FOREWORD to the 1976 Edition

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

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

Nursing has a solitariness until we find it has many companions inphilosophy, science, and art. It has a steadiness about its pace yetholds a potential for flights to higher elevations. It is constantlychanging yet has an enduring component of permanence. Good is the wordwe use every day; our vision, however, is of excellence. Its tasksoften have the appearance of homeliness until we glimpse that kind ofbeauty that is humanness. Nursing even sings very softly because ourears 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 theculture in which it exists. In our culture for the past quarter of acentury nursing has been assailed with rapid economic, technological, shortage- abundance, changing scenes' vicissitudes. In the individualnurse these arouse turmoil and uncertainty. These cultural stirringsinflame that part of the nurse's spirit capable of chaotic conflict anddoubt. Often she questions her professional identity. ''Just what is anurse?" Her nurse colleagues, other professionals, and nonprofessionalsfreely, directly and indirectly-on television, in the theater, throughthe news media and the literature-pummel her with their multitudinousvaried views. 

As searching, wondering, reflecting, relating microcosms within thisperplexing 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 livedexperiences. These metatheoretical essays on practice present anexistential alternative approach for a professional nurse's knowing andbecoming. 

These conceptualized existents are available because Miss MargueriteL. Burt, formerly Chief of Nursing Service, Northport, N. Y. VeteransAdministration Hospital called them forth from us. These chapters areour response to her call. In 1972 Miss Burt requested us to develop acourse for the professional nursing staff at Northport V. A. H. This bookhas evolved from the original presentations offered to the tenparticipants in the first course. While we taught and worked with fivesubsequent groups, we learned and continually revised and clarified ourconceptualizations. The course is entitled Humanistic Nursing. 

Fifty-three nurses have been involved in this course. Interest, appreciation, wonderment, effort, and investment characteristicallydepict their response. They convey that the humanistic nursing practicetheory reflects what nursing means to them. Their hungry approach to thesuggested readings has both surprised and pleased us. Our amazementpersists over the participants' ability to concentratedly discussabstract theory and concrete nursing practice for weekly day-longsessions over six-to nine-month periods. Presently requests toparticipate in the next humanistic nursing course are mounting fromnurses both within and outside the Northport complex. 

The course, the theory, and this book are the fruits of our individualand collaborative efforts. While sharing seminar responsibility forgraduate students in 1960, we began to dialogically and -dialecticallystruggle with professional and /clinical nursing issues. Discussing andsearchingly questioning ourselves and our students became avalue. Through conveying, struggling for clarification, openness tohonest argument, we grew in our awareness that each was moved beyond herbeginning 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 tellus of our chosen area-nursing. So dialectical dialogue has graduallybecome our predominant teaching method. We convey our ideas, are open toothers' questions, struggle to clarify and really communicate, andquestion ourselves, and others. In the process of the humanistic nursingcourse, using this methodology, which is deliberate and, yet, naturaland authentic for us, we and our professional nursing staff studentshave learned and become more human, more questioning, more clinical, andjust, more. 

We value our moreness. Appreciating and valuing the effects of ouractualizing selves as human beings, we must attest to our existentialmodes of nurse being; our inner mandate is: share. Hence, HumanisticNursing 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. Ourreflections on nursing as a lived experience flowed into the realm ofmetanursing. Obviously, these thoughts are only a beginning. They areoffered in the hope of stimulating response and further development. Dialogue may be difficult at first because humanistic nursing representsone of our discipline's less articulated streams. Yet, it is a streamtraceable to nursing's foundation and, as such, is related to nursing'sartistic, 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 nursingapproach does not reject advances in nursing technology, but rather ittries to increase their value by viewing their use within theperspective of the development of human potential. The same holds truefor scientific, artistic, and clinical developments in nursingpractice. They are the necessary means through which and in whichhumanistic nursing (a being and doing) is experienced and developed. 

At this time when serious concern is being expressed about the survivalof nursing as a profession, humanistic nursing offers a note ofoptimism. By examining the values underlying practice, it focuses onthe meaning and means of nursing's particular' mode of interhumancaring. It increases respect for that caring as a means of humandevelopment. Nurses have the privilege of being with persons who areexperiencing all the varied meanings of incarnate being with men andthings in time and space in the entire range from birth to death. Theynot only have the opportunity to co-experience and co-search withpatients the meaning of life, suffering, and death, but in the processthey may become and help others become more-more human. 

Beyond this, the humanistic nursing approach respects nursing experienceas a source of wisdom. By describing and conceptualizing the phenomenaexperienced in nursing situations, nurses could contribute to thedevelopment of nursing as a discipline. Even more, they could add to theknowledge of man. 

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

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

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

J. G. PL. 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 startof 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 tosuffer the oppression of the current South African regime; and the worldwill continue to be less than it could be. To cry aloud when there seemsno chance of being heard, belies a hope--perhaps an inherently humantrait--that someone, somewhere, somehow will hear that cry and respondto it. 

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

There is power in the call of one person and the potential response ofanother; and incredible power when the potential response becomes real. There is the power for each person to change as she becomes more thanshe was before the dialogue. There is the power to transcend thesituation as two people engage the events that are whirling around themand together try to make sense of their worlds and find a meaning totheir existence. When the call and response between two people is ashonest as it can be, there is the revolutionary power which the poetMuriel 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 andpatient has great power--the power to change the lived experiences ofboth patient and nurse, to change the situation, to change the world. Itis the same authenticity we search for in relationships with our friendsand lovers. The person who really listens to what we are saying, whoreally tries to understand our lived experiences of the world and whoasks the same from us. When found, it brings the same exhilaratingfeeling of self-affirmation and the comforting feeling of well-being. 

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

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

Nurse educators who seek such authentic exchanges with their studentsenjoy similar moments. The same can be said of deans of schools ofnursing, administrators of delivery systems, executives and staff ofnursing and professional organizations, and colleagues on a researchproject. It is the authentic dialogue between people that makes anyactivity worthwhile regardless of whether or not it is called successfulby others. 

When Josephine G. Paterson and Loretta T. Zderad first published theirbook _Humanistic Nursing_ in 1976, society was in the midst of the newwomen's movement and nurses were going through the phase ofassertiveness training, dressing for success, and learning to play thegames that mother never taught us. Since then, nurses have moved intomany sectors of society and have held power as we have never held itbefore. 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 toarticulate a vision clear enough so that others will join us. Thisre-issue of Paterson and {v} Zderad's classic work will help to remindus of another way of developing our power. Perhaps we can, once again, look for and call for authentic dialogue with our patients, ourstudents, and our colleagues. Paterson and Zderad are clear in theirmethod: discuss, question, convey, clarify, argue, and reflect. Theyremind us of our uniqueness and our commonality. They tell us that it isnecessary to do with and be with each other in order for any one of usto grow. They help us celebrate the power of our choices. 

Is it ironic and fortunate that _Humanistic Nursing_ should be re-issuednow 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 secularreligion. 

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

We have many choices before us: to adopt the values of commerce andredesign health care systems accordingly; to accept competition as themodus operandi or insist on other measures for people in need; to decidewho 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 buyersand sellers, providers and consumers; and turn back to an exchangebetween two people trying to understand the space they share. Perhaps itis time for a shared dialogue with patients for whom the questions aremost vital? Perhaps we need to hear their call and respondauthentically. Perhaps they need to hear ours? For only then, asPaterson and Zderad have made quite clear, will our lived experiences inhealth 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 BerniceJohnson 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. JoanGoulianos. 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 32 Foundations of Humanistic Nursing 113 Humanistic Nursing: A Lived Dialogue 214 Phenomenon of Community 37

PART TWO

METHODOLOGY--A PROCESS OF BEING 49

5 Toward a Responsible Free Research Nurse in the Health Arena 516 The Logic of a Phenomenological Methodology 657 A Phenomenological Approach to Humanistic Nursing Theory 778 Humanistic Nursing and Art 859 A Heuristic Culmination 95

Appendix 113Glossary 121Bibliography 123Index 127

{1}

Part 1

THEORETICAL ROOTS

{2} {3}

1

HUMANISTIC NURSING PRACTICE THEORY

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

Concisely, humanistic nursing practice theory proposes that nursesconsciously and deliberately approach nursing as an existentialexperience. Then, they reflect on the experience and phenomenologicallydescribe the calls they receive, their responses, and what they come toknow from their presence in the nursing situation. It is believed thatcompilation and complementary syntheses of these phenomenologicaldescriptions over time will build and make explicit a science ofnursing. 

HUMANISTIC NURSING: ITS MEANING

Nursing is an experience lived between human beings. Each nursingsituation reciprocally evokes and affects the expression andmanifestations of these human beings' capacity for and condition ofexistence. In a nurse this implies a responsibility for the condition ofherself or being. The term "humanistic nursing" was selectedthoughtfully to designate this theoretical pursuit to reaffirm andfloodlight this responsible characteristic as fundamentally inherent toall artful-scientific nursing. Humanistic nursing embraces more than abenevolent technically competent subject-object one-way relationshipguided by a nurse in behalf of another. Rather it dictates that nursingis a responsible searching, transactional relationship whosemeaningfulness demands conceptualization founded on a nurse'sexistential awareness of self and of the other. {4}

EXISTENTIAL EXPERIENCE

Uniqueness--Otherness

Existential experience infers human awareness of the self and ofotherness. It calls for a recognition of each man as existing singularlyin-his-situation and struggling and striving with his fellows forsurvival and becoming, for confirmation of his existence andunderstanding of its meaning. 

Martin Buber, philosophical anthropologist and rabbi, expressed artfullythis 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 projectwhich is himself-in-his situation. This awesome and lonely humancapacity for choice and novel evolvement presents both hope and fear asregards the unfolding of human "moreness. " Uniqueness is a universalcapacity of the human species. So, "all-at-once, " while each man isunique; paradoxically, he is also like his fellows. His very uniquenessis a characteristic of his commonality with all other men. 

Authenticity--Experiencing

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

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

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

Moreness--Choice

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

Man has the inherent capacity to respond to other man as other man. Onlyeach unique nurse faced with the chaos of her alternatives in asituation can then choose either to relate or not to relate and how torelate in-her-nursing-world to others. Choosing to and how to relate orrespond cannot be superimposed on man from the outside by another. Aperson, to a degree, can be coerced to behave outwardly in a certainway. For example, physically, in a spatial {6} sense, a nurse can beordered into parallel existence with another. Being existentially andgenuinely present with another is different. This human mode of being ischosen and controlled by the self. It takes responsible self-orderingthat 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 personthat such presence is of value and makes a difference in a situation. Ifit 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 betweenpersons. Consider the literary works that have conveyed or reflectedthis 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 havetried to share their experiences; some have not. And, there are thosewho are not genuine presences in the nursing situation. One wonders ifthis has influenced the distinctions nurses have made over the yearswith certainty when considering their nurse contemporaries. Often onehears, "she is a good nurse, a natural. " These positive critics areoften up against it when asked, "why, how, what?" Descriptive literaryconceptualizations of nursing that reflect this quality of nurse-being(presence, intersubjectiveness) call for nurses willing to search outand bring to awareness, the mysteries of their commonplace, theirfamiliar, and to appreciate the unique ideas, values, and meaningsfundamental to their practice. Conceptualization of these qualities bypracticing nurses is basic and necessary to the development of a scienceand an actualized profession of nursing. 

PHENOMENOLOGICAL DESCRIPTION

Phenomenology directs us to the study of the "thing itself. " Theexistential literature, descriptions of what man has come to know andunderstand in his experience, has evolved from the use of thephenomenological approach. In the humanistic nursing practice theory the"thing itself" is the existentially experienced nursing situation. Bothphenomenology and existentialism value experience, man's capacities forsurprise 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 livedexperiences and their own experiential-educational histories make "thebetween" of the nursing situation unique. Through in-touchness withself, authentic awareness and reflection on such experiences the humannurse comes to know. Humanistic nursing practice theory asks that thenurse describe what she comes to know: (1) the nurse's uniqueperspective and responses, (2) the other's knowable responses, and (3)the reciprocal call and response, the between, as they occur in thenursing situation. 

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

There are many reasons. Philosophically and fundamentally the reasonrelates to how humanistic nursing perceives the purpose and aim ofnursing. It views nursing as the ability to struggle with other manthrough peak experiences related to health and suffering in which theparticipants in the nursing situation are and become in accordance withtheir human potential. So, like Elie Wiesel, the novelist, who states in_One Generation After_ that he writes to attest to events of humanexistence and to come to understand, humanistic nursing proposes thathuman forms of existence in nursing situations need attestation and thatthrough describing, nurses will understand better and relate to man asman is. Thus the profession of nursing's service contribution to thecommunity 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 innursing situations will affect (1) the quality of the nursing situation, (2) man's general knowledge of the variation in human capacity forbeingness, and (3) the development and form of the evolvement of nursingtheory and science. 

How Can Nurses Begin to Describe Humanistic Nursing Phenomenologically?

The process of how to describe nursing events entails deliberateresponsible, conscious, aware, nonjudgmental existence of the nurse inthe nursing situation followed by disciplined authentic reflection anddescription. 

There are obvious common lived human experiences which if considered andwondered about, can advance a nurse's ability for phenomenologicaldescription. 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 analyticallyinterpreted, labeled, and dismissed. Examining, reexamining, mullingover, brooding on, and fussing with the situational context of theseexperiences as nonlabeled, raw human lived data can yield {8}knowledge. Knowledge of the nurse's and her other's unique humanexistence in their on-going struggle becomes explicit. Superficialtreatment of such human clues results in nonfulfillment of the realistichuman possibilities of artful-scientific professional knowing andnursing. 

Words are the major tools of phenomenological description. They arelimited by our human ability to express, and yet they are the best toolswe have for expressing the human condition. The novelist James Agee, in_Let Us Now Praise Famous Men_, says that though man or humanrelatedness never could be described perfectly it would be the greatercrime not to try. This, too, is a basic premise of the humanisticnursing 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'smeaning or make it more specific. Some problem is presented by words weare accustomed to using and hearing. Habit and our human fallibility canpromote only superficial comprehension. Thoughtful awareness of themeaning of these same sequentially expressed words can convey thecomplexity of the never completely fathomable "all-at-onceness" of livedexistence. This theory is expressed in terms like "existenceconfirming, " "striving, " "becoming, " "relation, " and "reflection. " Weintend such words to express the grasp with acceptance and recognitionof human limitations while awesomely pondering the open-ended scope ofeach man's potential. 

In time, with disciplined authentic reflective description, themescommon and significant to nursing situations become apparent. They arethen available for compilation, complementary synthesis, and on-goingrefinement. A nursing resource bank accrues: Not a bank that offers amap 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 withgroups of nurses in graduate schools and in nursing service situationshave reflected on, explored, and questioned our own and others' nursingsituational experiences. Over this period we have come to value andappreciate the meaningfulness of these situations to man's existence. This constantly augmented our feelings of responsibility forcontributing to these situations beneficially. Therefore, we looked atthem for their tractability to research methodology. Their loadednesswith variations, changes, uncontrollables, and our negative feelingsabout the implications of viewing human beings as predictable left thestrict scientism of positivistic method wanting at this stage of man'sknowing. We saw objectivity in nursing situations or our questions, nursing questions, in the realm of needing to now how man experiencedhis existence. This objectivity, or man's real lived realityparadoxically is subjectively ridden, man-world. 

The existential literature dealt with substantive themes encountered innursing experiences. As I previously stated this literature evolves froma phenomenological {9} approach to studying being and existence. Thisapproach to studying, describing, and developing an artistic science ofnursing became Dr. Zderad's and my long-sought haven. All alongexistentialism and phenomenology had been ours 'and many nurses' "what"and "how. " Now we had labels that were acceptable and reputable tomany--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 undercertain conditions--one human being needs a kind of help and anothergives it. The meaning of nursing as a living human act is in the actitself. To understand it, therefore, it is necessary to consider nursingas 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, thekind and degree of help needed, the duration of the need for help, thepatient's location and his potential for obtaining and using help, andthe nurse's perception of the need and her capacities for responding toit. Nursing varies also in relation to the sociocultural context inwhich it occurs. Being one element in an evolving complex system ofhealth care, nursing is continuously appearing in new specialized forms. As professionals, we are accustomed to viewing nursing as we practice itwithin these specialty contexts--for example, pediatric, medical, rehabilitation, intensive care, long-term care, community. There seemsto be no end to the proliferation of diversifications. Even the attemptsof 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 entitywithout having one's view colored by a particular clinical, functional, or societal context. Yet, if we can "bracket" (hold in abeyance) theseadjectival labels and the preconceived viewpoints they signify, we canconsider the thing itself, the act of nursing in its most simple andgeneral appearance. {12}

Well-Being and More-Being

In this most basic sense, then, disregarding the particular specializedforms in which it appears, the nursing act always is related to thehealth-illness quality of the human condition, or fundamentally, to aman's personal survival. This is not to say that all instances ofnursing are matters of life and death, but rather that every nursing acthas 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 isrelated is not so apparent. "Health" is valued as necessary for survivaland 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 "healthteaching" and "health supervision. " On the other hand, there areinstances in which health, taken in its narrowest meaning as freedomfrom disease, is not seen as an attainable goal, as evidenced, forexample, in labels given to patients such as "terminal, " "hopeless, " and"chronic. " Yet in actual practice these humans' conditions call forthsome of the most complete, expert, total, beautiful nursing care. Nursing, then, as a human response, implies the valuing of some humanpotential beyond the narrow concept of health taken as absence ofdisease. Nursing's concern is not merely with a person's well-being butwith his more-being, with helping him become more as humanly possible inhis particular life situation. 

Human Potential

Since nursing involves one human being helping another, the notion ofhumaneness has been associated traditionally with nursing. Nursingpractice is criticized justifiably when it is not humane and is takenfor granted or praised when it is. The expectation of humaneness is soingrained in the concept of nursing that some nurses are surprised whenit is acknowledged by patients. If a patient thanks them for theirkindness, patience, or concern, these nurses reply, in theirembarrassment, "Oh, that's part of my job. "

However, to equate nursing's humanistic character solely with anoverflowing of the milk of human kindness is a serious error ofoversimplification. Such a limited view, in fact, is a dehumanizingdenial of man's potentials. As a human transaction, the phenomenon ofnursing contains all the human potentials and limitations of each uniqueparticipant. For instance, frustration, discouragement, anger, rejection, withdrawal, loneliness, aggression, impatience, envy, grief, despair, pain, and suffering are constituents of nursing, as well astenderness, caring, courage, trust, joy, hope. In other words, sincenursing is lived by humans, the "stuff" of nursing includes all possibleresponses of man--man needing and man helping--in his situation. 

Intersubjective Transaction

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

On reflection, it is obvious that nursing is an intersubjectivetransaction. 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 theoriginator of human acts and of human responses to the other. In thissense, they are _in_dependent. The intersubjective transactionalcharacter of nursing cannot be escaped when one is experiencing thephenomenon, either as nurse or as patient. Consider for example, some ofthe most common nursing activities, such as, feeding and being fed, comforting and being comforted, giving and taking medications. Althoughthis intersubjectivity is unmistakably known in experience, it isextremely difficult to conceptualize and convey it to others. It rarelyis found in descriptions of nursing, and to the unfortunate extent thatit is missing, the descriptions are not true to life. 

In real life, nursing phenomena may be experienced from the referencepoints of nurturing, of being nurtured, or of the nurturing process inthe "between. " For instance, the nurse may describe comfort as anexperience of comforting another person; the patient, as an experienceof being comforted. However, while each has experienced something withinhimself, he also has experienced something of the "between, " namely, themessage or meaning of the "comforting-being comforted" process. Thisessential interhuman dimension of nursing is beyond and yet within thetechnical, procedural, or interactional elements of the event. It is aquality of being that is expressed in the doing. 

Being and Doing

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

When a nurse refers to a nurse-patient interaction during which a changein the patient's condition or behavior was noted, one hoping to get adescription of nursing may ask, "What did you do?" Often the answer is adescription of a {14} manual action or a verbal interchange. Sometimesthe nurse responds, "Nothing, I was just there. " Perhaps it is thequestion that is wrong. The respondent usually interprets "doing" in alimited sense. In reality, everything the nurse does is colored by thecharacter of her being in the situation. The nursing act itself is abehavioral 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 "beingthere, " that is really a kind of doing for it involves the nurse'sactive presence. To "be with" in this fuller sense requires turningone's attention toward the patient, being aware of and open to the hereand 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 andwarrants recognition. To become more aware of and explore more fullythis essential constituent of nursing we need to focus on theparticipants' modes of being in the situation. Rather than ask thenurse, "What did you do in the nurse-patient situation?" we ought toask, "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 reallife, one finds nursing embedded within the human context. As anurturing response of one person to another in need, it aims at thedevelopment of human potential, at well-being and more-being. Assomething that happens between people, it reflects all the humanpotential and limitations of the persons involved. As an intersubjectivetransaction, it holds the possibility for both persons to effect and beaffected, the possibility for both to become more. At its very base, then, nursing is humanistic. It is, at once, man's expression of and hisstriving for survival and further development in community. 

In a way, to specify nursing as humanistic seems redundant. In view ofits source and goals how could it be otherwise? However, the term"humanistic nursing" was coined thoughtfully and used purposely here todesignate a particular nursing approach. Not only does the term signifyfull recognition of nursing's human foundation and meaning but it alsopoints the direction for nursing's necessary development. What isproposed here is the enrichment of nursing by exploring and expandingits 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 engagementdirected toward nurturing human potential. The humanistic nurse valuesnursing as a situation in which the necessary conditions for such humanactualization exist and is open to the possibilities in the intimatelyshared nurse-patient here and now. {15}

Humanistic nursing calls for an existential involvement, that is, anactive presence with the whole of the nurse's being. This involvedpresence is personal and professional. It is personal--a live actstemming from this unique, individual nurse. It is a chosen humanresponse freely given; it cannot be assigned or programmed. Theinvolvement is professional--goal directed. It is based on anart-science; it is held accountable. 

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

Process--Choice and Intersubjectivity

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

Existentially speaking, man is his choices. This does not mean that aman can be anything he chooses. Naturally, each individual is unique, having his own particular potentials and limitations. Nor is this view adenial of the forces of unconscious motivation and habit. It does notimply that all of a person's actions result from totally consciousdeliberations. By saying, "I am my choices, " I mean I am this here andnow person because in my past life I took particular paths in preferenceto 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. ButI am also what I am not, what I have not become. I am a nurse, thisunique 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 experiencedgrowth from within. I know myself as a being capable of becoming more, capable of actualizing my possibilities, my self. So I am my choices notonly in terms of my past but also in regard to my future, mypossibilities. 

Man is an individual being necessarily related to other men in time andspace. As every man is beholden to other men for his birth anddevelopment, interdependence is inherent in the human situation. In thissense, human existence is coexistence. The deeper significance of thistruth has been recognized and elucidated by many thinkers, especiallythose in the existential stream. Over {16} and over, their writingsreveal the paradoxical tension of being human: each man is, at once, independent, a unique individual and interdependent, a necessarilyrelated being. As Wilfrid Desan says, referring to man as subsistentrelation, "He is towards-the-other but he is not-the-other. "[1]

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

Logically, it follows that the possibility for self-confirmation existsin any intersubjective situation. However, in everyday life thisself-confirmation is experienced to different degrees or on differentlevels in interhuman relating. Since both persons are independentsubjects acting with their human capacity for disclosing or enclosingthemselves, there is no guarantee that the availability and presencenecessary for a genuine confirming encounter will come forth. Presence, the gift of one's self, cannot be seized or called forth by demand, itcan only be given freely and be invoked or evoked. 

Since man becomes more through his choices and the aim of nursing is tohelp man toward well-being or more-being, the humanistic nursing effortis directed toward increasing the possibilities of making responsiblechoices. Such choice involves, in the first place, an openness to and anawareness of one's own situation. A choice is a response to possibility. Therefore, one must first recognize that possibilities or alternativesexist. This openness to options is experienced as a freedom to choose aswell as a freedom from the bonds of habit and stereotyped response, fromroutine, from the veils of the obvious. It means getting in touch withone's experience, one's subjective-objective world. As one becomes moreacutely aware of his personal freedom of choice, there arisesconcurrently an awareness of the quality of choice, of theresponsibility that is always implied in the freedom. Then followsreflective consideration of one's unique situation with its possiblealternatives and an examination of the values inherent in them. Finally, the act of choosing is expressed in a response to the situation with awillingness to accept the responsibility for its foreseeableconsequences. Through this experience the person becomes aware ofhimself 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 forboth persons, patient and nurse, to experience the process of makingresponsible choices. Through living this process in nursing situations, the nurse develops her own potential for responsible choosing. Thesatisfaction, often in the form {17} of a sense of vitality andstrength, that is felt in making responsible competent professionaljudgments reinforces the habit. In personally coming to experientiallyappreciate the growth promoting character of responsible choosing, thenurse may more readily recognize the value of such experiences for anyperson, including the one currently labeled "patient. " The humanisticnurse, therefore, is alert to opportunities for the patient to exercisehis freedom of choice within the limits of safe and sound practice. Sheis constantly assessing his capabilities and needs and encourages hismaximum participation in his own health care program. Throughcoexperiencing and supporting the process in the patient's experiencefrom his point of view, the nurse nurtures his human potential forresponsible choosing. Both patient and nurse become more through makingresponsible choices in the intersubjective, transactional nursingsituation. 

Theory and Practice

The term "humanistic nursing" refers to a kind of nursing practice andits theoretical foundations. The two are so interrelated that it isdifficult, in fact even somewhat distorting, to speak exclusively ofeither the practice or the theory of humanistic nursing. When, for thesake of clarity or emphasis, discussion is focused on either thepractical or the theoretical realm, thoughts of the other realm casttheir shadows on the fringes. For in our view, for the process ofnursing to be truly humanistic means that the nurse is involved as anexperiencing, valuing, reflecting, conceptualizing human person. Fromthe other side, the theory of humanistic nursing is derived from actualpractice, 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 theexistential sense. She is available with her total being in thenurse-patient situation. This involves a living out of the nurturing, intersubjective transaction with all of one's human capacities whichinclude a response to the experienced reality. Man is able to set hisworld at a distance as an independent opposite and enter into relationwith it. In fact, according to Buber, this is what distinguishesexistence as human. It is man's special way of being. [4] For nursing tobe humanistic in this full sense of the term requires being and doing inthe situation and subsequently setting the experienced reality at adistance (that is, objectifying it) and entering into relation with it. The nurse's reflective response to her lived world may take the shape ofany form of human dialogue with reality, such as, science, art, orphilosophy. 

Viewed existentially, every nursing event is unique, a liveintersubjective transaction colored and formed by the individualparticipants. Although the event is ephemeral, the resultantexperiential knowledge is lasting and cumulative. So {18} from thenurse's daily commonplace grows a body of clinical wisdom. The need fordescribing nursing phenomena, for expressing and conceptualizing livednursing worlds, is basic to the theoretical and actual development ofhumanistic nursing. In summary, we contend that humanistic nursingpractice necessarily involves the conceptualization of that practice andan examination of its inherent values and that humanistic nursing theorymust be derived from nurses' lived experience. The interwoven theory andpractice are reciprocally enlightening. 

Framework--The Human Situation

It is easy to recognize the intrinsic interrelatedness of humanisticnursing theory and practice and the consequent necessity for theirconcurrent development. It is even quite easy to take the next steps ofvaluing such development and committing oneself to the task. But thenthe 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 itsspecialized clinical, functional, or sociocultural form. So its domainincludes any or all nursing situations. And within this domain, sincehumanistic nursing is an intersubjective transaction aimed at nurturingwell-being and more-being, its "stuff" includes all possible human andinterhuman responses. To conceive of so limitless a universe for studyis at once exhilarating and overwhelming. How can one get a handle onthe nursing universe? Is it possible to envision an inclusive frame thatwould allow an orderly, systematic, and hopefully productive approach tothe development of humanistic nursing?

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

For example, in terms of man as incarnate, it is certainly not new fornurses to focus on man's bodily existence. Naturally, one of nursing'sbasic concerns always has been care of people's physical needs. To viewnursing from the perspective of the human situation, however, is to seebeyond physical care, {19} beyond the categorization of man as abiopsychosocial organism. The focus is on the person's unique being andbecoming in his situation. 

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

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

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

Finally, within this framework, all the phenomena experienced in thenursing situation could be explored in relation to their attributes oftime and space. More specifically, from an existential perspective, thefocus 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 throughspace in a wheelchair, crutchwalking, pacing, could be considered fromthe standpoint of the patient's experienced space and time, or from thenurse's, or as a shared event. Explorations of this kind could providevaluable insights into important nursing phenomena, such as, presence, empathy, comfort, timing. {20}

The human situation, then, is the ground within which nursing takesform. As such, it provides a framework for approaching the study anddevelopment of humanistic nursing. As an angular view, it holds thefocus on the basic question underlying nursing practice: Is thisparticular intersubjective, transactional nursing event humanizing ordehumanizing?

CONCLUSION

This chapter explored the foundations of humanistic nursing. Thediscussion flowed naturally, perhaps unavoidably, into the realm ofmeta-nursing. "Naturally, " for the humanistic nursing approach is itselfan outgrowth of the critical examination of nursing as an experiencedphenomenon. From this existential perspective of nursing as a livinghuman act, the meaning of nursing is found in the act itself, innursing's relation to its human context. 

Reflection on nursing as it is lived in the real world revealed itsexistential, nurturing, intersubjective, transactional character. Theprocess of humanistic nursing stemming from the nurse's authenticcommitment is a kind of being with and doing with. It aims at thedevelopment of human potential through inter subjectivity andresponsible choosing. 

The actualization of humanistic nursing is dependent on the concurrentdevelopment of its practice and theoretical foundations by practicingnurses. An open framework derived from the human situation was offeredto suggest possible dimensions of humanistic nursing practice that couldbe described and articulated into a body of theory. 

Nurses who have considered this humanistic nursing approach in terms oftheir daily practice have felt at home in the ideas. Theconceptualizations fit their personal nursing experience. If there isany strangeness in the approach, it is perhaps that it does not followthe contours of the clinical specialties to which we have grown soaccustomed that they may be more ruts than roads. This is not to saythat humanistic nursing is opposed to clinical specialization innursing. In fact, clinical nursing, as it exists in any form, is itsvery heart and base. Humanistic nursing is not compartmentalized intoclinical (or functional, or sociocultural) specialties because itapplies 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 genuinecross-clinical studies of nursing phenomena. If nurses with highlydeveloped abilities in particular forms of nursing would struggletogether 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 aUnited 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: BallantineBooks, 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, thatis, in the phenomenon of nursing as it is experienced in the everydayworld. Therefore, the interrelated practical and theoretical developmentof humanistic nursing is dependent on nurses experiencing, conceptualizing, and sharing their unique angular views of their uniquelived nursing worlds. An open framework suggesting dimensions for suchexploration was derived from a consideration of the phenomenon ofnursing within its basic context, namely, the human situation. Theelements 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 andas lived by patient and nurse) in a world of men and things. 

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

When I reflect on an act of mine (no matter how simple or complex) thatI can unhesitatingly label "nursing, " I become aware of it asgoal-directed (nurturing) being with and doing with another. Theintersubjective or interhuman element, "the between, " runs throughnursing interactions like an underground stream conveying the nutrientsof healing and growth. In everyday practice, we are usually so involvedwith the immediate demands of our "being with and {22} doing with" thepatient that we do not focus on the overshadowed plane of "the between. "However, occasionally, in beautiful moments, the interhuman currents areso strong that they flood our conscious awareness. Such rare andrewarding moments of mutual presence remind us of the elusiveever-present "between. "

>From these epiphanic episodes in our personal nursing experience, wehave certain and immediate knowledge of intersubjectivity. Through ourexperience, too, we know that both humanizing and dehumanizing effectscan result from human interactions. Therefore, it is essential for thedevelopment of humanistic nursing to explore and describe itsintersubjective character. 

Although many nurses have agreed in principle about the importance ofthis work, they also have expressed the feelings of frustration anddiscouragement attending it. There are real difficulties involved inattempting to describe something so real yet so nebulous as "thebetween. " The descriptions must be derived from our own real nursingexperiences. This means that we must develop habits of consciousawareness of experience, of recall, and of reflection. Then we muststruggle with our language finding the words in our physically andtechnologically oriented vocabularies, perhaps even creating terms, toconvey the substance and flavor of the experience of intersubjectivity. 

Furthermore, description of the intersubjective quality of nursing isdifficult because of its peculiar pervasiveness. Whether it isconsciously recognized or not, it is part of every nursing transaction. However, to consider and explore intersubjectivity solely as a componentor constituent of nursing, even a necessarily inherent or an essentialone, would be to see it out of true perspective. The "between" is morethan a factor or facet of nursing; it is the basic relation in which andthrough which nursing can occur. So the question remains. How can ourexperiences, our angular views, our glimpses of this foundation, thisnecessary means of nursing, be conceptualized and shared?

Once while reflecting on the nature of nursing against a background ofnotions about intersubjectivity drawn from experience and literature andtesting them against my own real life experiences of nursing, I suddenlysaw that _nursing itself is a particular form of human dialogue_. Thisinsight occurred to me with clarity, conviction, and all the force of abrand new idea. It was so obvious, so distinct, so simple, so clearly acentral intuition that could illuminate the phenomenon of nursing fromwithin. I experienced the idea as fresh and excitingly full of promise. 

Yet, when I said it out loud, "Nursing is dialogue, " the words seemedtoo meager to convey the true meaning of the idea and its realsignificance. There was, furthermore, an annoying shadow of familiaritylurking about it. It was almost as if I had expressed something similarpreviously. At first, I hesitated to share this insight with others forfear they would extinguish it by saying, "of course, everyone knowsthat, " or "I've heard you say something like that before. " Still, Iexperienced it as an idea I _had_ to express. Moved by the pressure offeelings 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 referencesto existential literature. Dissatisfaction with it prompted furtherrethinking and revision. Searching through my files during this process, I found, to my great surprise, some notes on the dialogic nature ofnursing written by myself three and six years previously. In fact, athree-year-old note contained the very title, "Dialogue Called Nursing"!Now, how is it possible to grasp a truth and then "forget" that oneknows it and later meet and grasp the old truth again as new? Thedifference in these experiences of knowing, for me at least in thiscase, is that now I know as if from the inside out that nursing isdialogical. The idea seems to have sprouted out of the lived phenomenon, to have broken forth from the ground of experience, as opposed to havingbeen concluded in my earlier "intellectual, " "theoretical, " or"philosophical" ponderings. But how did the earlier idea, the conclusionthat nursing is dialogical, become a live option for me? Why did itappeal to me? How did it come to make sense in the first place if notbecause of my experience?

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

LIVED DIALOGUE

The central insight (intuition or idea) from which this explorationgrows is this: nursing itself is a form of human dialogue. I mean thatthe phenomenon of nursing, that is, the nurturing, intersubjectivetransaction, the event lived or experienced by the participants in theeveryday 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 todenote a broader concept than the typical dictionary definition ofdialogue as "a conversation between two or more persons or betweencharacters in a drama or novel. " It is used in the existential sense. Itimplies an "ontological sphere, " in Buber's terms, or the "realm ofbeing" to which Marcel refers. Here it refers to a _lived_ dialogue, that is, to a particular form of intersubjective relating. This may beunderstood in terms of seeing the other person as a distinct uniqueindividual and entering into relation with him. In other words, nursingis a dialogical mode of being in an intersubjective situation. 

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

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

NURSING VIEWED AS DIALOGUE

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

Meeting

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

When a nurse and patient come together in a nursing situation, theirmeeting may be expected or planned by one or both or it may beunexpected by one or both. In any case, the goal or purpose of nursingholds. Even in a spontaneous interaction where they have met only bychance, in a health care facility or any place where one is identifiedas patient and the other as nurse, there is an implicit expectation thatthe nurse will extend herself in a helpful way if the patient needsassistance. If the meeting is planned or expected, this factorinfluences the dialogue. Each comes with feelings aroused byanticipation 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 orcontrol either nurse or patient had over their coming together. Intoday's complex health care systems, a nurse may be assigned to care fora particular patient, or for persons in an area or unit, or may becalled into service through a registry, {25} or may be approacheddirectly by a patient. From the other side, the patient also experiencesvarying degrees of control over his meetings with nurses depending onthe system in which the health care is offered, his location, hisfinancial means, and so forth. So when a patient and nurse do meet in agiven instance, each comes to the situation bearing remnants of feelingof having caused or not having caused this encounter with thisparticular individual. (Of course, even in the most de-individualizedsystems the nurse and/or patient can still control their meetings tosome extent, for example, avoidance by the nurse being too busy oravoidance by the patient feigning sleep. )

The patient and the nurse are two unique individuals meeting for apurpose. 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 isand all that he is not at this moment in this place. Each comes as aparticular incarnate being. Each is a specific being in a specific bodythrough which he affects the other and the world and through which he isaffected by them. This nurse who uses her eyes, ears, nose, hands, herbody, this way here and now meets this patient whose body in thiscondition serves him this way here and now. 

Furthermore, both the patient and the nurse have the human capacity fordisclosing or enclosing themselves. So they have some control over thequality of their meeting by choosing how and how much to be open withand to be open to the other. Their openness is influenced by their viewsof the purpose of the meeting. In general, the patient expects toreceive help and the nurse expects to give it. However, their views maydiffer 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 theshared situation. One's purpose is to nurture; the other's is to benurtured. This difference in the perspectives from which they approachthe meeting is reflected in the kind and degree of their openness toeach other. 

In describing their experiences nurses often have revealed that they areopen to patients in a certain way. This is evident when nurse andpatient meet. The nurse may have prior knowledge of the patient, perhapseven an image of him drawn from case history, charts, tour of dutyreports, and so forth; or she may meet him as a total stranger. But whenthey come together, the nurse sees "the patient as a whole. " This globalapprehension is not experienced as an additive summation but rather as agestalt. It may result in a very clear "picture" of the patient'scondition with nursing action initiated almost before the pictureregisters in full conscious awareness. Or the perception may beimprecise yet strong that "something is wrong. " From these experiencesone may infer that a nurse's openness involves being open to what is andto what is not in the patient's state of being as weighed against somenotion (or standard) of what "ought" to be, with the intention of doingsomething about the difference. Thus, the nurse is open-as-a-helper tothe patient. This kind of openness is a quality that characterizes thehumanistic nursing dialogue. Of course, every nurse-patient meetingdiffers, for each participant comes to the situation as the {26} uniqueindividual he is, with his own expectations and capacities for givingand taking help. 

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

Relating

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

Men can do with and be with each other because they are able to seeothers and things as distinct from themselves and enter into relationwith them. What distinguishes the human situation is that men can enterinto a dialogue with reality. They have a capacity for for internalrelationships, for knowing themselves and their worlds withinthemselves, they can relate as subject to object (for example, as knowerto 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 assubject to object. How could a person survive even one day withoutknowing and using objects? Therefore, man's abilities to abstract, objectify, conceptualize, categorize, and so forth, are necessary foreveryday living. Even beyond this, the human capacity for relating tothe other as object is basic to the advancement of mankind for itunderlies science, art, and philosophy. It is simply one way of beinghuman. 

Another mode of relating is open to men. Whenever two persons arepresent to each other as human beings, the possibility ofintersubjective dialogue exists. Since both are subjects with thecapabilities 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 uniqueidentities, they can participate in an interior union. Intersubjectiverelating is also necessary for human existence. For it is through hisrelationships with other men that a person develops his human potentialand becomes a unique individual. 

Nursing, being an interhuman event, has within it possibilities forvarious types and degrees of relationships. Both nurse and patient canview themselves and the other as objects and as subjects or in anyvariation or combination of these ways. A person can view and relate toanother 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, " "totalcare 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 placedbefore or opposite; it is anything that can be apprehendedintellectually. Through objectification the object is de-individualizedand therefore made replaceable for the purpose of study by any otherobject with the same properties. It is indifferent to the act by whichit is thought and, therefore, the subject studying the object may alsobe replaced by a similar subject. 

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

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

Presence

In the nursing world, as in the world at large, human encounters mayrange from the trivial to the extremely significant. Within a day'swork, the nurse may experience many levels of intersubjectivity from thelowest level of being called on as a function or being used as anobject, to the other end of the scale of being recognized as a presenceor a thou in genuine dialogue. 

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

There is a quality of unpredictableness or spontaneity about genuinedialogue. A nurse may be going through her daily activities, functioningeffectively, relating humanely, when suddenly she is stopped bysomething in the patient, perhaps a look of fear, a tug at her sleeve, amoan, a reaching for her hand, a question, emptiness. In a suspensefulpause two persons hover between their private worlds and the realm ofintersubjectivity. Two humans stand on the brink of the between for aprecious moment filled with promise and fear. With my hand on thedoorknob to open myself from within, I hesitate--should I, will I let meout, let him in? Time is suspended, then moves again as I move withresolve to recognize, to give testimony to the other presence. 

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

As was discussed earlier, the nursing dialogue occurs within the domainof health and illness and has a purpose in the minds of theparticipants. Nursing is a lived dialogue (a being with and doing with)aimed at nurturing well-being and more-being. This fact ofgoal-directedness modifies or characterizes dialogical presence. As anurse I try to be open to the other as a person, a presence, and to beavailable to the other. Yet, when I reflect upon my presence, I realizethat my openness is an openness to a "person-with-needs" and myavailability is an "availability-in-a-helping-way. " By comparison, myexperiences of openness and availability in social, family, or friendrelationships and in nurse-patient relationships differ. In the later, Ifind myself responding with a kind of "professional reserve. " While itis 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 liveddialogue of nursing. 

It is the qualitative differences in the various experiences of presencethat deserve, yet almost defy, description. For instance, the presenceseems to have a different quality of _intimacy_. It is not experiencedas less intense or less deep in the nurse-patient relationship, but assomehow colored by a sense of responsibility or regard for what is seenas 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 mypresence flows through a filter of therapeutic tact. 

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

Often in nursing it is necessary to focus my attention on some aspect ofthe patient's body or behavior. The patient may or may not have the samefocus of attention. At least momentarily then, or even for a prolongedperiod, I place some aspect of the patient before or opposite myself(that is, objectify it). And to the extent that this detail absorbs myattention, I lose my sight of and my relatedness to the whole person whohappens to be the patient. While I know this focusing on details to be anecessary step in the nursing process, sometimes I find myself abruptlyrefocusing my attention on the whole person with almost a twinge ofguilt for having abandoned him. (Patients have described thisuncomfortable intersubjective experience as feeling "looked at" or"watched" by staff. ) At other times, on reflection, I find my attentionwas oscillating between the detail and the person, or focusing on bothrelating one to the other. From these experiences it is evident thatdialogical presence is complicated in the nursing situation. It isinhibited when the focus of attention (of one or both participants) ison the patient's body itself or on his behavior. Yet the body is anintegral part of the person and his behavior is an expression of hismode of existence or his way of being in the world. Man is an embodiedbeing, and the nurse, in nurturing the patient's well-being andmore-being, must relate to him and his body in their mysteriousinterrelatedness. 

Call and Response

The dialogical character of nursing may be explored further byconsidering it in the general sense of a call and response. Nursing is apurposeful call and response, that is, it is related to some particularkind of help in the domain of health and illness. A patient calls for anurse with the expectation of being cared for, of having his need met. He is asking for something. A nurse responds to a patient for thepurpose of meeting his need, of caring for him. The nurse expects to beneeded. 

In reflecting on nursing experiences, it becomes obvious that the calland response in the nursing dialogue goes both ways for nursing istransactional. Both patient and nurse call and respond. The pattern ofthe 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 hiscall light to ask for something. This is not only a call but also aresponse to the nurse's previously stated suggestion that he use thesignal if he needs her help. Or again, a nurse may stop and talk with apatient during a chance meeting recalling that he previously hadexpressed feelings of loneliness, boredom, pain, or joy. Also, otherpersons or events may interrupt or end a nursing dialogue. For instance, the nurse is called away to help in another situation, the patient isdischarged on the nurse's day off, the patient expires. 

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

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

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

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

It is more difficult to find written descriptions of nonverbalnurse-patient communication, although this aspect is generallyrecognized to be of equal significance. Here again the call and responseframework could be a useful aid. For instance, what does a nurse's merephysical presence mean to a patient either as a call or response? Orfrom the nurse's standpoint, under what circumstances is a patient'spresence experienced as a call and, even more, as a call for aparticular nursing response? What prompts us to respond in terms of hisposture, his color, his facial expression, his behavior, the appearanceof his clothes? Are we almost unconsciously checking some kind of "vitalsigns" in the inter subjective realm?

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

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

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

DIALOGICAL NURSING IN THE REAL WORLD

It is necessary now to look again at dialogical nursing in a broaderperspective, for by limiting the exploration to the nurse, the patient, and their between, the previous discussion grossly oversimplified theway the dialogue actually evolves in real life. In the above, it was asif nursing were a drama acted out by two characters on a speciallydesigned stage where precisely placed props lay ready to serve theactors and the passage of time is controlled by the chiming of a clockor the dimming of lights. As it is actually lived, the nursing dialogueis subjected to all the chaotic forces of real life. Nursing takes placein a real world of men and things in time and space. In many cases, itis a special world, a health system world, within the everyday world. 

Other Human Beings

The dialogue lived between nurse and patient is affected by theirnumerous other interhuman relationships. For a nurse to be genuinelywith a patient involves her coexperiencing his world with him. Hisfamily, friends, and significant others are a very real part of thisworld whether they are physically present or distant. So to be open tothe patient is to be open to him as a person necessarily related toother men. 

Furthermore, in caring for a patient the nurse relates to him not onlyas an individual patient but also as one in a group of patients. Thegroup may be physically present (for example, in a ward, in an intensivecare unit, in a {32} waiting room, in a dining room, in a therapeuticgroup) or they may be present in the nurse's mind (for example, whilecaring for one she may think "I have three more patients to visit, " "soand so needs his medication in five minutes, " "I promised so and so I'dget back to him, " "three other patients are waiting to be fed"). Evenwhen the nurse is responsible for only one patient, she often views himin relation to other patients she has nursed. 

The nurse herself also functions within complex networks of interhumanrelationships that affect the nursing dialogue. As health care becomesmore specialized, more groups of health care workers arise and thevarious groups become more diversified. So the nurse's intersubjectivetransactions with her patients occur within an intra- andinterdisciplinary milieu of constantly changing personnel, functions, and roles. While her own role is expanding, extending, deepening, broadening, becoming more specialized, she must relate with othersundergoing similar change. And here again, as with the patients so withher colleagues, the nurse is constantly faced with the possibility andnecessity of relating to others in terms of their functions and aspersons. 

Finally, it should be recognized that while it is easy and common tothink of "the nurse" as synonymous with the function "nursing, " in reallife the nurse is a human being necessarily related to others. Shelearns to focus on those present in her here and now work situation. Butshe too is her history and brings to her work world all that she is andall that she is not including her past experienced and futureanticipated interhuman relationships. So each nurse affects her peoplednursing world and is affected by it in her own unique way. 

>From the other side, the patient also enters into the nursing dialoguewith his various networks of interhuman relationships. How heexperiences 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 interpersonalrelating. Of course, the current mode reflects his past, for example, learned habits of response, and his future, for example, concerns aboutanticipated changes in interpersonal relationships due to the effects ofhis illness. In some cases, the intersubjective behavior itself becomesthe focus of the nursing dialogue as the area of the patient's greatestneeds in attaining well-being and more-being. 

Things

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

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

On entering a health care facility, the patient finds himself in aforeign world of strange objects. In place of his familiar possessionshe is surrounded by equipment, machines, instruments, solutions, and soforth. He may experience these as bewildering, frightening, painful, supportive, soothing, life-sustaining. The nurse, on the other hand, mayexperience these same objects quite differently. To her they may befamiliar tools, useful aids, complex machines, annoyingly defectiveequipment. Even in a situation that does not have special equipment, forinstance in a home, the patient's world of things changes as the nurseconverts ordinary objects into tools. Thus, while nurse and patientshare a situation, the things in their shared world have differentmeanings for each. The things themselves as well as the persons'relations to them can serve to enhance or inhibit the intersubjectivetransaction of nursing. 

Time

To view dialogical nursing as it is actually experienced in the realworld, one must conceive of it as occurring in time, not simply measuredtime but also time as lived by patient and nurse. Certainly bothparticipants are caught up in measured time and this influences theirshared world, for example, eight-hour tours of duty, a day off, surgeryscheduled 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 andnurse must live by the clock and calendar. 

However, equally important, or perhaps even more important, in the liveddialogue of nursing is the participants' experience of time. Somereferences were made to lived time in the section on call and responsewhere it was noted how the nursing dialogue unfolds over time frommoments to years. How the involved persons experience this continuity isan individual matter. 

The nurse may conceive of herself as one of many persons contributing toa continuous stream of caring for the patient. So she will give and hearand write and read reports, note observations, keep records. She willcarry an image of the patient in her mind continually adding to it orchanging it with each interaction or report. Sometimes, after not seeingthe patient for a time, on meeting him again she will "pick up where sheleft 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 shemay be startled by the visible changes and resume the dialogue from thatpoint. Or even if change is not visible, she may be aware that it mayhave occurred and try to fill in the gap. 

These possibilities may be mirrored from the patient's standpoint, forhe likewise experiences continuity or lack of it in his care. And yet, the experience must be different for him. For instance, nurses may thinkof continuity of care in terms of "coverage" for a planned program ofcare. So it has often been {34} claimed that "the nurse is with thepatient 24 hours a day. " From the patient's point of view this is nottrue. _A_ nurse may be with him but each nurse is different. Thefunction of nursing may be continuous, but individual nurses come andgo; the day nurse, the evening nurse, the night nurse are each uniqueindividuals. And the nursing dialogue as lived, intersubjectivetransaction occurs between a particular nurse and a particular patient. 

When we speak of a nurse and a hospitalized patient spending a daytogether, we usually are referring to eight hours out of a 24-hour day. They may both experience the spacing of this time by functions oractivities such as meal time, medicine time, visiting time. Yet themeasured minutes and hours are experienced differently by each in theirdifferent modes of being in the situation. Nurses often express feelingsof not having enough time to give the care they want to give; of havingtoo many demands on their time; of trying to "make time" for patientswho ask "do you have a minute?" Patients live their time in relation toboredom, pain, loneliness, separation, waiting. The nursing dialogueruns its course in clock time but both nurse and patient live it intheir 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 withthe patient. This kind of timing is related to the transactionalcharacter of nursing and to its goal of nurturing the development ofhuman potential. It is experienced in openness, availability, andpresence, as well as in nursing care activities. The nurse feels inharmony with the rhythm of the dialogue and, sensing the timing of itsflow, she paces her call and response to patient's ability to call andrespond in that moment. So, as a nurse, you may find yourself almostunconsciously or intuitively waiting, holding back, anticipating, urgingthe patient. This kind of synchronization or timing is intersubjectivefor the clues or reasons for encouraging or waiting are not found solelyin the patient's behavior nor only in the nurse's knowledge orexperience. "Good" or "right" timing somehow involves the "between. " Itimplies 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 worldthe factor of space becomes apparent. Here again the dialogue isinfluenced by space as it is measured and space as it is experienced bynurse and patient. When thinking of health care facilities, "space" maybe 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 thenursing dialogue. However, the person's experience of the space may beeven more important. 

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

Place is a kind of lived space. It is personalized space. One says, forexample, "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 inmy place; I felt put down. " The patient may feel "out of place" in thehealth care setting, while it may be commonplace to the nurse. There maybe 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 bein a place together, yet one feels at home and the other does not. Forthe 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 along time often express a proprietary attitude toward the hospital. Thesame holds true for personnel. With time and familiarity a feeling ofreciprocal belongingness grows. The person belongs in the place and theplace belongs to the person. On the other hand, when a person findshimself in a new place he may feel the discomfort of not belonging. Thisis as true for the nurse in an unfamiliar setting as for the patient. Again in this regard, the lived nursing dialogue is enhanced by thenurse's awareness of not only her own experience of space but thepatient's as well. 

CONCLUSION

This chapter explored the basic view of humanistic nursing as aphenomenon in which human persons meet in a nurturing, intersubjectivetransaction. Beginning with the central intuition that nursing is liveddialogue, the examination turned to its existential source, the nursingsituation as it is lived. Reflection on actual experience clarified thephenomena of meeting, relating, presence, and call and response as theyoccur in humanistic nursing. Dialogical nursing was then reconsidered inbroader perspective as it actually evolves in the real world of men andthings in time and space. 

As scientific advances multiply in the health field, nursing is sweptalong in the tide. Continuous technological changes, ever increasingspecialization, emphasis in nursing education and research on scientificmethodology all have marked influence on the development of nursing. Science (with a capital S) colors the nursing world. At every turn itpermeates the nurse's being with and {36} doing with the patient. Itoffers a certain security by providing a consistent and effectiveapproach to some problems and questions, and, in some cases, results ingeneral laws to guide practice. At the same time, in the lived nursingworld the nurse experiences a reality that is not open to the scientificapproach, a reality not always verifiable through sense perception, areality of individuality. The uniqueness of individuality (her own aswell as the patient's) pervades the nursing dialogue. 

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

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

Humanistic nursing, viewed as a lived dialogue, offers a frame oforientation that places the center of our universe at the nurse-patientinter subjective transaction. Insightful recognition of the livednursing act as the point around which all our functions revolve, couldrequire a Copernican revolution of orientation of some nurses. It doesprovide, for all nurses, a true sense of direction that can beactualized by each unique nurse through creative human dialogue. {37}

4

PHENOMENON OF COMMUNITY

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

MY ANGULAR VIEW

One can view members of a family, a student class, a hospital unit, ahospital staff, several related hospital staffs, health servicesorganizations within a geographic area, a profession, a town to a worldor universe as community. Man's mind, my mind, determines where Isuperimpose the limits or lift the limits or relate components. In _TheRepublic_ Plato depicted a community as a macrocosm. [1] Its nature wasconditioned by the kinds of men, the microcosms, that composed it. Themacrocosm was a reflection of its microcosms. 

So each human person, each nurse, as a microcosm, could make adifference. Reflecting on the lived worlds of nurses, their communities, if we use Plato's philosophical analogy of macrocosm-microcosm, despitethe varieties of situation, we can make meaningful a basic concept ofcommunity. Such a concept utilized by a nurse to view her particularongoing 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 tothe endless innovative possibilities and unattempted choices availableto her. {38} The ability to thus open one's self requires our exposingour biases, the shades through which we regard the world, to thesunlight. In nursing our shades often are closed categories, labels, diagnoses, trite superficial hackneyed expressions learned by us, taughtto us as fact, taken in unexamined, and left unreexamined despite otherchanges in ourselves and our situations. Socrates said, and it stillholds, that the unexamined life is not worth living. Our shades can becherished concepts, beliefs that guide us automatically rather thanthoughtfully. Whether they are entirely myth or partial truths, they cancause us agonizing dilemma because they obscure the obviously relevantand the possibilities beyond. A concept of community, if grasped and ifa nurse is truly consciously aware, can help her to understand how hernursing world has evolved, is presently, and how she can be, to shapeits future in accordance with her values. 

As nurses one of our shades is often the confining labels we give toourselves as doers in service giving profession. I would like to go onrecord as most respectful of this aspect of my world. I regret, nonetheless, that we have not always similarly crystallized andfloodlighted the discovery and creative possibilities in ourcommunities. In our very personal, intimate, involved professionalnursing relations with other man we are privileged to be included inhuman happenings open to no other group. As nurses, we have had and arehaving emphasized to us the importance of facts handed to us. Can weactuate the importance of the knowledge of man that becomes part of usthrough our nursing worlds? It is hard to honor the significance of theeveryday, the commonplace, the intimately known? It has been said thatone could know of the whole universe if one could make every possiblerelationship starting from a piece of bread. Think of a "simple" or"routine" nursing situation. Think of its true complexity and how it cantrigger puzzlement, wonderment, and thinking. As learning situations, nurses' situations are existentially priceless. Returning now to Plato'sconception of community understood through the terms macrocosm andmicrocosm, what can the nursing world situation reveal to us ofcommunity? 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 havestructured facts about man, family, and community precisely forpresentation. Approaching the data sociopsychologically I framed it inthe public health model of promotion of health, prevention of illness, treatment, rehabilitation, and maintenance. I thought of familysociologically as nuclear, procreative, and extended. In accordance withthe 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} closedparadigm, ranging from ideal to abysmal, from the smallest to thelargest unit in which persons congregated for common purposes. Iselected from experience nursing examples to make thesesociopsychological public health constructs meaningful. I did not startfrom nursing experiences to come up with nursing concepts of man, family, and community. I denied my particular self as a source ofknowledge of these areas. Had education programmed me to value onlyothers' ideas gleaned in the classroom or from books? I projected thisdevaluation of my own ideas onto my colleagues and until I really knewthem gave them what I thought they wanted, others' ideas. Presently Iprize my uncertainty about the nature of man in family and community andmy striving toward an ever explorative process of being and becoming, available for surprise. Paradoxically, I believe it was these very samecapacities, uncertainty and striving, that compelled my superimposing onmy 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 mycertainty is at once a truth and a nontruth. I see my aim as everstriving toward certainty while constantly wrestling with the discomfortof uncertainty. 

EACH NURSE: A _NOETIC LOCUS_[2]

Each nurse is a "knowing place. " It feels as if my greatest talents, asa human nurse person, awaited my acceptance that came through as Irelated 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 thephenomena--man, family, community--Theresa G. Muller, nurse educator andclinician, who quoted Hersey from his novel, _A Single Pebble_, comes tomind. [3] He said, "I approached the river as a dry scientific problem; Ifound it instead an avenue along which human beings moved whom I had notthe insight, even though I had the vocabulary, to understand. " Iconsider my greatest gifts as a human being nurse my ability to relateto other man, to wonder, search, and imagine about my experience, and tocreate out of what I come to know. My ever developing internalizedcommunity of world thinkers dynamically interrelated with my consciousawareness of my experienced nursing realm allows my appreciation of myhuman gifts and the ever enrichment of myself as a "knowing place. "

NURSE: EXPERIENCE INTERNALIZED

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

Valuing the complexity of this conception of man and therefore ofcommunity I find myself smiling at the naivety of the earlier morestatic frames of order I superimposed on these phenomena. Theseoversimplifications maintained the shade through which I viewed myworld. The shade was: others are knowing places, they are responsible;therefore if I quote authority from outside of myself, I can speak withcertainty about what I know and believe and no one can attack me. Andyet, my unique knowledge was not given and so my defense, my clutchingat security foiled my human need for conceptualization of and expressionof my own nurse vision of reality. This defeated the development by meof nursing theory. 

Now I realize how I underestimated the potentialities of my nursingeffect, of the difference I made, and could make. Just consider thegiven human uniqueness of each participant in the nursing situationwhose familial potential goes back to an origin of thinking being orconsciousness, and forward to his anticipation of the future, hiseternity. 

In the nursing literature, it is rather infrequent that wephilosophically share our innermost thoughts, dreams, ideals, andstrivings without a strong overlay of indoctrination or conversion. Nietzsche presents philosophy as autobiographical, such sharing does notoffer maps. It could offer relevant resources and stimulate other nursesto influence the shape and becoming of the profession. 

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

Man's Experience

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

Adults, in response to and through one another, procreate new sensitivebeings whom they want and/or do not want and whom they may and/or maynot experience as their responsibility in varying degrees. Marcel, aFrench existentialist philosopher, views procreation and responsibleparenthood as quite different. My past nursing experience substantiatesthis. Marcel expresses my bias about responsible parenthood, and thisstatement is also worthy of consideration by nurses in positions ofauthority to others. He says, "We have to lay down the principle thatour children (or those for whom we care) are destined, as we areourselves, to render a special service, to share in a work, we havehumbly to acknowledge that we cannot conceive of this work in itsentirety and that _a fortiori_ we are incapable of knowing or imagininghow it is destined to shape itself for the young will, it is ourprovince to awaken to a consciousness of itself. "[5] Think of thisstatement of responsible authority. How has it been evidenced infamilies and nursing situations of your nursing world? What are yourexpectations of your patients or nurses with whom you work?

Teilhard de Chardin, paleontologist, biologist, and philosopher, likeNietzsche, depicts man as lacking a fixed nature with his own mode ofbeing as his fundamental project. [6] Initially, each person takes on amode of being in his world dependent upon his degree of freedom and thehow and what of the world as presented by his family and perceived byhim. The world as presented is reflective of the family's culture, theirprovincial world view, their unique experienced "here and now, " and thetimes. Metaphorically, the family's lived world, how they experience atthis particular cross-section of their lives, can be symbolicallydescribed as a kaleidoscopic telescoping of its past and anticipatedfuture. Now, this would be what was presented at any particular time. What would a child's perception do to this metaphorical symbol? Thechild's current human development and his narrow experience would belike a circus house mirror that would interpret the metaphorical symboldistortedly. Witness a three-year-old speaking questioningly andcomplainingly about her tension headache to her mute, nonperceptivedoll, and asking her to please, please stop making such a mess andracket. 

The earliest childhood views of family and community are influenced overtime, gradually and abruptly, and grow in complexity. The child'spuzzlement is aroused by others' comings and goings, happenings withinthe family, immediate neighborhood, and adjacent community, and theworld presented through books and technologically, on radio, television, and tape recorder. Each child attends these presentations with varyingmeasures of complacency, questioning, bafflement, and involvement. 

{42}

For instance, for myself, as a child there was the excitement of theconstruction of a new house in the woods next door and meeting newneighbors. Initially my parents expressed their differences fromourselves. The differences they perceived were followed by negativeprojections on these unknown folk. Were these others really humanlydifferent? I investigated; my family investigated. The folk becamepersons. They expressed themselves differently in volume and sometimesin language. They looked different. Yet they were not fearsome. Theyfelt, cared, responded, and worried much as we did. Mutual knowledgeallowed increasing closeness and liking. 

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

Adult family members whispered about a neighbor woman from across thestreet. She was apparently hospitalized permanently. When I inquired asto why, eyebrows were raised and strange looks were exchanged. I wastold in a not believable way, "She broke her leg falling off the backporch. "

A neighbor husband and wife frequently could be heard fighting bothverbally and physically. Family talk at our house depicted the husbandas "evil, " the wife as a "poor soul. " I did not enjoy being in thesepeoples' house. Perhaps the violence frightened me; perhaps I wasuncertain when it might erupt? Perhaps I was concerned that I might oneday somehow become part of such a situation? Now, looking back over theyears, 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 andmysterious way. All expressed great sorrow for her always solitary andmysterious way. All expressed great sorrow for her elderly mother andfather on her admission to the "State Hospital. " Years later I wondered, and still wonder what happened to that girl, herself? What kind of anexistence has she experienced?

During these early years there was also separation from and loss ofclose loved family members. When I was three and a half a great aunt whoalways appreciated my side of things moved out of our home due to afamily argument. Perhaps most confusing of all during these preschoolyears, at four and a half, my father died suddenly. "They" said that hewent to heaven, that God called him. Why did he go? Why would he leaveus? Most important how could he leave me? What had I done wrong? Was itthat 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 howshould one act toward authority and power? The world didn't feel like avery safe place nor did persons appear to be dependable. 

Then there was school. With additional authorities and peers there arosenew 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 wasat school? Could I depend on things being safe? In kindergarten I madean ash tray of clay for my already dead father. 

In my child world there were books, radio, and the movies. Todaychildren experience these, as well as television and record players. Forme, books, radio, and the movies brought into my world new aspects offear, excitement, joy, love, horror, violence, imagination, andsuspense. They depicted at times the ideal and at times the abysmal. Sometimes, despite everything, good triumphed. At other times regardlessof the effort invested all was lost. Where was the harmony of logicalreason? Is our world absurd? Are we absurd to respond to it with anexpectation of reason?

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

More than earlier, today there are multiple community groups forchildren where activities are guided and supervised. Within thesesituations and in the free play of neighborhood children, there isalways the confusing, enlightening, and frequently distorted informationgained 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 parentalfuror. Furor and different reactions from different involved parentslead to further child confusion and focus. 

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

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

When the focus of our responsibility shifts from play to work, duringthese early years of becoming, depends on our particular circumstancesand abilities. For most persons there is a tipping of the balancebetween these. Hopefully neither extreme is the master. Fortunately, inmany instances, as the child's work as been to play; the adult's workworld, his world of responsibility is lived, experienced by him, to anextent as play--it gives satisfaction and pleasure. 

{44}

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

MAN BECOMES EVER MORE

Buber perceives man becoming more through his human capacity to relateto other being in all forms from the materialistic to the spiritual in"I-Thou, " "I-It, " and "We" ways. [8] Gestation, with the closeness ofmother and child, has left man with an ingrained knowing of theexperience of closeness. Thus, throughout man's life his condition ofexistence is affected by and desires relationship with and closeness toother being. The closeness of the conditions of gestation is never againpossible, hence existential loneliness. Yet because of this prenatalexperience Buber conceives of man as born with a "Thou"--another--beforehe is conscious of himself, his "I. " With growing consciousness he sortsout his "I" from his "Thou. " You can see the late infant doing, actingthrough, this separation. During this growing phase, often to thecare-taking adult's frustration, he repeatedly, intensely, and excitedlythrows his toys or bottle out of the crib, carriage, or playpen. Oftenhe runs away from his "Thou, " his parental security source, to a safedistance with intense awareness of what he is doing. While internalizingthese and subsequent "Thous" as part of his "I, " his knowing place, paradoxically, he sorts out who he is, and who and what is other thanhimself. So with ever more relationship, ever more experience, hebecomes ever more the person he has the human capacity to be. He becomesmore 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 alwaysnecessitating an "I, " a man, capable of recognizing self as at adistance, apart from otherness. Therefore, his "I-Thou" relating, amerging of beings, is not like the psychological defense, unconsciousidentification. Buber's "I-Thou" relating emphasizes awareness of eachbeing's uniqueness without a superimposing, or a deciding about theother without a knowing. Such relating is a turning to the other, offering the other authentic presence, allowing the authentic presenceof the other with the self, and maintaining one's capacity to question. It is not then identification or an idealization of the other. Withinthis mysterious happening of "I-Thou" relating, when both participantsare human, each becomes more. Buber refers to the event of this mergingof otherness, of man with other being, as "the between. " Humanisticnursing is concerned with "the between" of nurses and their others. Their others, the {45} microcosms of their communities, would bepatients, patients' families, professional colleagues, and other healthservice personnel. 

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

Finally man relates with others as "We. " This permits the phenomenon ofcommunity and of adult unique contribution. So man becomes throughrelating with family, others, and community, like Hesse's onion or abeing 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 senseeach unique person might be viewed as a community of the beings withwhom 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 togethersupposedly for a common purpose. Since time began, man in community hasbeen experienced by man as chaotic. Thus Plato wrote _The Republic_. [10]This presentation depicted an impossible scheme for developing an idealcommunity. As a classic, _The Republic_ continues to be a thoughtprovoking thesis. Its antiquity makes one realize that this desire tocontrol, our continued concern with genetic planning, is a part of thevery nature of man. And yet, considering man's ever existing recognitionof 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 ofthe individual's existence in accordance with his particular potentialfor development to fulfill the needs of his ideally conceptualizedcommunity. Today Heinlein, a science fiction novelist, still writes ofbreeding for longevity in man, as we breed animal stock for the greatestamount of meat and profit. [11] Giving Plato his due, he recognized atthe end of his book concern and doubt as to whether men so carefullymated and reared would fulfill their designated responsibilities. Hewondered if things could, would, or would not go in accordance with hisplan. He then logically indicated the process and kinds of communitydeteriorations which could ensue. Plato had a concept of an idealcommunity, of ideal types of necessary men, and of ideal male-femalebreeding relationships. He viewed our present-style family as one thatsaps the {46} strength of community and does not support this concept. He conceived of communal living more like the communal living of ourpresent-day communes. However, Plato's communes would have beenregulated by the plan as he conceived it. Existence in these communeswas 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. Nursesdo influence who gets the hospital bed and who does not, who gets thespecialized treatment and equipment, who is discharged and when, andwhat 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, andfamily size. So nurses can make a difference regarding communitythought, purpose, and action. 

Nietzsche put forth a concept of community of a more indefinite naturethan Plato's. [12] Two major themes dominated the nature of community inhis conception: (1) the legitimate purpose of community was the totalsupport of its elite men and (2) the criterion for determining the elitewas to be based on those who selected their own values with a "will" tosay, "yes" to life. He referred to his elite as supermen. He questionedthe realization of such a community because of the preponderance ofconforming nonquestioning mediocre men. This complacent majority fearfulof the different or strange would subdue the possibility of hissupermen. 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" wasnecessary for becoming superman. 

To me it is wondrous to ponder my own conscious purposefulness andunconscious purposelessness, my quality of force as a member of thenursing and health communities, viewed through the deep extensiveconceptualized thought Nietzsche bequeathed. I offhand consider ourcommunities as egalitarian, part of a larger egalitarian society. Arethey really? Does the citizen affect the quality of organizationalstructure in accordance with his existential needs while in ourcommonplace--the health-nursing world? Whose values set and direct onthis stage of life? Do I, nurse, search out the values on which I wantto base my nursing practice? Do I look for direction and values fromothers? Did I take on values during my initial nursing experience--valuesnever to be reexamined?

Within the nursing community are there nurses eagerly noncomplacent anddesirous of looking at, of sharing their explorations, and ofdetermining and choosing the values that they want to underlie theirnursing practice? {47} Would supernurses be allowed to be the mediocremany? Who would determine the elite of the nursing community? Couldsupernurses survive without approval of their being different? Wouldthey be strengthened by the fruits of suffering in their struggle withinthe profession? Would these fruits of suffering contributeconstructively to the strengthening of the nursing community?

Buber, like Nietzsche, sees man-in-community with possibilities forevolving, being, and becoming more. Buber trusts each man as a uniquepotential involved in an ongoing struggle with his fellows directedtoward a center. [13] His nonstatic, nonselected community where menbecome in and through ongoing struggle with each other expresses thereality of my nursing world. Who would expect a community withoutstruggle if they accepted each man as his history inclusive ofantecedents that go back to beginnings of man's consciousness and ofanticipations that go forth into this man's notions of eternity?Considering the complexity of each man's being and becoming, it issurprising 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 withother man (patients, patients' families, professional colleagues, andother health service personnel) as "We" in an ongoing struggle ofcommunity considering their multitudinous differences? Norman Cousins, in _Who Speaks for Man_, comments on man's inability to respondaffirmatively to those he experiences as different from himself. [14] Forthe human community to progress he suggests federation. A unity in whichdifferences would be valued as promoting thought, human evolvement, andcommunity advancement. Cousins gives examples of man's inhumanity to manbased on differences viewed as nonvalues. The prevalence of this latterview of differences is very evident in our commonplace health-nursingworld. Can nurses and other health care maintainers look at the waysthey respond to differences consciously, and can they deliberatelychoose to be open to responding to them as valuable? Can we conceive ofthere 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 anexistential way with my contemporaries, patients, patients' familieswhen their values in reality are so different from my own? How do I gobeyond a negative judgmental to a prizing attitude that would open thepossibility of seeing strengths in others' views perhaps lost, discarded, or never previously existent in my own? Nonsuperimposing ofmy own value system through recognizing and bracketing it is a difficultprofessional goal. And yet, a goal that if coupled with the courage forpersonal existence, could sustain me in the health-nursing community. {48}

So for a health-nursing community to truly be actualized each nursewould 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 theexistent community. Over time a merger of the values of the nurse and ofthe existing community would be reflected as moreness in each. The nursewould be more through her relation with the community; the communitywould be more through its relation with the nurse. Each would make animportant difference in the other. The macrocosm, the community, wouldreflect the nurse's quality of presence. The microcosm, the nurse, wouldreflect the presence of the community with her. Each unique man becomesin 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 (NewYork: 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 ofNietzsche_ (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 MacmillanCompany, 1953). 

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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 conditionof humanness is necessary in the nurse for the actualization ofnursing's research potential? This chapter will attempt to share somebrooding and mulling on this problem. 

Nurses practice within ever-moving, changing settings where formulatedplans frequently and suddenly go awry. Unexpected patient needs arise. Powerful others make both reasonable and unreasonable demands. Dependedon others fail us due to human frailty or lack of dependability. Thenurse's setting, her researchable area, is the extreme opposite of hercolleague's, the laboratory investigator's. Her area is beyond researchcontrol measures. Too, it lacks the quiet isolated atmosphere conduciveto contemplation and creative thinking associated with research. 

Conversely, it is oversaturated with the "stuff" of meaningfulexistence. It can stimulate questions to the frenzy of immobilization. The human nurse's system can become overloaded. Such overloadingreflects the humanness of the nurse; like all man she can envisionpossibilities beyond any human being's ability of fulfillment. 

Nurses know there are events in their commonplace worlds that scream forhuman interpretation, understanding, and attestation. The questionbecomes "how. " This "how" depends on more than concretes and events inthe nurse's setting. This "how" depends on relevant "ifs. " Themeaningfulness 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 availableand visible to nurses in the health setting to be preserved, conceptualized for durability, it needs to be valued by theinstitutional health community. Still, most necessary to its duration isthe 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 awedwith the need to be cognizant of multitudinous factors. At this initialintroductory phase one could say her "being" as a nurse is programmed orimprinted with: It is your responsibility to report and attend all thethings that influence the response and comfort of those for whom youcare. This programming supports and is supported by any already existingtendencies within the nurse student toward unrealistic, perfectionisticexpectations of self. 

Then in research courses, usually positivistically geared, herprogramming jams. Her system is fed: Select out, isolate, focus down ona single question, limit your variables, establish a protocol ofoperation, control for reliability and validity, tunnel your vision, andsafeguard objectivity. The jamming is the result of the human nurse'scapacity to see relationships between the part and the whole. Humanintelligence, as a condition of humanness, demands this relating of onething to another. Often such relating is intuitive, human, based on muchthinking for purposes of understanding and solution. Yet, often itcannot be substantiated fully and conceptualized logically at specifictimes, therefore it is subjective. 

To highlight the obvious in the above I attempted facetiousness. Manynurses acutely aware of the complexities, contradictions, andinconsistencies of their nursing worlds have struggled and used thepositivistic method in research studies. Hence, they have isolated aresearchable question, stated their basic assumptions, hypothesizedoutcomes, selected samples, established experimental and control groups, formulated methodologies, searched out and utilized appropriatefindings, and have made recommendations. Usually these research effortshave advanced scientific knowing and knowledge of existents within thehealth-nursing situation. And yet, often these efforts have discouragedthe research wonderment of the nurse interested in the nature andmeaning of the nursing act and how the event of nursing is lived, experienced, and responded to by the participants. These positivisticresearch methods have made available answers. Still, they have notanswered the questions most relevant to nursing practice and to nurses. 

These nurses were certain that man generally could not be prescribed forinterpersonally; he was not predictable, not yet an automaton. Facedwith alternatives men often surprised. Consequently these positivisticapproaches to studying human events, unless one forced one's datacrowbar 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 themost 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 adisquiet that has to be understood and endured. Necessities forscientific study in the nurse's world of the nursing event or situationare wonderment, concern, and responsibility. Open adherence to suchqualities frequently startles others into speculating about theresearcher. She, herself, becomes an oddity. Persons ponder thepossibility of her study's having a hidden agenda that involves them. Over time these persons generally accept or reject the searcher'sefforts. If rejected the searcher is often labeled a worthless noseytroublemaker. Subtly it is conveyed among those involved that she is tobe interfered with often by mechanisms of ignoring or forgetting orrighteously setting "patient's needs" above conforming to the studyplan. For instance, how often have research nurses met with responsesfrom staff at the time of their planned arrival on a unit to work with apatient, "Oh, he seemed to need activity, he was restless, I forgot youwere coming, I sent him to the gym, " or "Oh, (surprise) did you want togive the patient his morning care? That was done a while ago; we givecare early. " If accepted the searcher is often labeled an interested, interesting person whose efforts are to be fostered because her findingswill enhance situation nursing. The distinction frequently is based instaffs' responses to the searcher's personality more than in the valueof the issues of the investigation. 

Significant to negative staff responses toward a nurse searcher is thenecessity for her to withhold information. This withholding may benecessary to protect the study results. For example, it is necessarywhen a special type of patient care is being tested against usualpatient care or when confidentiality is an issue. Confidentialityrequires a nurse, searcher or not, to censor communications whenpersonal knowledge of individuals make them identifiable. The need forconfidentiality can be determined by the nurse's considering theknowledge gained in view of whether it will or will not influence theover-all treatment plan. If it will affect the plan, there is reason toreveal it; then it must be related in a manner that insures thepatient's continued protection and, if possible, with his permission. Ifover-all treatment is not influenced, one must censor the knowledgegained to check one's own free communications. Would the patient want itrevealed; is it knowledge of a quality that brings ridicule, is lookedat negatively or nonacceptably in our particular culture generally? Isit of a sensitive nature and therefore knowledge we do not just revealto anyone?

Other patient care givers may sense this withholding by the nursesearcher. They may reasonably accept it or unreasonably not accept it. The researcher may or may not be aware of or concern herself with hercolleagues' sensitivity. This would depend on the searcher's usual modusoperandi and on the importance she associates with her colleagues' swayin her investigation. The latter can be much greater than is obvious. {54}

Confidentiality--Description: Humanistic Nursing

Humanistic nursing practice theory proposes phenomenology, a descriptiveapproach to participants in the nursing situation as a method forstudying, interpreting, and attesting the nature and meaning of thelived events. Humane nursing is not humanistic nursing within thistheory unless that which becomes visible to the nurse in the nursingsituation 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 professionalhelping realm, a practitioner or researcher is wed to "ought" and"should" virtues. The knowledge gained "ought" to be dispersed tocolleagues for their increased understanding. It "should" enhance theconstructive force of the profession. To so enhance it "must" becommunicated in a manner that allows understanding while protectingdistinct individuals and groups. Words and conceptualized ideas are thetools of phenomenology. Protection of distinct persons and meaningfulcommunication can be augmented through the utilization of abstractions, metaphors, analogies, and parables. So humanistic nurses, aspractitioners and researchers, are inherently responsible for theirmanner of being, responding, and consciously sculpturing knowledge intowords. 

Responsibility When Sharing: Understanding of Man

How does a nurse searcher, who wonders, notices, relates, and comes toknow, become humanly responsible? Nietzsche's philosophical works woulddirect a nurse searcher to look at her values. The values known throughlooking at what determines her actual behavior considering how thesevalues 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 hopefullybenefits them. Despite the human excitement of discovery, disciplinedeffort and rigorous evaluation enter into preparing knowledge of man fordispersal. Revelation should not merely shock; rather, professionally weuse shock to awaken surprise, a fundamental, for human constructivemovement toward moreness. The former, mere shock, needs to be guardedagainst. The latter, shock to awaken surprise needs to be exactingly, uncompromisingly attended for the communicability of knowledge and theactualization of the phenomenon, nursing. 

In considering confidentiality and the quality of knowledge of manavailable to me, as nurse, my consciousness is confronted with my formermentor, and internalized "Thou, " Paul V. Lemkau, M. D. , psychiatrist. He{55} emphasized repeatedly that the professional person, as heincreasingly understands man, should take on increasing responsibilityto man, one's self and one's others. Buber says, "As we become free . .. Our responsibility must become personal and solitary. "[1] One can extendthis and say that to help others struggle for freedom one must realizethat others must responsibly decide and that although they do thisthrough and in the authentic presence of a nurse, these others are alonein deciding. And nurses in deciding what and how to convey of theirknowing must decide freely, responsibly, personally, and alone. 

The nurse in deciding what and how to convey, considering theprofessional necessities of both confidentiality and dispersion ofknowledge, can be guided by a conception of the nature ofman-in-his-world. Man in humanistic nursing practice theory is viewed asa conflictual, contradictory, inconsistent dilemma. One horn of thedilemma 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'snature, as such, supports greater self-acceptance. Self-acceptance andthis view of man-in-his-world, like a magnifying glass, unmasks for anurse her possible responses, motivations, and alternatives. Cognizantof these, she can responsibly select what knowledge to disperse toprotect individuals and to continually shape and conceptually actualizethe nursing profession. Utilizing this magnifying glass on self inhumanistic nursing practice theory to let one's existing mixed, varied, struggling responses, motives, and alternatives into self-awareness isan axiom referred to as authenticity with self. 

Acceptance of the others' human nature or human condition of being isusually easier than acceptance of our own. Usually each man is his ownseverest judge. Lilyan Weymouth, R. N. , clinical specialist, my pastteacher and present friend, in sympathetic moments, speaking ofsuffering others, often says, "the poor devils. " Once, feeling anxiousand annoyed, I responded, "we are all poor devils. " She retorted, "I amglad you recognize that. " Stopped short, I found myself continuing toponder the phrase, "poor devils. " Man's dilemma is that he is neithersaint nor devil. He is a "poor saint" and a "poor devil, " and by hisnature he is pushed and pulled in both directions, "all-at-once. " Ourhuman existence in the world calls for an enduring with our virtues andvices, our energy and our laziness, our altruism and our selfishness, ina word with our humanness. 

What meaning does this conception of man have for humanistic nursingpractice theory? This theory necessitates a nurse who accepts andbelieves in the chaos of existence as lived and experienced by each mandespite the shadows he casts interpreted as poise, control, order, andjoy. 

Labeled mental patients in therapeutic situation, in the sun beyond theshadows, express how they set themselves apart from the rest of thecommunity {56} of man. They express how they experience themselves. They view themselves as the worst, the noblest, the unhappiest, the mostmaligned, and the most afraid. It comes out as if these superlativedistinctions are their only claims to fame. In my humanness I appreciatethe awesome dreads they live. They need to know that they exist in theirunique distinctness. And yet, the separation and loneliness with whichthey adorn themselves and which professionally we have fostered withfear 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 assuffering the turmoil of existence as part of the human community, suchas it is. One usually can note their surprise and disbelief of my view. Then, momentarily at least, tension seems to visibly fall from theirfaces and forms. When this idea of them is heard by them, its effectcorresponds to how I experienced the technique in sensitivity group ofliterally being allowed to dance into what felt like the circle of man, our group. 

To hear opportunities for humanistic nursing acceptance and supportnurses, too, need to question their self-nurse-image within the nursingand health community. Do they know that they make and have realpotential for making a difference, an important difference? Do theyaccept themselves as nurse? To me, a nurse is a being, becoming throughintersubjectively calling and responding in her suffering, joyous, struggling, chaotic humanness, always trying beyond the possible whilenever completely free from ignoble personal human wants. And, throughher presence it is possible for other persons to be all they can be incrisis situations of their worlds. For the nurse to be humanistic it isnecessary for her to live her human condition-in-her-nursing-worldproudly with all its vulnerability and all its wonders. As man, thenurse can recall and reflect on her "I, " on her past "I-Other"experiences, and she can come to know and accept more and more ofherself, as she becomes more. In humanistically recalling and reflectinga nurse will understand and respond empathetically and sympatheticallyto both her own humanness and the other's. She will recognize both selfand other as "poor devil" and "poor saint, " all-at-once. 

On the other hand, if a nurse denies her own struggling humanness, sheself-righteously will be apt to accuse either self or her other. Thisway of being denies, suppresses, and represses one's own and the other'sability to be, to be as much as potentially possible. Understanding manthrough this conception of him is important to the possibility ofaugmenting 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 livedworlds, our experience, a return to the study of "the thing itself. "Looking at the lived worlds of nurses one is confronted with conflictsand multiple {57} values. In their nursing worlds nurses often riskthemselves in their commitment to good for their patients. They come toknow aspects of their own and others' unique natures. These are oftendifferent from and frequently in conflict with generally acceptedcultural values and/or institutional policies and rules. Ifconfidentiality is an issue, does this dictate a suppression of nurses'complete knowing? Or does this call for a recognition of as complete aknowing as possible followed by responsible selection and revelation ofthat knowing which will advance knowledge and understanding of man?Understanding of man can change a person's way of being with other manand his way of existing in and responding to his world. I suggest thelatter, as complete knowing as possible followed by responsibleselection and revelation, with occasional risk taking to deepen thelevel of accepted cultural knowledge of man. Always, the nurse wouldprotect an individual other man. This dispersion of knowledge, then, requires not only responsible being in the nursing situation but alsomulling, pondering, assessing, and judging prior to disclosure. 

As complete a knowing as possible, in humanistic nursing refers to itsaxiom, authenticity with the self. When I, nurse, respond in the arenaof my lived nursing world, I respond to a particular person in this"here and now" with all my background and all my anticipation of thefuture. By respond, I do not mean to indicate that I overtlydeliberately communicate or verbalize my total response. Rather I meanthat I strive for _awareness_ of my total response within myself to aparticular person in a particular "here and now" viewed through myparticular past and anticipated future. It is a struggle to grasp how Iperceive and respond within all my capacity of human beingness. Toattain the highest possible level of authenticity with the self requireslater recollection of ongoing perceptions of the other and reciprocalresponses, selected communications, and actions by the self. Theserecollections now become raw data available for analyzing, questioning, relating, synthesizing, hypothetically considering, and ongoingcorrecting. Sometimes sharing such recollections with a trustworthyconfidant (clinical specialist, consultant) for purposes of realitytesting is helpful. Often this can broaden the professional meaning baseI attribute to both my perceptions and my responses. On return to thearena of my nursing world I then verify my perceptions. I can let theother know how I perceived his actions and be open to his furtherexpression of how this world is for him. In professional nursing thiskind of experiencing, searching, validating, utilizing of one's humanpotential capacity must be based in the ideals on which nursing rests. Primarily for me, I see myself, nurse, as comforter or being nurse insuch a way that my other is helped to be all that he can humanly be inthis particular "here and now" considering his unique potential. 

So, being authentic with the self, is not an acting out of a nonthoughtthrough response or merely a doing of what one feels like doing. Ratherit is the very opposite of this. It is a thought through responsiblechoosing of overt response based in knowledge and on nursing values. Itmust correspond positively with one's belief that searching and sharingin one's nursing world will promote both the nursed and the nurse to bemore. If it is merely a {58} peeking in on, an exploitation of theother, for selfish learning purposes, it desecrates the very concept ofnursing. One has the broad human potential of feeling like doing manythings, all-at-once, that extend into all kinds of living. And this istrue in, as well as outside, a nurse world. In recollecting andreflecting on perceptions and responses in all these extremes onebecomes freer to select from within one's self the values to be chosen, actualized, and potentiated in one's nursing practice. Authenticity withthe self calls forth confrontation of the self with one's motivationsand alternatives. This permits a purposeful selection and an awareactualized overt response based on one's nursing value criteria artfullytailored 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 inaccordance with our uniqueness. Many nurses given the same data wouldaccomplish with the same or a similar degree of adequacy through use oftheir particular distinct selves. Therefore, though the function calledfor might be the same, each nurse would approach the function and thepatient differently. How one actualizes the result of thinking, andbeing 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 ofnursing's potential. " In it I have been trying to say, the more ofourselves we are able to awarely include, the more of the other we canbe open to and with. A capacity for presence with others allows us toshare ourselves. Through this sharing others become more. They are ableto 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 isto be striven for. It is a taking advantage of and appreciating of ourhuman ability and spirit. It fosters our pursuit of inquiry, improvesour caring for others, the contributing of our unique knowing, and itallows us to shape ever further a scientific-artistic profession ofnursing. 

Authenticity With the Self: Potentiated in Lived Experience

This example is offered to support the claims for authenticity with theself made in the last paragraph of the prior section. 

{59}

As clinical supervisor and thesis advisor to a young graduate nursingstudent in her twenties the benefits of authenticity with the self wereagain brought home to me. She was taping her therapy sessions with twopatients. These taped materials were to become her thesis data. 

One of her patients was not much younger than herself. The other was adivorced woman in her forties, around my age. This young graduatenursing student was receiving clinical nursing supervision as anecessity in her particular situation not by personal choice orawareness of need. 

>From the onset of her clinical supervision with me I was aware that itaroused her feelings about dependence. At her age this had meaning sinceshe was still struggling for independence and interdependence. This is adifficult time. Her response to me was "respectful, " sweetly andunawarely hostile, and she made it apparent that I was another nurseauthority to be appeased, manipulated, and outsmarted. This behavior hadbeen successful for her with past authorities. She was bright and hadbeen able to complete intellectual requests and assignments at the lastminute with little effort. During the initial phase of our relationshipawareness of her struggle, her difficulties and her assets, allowed meto maintain a supportive kind of being with her. 

In listening to her therapy tapes I realized that another clinicalsupervisory approach was called for. She was defending against relatingto her older patient by behaving toward her as she probably felt towardher own mother, and often toward me. Also, she was defeating hertherapeutic purpose with her younger patient by viewing her as if thepatient were herself. The older suicidal, depressed patient was beggingher for an understanding therapeutic relationship. She needed terriblyto share her suffering. This woman did not need a "rejecting daughter"working hard to outwit her. The younger patient needed to share herangry 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 thistime neither the student's need to understand nor the patients'therapeutic needs were being met. The student, too, was aware of this ina 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 myshoulders. So if there were no beneficial outcomes, obviously the blamecould be placed. 

During the initial phase of my relationship with the graduate studentand during the initial phases of her relationship with her patients Icame to understand. I listened, got into the rhythm of these otherspirits, reflected on what I had come to know, and out of thisexperience 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-ratetherapist. Together we explored the implications of the above. Shebecame invested, involved, and excited about herself becoming more. We, myself and each of her patients, become for her more whom we essentiallywere. Most important to her and to me, this graduate student grew in herrecognition and acceptance {60} of herself and her ability as an adultnurse therapist. The thanks and meaningful praise she received from bothher patients on termination of therapy made this apparent. It broughttears to both her eyes and mine. I felt joy in being with anow-respected colleague, as opposed to the earlier being with a personwho felt like an unasked for "awe struck defensive daughter. "

Authenticity with myself, and this graduate student's ability forauthenticity with herself allowed these patients' progress to occur. Itallowed a realistic articulation in this student's phenomenologicalmaster's thesis of her lived nurse experience. From such articulationwill 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, aprofessional history is possible, accrues, and has lasting duration. Thestudy of the nursing event itself and its conceptualization as proposedin humanistic nursing practice theory is an application ofphenomenology. Articulation of our perspective, experience, and ideas isthe human way of phenomenology. 

Words are symbols to which man gives meaning as an outgrowth of hiscivilization within his culture. Through words man attempts tocommunicatively describe his experienced states of being-in-his-world. In describing, of necessity, he relegates his uniquely known experiencesto already known word symbols or categories. Thus, the conceptualizedexperience is limited, or less real than the lived unique experience. So, while words prevent the loss of the wisdom of lived experience, theyare both a wonder of humanness and a limitation of humanness. 

In describing human experiences there are efforts that can cut back thislimitation. If we truly wish to convey meaning to others, really want toshare what we have experienced in living, we will put forth the effort. To put forth such effort requires going beyond "I must publish topublish. " It takes writing, structuring, rewriting, and restructuringoften to a point where for a period one comes to hate materials he onceheld dear. 

Through the years many of us come to use words as a means of passing acourse, or we view words as a mode for self-explosion, expression, andself-understanding. In these ways they hold much purpose. Therequirement that words convey unique experiences of being to othersdemands much more. This necessitates one selecting words that depictone's perspective, his unique human angular view; or depict for another, this particular man as he perceives and responds to his uniqueexperience. Such a depiction has to be unknown to the other; each one'svantage 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 tothe nurse. An adequate dictionary and thesaurus can be useful. 

The actual presentation of experience for an audience demands anordering of data in a sequence that will be sensibly logical for them. We live experience in an order that flows from our being and historywithin a multiplicity of calls and responses. Presently human expressionis limited to sequentiality. So again we see that the conceptualizedexperience is different from and lacks the reality of the uniquely livedevent. Structuring a logical sequential presentation of data, decidingon those aspects that influenced meaning, and having it conform asclosely as possible to the real is difficult. 

Often, when it seems that one has done his very best, it is wise to havea trusted other react to conceptualizations. Another's questions canbring to the conceptualizer's awareness thought connections that movedhim along and that he has failed to convey. Also, such a reader canindicate aspects of thought trips the writer took that add nothing tothe issue at stake and weaken his message. Too, another's response canmake apparent to a writer the need to clarify meaning. Thisclarification may merely entail a better choice of words or phrases, orit may suggest the use of a meaningful metaphor, analogy, or parable. 

These last imaginative forms of expression we frequently usemeaningfully, sometimes like a shorthand, with our intimates. A phrase, metaphor, or analogy conveys with an immediacy the quality or spirit ofan event. For example, a nurse working in a psychiatric hospital unitspeaking of a patient said, "He came down the hall looking like anaccident about to happen. " A page of technical description could nothave given me as much feeling for what she and the patient wereexperiencing at that moment. In nurses' efforts to express objectively, scientifically, and eruditely such modes of expression are often deletedfrom our written professional works. It is as if we enforce the rules ofmedical record charting of precision, conciseness, and use of "weasel"words onto all our written works to the detriment of a theoretical andprofessional enduring body of nursing knowledge being actualized. Ittakes considerable pain and endeavor to find egress from such humanprogramming. With it we have purified, equalized, wearied, anddehumanized supreme experiences of human existence. And, we have negatedthe meaning and importance of ourselves and nursing. How often have youheard, "I am _just_ a nurse"?

Phenomenology requires rigorous investment into respectfully, appreciatively, and acceptingly making evident our lived worlds andtheir ramifications for the now, the past, and the anticipated future. Nursing literature of this caliber would call and inspire those whoattended it to further nursing practice and responsibly share themeaning they attribute to their area of specialized dedication. 

The raw data of our lived nursing worlds do not easily reveal theirmeanings or messages. Many see their worlds only superficially, andthemselves as mere functions. How often a nurse is surprised, confounded, on hearing a relative or friend speak of a nursing event intheir lives that may have occurred {62} from 10 to 40 years previously. Frequently persons express appreciation for the meaning these eventshave 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 messageto a nurse. New data are sucked easily and immediately into old, wornout, known theoretical frames and networks of words. Severeself-discipline enters into describing nursing experience with the vigorof how it was lived. Too easily the description is let fall to mediocrecommon forms. Proper grammar and plain English should suffice. Thiswould carry the nursing message, as jargon borrowed from otherdisciplines in which the nurse always speaks as an alien, never will. Humanistic nursing practice theory in asking for description does notask one to forget or deny known terms and knowledge. Rather it asks fora bracketing or holding of this knowledge to the side. The nursingexperience should be given an opportunity to be seen in its pure form, rather than forcing it to conform to foreign prestigious terms borrowedfrom other areas of specialization, which beg the meaning of the nursingevent. Prior to dispersion, of course, one should weigh one's expressionin English against one's expression in one's known foreign jargon. Thenone will be open to choose how one wants to express and share themeaning of her nursing world. 

Phenomenology accepts categorization as a necessity of communicating. Itholds, nevertheless, that this is secondary to initial awareexperiencing. This study method acknowledges the unfathomable complexityof existing and knowing. It strives for as adequate conceptualization ofthe existential experience as possible. It honors the knowing person'scontinued capacity for surprise and wonderment. Phenomenology asks us togo beyond the common labels to the surprise of our own and other'sunique existences-in-the-world. A nurse who had been struggling overmany months with a family in their home, on the day she firstexperienced an "I-Thou" relationship with them said, "It was as if I hadgone beyond the uncooperativeness and dirtiness of the situation. "Immediacy in labeling offers us the complacency and security of awrapped up problem. How could a nurse be held responsible for whathappened to a "dirty, " "uncooperative" family. The many commonly heardlabels humans attribute inhumanely to others rarely relate to answers insituations or to the dreadful human suffering problems generate. 

Phenomenology seeks attestation of the meaning of a situation to aparticipant. Positivism seeks general objective categories within theuniversal. Phenomenology prizes differences, variations, and strugglesfor their representation as parts of the whole. Rather than emphasizethe majority as holding sway, it recognizes that the unique contributioncan 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 healtharena she accepts her lived nursing world as beyond the controls valuedin positivistic science. She appreciates her lived nursing world assaturated with knowledge to be extracted or wrung. Then she mustexamine, recognize, appreciate, and unfold her history, her angularview, and her human nurse potential. In prizing her view, as nurse, shewill ask relevant nursing questions. To attain her potential as nurseshe will discipline herself rigorously for authenticity with the self. With the self-acceptance that comes with self-authenticity she will knowthe importance of the difference she and the nursing profession make andcan make in the community of man. Then out of her own human social needand for the survival of nursing she will describe to propel knowledge, nursing theory, and practice forward. In this process and in its effectsshe 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. Delland 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, proposethat nursing practice when studied, like any other area studied, willonly become available for human conceptualization if the study methodsare appropriate to its nature. Therefore, the methodology presented inthis chapter is relevant to humanistic nursing practice theory. 

Embraced within this chapter is a methodology for studying nursing thatevolved out of the process of my nursing practice. The logic of thismethod and of my process of nursing are one. It is not a method ofanother discipline superimposed on nursing. So this method did not forcenursing or change nursing to have it mold or conform. As this methodunfolded it arose from and in accord with nursing process. Thismethodology came into being only after years in which various attemptswere made to get positivistic methodology to answer relevant nursingquestions and to develop a professional scientific theory of nursing. 

The method presented here was used initially to creatively conceptualizenursing constructs in 1967-68. The data for the development of theconstructs "comfort" and "clinical" were gathered from my clinicalnursing practice and while I was deeply engrossed in existentialreadings. The process or method used was not conceptualized until it wascalled for while writing my doctoral dissertation in 1968. It had thenbeen used to study the clinical literary works of two psychiatric mentalhealth nurses, Theresa G. Muller and Ruth Gilbert. [1] Itsconceptualization at that time was rudimentary. Gradually it has beenfurther 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 articleand repeated the process of the methodology in their studies of theirclinical nursing data. Reflecting on this article and realizing howothers had to study and struggle with it. I became aware that still onlythe bare bones of my thinking were presented. Further elaboration ofthis methodology was called forth to share it with the _humanisticnursing practice theory_ course participants. Since 1970 I have delvedinto phenomenologists' writings and at this time can say that thisprocess of studying nursing is a phenomenological method of nursology. Interesting to me is that the initiation of this method came when Ifirst began to read the existentialist literature. Existentialism can beviewed as the fruits of phenomenological study. The process of thismethod has become clearer and clearer to me over time. Phenomenologicallythe 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 andis a conceptualization of this method as I understand it now. 

The following quote is offered to support and validate the efforts putinto conceptualizing this method. The philosopher of science AbrahamKaplan 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 isoffered. Positivistic science aims at objectivity and its results areviewed as scientific facts. Nursing practice has been understood by manyas an implementation of such theoretical facts. Considering my and othernurses' implementation of such facts it is apparent that in theseendeavors nurses come to know much about human existence. 

Philosophy is often viewed as man's contemplations, autobiographicalrevelations, and the values and belief systems that underlie man'sactions, Can an explicit philosophy of nursing allow for more meaningfulquality practice, be a resource for nurses, improve service, beavailable for reexamination, correction, and the forwarding ofknowledge? If nursing practice is viewed as the implementation ofscientific facts and what they call forth in the nursing situationrelated to man's condition of existence, is a heuristic science ofnursing developed from this situation, by nurses, an appropriatepractical professional aim?

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This presentation is my answer, a committed "Yes. "

The method offered here, a phenomenological method of nursology, aims atthe reality of man, how he experiences his world, or it aims at asubjective-objective state. It aims at description of the professionalclinical nursing situation which in reality is subjective-objectiveworld that occurs between subjective-objective beings. The descriptionfocuses on this between and preserves the complex mobile flow of theriver of nursing to make apparent that superficial precise portrayalsare only an overlay of its river bed, course, and eventual destinations. 

The relevance of phenomenological nursology ranges from the formulationof nursing constructs to the creation of theoretical propositions. It isapplicable to one's own clinical data and to others' clinical data, hereand now, or in historical study of the literature. 

METHODOLOGICAL STARTING POINT

This method addresses itself to the question: How can a nurse, asubjective-objective human being know self and the other and compare andcomplementarily synthesize these known betweens?

Basic to this method is a belief system, a philosophy about the natureof 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 themost intimate circumstances. We, too, can not be certain about what wecome to know in our betweens. We can be sure that these realities ofhuman experience are worthy of exploration. Our opportunities areunique, only we can describe man in the nursing situation. 

In _Let Us Now Praise Famous Men_, James Agee voices a similar concernabout the need to describe man-in-his-world and the adequacy of humandescription. [5] Aware of the wonders and complexities of man heconsiders not trying to describe worse than the inadequacy ofdescription. 

Thinkers have also acknowledged that we can come to know from others. Apoem 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 webecome through our relations with others. Each human person hassomething 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 applyin-the-lived-experienced-world. We each view the world through ourunique 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, hesays:

 "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 herparticular knowing with fellow struggling human beings. Only througheach describing can there be correction and complementary synthesis tomovement beyond. 

The nurse's world is an experiential place for becoming influenced byeach participant's "here and now" inclusive or origin, history, andhopes, fears, and alternatives of the confronting future. Positivisticscience 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 ofconsciousness which is intersubjectively influential. 

So as human nurses we are limited in our ability to express the realityof our-lived worlds. Yet, also, this world depends on and demands thatwe, as human nurses, give it meaning, understand it in accordance withour {69} humanness. Will and Ariel Durant, historians, professionalswho 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 humanbeings. As such we are capable of looking at our existence, choosing ourvalues, giving our world meaning and of constantly transcendingourselves, or becoming more. If we value and prize our human nursingworld and our human potential for consciousness and expression, we willactuate our potential and conceptualize our human nurse-world. Thissuggests questions to me. What do I want nursing to be? How can Iinfluence the meaning of the term, nursing? How committed am I? Whatinvestment am I willing to make? Will I risk exploring and saying what Isee in my nursing world? Am I open to knowing? How can I actuate myuniqueness to allow the realistic potential of my nursing profession tobecome, become ever more? Am I contributing my "nursing here and now" tonursing's history through a lasting form of expression? Of whatimportance is what I think or say; do I make any difference? HermannHesse 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 amongnurses, then, confronts us with a responsibility that belongs to oneelse. 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 conditionedstate. Only each nurse can be responsible for herself. The wonders offreedom are {70} paradoxically, "all-at-once, " both a delight and aburden. In nursing it is important for us to understand freedom not asopposing or agreeing: freedom is choosing--choosing and saying "yes" toone's self. 

Human endeavor between man and men in their-worlds, in this instanceprofessional clinical nursing, if explored and described is viewed ascontributing to man's human evolvement and to knowledge of the humancondition and how man becomes. 

Integrally all the above statements are the bases and biases of thishuman phenomenological method of nursology. In a phrase, I suppose whatall these _starting point_ statements say is: Nursing situations makeavailable human existence events significantly worthy of description. Only human nurses can describe them. Humans' ability to describe realityadequately has its limits. We should describe since pridefully we humansare the only existing beings capable of giving meaning to, looking at, and expressing our consciousness. In the long run this effort couldyield 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 "knowingplace. " Risk taking necessitates decision. Decision imposes confrontingambivalence in one's self. The ambivalence of wanting to be"all-at-once" responsible and dependent. Superimposing an alreadyaccepted and acceptable structure on data is safe feeling. Approachingthe situation or data openly, letting the structure emerge from it, notdeciding what to look for, being willing to be surprised, give feelingsof excitement, fear, and uncertainty. There exists the possibility thatour humanness may include the dilemma of our not being able to perceivethe messages of our data, that we will not be able to merge with it andbecome more. The question arises, Are we knowing places that can relateto otherness and intuitively synthesize knowledge? This process ofaccepting the decision to approach the unknown openly is experienced asan internal struggle and we become consciously aware of our rigidity andsatisfaction with the status quo. Conforming to the usual, in this casepositivism, gives a security that is not easily relinquished despite theadvantages 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 givesthe flavor of the process of preparing the mind. He says, "Through one'swindows one sees not only the joy and beauty of the world, but also itspain and cruelty and ugliness, and the one is as well worth seeing asthe other, and one must look into hell before one has any right to speakof heaven. "[12] Pain, cruelty, ugliness, hell seem appropriate words toconvey seeing our {71}long-cherished ideas and values, our securityblankets, as only false gods. Nietzsche in speaking of confrontation ofone's values said, "And now only cometh to him the great terror, thegreat outlook, the great sickness, the great nausea, the greatseasickness. "[13] So this human methodology seeks a condition of beingin the investigator. The investigator must be aware of her own angularview and democratically open to giving the angular views apparent in thedata, the called for representation. 

The first phase of this method of research correlates well with thestruggle experienced by me in clarifying my approach to patients inpublic health, medical-surgical, and psychiatric mental healthsituations. In these situations, one truly has to struggle withdemocratically keeping one's windows open to the world. And this is acontinual process. Having experienced this struggle in clinical nursingmade this approach to research valid and meaningful to me. 

Preparing the mind for knowing in clinical or research endeavors may beaccomplished by several means. One means is by immersing one's self indramatic and literary works and contemplating, reflecting on, anddiscussing them as they relate to the knower's already known, in thiscase, nursing practice. In clinical or research nursing the selection ofliterary works to stimulate the opening of one's human view is based ontheir presentation, depictions, and descriptions of man's nature. Inliterature authors share their thoughts as men and present possible waysmen 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 imaginationgetting inside of, into _le durée_, into the rhythm and mobility of theother. Living the rhythm of the other he believes results in anabsolute, intuitive, inexpressible, unique knowledge of the other. Hesays:

 ". .. 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 ofnursing situations was intuitive. Most times this was offered ratherdisparagingly although the nursing outcomes were most times successful. Along with having {72} the attribute of intuition assigned to mepersons often asked, "Why are you so fascinated with other persons'situations?" Together these relate to Dewey's view of intuition. Heviews intuition as a mulling over of conditions and a mental synthesisthat results in true judgments since the controlling standards areintelligent selection, estimation, and problem solution. [15] In nursingpractice research knowing the other and how he experiences and views hisworld is viewed as the problem. 

Knowing intuitively, as described by Bergson, is comparable to Buber'sconsiderations 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 inthis human or phenomenological nursology approach. [16] Buber held asprerequisite for intuitive type knowing of the other, or imagining thereal of his potential for being, a knower, and "I, " capable of distancefrom the other, able to see the other as a unique other, one who turnsto the other, makes his being present to the other, and allows the otherpresence. The knowing, "I, " in this case the nurse, responds to theother's uniqueness, does not superimpose, maintains a capacity forsurprise and question, and is with the other, as opposed to "seeming tobe. " This kind of relating cannot be superimposed on a nurse clinicianor researcher. It must be personally responsibly chosen and invested in. 

The approach then of the second phase of this method and of thetransactional phase of nursing when nurses are in the arena with othersis the same. This method proposes that to study nursing from outside thearena for purposes of objectivity bursts asunder the very nature ofnursing practice. The studier is a part of that which is being studied. Observations interpreted from outside the situation could be classifiedonly as projections. 

Phase III: Nurse Knowing the Other Scientifically

Bergson believes man knows incompletely through standing outside thething to be known, metaphorically walking around it, and observing it. This analytical process, this viewing of a thing's many aspects, heconceives as the habitual function of positive science. This is thethird phase of this phenomenological nursology method. Bergson says:

 ". .. Analysis multiplies endlessly the points of view . .. To complete the ever incomplete representation. "

 "All analysis is thus a translation, a development into symbols, a representation taken from successive points of view. "

 "Analysis . .. Is the operation which reduces the object to elements already known, that is, common to that object and to others. "[17]

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So phenomenological nursology proposes that after the studier hasexperienced the other intuitively and absolutely, the experience beconceptualized and expressed in accordance with the nurse's humanpotential. Humanly we can express only sequentially while our actualexperienced lived worlds flow in an "all-at-once" fashion. Our words areknown symbols and categories used to convey the experience and thus denythe uniqueness of each realized experience. 

Buber's description of man's "I-It" way of relating to the world is inagreement with Bergson. He conveys the necessity of this kind ofrelating by man to his world; and despite its lacks proposes that manprize his analytical ability. Like Bergson, Buber views knowing as amovement from intuition to analysis, and not the other way around. Bubersees knowledge expressed or science created through the knowing "I"transcending itself, recollecting, reflecting on, and experiencing itspast "I-Thou" relation as an "It. " This is man being conscious of, looking at, himself and that which he has taken in, merged with, madepart of himself. This is the time when he mulls over, analyzes, sortsout, compares, contrasts, relates, interprets, gives a name to, andcategorizes. 

The third phase of this methodology is the same as that phase ofclinical nursing practice in which the nurse, removed from the nursingarena, replays and reflects on this area and transcribes her angularview of it. In this reflective state the nurse analyzes, considersrelationships between components, synthesizes themes or patterns, andthen conceptualizes or symbolically interprets a sequential view of thispast lived reality. The challenge of communicating a lived nursingreality demands authenticity with the self and rigorous effort in theselection 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 ofcomparison:

 "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 theposition of the knowing place. The knower, like an interpreter, allowsdialogue between the multiple known realities. These realities areunknowable to each other directly. The knower interprets, sorts, andclassifies. 

In the human knowing place discovered differences in similar realitiesdo not compete, one does not negate the other. Each can be true, present, "all-at-once. " Differences can make visible the greaterrealities of each. Desan, the philosopher, says of this kind ofsynthesis:

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 ". .. A synthetic view where two or more positions are seen to illuminate and to transfigure one another through their mutual presence. "[19]

The knower alert to an aspect present in a single reality can questionthe other reality on this aspect. This aspect may be present in both, more blatant in one than in another. Its forms may be different ormodified in each. It may be totally absent in one. Differences found mayarouse or bring to consciousness other questions to ask of the data. This oscillating, dialectical process continues throughout reflection onthe multiple realities. This indirect dialogue is recorded by theinvestigator as the complementary synthesis. 

This synthesis is more than additive because it allows mutualrepresentation and the illumination of one reality by another. 

The fourth phase of this research methodology is like that phase ofclinical nursing in which a nurse compares and synthesizes thesimilarities and differences of like nursing situations and arrives atan expanded view. 

Phase V: Succession Within the Nurse From the Many to the ParadoxicalOne

This phase of phenomenological nursology is highly probable if notabsolutely 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 nowconsciously 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 betweenthe multiple views, insightfully corrects and expands her own angularview. This is not a right-wrong type of correction. Such correctionwould amount only to an ongoing eternal recurrence of a frustratingnature. Rather this correction takes the form of ever moreinclusiveness. Struggling with the communion of the different ideas theknower takes an intuitive leap, through and yet beyond these ideas, intoa greater understanding. She then may come up with a conception orabstraction that is inclusive of and beyond the multiplicities andcontradictions. 

This inclusive conception or abstraction is an expression of theinvestigator in her here and now, with the old truths and the noveltruths, none obliterated. 

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The fifth phase of this phenomenological nursology method can be equatedto that phase of clinical professional nursing in which the nursepropels nursing knowledge forward. In this phase a nurse struggling withthe mutual communion of multiple nursing situations arrives at aconception that is meaningful to the many or to all. From the specificconcrete ideas of the many situations she moves through dilemma toresolution which is nursing expressed abstractly in units or as a whole, as one. 

Experiential knowledge of nursing, years in which I came to know selfand the other while implementing scientific facts, allowed me as aknower to recognize the relevance of this philosophical nursologymethod. This method does not aim at conventionality. Rather it strivesto meaningfully augment and share conceptualized nurse-world realities. 

FOOTNOTES:

[1] Josephine G. Paterson, "Echo into Tomorrow: A Mental HealthPsychiatric Philosophical Conceptualization of Nursing" D. N. Sc. Dissertation, Boston University, 1969. 

[2] Josephine G. Paterson "From a Philosophy of Clinical Nursing to aMethod of Nursology, " _Nursing Research_, Vol. XX (March-April, 1971), pp. 143-146. 

[3] Abraham Kaplan, _Conduct of Inquiry_ (San Francisco: ChandlerPublishing 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: BallantineBooks, 1939), pp. 91-102. 

[6] Johann Wolfgang von Goethe, "On Originality. " In _Great Writings ofGoethe_, 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 andCary 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: Simonand 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 inthe Twentieth Century_, ed. William Barrett and Henry D. Aiken (NewYork: Random House, 1962), pp. 303-331. 

[15] John Dewey, _How We Think_ (Boston: D. C. Heath & Co. , Publishers, 1910), p. 105. 

[16] Martin Buber, "Distance and Relation, " trans. Ronald Gregor Smith, in _The Knowledge of Man_, ed. Maurice Friedman. (New York: Harper &Row, Publishers, 1965), pp. 60-82. 

[17] Bergson, "_An Introduction to Metaphysics_, " pp. 303-331. 

[18] Martin Buber, _I and Thou_, 2nd ed. , trans. Ronald Gregor Smith, (New York: Charles Scribner's Sons, 1958). Pp. 3-34. 

[19] W. D. Desan, _Planetary Man_ (New York: The Macmillan Company, 1972), p. 77. 

[20] _Ibid. _

[21] _Ibid. _, p. 80. 

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7

A PHENOMENOLOGICAL APPROACH TO HUMANISTIC NURSING THEORY

Humanistic nursing is dialogical in the theoretical as well as thepractical realm. Just as the meaning of humanistic nursing is found inthe existential intersubjective act, that is, in the dialogue as it islived out by nurse and patient in the real world, so the theory ofhumanistic nursing is formed, in the dialogical interplay of articulatedexperiences shared by searching, abstracting, conceptualizing nurses. 

The theory of humanistic nursing originates from and is continuallyrevitalized and refined by actual nursing experience. But each nurse, asa unique human being, necessarily experiences the nursing dialogue andher nursing world in a unique way. So the development of humanisticnursing theory rests on the sharing of individual unique angular views. And the theory as a totality will become richer, more consonant withreality, as it represents more and more nurses' views. 

So often nurses, even nurses who know that their clinical expertise grewout of their practice, hesitate to share their nursing experiences. Theyare apt to say deprecatingly, "Oh, that's _only_ my _personal_experience. " Yet that is precisely where the value lies, in theuniqueness of human experience. Since each nurse's description of hernursing experience is a glimpse of a real nursing world, the viewscannot justifiably be judged as right or wrong; they simply are. Oncethe various views are expressed, they can be compared and contrasted, not for the purpose of accepting some and rejecting others but rather inthe interest of clarifying each in relation to the other. Such adialogue of experientially based conceptualizations can result in acomplementary synthesis. The process calls for not only a trueappreciation of personal experience by each nurse but also commitment toa collaborative effort of open sharing by a genuine community of nurses. 

This view, that the development of humanistic nursing practice theory isa dialogical process, has led to our valuing (in fact, insisting on) thedescription {78} of nursing phenomena. We see phenomenologicaldescription as a basic and essential step in theory building. Indeed, considering the "state-of-the-art" of nursing theory development, it isthe most crucial and immediate need. 

Looking back at the historical evolvement of our humanistic nursingapproach, it is obvious that we had been using and developing aphenomenological approach for a number of years before we graced ourefforts with the impressive label, "Phenomenological Psychiatric MentalHealth Nursing, " in a course offered to a group of nurses at NorthportVeterans Administration Hospital in April 1972. Although we were awaremuch earlier that our interests and work were flowing in the generalstream of phenomenology, we usually refrained from using the labelbecause it did little to clarify our position. [1] The term has grownless precise with the extension of its use in different disciplines andwith variations in methodology. 

When we began applying the term "phenomenological" to our work, welearned that to many persons it sounds strange, unpronounceable, foreign; to some forbidding; to others enticing. We later coined thetitle "humanistic nursing" as being more suitable for it encompasses ourgeneral existential bent. However, this change in title does not implyany abandonment of our phenomenological approach. The description ofnursing phenomena is as highly prized now as ever. In humanisticnursing, phenomenological and existential currents interrelate. Havingan existential view of nursing as a living dialogue influences whichphenomena one becomes aware of, experiences, values, studies, anddescribes. Reciprocally, as one discovers and struggles to describe anddevelop meaningful ways of describing nursing phenomena, the livednursing 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 EdmundHusserl's original work, the approach has been used by differentdisciplines. With its spread there has developed a correspondingvariation in methodology. This, in a sense, is the beauty ofphenomenology: it thrives on variety of perspective; it allows, perhapsrequires, 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 ofphenomenological methodology as they relate to humanistic nursing. Thegeneral approach and procedures discussed below have been used, individually {79} and collaboratively, by Dr. Josephine Paterson andmyself with individual and groups of nurses to explore and describetheir nursing experiences. They have helped nurses in various levels andtypes of nursing service to take a fresh look at their practice and makedesirable changes. We have lived through the process with graduatestudents in nursing, and it has led both the students and us to newconceptualizations and reconceptualizations of nursing phenomena. Wehave found this to be a fruitful research method when applied toclinical nursing phenomena personally experienced and/or reported in theliterature. And we are currently exploring its potentials withinterested nurses at Northport Veterans Administration Hospital. 

A PHENOMENOLOGICAL APPROACH

The method may be characterized generally as descriptive but it is not asimple cataloguing of qualities or counting of elements. Basically, itinvolves an openness to nursing phenomena, a spirit of receptivity, readiness for surprise, the courage to experience the unknown. Equallyimportant 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, aconceptualization from which emanates insightful description. 

More specifically, the method entails _an intuitive grasp of thephenomenon, analytic examination of its occurrences, synthesis, anddescription_. In actuality, as the method is carried out, one does notnecessarily recognize or focus on these processes as distinct phases orsteps. In the flow of the experience, at times, some seem to occursimultaneously or in oscillation. Bearing this in mind, the processeswill be considered in more detail. 

Intuitive Grasp of the Phenomenon

Phenomenology is grounded in experience. It values the raw data ofimmediate experience. ("To the things themselves, " was the slogan thatinspired and guided Husserl and his followers. ) So this approachrequires, in the first place, attitudes of openness and awareness. Itinvolves learning to become conscious of spontaneous perceptions, or inother words, getting in touch with one's sensations and feelings. Itmeans capturing prereflective experience, that is, becoming aware ofone'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, aphenomenon may be grasped intuitively. It is as if a particular bit ofreality, a happening, flashes _impressively_ into one's awareness. Theintensity of the experience and the absorption of one's attention in thephenomenon vary over a wide range. There may be only a fleetingrecognition of a phenomenon accompanied by {80} a half-formulatedthought or judgment, such as, "hmm, that's interesting, " with immediatedismissal from or replacement of it by something else in one'sconsciousness. The impression may, of course, be stored in memory andpop out again at a later time. Or the phenomenon may strike on one'sconsciousness more forcefully causing further pondering and wonder. Orthe impression of the phenomenon may be so startling that it fills one'sconsciousness to the point of pushing all else out; a person ismomentarily "stopped in his tracks. "

In the intuitive grasp, regardless of its intensity or duration, thephenomenon appears clear and distinct. The intuitive grasp is an insightinto reality that bears the certainty of immediate experience. Nodiscursive process intervenes; one simply knows the phenomenon as it isexperienced. Furthermore, the intuitive grasp provides a kind ofdefinite and whole understanding, a gestalt, that allows recognition ofthe phenomenon in other situations. So when the person is faced withanother event he can say, "Yes, that is the phenomenon underconsideration, " or "No, that is not it. "

In order to be open to the data of experience in using aphenomenological approach, one strives to eliminate "the _a priori_"(that which exists in his mind prior to and independent of theexperience). This is done by attempting to "bracket" (hold in abeyance)theoretical presuppositions, interpretations, labels, categories, judgments, and so forth. Granted, a person cannot be completelyperspectiveless. Man is an individual; he is a unique here and nowperson. So naturally, _necessarily_, he has an "angular" view for heexperiences reality from the angle of his own particular "here" and hisown particular "now. " Or, stated differently, as a knowing, experiencingsubject, each man must have _some_ perspective of the phenomenon beingexperienced. However, by recognizing and considering the particularperspective from which he is experiencing it, a person may become moreopen to the thing itself. 

Furthermore, this kind of openness to one's own perspective can bedeveloped through deliberate practice. Several approaches may be used. To begin with, a person can develop the habit of recognizing andexposing his own biases. This could involve something as basic asstating the actual physical situation or circumstance in which thephenomenon was experienced. For example: the phenomenon could besomething seen from above or below, at a distance or nearby; somethingheard in a quiet room or above the din of background noise; a patient'sbehavior in a large group or in a small group, with his family, with onparticular nurse, with his doctor; a patient's response while being fed, bathed, monitored. 

Beyond this unavoidable bias of the angle of perception, the nurse'sexperience of her lived world may be dulled by habituation. It isnecessary to break through the tunnel vision of routine. For instance, anurse new to a situation may notice a patient's response to her andremark about it to another nurse. The second nurse, to whom thepatient's behavior is familiar, may respond, "Oh, he's done that foryears. " Often this is the end of the dialogue; it should be thebeginning, for the duration of a phenomenon is not {81} equal to itsdescription or meaning, but rather, is an indication of itssignificance. 

The mystery of the commonplace is hidden by veils of the obvious. Torecognize one's biases means to put one's beliefs, one's cherishednotions, out on the table. A helpful aid in reflecting on andarticulating an experience is the question, "What am I taking forgranted?" Commonly used terms, such as, "psychiatric patient, ""orthopedic patient, " "oncology unit, " "uncooperative, " "emotional, ""chronic, " "terminal, " "hopeless, " "outpatient, " "ambulatory, ""visitors, " "family, " "doctor, " "nurse, " "administration, " "frontoffice" have an aura of connotations that may correspond to or differgreatly from the actual immediate experience. It may be a case wherebelieving is seeing. The habit of premature labeling may close a personto the full savoring of experience. 

Another means of increasing openness to one's own perspective is toconsciously note whether the phenomenon is being experienced actively orpassively. For example, the phenomenon may be the motion of changing apatient's position in bed. Both experience the motion, but it is adifferent experience for the nurse who actively moves the patient andfor the patient who is moved passively. Or again, many studies of thephenomenon of empathy have been reported in the literature. Almostexclusively, these are descriptions of empathizing with someone; onlyrarely are they concerned with the experience of being empathized with. Yet obviously, the active and passive experiences of the phenomenon ofempathy are different. The same holds true for touching and beingtouched, bathing and being bathed, feeding and being fed, supporting andbeing supported, reassuring and being reassured, and many otherphenomena in nursing. 

Similarly, awareness of one's perspective may be increased byconsciously realizing whether the phenomenon is being viewed objectivelyor subjectively. Consider for example, phenomena such as pain, anxiety, sleep, restlessness, boredom. Seeing evidence of pain in another personis not the same as feeling pain within myself. Recognizing objectivesigns of anxiety in another person differs from the subjectiveexperience of feeling anxious myself. Sleeping and observing someonesleeping are two different experiences. The same hold true forrestlessness, boredom, and so forth. 

In view of nursing's dialogical character it may be assumed that manyphenomena of major concern would be intersubjective or transactional. Itis important then for nurses, attempting to develop openness to theirown perspectives, to consider whether the phenomenon involves twosubjects and their between. Does the action go both ways? Are bothpersons calling and responding to each other simultaneously? Take thephenomenon of "timing" for example. The nurse's verbal response to apatient depends not only on her perception of her own here-and-now andhis perception of his here-and-now but rather it also involves theirperceptions of their shared here-and-now situation. The nursing world isfilled with intersubjective phenomena such as, eye {82} contact, touch, silence. To describe these fully the nurse must be open to herperspective, the patient's perspective, and their between. 

Analysis, Synthesis, and Description

After a nursing phenomenon is grasped intuitively, it is desirable tofind 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. Thephenomenon may be experienced directly. In which case, it is describedand reflected on and descriptions, reflections, and questions arerecorded. When she observes the phenomenon in others, the nurse may askthem to describe it and verify her own observations. Some nurses haveinvolved other staff members in discovering and describing instances ofthe phenomenon being studied. Similarly, one becomes more open todescriptions of it in the literature--any literature--or in any form ofhuman expression, for example, poetry, drama, art, science. As manydescriptions of the phenomenon are gathered from as many angles aspossible, these are the data to be analytically examined, synthesized, and described. 

The three processes of analysis, synthesis, and description are sointerrelated and so intertwined in reality that it is simpler to discusstechniques in relation to all three. Some techniques are equally usefulin the analytic examination and the description of phenomena. In asense, a person does both at once. And often, it is during this processof shifting back and forth, analyzing and describing an experience thatsynthesis occurs. A person gets a sudden insight, "everything falls intoplace, " "it clicks. " One gets a gestalt, a whole, not necessarily awhole in the sense of complete and entire, but a whole frame, form, orstructure that allows for further developing and filling in of details. 

There are many ways of going about the analysis and description. Thefollowing are some that have been found useful in the explication ofnursing phenomena. 

Comparing and contrasting instances of the phenomenon lead to thediscovery of similarities and differences. For instance, in studyingpatients' crying it was found that their crying was with or withouttears; loud or silent; expressing pain, anger, fear, sorrow. Or again, silence may be defined simply as absence of sound. But silence asexperienced in the real nursing world has other characteristics. It mayconvey anger, fear, peacefulness, and so forth. It is these nuances orqualities of silence that are significant cues for the nursing dialogue. They could be brought to light by comparing and contrasting descriptionsof silence. 

Various instances of the phenomenon being studied may be examined todiscover common elements. Characteristics or elements seen in oneinstance are sought in the others. For example, when descriptions ofinterpersonal empathy were scrutinized, it became evident that in allcases there were physiological, psychological, and social components. Examining experiences {83} of reassurance revealed they had elementssuch as empathy, sympathy, reality orientation, feelings of hope andcomfort. 

One may determine which elements are essential to the phenomenon byimaginative variation, that is, by trying to imagine the phenomenonwithout a particular element. For instance, reassurance without empathyor sympathy would be false reassurance or, in other words, would notreassure. 

The elements of the phenomenon can be studied to determine how they areinterrelated. One may ask, is there a priority in time? Does one elementdevelop from another? Consider the phenomenon of reassurance; doesempathy precede sympathy? Or, to take another example, in the empathicexperience, an openness to the other and an imaginative projection intohis place lead to the vicarious experiencing of his situation. 

For further clarification of its distinctive qualities the phenomenonmay be related to and distinguished from other similar phenomena. Forexample, 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, thephenomenon being described may be classified as being subsumed in abroader category. Thus, empathy is a human response, a coalescentmovement, a form of relating. 

The phenomenon may be described by selecting its central or decisivecharacteristics and abstracting its accidentals. For instance, interpersonal empathy always involves movement into another'sperspective and as a form of movement it has directions, dimensions, anddegrees. 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 describedcompletely by negation but it may be clarified to some extent by sayingwhat it is not. For instance, empathy is not sympathy; it is notprojection; it is not identification. 

Analogy may be used to promote analytic examination and description. This involves a comparison based on partial similarity between likefeatures of two things. For example, the movement of empathy is like thecurrents in the sea; the heart is like a pump. The advantage of usinganalogy is that the comparison raises questions about the nature of thephenomenon under consideration. However, since the similarity betweenthe analogues is always partial, one must guard against overextendingthe comparison to unwarranted conclusions. The description must alwaysbe consonant with the phenomenon as it occurs in reality. 

The use of a metaphor also may enhance description and analysis. Ametaphor suggests comparison of the phenomenon with another by thenonliteral application of a word. For example, "the between is a secretplace. " The use of metaphor may be criticized in regard to its lack ofprecision. On the other hand, there are some (for example, Marcel, Buber) who hold that the intersubjective realm can be described onlymetaphorically because it is {84} beyond the level of objectivity. Andto attempt to describe intersubjective phenomena in precise termsrelated to the physical world would tend to distort rather than clarify. Many of the nursing phenomena requiring description occur within theintersubjective realm. Metaphors could cast some light on these. 

CONCLUSION

As a theory of practice, humanistic nursing is derived from individualnurses' actual experiences in their uniquely perceived but commonlyshared nursing world. Its development, therefore, depends on thearticulation of their angular views and also on the truly collaborativeeffort of a genuine community of nurses struggling together to describehumanistic nursing practice. 

Since the description of nursing phenomena is recognized as a basic andessential step in theory development, this chapter presented an approachand detailed some techniques used by nurses to describe phenomena. It ishoped that these would be viewed critically and creatively; that theywould be used, varied, combined adapted, and lead to new methods suitedto the description of nursing phenomena. And if they are developed, itis hoped that they will be shared for the growth of humanistic nursingdepends not only on using and sharing what we learn but also ondescribing how we come to know. Then humanistic nursing theory will growin dialogue. 

FOOTNOTES:

[1] Loretta T. Zderad, "A Concept of Empathy" (Ph. D. Dissertation, Georgetown University, 1968). Josephine G. Paterson, "Echo intoTomorrow: A Mental Health Psychiatric Philosophical Conceptualization ofNursing" (D. N. Sc. Dissertation, Boston University, 1969). Loretta T. Zderad, "Empathy--From Cliche to Construct, " _Proceedings of the ThirdNursing Theory Conference_ (University of Kansas Medical CenterDepartment of Nursing Education, 1970), pp. 46-75. Josephine G. Paterson, "From a Philosophy of Clinical Nursing to a Method ofNursology, " _Nursing Research_, Vol. XX (March-April, 1972), pp. 143-146. Josephine G. Paterson and Loretta T. Zderad, "All TogetherThrough Complementary Synthesis, " _Image_, Vol. IV, No. 3 (1970-71), pp. 13-16. 

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8

HUMANISTIC NURSING AND ART

The term "humanistic nursing" often is interpreted as implyinghumaneness. Logically, humane caring must be one aspect (a major aspect)or a natural expression of humanistic nursing practice theory. But theterm means more. According to the position being taken here, nursing maybe described appropriately as humanistic since at its very base it is aninter-human event. As an intersubjective transaction, its meaning isfound in the human situation in which it occurs. As an existential act, it involves all the participants' capacities and aims at the developmentof human potential, that is, at well-being and more-being. Our approachqualifies, then, as a form of humanism, according to the dictionarydefinition, being "a system or mode of thought or action in which humaninterests, values, and dignity are taken to be of primary importance. "

In another sense of the word, our theoretical stance is humanistic byvirtue of its regard for the humanities and arts. Philosophy, literature, poetry, drama, and other forms of art are valued asresources for enriching our knowledge of man and the human situation. They also are seen as suitable means for expressing or describing thelived realities of the nurse's world. 

Contemporary nursing, being a true child of its time, reflects Americansociety's high regard for "Science. " Values of science are easilydiscernible in nursing and affect the character of its research, education, and practice. Consider, for instance, how the nursingdialogue is influenced by the prizing of objectivity, precision oflanguage, operational definitions, scientific jargon, development ofconstructs and theories, methodology of scientific inquiry, emphasis onquantification and measurement. 

There is much more written in our current literature about nursing as ascience than about nursing as an art. Although slighted, the humanitieshave not been rejected. In fact, some nurses and educators are urgingthat the role {86} of the humanities and arts be recognized in nursingand that they be used more effectively in undergraduate and graduatenursing education. [1]

Turning to my own personal experience, I recall that one of the firstdefinitions I had to learn in my basic nursing program began with thestatement, "Nursing is an art and science. .. . " (It is interesting thatnow, years later, this is all I can recall of the definition!) At thattime, I accepted the statement at face value. I did not question it. Perhaps I had not thought enough about art and science and certainly Idid not know enough about nursing to question the description. Yet overthe years many experiences and insights have turned into questions thatchallenge this adopted cherished notion. 

In the beginning I merely accepted the view that nursing is an art inthe sense of being a skillful or aesthetic application of scientificprinciples. After all, we had a course in nursing arts (later calledfundamentals of nursing). This had to do with bathing, feeding, makingbeds, and hundreds of other nursing procedures that were presented as"nursing arts, " the doing of nursing. At the time I also had courses inthe humanities and liberal arts. These courses were not related directlyto 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 doesthe art of nursing differ from other arts?

The notion (perhaps "conviction" would be more accurate) that nursing isan art in some sense other than an artful application of scientificprinciples has been with me for a long time. I do not know its originnor even the form in which the view first appealed to me. I do recallhaving difficulty on several occasions in trying to express let aloneexplain, my idea. At these times, what I experienced subjectively as anintuitive flash of insight would end up objectified in an amorphous blobof words. Yet the theme returns over and over in a variety of questionsand issues that demand response if not resolution. This chapter offerssome further reflections on the relatedness of humanistic nursing andart. 

USE OF ARTS

One of the most obvious ways in which nursing and art are related is innursing's use of the arts. This may be seen in nursing education as wellas in nursing practice. 

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Liberalization

Usually, when arts and humanities are included in nursing educationprograms, it is for their humanizing effects. Traditionally they havebeen recognized as having a civilizing influence. So in nursing they areseen as supporting the elements of humaneness and humanitarianism. Furthermore, they are a necessary antidote for the depersonalizationthat accompanies scientific technology and mechanization. 

The arts are valued also for their liberalizing effect. They stimulateimaginative creativity. They broaden a person's perspective of the humansituation, of man in his world. For instance, depictions of sufferingman or of other aspects of the human condition that are found in poetry, drama, or literature are far more descriptive and much closer to realitythan those given in typical textbooks. 

Current nursing practice reflects the educational preparation of nursesthat is weighted heavily with scientific courses and the methodology ofpositivistic science. Arts and humanities are a necessary complement. Science aims at universals and the discovery of general laws; artreveals the uniqueness of the individual. While science strives forquantification, art is more concerned with quality. Strict conformanceto methodology and replicability are prized in scientific studies, whereas freedom and uniqueness of style reign in art. Science, foreverupdating itself, opens the nurse's eyes to constant change andinnovation; the classics promote a sense of the unchanging and lastingin man's world. Science may provide the nurse with knowledge on which tobase her decision, but it remains for the arts and humanities to directthe 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 nurseswho are also artists use their respective arts to express their nursingexperience. Poetry is a good example. 

In an article, "Nurses as Poets, " Trautman notes that since the 1940sprogressively greater numbers of poems about nursing have been publishedand since the 1960s the quality of these poems has improvedconsiderably. [2] She believes that nurses' ability to express theirfeelings about nursing in poetry cannot be attributed entirely to achange in times. Rather, it is a reflection of change in nursingpractice. For one thing, contemporary nursing requires a great deal ofabstract thinking. It calls for an understanding involving mental andemotional investment, and imaginative feeling _with_ the patient. The{88} nurse-poet puts aside technical terms, looks at her patient in afresh and creative way and shares her view in a poem. 

A second reason offered by Trautman is the increased emphasis in nursingeducation on communication and verbal skills. A nurse with a talent forwriting may be moved by a particular experience to share it. Thus, "thesensitive nurse-writer may use poetic expression to work through aproblem, to muse about a detail, or to record a profound experience. "[3]

Finally, she states that some nurses write poetry about aspects of theirwork that defy scientific analysis and cannot be easily contained intechnical papers. In this, then, nurses' poetry goes beyond the personalsatisfaction accompanying expression; it preserves a unique angular viewof nursing's lived world and adds to our store of clinical wisdom. AsTrautman 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 scientificexploration and discovery while others, equally important and likewisedeserving expression, reveal themselves only through the artist'svision. So what has been said of poetry, therefore, may hold true inother arts. Each art has its own form of dialogue with reality. Thepainter, for example, feels with his eyes; he feels lines, points, planes, texture, and color. [5] What could the nurse-painter share? Or asGarner, a nurse-musician, suggests, nursing could be conceptualizedalong the schema of tones, texture, rhythm, meter, intensity, temperament. [6]

What nursing content would accrue if the various nurse-artists usedtheir forms of knowledge, skill, and vision to explore nursing as thevarious nurse-scientists do? What can our poets, painters, musicians anddancers 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 therapeuticeffects, especially with psychiatric, geriatric, and pediatric patients. The nurse and a patient or a group of patients participate in anartistic experience together. These may be passive activities, such as, attending a concert or play or visiting {89} an art exhibit; or theymay be active ones in which nurse and patients are involved in artisticexpression or creation. 

Music, poetry, painting, drama, and dance have been used effectively invarious nursing situations. For instance, Christoffers, a nurse anddancer, emphasizes the importance of body language as communication andsupports her view with clinical evidence. She urges nurses to become"physically literate--to develop an understanding and appreciation ofthe part played by body language in human relationships. "[7] Or again, according to Garner, "Music, when carefully planned, can be used as asource of culture, nurturance, communication, socialization, andtherapeusis. "[8]

A major therapeutic value of art lies in the fact that it confronts onewith reality. "Art is a lie which makes us realize the truth. "[9] In hisnovel, _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 agroup, the members have the additional advantage of sharing in others'expressions and of developing fellow-feeling. Increased socialization isanother important therapeutic effect nurse-artists/art appreciators seekin the use of art. A corollary benefit is improved communication betweenthe patient and the nurse or between the patient and others. 

Obviously, self-knowledge and fellow-feeling are consistent with the aimof humanistic nursing to nurture well-being and more-being. A persondevelops his human potential and becomes the unique individual he isthrough his relationships with other men. 

NURSING AS ART

Thus far, this chapter has been concerned with the relatedness ofnursing and art. It was seen that nurses may study arts and humanitiesfor a broader understanding of the human situation, may express theirnursing worlds through various art forms, and may use the artstherapeutically. Now the question is raised whether nursing is an art, and if so, what kind of art. 

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Artful Application

Even the most scientific nurses do not deny that nursing is, in someway, an art. But precisely how the art and science of nursing areinterrelated 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 scienceof nursing, the view expressed is that science has to do with generalprinciples and laws that govern nursing and art has to do with theparticular application of principles in individual cases. Furthermore, when a nurse describes some event as "beautiful nursing" and is pressedto elaborate, she usually describes nursing actions that were performed"artfully, " "skillfully, " "harmoniously. " Thus, in some way, the art ofnursing has to do with the nurse's response to human needs throughactions that are purposeful and aesthetic. 

Useful Art

In current usage, the term "art" is most commonly associated with thebeautiful, that is, with aesthetics or the fine arts. Frequently, it isrestricted even more to signify one group of the fine arts, namely, painting and sculpture. For instance, one refers simply to an "artexhibit" or an "art" museum but specifies further "a center for theperforming arts. "

However, historically the word "art" was related to utility andknowledge, and its traditional meanings still exist today. For example, we speak of "industrial arts" and "arts and crafts" through which usefulthings are produced. On the other hand, "liberal arts" (work befitting afree man) are those related to skills of the mind. We also refer to theart of medicine, of teaching, of nursing, of politics, of navigation, ofmilitary 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 skillof the artist). It is obvious that not only knowledge but also some formof work and skill are involved in all art, useful or fine. "Art" is theroot of "artisan" as well as of "artist. "[12]

Some arts, such as nursing, medicine, and teaching, may be considereduseful, 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 workskillfully to get them. The nurse cannot make well-being or comfort orhealth as one can make a shoe or a painting or a speech. The art ofnursing involves a skillful doing rather than a making. Furthermore, nursing is concerned with changes in human persons not merely with thetransformation of physical objects. It is intersubjective andtransactional, so the art of nursing must involve a doing with and abeing with. 

Performing Art

Along this vein, nursing may be viewed as a kind of performing art. Fahy, nurse-educator-actress, draws an interesting comparison betweenthe 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 anurse was trying to describe the nursing care she received from anothernurse when she had been ill. She struggled with some details of finerpoints and then summed it up by saying, "I felt her nursing care wasjust 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 otherways. 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 herown unique style. {92} If nursing really is viewed as a performing art, there are opportunities for creative exploration and development of theart of nursing. And furthermore, these individualized styles of nursingare worthy of description and sharing. 

Another similarity is the ephemeral character of nursing, music, anddrama. A particular nursing transaction, like a concert or play, istransitory, short-lived. Yet the effects may be long-lasting andremembered. There is this difference in nursing, I believe. Each nursingtransaction may flow into a stream of nursing care extendingcontinuously over 24 hours a day for weeks, months, years. And manyindividual nurses "get into the act. " How does this affect the art ofnursing? How is nursing like and unlike the other performing arts? Theanswers 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 characteristicsas discussed above. Both art and nursing are kinds of lived dialogue. Inboth, man responds to his world of men and things through distance andrelation. They affect him and he affects them with the creative force ofhis relation. 

In fact, one may say further that humanistic nursing is _itself_ anart--a clinical art--creative and existential. This is evident when onereturns again to the thing itself, to the nursing dialogue as it islived in the everyday world. 

In genuine meeting the nurse recognizes the patient as distinct fromherself 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 genuinelived dialogue, the nurse sees within the patient a form (that is, apossibility) of well-being or more-being (or comfort or health orgrowth, and so forth). Like a beautiful landscape inspiring a painter orpoet, the form in the patient addresses itself to the nurse, a call forhelp demanding recognition and response. The form is clearer thanexperienced objects; it is not an image of her fancy; it exists in thepresent although it is not "objective. " The relation in which the nurse(artist) stands to the form is real for it affects her and she affectsit. If she enters into genuine relation with the patient (I-Thou) hereffective power (caring, nursing skills, hope) brings forth the form(well-being, more-being, comfort, growth), just as the painter's orpoet's power and skill create a painting or a poem. 

Of course, there is this difference. The art of nursing, beinggoal-directed and intersubjective, is more complex than the arts ofpainting and poetry, for example. As a clinical art, it involves _beingwith_ and _doing with_. For the patient must participate as an activesubject to actualize the possibility (form) within himself. Perhaps theart of nursing could be described as transactional. Not only does thenurse see the possibilities in the patient but the patient also sees aform in the nurse (for example, possibility of help, of comfort, ofsupport), and he responds in relation to bring it forth. {93}

Then the question logically may be raised: Is the patient's responses inrelation (I-Thou) a necessary condition for the art of nursing? Or tostate it differently: can there be any art of nursing the infant, theunresponsive, the comatose, the dying? I would answer that the art ofnursing can exist even if the relation is not mutual. For as Buberwrites, "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 viewwith a particular purpose. They are human responses to the everydayworld in which man lives. Existentially speaking, each is a form ofliving dialogue between man and his human situation. 

It is possible that there is in nursing a kind of human response toreality that is a combination, a true synthesis of art and science? Themore one focuses on nursing as it is lived, on the intersubjectivetransaction as it is experienced in the everyday world, the morequestions arise about it as art and science. Elements of both art andscience are evident in nursing. The practicing nurse must integrate themin her mode of being in the situation. 

While Dr. Josephine Paterson was developing a methodology of inquiryfrom a clinical nursing process and describing her construct of the"all-at-once, " she was so intent on communicating the interrelatedreality of the art and science elements in nursing, that she welded themtogether with a hyphen into one word, "art-science. " And even then thereis 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 synthesisof art and science that takes place in the nursing process. The nursingdialogue reflects the orientations of art and science for it involvesboth the patient's and the nurse's subjective and objective worlds. Ibelieve the synthesis of art and science is _lived_ by the nurse in thenursing act. This is a phenomenon more readily experienced thandescribed. 

Yet if we truly experience nursing as a kind of art-science, as aparticular kind of flowing, synthesizing, subjective-objectiveintersubjective dialogue, then nursing offers a unique path to humanknowledge and it is our responsibility to try to describe and share it. 

FOOTNOTES:

[1] New England Council on Higher Education for Nursing, _Humanities andthe Arts as Bases for Nursing:_ Implications for Newer Dimensions inGeneric Nursing Education, Proceedings of the Fifth Inter-UniversityWork Conference (Lennox, Mass: New England Council on Higher Educationfor 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 inNursing Education, " _Nursing Outlook_, Vol. 18, No. 9 (September, 1970), pp. 30-31. Marion E. Kalkman, "The Role of the Humanities in GraduatePrograms in Nursing, " in _Doctoral Preparation for Nurses_, ed. EstherA. Garrison (San Francisco: University of California, 1973), pp. 138-155. 

[2] Mary Jane Trautman, "Nurses as Poets, " _American Journal ofNursing_, Vol. 71, No. 4 (April, 1971), p. 727. 

[3] _Ibid. _, p. 728. 

[4] _Ibid. _

[5] Chaim Potok, _My Name Is Asher Lev_ (Greenwich, Conn. : FawcettPublications, 1972), p. 105. 

[6] Grayce C. Scott Garner, "Qualitative and Quantitative Analyses ofSchizophrenic Verbal and Non-Verbal Acts Related to Selected Kinds ofMusic, " _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, " _NursingResearch_, Vol. XVIII (September-October, 1969), p. 393. 

[12] "Art, " _The Great Ideas_: A Syntopicon of Great Books of theWestern World I, Vol. 2, 1952, pp. 64-65. 

[13] Ellen T. Fahy, "Nursing Process as a Performing Art, " _Humanitiesand the Arts_, p. 124. 

[14] Martin Buber, _I and Thou_, 2nd ed. , trans. Ronald Gregor Smith(New York: Charles Scribner's Sons, 1958), p. 9. 

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9

A HEURISTIC CULMINATION

This chapter presents an application of the humanistic nursing practicetheory over time and an outcome. The outcome represents my presentconscious conceptualization of my personal theory of nursing. It hasgrown out of my nursing practice experience, my reflecting, relating, describing, and synthesizing. This is heuristic culmination of muchmulling over my lived world of nursing. 

ANGULAR VIEW: PRESENT PERSPECTIVE

In 1971 after a presentation on concept development I heard myself in achatty response to the audience declare my unique theory of nursing. Itwas based in constructs that I had developed and conceptualized. Previously I had viewed these constructs only as distinct entities. Mysynthesis of them surprised me. This was the first time I conveyed themas my why, how, and what of nursing. This synthesis may have emerged asa sequence to my reexamination and reflection on each of theseconstructs in preparation for this 1971 presentation. [1] Now it becameevident that their sequential evolvement had a logic that had come frommy being without my awareness. 

Since 1971 I have planned to reflect on these synthetic constructs tobetter understand how they relate to one another complementarily. Why?To further the development of these constructs and to state them aspropositions. Statements of propositions are movement toward nursingtheory. Theory is considered here as a conceptualized vision teased outof my knowing from my nursing experience. 

{96}

Like Elie Wiesel, the novelist and literary artist, I write to betterunderstand and to attest to happenings. This chapter is the fruit ofthis endeavor. 

The first term, "comfort, " was developed as a construct in 1967. Afterrecording and exploring my clinical experiential data, a conceptualizedresponse emerged to my question: "Why, as a nurse, am I in the clinicalhealth-nursing situation?" The second term, "clinical, " was developed asa construct in 1968. It was a conceptualized response to a dialecticalprocess within myself. I asked, "What is clinical?" I answered, "I am aclinician. " I asked, "As a nurse clinician what do I do; what is thecondition of my being in the nursing situation?" I answered, "Thisdescribed would equate to clinical. " Consequently I compared andcontrasted two nursing experiences similarly labeled to properly graspthe principle of "clinical" for conceptualization. The third term orphrase, "all-at-once, " arose intuitively within me as a construct in1969 and was partially conceptualized. It arose after mulling over othernurses' published clinical data and asking, "What can you tell me of theclinical nursing situation?" "What do you perceive as the nature ofnursing?" Therese G. Muller's, Ruth Gilbert's and my thought on thenursing situation merged into a view of these as multifariously loadedwith all levels of incomparable data, the "all-at-once. "Incommensurables relate to the nature of nursing and its concerns. Howcan one study unrelated appearances? Muller often used an historicalapproach while Gilbert emphasized individualization. In humanisticnursing practice theory a descriptive, intersubjective, phenomenologicalapproach is proposed for greater understanding and attestation of theevents and process of the nursing situation. The construction of"comfort, clinical, and all-at-once" I would now label as conceptualizedphenomenologically. I view them as relevant phenomena to any nurse andthis nurse-in-her-nursing-world. 

Theory: Unrest, Beginning Involvement

This desire to develop nursing theory goes back to my years (1959-64) asa 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 developedin and for other disciplines using nursing examples. There were bothsimilarities and differences in the many nursing examples in whichattempts were made to describe the qualities of the participants'beings. Emphasis was placed on the observations by the nurse of theothers' responses in the nursing situation. Nursing education was rifewith lengthy repetitive examples utilized to focus on particularvariations. I desired a unifying base applicable to all nursingsituations. This was not a seeking for conformity nor an attempt tonegate individuality. Certainly I did not want such a base to excludeindividual nurses' talents. Rather this base, foundation of nursingindicative of the nature of nursing, would heuristically promote endlessvariations to flow, blossom, cross-pollinate, and evolve. {97}

In these observations and thinkings I was attempting to understand, sortout, and clarify the questions that underlay my puzzlement. Thispuzzlement arose out of my 18 years in nursing practice and education. In a theory course and a philosophy of science course, while in doctoralstudy, I recognized and learned to label my unrest and puzzlement as arecognition of the need for nursing theory. 

In 1966 in discussing my purposes for doctoral study, I expressed thisunrest and puzzlement. I viewed my varied past experiences in nursing asexcellent. I sought time to reflect on the past 24 years of livingnursing to see what it could tell me, and to come to better understandits meaning to the profession of nursing. The philosophical nature ofthese questions and what they express of myself is evident. Suchpersonal revelation at this time is no risk, and withholding would onlydeprive myself and others of the answers that might be brought forth. 

As in most school situations initially responding to class assignmentsand involvement in new clinical situations consumed my time and thwartedmy personal, professional interests. When I commented on this myinterests were interpreted to me as a desire to live in the past. Livingin the present was recommended and terms like "up-to-date" and"progressive" were employed. I felt stopped cold. I had never viewedmyself as old fashioned or non-progressive. Many of my past nursingexperiences were still avant-garde as compared with general currentpractices. 

There was something different though in recalling and reflecting on thepast as opposed to current experiences. One's past would be visible inview of how one approached and experienced the present. Self-confrontation moved me beyond confining myself either to the pastor to the present. In my writings one could detect a comparison of whathad been known with what was coming to be known. It was as if a light ofa different hue lit up the whole--past and present--as a differentscene. Similarly I viewed and experienced my clinical experiencedifferently. I gained awareness of a quality of my being that always hadbeen there, but which I hid. Now I valued this part, struggled with it, and expressed it directly with courage, integrity, and pride. The powerwith which this self-actualization imbued me has been sculpturing my "I"into a form of my choosing ever more acceptable to me, and accepting ofothers. 

Concept Development

In a nursing theory course the final assignment was: develop a conceptrelevant to nursing. Again I found myself struggling. The didacticallystated importance of investing precious time and energy intoconstructing a synthetic conceptualization of a term eluded me. Time andenergy spent to better understand man as he was known to me in thenursing situation seemed so limited. In these situations persons wereexpressing so many things at one time, how could the conceptualizationof one term be relevant. Finally I understood: no one was saying thatany one term could equate any particular or group of {98} nursingsituations. They were saying that to communicate the nature orexperience of nursing with words, to develop nursing theory, relevantterms needed clarification as to the meaning they conveyed anddelineation as to their inclusiveness and exclusiveness. 

As this struggle subsided I could hear, "a term could be developed as aconcept or synthetic construct if one conceptualized its why, what, how, when, and where and how these interrelated. " In approaching conceptdevelopment the last but not least hurdle was, what term did I considerrelevant enough in nursing to expend this precious time and energy onconsidering the many possibilities. The first term I began tointellectually play with was "ambivalence. " Now, I would attribute myselection of "ambivalence" to my then existing ambivalence aboutconceptualizing a synthetic construct. Then, I based its selection onlyon its existence in my clinical nursing world. I was workingtherapeutically on a regular, individual basis with an ambivalentadolescent male labeled diagnostically as a paranoid schizophrenic. Ibegan to consider my clinically recorded data of my sessions with Bobthrough ambivalence. What were the relationships between why, how, what, when, and where Bob expressed ambivalence?

Struggling with the term "ambivalence" involved and interested me inconcept development. During this phase I overcame my fear of exposing mythoughts, I took the risk, and my courage had the upper hand. Nevertheless, another choice had to be made since now I was not willingto invest this much time on conceptualizing "ambivalence" as so relevantto nursing. Perhaps this signified that my own ambivalence haddissipated. And again, I faced the question, what term would I want todevelop 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 myvalue mainly as growth, health, freedom, or openness promotion? I workedfor a while with each of these terms and eventually discarded them. Somelong-hospitalized persons with whom I was working on a demonstrationpsychiatric unit to prepare them for a more independent and appropriateform of community living would never be stably balanced in health, growing, freedom or openness. For many, these could be only flittingmemorable beautiful moments. Still I believed I was very much there inthe nursing situation for these persons, as well as for those who movedinto the community and found work and social satisfactions. Somethingoccurred between all of these 15 patients and myself--and that wasnursing. 

COMFORT: WHY

While considering what construct to conceptualize, I was in the processof recording my three-hour, twice a week interactions in thedemonstration unit. I reflected on these interactions and waited for thedata to reveal to me the major value underlying my nursing practice. Then the term "comfort" came {99} to mind. Perhaps at this point Ibecame comfortable in this unit, or perhaps the unit, itself, became amore comfortable setting. When I had first begun my experience with thisdemonstration unit, it was still being planned and the hospital was newto me. However, the term "comfort" has long been associated withnursing. One can find it as a historical constant throughout theprofessional nursing literature. The term had been used recently in anANA publication. [2] When I considered the idea of comforting in nursingpractice I felt such experiences had fulfilled and satisfied me, made mefeel adequate. I could recall specific experiences that went back to myinitial nursing practice settings. I could conceive of comfort as anumbrella under which all the other terms--growth, health, freedom, andopenness--could be sheltered. Some of my contemporaries scoffed andviewed this term as much too trivial. 

Now, again reviewing my months of gathered clinical data, I sorted out12 nurse behaviors that I viewed as aiming toward patient comfort. Theywere:

 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 ofrecording patient-nurse interactions. For the conceptualization of theterm "comfort, " a representative clinical example was given to enhancethe meaning of the behavior cited (see Appendix). When compilingmaterials for the conceptualization of this term, I found 12 assumptionsabout psychiatric nursing that I had written for the theory course inone of the first class sessions. Although these assumptions wereexpressed in different words, their congruence with my 12 selectedbehaviors made me believe that these behaviors were somehow verifiedboth in my conceptualized philosophy of psychiatric nursing and in mybehavior while being a psychiatric nurse. 

Next I struggled with an idealistic conception of comfort as opposed toa continuum of behavior which would indicate a person's degree or stateof discomfort-comfort. Again, reflecting on and teasing out aspects ofmy data, I set up four behaviorally recognizable criteria for estimatinga 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 toevaluate the effects of this aim of nursing on a patient's actualcomfort status at any particular point in time. 

Considering the concept of comfort as a proper aim of psychiatricnursing brought forth the necessity of considering its opposite, discomfort, as a concept. Evidence for the existence of discomfort couldbe inferred in the absence of the above behavioral criteria. {101}

The basic foundation to justify the concept of comfort as a proper aimof psychiatric nursing would be both organic and environmental. In ourculture, among the species man, we are moving toward being able toeffect some organic conditions by genetic controls and surgical andchemical means. The professions have struggled long years to influenceenvironmental deterrents to comfort. If an individual as a fetus, or asan infant, or young child never internalizes comfort of any kind fromhis environs, the probability of initiating a continuum within himselfas an adult that is propelled toward comfort seems unlikely. Suchindividuals, lacking any potential capacity for comfort, I suspect arerare. There is evidence for the existence of this dormant seed ofcomfort in persons with schizophrenia in the hospital setting. Considerhow repetitively and ambivalently they "reach out" to authority figures. This dormant comfort seed requires nourishment of a high quality fortesting whether it can develop and bear the fruits of health, growth, freedom, and openness. 

When the development of this synthetic construct of comfort wasdiscussed in the theory course a question was raised: Is a person whodenies all feeling, presents himself as emotionally dead, comfortable?If feelings are not relegated to the mind alone, as the effects of apeptic ulcer cannot be relegated to the stomach, if feelings are anessential of the nature of humanness, a human who denies this essentialof his nature would not fit into this concept as comfortable. Thissynthetic construct of comfort, like its synonym contentment, describedby Plutarch A. D. 46-120, does not imply passivity, resignation, retirement, or a simple avoiding of trouble. Plutarch said, "Contentmentcomes very dear if its price is inactivity. "[3] I would perceive ofcomfort or contentment as implying that a human being was all he couldbe in accordance with his potential at any particular time in anyparticular situation. 

Continuing the aforementioned twelve nurse behaviors, observing behaviorthrough the four established criteria and conceptualizing the constructof comfort, I began to wonder. Was I seeing what I had decided was thestate of psychiatric patients' conditions of being? Was I projectingdiscomfort onto patients? I did not expect straight answers. Nonetheless, I decided to ask patients about their discomfort-comfortstates to verify my perception of the condition of their beings. Allfourteen patients I asked assured me by their responses that I was notprojecting or seeing discomfort where it did not exist. 

Some described physical discomfort and sought the cause within andoutside themselves (either another caused it, or another could cure it, pills would cure it), negatively viewed self-images, guilt based intheir behaviors or thoughts. One patient defined comfort by analogy andstated directly to my surprise that he seldom felt comfortable and thathis excessive ritualistic behavior was his way of coping with hisdiscomfort. One repetitively stated a happy illusion that he seemed tohang on to for dear life. When I asked what he would do if this illusionwas not truth, he said that he had never considered {102} thispossibility. I knew he had been confronted with the truth of hissituation many times in many ways. One patient merely looked directly atme and walked away. 

Then I again reviewed my clinical recorded data to see what kinds ofknowledge nursing with an aim to comfort would infer as necessary. Fifty-two items of knowledge were extrapolated from the clinicalexamples selected as representative of the twelve nurse behaviors. Theseitems were categorized under broad cognitive and affective domains. Thiswas an arbitrary point of separation. They were teased apart simply asan aid to conceptualization and understanding. If these knowledgedomains had related to one another in a simple direct manner, I wouldhave conveyed them in a table in which each would have been across fromits mate. Their relationships to one another were far too complex to behandled in any such a way. The affective domain knowledge areas were adynamic internalized synthesis of several knowledge areas from thecognitive domain. Thus, the expression of these affective knowledgeareas was evidence of the practice of nursing as an artful form ofexpressing cognitive knowing. 

In looking directly at the discomfort of long-term hospitalizedpsychiatric patients, I found myself faced with behaviors that resultedpossibly from a muddle of many contributories. What in the behaviorresulted from lifetime environmental influences and compounded responsesthat deepened scars? What resulted from long-term hospitalization? Howmany varieties of ills superimposed like layers on the above wereexpressed in what I saw as discomfort in these psychiatric patients?Diagnostic classifications are necessary for statistical economicplanning reasons. Still, how naively and superficially they convey thehuman therapeutic care needs of each person. 

At this point of construct development I saw a positive relationship inmy thinking about comfort as a proper aim of psychiatric nursing andViktor Frankl's description of his aim in logotherapy toward meaning. Ihad struggled with the idea of aiming at comfort while with patients whopossessed ability and a favorable prognosis, often purposefully anddeliberately asking them to consider ideas that caused them immediategreater discomfort. Frankl's quotes from Nietzsche and Goethe supportedmy 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 ofcomfort as an aim of psychiatric nursing I can say: Comfort is an aimtoward {103} which persons' conditions of being move throughrelationship with others by internalizing freedom from painfulcontrolling effects of the past. These effects have inhibited theirself-control, realistic planning, and prevented them from being all thatthey could be in accordance with their potential at any particular timein any particular situation. I would project this as an aim for nursingin all situations although the data for constructing thisconceptualization were gathered in a clinical psychiatric setting. 

CLINICAL: HOW

As a component of my doctoral examinations I was faced with having torewrite a clinical paper. This led to my deliberately and personallychoosing to conceptualize a synthetic construct of "clinical. " This wasmy decision. It speaks well for the value of having had the experienceof conceptualizing "comfort. " Often it is said that man repeats thatwhich he finds as meaningful and good. This choice also signifies a realovercoming of my resistance and ambivalence toward synthetic constructdevelopment in a year's time. 

"Clinical" was developed as a synthetic construct in 1968. It was aconceptualized response to a dialectical process within myself. If I ama clinician, then "how" I am in the health-nursing situation wouldequate to "clinical. " In conceptualizing this construct I teased out ofmy lived-nursing-world the "how" of my working toward my own and others'comfort. 

Confusion, over what was meant when persons casually and currentlypopularly attributed the term "clinical" to situations and persons, called forth this conceptualization. It grew out of comparing andcontrasting two nursing consultation experiences in thepsychiatric-mental health area. Beginning this conceptualization I wouldhave referred to both these experiences as "clinical. " At thetermination of the conceptualization they were both "clinical. " Theywere very different experiences for me, and yet of equal value in myadvancement toward my more of being. Prior to this conceptualizationbecause my attending emotions were so disturbing and unacceptable to mein relation to one of these experiences, automatically I repressed partof them and found reasons to suppress the rest of them. Unfortunately, all else that was of value to me in having lived this experience wasintegrally enmeshed with these emotions. This, too, became unavailableto my conscious awareness. Conceptualization made recall and reflectiona necessity. Clinical includes inherently a process of experiencingawarely and then recalling, looking at, reflecting on, and sorting outto come to knowing. 

Before knowing how to approach the rewriting of my clinical paper as apartial requirement for receiving my doctoral degree I experienced adepression. I felt frightened, angry, and inadequate. The originalclinical paper had been judged as more intellectual and scholarly thanclinical. I could conceive of only two alternatives. Both seemedself-defeating. One, I could revise my former clinical paper into a moreintellectual and scholarly paper that still {104} would not be clinicaland would still leave my "I" out. Or, two, I could revise my formerclinical paper, dump all my feelings in the situational experience, blame everyone else for these feelings, and culminate at least with myclinical passions visible. Conflict resulted from my consideringpursuing either of these routes. I was immobilized for a time. A timelimitation and time passing pushed me to begin somewhere. I began. Choosing the second alternative in the belief that at least throughwriting I would better understand what I had lived in the experience. 

I could support the value of dredging up these old feelings and lookingat them. Authentically letting myself be aware of what I hadexperienced, not necessarily communicating this or acting out inaccordance with these redredged feelings; just really looking at themmight allow me choice in how I wanted to live with them. One support forthe value of looking at these old feelings was my own past three andone-half years in psychoanalysis in which I profited through such aprocess. The other support was my readings of the past two years. Theseincluded 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, Ibegan to view this product as like an existential play filled withblatant atrocities and absurdities that had to be nonrealities. Thisproduction, also, made visible beautiful raw data. As meaning in thisclinical nursing consultation experience as a graduate student becameevident, comparison of it with the meaning of clinical work experiencesin nursing consultation situations flowed naturally. Then joy, it waslike sunshine burst forth and warmed my spirit. 

Before entering school, I was, for two years, a mental healthpsychiatric clinical nurse consultant to a staff of forty-five visitingnurses. I had become intrigued {105} with what I had come to understandabout consultation related to clinical situations. I wrote a paper forpublication on the subject. Busy in the process of returning to school, and awaiting the publication of two other papers--both of theseproceedings feeling unreal and out of my control, not to mentionself-exposing--I merely filed in my desk the typed submittable renditionof this consultation paper. Now, I dug it out. This meant that I had twoconceptualized presentations of similar type personal experiences innursing consultation to compare and contrast. From these, myconceptualization of clinical, and the values on which my clinicalpractice 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 apassion-filled experience for me. As a nurse-student consultant amonginterdisciplinary nonstudent-consultants I experienced dependency for mybeing and doing on persons I viewed as anxious, critical, nonempathetic, and inadequate. We were attempting to offer consultation to aprofessional group of nonpsychiatric mental health oriented consulteeswho were anxious and felt inadequate in this area. I felt forced into anobserver rather than participant mode of being, and my recorded datasupport this. Impotency comes to mind when I recall this experience, aswell as a racking rage and suffering that obliterates feelings of love, good-will, tenderness, or hope. About that time I was readingNietzsche's eternal recurrence phenomenon[15] and viewed it mostpessimistically--all was awful, it would continue to be awful, life wasjust a vicious cycle of awfulness. 

Defense or health, it is questionable. Suddenly, perhaps it was havinghit feelings of rock bottom, I began to view Nietzsche's eternalrecurrence phenomenon optimistically. Did the polarization of mynegative feelings magnetically call forth my opposite feelings? All, now, contained the new, it would continue to contain the new, life was aseries of similar and yet different cycles that always contained thenew. 

Now my reflections let in hope, positiveness, comradeship, goodfeelings, and progress made by myself and others in our year and a halftogether as consultants. During this period we met with the consulteesfor an hour once or twice a week. The group had continued over thisperiod despite its components of psychiatric mental health professionalsand 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 ahalf, during the last three months, the focus of discussion was onpatients and their worlds for longer periods of time. There was lessdefensive acting out in which things, fees, time, and mechanics consumedthe hour. 

{106}

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

During the last three months of meeting I began to feel related on adeeper level with a few of the participants, consultants and consultees. Individual to individual we began to communicate collaboratively withone another as professional colleagues. We discussed both patients'lived worlds and the meaning of psychiatric mental health terms andideas. I can conceive, now, that this may have occurred between othergroup members before or after sessions. Initially there were often onlytwo to three consultees to five or six consultants. Later the totalgroup contained fifteen to sixteen people. Now I would project that thevery 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 dispassionateexperience. As a working consultant I met with consultees either aloneor as part of a collaborating team of consultants. Often the situationsthe consultees presented which they struggled with and stayed in struckme with awe. They aroused my humility while making me feel whole andfulfilled in my participation with the consultees. In my explorations ofand with the consultees my presence, thereness, and authenticity wereall important. Buber would say that my aim in consultation was to"imagine the real" of what the consultee and the patients and familiesshe discussed with me "could be. "[16] This was my initial disposition. Iaimed 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 couldcome to know intuitively the experience of this particular othernurse-in-her-lived-nursing-world. The consultees offered theirlived-nursing-worlds each in their unique ways. Some discussed directlytheir pains, joys, adequacies, and inadequacies. Some discussedindirectly their panic, success, action, and immobilization. Some beyondbeing able to discuss their lived-worlds {107} spontaneously acted outtheir lived-worlds. For example, these often behaved toward me as theirpatients and families behaved toward them. These kinds of acted outlived-worlds I had to sense my way into to understand. When I began towonder what it was that they wanted from consultation to take back totheir lived-nursing-worlds, I would pull out of the "I-Thou" form ofrelating. This wonderment became my conscious clue. It was time toreflect 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 thatI had intuitively taken on from the consultee, I would set it apart frommyself, and see it as an empathic response. I knew that these feelings Iexperienced which I received existentially, globally through thecompound of the consultee's words, tone inflection, volume, facialexpression, posture, and positioning to me were what she experienced inher-nursing world. Verbalization of this empathized understandingfulfilled several purposes: (1) it conveyed my sympathy or joy with, andalways my caring, (2) it validated that I saw it as it was for thisnurse, and (3) it opened the door to our working through the possiblemeanings of the nurse's experience and to speculating about outcomes ofalternative future nurse actions and behaviors. 

Cognitively the range of these consultation discussions was broad. Somecommon themes were social and health histories of families, pertinentpsychological growth and development factors of persons in the familiesof concern to the consultees, relationships between persons within thesituations, resources available to the families, ways the consulteescould relate with the parents and patients' families, friends, and otherprofessionals in the situation, and the meaning of all these themes tothe particular consultee. 

This clinical consultation experience necessitated my being certainways. It necessitated my being authentic with myself with regard to whatresponses were called forth in me in relating with a particularconsultee. I viewed honesty with the consultee as a value necessary tothe consultation process. In approaching the consultation I needed to beopen to the consultee's angular view and predisposed toward an "I-Thou"relationship. The "I-Thou" relating necessitated subsequent scientificunderstanding extrapolated from it through reflection on it as "I-It. "My hope in consultation was to offer both a cognitive, as well as, anontic experience in which a mutual feeling apart from and toward theother would exist. This latter seemed most important to me. If theconsultee experienced my being authentically present with her, she thenwould be apt to offer this type of relationship to the patients andfamilies of concern to her. 

Results of Comparison

The two clinical consultation experiences were juxtaposed, contrasted, questioned, related, and synthesized to envision their unifiedcontribution to the construct of "clinical. " The synthetic construct of"clinical" is not viewed as a mere juxtaposing, a disintegrating, orreconstructing of the contributions {108} to my knowing from either ofthese experiences. This comparison is viewed as a facing of themultiplicities they both present. The synthesis is an illumination ofboth experiences with each transfigured through their mutual presence inthe "knowing place" of the comparer. [17]

In this comparison my appreciation grew of how I had uniquelyimplemented and conceptualized clinical consultation in my workexperience. I recognized through the comparison that adequate clinicalconsultation demands both a passionate and dispassionate phase of"I-Thou" and "I-It" relating. Without either of these forms ofconsultant being-in-the-situation we degrade the term "clinical" if weemploy it. Consultation lends itself naturally to a collaborativecooperative relationship. The consultant is dependent on the consulteefor presentation of the specifics of particular situations. Theconsultee is dependent on the consultant for the tailoring of generalknowledge to the consultees' particular situations. The relationship ifappropriately called consultation is then of necessity interdependent. In being separate from the other while feeling with the other theconsultant does not lose the ability to question. Passion undealt withor identification with the consultee inhibits the clinical purpose ofthe consultant and of the consultation. In identification one feels asif he were the other, rather than turning to the other and feeling withhim. The degree of anxiety this provokes in the consultant can preventlooking 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 studentnursing consultation experience in an "I-It" way. At this time it becamea "clinical" experience for me. The lack of this reflective phase inthis experience highlighted the reflective phase already existent in theworking clinical consultation experience. The existence of this phase inthe working clinical consultation experience highlighted its absence inthe graduate student nursing consultation experience. My commonplacenursing world through this comparison became awarely meaningful andavailed 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 uniquepotential or ontic wholeness, and noetically transcending this relatingconceptualizes its meaning. 

Clinician signifies a particular mode of being and a particular kind ofcognitive knowledge. With all his human capacity the clinician relateswith his clinical-world consciously and deliberately in "I-Thou, " and"I-It. "

Relating in "I-Thou" with the other in-his-clinical-world the cliniciangives 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 thisrelating. He is confirmed and confirms the other through the other'spresence with him. Thus, he calls forth the other's actualizing of selfthrough the clinical relationship. In accepting the other as he is theclinician imagines and responds to the reality of his potential forbecoming, becoming according to his unique capacity for humanness. 

Relating in "I-It" with his clinical world the clinician noeticallytranscends himself, objectifies himself, and studies his "I-Thou"knowing. He teases it apart. He classifies and studies it. He asks itquestions. He compares and contrasts it to other clinical experiences. He discusses its many aspects in dialogue with his "inward, " andpossibly "outward" "Thous. " He reorders its parts. He shapes, creates, plans from and for its clinical existence. Thus, he ever augments aworld of heuristic knowing. 

This "how" allows the clinical fulfillment of my nursing "why. " Comfortis "why" I, as a nurse, am in the health-nursing situation. Asconceptualized "comfort" is being able to freely control and plan forone's self, being fully in accord at a particular time, in a particularsituation, with one's unique potential. Now, "what" is the nature of thenurse's world, the health-nursing situation?

ALL-AT-ONCE: WHAT

The term "all-at-once, " arose within me as a construct that wouldmetaphorically describe the multifarious multiplicities that existwithin nursing situations. Completing my comparison of Gilbert's andMuller's written works to grasp how they viewed the nature ofpsychiatric mental health nursing I found myself mulling over andfussing. [18] Your question is probably, mulling and fussing over what?While I mulled over and fussed I believe I, too, was perplexed. Why wasI unsatisfied?

I had compared Gilbert's and Muller's writing styles, their conceptionsof man, approaches to nursing, nursing education, supervision, andconsultation. Their similarities and differences were noted, and howeach presented herself predominantly. Then I cited the nursingcommunities they sought to influence and those in which they were whilewriting. Through reviewing their bibliographies and biographies Iindicated the sources that had influenced them. 

Still I mulled over, fussed, and was perplexed. I awakened in the middleof 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 hadfelt unrelated to the reality of the nurse's world. They oversimplifiedits complexity. The nature of nursing was complex. It seemed to me thatwe needed, as a profession, constructs that simplified and allowed clearcommunications. We, also, needed constructs that conveyed the realityand complexity of the {110} worlds in which nurses nursed. Perhaps adescription of what "all-at-once" expressed for me would convey toothers 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" occurringsimultaneously and not only in sequence as he expressed it. These twoways that man can relate to and come to know his world and himselfdemand sequential expression for clear communication. However, theresponsible authentic nurse in the nursing arena lives them"all-at-once. " Aware of the multifarious multiplicities of her responsesto another and at once to the surrounding field of action, the nurseselects 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 theself 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 componentof "I-It" relating, while acting and being. Therefore both "I-Thou andI-It" modes of being are "all-at-once. "

This necessity for a nurse's duality in her mode of being came to myawareness through comparing Gilbert' and Muller's works, studyingBuber's conceptions of man, and considering them in relation to mycurrent and past lived-experiences in the nursing-arena. In my nursingworld of "I-Thou" relating reflection is called forth prior to my overtresponse to allow response selection concordant with my nursing purpose. The very character of multifarious multiplicities of the nursing worldundoubtedly has called for nurses to develop their human capacity forduality in their mode of being. 

To make these "multifarious multiplicities" explicit I would like tooffer a description of a recent, personal nursing experience. In acommunity psychiatric mental health psychosocial clinic, I sat acrossfrom and focused on relating with a psychiatric client. After long yearsof hospitalization he was now living in a community foster home andvisiting the clinic three days a week. When there was no special clinicactivity in progress and often even when there was, he sat by himselfand played poker. He told me about his game many times, over weeks andmonths. He dealt out five poker hands. Each hand was dealt to a memberof his family, long dead. He did not accept their deadness. One daywhile describing the poker games and his relatives, he intermittentlyexpressed his fantasies which he projected on to a sweet cheerful65-year-old community volunteer. She was somewhat deaf. His fantasieswere angry. When he gestured toward her, she in a motherly way came overto him, put her arm around him, and her ear down to his mouth. It was amoment of possible client explosion. With my eyes I attempted tocommunicate with her. This, and the tone of the patient's voice warnedher to move away. While this was occurring another patient jealous of myattentions to this patient walked up and down, and in passing negativelycommented on the religious background of the man I was sitting with. Inthe rear of the room a dietician was conducting a group on obesity. Andall of this was set to the {111} melodious, sanguine strains of "If ILoved You" being poorly beat out on a piano about ten feet away byanother volunteer accompanied in song by a few clients. Meanwhile twostaff nurses were observing my part in all this since I was labeled"expert. " The client did support me that day and responded to my stayingwith him. Much to my surprise he began playing poker with me. He dealtme out a hand. This was, at this time, a new behavior on his part. Itwas movement toward his potential for relating to live persons in hiscurrent world. This, again, is just one example of the multifariousmultiplicities of one very common type of nursing situation. 

The inference from the above is that professional artistic-scientificnurses relate in "I-Thou, I-It, all-at-once" to the specific general, critical nonconsequential, and the healthy ill. This presents aparadoxical dilemma. Nurses, as human beings, have a highly developedcapacity for living "all-at-once" in and with the flow of themultifarious multiplicities of their worlds. Nurses, as human beings, like all other human beings, are limited to thinking, interpreting, andexpressing conceptually only in succession. 

This metaphoric synthetic construct, "all-at-once, " has allowed me tobetter convey how I experience the health nursing situation. It also hasaided my understanding of the multifarious multiplicity of angular viewsexpressed by several professionals in responding to and describing asimilar situation. I can accept each description as truth for eachresponder. Each responds with his uniqueness in the situation. Comparing, contrasting, and complementarily synthesizing these multipleviews inclusive of their inconsistencies and contradictions, nonenegating the other, allows a better understanding of man-in-his-world inthe health situation than the so frequently presented oversimplifications. These oversimplified presentations usually deal only with what isoccurring that is important to the particular interests of the reporter. And they are offered only after the selected material has been putthrough a process of interpretation and logical sequencing to emphasizethe reporter's particular point. In such reporting the existent in thesituation labeled unimportant, unacceptable, or unrelated is notconsidered. Such existents, nonetheless, may control the patients, thefamilies, the nurses and health professionals generally. Their controlmay well be more powerful than any erudite oversimplification or itspresentation. 

Humanistic nursing practice theory in asking for phenomenologicaldescriptions of the nurse's lived-world of experiencing proposesauthentic awareness with the self of what is existent in the situationprior to conceptualization for dispersal. Unless nurses appreciate andgive recognition to the dynamic meaningful breadth, depth, and futureinfluence of their worlds the actualization of the potential thrust ofthe 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, andinconsistencies) as metaphorically representative of what exists in thenurse's world. 

"Comfort" is a state valued by a nurse as an aim in which a person isfree to be and become, controlling and planning his own destiny, inaccordance with his potential at a particular time in a particularsituation. 

FOOTNOTES:

[1] Josephine G. Paterson, "A Perspective on Teaching Nursing: HowConcepts Become, " in _A Conceptual Approach to the Teaching of Nursingin Baccalaureate Programs_, a report of a project directed by Rose M. Herrera (Washington, D. C. : The Catholic University of America, School ofNursing, 1973), pp. 17-27. 

[2] American Nurses' Association, Division on Psychiatric-Mental HealthNursing, _Statement on Psychiatric Nursing Practice_ (New York: AmericanNurses' 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 Philosophyof 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 theGreat Books_, ed. Robert W. Hutchins, et al. (Chicago: EncyclopaediaBritannica, 1963). 

[11] Martin Buber, _Between Man and Man_, trans. Ronald Gregor Smith(Boston: Beacon Press, 1955); _I and Thou_, 2nd ed. , trans. RonaldGregor Smith (New York: Charles Scribner's Sons, 1958); _The Knowledgeof Man_, ed. Maurice Friedman (New York: Harper & Row, Publishers, 1965). 

[12] Henri Bergson, "Introduction to Metaphysics, " in _Philosophy in theTwentieth Century_, Vol. III, ed. William Barrett and Henry D. Aiken(New York: Random House, 1962) and "Time in the History of WesternPhilosophy, " 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 MacmillanCompany, 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 HealthPsychiatric 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 ofpsychiatric nursing I extracted 12 nurse behaviors from my clinical datathat were used repeatedly to increase patient comfort. I quantifiedthese behaviors for two months. The following are a list of thesebehaviors with a representative example of all but the first. The firstwas 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 tablesuddenly 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 upand 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'thave to do that, he should control himself, the rest of us controlourselves. " I said, "When others express how miserable they feel, itsometimes arouses our own feelings about our misery. " This was anattempt to provoke 32-year-old Arthur to work on his own {114} feelingsof misery and to deter his projection of anger at himself out ontoSidney. Arthur looked at me sharply, like he had gotten the message, andagreed by relaxedly nodding his head. 

(b) Alice, diagnosed as manic depressive, has been depressed. Thisdepression dates from her going out to a department store and asking fora job. She was hired for a five-day-a-week job. This was done on herown. Later her readiness for a five-day-a-week job and her participationin the unit were questioned. Then Alice became depressed. 

Alice was sitting in the dayroom. I sat down next to her. She lookedvery sad, her eyelids as well as her mouth, drooped. Her mouth worked asif she wanted to talk, but she was quiet. I asked her about her jobdecision. She said that she had not taken it. I said, "You look so sadthat 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 ofwanting to do two things at once in the present and not being able tocan bring up the feelings of a past very much more important similarexperience. " 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 leavesaying goodbyes to various people. Alice came out of a side room, putboth her hands out to me, and said, "goodbye and thank you. " In aprevious 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 thedayroom when I went in. She had not spoken at coffee. Now she sat verystiffly 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 ofa cornered animal. She blurted out, "I don't believe I've met you. " Itwas like she had said, "go away. " I smiled at her and said, "We wereintroduced at coffee, but with so many new people it's hard toremember. " Conversation continued to be tense. At one point Marionbolted 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. Wecontinued to talk about the fish. Marion came back and sat down a fewseats away from me. I said that I felt I'd been asking her an awful lotof questions but that I was only trying to get to know her. Marionseemed to relax in her chair and gave a great deal of information aboutherself in a strange stiff sort of way often inserting a word that didnot have meaning for me. I encouraged, supported and showed my interest. Finally she said that she {115} had been admitted to McLean in herthird year of nurses' training just before her psychiatric experience. She had been in therapy there, one-to-one for a couple of years. Iteased her about knowing the ropes, yet giving me a difficult time. Thiswas an attempt to increase her feelings of adequacy by bringing out thesimilarities of the old situation which she knew and this new situation. For the first time she really grinned at me, almost laughed. Marion isin 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, wasliberally gobbling her food with alertness for only more to be had. Heronly rather loud, irrelevant, smiling expression was about her daughterwho was a go-go dancer, had three children, and whom she had visitedtwice by bus in California. This day she approached me and asked if Iwould file her nails. I said that I would but asked if she knew if therewas a file in the unit. Another patient offered his. We sat down and Ifiled. The patient poured out a life story full of misery. This was aside of this patient that I had not perceived. I listened, nodded, andfiled. The story started in the 1930s about her husband andmother-in-law's behavior; their marital separation; his being killed inWorld War II; their two children; their son, now thirty, was born withcerebral palsy, is blind and mute, and has been institutionalized sinceeleven months old; their daughter's husband left her with three childrenafter fourteen years of marriage. I silently wondered what old feelingmight have been aroused in her by her daughter's marital separation. Herdaughter is so busy that she is unable to write regularly. She has toldMary not to worry if she doesn't hear from her. Mary then expressedconcern 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. Iinquired if her mother lived alone. Yes, but next to relatives. She thenrelated the drastic physical problems of a relative. I felt the sadnessof this woman as she talked and empathized with the tough time she hadhad. 

 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. Acasual conversation ensued about Thanksgiving as it had been andChristmas as it might be. There was talk of having been at home andplans for being at home. I supported and encouraged the discussionbecause of the meaningfulness of holidays, past and present. Snow wasinitiated as a {116} topic. I said, "It would be nice to have a whiteChristmas, but not too white. " Vincent, a stiff, exact, ritualisticperson who avoids stepping in an obvious fashion on thresholds, doeslittle jiggle-like dance steps before sitting down, and again beforesettling in his chair, suddenly spoke. "Josephine, I beg your pardon, but I must take issue with you. " I encouraged his unusual behavioralexpression. 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 hewas getting at rather than each specific rapidly mentioned issue. Hewent from white to black, day to night, goodness to badness, love tohate, this side of the world to the other side of the world (Vietnam). Iexpressed that he seemed to keep mentioning two sides of things and thatfor some reason I could not help thinking of boys and girls. I said thathe was over on that side of the world (room) and that I was over on thisside of the world. I asked why he did not come over to my side, paused aminute, felt this was asking too much of this patient, and said, "WellI'll come over to your side then. " When I sat down next to Vincent, hegiggled as he does. Arthur, a younger patient, made a critical jealoustype comment about Vincent's age (50ish). Arthur has done this beforewhen I give attention to Vincent. Has Arthur a stereotype of fatherimages and perhaps mother images? I said to Vincent "you have beautifulwhite hair, and big, brown, smiling Italian eyes. " Vincent sat backsmiling 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 herweekend at home. Alice is a quiet, bland, soft-spoken person aboutfifty. She wears a worried expression even when she smiles and strikesme like she is "turned inside" herself. I encouraged her to talk abouther time at home. She told me about how they had painted the living roomwith what for her was a show of real excitement. I said that her wish tobe at home was very understandable. I did this because this patientalmost whispers her wish to be at home and, generally, no one respondsto it. Alice talked on with encouragement about the single sister whomshe visits and the pleasure it gives her to be with this sister. 

[I have other examples of this nurse behavior that indicate supportingof relationships between patients and between patients and otherpersonnel. ]

 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 newpair of shoes. The issues were where these might be gotten (Carolyn has{117} money), what kind she should get, and who and when someone wouldtake her for them. It struck me as if Carolyn might not have beenpresent. I asked Carolyn what kind of shoes she would like. Carolynresponded that she did not know whether she should buy regular shoes, orsneakers, or canvas shoes like Marilyn had gotten. She beamed. Since, she has come up to me several times and discussed the two pairs ofdifferent kinds of shoes she bought and why. Carolyn is a sweet, simple, retarded, deaf sixty year old whose behavior resembles an eight yearold. 

 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 laughingway for having been away. Then she moved from a seat in the corner ofthe room to a chair behind me at the coffee table. I moved to allow herto move up to the table, but she did not. After coffee Irene nonverballywith eyes and body movements told me to follow her. She led me into asmall beauty parlor room and we both sat down. She closed her eyes. Isaid, "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 behelpful to you to talk about your present missing feelings as you hadsome very important losses of people when you were younger. " Her eyesliterally popped open and she again blurted, "You mean my parents?" Isaid, "Yes and your therapist could help you with this. " I then asked ifshe ever had the opportunity to talk with anyone about such things. Shereplied, "No, well I had a social worker when I was a little girl. " Itried 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 Ireneclosed 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 thequestion of what she was really asking for. I believe she was asking forconcrete attention to test my ability to care for her. I was trying tosay, 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 atsome length about her suicidal thoughts. I supported this on the basisthat {118} verbal expression might make active expression unnecessaryif she experienced empathy regarding how dreadful she felt. Then withlittle encouragement she had come down to the unit with me. Today, Alicewas always near me, but nonverbal except for concise responses toquestions that were offered with effort. I verbalized my reflections onher behavior and said that I was wondering about it. She said, "I likehaving you around; it takes me away from my thoughts. " "How are yourthoughts?" "The same, I wonder if I'll ever get better?" "You've gottenbetter before. I wonder if you're not more concerned about whether youcan stay well. " Alice, eyes watery, agreed with a nod. Irene, anotherpatient, interrupted, "Don't expect too much from me, I've been heretwelve 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 hisexaggerated conscious expression of only the true, the good, and thebeautiful. On this occasion we had just had a long talk about hisweekend at home, his concerns about his family, and his food likes anddislikes. As we left a room he took his usual long step over thethreshold. 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 heconsciously or unconsciously is selecting what he is going to say. Wecame to the next threshold. He stopped me by touching my arm and said, "Josephine, I almost grabbed you to prevent your bumping into thatpatient. " In relation to my last question I focused on the "grabbed you"and said, "Vincent, to think about grabbing me is a pretty naturalthought, and no reason to take a wide step over a threshold. " He put hisfoot very deliberately if rather testily, right in the middle of thisthreshold. 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 atresponding to me agreeably as he thinks I want him to, he frequentlygoes out of his way to make cutting comments to me about middle-aged menpatients, and he responds with anger or teasing to a female patient hisage. Arthur has a mother, father, and two older sisters. He obviouslylet me win at Ping-pong several times. I discussed this with him andasked if {119} he had ever talked with anyone about his responses toolder 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 thetalking it over. He said, "I haven't had much chance for that. " Thenstaring at me he asked seriously, "Do you think talking it over wouldhelp?" I said, "I think that it would take a great deal of effort onyour 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 thedifficulties of living outside the hospital, past relationships withnursing personnel, and her past practical nurse jobs suddenly said, "Iworry about being sexually OK. " This was kind of blurted out and sheobserved me closely. I said, "I thought that you had some concerns aboutthis in relation to how you responded to my cutting the hairs on yourface. I guess everyone worries at times about their adequacy in thisarea. " She said, "I've never been able to have intercourse; I can justgo as far as heavy petting. People say you can get a lot expressed ifyou have intercourse. " I said, "Some people can, but if you have otherstandards that you've grown up with, (I suspect a rather religious, rigid Jewish background) it might cause difficulties to go against thosestandards. " (Alice first became ill at sixteen, left school, and hadsome treatment in the community. ) "It's pretty responsible not to bewilling to bring a fatherless baby into the world, and I'm sure you'dhave feelings about how your family might have responded to this sort ofthing. " Alice nodded and said "It's just that I don't know how womanly Iam. " I said with gestures and emphatically, "Well, Alice, if you havetwo things up here and no thing down here, then the fact is that you area woman. " Discussion pursued about her further talking about this topicwith her therapist and the value of her working through her feelings inthis area. This was a lengthy discussion and the first talking I hadexperienced Alice doing since her depression. {120} {121}

 GLOSSARY

~angular view. ~ An individual's unique vision of reality necessarilyrestricted 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 inexistence or the experience of living. 

~existential dialogue. ~ A unique individual person with the wholeness ofhis being is present, open to, and relates to the other seen in hisunique individual wholeness; an exchange in which two persons transcendthemselves and participate in the other's being; an interiorunification; a mutual common union in being. 

~existential experience. ~ Contact with reality with the whole of one'sbeing; involves all that a man _is_ as opposed to experiencing throughone or several faculties. 

~existentialism. ~ Philosophy based on phenomenological studies ofreality; centers on the analysis of existence particularly of theindividual human being, stresses the freedom and responsibility of theindividual, regards human existence as not completely describable orunderstandable in idealistic or scientific terms. 

~here and now. ~ An individual's unique experience of his present spatialand temporal reality including his past experiences and expectations ofthe future. 

~humanistic nursing. ~ A theory and practice that rest on an existentialphilosophy, value experiencing and the evolving of the "new, " and aim atphenomenological description of the art-science of nursing viewed as alived intersubjective transactional experience; nursing seen within itshuman context. 

~intersubjective. ~ Pertaining to two or more human persons and theirshared between; a relationship of two or more human beings in which eachis the originator of human acts and responses. {122}

~lived dialogue. ~ A form of existential intersubjective relatingexpressed in being with and doing with the other who is regarded as apresence (as opposed to an object); a lived call and response. 

~lived world. ~ The everyday world as it is experienced in the here andnow. 

~metanursing. ~ A discipline designed to deal critically with nursing, ontological study of nursing; study of the phenomenon of nursing; acritical study of nursing within its human context. 

~metatheoretical. ~ Transcending theory; ontological inquiry from whichtheory may be derived. 

~nursology. ~ Study of the phenomenon of nursing aimed toward thedevelopment of nursing theory. 

~phenomenology. ~ The descriptive study of phenomena. 

~phenomenon. ~ An observable fact, event, occurrence or circumstance; anappearance or immediate object of awareness in experience. A phenomenonmay be objective (that is, external to the person aware of it) orsubjective (for example, a thought or feeling). 

~prereflective experience. ~ Primary awareness or perception of realitynot yet thought about; spontaneous experience; immediate experience orperception. 

~presence. ~ A mode of being available or open in a situation with thewholeness of one's unique individual being; a gift of the self which canonly be given freely, invoked, or evoked. 

~transactional. ~ An aware knowing of one's effect in a situation ofwhich 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 sincethe initial publication of Paterson and Zderad's _Humanistic Nursing_, the work has been formally cited and or discussed in the nursingliterature. This selected bibliography was compiled by Helen Streubert, MSN, RN doctoral candidate and research assistant in the Department ofNursing 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 ofPaterson and Zderad. In P. Winstead-Fry (Ed. ), _Case studies in nursingtheory_ (pp. 167-195). New York: National League for Nursing. 

Leininger, M. (1985). Ethnography and ethnonursing models and modes ofqualitative data analysis. In M. Leininger (Ed. ), _Qualitative researchmethods 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. _ NewYork: National League for Nursing. 

Munhall, P. L. , & Oiler, C. J. (1986), _Nursing research: A qualitativeperspective_. 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: NationalLeague for Nursing. 

Phipps, W. J. , Long, B. C. , & Woods, N. F. (1987). _Medical-surgicalnursing: Concepts and clinical practice_ (3rd ed. ). St. Louis: MosbyCompany. 

Roy, C. (1984). _Introduction to nursing: An adaptation model_ (2nded. ). 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 developmentof nursing theory. In H. H. Werley & J. J. Fitzpatrick (Eds. ), _Annualreview of nursing research_ (pp. 241-267). New York: Springer PublishingCompany. 

Zderad, L. T. (1978). From here-and-now to theory: Reflections on "how". In _Theory development: What, why, how (pp. 35-48). New York: NationalLeague for Nursing_. 

ARTICLES

Bael, E. D. , & Lowry, B. J. (1987). Patient and situational factors thataffect nursing students' like or dislike of caring for patient. _NursingResearch, 36_ (5), 298-302. 

Beckstrand, J. (1980). A critique of several conceptions of practicetheory in nursing. _Research in Nursing and Health, 3_, 69-79. 

Bottorff, J. L. , & D'cruz, J. V. (1984). Towards inclusive notions ofpatient 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. _Topicsin Clinical Nursing, 8_ (2), 56-62. 

Chenitz, W. C. , & Swanson, J. M. (1984). Surfacing nursing process--Amethod for generating nursing theory from practice. _Journal of AdvancedNursing, 9_ (2), 205-215. 

Drew, N. (1986). Exclusion and confirmation: A phenomenology ofpatients' experiences with caregivers. _Image, 18_ (2), 39-43. 

Flaskerud, J. H. (1986). On toward a theory of nursing action skills andcompetency in nurse-patient interaction. _Nursing Research, 35_ (4), 250-252. {125}

King, E. C. (1984). Humanistic education: Theory and teachingstrategies. _Nurse Education 8_ (4), 39-42. 

Nahon, N. E. (1982). The relationship of self-disclosure, interpersonaldependency, and life changes to loneliness in young adults. _NursingResearch, 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 ofhelpfulness 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 forholistic nursing theory. _Advances in Nursing Science, 9_ (2), 1-9. 

Taylor, S. G. (1985). Rights and responsibilities: Nurse patientrelationships. _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 thisversion. ]

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 itFootnote 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, ]