CLINICAL: HOW
As a component of my doctoral examinations I was faced with having to rewrite a clinical paper. This led to my deliberately and personally choosing to conceptualize a synthetic construct of "clinical." This was my decision. It speaks well for the value of having had the experience of conceptualizing "comfort." Often it is said that man repeats that which he finds as meaningful and good. This choice also signifies a real overcoming of my resistance and ambivalence toward synthetic construct development in a year"s time.
"Clinical" was developed as a synthetic construct in 1968. It was a conceptualized response to a dialectical process within myself. If I am a clinician, then "how" I am in the health-nursing situation would equate to "clinical." In conceptualizing this construct I teased out of my lived-nursing-world the "how" of my working toward my own and others"
comfort.
Confusion, over what was meant when persons casually and currently popularly attributed the term "clinical" to situations and persons, called forth this conceptualization. It grew out of comparing and contrasting two nursing consultation experiences in the psychiatric-mental health area. Beginning this conceptualization I would have referred to both these experiences as "clinical." At the termination of the conceptualization they were both "clinical." They were very different experiences for me, and yet of equal value in my advancement toward my more of being. Prior to this conceptualization because my attending emotions were so disturbing and unacceptable to me in relation to one of these experiences, automatically I repressed part of them and found reasons to suppress the rest of them. Unfortunately, all else that was of value to me in having lived this experience was integrally enmeshed with these emotions. This, too, became unavailable to my conscious awareness. Conceptualization made recall and reflection a necessity. Clinical includes inherently a process of experiencing awarely and then recalling, looking at, reflecting on, and sorting out to come to knowing.
Before knowing how to approach the rewriting of my clinical paper as a partial requirement for receiving my doctoral degree I experienced a depression. I felt frightened, angry, and inadequate. The original clinical paper had been judged as more intellectual and scholarly than clinical. I could conceive of only two alternatives. Both seemed self-defeating. One, I could revise my former clinical paper into a more intellectual and scholarly paper that still {104} would not be clinical and would still leave my "I" out. Or, two, I could revise my former clinical paper, dump all my feelings in the situational experience, blame everyone else for these feelings, and culminate at least with my clinical pa.s.sions visible. Conflict resulted from my considering pursuing either of these routes. I was immobilized for a time. A time limitation and time pa.s.sing pushed me to begin somewhere. I began.
Choosing the second alternative in the belief that at least through writing I would better understand what I had lived in the experience.
I could support the value of dredging up these old feelings and looking at them. Authentically letting myself be aware of what I had experienced, not necessarily communicating this or acting out in accordance with these redredged feelings; just really looking at them might allow me choice in how I wanted to live with them. One support for the value of looking at these old feelings was my own past three and one-half years in psychoa.n.a.lysis in which I profited through such a process. The other support was my readings of the past two years. These included works of Russell,[6] Nietzsche,[7] Plato,[8] Popper,[9]
Dewey,[10] Buber,[11] Bergson,[12] Cousins,[13] and de Chardin.[14]
As this experience became in shape and meaning through my writing, I began to view this product as like an existential play filled with blatant atrocities and absurdities that had to be nonrealities. This production, also, made visible beautiful raw data. As meaning in this clinical nursing consultation experience as a graduate student became evident, comparison of it with the meaning of clinical work experiences in nursing consultation situations flowed naturally. Then joy, it was like sunshine burst forth and warmed my spirit.
Before entering school, I was, for two years, a mental health psychiatric clinical nurse consultant to a staff of forty-five visiting nurses. I had become intrigued {105} with what I had come to understand about consultation related to clinical situations. I wrote a paper for publication on the subject. Busy in the process of returning to school, and awaiting the publication of two other papers--both of these proceedings feeling unreal and out of my control, not to mention self-exposing--I merely filed in my desk the typed submittable rendition of this consultation paper. Now, I dug it out. This meant that I had two conceptualized presentations of similar type personal experiences in nursing consultation to compare and contrast. From these, my conceptualization of clinical, and the values on which my clinical practice rests, could be extrapolated.
A Student Consultation Experience Becomes Clinical
In the graduate student nurse consultation experience I felt helpless, confused, unwanted, guilty, anxious, and unimportant. It was a pa.s.sion-filled experience for me. As a nurse-student consultant among interdisciplinary nonstudent-consultants I experienced dependency for my being and doing on persons I viewed as anxious, critical, nonempathetic, and inadequate. We were attempting to offer consultation to a professional group of nonpsychiatric mental health oriented consultees who were anxious and felt inadequate in this area. I felt forced into an observer rather than partic.i.p.ant mode of being, and my recorded data support this. Impotency comes to mind when I recall this experience, as well as a racking rage and suffering that obliterates feelings of love, good-will, tenderness, or hope. About that time I was reading Nietzsche"s eternal recurrence phenomenon[15] and viewed it most pessimistically--all was awful, it would continue to be awful, life was just a vicious cycle of awfulness.
Defense or health, it is questionable. Suddenly, perhaps it was having hit feelings of rock bottom, I began to view Nietzsche"s eternal recurrence phenomenon optimistically. Did the polarization of my negative feelings magnetically call forth my opposite feelings? All, now, contained the new, it would continue to contain the new, life was a series of similar and yet different cycles that always contained the new.
Now my reflections let in hope, positiveness, comradeship, good feelings, and progress made by myself and others in our year and a half together as consultants. During this period we met with the consultees for an hour once or twice a week. The group had continued over this period despite its components of psychiatric mental health professionals and nonpsychiatric mental health profession culturally, professionally, and historically having been quite alienated from one another.
Attendance had improved some over time. Toward the end of the year and a half, during the last three months, the focus of discussion was on patients and their worlds for longer periods of time. There was less defensive acting out in which things, fees, time, and mechanics consumed the hour.
{106}
Toward the end of these sessions the consultant chief found more acceptable s.p.a.ce in which to meet for the consultation. Eating lunch became part of the session. Food can be looked at in many ways. In this case it seemed to be a cohesive force, rather than a distracting, socializing force. Was this because of the underlying meanings food had for these people? Or was the meaning of food in this situation concrete?
Now the consultees could have their lunch served to them while receiving consultation. This latter saved their time and meant money to them. This was a giving gesture on the part of the consultants even though the lunch monies did come out of the project funding source. The meaning of food was never discussed in the group. I wonder if this feeding was done with deliberate awareness or was just serendipitous.
During the last three months of meeting I began to feel related on a deeper level with a few of the partic.i.p.ants, consultants and consultees.
Individual to individual we began to communicate collaboratively with one another as professional colleagues. We discussed both patients"
lived worlds and the meaning of psychiatric mental health terms and ideas. I can conceive, now, that this may have occurred between other group members before or after sessions. Initially there were often only two to three consultees to five or six consultants. Later the total group contained fifteen to sixteen people. Now I would project that the very existence of this group could influence future groups positively.
A Clinical Work Consultation Experience
In this work consultation experience my feelings were openness, reflectiveness, pain, helpfulness, alertness, searchfulness, appreciativeness, receptiveness, responsiveness, wantedness, competence, joy, and importance. It was both a pa.s.sionate and a dispa.s.sionate experience. As a working consultant I met with consultees either alone or as part of a collaborating team of consultants. Often the situations the consultees presented which they struggled with and stayed in struck me with awe. They aroused my humility while making me feel whole and fulfilled in my partic.i.p.ation with the consultees. In my explorations of and with the consultees my presence, thereness, and authenticity were all important. Buber would say that my aim in consultation was to "imagine the real" of what the consultee and the patients and families she discussed with me "could be."[16] This was my initial disposition. I aimed to be open to and accept the potentials of these others.
In initial receptiveness, grounded in my comfort, was the "key" to the "door" of the consultant-consultee "I-Thou" relation in which I could come to know intuitively the experience of this particular other nurse-in-her-lived-nursing-world. The consultees offered their lived-nursing-worlds each in their unique ways. Some discussed directly their pains, joys, adequacies, and inadequacies. Some discussed indirectly their panic, success, action, and immobilization. Some beyond being able to discuss their lived-worlds {107} spontaneously acted out their lived-worlds. For example, these often behaved toward me as their patients and families behaved toward them. These kinds of acted out lived-worlds I had to sense my way into to understand. When I began to wonder what it was that they wanted from consultation to take back to their lived-nursing-worlds, I would pull out of the "I-Thou" form of relating. This wonderment became my conscious clue. It was time to reflect and look at what my explorations had uncovered.
At this point transcending this "I-Thou" relation, I would look at "It."
Seeing, now, what was within me, what the condition of my being was that I had intuitively taken on from the consultee, I would set it apart from myself, and see it as an empathic response. I knew that these feelings I experienced which I received existentially, globally through the compound of the consultee"s words, tone inflection, volume, facial expression, posture, and positioning to me were what she experienced in her-nursing world. Verbalization of this empathized understanding fulfilled several purposes: (1) it conveyed my sympathy or joy with, and always my caring, (2) it validated that I saw it as it was for this nurse, and (3) it opened the door to our working through the possible meanings of the nurse"s experience and to speculating about outcomes of alternative future nurse actions and behaviors.
Cognitively the range of these consultation discussions was broad. Some common themes were social and health histories of families, pertinent psychological growth and development factors of persons in the families of concern to the consultees, relationships between persons within the situations, resources available to the families, ways the consultees could relate with the parents and patients" families, friends, and other professionals in the situation, and the meaning of all these themes to the particular consultee.
This clinical consultation experience necessitated my being certain ways. It necessitated my being authentic with myself with regard to what responses were called forth in me in relating with a particular consultee. I viewed honesty with the consultee as a value necessary to the consultation process. In approaching the consultation I needed to be open to the consultee"s angular view and predisposed toward an "I-Thou"
relationship. The "I-Thou" relating necessitated subsequent scientific understanding extrapolated from it through reflection on it as "I-It."
My hope in consultation was to offer both a cognitive, as well as, an ontic experience in which a mutual feeling apart from and toward the other would exist. This latter seemed most important to me. If the consultee experienced my being authentically present with her, she then would be apt to offer this type of relationship to the patients and families of concern to her.
Results of Comparison
The two clinical consultation experiences were juxtaposed, contrasted, questioned, related, and synthesized to envision their unified contribution to the construct of "clinical." The synthetic construct of "clinical" is not viewed as a mere juxtaposing, a disintegrating, or reconstructing of the contributions {108} to my knowing from either of these experiences. This comparison is viewed as a facing of the multiplicities they both present. The synthesis is an illumination of both experiences with each transfigured through their mutual presence in the "knowing place" of the comparer.[17]
In this comparison my appreciation grew of how I had uniquely implemented and conceptualized clinical consultation in my work experience. I recognized through the comparison that adequate clinical consultation demands both a pa.s.sionate and dispa.s.sionate phase of "I-Thou" and "I-It" relating. Without either of these forms of consultant being-in-the-situation we degrade the term "clinical" if we employ it. Consultation lends itself naturally to a collaborative cooperative relationship. The consultant is dependent on the consultee for presentation of the specifics of particular situations. The consultee is dependent on the consultant for the tailoring of general knowledge to the consultees" particular situations. The relationship if appropriately called consultation is then of necessity interdependent.
In being separate from the other while feeling with the other the consultant does not lose the ability to question. Pa.s.sion undealt with or identification with the consultee inhibits the clinical purpose of the consultant and of the consultation. In identification one feels as if he were the other, rather than turning to the other and feeling with him. The degree of anxiety this provokes in the consultant can prevent looking at the consultation situation and issues in an "I-It" manner.
The consultant loses the ability to question.
Through this comparison I was able to reflect on the graduate student nursing consultation experience in an "I-It" way. At this time it became a "clinical" experience for me. The lack of this reflective phase in this experience highlighted the reflective phase already existent in the working clinical consultation experience. The existence of this phase in the working clinical consultation experience highlighted its absence in the graduate student nursing consultation experience. My commonplace nursing world through this comparison became awarely meaningful and availed itself for conceptualization. A situation is not a "clinical"
experience until the "would be" clinician can reflect, a.n.a.lyze, categorize, and synthesize it.
Clinical Is
A potentially clinical psychiatric mental health situation becomes "clinical" if the clinician relates to the helpee to awaken his unique potential or ontic wholeness, and noetically transcending this relating conceptualizes its meaning.
Clinician signifies a particular mode of being and a particular kind of cognitive knowledge. With all his human capacity the clinician relates with his clinical-world consciously and deliberately in "I-Thou," and "I-It."
Relating in "I-Thou" with the other in-his-clinical-world the clinician gives himself and receives back the other and himself in the sphere of "the between." {109} He knows the other and the more of himself in this relating. He is confirmed and confirms the other through the other"s presence with him. Thus, he calls forth the other"s actualizing of self through the clinical relationship. In accepting the other as he is the clinician imagines and responds to the reality of his potential for becoming, becoming according to his unique capacity for humanness.
Relating in "I-It" with his clinical world the clinician noetically transcends himself, objectifies himself, and studies his "I-Thou"
knowing. He teases it apart. He cla.s.sifies and studies it. He asks it questions. He compares and contrasts it to other clinical experiences.
He discusses its many aspects in dialogue with his "inward," and possibly "outward" "Thous." He reorders its parts. He shapes, creates, plans from and for its clinical existence. Thus, he ever augments a world of heuristic knowing.
This "how" allows the clinical fulfillment of my nursing "why." Comfort is "why" I, as a nurse, am in the health-nursing situation. As conceptualized "comfort" is being able to freely control and plan for one"s self, being fully in accord at a particular time, in a particular situation, with one"s unique potential. Now, "what" is the nature of the nurse"s world, the health-nursing situation?
ALL-AT-ONCE: WHAT
The term "all-at-once," arose within me as a construct that would metaphorically describe the multifarious multiplicities that exist within nursing situations. Completing my comparison of Gilbert"s and Muller"s written works to grasp how they viewed the nature of psychiatric mental health nursing I found myself mulling over and fussing.[18] Your question is probably, mulling and fussing over what?
While I mulled over and fussed I believe I, too, was perplexed. Why was I unsatisfied?
I had compared Gilbert"s and Muller"s writing styles, their conceptions of man, approaches to nursing, nursing education, supervision, and consultation. Their similarities and differences were noted, and how each presented herself predominantly. Then I cited the nursing communities they sought to influence and those in which they were while writing. Through reviewing their bibliographies and biographies I indicated the sources that had influenced them.
Still I mulled over, fussed, and was perplexed. I awakened in the middle of one night in 1969 understanding what had been causing my struggle.
The "all-at-once" was my answer.
The description of single constructs and single examples originally had felt unrelated to the reality of the nurse"s world. They oversimplified its complexity. The nature of nursing was complex. It seemed to me that we needed, as a profession, constructs that simplified and allowed clear communications. We, also, needed constructs that conveyed the reality and complexity of the {110} worlds in which nurses nursed. Perhaps a description of what "all-at-once" expressed for me would convey to others the lived-un.o.bservable-worlds of nurses.
Nurses relate to other man in situations of "all-at-once." The "all-at-once" is equated by me to Buber"s "I-Thou" and "I-It" occurring simultaneously and not only in sequence as he expressed it. These two ways that man can relate to and come to know his world and himself demand sequential expression for clear communication. However, the responsible authentic nurse in the nursing arena lives them "all-at-once." Aware of the multifarious multiplicities of her responses to another and at once to the surrounding field of action, the nurse selects and overtly expresses her responses that actualize the purpose, values, and potential of the artful science of professional nursing.
Awareness of the multifarious multiplicities affecting the other and the self in the nursing arena is a component of "I-Thou" relating.
Selectively overtly expressing concordantly with the purpose, values, and potential of nursing necessitates a looking at, which is a component of "I-It" relating, while acting and being. Therefore both "I-Thou and I-It" modes of being are "all-at-once."