. They are the necessary means through which and in which
humanistic nursing (a being and doing) is experienced and developed.

At this time when serious concern is being expressed about the survival
of nursing as a profession, humanistic nursing offers a note of
optimism.  By examining the values underlying practice, it focuses on
the meaning and means of nursing's particular' mode of interhuman
caring. It increases respect for that caring as a means of human
development. Nurses have the privilege of being with persons who are
experiencing all the varied meanings of incarnate being with men and
things in time and space in the entire range from birth to death. They
not only have the opportunity to co-experience and co-search with
patients the meaning of life, suffering, and death, but in the process
they may become and help others become more-more human.

Beyond this, the humanistic nursing approach respects nursing experience
as a source of wisdom. By describing and conceptualizing the phenomena
experienced in nursing situations, nurses could contribute to the
development of nursing as a discipline. Even more, they could add to the
knowledge of man.

Humanistic nursing, then, is neither a break with nor a repetition of
nursing's past. It is neither a rejection of nor a satisfaction with
nursing's present. Rather it is an awakening to the possibilities of
shaping our nursing world here and now and for the future.

Thanks to Miss Marguerite L. Burt are in order for she provoked our
conceptualizations of our lived nursing worlds. Dr. Frederick H. Wescoe,
while Chief of Nursing Service, Northport, N.Y., VAH administratively
facilitated the time and the means for our compiling these materials
into a manuscript. Past nursing students challenged and grappled with
our ideas and theirs insisting always on our forwarding our
thinking. Our consultants, Miss Lilyan Weymouth and Miss Rose Godbout,
were marvelous resources and counselors.

Immediately we are most grateful to the participants in the six
humanistic nursing courses taught here at the Northport VAH. As nurses,
they received and accepted our expressed ideas to the extent of testing
them in the fires of their real lived nursing practice settings. While
struggling with our ideas and us, they gave to us. They were supportive,
loving, and truly present with us in the community of nurses at
Northport, VAH. Miss Sue McCann, clinical nurse specialist, one of our
first course participants, has read and reviewed our materials. More
than this Miss McCann has been a counselor, resource person, and a
dependable friend in our humanistic nursing effort of the last three
years.  We hope our chapters give back to others, at least just a part
of what we have received from them in our travels in the nursing world.

J.G.P
L.T.Z.

[Transcriber's Note: to the 1988 Edition

Italic text has been marked as _text_.
Bold text has been marked as ~text~.
Obvious punctuation errors in the original have been corrected.
Other corrections are noted at the end of the text.
The original page numbers have been retained, e.g. {1} marks the start
of page 1 in the original text.]

HUMANISTIC NURSING

_Josephine G. Paterson, DNSc, RN_
_Loretta T. Zderad, PhD, RN_

PREFACE

    Somewhere there's a child a crying
    Somewhere there's a child a crying
    Somewhere there's a child a crying
    Crying for freedom in South Africa.[1]

But until someone hears the cry and responds, the child will continue to
suffer the oppression of the current South African regime; and the world
will continue to be less than it could be. To cry aloud when there seems
no chance of being heard, belies a hope--perhaps an inherently human
trait--that someone, somewhere, somehow will hear that cry and respond
to it.

This same hope, that someone would hear and respond, allowed existential
psychologist Viktor Frankl to survive the systematic torture and
degradation in Nazi death camps. As Frankl and others sought their way,
they found meaning and salvation "through love and in love;" and by
choosing to believe that "life still waited for him, that a human being
waited for his return."[2]

There is power in the call of one person and the potential response of
another; and incredible power when the potential response becomes real.
There is the power for each person to change as she becomes more than
she was before the dialogue. There is the power to transcend the
situation as two people engage the events that are whirling around them
and together try to make sense of their worlds and find a meaning to
their existence. When the call and response between two people is as
honest as it can be, there is the revolutionary power which the poet
Muriel Rukeyser speaks of:

    What would happen if one woman told the truth about her life?
      The world would split open.[3]

{iv}

The call and response of an authentic dialogue between a nurse and
patient has great power--the power to change the lived experiences of
both patient and nurse, to change the situation, to change the world. It
is the same authenticity we search for in relationships with our friends
and lovers. The person who really listens to what we are saying, who
really tries to understand our lived experiences of the world and who
asks the same from us. When found, it brings the same exhilarating
feeling of self-affirmation and the comforting feeling of well-being.

For, if as holistic beings we are the implicate order explicating
itself, as suggested by Bohm[4] and Newman[5] among others, then the
responsibilities of those who would help (e.g., nurses) include making
sense out of the chaos that can occur as illness disrupts past order and
as the ever-present threat of non-being disrupts all order. When we are
successful in helping patients and their loved ones make sense of their
lives by bringing meaning to them, we make sense of and bring meaning to
our own.

And when we help create meaning, it is easier to remember why we chose
nursing and why we continue to choose it despite what an underpaid and
undervalued job it has become in today's marketplace. These are the
moments when by a look or a word or a touch, the patient lets us know
that he understands what is happening to him, what his choices are, and
what he is going to do; that he knows we know; and that each knows that
the other knows. When we get past our science and theories, our
technical prowess, our titles and positions of influence, it is this
shared moment of authenticity--between patient and nurse--that makes us
smile and allows us to move forward in our own life projects.

Nurse educators who seek such authentic exchanges with their students
enjoy similar moments. The same can be said of deans of schools of
nursing, administrators of delivery systems, executives and staff of
nursing and professional organizations, and colleagues on a research
project. It is the authentic dialogue between people that makes any
activity worthwhile regardless of whether or not it is called successful
by others.

When Josephine G. Paterson and Loretta T. Zderad first published their
book _Humanistic Nursing_ in 1976, society was in the midst of the new
women's movement and nurses were going through the phase of
assertiveness training, dressing for success, and learning to play the
games that mother never taught us. Since then, nurses have moved into
many sectors of society and have held power as we have never held it
before. We have proved ourselves as politicians, administrators,
researchers, and writers. We have refined our abilities to assess,
diagnose, treat, and evaluate. We've raised money and balanced budgets.
We've networked, organized, and formed coalitions.

Yet, individually we are uneasy and collectively we are unable to
articulate a vision clear enough so that others will join us. This
re-issue of Paterson and {v} Zderad's classic work will help to remind
us of another way of developing our power. Perhaps we can, once again,
look for and call for authentic dialogue with our patients, our
students, and our colleagues. Paterson and Zderad are clear in their
method: discuss, question, convey, clarify, argue, and reflect. They
remind us of our uniqueness and our commonality. They tell us that it is
necessary to do with and be with each other in order for any one of us
to grow. They help us celebrate the power of our choices.

Is it ironic and fortunate that _Humanistic Nursing_ should be re-issued
now when it is needed even more than it was during the late 1970s? Then,
humanitarianism was in vogue. Now, it is under attack as a secular
religion.

Today, the technocratic imperative infiltrates an ever-increasing number
of our lived experiences; and it becomes more difficult to ignore or
dismiss Habermas's analysis that all interests have become technical
rather than human.[6] As health care becomes increasingly commercial the
profound experiences of living and dying are discussed in terms of
profit and loss. Life itself is the focus of public debates about
whether surrogacy involves a whole baby being bought and sold or only
half of a baby, since one half already "belongs" to the natural father
and so he cannot buy what he already owns.

We have many choices before us: to adopt the values of commerce and
redesign health care systems accordingly; to accept competition as the
modus operandi or insist on other measures for people in need; to decide
who will be cared for, who won't, who will pay, and how much?

Perhaps it is time for us to turn away from the exchange between buyers
and sellers, providers and consumers; and turn back to an exchange
between two people trying to understand the space they share. Perhaps it
is time for a shared dialogue with patients for whom the questions are
most vital? Perhaps we need to hear their call and respond
authentically. Perhaps they need to hear ours? For only then, as
Paterson and Zderad have made quite clear, will our lived experiences in
health care have any real meaning.

    Patricia Moccia PHD, RN
    Associate Professor and Chair
    Department of Nursing Education
    Teachers College Columbia University


FOOTNOTES:

[1] _Azanian Freedom Song._ Lyrics by Otis Williams, music by Bernice
Johnson Reagon. Washington, DC: Songtalk Publishing Co., 1982.

[2] Frankl, Viktor. _Man's Search For Meaning._ Boston: Beacon Press,
1959.

[3] Rukeyser, Muriel. "Kathe Kollwitz," in _By a Woman Writ_, ed. Joan
Goulianos. New York: Bobbs Merrill, 1973, p. 374.

[4] Bohm, David. _Wholeness and the Implicate Order._ London: Ark, 1980.

[5] Newman, Margaret. _Health As Expanding Consciousness._ St. Louis: C.
V. Mosby Company, 1986.

[6] Habermas, Jurgen. _Knowledge and Human Interest_, (trans. J.
Shapiro.) Boston: Beacon Press, 1971.

CONTENTS

PART ONE

THEORETICAL ROOTS                                        1

1 Humanistic Nursing Practice Theory                     3
2 Foundations of Humanistic Nursing                      11
3 Humanistic Nursing: A Lived Dialogue                   21
4 Phenomenon of Community                                37


PART TWO

METHODOLOGY--A PROCESS OF BEING                          49

5 Toward a Responsible Free Research Nurse in the Health Arena  51
6 The Logic of a Phenomenological Methodology            65
7 A Phenomenological Approach to Humanistic Nursing Theory  77
8 Humanistic Nursing and Art                             85
9 A Heuristic Culmination                                95

Appendix                                                 113
Glossary                                                 121
Bibliography                                             123
Index                                                    127

{1}

Part 1

THEORETICAL ROOTS

{2} {3}

1

HUMANISTIC NURSING PRACTICE THEORY


Substantively this chapter introduces two aspects of the humanistic
nursing practice theory: first, what this theory proposes and, second,
how the proposals of the theory evolved.

Concisely, humanistic nursing practice theory proposes that nurses
consciously and deliberately approach nursing as an existential
experience. Then, they reflect on the experience and phenomenologically
describe the calls they receive, their responses, and what they come to
know from their presence in the nursing situation. It is believed that
compilation and complementary syntheses of these phenomenological
descriptions over time will build and make explicit a science of
nursing.


HUMANISTIC NURSING: ITS MEANING

Nursing is an experience lived between human beings. Each nursing
situation reciprocally evokes and affects the expression and
manifestations of these human beings' capacity for and condition of
existence. In a nurse this implies a responsibility for the condition of
herself or being. The term "humanistic nursing" was selected
thoughtfully to designate this theoretical pursuit to reaffirm and
floodlight this responsible characteristic as fundamentally inherent to
all artful-scientific nursing. Humanistic nursing embraces more than a
benevolent technically competent subject-object one-way relationship
guided by a nurse in behalf of another. Rather it dictates that nursing
is a responsible searching, transactional relationship whose
meaningfulness demands conceptualization founded on a nurse's
existential awareness of self and of the other. {4}


EXISTENTIAL EXPERIENCE


Uniqueness--Otherness

Existential experience infers human awareness of the self and of
otherness. It calls for a recognition of each man as existing singularly
in-his-situation and struggling and striving with his fellows for
survival and becoming, for confirmation of his existence and
understanding of its meaning.

Martin Buber, philosophical anthropologist and rabbi, expressed artfully
this uniqueness, struggle, and potential of each man. He said:

     "Sent forth from the natural domain of species into the hazard
     of the solitary category, [man] surrounded by the air of a
     chaos which came into being with him, secretly and bashfully he
     watches for a Yes which allows him to be and which can come to
     him only from one human person to another."[1]

With such uniqueness of each human being as a given, an assumed fact,
only each person can describe or choose the evolvement of the project
which is himself-in-his situation. This awesome and lonely human
capacity for choice and novel evolvement presents both hope and fear as
regards the unfolding of human "moreness." Uniqueness is a universal
capacity of the human species. So, "all-at-once," while each man is
unique; paradoxically, he is also like his fellows. His very uniqueness
is a characteristic of his commonality with all other men.


Authenticity--Experiencing

In humanistic nursing existential awareness calls for an authenticity
with one's self. As a visionary aim, such authenticity,
self-in-touchness, is more than what usually is termed intellectual
awareness. Auditory, olfactory, oral, visual, tactile, kinesthetic, and
visceral responses are involved and each can convey unique meaning to
man's consciousness. In-touchness with these sensations and our
responses informs us about our quality of being, our thereness, our
degree of presence with others. The kind of "between" we live with
others depends on both our degree of awareness and the meaning we
attribute to this awareness. This awareness, reflected on, sometimes
shared with a responsible other for reality testing, offers us
opportunity for broadening our meaning base, for becoming more--more in
accord with our potential for humanness.

Perhaps a statement made by Dr. Gene Phillips, professor of education at
Boston University, will clarify the importance I attach to each nurse
becoming as much as she can be. He said, "The more mature we are the
less it is necessary for us to exclude." Presently I would paraphrase
this statement {5} and say, the more of ourselves we do not have to
exclude, the more of the other we can be open to. Our self-awareness,
in-touchness, self-acceptance, actualization of our potential allows us
to share with others so they can become in relationship with us.

In this kind of existential relating, presence with another, a nurse is
confronted with man as singular in his own peculiar angular, biased, or
shaded reality. It becomes apparent that each has his very own lived
world. So one might describe human existence as man-world as some refer
to man as mind-body, using a hyphen rather than "and." Man's universal
species commonality and peculiar perplexing noncommonality, has this
manness, affect and constantly interplay with one another. This arena of
interplay is complicated further by man's capacity for nondeterminedness,
his ability for envisioning and considering a variety of alternatives
and choosing selectively. Often these alternatives are experienced as
contradictory and inconsistent. Humanistic nursing calls forth in the
nurse the struggle of recognizing the complexity of men's relating in
the nursing world as "just how man is" and his nature, his human
condition, as searching, experiencing, and an unfolding becoming.


Moreness--Choice

How can a nurse let herself know her human responses and the breadth and
depth of the possibilities called forth by the other? How can she be,
search, experience, become in an accord with the calls and responses of
her lived nursing world? It is a chosen, deliberate life-long process.
The process itself is generative. One experience opens the door for the
next. In humanistic nursing practice theory we call this kind of
experiencing authentic, genuine, or "letting be what is." It is man
conscious of himself, not necessarily acting out, but aware of his human
responses to his world and their meanings to him. This quality of
personal authenticity allows one's responsible chosen actions to be
based in human knowledge rather than human defensiveness. Man is a
knowing place. From education and living experience one assumes an
initial innate force in human beingness that moves man to come to know
his own and others' angular views of the world. Humanistic nursing is
concerned with these angular views, these differences being viewed by
nurses responsibly and as realities that are beyond the
negative-positive, good-evil standard of judgement. Or, for example,
nursing is concerned with how this particular man, with his particular
history, experiences being labeled with this general diagnosis and being
admitted, discharged, and living out his life with his condition as he
views it in-his-world.

Man has the inherent capacity to respond to other man as other man. Only
each unique nurse faced with the chaos of her alternatives in a
situation can then choose either to relate or not to relate and how to
relate in-her-nursing-world to others. Choosing to and how to relate or
respond cannot be superimposed on man from the outside by another. A
person, to a degree, can be coerced to behave outwardly in a certain
way. For example, physically, in a spatial {6} sense, a nurse can be
ordered into parallel existence with another. Being existentially and
genuinely present with another is different. This human mode of being is
chosen and controlled by the self. It takes responsible self-ordering
that can arise only in the spirit of one's own disciplined being.


Value--Nonvalue

To offer genuine presence to others, a belief must exist within a person
that such presence is of value and makes a difference in a situation. If
it is a value for a nurse, it will be offered in her nursing situation.
Libraries, concrete buildings bursting with words of great thinkers,
support the value of genuine presence and authentic dialogue between
persons. Consider the literary works that have conveyed or reflected
this message throughout the existence of intellectual man. Plato,
Rousseau, Goethe, Proust, Nietzsche, Whitehead, Jung, May, Frankl,
Hesse, de Chardin, Bergson, Marcel and Buber effortlessly come to mind.

Many nurses are genuine presences in the nursing situation. Some have
tried to share their experiences; some have not. And, there are those
who are not genuine presences in the nursing situation. One wonders if
this has influenced the distinctions nurses have made over the years
with certainty when considering their nurse contemporaries. Often one
hears, "she is a good nurse, a natural." These positive critics are
often up against it when asked, "why, how, what?" Descriptive literary
conceptualizations of nursing that reflect this quality of nurse-being
(presence, intersubjectiveness) call for nurses willing to search out
and bring to awareness, the mysteries of their commonplace, their
familiar, and to appreciate the unique ideas, values, and meanings
fundamental to their practice. Conceptualization of these qualities by
practicing nurses is basic and necessary to the development of a science
and an actualized profession of nursing.


PHENOMENOLOGICAL DESCRIPTION

Phenomenology directs us to the study of the "thing itself." The
existential literature, descriptions of what man has come to know and
understand in his experience, has evolved from the use of the
phenomenological approach. In the humanistic nursing practice theory the
"thing itself" is the existentially experienced nursing situation. Both
phenomenology and existentialism value experience, man's capacities for
surprise and knowing, and honor the evolving of the "new."


What Does Humanistic Nursing Practice Theory Ask the Nurse to Describe?

Nurses experience with other human beings peak life events: creation,
birth, winning, nothingness, losing, separation, death. Their "I-Thou"
empathetic {7} relations with persons during these actual lived
experiences and their own experiential-educational histories make "the
between" of the nursing situation unique. Through in-touchness with
self, authentic awareness and reflection on such experiences the human
nurse comes to know. Humanistic nursing practice theory asks that the
nurse describe what she comes to know: (1) the nurse's unique
perspective and responses, (2) the other's knowable responses, and (3)
the reciprocal call and response, the between, as they occur in the
nursing situation.


Why Does Humanistic Nursing Practice Theory Ask That Existential Nursing
Experience Be Described Phenomenologically?

There are many reasons. Philosophically and fundamentally the reason
relates to how humanistic nursing perceives the purpose and aim of
nursing. It views nursing as the ability to struggle with other man
through peak experiences related to health and suffering in which the
participants in the nursing situation are and become in accordance with
their human potential. So, like Elie Wiesel, the novelist, who states in
_One Generation After_ that he writes to attest to events of human
existence and to come to understand, humanistic nursing proposes that
human forms of existence in nursing situations need attestation and that
through describing, nurses will understand better and relate to man as
man is. Thus the profession of nursing's service contribution to the
community of man will ever become more.

The reasons for phenomenologically describing nursing are complex,
interinfluential, and their ramifications are far reaching.
Sequentially, the study and description of human phenomena presented in
nursing situations will affect (1) the quality of the nursing situation,
(2) man's general knowledge of the variation in human capacity for
beingness, and (3) the development and form of the evolvement of nursing
theory and science.


How Can Nurses Begin to Describe Humanistic Nursing Phenomenologically?

The process of how to describe nursing events entails deliberate
responsible, conscious, aware, nonjudgmental existence of the nurse in
the nursing situation followed by disciplined authentic reflection and
description.

There are obvious common lived human experiences which if considered and
wondered about, can advance a nurse's ability for phenomenological
description. These experiences are easily cited, yet not easily plumbed.
Often experiences such as anger, frustration, waiting, apathy,
confusion, perplexity, questioning, surprise, conflict, headache,
crying, laughing, joy are quickly theoretically and analytically
interpreted, labeled, and dismissed. Examining, reexamining, mulling
over, brooding on, and fussing with the situational context of these
experiences as nonlabeled, raw human lived data can yield {8}
knowledge. Knowledge of the nurse's and her other's unique human
existence in their on-going struggle becomes explicit. Superficial
treatment of such human clues results in nonfulfillment of the realistic
human possibilities of artful-scientific professional knowing and
nursing.

Words are the major tools of phenomenological description. They are
limited by our human ability to express, and yet they are the best tools
we have for expressing the human condition. The novelist James Agee, in
_Let Us Now Praise Famous Men_, says that though man or human
relatedness never could be described perfectly it would be the greater
crime not to try. This, too, is a basic premise of the humanistic
nursing practice theory.

The words we use to describe and discuss this theory are easy words,
everyday English words. We all know them. We, at times, narrow a word's
meaning or make it more specific. Some problem is presented by words we
are accustomed to using and hearing. Habit and our human fallibility can
promote only superficial comprehension. Thoughtful awareness of the
meaning of these same sequentially expressed words can convey the
complexity of the never completely fathomable "all-at-onceness" of lived
existence. This theory is expressed in terms like "existence
confirming," "striving," "becoming," "relation," and "reflection." We
intend such words to express the grasp with acceptance and recognition
of human limitations while awesomely pondering the open-ended scope of
each man's potential.

In time, with disciplined authentic reflective description, themes
common and significant to nursing situations become apparent. They are
then available for compilation, complementary synthesis, and on-going
refinement. A nursing resource bank accrues: Not a bank that offers a
map of how and what to do but rather one that further stimulates nurses'
exploration and understanding.


THE EVOLVEMENT OF HUMANISTIC NURSING PRACTICE THEORY

Since 1960 Loretta T. Zderad and myself in dialogue, together, and with
groups of nurses in graduate schools and in nursing service situations
have reflected on, explored, and questioned our own and others' nursing
situational experiences. Over this period we have come to value and
appreciate the meaningfulness of these situations to man's existence.
This constantly augmented our feelings of responsibility for
contributing to these situations beneficially. Therefore, we looked at
them for their tractability to research methodology. Their loadedness
with variations, changes, uncontrollables, and our negative feelings
about the implications of viewing human beings as predictable left the
strict scientism of positivistic method wanting at this stage of man's
knowing. We saw objectivity in nursing situations or our questions,
nursing questions, in the realm of needing to now how man experienced
his existence. This objectivity, or man's real lived reality
paradoxically is subjectively ridden, man-world.

The existential literature dealt with substantive themes encountered in
nursing experiences. As I previously stated this literature evolves from
a phenomenological {9} approach to studying being and existence. This
approach to studying, describing, and developing an artistic science of
nursing became Dr. Zderad's and my long-sought haven. All along
existentialism and phenomenology had been ours 'and many nurses' "what"
and "how." Now we had labels that were acceptable and reputable to
many--most of all to ourselves.


FOOTNOTES:

[1] Martin Buber, "Distance and Relation," trans. Ronald Gregor Smith,
in _The Knowledge of Man_, ed. Maurice Friedman (New York: Harper & Row,
Publishers, 1965), p. 71.

{10} {11}

2

FOUNDATIONS OF HUMANISTIC NURSING


Nursing is a response to the human situation. It comes into being under
certain conditions--one human being needs a kind of help and another
gives it. The meaning of nursing as a living human act is in the act
itself. To understand it, therefore, it is necessary to consider nursing
as an existent, a phenomenon occurring in the real world.


THE PHENOMENON OF NURSING

The phenomenon of nursing appears in many forms in the real lived world.
It varies with the age of the patient, the pathology or disability, the
kind and degree of help needed, the duration of the need for help, the
patient's location and his potential for obtaining and using help, and
the nurse's perception of the need and her capacities for responding to
it. Nursing varies also in relation to the sociocultural context in
which it occurs. Being one element in an evolving complex system of
health care, nursing is continuously appearing in new specialized forms.
As professionals, we are accustomed to viewing nursing as we practice it
within these specialty contexts--for example, pediatric, medical,
rehabilitation, intensive care, long-term care, community. There seems
to be no end to the proliferation of diversifications. Even the attempts
of practitioners to combine specialties give rise to new specialties,
such as, community mental health nursing and child psychiatric nursing.

So it is difficult to focus on the phenomenon of nursing as an entity
without having one's view colored by a particular clinical, functional,
or societal context. Yet, if we can "bracket" (hold in abeyance) these
adjectival labels and the preconceived viewpoints they signify, we can
consider the thing itself, the act of nursing in its most simple and
general appearance. {12}


Well-Being and More-Being

In this most basic sense, then, disregarding the particular specialized
forms in which it appears, the nursing act always is related to the
health-illness quality of the human condition, or fundamentally, to a
man's personal survival. This is not to say that all instances of
nursing are matters of life and death, but rather that every nursing act
has to do with the quality of a person's living and dying.

That nursing is related to health and illness is self-evident. How it is
related is not so apparent. "Health" is valued as necessary for survival
and is often proposed as the goal of nursing. There are, in actuality,
many instances of nursing that could be described as "health restoring,"
"health sustaining," or "health promoting." Nurses engage in "health
teaching" and "health supervision." On the other hand, there are
instances in which health, taken in its narrowest meaning as freedom
from disease, is not seen as an attainable goal, as evidenced, for
example, in labels given to patients such as "terminal," "hopeless," and
"chronic." Yet in actual practice these humans' conditions call forth
some of the most complete, expert, total, beautiful nursing care.
Nursing, then, as a human response, implies the valuing of some human
potential beyond the narrow concept of health taken as absence of
disease. Nursing's concern is not merely with a person's well-being but
with his more-being, with helping him become more as humanly possible in
his particular life situation.


Human Potential

Since nursing involves one human being helping another, the notion of
humaneness has been associated traditionally with nursing. Nursing
practice is criticized justifiably when it is not humane and is taken
for granted or praised when it is. The expectation of humaneness is so
ingrained in the concept of nursing that some nurses are surprised when
it is acknowledged by patients. If a patient thanks them for their
kindness, patience, or concern, these nurses reply, in their
embarrassment, "Oh, that's part of my job."

However, to equate nursing's humanistic character solely with an
overflowing of the milk of human kindness is a serious error of
oversimplification. Such a limited view, in fact, is a dehumanizing
denial of man's potentials. As a human transaction, the phenomenon of
nursing contains all the human potentials and limitations of each unique
participant. For instance, frustration, discouragement, anger,
rejection, withdrawal, loneliness, aggression, impatience, envy, grief,
despair, pain, and suffering are constituents of nursing, as well as
tenderness, caring, courage, trust, joy, hope. In other words, since
nursing is lived by humans, the "stuff" of nursing includes all possible
responses of man--man needing and man helping--in his situation.


Intersubjective Transaction

Looking again at the phenomenon of nursing as it occurs in the real
lived world, obviously it is always an interhuman event. Whenever
nursing takes {13} place two (or more) human beings are related in a
shared situation. Each participates according to his own mode of being
in the situation, that is, as a person nursing or as a person begin
nursed. Since one is nursing and the other is being nursed, it follows
that the essential character of the situation is "nurturance." In other
words, the phenomenon of nursing involves nurturing, being nurtured, and
a relation--the "between" in which or through which the nurturance
occurs.

On reflection, it is obvious that nursing is an intersubjective
transaction. Both persons, nurse and patient (client, family, group),
necessarily participate in the proceedings. In this sense, they are
_inter_dependent. Yet, they are both subjects, that is, each is the
originator of human acts and of human responses to the other. In this
sense, they are _in_dependent. The intersubjective transactional
character of nursing cannot be escaped when one is experiencing the
phenomenon, either as nurse or as patient. Consider for example, some of
the most common nursing activities, such as, feeding and being fed,
comforting and being comforted, giving and taking medications. Although
this intersubjectivity is unmistakably known in experience, it is
extremely difficult to conceptualize and convey it to others. It rarely
is found in descriptions of nursing, and to the unfortunate extent that
it is missing, the descriptions are not true to life.

In real life, nursing phenomena may be experienced from the reference
points of nurturing, of being nurtured, or of the nurturing process in
the "between." For instance, the nurse may describe comfort as an
experience of comforting another person; the patient, as an experience
of being comforted. However, while each has experienced something within
himself, he also has experienced something of the "between," namely, the
message or meaning of the "comforting-being comforted" process. This
essential interhuman dimension of nursing is beyond and yet within the
technical, procedural, or interactional elements of the event. It is a
quality of being that is expressed in the doing.


Being and Doing

As an intersubjective, transactional experience, nursing necessarily
involves both a mode of being and a doing of something. The being and
doing are interrelated so inextricably that it is difficult, even
distorting, to speak of one without the other. Descriptions of nursing,
however, often focus primarily (sometimes exclusively) on the doing
aspect of the process, on the nursing techniques or procedures. The
observable acts are more easily discerned and discussed. They can be
measured, counted, and charted. Yet, in the actual interhuman experience
of nursing the weight of being is felt. Presence and the effect of one's
presence can be known much more vividly than they can be described.
Still, not to attempt to describe them is to present only a half, or
perhaps less than half, of the nursing picture.

When a nurse refers to a nurse-patient interaction during which a change
in the patient's condition or behavior was noted, one hoping to get a
description of nursing may ask, "What did you do?" Often the answer is a
description of a {14} manual action or a verbal interchange. Sometimes
the nurse responds, "Nothing, I was just there." Perhaps it is the
question that is wrong. The respondent usually interprets "doing" in a
limited sense. In reality, everything the nurse does is colored by the
character of her being in the situation. The nursing act itself is a
behavioral expression of the nurse's state of being, for example,
concerned, fatigued, hurried, confident, hopeless.

Furthermore, there is a kind of being, a "being with" or a "being
there," that is really a kind of doing for it involves the nurse's
active presence. To "be with" in this fuller sense requires turning
one's attention toward the patient, being aware of and open to the here
and now shared situation, and communicating one's availability.

Whether the nursing act is verbal, or manual, or both, a silent glance,
or physical presence, some degree of intersubjectivity is involved and
warrants recognition. To become more aware of and explore more fully
this essential constituent of nursing we need to focus on the
participants' modes of being in the situation. Rather than ask the
nurse, "What did you do in the nurse-patient situation?" we ought to
ask, "What happened between you?"


HUMANISTIC NURSING

When the meaning of nursing is sought by scrutinizing the phenomenon,
that is, by examining the nursing event itself as it occurs in real
life, one finds nursing embedded within the human context. As a
nurturing response of one person to another in need, it aims at the
development of human potential, at well-being and more-being. As
something that happens between people, it reflects all the human
potential and limitations of the persons involved. As an intersubjective
transaction, it holds the possibility for both persons to effect and be
affected, the possibility for both to become more. At its very base,
then, nursing is humanistic. It is, at once, man's expression of and his
striving for survival and further development in community.

In a way, to specify nursing as humanistic seems redundant. In view of
its source and goals how could it be otherwise? However, the term
"humanistic nursing" was coined thoughtfully and used purposely here to
designate a particular nursing approach. Not only does the term signify
full recognition of nursing's human foundation and meaning but it also
points the direction for nursing's necessary development. What is
proposed here is the enrichment of nursing by exploring and expanding
its relations to its human context.


Authentic Commitment

When it is genuinely humanistic, nursing is an expression, a living out,
of the nurse's authentic commitment. It is an existential engagement
directed toward nurturing human potential. The humanistic nurse values
nursing as a situation in which the necessary conditions for such human
actualization exist and is open to the possibilities in the intimately
shared nurse-patient here and now. {15}

Humanistic nursing calls for an existential involvement, that is, an
active presence with the whole of the nurse's being. This involved
presence is personal and professional. It is personal--a live act
stemming from this unique, individual nurse. It is a chosen human
response freely given; it cannot be assigned or programmed. The
involvement is professional--goal directed. It is based on an
art-science; it is held accountable.

Anyone familiar with typical hectic nursing situations could justifiably
question the actual attainability of such an existential involvement. It
goes without saying that it would be humanly impossible for a nurse to
be wholly present to numerous patients for eight hours a day. But any
nurse who has experienced moments of genuine presence in the
nurse-patient situation will attest to their reality and to the fact
that it is these beautiful moments that give meaning to nursing. In
terms of actual practice, then, it is more realistic to think of
humanistic nursing as occurring in various degrees. It may be more
useful, in fact, to consider humanistic nursing a goal worth striving
for; or an attitude that strengthens one's perseverance toward attaining
the difficult goal; or fundamentally, a major value shaping one's
nursing practice.


Process--Choice and Intersubjectivity

For the process of nursing to be truly humanistic it must bear out, that
is, be a lived expression of, the nurse's recognition and valuing of
nursing as an opportunity for the development of the human person. To
this end, humanistic nursing process echoes existential themes related
to a person's becoming through choice and intersubjectivity.

Existentially speaking, man is his choices. This does not mean that a
man can be anything he chooses. Naturally, each individual is unique,
having his own particular potentials and limitations. Nor is this view a
denial of the forces of unconscious motivation and habit. It does not
imply that all of a person's actions result from totally conscious
deliberations. By saying, "I am my choices," I mean I am this here and
now person because in my past life I took particular paths in preference
to others; of the possibilities open to me, I actualized certain ones.

In this sense, I am my history, I am what I am, what I have become. But
I am also what I am not, what I have not become. I am a nurse, this
unique here and now nurse with particular experience, knowledge, skills,
and values; without other experience, knowledge, skills, and values.
Through self-reflection I know that I have changed, I have experienced
growth from within. I know myself as a being capable of becoming more,
capable of actualizing my possibilities, my self. So I am my choices not
only in terms of my past but also in regard to my future, my
possibilities.

Man is an individual being necessarily related to other men in time and
space. As every man is beholden to other men for his birth and
development, interdependence is inherent in the human situation. In this
sense, human existence is coexistence. The deeper significance of this
truth has been recognized and elucidated by many thinkers, especially
those in the existential stream. Over {16} and over, their writings
reveal the paradoxical tension of being human: each man is, at once,
independent, a unique individual and interdependent, a necessarily
related being. As Wilfrid Desan says, referring to man as subsistent
relation, "He is towards-the-other but he is not-the-other."[1]

Furthermore, as Martin Buber and Gabriel Marcel maintain, it is actually
through his relations with other men that a man becomes, that his unique
individuality is actualized. To know myself as "individual" is to
experience myself as this particular unique here-and-now person and
other than that there-and-now person. Or in other words, to know myself
as me is to see myself in relation to and distant from other selves. As
Buber so beautifully states, "It is from one man to another that the
heavenly bread of self-being is passed."[2]

Logically, it follows that the possibility for self-confirmation exists
in any intersubjective situation. However, in everyday life this
self-confirmation is experienced to different degrees or on different
levels in interhuman relating. Since both persons are independent
subjects acting with their human capacity for disclosing or enclosing
themselves, there is no guarantee that the availability and presence
necessary for a genuine confirming encounter will come forth. Presence,
the gift of one's self, cannot be seized or called forth by demand, it
can only be given freely and be invoked or evoked.

Since man becomes more through his choices and the aim of nursing is to
help man toward well-being or more-being, the humanistic nursing effort
is directed toward increasing the possibilities of making responsible
choices. Such choice involves, in the first place, an openness to and an
awareness of one's own situation. A choice is a response to possibility.
Therefore, one must first recognize that possibilities or alternatives
exist. This openness to options is experienced as a freedom to choose as
well as a freedom from the bonds of habit and stereotyped response, from
routine, from the veils of the obvious. It means getting in touch with
one's experience, one's subjective-objective world. As one becomes more
acutely aware of his personal freedom of choice, there arises
concurrently an awareness of the quality of choice, of the
responsibility that is always implied in the freedom. Then follows
reflective consideration of one's unique situation with its possible
alternatives and an examination of the values inherent in them. Finally,
the act of choosing is expressed in a response to the situation with a
willingness to accept the responsibility for its foreseeable
consequences. Through this experience the person becomes aware of
himself as an individual. As a subject choosing freely and responsibly,
he knows himself as distinct from and yet related to others.

Nursing, being an intersubjective transaction, presents an occasion for
both persons, patient and nurse, to experience the process of making
responsible choices. Through living this process in nursing situations,
the nurse develops her own potential for responsible choosing. The
satisfaction, often in the form {17} of a sense of vitality and
strength, that is felt in making responsible competent professional
judgments reinforces the habit. In personally coming to experientially
appreciate the growth promoting character of responsible choosing, the
nurse may more readily recognize the value of such experiences for any
person, including the one currently labeled "patient." The humanistic
nurse, therefore, is alert to opportunities for the patient to exercise
his freedom of choice within the limits of safe and sound practice. She
is constantly assessing his capabilities and needs and encourages his
maximum participation in his own health care program. Through
coexperiencing and supporting the process in the patient's experience
from his point of view, the nurse nurtures his human potential for
responsible choosing. Both patient and nurse become more through making
responsible choices in the intersubjective, transactional nursing
situation.


Theory and Practice

The term "humanistic nursing" refers to a kind of nursing practice and
its theoretical foundations. The two are so interrelated that it is
difficult, in fact even somewhat distorting, to speak exclusively of
either the practice or the theory of humanistic nursing. When, for the
sake of clarity or emphasis, discussion is focused on either the
practical or the theoretical realm, thoughts of the other realm cast
their shadows on the fringes. For in our view, for the process of
nursing to be truly humanistic means that the nurse is involved as an
experiencing, valuing, reflecting, conceptualizing human person. From
the other side, the theory of humanistic nursing is derived from actual
practice, that is, from being with and doing with the patient. "Theory,"
says R. D. Laing, "is the articulated vision of experience."[3]

Humanistic nursing is not a matter solely of doing but also of being.
The humanistic nurse is open to the reality of the situation in the
existential sense. She is available with her total being in the
nurse-patient situation. This involves a living out of the nurturing,
intersubjective transaction with all of one's human capacities which
include a response to the experienced reality. Man is able to set his
world at a distance as an independent opposite and enter into relation
with it. In fact, according to Buber, this is what distinguishes
existence as human. It is man's special way of being.[4] For nursing to
be humanistic in this full sense of the term requires being and doing in
the situation and subsequently setting the experienced reality at a
distance (that is, objectifying it) and entering into relation with it.
The nurse's reflective response to her lived world may take the shape of
any form of human dialogue with reality, such as, science, art, or
philosophy.

Viewed existentially, every nursing event is unique, a live
intersubjective transaction colored and formed by the individual
participants. Although the event is ephemeral, the resultant
experiential knowledge is lasting and cumulative. So {18} from the
nurse's daily commonplace grows a body of clinical wisdom. The need for
describing nursing phenomena, for expressing and conceptualizing lived
nursing worlds, is basic to the theoretical and actual development of
humanistic nursing. In summary, we contend that humanistic nursing
practice necessarily involves the conceptualization of that practice and
an examination of its inherent values and that humanistic nursing theory
must be derived from nurses' lived experience. The interwoven theory and
practice are reciprocally enlightening.


Framework--The Human Situation

It is easy to recognize the intrinsic interrelatedness of humanistic
nursing theory and practice and the consequent necessity for their
concurrent development. It is even quite easy to take the next steps of
valuing such development and committing oneself to the task. But then
the question arises: Where to begin?

Humanistic nursing is concerned with what is basically nursing, that is,
with the phenomenon of nursing wherever it occurs regardless of its
specialized clinical, functional, or sociocultural form. So its domain
includes any or all nursing situations. And within this domain, since
humanistic nursing is an intersubjective transaction aimed at nurturing
well-being and more-being, its "stuff" includes all possible human and
interhuman responses. To conceive of so limitless a universe for study
is at once exhilarating and overwhelming. How can one get a handle on
the nursing universe? Is it possible to envision an inclusive frame that
would allow an orderly, systematic, and hopefully productive approach to
the development of humanistic nursing?

The key is to return again to the source, to look at the phenomenon of
nursing as it occurs in real life. From this perspective, the human
situation sets the stage where nursing is lived. The major dimensions of
humanistic nursing, then, may be derived from this situation.
Existentially, man is an incarnate being always becoming in relation
with men and things in a world of time and space. The nursing situation
is a particular kind of human situation in which the interhuman relating
is purposely directed toward nurturing the well-being or more-being of a
person with perceived needs related to the health-illness quality of
living. The elements of the frame, based on this view of humanistic
nursing, would include incarnate men (patient and nurse) meeting (being
and becoming) in a goal directed (nurturing well-being and more-being)
intersubjective transaction (being with and doing with) occurring in
time and space (measured and as lived by patient and nurse) in a world
of men and things. In other words, the inexhaustible richness of lived
nursing worlds could be explored freely, imaginatively, and creatively
in any direction suggested by the dimensions of this open framework. It
allows for a variety of angular views.

For example, in terms of man as incarnate, it is certainly not new for
nurses to focus on man's bodily existence. Naturally, one of nursing's
basic concerns always has been care of people's physical needs. To view
nursing from the perspective of the human situation, however, is to see
beyond physical care, {19} beyond the categorization of man as a
biopsychosocial organism. The focus is on the person's unique being and
becoming in his situation.

Every man is inserted into the common world of men and things through
his own unique body. Through it he affects the world and the world
affects him. Through it he develops his own unique personal private
world. When a person's bodily functions change during illness _the_
world and _his_ world change for him. The nurse needs to consider how
the patient experiences his lived world. Ordinary things which nurses
simply take for granted, such as, hospital noises or odors, touching,
bathing, feeding, sleep or meal schedules, may have very different
meaning for individual patients. They may or may not be experienced as
nurturing in a particular person's lived world.

In the humanistic perspective the nurse also is viewed as a human
person, as a being in a body rather than merely as a function or a doer
of activities. Conscious recognition of this fact opens many areas for
exploration. Obviously, the nurse's actions (her being with and doing
with), that affect the patient's world, are expressed through her body.
How is nurturance communicated and actually effected through nursing
activities? From the other side, consider the nurse as being affected by
the world through her body. What depths of "nursing content" could we
fathom if we accepted the existential dictum that "the body knows?"
Would we dismiss so lightly those gems of clinical wisdom nurses
attribute disparagingly to "gut reaction," "unscientific intuition," or
"years of experience"? Would we value serious exploration and extraction
of these natural resources in the nursing world?

The framework suggests, further, the possibilities of exploring the
development of human potential, both patient's and nurse's, as it occurs
in the unique domain of nursing's intersubjective transactions. What
human resources are called forth in the shared situations during which
nurses coexperience and cosearch with patients the varied meanings of
being and becoming over the entire range of life from birth to death?
How does it occur? What is the process? What promotes well-being or
becoming more when facing life, suffering, death? For the patient? For
the nurse? What knowledge gained through the study of nursing, a
particular form of the human situation, could be contributed to the
general body of human sciences?

Finally, within this framework, all the phenomena experienced in the
nursing situation could be explored in relation to their attributes of
time and space. More specifically, from an existential perspective, the
focus would be directed toward the significance of lived time and space,
that is, time and space as experienced by the patient and/or the nurse,
and as shared intersubjectively. For example, waiting, silence,
chronicity, emergency, positioning a patient in bed, moving through
space in a wheelchair, crutchwalking, pacing, could be considered from
the standpoint of the patient's experienced space and time, or from the
nurse's, or as a shared event. Explorations of this kind could provide
valuable insights into important nursing phenomena, such as, presence,
empathy, comfort, timing. {20}

The human situation, then, is the ground within which nursing takes
form. As such, it provides a framework for approaching the study and
development of humanistic nursing. As an angular view, it holds the
focus on the basic question underlying nursing practice: Is this
particular intersubjective, transactional nursing event humanizing or
dehumanizing?


CONCLUSION

This chapter explored the foundations of humanistic nursing. The
discussion flowed naturally, perhaps unavoidably, into the realm of
meta-nursing. "Naturally," for the humanistic nursing approach is itself
an outgrowth of the critical examination of nursing as an experienced
phenomenon. From this existential perspective of nursing as a living
human act, the meaning of nursing is found in the act itself, in
nursing's relation to its human context.

Reflection on nursing as it is lived in the real world revealed its
existential, nurturing, intersubjective, transactional character. The
process of humanistic nursing stemming from the nurse's authentic
commitment is a kind of being with and doing with. It aims at the
development of human potential through inter subjectivity and
responsible choosing.

The actualization of humanistic nursing is dependent on the concurrent
development of its practice and theoretical foundations by practicing
nurses. An open framework derived from the human situation was offered
to suggest possible dimensions of humanistic nursing practice that could
be described and articulated into a body of theory.

Nurses who have considered this humanistic nursing approach in terms of
their daily practice have felt at home in the ideas. The
conceptualizations fit their personal nursing experience. If there is
any strangeness in the approach, it is perhaps that it does not follow
the contours of the clinical specialties to which we have grown so
accustomed that they may be more ruts than roads. This is not to say
that humanistic nursing is opposed to clinical specialization in
nursing. In fact, clinical nursing, as it exists in any form, is its
very heart and base. Humanistic nursing is not compartmentalized into
clinical (or functional, or sociocultural) specialties because it
applies in all clinical areas. It is, in the most basic sense,
cross-clinical. This may be the great advantage of humanistic nursing.
By orienting its explorations ontologically, it may foster genuine
cross-clinical studies of nursing phenomena. If nurses with highly
developed abilities in particular forms of nursing would struggle
together in collaborative cross-clinical studies of nursing phenomena,
specialization would serve to advance rather than fragment all nursing.



FOOTNOTES:

[1] Wilfred Desan, _The Planetary Man_, Vol. I, _A Noetic Prelude to a
United World_ (New York: The Macmillan Company, 1972). p. 37.

[2] Martin Buber, "Distance and Relation," trans. Ronald Gregor Smith,
in _The Knowledge of Man_, ed. Maurice Friedman (New York: Harper & Row,
Publishers, 1965), p. 71.

[3] R. D. Laing, _The Politics of Experience_ (New York: Ballantine
Books, 1967), p. 23.

[4] Buber, _The Knowledge of Man_, p. 60.

{21}



3

HUMANISTIC NURSING: A LIVED DIALOGUE


The meaning of humanistic nursing is found in the human act itself, that
is, in the phenomenon of nursing as it is experienced in the everyday
world. Therefore, the interrelated practical and theoretical development
of humanistic nursing is dependent on nurses experiencing,
conceptualizing, and sharing their unique angular views of their unique
lived nursing worlds. An open framework suggesting dimensions for such
exploration was derived from a consideration of the phenomenon of
nursing within its basic context, namely, the human situation. The
elements of this humanistic nursing framework include incarnate men
(patient and nurse) meeting (being and becoming) in a goal-directed
(nurturing well-being and more-being), intersubjective transaction
(being with and doing with) occurring in time and space (as measured and
as lived by patient and nurse) in a world of men and things.

The framework offers a little security by providing some reference
points for the exploration. However, what is gained in clarity by
conceptual abstraction is lost from the flavor of the actual experience.
Like a weather map that statically represents major factors and currents
in their interrelatedness, the framework discloses a nexus of elements.
But it is as far from the real phenomenon of nursing with its pains and
suffering and comforting and joys and hopes as the weather map is from
real weather with its wind and rain and heat and cold. This chapter is
concerned with the same basic framework of humanistic nursing but seen
in an enlivened form. To inspirit its constructs the search must return
again to the existential source, to the nursing situation as it is
lived.

When I reflect on an act of mine (no matter how simple or complex) that
I can unhesitatingly label "nursing," I become aware of it as
goal-directed (nurturing) being with and doing with another. The
intersubjective or interhuman element, "the between," runs through
nursing interactions like an underground stream conveying the nutrients
of healing and growth. In everyday practice, we are usually so involved
with the immediate demands of our "being with and {22} doing with" the
patient that we do not focus on the overshadowed plane of "the between."
However, occasionally, in beautiful moments, the interhuman currents are
so strong that they flood our conscious awareness. Such rare and
rewarding moments of mutual presence remind us of the elusive
ever-present "between."

>From these epiphanic episodes in our personal nursing experience, we
have certain and immediate knowledge of intersubjectivity. Through our
experience, too, we know that both humanizing and dehumanizing effects
can result from human interactions. Therefore, it is essential for the
development of humanistic nursing to explore and describe its
intersubjective character.

Although many nurses have agreed in principle about the importance of
this work, they also have expressed the feelings of frustration and
discouragement attending it. There are real difficulties involved in
attempting to describe something so real yet so nebulous as "the
between." The descriptions must be derived from our own real nursing
experiences. This means that we must develop habits of conscious
awareness of experience, of recall, and of reflection. Then we must
struggle with our language finding the words in our physically and
technologically oriented vocabularies, perhaps even creating terms, to
convey the substance and flavor of the experience of intersubjectivity.

Furthermore, description of the intersubjective quality of nursing is
difficult because of its peculiar pervasiveness. Whether it is
consciously recognized or not, it is part of every nursing transaction.
However, to consider and explore intersubjectivity solely as a component
or constituent of nursing, even a necessarily inherent or an essential
one, would be to see it out of true perspective. The "between" is more
than a factor or facet of nursing; it is the basic relation in which and
through which nursing can occur. So the question remains. How can our
experiences, our angular views, our glimpses of this foundation, this
necessary means of nursing, be conceptualized and shared?

Once while reflecting on the nature of nursing against a background of
notions about intersubjectivity drawn from experience and literature and
testing them against my own real life experiences of nursing, I suddenly
saw that _nursing itself is a particular form of human dialogue_. This
insight occurred to me with clarity, conviction, and all the force of a
brand new idea. It was so obvious, so distinct, so simple, so clearly a
central intuition that could illuminate the phenomenon of nursing from
within. I experienced the idea as fresh and excitingly full of promise.

Yet, when I said it out loud, "Nursing is dialogue," the words seemed
too meager to convey the true meaning of the idea and its real
significance. There was, furthermore, an annoying shadow of familiarity
lurking about it. It was almost as if I had expressed something similar
previously. At first, I hesitated to share this insight with others for
fear they would extinguish it by saying, "of course, everyone knows
that," or "I've heard you say something like that before." Still, I
experienced it as an idea I _had_ to express. Moved by the pressure of
feelings of responsibility and desire to share, in 1973 I wrote a paper,
"The Dialogue Called Nursing." {23}

In retrospect, that paper has the marks of a hesitant beginning,
restrained by cautious statements and supposedly protective references
to existential literature. Dissatisfaction with it prompted further
rethinking and revision. Searching through my files during this process,
I found, to my great surprise, some notes on the dialogic nature of
nursing written by myself three and six years previously. In fact, a
three-year-old note contained the very title, "Dialogue Called Nursing"!
Now, how is it possible to grasp a truth and then "forget" that one
knows it and later meet and grasp the old truth again as new? The
difference in these experiences of knowing, for me at least in this
case, is that now I know as if from the inside out that nursing is
dialogical. The idea seems to have sprouted out of the lived phenomenon,
to have broken forth from the ground of experience, as opposed to having
been concluded in my earlier "intellectual," "theoretical," or
"philosophical" ponderings. But how did the earlier idea, the conclusion
that nursing is dialogical, become a live option for me? Why did it
appeal to me? How did it come to make sense in the first place if not
because of my experience?

The concept and the actual experience revitalize each other. Perhaps
this is the value of an existentially grounded insight; it has a kind of
durability resulting from its continuous rejuvenation by the interplay
of experiencing and conceptualizing. Some old ideas are always new. In
this spirit, this chapter looks again at humanistic nursing as lived
dialogue.


LIVED DIALOGUE

The central insight (intuition or idea) from which this exploration
grows is this: nursing itself is a form of human dialogue. I mean that
the phenomenon of nursing, that is, the nurturing, intersubjective
transaction, the event lived or experienced by the participants in the
everyday world, is a dialogue.

Much has been written about dialogue and, as the word is now in vogue,
it is being used in different ways. Here, the term "dialogue" is used to
denote a broader concept than the typical dictionary definition of
dialogue as "a conversation between two or more persons or between
characters in a drama or novel." It is used in the existential sense. It
implies an "ontological sphere," in Buber's terms, or the "realm of
being" to which Marcel refers. Here it refers to a _lived_ dialogue,
that is, to a particular form of intersubjective relating. This may be
understood in terms of seeing the other person as a distinct unique
individual and entering into relation with him. In other words, nursing
is a dialogical mode of being in an intersubjective situation.

As in common usage, here also, the term "dialogue" implies
communication, but in a much more general sense. It is not restricted to
the notion of sending and receiving messages verbally and nonverbally.
Rather, dialogue is viewed as communication in terms of call and
response. {24}

Nursing implies a special kind of meeting of human persons. It occurs in
response to a perceived need related to the health-illness quality of
the human condition. Within that domain, which is shared by other health
professions, nursing is directed toward the goal of nurturing well-being
and more-being (human potential). Nursing, therefore, does not involve a
merely fortuitous encounter but rather one in which there is purposeful
call and response. In this vein, humanistic nursing may be considered as
a special kind of lived dialogue.


NURSING VIEWED AS DIALOGUE

These considerations of the dialogical character of nursing will be more
fruitful if they are related to some concrete nursing experience.
Reflect for a moment on your daily nursing practice. Recall an
encounter, a specific interaction with a patient (client). Try to
remember the details. Where were you? What time of day was it? Who was
present? What was your state of being--what were you feeling, thinking,
doing? How did the interaction begin? What happened between you? What
was felt, said, done? What was left unsaid, undone? How did the
interaction end or close? How long did the flavor last? Now keep this
concrete instance of your lived nursing reality in mind and let it raise
its questions in the following exploration.


Meeting

The act of nursing involves a meeting of human persons. As was noted
above, it is a special or particular kind of meeting because it is
purposeful. Both patient and nurse have a goal or expectation in mind.
The inter subjective transaction, therefore, has meaning for them; the
event is experienced in light of their goal(s). Or in other words, the
living human act of nursing is formed by its purpose. Its
goal-directedness colors the attributes and process of the nursing
dialogue.

When a nurse and patient come together in a nursing situation, their
meeting may be expected or planned by one or both or it may be
unexpected by one or both. In any case, the goal or purpose of nursing
holds. Even in a spontaneous interaction where they have met only by
chance, in a health care facility or any place where one is identified
as patient and the other as nurse, there is an implicit expectation that
the nurse will extend herself in a helpful way if the patient needs
assistance. If the meeting is planned or expected, this factor
influences the dialogue. Each comes with feelings aroused by
anticipation of the event, for example anxiety, fear, dread, hope,
pleasure, waiting, impatience, dependence, hostility, responsibility.

Another factor experienced in their meeting is the amount of choice or
control either nurse or patient had over their coming together. In
today's complex health care systems, a nurse may be assigned to care for
a particular patient, or for persons in an area or unit, or may be
called into service through a registry, {25} or may be approached
directly by a patient. From the other side, the patient also experiences
varying degrees of control over his meetings with nurses depending on
the system in which the health care is offered, his location, his
financial means, and so forth. So when a patient and nurse do meet in a
given instance, each comes to the situation bearing remnants of feeling
of having caused or not having caused this encounter with this
particular individual. (Of course, even in the most de-individualized
systems the nurse and/or patient can still control their meetings to
some extent, for example, avoidance by the nurse being too busy or
avoidance by the patient feigning sleep.)

The patient and the nurse are two unique individuals meeting for a
purpose. In the existential sense, each of these persons is his choice,
each is his history. Each comes to meet the other with all that he is
and all that he is not at this moment in this place. Each comes as a
particular incarnate being. Each is a specific being in a specific body
through which he affects the other and the world and through which he is
affected by them. This nurse who uses her eyes, ears, nose, hands, her
body, this way here and now meets this patient whose body in this
condition serves him this way here and now.

Furthermore, both the patient and the nurse have the human capacity for
disclosing or enclosing themselves. So they have some control over the
quality of their meeting by choosing how and how much to be open with
and to be open to the other. Their openness is influenced by their views
of the purpose of the meeting. In general, the patient expects to
receive help and the nurse expects to give it. However, their views may
differ on the precise need and the kind of help to be given.

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

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

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


Relating

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

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

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

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

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

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

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

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


Presence

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

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

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

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

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

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

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

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


Call and Response

The dialogical character of nursing may be explored further by
considering it in the general sense of a call and response. Nursing is a
purposeful call and response, that is, it is related to some particular
kind of help in the domain of health and illness. A patient calls for a
nurse with the expectation of being cared for, of having his need met.
He is asking for something. A nurse responds to a patient for the
purpose of meeting his need, of caring for him. The nurse expects to be
needed.

In reflecting on nursing experiences, it becomes obvious that the call
and response in the nursing dialogue goes both ways for nursing is
transactional. Both patient and nurse call and respond. The pattern of
the dialogue is complex. It continues over time, from moments to years,
in an ongoing sequence that either patient or nurse may begin,
interrupt, resume, or end. For instance, {30} the patient turns on his
call light to ask for something. This is not only a call but also a
response to the nurse's previously stated suggestion that he use the
signal if he needs her help. Or again, a nurse may stop and talk with a
patient during a chance meeting recalling that he previously had
expressed feelings of loneliness, boredom, pain, or joy. Also, other
persons or events may interrupt or end a nursing dialogue. For instance,
the nurse is called away to help in another situation, the patient is
discharged on the nurse's day off, the patient expires.

Furthermore, the call and response are not only sequential but also
simultaneous. In this live dialogue both patient and nurse are calling
and responding all at once. The patient's request, for instance, is a
call for help and at the same time a response to the nurse's
availability or offer to be of help. From the other side, the _way_ a
nurse responds to a patient's call is, _itself_, a call to him for a
particular kind of response, a call for his participation in the
dialogue.

Reflect for a moment on your own example. Was your response to the
patient influenced by the value you placed on such factors as his
independence, motivation, rehabilitation, growth, strengths, pathology;
on time, on place; on agency policy? Here again goal-directedness
affects nursing dialogue. Our interpretation of the patient's calls as
well as our responses are colored by the aim of our practice. Our values
are like calls within the calls. Or to state it differently, the values
underlying our practice give meaning to the calls.

Viewing dialogical nursing as a particular form of call and response
highlights its complexity. It reveals the intricacy not only of its
patterns of flow but also of its means of expression. Nursing is a lived
call and response reflective of every mode of human communication.

Much has been studied and written about verbal dialogue between patient
and nurse. Examining verbal exchanges from the perspective of call and
response could uncover even more about this aspect of the nursing
dialogue.

It is more difficult to find written descriptions of nonverbal
nurse-patient communication, although this aspect is generally
recognized to be of equal significance. Here again the call and response
framework could be a useful aid. For instance, what does a nurse's mere
physical presence mean to a patient either as a call or response? Or
from the nurse's standpoint, under what circumstances is a patient's
presence experienced as a call and, even more, as a call for a
particular nursing response? What prompts us to respond in terms of his
posture, his color, his facial expression, his behavior, the appearance
of his clothes? Are we almost unconsciously checking some kind of "vital
signs" in the inter subjective realm?

Nursing dialogue is characterized by the unique feature of occurring
through nursing acts. The dialogue is experienced in what the nurse does
with the patient. A call and response of caring is lived through in
nurse-patient transactions (nursing care activities) from the simplest,
most basic acts of bathing and feeding to the most dramatic
resuscitation. {31}

The nursing act itself contains a meaning for each person in the
dialogue and the meanings may differ (for example, touching and being
touched, feeding and being fed, bathing and being bathed). In addition,
as a behavioral expression, the nursing act conveys a message, a
reflection of the nurse's state of being (for example, anxious, hurried,
troubled, absent, present, fully present). Furthermore, a nursing act
may serve as an occasion, or even a catalyst, for opening or moving the
dialogue in some direction on a verbal level (for example, bathing a
patient may prompt his discussion of his body image or of his fear of
disfigurement).

The complexity of possibilities in this unique feature of nursing
dialogue (occurring through nursing acts) is staggering, especially so
when one considers the additional factors associated with the effects of
technological advances in nursing. Think, for instance, of the influence
on your nursing dialogue of any technical nursing procedure. What
happens between you and the patient when you place a thermometer into
his mouth? Take his blood pressure? Give him an injection? Aspirate him?
Do any form of monitoring, from the simplest to the most complex? Are
the technical procedures and instruments bridges or barriers in the
between?


DIALOGICAL NURSING IN THE REAL WORLD

It is necessary now to look again at dialogical nursing in a broader
perspective, for by limiting the exploration to the nurse, the patient,
and their between, the previous discussion grossly oversimplified the
way the dialogue actually evolves in real life. In the above, it was as
if nursing were a drama acted out by two characters on a specially
designed stage where precisely placed props lay ready to serve the
actors and the passage of time is controlled by the chiming of a clock
or the dimming of lights. As it is actually lived, the nursing dialogue
is subjected to all the chaotic forces of real life. Nursing takes place
in a real world of men and things in time and space. In many cases, it
is a special world, a health system world, within the everyday world.


Other Human Beings

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

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

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

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

>From the other side, the patient also enters into the nursing dialogue
with his various networks of interhuman relationships. How he
experiences his relationships with his family and significant others,
with the patient groups of which he becomes a part in different degrees,
with members of various disciplines and health services groups, with
"the" nurse and "his" nurse, all influence the lived nursing dialogue.
It is always colored by the patient's current mode of interpersonal
relating. Of course, the current mode reflects his past, for example,
learned habits of response, and his future, for example, concerns about
anticipated changes in interpersonal relationships due to the effects of
his illness. In some cases, the intersubjective behavior itself becomes
the focus of the nursing dialogue as the area of the patient's greatest
needs in attaining well-being and more-being.


Things

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

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

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


Time

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

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

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

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

When we speak of a nurse and a hospitalized patient spending a day
together, we usually are referring to eight hours out of a 24-hour day.
They may both experience the spacing of this time by functions or
activities such as meal time, medicine time, visiting time. Yet the
measured minutes and hours are experienced differently by each in their
different modes of being in the situation. Nurses often express feelings
of not having enough time to give the care they want to give; of having
too many demands on their time; of trying to "make time" for patients
who ask "do you have a minute?" Patients live their time in relation to
boredom, pain, loneliness, separation, waiting. The nursing dialogue
runs its course in clock time but both nurse and patient live it in
their private times.

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


Space

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

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

Place is a kind of lived space. It is personalized space. One says, for
example, "Come to my place" meaning to my home. Or even more personally,
it relates to where I feel I belong or am, for instance, "he put me in
my place; I felt put down." The patient may feel "out of place" in the
health care setting, while it may be commonplace to the nurse. There may
be areas in the setting that the patient experiences as his territory,
for example, his bed, his room, his ward; while other areas are "theirs"
or "restricted to authorized personnel." So a nurse and a patient may be
in a place together, yet one feels at home and the other does not. For
the nurse to be really _with_ the patient involves her knowing him in
_his_ lived space, in his here and now.

Lived space is interrelated with lived time. Patients hospitalized for a
long time often express a proprietary attitude toward the hospital. The
same holds true for personnel. With time and familiarity a feeling of
reciprocal belongingness grows. The person belongs in the place and the
place belongs to the person. On the other hand, when a person finds
himself in a new place he may feel the discomfort of not belonging. This
is as true for the nurse in an unfamiliar setting as for the patient.
Again in this regard, the lived nursing dialogue is enhanced by the
nurse's awareness of not only her own experience of space but the
patient's as well.


CONCLUSION

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

As scientific advances multiply in the health field, nursing is swept
along in the tide. Continuous technological changes, ever increasing
specialization, emphasis in nursing education and research on scientific
methodology all have marked influence on the development of nursing.
Science (with a capital S) colors the nursing world. At every turn it
permeates the nurse's being with and {36} doing with the patient. It
offers a certain security by providing a consistent and effective
approach to some problems and questions, and, in some cases, results in
general laws to guide practice. At the same time, in the lived nursing
world the nurse experiences a reality that is not open to the scientific
approach, a reality not always verifiable through sense perception, a
reality of individuality. The uniqueness of individuality (her own as
well as the patient's) pervades the nursing dialogue.

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

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

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



4

PHENOMENON OF COMMUNITY


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


MY ANGULAR VIEW

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

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

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

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


HISTORY: THE SHADES OF MY WORLD, BRACKETED

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


EACH NURSE: A _NOETIC LOCUS_[2]

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


NURSE: EXPERIENCE INTERNALIZED

Nursing experience taught me that each man, each family, each community
was at once alike and different. Hesse, an existential novelist, in
_Steppenwolf_, {40} describes each man who has become in family and
community as like an onion with hundreds of integuments or a texture
with many threads.[4] Then man's differences would be in the quality of
his integuments and their development or in his threads in their
preponderance. Contemplating the struggles in community regarding mutual
understanding, I expanded Hesse's conception of man and found my vision
of community to be a salad tossing or a patchwork quilt tumble drying.

Valuing the complexity of this conception of man and therefore of
community I find myself smiling at the naivety of the earlier more
static frames of order I superimposed on these phenomena. These
oversimplifications maintained the shade through which I viewed my
world. The shade was: others are knowing places, they are responsible;
therefore if I quote authority from outside of myself, I can speak with
certainty about what I know and believe and no one can attack me. And
yet, my unique knowledge was not given and so my defense, my clutching
at security foiled my human need for conceptualization of and expression
of my own nurse vision of reality. This defeated the development by me
of nursing theory.

Now I realize how I underestimated the potentialities of my nursing
effect, of the difference I made, and could make. Just consider the
given human uniqueness of each participant in the nursing situation
whose familial potential goes back to an origin of thinking being or
consciousness, and forward to his anticipation of the future, his
eternity.

In the nursing literature, it is rather infrequent that we
philosophically share our innermost thoughts, dreams, ideals, and
strivings without a strong overlay of indoctrination or conversion.
Nietzsche presents philosophy as autobiographical, such sharing does not
offer maps. It could offer relevant resources and stimulate other nurses
to influence the shape and becoming of the profession.

This chapter attempts to discuss ideas of community, the macrocosm, by
considering man, the microcosm, as he develops in family and community.
The ideas represent my "here and now" as it reflects my past and
anticipated nursing world, including my hopes and expectations.


Man's Experience

Each human being carries a view of persons, families, and communities
shaded by the views of his nuclear family. The past usually is
corrected; it is never erased. So in his family of origin man
internalizes ideas of "right-wrong," "appropriate-inappropriate,"
"expected-unexpected." Each family's shaded world echoes its
procreators' familial, psychosocialeconomic, religious and experiential
breadth, closely resembled or distorted. Two persons, perhaps more,
usually husband and wife, bring shaded views together in some
combination or balance that becomes the "stuff," the authority, of {41}
their children's worlds. Thus, children see their early worlds through
the complementariness and conflict of this initial home view, acting at
times with it; at times against it.

Adults, in response to and through one another, procreate new sensitive
beings whom they want and/or do not want and whom they may and/or may
not experience as their responsibility in varying degrees. Marcel, a
French existentialist philosopher, views procreation and responsible
parenthood as quite different. My past nursing experience substantiates
this. Marcel expresses my bias about responsible parenthood, and this
statement is also worthy of consideration by nurses in positions of
authority to others. He says, "We have to lay down the principle that
our children (or those for whom we care) are destined, as we are
ourselves, to render a special service, to share in a work, we have
humbly to acknowledge that we cannot conceive of this work in its
entirety and that _a fortiori_ we are incapable of knowing or imagining
how it is destined to shape itself for the young will, it is our
province to awaken to a consciousness of itself."[5] Think of this
statement of responsible authority. How has it been evidenced in
families and nursing situations of your nursing world? What are your
expectations of your patients or nurses with whom you work?

Teilhard de Chardin, paleontologist, biologist, and philosopher, like
Nietzsche, depicts man as lacking a fixed nature with his own mode of
being as his fundamental project.[6] Initially, each person takes on a
mode of being in his world dependent upon his degree of freedom and the
how and what of the world as presented by his family and perceived by
him. The world as presented is reflective of the family's culture, their
provincial world view, their unique experienced "here and now," and the
times. Metaphorically, the family's lived world, how they experience at
this particular cross-section of their lives, can be symbolically
described as a kaleidoscopic telescoping of its past and anticipated
future. Now, this would be what was presented at any particular time.
What would a child's perception do to this metaphorical symbol? The
child's current human development and his narrow experience would be
like a circus house mirror that would interpret the metaphorical symbol
distortedly. Witness a three-year-old speaking questioningly and
complainingly about her tension headache to her mute, nonperceptive
doll, and asking her to please, please stop making such a mess and
racket.

The earliest childhood views of family and community are influenced over
time, gradually and abruptly, and grow in complexity. The child's
puzzlement is aroused by others' comings and goings, happenings within
the family, immediate neighborhood, and adjacent community, and the
world presented through books and technologically, on radio, television,
and tape recorder. Each child attends these presentations with varying
measures of complacency, questioning, bafflement, and involvement.

{42}

For instance, for myself, as a child there was the excitement of the
construction of a new house in the woods next door and meeting new
neighbors. Initially my parents expressed their differences from
ourselves. The differences they perceived were followed by negative
projections on these unknown folk. Were these others really humanly
different? I investigated; my family investigated. The folk became
persons. They expressed themselves differently in volume and sometimes
in language. They looked different. Yet they were not fearsome. They
felt, cared, responded, and worried much as we did. Mutual knowledge
allowed increasing closeness and liking.

Forbidden! This was the neighborhood across the tracks. I cried when an
uncle teasingly proclaimed one day that my missing mother was over
there. Later I attended school with both white and black children who
lived over there. And again, each was different, yet not different; each
was knowable, likeable, and loveable.

Adult family members whispered about a neighbor woman from across the
street. She was apparently hospitalized permanently. When I inquired as
to why, eyebrows were raised and strange looks were exchanged. I was
told in a not believable way, "She broke her leg falling off the back
porch."

A neighbor husband and wife frequently could be heard fighting both
verbally and physically. Family talk at our house depicted the husband
as "evil," the wife as a "poor soul." I did not enjoy being in these
peoples' house. Perhaps the violence frightened me; perhaps I was
uncertain when it might erupt? Perhaps I was concerned that I might one
day somehow become part of such a situation? Now, looking back over the
years, I would guess that both this husband and wife were "poor souls"
struggling with their humanness as best they could.

An adolescent girl lived down the block. She was labeled as "strange,"
"peculiar," "odd," "crazy." Often one saw her talking to herself,
skipping and rotating as she moved along in her always solitary and
mysterious way. All expressed great sorrow for her always solitary and
mysterious way. All expressed great sorrow for her elderly mother and
father on her admission to the "State Hospital." Years later I wondered,
and still wonder what happened to that girl, herself? What kind of an
existence has she experienced?

During these early years there was also separation from and loss of
close loved family members. When I was three and a half a great aunt who
always appreciated my side of things moved out of our home due to a
family argument. Perhaps most confusing of all during these preschool
years, at four and a half, my father died suddenly. "They" said that he
went to heaven, that God called him. Why did he go? Why would he leave
us? Most important how could he leave me? What had I done wrong? Was it
that I had not loved him enough? Been good enough to him? Was he angry?
What kind of God is God, anyway? Is he benevolent, malevolent,
indifferent? Is he real: is he believable? What can one expect and how
should one act toward authority and power? The world didn't feel like a
very safe place nor did persons appear to be dependable.

Then there was school. With additional authorities and peers there arose
new wonderment and expectation. The way one was to be in school was
{43} different from at home. And what was happening at home while I was
at school? Could I depend on things being safe? In kindergarten I made
an ash tray of clay for my already dead father.

In my child world there were books, radio, and the movies. Today
children experience these, as well as television and record players. For
me, books, radio, and the movies brought into my world new aspects of
fear, excitement, joy, love, horror, violence, imagination, and
suspense. They depicted at times the ideal and at times the abysmal.
Sometimes, despite everything, good triumphed. At other times regardless
of the effort invested all was lost. Where was the harmony of logical
reason? Is our world absurd? Are we absurd to respond to it with an
expectation of reason?

For each child there are very special, long-remembered events: being
taught to swim by one's father, family picnics, trips into the world
beyond city or country, going to the circus, a world's fair, a zoo or a
fantasy land. There, also are the events of being loved and loving
deeply, linked somehow with times of feeling unloved and unloving.

More than earlier, today there are multiple community groups for
children where activities are guided and supervised. Within these
situations and in the free play of neighborhood children, there is
always the confusing, enlightening, and frequently distorted information
gained through discovering your relationship with both boys and girls.
Exploration by children into their sexual similarities and differences,
a healthy pursuit, in the past more than today often aroused parental
furor. Furor and different reactions from different involved parents
lead to further child confusion and focus.

Within childhood peer relations there are games, play, and schoolwork
that allow the child to come to know personally the meanings and
feelings of competing, collaborating, fighting, winning, losing,
destroying, building, aggression, passivity, constriction, freedom, and
choice.

Then there is adolescence with all its moodiness, questions, fears, and
experimenting related to adult modes of being. The moods are a mystery
and the questions often unanswerable or the answers contradictory.
Norman Kiell in _The Universal Experience of Adolescence_ says that as
adults we forget the intensity, turmoil, and concretes of this period
and that perhaps we have to.[7] Yet, it is not possible that the
instability and discomfort of spirit lived in adolescence does not leave
its ingrained tracing as part of our eternal presents.

When the focus of our responsibility shifts from play to work, during
these early years of becoming, depends on our particular circumstances
and abilities. For most persons there is a tipping of the balance
between these. Hopefully neither extreme is the master. Fortunately, in
many instances, as the child's work as been to play; the adult's work
world, his world of responsibility is lived, experienced by him, to an
extent as play--it gives satisfaction and pleasure.

{44}

Some adults select another and are chosen by this other for a sharing of
their worlds. Some go it alone. Some procreate new beings; some create
in other ways; some give-take and exist; some just lean. These last
appear to be, and yet to not be, "all-at-once."


MAN BECOMES EVER MORE

Buber perceives man becoming more through his human capacity to relate
to other being in all forms from the materialistic to the spiritual in
"I-Thou," "I-It," and "We" ways.[8] Gestation, with the closeness of
mother and child, has left man with an ingrained knowing of the
experience of closeness. Thus, throughout man's life his condition of
existence is affected by and desires relationship with and closeness to
other being. The closeness of the conditions of gestation is never again
possible, hence existential loneliness. Yet because of this prenatal
experience Buber conceives of man as born with a "Thou"--another--before
he is conscious of himself, his "I." With growing consciousness he sorts
out his "I" from his "Thou." You can see the late infant doing, acting
through, this separation. During this growing phase, often to the
care-taking adult's frustration, he repeatedly, intensely, and excitedly
throws his toys or bottle out of the crib, carriage, or playpen. Often
he runs away from his "Thou," his parental security source, to a safe
distance with intense awareness of what he is doing. While internalizing
these and subsequent "Thous" as part of his "I," his knowing place,
paradoxically, he sorts out who he is, and who and what is other than
himself. So with ever more relationship, ever more experience, he
becomes ever more the person he has the human capacity to be. He becomes
more through his relations with others, never the same as these others,
though he does internalize these others as part of himself.

Buber describes "I-Thou" relating, man merging with otherness, as always
necessitating an "I," a man, capable of recognizing self as at a
distance, apart from otherness. Therefore, his "I-Thou" relating, a
merging of beings, is not like the psychological defense, unconscious
identification. Buber's "I-Thou" relating emphasizes awareness of each
being's uniqueness without a superimposing, or a deciding about the
other without a knowing. Such relating is a turning to the other,
offering the other authentic presence, allowing the authentic presence
of the other with the self, and maintaining one's capacity to question.
It is not then identification or an idealization of the other. Within
this mysterious happening of "I-Thou" relating, when both participants
are human, each becomes more. Buber refers to the event of this merging
of otherness, of man with other being, as "the between." Humanistic
nursing is concerned with "the between" of nurses and their others.
Their others, the {45} microcosms of their communities, would be
patients, patients' families, professional colleagues, and other health
service personnel.

Buber describes man's ability to come to know and relate in "I-It" as
man looking back, reflecting on his past "I-Thou" relations. Looking
back these "I-Thou" relations are viewed as an object to be known, as
"It". "I-It" relating allows man to interpret, categorize, and accrue
scientific knowledge.

Finally man relates with others as "We." This permits the phenomenon of
community and of adult unique contribution. So man becomes through
relating with family, others, and community, like Hesse's onion or a
being who actively moves toward ever more integuments, qualities,
threads, and complexity.[9] Many unique contradictory type beings, then,
have influenced the becoming of each individual human person. In a sense
each unique person might be viewed as a community of the beings with
whom he has meaningfully related in struggle and/or complementariness.
In fact Buber talks of thinking man as a dialogue of internalized
"Thous."


COMMUNITY: NURSING

If each man can be likened to a community of his internalized "Thous,"
logically think of the outcome of many men struggling together
supposedly for a common purpose. Since time began, man in community has
been experienced by man as chaotic. Thus Plato wrote _The Republic_.[10]
This presentation depicted an impossible scheme for developing an ideal
community. As a classic, _The Republic_ continues to be a thought
provoking thesis. Its antiquity makes one realize that this desire to
control, our continued concern with genetic planning, is a part of the
very nature of man. And yet, considering man's ever existing recognition
of the chaos of community how naive we often behave, for example,
enraged at experiencing _another_ communication break.

Plato envisioned regulating and controlling almost every dimension of
the individual's existence in accordance with his particular potential
for development to fulfill the needs of his ideally conceptualized
community. Today Heinlein, a science fiction novelist, still writes of
breeding for longevity in man, as we breed animal stock for the greatest
amount of meat and profit.[11] Giving Plato his due, he recognized at
the end of his book concern and doubt as to whether men so carefully
mated and reared would fulfill their designated responsibilities. He
wondered if things could, would, or would not go in accordance with his
plan. He then logically indicated the process and kinds of community
deteriorations which could ensue. Plato had a concept of an ideal
community, of ideal types of necessary men, and of ideal male-female
breeding relationships. He viewed our present-style family as one that
saps the {46} strength of community and does not support this concept.
He conceived of communal living more like the communal living of our
present-day communes. However, Plato's communes would have been
regulated by the plan as he conceived it. Existence in these communes
was to be predetermined and very determined.

Nursing, though not generally the ruling force of this type of planning,
certainly is involved in control measures analogous to Plato's. Nurses
do influence who gets the hospital bed and who does not, who gets the
specialized treatment and equipment, who is discharged and when, and
what goes into the education and planning for post-hospital health care.
Also, how do our biases influence our teaching regarding family?
Innuendoes are frequent in the areas of birth control, abortion, and
family size. So nurses can make a difference regarding community
thought, purpose, and action.

Nietzsche put forth a concept of community of a more indefinite nature
than Plato's.[12] Two major themes dominated the nature of community in
his conception: (1) the legitimate purpose of community was the total
support of its elite men and (2) the criterion for determining the elite
was to be based on those who selected their own values with a "will" to
say, "yes" to life. He referred to his elite as supermen. He questioned
the realization of such a community because of the preponderance of
conforming nonquestioning mediocre men. This complacent majority fearful
of the different or strange would subdue the possibility of his
supermen. Nietzsche did not seem to trust man; he spoke of him as
"human, all too human." Unlike Plato, Nietzsche viewed "good" and "evil"
as arising from a common source. Man in his humanness, Nietzsche felt,
denied his animal heritage and animal qualities. Recognition of these,
of one's Dionysian nature, as a source of both "good" and "evil" was
necessary for becoming superman.

To me it is wondrous to ponder my own conscious purposefulness and
unconscious purposelessness, my quality of force as a member of the
nursing and health communities, viewed through the deep extensive
conceptualized thought Nietzsche bequeathed. I offhand consider our
communities as egalitarian, part of a larger egalitarian society. Are
they really? Does the citizen affect the quality of organizational
structure in accordance with his existential needs while in our
commonplace--the health-nursing world? Whose values set and direct on
this stage of life? Do I, nurse, search out the values on which I want
to base my nursing practice? Do I look for direction and values from
others? Did I take on values during my initial nursing experience--values
never to be reexamined?

Within the nursing community are there nurses eagerly noncomplacent and
desirous of looking at, of sharing their explorations, and of
determining and choosing the values that they want to underlie their
nursing practice? {47} Would supernurses be allowed to be the mediocre
many? Who would determine the elite of the nursing community? Could
supernurses survive without approval of their being different? Would
they be strengthened by the fruits of suffering in their struggle within
the profession? Would these fruits of suffering contribute
constructively to the strengthening of the nursing community?

Buber, like Nietzsche, sees man-in-community with possibilities for
evolving, being, and becoming more. Buber trusts each man as a unique
potential involved in an ongoing struggle with his fellows directed
toward a center.[13] His nonstatic, nonselected community where men
become in and through ongoing struggle with each other expresses the
reality of my nursing world. Who would expect a community without
struggle if they accepted each man as his history inclusive of
antecedents that go back to beginnings of man's consciousness and of
anticipations that go forth into this man's notions of eternity?
Considering the complexity of each man's being and becoming, it is
surprising that we come to understand each other in community at all,
rather than the reverse.

How can we hope for a sustained thereness, presences of nurses with
other man (patients, patients' families, professional colleagues, and
other health service personnel) as "We" in an ongoing struggle of
community considering their multitudinous differences? Norman Cousins,
in _Who Speaks for Man_, comments on man's inability to respond
affirmatively to those he experiences as different from himself.[14] For
the human community to progress he suggests federation. A unity in which
differences would be valued as promoting thought, human evolvement, and
community advancement. Cousins gives examples of man's inhumanity to man
based on differences viewed as nonvalues. The prevalence of this latter
view of differences is very evident in our commonplace health-nursing
world. Can nurses and other health care maintainers look at the ways
they respond to differences consciously, and can they deliberately
choose to be open to responding to them as valuable? Can we conceive of
there being value in that which we see as "not right," "untrue,"
"wrong?"

The ability to be there, to stay involved in community with my fellows,
is a problem worthy of concern to me as a nurse. How do I stay in an
existential way with my contemporaries, patients, patients' families
when their values in reality are so different from my own? How do I go
beyond a negative judgmental to a prizing attitude that would open the
possibility of seeing strengths in others' views perhaps lost,
discarded, or never previously existent in my own? Nonsuperimposing of
my own value system through recognizing and bracketing it is a difficult
professional goal. And yet, a goal that if coupled with the courage for
personal existence, could sustain me in the health-nursing community.
{48}

So for a health-nursing community to truly be actualized each nurse
would prepare to be all it was possible for her to be as a nurse. Then,
through exploration there would be a recognition of the reality of the
existent community. Over time a merger of the values of the nurse and of
the existing community would be reflected as moreness in each. The nurse
would be more through her relation with the community; the community
would be more through its relation with the nurse. Each would make an
important difference in the other. The macrocosm, the community, would
reflect the nurse's quality of presence. The microcosm, the nurse, would
reflect the presence of the community with her. Each unique man becomes
in community through communication with other uniquely different men.

FOOTNOTES:

[1] Plato, _The Republic_, trans. Francis MacDonald Cornford (New York:
Oxford University Press, 1945).

[2] Wilfrid Desan, _Planetary Man_ (New York: The Macmillan Company,
1972).

[3] John Hersey, _A Single Pebble_ (New York: Alfred A. Knopf, 1956), p.
18.

[4] Hermann Hesse, _Steppenwolf_ (New York: Holt, Rinehart and Winston,
1966), p. 60.

[5] Gabriel Marcel, _Homo Viator_ (New York: Harper & Row, Publishers,
Harper Torchbooks, 1962), p. 121.

[6] Teilhard de Chardin, _The Phenomenon of Man_ (New York: Harper &
Row, Publishers, 1961).

[7] Norman Kiell, _The Universal Experience of Adolescence_ (New York:
International Universities Press, 1964), pp. 22-44.

[8] Martin Buber, _I and Thou_, 2nd ed., trans. Ronald Gregor Smith (New
York: Charles Schribner's Sons, 1958).

[9] Hesse, _Steppenwolf_, p. 60.

[10] Plato, _The Republic_.

[11] Robert A. Heinlein, _Time Enough for Love_ (New York: G. P.
Putnam's Sons. 1973).

[12] Frederich Nietzsche, "Beyond Good and Evil," trans. Helen Zimmern,
in _The Philosophy of Nietzsche_ (New York: Random House, 1927) and
"Thus Spoke Zarathustra." trans. Thomas Common, in the _Philosophy of
Nietzsche_ (New York: Random House, 1927).

[13] Martin Buber, _Between Man and Man_, trans. Ronald Gregor Smith
(Boston: Beacon Press, 1955).

[14] Norman Cousins, _Who Speaks for Man?_ (New York: The Macmillan
Company, 1953).

{49}

Part 2

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.

{64} {65}


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?

{67}

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]

{73}

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:

{74}

     "... 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.

{75}

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.

{76} {77}

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.

{85}



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.

{87}


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.

{90}


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.

{94} {95}

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.

{106}

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

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


A Clinical Work Consultation Experience

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

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





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