These considerations of the dialogical character of nursing will be more fruitful if they are related to some concrete nursing experience.
Reflect for a moment on your daily nursing practice. Recall an encounter, a specific interaction with a patient (client). Try to remember the details. Where were you? What time of day was it? Who was present? What was your state of being--what were you feeling, thinking, doing? How did the interaction begin? What happened between you? What was felt, said, done? What was left unsaid, undone? How did the interaction end or close? How long did the flavor last? Now keep this concrete instance of your lived nursing reality in mind and let it raise its questions in the following exploration.
Meeting
The act of nursing involves a meeting of human persons. As was noted above, it is a special or particular kind of meeting because it is purposeful. Both patient and nurse have a goal or expectation in mind.
The inter subjective transaction, therefore, has meaning for them; the event is experienced in light of their goal(s). Or in other words, the living human act of nursing is formed by its purpose. Its goal-directedness colors the attributes and process of the nursing dialogue.
When a nurse and patient come together in a nursing situation, their meeting may be expected or planned by one or both or it may be unexpected by one or both. In any case, the goal or purpose of nursing holds. Even in a spontaneous interaction where they have met only by chance, in a health care facility or any place where one is identified as patient and the other as nurse, there is an implicit expectation that the nurse will extend herself in a helpful way if the patient needs a.s.sistance. If the meeting is planned or expected, this factor influences the dialogue. Each comes with feelings aroused by antic.i.p.ation 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 or control either nurse or patient had over their coming together. In today"s complex health care systems, a nurse may be a.s.signed to care for a particular patient, or for persons in an area or unit, or may be called into service through a registry, {25} or may be approached directly by a patient. From the other side, the patient also experiences varying degrees of control over his meetings with nurses depending on the system in which the health care is offered, his location, his financial means, and so forth. So when a patient and nurse do meet in a given instance, each comes to the situation bearing remnants of feeling of having caused or not having caused this encounter with this particular individual. (Of course, even in the most de-individualized systems the nurse and/or patient can still control their meetings to some extent, for example, avoidance by the nurse being too busy or avoidance by the patient feigning sleep.)
The patient and the nurse are two unique individuals meeting for a purpose. 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 is and all that he is not at this moment in this place. Each comes as a particular incarnate being. Each is a specific being in a specific body through which he affects the other and the world and through which he is affected by them. This nurse who uses her eyes, ears, nose, hands, her body, this way here and now meets this patient whose body in this condition serves him this way here and now.
Furthermore, both the patient and the nurse have the human capacity for disclosing or enclosing themselves. So they have some control over the quality of their meeting by choosing how and how much to be open with and to be open to the other. Their openness is influenced by their views of the purpose of the meeting. In general, the patient expects to receive help and the nurse expects to give it. However, their views may differ 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 the shared situation. One"s purpose is to nurture; the other"s is to be nurtured. This difference in the perspectives from which they approach the meeting is reflected in the kind and degree of their openness to each other.
In describing their experiences nurses often have revealed that they are open to patients in a certain way. This is evident when nurse and patient meet. The nurse may have prior knowledge of the patient, perhaps even an image of him drawn from case history, charts, tour of duty reports, and so forth; or she may meet him as a total stranger. But when they come together, the nurse sees "the patient as a whole." This global apprehension is not experienced as an additive summation but rather as a gestalt. It may result in a very clear "picture" of the patient"s condition with nursing action initiated almost before the picture registers in full conscious awareness. Or the perception may be imprecise yet strong that "something is wrong." From these experiences one may infer that a nurse"s openness involves being open to what is and to what is not in the patient"s state of being as weighed against some notion (or standard) of what "ought" to be, with the intention of doing something about the difference. Thus, the nurse is open-as-a-helper to the patient. This kind of openness is a quality that characterizes the humanistic nursing dialogue. Of course, every nurse-patient meeting differs, for each partic.i.p.ant comes to the situation as the {26} unique individual he is, with his own expectations and capacities for giving and taking help.
When these factors are considered in terms of an actual personal nursing experience (for instance, the example recalled above by the reader), they highlight a tension in the lived nursing world. The meeting through which the nursing dialogue is initiated and consequently is possible is, to a certain extent, out of the nurse"s control. She is a.s.signed to approach or she approaches the patient in terms of her function. In this sense, "the nurse" is synonymous with the function "nursing." Yet she experiences each meeting as herself--a unique individual person, this here-and-now being in this body responding in this situation. She is at once a replaceable cog in a wheel of an 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? How can they be lived in the nursing dialogue?
Relating
As a human response to a person in need, the nursing act is necessarily an intersubjective transaction. Or to put it in other words, regardless of the complexity of need and/or response, when nurse and patient meet in the event of nursing both have "to do" with each other. Since both are human, their doing with means being with. (Reflect for a moment on the personally experienced patient encounter you recalled at the beginning of this exploration. Relive it and see clearly again that the nursing dialogue involves being with and doing with the patient.)
Men can do with and be with each other because they are able to see others and things as distinct from themselves and enter into relation with them. What distinguishes the human situation is that men can enter into a dialogue with reality. They have a capacity for for internal relationships, for knowing themselves and their worlds within themselves, they can relate as subject to object (for example, as knower to 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 as subject to object. How could a person survive even one day without knowing and using objects? Therefore, man"s abilities to abstract, objectify, conceptualize, categorize, and so forth, are necessary for everyday living. Even beyond this, the human capacity for relating to the other as object is basic to the advancement of mankind for it underlies science, art, and philosophy. It is simply one way of being human.
Another mode of relating is open to men. Whenever two persons are present to each other as human beings, the possibility of intersubjective dialogue exists. Since both are subjects with the capabilities 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 unique ident.i.ties, they can partic.i.p.ate in an interior union. Intersubjective relating is also necessary for human existence. For it is through his relationships with other men that a person develops his human potential and becomes a unique individual.
Nursing, being an interhuman event, has within it possibilities for various types and degrees of relationships. Both nurse and patient can view themselves and the other as objects and as subjects or in any variation or combination of these ways. A person can view and relate to another 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," "total care 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 placed before or opposite; it is anything that can be apprehended intellectually. Through objectification the object is de-individualized and therefore made replaceable for the purpose of study by any other object with the same properties. It is indifferent to the act by which it is thought and, therefore, the subject studying the object may also be replaced by a similar subject.
Although it is possible to view a person as an object, persons and things are necessarily different kinds of objects. A thing, as object, is open to a subject"s scrutiny, while a person, as object, can make himself knowable or set up barriers to objectification. He can keep his thoughts to himself, remain silent, or deliberately conceal some of his qualities.
Through the scientific objective approach, that is, subject-object relating, it is possible to gain certain knowledge about a person; through intersubjective, that is, subject-subject relating, it is possible to know a person in his unique individuality. Thus, both subject-subject and subject-object relationships are essential to the clinical nursing process. Both are integral elements of humanistic nursing.
Presence
In the nursing world, as in the world at large, human encounters may range from the trivial to the extremely significant. Within a day"s work, the nurse may experience many levels of intersubjectivity from the lowest level of being called on as a function or being used as an object, to the other end of the scale of being recognized as a presence or a thou in genuine dialogue.
Nursing activities bring a nurse and patient into close physical proximity, but this in itself does not guarantee genuine intersubjectivity in which a man relates to another person as a "presence" rather than an object. A presence cannot be grasped or seized like an object. It cannot be demanded or {28} commanded; it only can be welcomed or rejected. In a sense, it lies beyond comprehension and can only be invoked or evoked.
There is a quality of unpredictableness or spontaneity about genuine dialogue. A nurse may be going through her daily activities, functioning effectively, relating humanely, when suddenly she is stopped by something in the patient, perhaps a look of fear, a tug at her sleeve, a moan, a reaching for her hand, a question, emptiness. In a suspenseful pause two persons hover between their private worlds and the realm of intersubjectivity. Two humans stand on the brink of the between for a precious moment filled with promise and fear. With my hand on the doork.n.o.b to open myself from within, I hesitate--should I, will I let me out, let him in? Time is suspended, then moves again as I move with resolve to recognize, to give testimony to the other presence.
Thus, for genuine dialogue to occur there must be a certain openness, a receptivity, readiness, or availability. 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. (I can only ask you to substantiate this statement with your own experience.) Availability implies, therefore, not only being at the other"s disposal but also being with him with the whole of oneself.
Furthermore, it involves a reciprocity. The other is also seen as a presence, as a person rather than an object, such as a function or a case.
As was discussed earlier, the nursing dialogue occurs within the domain of health and illness and has a purpose in the minds of the partic.i.p.ants. Nursing is a lived dialogue (a being with and doing with) aimed at nurturing well-being and more-being. This fact of goal-directedness modifies or characterizes dialogical presence. As a nurse I try to be open to the other as a person, a presence, and to be available to the other. Yet, when I reflect upon my presence, 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." While it is 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 lived dialogue of nursing.
It is the qualitative differences in the various experiences of presence that deserve, yet almost defy, description. For instance, the presence seems to have a different quality of _intimacy_. It is not experienced as less intense or less deep in the nurse-patient relationship, but as somehow colored by a sense of responsibility or regard for what is seen as 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 my presence flows through a filter of therapeutic tact.
Or again, the _mutuality_ of presence may be experienced in the nurse-patient situation. At times I become consciously and acutely aware of the reciprocal flow of openness in the dialogue. It is as strong, definite, immediate, and total as in other dialogical relationships and yet it is somehow different. It is felt as a flow between two persons with different modes of being in the shared situation. My reason for being there, to nurture, and his, to be nurtured, bob into my consciousness like buoys marking the channel of openness.
Often in nursing it is necessary to focus my attention on some aspect of the patient"s body or behavior. The patient may or may not have the same focus of attention. At least momentarily then, or even for a prolonged period, I place some aspect of the patient before or opposite myself (that is, objectify it). And to the extent that this detail absorbs my attention, I lose my sight of and my relatedness to the whole person who happens to be the patient. While I know this focusing on details to be a necessary step in the nursing process, sometimes I find myself abruptly refocusing my attention on the whole person with almost a twinge of guilt for having abandoned him. (Patients have described this uncomfortable intersubjective experience as feeling "looked at" or "watched" by staff.) At other times, on reflection, I find my attention was oscillating between the detail and the person, or focusing on both relating one to the other. From these experiences it is evident that dialogical presence is complicated in the nursing situation. It is inhibited when the focus of attention (of one or both partic.i.p.ants) is on the patient"s body itself or on his behavior. Yet the body is an integral part of the person and his behavior is an expression of his mode of existence or his way of being in the world. Man is an embodied being, and the nurse, in nurturing the patient"s well-being and more-being, must relate to him and his body in their mysterious interrelatedness.
Call and Response
The dialogical character of nursing may be explored further by considering it in the general sense of a call and response. Nursing is a purposeful call and response, that is, it is related to some particular kind of help in the domain of health and illness. A patient calls for a nurse with the expectation of being cared for, of having his need met.
He is asking for something. A nurse responds to a patient for the purpose of meeting his need, of caring for him. The nurse expects to be needed.
In reflecting on nursing experiences, it becomes obvious that the call and response in the nursing dialogue goes both ways for nursing is transactional. Both patient and nurse call and respond. The pattern of the 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 his call light to ask for something. This is not only a call but also a response to the nurse"s previously stated suggestion that he use the signal if he needs her help. Or again, a nurse may stop and talk with a patient during a chance meeting recalling that he previously had expressed feelings of loneliness, boredom, pain, or joy. Also, other persons or events may interrupt or end a nursing dialogue. For instance, the nurse is called away to help in another situation, the patient is discharged on the nurse"s day off, the patient expires.
Furthermore, the call and response are not only sequential but also simultaneous. In this live dialogue both patient and nurse are calling and responding all at once. The patient"s request, for instance, is a call for help and at the same time a response to the nurse"s availability or offer to be of help. From the other side, the _way_ a nurse responds to a patient"s call is, _itself_, a call to him for a particular kind of response, a call for his partic.i.p.ation in the dialogue.
Reflect for a moment on your own example. Was your response to the patient influenced by the value you placed on such factors as his independence, motivation, rehabilitation, growth, strengths, pathology; on time, on place; on agency policy? Here again goal-directedness affects nursing dialogue. Our interpretation of the patient"s calls as well as our responses are colored by the aim of our practice. Our values are like calls within the calls. Or to state it differently, the values underlying our practice give meaning to the calls.
Viewing dialogical nursing as a particular form of call and response highlights its complexity. It reveals the intricacy not only of its patterns of flow but also of its means of expression. Nursing is a lived call and response reflective of every mode of human communication.
Much has been studied and written about verbal dialogue between patient and nurse. Examining verbal exchanges from the perspective of call and response could uncover even more about this aspect of the nursing dialogue.
It is more difficult to find written descriptions of nonverbal nurse-patient communication, although this aspect is generally recognized to be of equal significance. Here again the call and response framework could be a useful aid. For instance, what does a nurse"s mere physical presence mean to a patient either as a call or response? Or from the nurse"s standpoint, under what circ.u.mstances is a patient"s presence experienced as a call and, even more, as a call for a particular nursing response? What prompts us to respond in terms of his posture, his color, his facial expression, his behavior, the appearance of his clothes? Are we almost unconsciously checking some kind of "vital signs" in the inter subjective realm?
Nursing dialogue is characterized by the unique feature of occurring through nursing acts. The dialogue is experienced in what the nurse does with the patient. A call and response of caring is lived through in nurse-patient transactions (nursing care activities) from the simplest, most basic acts of bathing and feeding to the most dramatic resuscitation. {31}
The nursing act itself contains a meaning for each person in the dialogue and the meanings may differ (for example, touching and being touched, feeding and being fed, bathing and being bathed). In addition, as a behavioral expression, the nursing act conveys a message, a reflection of the nurse"s state of being (for example, anxious, hurried, troubled, absent, present, fully present). Furthermore, a nursing act may serve as an occasion, or even a catalyst, for opening or moving the dialogue in some direction on a verbal level (for example, bathing a patient may prompt his discussion of his body image or of his fear of disfigurement).
The complexity of possibilities in this unique feature of nursing dialogue (occurring through nursing acts) is staggering, especially so when one considers the additional factors a.s.sociated with the effects of technological advances in nursing. Think, for instance, of the influence on your nursing dialogue of any technical nursing procedure. What happens between you and the patient when you place a thermometer into his mouth? Take his blood pressure? Give him an injection? Aspirate him?
Do any form of monitoring, from the simplest to the most complex? Are the technical procedures and instruments bridges or barriers in the between?
DIALOGICAL NURSING IN THE REAL WORLD
It is necessary now to look again at dialogical nursing in a broader perspective, for by limiting the exploration to the nurse, the patient, and their between, the previous discussion grossly oversimplified the way the dialogue actually evolves in real life. In the above, it was as if nursing were a drama acted out by two characters on a specially designed stage where precisely placed props lay ready to serve the actors and the pa.s.sage of time is controlled by the chiming of a clock or the dimming of lights. As it is actually lived, the nursing dialogue is subjected to all the chaotic forces of real life. Nursing takes place in a real world of men and things in time and s.p.a.ce. In many cases, it is a special world, a health system world, within the everyday world.