Foundation of Humanistic Nursing Theory
Logic of Phenomenological Methodology
THEORETICAL ROOTS
Humanistic Nursing: A Lived Dialogue
Chapter Three
Humanistic Nursing: A Lived Dialogue
Dr. Zderad referred to the elements of the humanistic nursing framework (see prior chapter) as a conceptual abstraction. Somewhat like that of a black and white photo is in comparison to a glorious color photograph, the framework doesn't do justice to the actual experience. These moments, when nurses are aware of the intersubjective transaction, are illuminating, richly rewarding, and remind that there is an ever present "between" not explainable scientifically.
Nurses also know that the effect of human interaction can be humanizing or dehumanizing. For humanistic theory development, the importance of holding this transaction up to the light, examining it, exploring the thing itself, describing the character, and ruminating on the experience, is necessary for further development and expansion.
Part of the problem in doing this work is that nurses are hampered by mere words. Like the old saying that "a picture is worth a thousand words" so is humanistic theory description hampered. How does one translate into words the "in between" occurrence? It is such an essential part of what nursing is, but so difficult and almost impossible to conceptualize and share.
"Nursing itself is a particular form of human dialogue." (P & Z, p. 22) This was an epiphany for Zderad but in the saying so, its total overwhelming effect was lost in the spokenness of the phrase. Just as an epiphanic insight needs sharing, to this Dr. Zderad wrote a paper in 1973 called The Dialogue Called Nursing and started her walk down the theory path.
Nursing, as lived dialogue, is under the umbrella of being in the health-illness continuum, is purposeful to a call and response, and is concerned with the human potential. With this in mind Dr. Zderad writes about "meeting, relating, presence, call and response, things, time, and space" ( P & Z, p. 23-31) and how it fits into the concept of humanistic nursing.
Meeting in the humanistic nursing sense is a particular kind of meeting because it is purposeful. There is either an expectation and/or goal in mind in the meeting with the nurse helping and the patient needing assistance. This event is colored by a number of factors including emotions, workload, and physical constraints, and each has the ability to control the quality of the meeting. The perception of each may be different or alike with some perception based in the obvious and others imprecise, unconscious 'gut hunch' type feeling. With each human-to-human meeting each carries away from the meeting a sense of the other. The nurse "is at once a replaceable cog in a wheel of incomprehensibly complex system and a unique human being sharing most intimately in another's search for the meanings of suffering, living, dying. Can these two world views be reconciled?" (P & Z, p. 26)
Relating is what man does when he sees himself apart from others, distinct yet also part of a whole with the ability to enter into a relationship with others like him. Man makes the distinction and knows that one is unable to enter into a relationship with objects but is able to qualify that he can relate as subject to object. With human-to-human contact there is always the possibility of intersubjective dialogue or relating. Both subject-to-subject (human-to-human) and subject-to-object (human-to-object) are necessary for the clinical nursing process.
Presence cannot be held like an object. Like the term, love, it can only be given or invoked, welcomed or rejected. It is not called forth on demand. Presence then is ephemeral, without form yet as real as any object that can be seen.
The open or available person reveals himself as 'present. This is not the same as being attentive; a listener may be attentive and still refuse to give himself. Visible actions do not necessarily signify presence so it cannot be proven. But it can be revealed directly and unmistakably in a glance, a touch, a tone of voice....Availability implies therefore, not only being at the other's disposal but also being with him with the whole of oneself. Furthermore, it involves reciprocity. The other is also seen as a presence, as a person rather than an object, such as a function or a case....'I realize that my openness is an openness to a 'person-with-needs' and my availability is an 'availability-in-a-helping-way'. By comparison, my experiences of openness and availability in social, family, or friend relationships and in nurse-patient relationships differ. In the later, I find myself responding with a kind of 'professional reserve .' (P & Z, p. 28)
Call and Response in nursing dialogue is bi-directional in order to be transactional. Both nurse and patient experience the complex dialogue which may occur as a single occurrence to sequential meetings where it can be stopped, started, resumed at any time by either. The call and response is also simultaneous, both call and respond at once, and is reflective of every form of human communication from verbal to body language. Call and response is lived through nursing care activities from giving a sip of water to actively doing CPR. The nursing act conveys a message and the complexities of possible messages given and received by both can be staggering.
While the aforementioned is simplistic, nursing dialogue is far from it. Also it is subjected to all the active stimuli and chaotic forces or real life. In addition, there may be numerous human-to-human contacts occurring simultaneously, such as with part of a group, not necessarily one-on-one. As specialization enters the picture, the nursing dialogue changes to accommodate this expansion while still maintaining the basics.
Ordinary objects (things) affect and influence how nursing dialogue may take place. To the nurse, things may be her tools, to the patient, things may be strange, weird and unknown. Each approaches the object differently depending on what is known, unknown and past history.
Time is not only measured but lived. Each may approach the same measured minutes differently depending on what may be happening in their environment or situation. Each may approach these minutes in a different way depending on their emotional status at the time. Time is also measured by the person's age. A perception of the nurse may be of continuous care when thinking of 'coverage' but to the patient, many 'nurses' (actual vs perceived) will interact with him over a 24-hour period. With genuine intersubjective "between" the nurse feels in harmony with the dialogue and synchronizes, anticipates or delays this "between" for the best outcome. Thus, time and timing involve the "between" and share not just measured time but lived time.
Space and perception of space may be as in a physical setting but is not limited to this. Factor in the health-illness continuum and changes in body movement, such as in a stroke or blindness, and the perception of space can be quite different to the nurse and the patient. There is a perception of personal and lived space. This is where each is in his or her comfort zone. To be in tune with the patient, the nurse must know the patient in the patient's world or lived space and in the here and now. Lived space is further defined by lived time, that is, familiarity creates comfort.
Science overwhelms the nursing realm. Scientific progress and advances in technology are ever at the forefront of nursing development and flavors its world. Humanistic nursing as a lived dialogue cannot be studied and advanced in this scientific method but it is brought alive with experienced phenomena and qualitative methods. "Humanistic nursing, viewed as a lived dialogue, offers a frame of orientation that places the center of our universe at the nurse-patient intersubjective transaction." (P & Z, p. 36)
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