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FOUNDATIONS OF HUMANISTIC NURSING
Nursing is a response to the human situation. It comes into being under certain conditions--one human being needs a kind of help and another gives it. The meaning of nursing as a living human act is in the act itself. To understand it, therefore, it is necessary to consider nursing as an existent, a phenomenon occurring in the real world.
THE PHENOMENON OF NURSING
The phenomenon of nursing appears in many forms in the real lived world.
It varies with the age of the patient, the pathology or disability, the kind and degree of help needed, the duration of the need for help, the patient"s location and his potential for obtaining and using help, and the nurse"s perception of the need and her capacities for responding to it. Nursing varies also in relation to the sociocultural context in which it occurs. Being one element in an evolving complex system of health care, nursing is continuously appearing in new specialized forms.
As professionals, we are accustomed to viewing nursing as we practice it within these specialty contexts--for example, pediatric, medical, rehabilitation, intensive care, long-term care, community. There seems to be no end to the proliferation of diversifications. Even the attempts of pract.i.tioners 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 ent.i.ty without having one"s view colored by a particular clinical, functional, or societal context. Yet, if we can "bracket" (hold in abeyance) these adjectival labels and the preconceived viewpoints they signify, we can consider the thing itself, the act of nursing in its most simple and general appearance. {12}
Well-Being and More-Being
In this most basic sense, then, disregarding the particular specialized forms in which it appears, the nursing act always is related to the health-illness quality of the human condition, or fundamentally, to a man"s personal survival. This is not to say that all instances of nursing are matters of life and death, but rather that every nursing act has to do with the quality of a person"s living and dying.
That nursing is related to health and illness is self-evident. How it is related is not so apparent. "Health" is valued as necessary for survival and is often proposed as the goal of nursing. There are, in actuality, many instances of nursing that could be described as "health restoring,"
"health sustaining," or "health promoting." Nurses engage in "health teaching" and "health supervision." On the other hand, there are instances in which health, taken in its narrowest meaning as freedom from disease, is not seen as an attainable goal, as evidenced, for example, in labels given to patients such as "terminal," "hopeless," and "chronic." Yet in actual practice these humans" conditions call forth some of the most complete, expert, total, beautiful nursing care.
Nursing, then, as a human response, implies the valuing of some human potential beyond the narrow concept of health taken as absence of disease. Nursing"s concern is not merely with a person"s well-being but with his more-being, with helping him become more as humanly possible in his particular life situation.
Human Potential
Since nursing involves one human being helping another, the notion of humaneness has been a.s.sociated traditionally with nursing. Nursing practice is criticized justifiably when it is not humane and is taken for granted or praised when it is. The expectation of humaneness is so ingrained in the concept of nursing that some nurses are surprised when it is acknowledged by patients. If a patient thanks them for their kindness, patience, or concern, these nurses reply, in their embarra.s.sment, "Oh, that"s part of my job."
However, to equate nursing"s humanistic character solely with an overflowing of the milk of human kindness is a serious error of oversimplification. Such a limited view, in fact, is a dehumanizing denial of man"s potentials. As a human transaction, the phenomenon of nursing contains all the human potentials and limitations of each unique partic.i.p.ant. For instance, frustration, discouragement, anger, rejection, withdrawal, loneliness, aggression, impatience, envy, grief, despair, pain, and suffering are const.i.tuents of nursing, as well as tenderness, caring, courage, trust, joy, hope. In other words, since nursing is lived by humans, the "stuff" of nursing includes all possible responses of man--man needing and man helping--in his situation.
Intersubjective Transaction
Looking again at the phenomenon of nursing as it occurs in the real lived world, obviously it is always an interhuman event. Whenever nursing takes {13} place two (or more) human beings are related in a shared situation. Each partic.i.p.ates according to his own mode of being in the situation, that is, as a person nursing or as a person begin nursed. Since one is nursing and the other is being nursed, it follows that the essential character of the situation is "nurturance." In other words, the phenomenon of nursing involves nurturing, being nurtured, and a relation--the "between" in which or through which the nurturance occurs.
On reflection, it is obvious that nursing is an intersubjective transaction. Both persons, nurse and patient (client, family, group), necessarily partic.i.p.ate in the proceedings. In this sense, they are _inter_dependent. Yet, they are both subjects, that is, each is the originator of human acts and of human responses to the other. In this sense, they are _in_dependent. The intersubjective transactional character of nursing cannot be escaped when one is experiencing the phenomenon, either as nurse or as patient. Consider for example, some of the most common nursing activities, such as, feeding and being fed, comforting and being comforted, giving and taking medications. Although this intersubjectivity is unmistakably known in experience, it is extremely difficult to conceptualize and convey it to others. It rarely is found in descriptions of nursing, and to the unfortunate extent that it is missing, the descriptions are not true to life.
In real life, nursing phenomena may be experienced from the reference points of nurturing, of being nurtured, or of the nurturing process in the "between." For instance, the nurse may describe comfort as an experience of comforting another person; the patient, as an experience of being comforted. However, while each has experienced something within himself, he also has experienced something of the "between," namely, the message or meaning of the "comforting-being comforted" process. This essential interhuman dimension of nursing is beyond and yet within the technical, procedural, or interactional elements of the event. It is a quality of being that is expressed in the doing.
Being and Doing
As an intersubjective, transactional experience, nursing necessarily involves both a mode of being and a doing of something. The being and doing are interrelated so inextricably that it is difficult, even distorting, to speak of one without the other. Descriptions of nursing, however, often focus primarily (sometimes exclusively) on the doing aspect of the process, on the nursing techniques or procedures. The observable acts are more easily discerned and discussed. They can be measured, counted, and charted. Yet, in the actual interhuman experience of nursing the weight of being is felt. Presence and the effect of one"s presence can be known much more vividly than they can be described.
Still, not to attempt to describe them is to present only a half, or perhaps less than half, of the nursing picture.
When a nurse refers to a nurse-patient interaction during which a change in the patient"s condition or behavior was noted, one hoping to get a description of nursing may ask, "What did you do?" Often the answer is a description of a {14} manual action or a verbal interchange. Sometimes the nurse responds, "Nothing, I was just there." Perhaps it is the question that is wrong. The respondent usually interprets "doing" in a limited sense. In reality, everything the nurse does is colored by the character of her being in the situation. The nursing act itself is a behavioral expression of the nurse"s state of being, for example, concerned, fatigued, hurried, confident, hopeless.
Furthermore, there is a kind of being, a "being with" or a "being there," that is really a kind of doing for it involves the nurse"s active presence. To "be with" in this fuller sense requires turning one"s attention toward the patient, being aware of and open to the here and now shared situation, and communicating one"s availability.
Whether the nursing act is verbal, or manual, or both, a silent glance, or physical presence, some degree of intersubjectivity is involved and warrants recognition. To become more aware of and explore more fully this essential const.i.tuent of nursing we need to focus on the partic.i.p.ants" modes of being in the situation. Rather than ask the nurse, "What did you do in the nurse-patient situation?" we ought to ask, "What happened between you?"
HUMANISTIC NURSING
When the meaning of nursing is sought by scrutinizing the phenomenon, that is, by examining the nursing event itself as it occurs in real life, one finds nursing embedded within the human context. As a nurturing response of one person to another in need, it aims at the development of human potential, at well-being and more-being. As something that happens between people, it reflects all the human potential and limitations of the persons involved. As an intersubjective transaction, it holds the possibility for both persons to effect and be affected, the possibility for both to become more. At its very base, then, nursing is humanistic. It is, at once, man"s expression of and his striving for survival and further development in community.
In a way, to specify nursing as humanistic seems redundant. In view of its source and goals how could it be otherwise? However, the term "humanistic nursing" was coined thoughtfully and used purposely here to designate a particular nursing approach. Not only does the term signify full recognition of nursing"s human foundation and meaning but it also points the direction for nursing"s necessary development. What is proposed here is the enrichment of nursing by exploring and expanding its relations to its human context.
Authentic Commitment
When it is genuinely humanistic, nursing is an expression, a living out, of the nurse"s authentic commitment. It is an existential engagement directed toward nurturing human potential. The humanistic nurse values nursing as a situation in which the necessary conditions for such human actualization exist and is open to the possibilities in the intimately shared nurse-patient here and now. {15}
Humanistic nursing calls for an existential involvement, that is, an active presence with the whole of the nurse"s being. This involved presence is personal and professional. It is personal--a live act stemming from this unique, individual nurse. It is a chosen human response freely given; it cannot be a.s.signed or programmed. The involvement is professional--goal directed. It is based on an art-science; it is held accountable.
Anyone familiar with typical hectic nursing situations could justifiably question the actual attainability of such an existential involvement. It goes without saying that it would be humanly impossible for a nurse to be wholly present to numerous patients for eight hours a day. But any nurse who has experienced moments of genuine presence in the nurse-patient situation will attest to their reality and to the fact that it is these beautiful moments that give meaning to nursing. In terms of actual practice, then, it is more realistic to think of humanistic nursing as occurring in various degrees. It may be more useful, in fact, to consider humanistic nursing a goal worth striving for; or an att.i.tude that strengthens one"s perseverance toward attaining the difficult goal; or fundamentally, a major value shaping one"s nursing practice.
Process--Choice and Intersubjectivity
For the process of nursing to be truly humanistic it must bear out, that is, be a lived expression of, the nurse"s recognition and valuing of nursing as an opportunity for the development of the human person. To this end, humanistic nursing process echoes existential themes related to a person"s becoming through choice and intersubjectivity.
Existentially speaking, man is his choices. This does not mean that a man can be anything he chooses. Naturally, each individual is unique, having his own particular potentials and limitations. Nor is this view a denial of the forces of unconscious motivation and habit. It does not imply that all of a person"s actions result from totally conscious deliberations. By saying, "I am my choices," I mean I am this here and now person because in my past life I took particular paths in preference to others; of the possibilities open to me, I actualized certain ones.
In this sense, I am my history, I am what I am, what I have become. But I am also what I am not, what I have not become. I am a nurse, this unique here and now nurse with particular experience, knowledge, skills, and values; without other experience, knowledge, skills, and values.
Through self-reflection I know that I have changed, I have experienced growth from within. I know myself as a being capable of becoming more, capable of actualizing my possibilities, my self. So I am my choices not only in terms of my past but also in regard to my future, my possibilities.
Man is an individual being necessarily related to other men in time and s.p.a.ce. As every man is beholden to other men for his birth and development, interdependence is inherent in the human situation. In this sense, human existence is coexistence. The deeper significance of this truth has been recognized and elucidated by many thinkers, especially those in the existential stream. Over {16} and over, their writings reveal the paradoxical tension of being human: each man is, at once, independent, a unique individual and interdependent, a necessarily related being. As Wilfrid Desan says, referring to man as subsistent relation, "He is towards-the-other but he is not-the-other."[1]
Furthermore, as Martin Buber and Gabriel Marcel maintain, it is actually through his relations with other men that a man becomes, that his unique individuality is actualized. To know myself as "individual" is to experience myself as this particular unique here-and-now person and other than that there-and-now person. Or in other words, to know myself as me is to see myself in relation to and distant from other selves. As Buber so beautifully states, "It is from one man to another that the heavenly bread of self-being is pa.s.sed."[2]
Logically, it follows that the possibility for self-confirmation exists in any intersubjective situation. However, in everyday life this self-confirmation is experienced to different degrees or on different levels in interhuman relating. Since both persons are independent subjects acting with their human capacity for disclosing or enclosing themselves, there is no guarantee that the availability and presence necessary for a genuine confirming encounter will come forth. Presence, the gift of one"s self, cannot be seized or called forth by demand, it can only be given freely and be invoked or evoked.
Since man becomes more through his choices and the aim of nursing is to help man toward well-being or more-being, the humanistic nursing effort is directed toward increasing the possibilities of making responsible choices. Such choice involves, in the first place, an openness to and an awareness of one"s own situation. A choice is a response to possibility.
Therefore, one must first recognize that possibilities or alternatives exist. This openness to options is experienced as a freedom to choose as well as a freedom from the bonds of habit and stereotyped response, from routine, from the veils of the obvious. It means getting in touch with one"s experience, one"s subjective-objective world. As one becomes more acutely aware of his personal freedom of choice, there arises concurrently an awareness of the quality of choice, of the responsibility that is always implied in the freedom. Then follows reflective consideration of one"s unique situation with its possible alternatives and an examination of the values inherent in them. Finally, the act of choosing is expressed in a response to the situation with a willingness to accept the responsibility for its foreseeable consequences. Through this experience the person becomes aware of himself as an individual. As a subject choosing freely and responsibly, he knows himself as distinct from and yet related to others.
Nursing, being an intersubjective transaction, presents an occasion for both persons, patient and nurse, to experience the process of making responsible choices. Through living this process in nursing situations, the nurse develops her own potential for responsible choosing. The satisfaction, often in the form {17} of a sense of vitality and strength, that is felt in making responsible competent professional judgments reinforces the habit. In personally coming to experientially appreciate the growth promoting character of responsible choosing, the nurse may more readily recognize the value of such experiences for any person, including the one currently labeled "patient." The humanistic nurse, therefore, is alert to opportunities for the patient to exercise his freedom of choice within the limits of safe and sound practice. She is constantly a.s.sessing his capabilities and needs and encourages his maximum partic.i.p.ation in his own health care program. Through coexperiencing and supporting the process in the patient"s experience from his point of view, the nurse nurtures his human potential for responsible choosing. Both patient and nurse become more through making responsible choices in the intersubjective, transactional nursing situation.
Theory and Practice
The term "humanistic nursing" refers to a kind of nursing practice and its theoretical foundations. The two are so interrelated that it is difficult, in fact even somewhat distorting, to speak exclusively of either the practice or the theory of humanistic nursing. When, for the sake of clarity or emphasis, discussion is focused on either the practical or the theoretical realm, thoughts of the other realm cast their shadows on the fringes. For in our view, for the process of nursing to be truly humanistic means that the nurse is involved as an experiencing, valuing, reflecting, conceptualizing human person. From the other side, the theory of humanistic nursing is derived from actual practice, that is, from being with and doing with the patient. "Theory,"
says R. D. Laing, "is the articulated vision of experience."[3]
Humanistic nursing is not a matter solely of doing but also of being.
The humanistic nurse is open to the reality of the situation in the existential sense. She is available with her total being in the nurse-patient situation. This involves a living out of the nurturing, intersubjective transaction with all of one"s human capacities which include a response to the experienced reality. Man is able to set his world at a distance as an independent opposite and enter into relation with it. In fact, according to Buber, this is what distinguishes existence as human. It is man"s special way of being.[4] For nursing to be humanistic in this full sense of the term requires being and doing in the situation and subsequently setting the experienced reality at a distance (that is, objectifying it) and entering into relation with it.
The nurse"s reflective response to her lived world may take the shape of any form of human dialogue with reality, such as, science, art, or philosophy.