Humanistic Nursing Part 3

Viewed existentially, every nursing event is unique, a live intersubjective transaction colored and formed by the individual partic.i.p.ants. Although the event is ephemeral, the resultant experiential knowledge is lasting and c.u.mulative. 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 s.p.a.ce. 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 s.p.a.ce (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 s.p.a.ce. More specifically, from an existential perspective, the focus would be directed toward the significance of lived time and s.p.a.ce, that is, time and s.p.a.ce 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 s.p.a.ce in a wheelchair, crutchwalking, pacing, could be considered from the standpoint of the patient's experienced s.p.a.ce 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.

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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 s.p.a.ce (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 const.i.tuent 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 t.i.tle, "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 partic.i.p.ants 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