FOOTNOTES:
[1] Wilfred Desan, The Planetary Man, Vol. I, A Noetic Prelude to a United 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: Ballantine Books, 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, that is, in the phenomenon of nursing as it is experienced in the everyday world. Therefore, the interrelated practical and theoretical development of humanistic nursing is dependent on nurses experiencing, conceptualizing, and sharing their unique angular views of their unique lived nursing worlds. An open framework suggesting dimensions for such exploration was derived from a consideration of the phenomenon of nursing within its basic context, namely, the human situation. The elements 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 and as lived by patient and nurse) in a world of men and things.
The framework offers a little security by providing some reference points for the exploration. However, what is gained in clarity by conceptual abstraction is lost from the flavor of the actual experience. Like a weather map that statically represents major factors and currents in their interrelatedness, the framework discloses a nexus of elements. But it is as far from the real phenomenon of nursing with its pains and suffering and comforting and joys and hopes as the weather map is from real weather with its wind and rain and heat and cold. This chapter is concerned with the same basic framework of humanistic nursing but seen in an enlivened form. To inspirit its constructs the search must return again to the existential source, to the nursing situation as it is lived.
When I reflect on an act of mine (no matter how simple or complex) that I can unhesitatingly label "nursing," I become aware of it as goal-directed (nurturing) being with and doing with another. The intersubjective or interhuman element, "the between," runs through nursing interactions like an underground stream conveying the nutrients of healing and growth. In everyday practice, we are usually so involved with the immediate demands of our "being with and {22} doing with" the patient that we do not focus on the overshadowed plane of "the between." However, occasionally, in beautiful moments, the interhuman currents are so strong that they flood our conscious awareness. Such rare and rewarding moments of mutual presence remind us of the elusive ever-present "between."
>From these epiphanic episodes in our personal nursing experience, we have certain and immediate knowledge of intersubjectivity. Through our experience, too, we know that both humanizing and dehumanizing effects can result from human interactions. Therefore, it is essential for the development of humanistic nursing to explore and describe its intersubjective character.
Although many nurses have agreed in principle about the importance of this work, they also have expressed the feelings of frustration and discouragement attending it. There are real difficulties involved in attempting to describe something so real yet so nebulous as "the between." The descriptions must be derived from our own real nursing experiences. This means that we must develop habits of conscious awareness of experience, of recall, and of reflection. Then we must struggle with our language finding the words in our physically and technologically oriented vocabularies, perhaps even creating terms, to convey the substance and flavor of the experience of intersubjectivity.
Furthermore, description of the intersubjective quality of nursing is difficult because of its peculiar pervasiveness. Whether it is consciously recognized or not, it is part of every nursing transaction. However, to consider and explore intersubjectivity solely as a component or constituent of nursing, even a necessarily inherent or an essential one, would be to see it out of true perspective. The "between" is more than a factor or facet of nursing; it is the basic relation in which and through which nursing can occur. So the question remains. How can our experiences, our angular views, our glimpses of this foundation, this necessary means of nursing, be conceptualized and shared?
Once while reflecting on the nature of nursing against a background of notions about intersubjectivity drawn from experience and literature and testing them against my own real life experiences of nursing, I suddenly saw that nursing itself is a particular form of human dialogue. This insight occurred to me with clarity, conviction, and all the force of a brand new idea. It was so obvious, so distinct, so simple, so clearly a central intuition that could illuminate the phenomenon of nursing from within. I experienced the idea as fresh and excitingly full of promise.
Yet, when I said it out loud, "Nursing is dialogue," the words seemed too meager to convey the true meaning of the idea and its real significance. There was, furthermore, an annoying shadow of familiarity lurking about it. It was almost as if I had expressed something similar previously. At first, I hesitated to share this insight with others for fear they would extinguish it by saying, "of course, everyone knows that," or "I've heard you say something like that before." Still, I experienced it as an idea I had to express. Moved by the pressure of feelings 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 references to existential literature. Dissatisfaction with it prompted further rethinking and revision. Searching through my files during this process, I found, to my great surprise, some notes on the dialogic nature of nursing written by myself three and six years previously. In fact, a three-year-old note contained the very title, "Dialogue Called Nursing"! Now, how is it possible to grasp a truth and then "forget" that one knows it and later meet and grasp the old truth again as new? The difference in these experiences of knowing, for me at least in this case, is that now I know as if from the inside out that nursing is dialogical. The idea seems to have sprouted out of the lived phenomenon, to have broken forth from the ground of experience, as opposed to having been concluded in my earlier "intellectual," "theoretical," or "philosophical" ponderings. But how did the earlier idea, the conclusion that nursing is dialogical, become a live option for me? Why did it appeal to me? How did it come to make sense in the first place if not because of my experience?
The concept and the actual experience revitalize each other. Perhaps this is the value of an existentially grounded insight; it has a kind of durability resulting from its continuous rejuvenation by the interplay of experiencing and conceptualizing. Some old ideas are always new. In this spirit, this chapter looks again at humanistic nursing as lived dialogue.
LIVED DIALOGUE
The central insight (intuition or idea) from which this exploration grows is this: nursing itself is a form of human dialogue. I mean that the phenomenon of nursing, that is, the nurturing, intersubjective transaction, the event lived or experienced by the participants in the everyday 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 to denote a broader concept than the typical dictionary definition of dialogue as "a conversation between two or more persons or between characters in a drama or novel." It is used in the existential sense. It implies an "ontological sphere," in Buber's terms, or the "realm of being" to which Marcel refers. Here it refers to a lived dialogue, that is, to a particular form of intersubjective relating. This may be understood in terms of seeing the other person as a distinct unique individual and entering into relation with him. In other words, nursing is a dialogical mode of being in an intersubjective situation.
As in common usage, here also, the term "dialogue" implies communication, but in a much more general sense. It is not restricted to the notion of sending and receiving messages verbally and nonverbally. Rather, dialogue is viewed as communication in terms of call and response. {24}
Nursing implies a special kind of meeting of human persons. It occurs in response to a perceived need related to the health-illness quality of the human condition. Within that domain, which is shared by other health professions, nursing is directed toward the goal of nurturing well-being and more-being (human potential). Nursing, therefore, does not involve a merely fortuitous encounter but rather one in which there is purposeful call and response. In this vein, humanistic nursing may be considered as a special kind of lived dialogue.
NURSING VIEWED AS DIALOGUE
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 assistance. If the meeting is planned or expected, this factor influences the dialogue. Each comes with feelings aroused by anticipation 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 assigned 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 participant 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 assigned 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 identities, they can participate 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 doorknob 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 participants. 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 participants) 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 participation 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 circumstances 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 associated 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 passage 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 space. In many cases, it is a special world, a health system world, within the everyday world.
Other Human Beings
The dialogue lived between nurse and patient is affected by their numerous other interhuman relationships. For a nurse to be genuinely with a patient involves her coexperiencing his world with him. His family, friends, and significant others are a very real part of this world whether they are physically present or distant. So to be open to the patient is to be open to him as a person necessarily related to other men.
Furthermore, in caring for a patient the nurse relates to him not only as an individual patient but also as one in a group of patients. The group may be physically present (for example, in a ward, in an intensive care unit, in a {32} waiting room, in a dining room, in a therapeutic group) or they may be present in the nurse's mind (for example, while caring for one she may think "I have three more patients to visit," "so and so needs his medication in five minutes," "I promised so and so I'd get back to him," "three other patients are waiting to be fed"). Even when the nurse is responsible for only one patient, she often views him in relation to other patients she has nursed.
The nurse herself also functions within complex networks of interhuman relationships that affect the nursing dialogue. As health care becomes more specialized, more groups of health care workers arise and the various groups become more diversified. So the nurse's intersubjective transactions with her patients occur within an intra- and interdisciplinary milieu of constantly changing personnel, functions, and roles. While her own role is expanding, extending, deepening, broadening, becoming more specialized, she must relate with others undergoing similar change. And here again, as with the patients so with her colleagues, the nurse is constantly faced with the possibility and necessity of relating to others in terms of their functions and as persons.
Finally, it should be recognized that while it is easy and common to think of "the nurse" as synonymous with the function "nursing," in real life the nurse is a human being necessarily related to others. She learns to focus on those present in her here and now work situation. But she too is her history and brings to her work world all that she is and all that she is not including her past experienced and future anticipated interhuman relationships. So each nurse affects her peopled nursing world and is affected by it in her own unique way.
>From the other side, the patient also enters into the nursing dialogue with his various networks of interhuman relationships. How he experiences 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 interpersonal relating. Of course, the current mode reflects his past, for example, learned habits of response, and his future, for example, concerns about anticipated changes in interpersonal relationships due to the effects of his illness. In some cases, the intersubjective behavior itself becomes the focus of the nursing dialogue as the area of the patient's greatest needs in attaining well-being and more-being.
Things
The nursing dialogue takes place in a real world of things, ordinary things of everyday living and all forms of health care equipment. Both types of objects affect the nurse-patient transactions and their influence varies for they may be experienced differently by nurse and patient.
Ordinary objects used everyday—eating utensils, clothes, furniture, books, television sets—are so familiar that one usually takes their use for granted. {33} However due to illness a person may be unable to manipulate a knife and fork, for example. They become frustrating objects. His tools are no longer extensions of himself but impediments and barriers. He feels handicapped. His world of things changes.
On entering a health care facility, the patient finds himself in a foreign world of strange objects. In place of his familiar possessions he is surrounded by equipment, machines, instruments, solutions, and so forth. He may experience these as bewildering, frightening, painful, supportive, soothing, life-sustaining. The nurse, on the other hand, may experience these same objects quite differently. To her they may be familiar tools, useful aids, complex machines, annoyingly defective equipment. Even in a situation that does not have special equipment, for instance in a home, the patient's world of things changes as the nurse converts ordinary objects into tools. Thus, while nurse and patient share a situation, the things in their shared world have different meanings for each. The things themselves as well as the persons' relations to them can serve to enhance or inhibit the intersubjective transaction of nursing.
Time
To view dialogical nursing as it is actually experienced in the real world, one must conceive of it as occurring in time, not simply measured time but also time as lived by patient and nurse. Certainly both participants are caught up in measured time and this influences their shared world, for example, eight-hour tours of duty, a day off, surgery scheduled 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 and nurse must live by the clock and calendar.
However, equally important, or perhaps even more important, in the lived dialogue of nursing is the participants' experience of time. Some references were made to lived time in the section on call and response where it was noted how the nursing dialogue unfolds over time from moments to years. How the involved persons experience this continuity is an individual matter.
The nurse may conceive of herself as one of many persons contributing to a continuous stream of caring for the patient. So she will give and hear and write and read reports, note observations, keep records. She will carry an image of the patient in her mind continually adding to it or changing it with each interaction or report. Sometimes, after not seeing the patient for a time, on meeting him again she will "pick up where she left 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 she may be startled by the visible changes and resume the dialogue from that point. Or even if change is not visible, she may be aware that it may have occurred and try to fill in the gap.
These possibilities may be mirrored from the patient's standpoint, for he likewise experiences continuity or lack of it in his care. And yet, the experience must be different for him. For instance, nurses may think of continuity of care in terms of "coverage" for a planned program of care. So it has often been {34} claimed that "the nurse is with the patient 24 hours a day." From the patient's point of view this is not true. A nurse may be with him but each nurse is different. The function of nursing may be continuous, but individual nurses come and go; the day nurse, the evening nurse, the night nurse are each unique individuals. And the nursing dialogue as lived, intersubjective transaction occurs between a particular nurse and a particular patient.
When we speak of a nurse and a hospitalized patient spending a day together, we usually are referring to eight hours out of a 24-hour day. They may both experience the spacing of this time by functions or activities such as meal time, medicine time, visiting time. Yet the measured minutes and hours are experienced differently by each in their different modes of being in the situation. Nurses often express feelings of not having enough time to give the care they want to give; of having too many demands on their time; of trying to "make time" for patients who ask "do you have a minute?" Patients live their time in relation to boredom, pain, loneliness, separation, waiting. The nursing dialogue runs its course in clock time but both nurse and patient live it in their 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 with the patient. This kind of timing is related to the transactional character of nursing and to its goal of nurturing the development of human potential. It is experienced in openness, availability, and presence, as well as in nursing care activities. The nurse feels in harmony with the rhythm of the dialogue and, sensing the timing of its flow, she paces her call and response to patient's ability to call and respond in that moment. So, as a nurse, you may find yourself almost unconsciously or intuitively waiting, holding back, anticipating, urging the patient. This kind of synchronization or timing is intersubjective for the clues or reasons for encouraging or waiting are not found solely in the patient's behavior nor only in the nurse's knowledge or experience. "Good" or "right" timing somehow involves the "between." It implies 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 world the factor of space becomes apparent. Here again the dialogue is influenced by space as it is measured and space as it is experienced by nurse and patient. When thinking of health care facilities, "space" may be 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 the nursing dialogue. However, the person's experience of the space may be even more important.
Space is lived in terms of large and small, far and near, long and short, high and deep, above and below, before and behind, left and right, across, all {35} around, empty, crowded. These perceptions and experiences of space may be influenced by the effects of illness, for example, changes in vision or locomotor ability. Thus, a patient's spatial world may change, expand or diminish, become unmanageable or manageable day by day. Furthermore, a patient's attitude toward and experience of a particular place may be affected by his mental association to it (for example, oncology ward, psychiatric unit), his previous experience in it (for example, emergency room, operating room), or a desire to be somewhere else (for example, "This is a nice hospital but I'd rather be home").
Place is a kind of lived space. It is personalized space. One says, for example, "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 in my place; I felt put down." The patient may feel "out of place" in the health care setting, while it may be commonplace to the nurse. There may be 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 be in a place together, yet one feels at home and the other does not. For the 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 a long time often express a proprietary attitude toward the hospital. The same holds true for personnel. With time and familiarity a feeling of reciprocal belongingness grows. The person belongs in the place and the place belongs to the person. On the other hand, when a person finds himself in a new place he may feel the discomfort of not belonging. This is as true for the nurse in an unfamiliar setting as for the patient. Again in this regard, the lived nursing dialogue is enhanced by the nurse's awareness of not only her own experience of space but the patient's as well.
CONCLUSION
This chapter explored the basic view of humanistic nursing as a phenomenon in which human persons meet in a nurturing, intersubjective transaction. Beginning with the central intuition that nursing is lived dialogue, the examination turned to its existential source, the nursing situation as it is lived. Reflection on actual experience clarified the phenomena of meeting, relating, presence, and call and response as they occur in humanistic nursing. Dialogical nursing was then reconsidered in broader perspective as it actually evolves in the real world of men and things in time and space.
As scientific advances multiply in the health field, nursing is swept along in the tide. Continuous technological changes, ever increasing specialization, emphasis in nursing education and research on scientific methodology all have marked influence on the development of nursing. Science (with a capital S) colors the nursing world. At every turn it permeates the nurse's being with and {36} doing with the patient. It offers a certain security by providing a consistent and effective approach to some problems and questions, and, in some cases, results in general laws to guide practice. At the same time, in the lived nursing world the nurse experiences a reality that is not open to the scientific approach, a reality not always verifiable through sense perception, a reality of individuality. The uniqueness of individuality (her own as well as the patient's) pervades the nursing dialogue.
The ever-present individual differences may be regarded as intractable elements to be conquered for the sake of the efficiency of the system (for example, fit the patient to the treatment program). Or they may be valued as indicators of the inexhaustible richness of human potential to be developed. In their daily practice, nurses are drawn toward the two realities—the reality of the "objective" scientific world and the reality of the "subjective-objective" lived world. This tension is lived out in the nursing act. Doing with and being with the patient calls for a complementary synthesis by the nurse of these two forms of human dialogue, "I-It" and "I-Thou." Both are inherent in humanistic nursing for it is a dialogue lived in the objective and intersubjective realms of the real world.
In the highly complex health care system nurses experience many demands from many directions. Their clinical judgments in daily practice must be made within a continuous stream of decisions about priorities of investment of their time and efforts. Sometimes, survival in the system reduces the nurse to following the line of least resistance, that is, responding to the immediate or to the loudest demands. However, even with their total commitment this course of response does not guarantee that nurses are making their greatest possible contribution to health care. This can happen only if we are able to see demands and opportunities in relation to our reason for being—nurturing the well-being and more-being of persons in need.
Humanistic nursing, viewed as a lived dialogue, offers a frame of orientation that places the center of our universe at the nurse-patient inter subjective transaction. Insightful recognition of the lived nursing act as the point around which all our functions revolve, could require a Copernican revolution of orientation of some nurses. It does provide, for all nurses, a true sense of direction that can be actualized by each unique nurse through creative human dialogue. {37}
4
PHENOMENON OF COMMUNITY
Humanistic nursing creates, happens within, and is affected by community. This chapter will discuss the abstract term "community." To stimulate thought on a nurse's influence on community, consideration will be given to three points: (1) my angular view of community and its evolvement, (2) how man has considered community over time, (3) how a human being comes to be through community.
MY ANGULAR VIEW
One can view members of a family, a student class, a hospital unit, a hospital staff, several related hospital staffs, health services organizations within a geographic area, a profession, a town to a world or universe as community. Man's mind, my mind, determines where I superimpose the limits or lift the limits or relate components. In The Republic Plato depicted a community as a macrocosm.[1] Its nature was conditioned by the kinds of men, the microcosms, that composed it. The macrocosm was a reflection of its microcosms.
So each human person, each nurse, as a microcosm, could make a difference. Reflecting on the lived worlds of nurses, their communities, if we use Plato's philosophical analogy of macrocosm-microcosm, despite the varieties of situation, we can make meaningful a basic concept of community. Such a concept utilized by a nurse to view her particular ongoing 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 to the endless innovative possibilities and unattempted choices available to her. {38} The ability to thus open one's self requires our exposing our biases, the shades through which we regard the world, to the sunlight. In nursing our shades often are closed categories, labels, diagnoses, trite superficial hackneyed expressions learned by us, taught to us as fact, taken in unexamined, and left unreexamined despite other changes in ourselves and our situations. Socrates said, and it still holds, that the unexamined life is not worth living. Our shades can be cherished concepts, beliefs that guide us automatically rather than thoughtfully. Whether they are entirely myth or partial truths, they can cause us agonizing dilemma because they obscure the obviously relevant and the possibilities beyond. A concept of community, if grasped and if a nurse is truly consciously aware, can help her to understand how her nursing world has evolved, is presently, and how she can be, to shape its future in accordance with her values.
As nurses one of our shades is often the confining labels we give to ourselves as doers in service giving profession. I would like to go on record as most respectful of this aspect of my world. I regret, nonetheless, that we have not always similarly crystallized and floodlighted the discovery and creative possibilities in our communities. In our very personal, intimate, involved professional nursing relations with other man we are privileged to be included in human happenings open to no other group. As nurses, we have had and are having emphasized to us the importance of facts handed to us. Can we actuate the importance of the knowledge of man that becomes part of us through our nursing worlds? It is hard to honor the significance of the everyday, the commonplace, the intimately known? It has been said that one could know of the whole universe if one could make every possible relationship starting from a piece of bread. Think of a "simple" or "routine" nursing situation. Think of its true complexity and how it can trigger puzzlement, wonderment, and thinking. As learning situations, nurses' situations are existentially priceless. Returning now to Plato's conception of community understood through the terms macrocosm and microcosm, what can the nursing world situation reveal to us of community? 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 have structured facts about man, family, and community precisely for presentation. Approaching the data sociopsychologically I framed it in the public health model of promotion of health, prevention of illness, treatment, rehabilitation, and maintenance. I thought of family sociologically as nuclear, procreative, and extended. In accordance with the 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} closed paradigm, ranging from ideal to abysmal, from the smallest to the largest unit in which persons congregated for common purposes. I selected from experience nursing examples to make these sociopsychological public health constructs meaningful. I did not start from nursing experiences to come up with nursing concepts of man, family, and community. I denied my particular self as a source of knowledge of these areas. Had education programmed me to value only others' ideas gleaned in the classroom or from books? I projected this devaluation of my own ideas onto my colleagues and until I really knew them gave them what I thought they wanted, others' ideas. Presently I prize my uncertainty about the nature of man in family and community and my striving toward an ever explorative process of being and becoming, available for surprise. Paradoxically, I believe it was these very same capacities, uncertainty and striving, that compelled my superimposing on my 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 my certainty is at once a truth and a nontruth. I see my aim as ever striving toward certainty while constantly wrestling with the discomfort of uncertainty.
EACH NURSE: A NOETIC LOCUS[2]
Each nurse is a "knowing place." It feels as if my greatest talents, as a human nurse person, awaited my acceptance that came through as I related 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 the phenomena—man, family, community—Theresa G. Muller, nurse educator and clinician, who quoted Hersey from his novel, A Single Pebble, comes to mind.[3] He said, "I approached the river as a dry scientific problem; I found it instead an avenue along which human beings moved whom I had not the insight, even though I had the vocabulary, to understand." I consider my greatest gifts as a human being nurse my ability to relate to other man, to wonder, search, and imagine about my experience, and to create out of what I come to know. My ever developing internalized community of world thinkers dynamically interrelated with my conscious awareness of my experienced nursing realm allows my appreciation of my human gifts and the ever enrichment of myself as a "knowing place."
NURSE: EXPERIENCE INTERNALIZED
Nursing experience taught me that each man, each family, each community was at once alike and different. Hesse, an existential novelist, in Steppenwolf, {40} describes each man who has become in family and community as like an onion with hundreds of integuments or a texture with many threads.[4] Then man's differences would be in the quality of his integuments and their development or in his threads in their preponderance. Contemplating the struggles in community regarding mutual understanding, I expanded Hesse's conception of man and found my vision of community to be a salad tossing or a patchwork quilt tumble drying.
Valuing the complexity of this conception of man and therefore of community I find myself smiling at the naivety of the earlier more static frames of order I superimposed on these phenomena. These oversimplifications maintained the shade through which I viewed my world. The shade was: others are knowing places, they are responsible; therefore if I quote authority from outside of myself, I can speak with certainty about what I know and believe and no one can attack me. And yet, my unique knowledge was not given and so my defense, my clutching at security foiled my human need for conceptualization of and expression of my own nurse vision of reality. This defeated the development by me of nursing theory.
Now I realize how I underestimated the potentialities of my nursing effect, of the difference I made, and could make. Just consider the given human uniqueness of each participant in the nursing situation whose familial potential goes back to an origin of thinking being or consciousness, and forward to his anticipation of the future, his eternity.
In the nursing literature, it is rather infrequent that we philosophically share our innermost thoughts, dreams, ideals, and strivings without a strong overlay of indoctrination or conversion. Nietzsche presents philosophy as autobiographical, such sharing does not offer maps. It could offer relevant resources and stimulate other nurses to influence the shape and becoming of the profession.
This chapter attempts to discuss ideas of community, the macrocosm, by considering man, the microcosm, as he develops in family and community. The ideas represent my "here and now" as it reflects my past and anticipated nursing world, including my hopes and expectations.
Man's Experience
Each human being carries a view of persons, families, and communities shaded by the views of his nuclear family. The past usually is corrected; it is never erased. So in his family of origin man internalizes ideas of "right-wrong," "appropriate-inappropriate," "expected-unexpected." Each family's shaded world echoes its procreators' familial, psychosocialeconomic, religious and experiential breadth, closely resembled or distorted. Two persons, perhaps more, usually husband and wife, bring shaded views together in some combination or balance that becomes the "stuff," the authority, of {41} their children's worlds. Thus, children see their early worlds through the complementariness and conflict of this initial home view, acting at times with it; at times against it.
Adults, in response to and through one another, procreate new sensitive beings whom they want and/or do not want and whom they may and/or may not experience as their responsibility in varying degrees. Marcel, a French existentialist philosopher, views procreation and responsible parenthood as quite different. My past nursing experience substantiates this. Marcel expresses my bias about responsible parenthood, and this statement is also worthy of consideration by nurses in positions of authority to others. He says, "We have to lay down the principle that our children (or those for whom we care) are destined, as we are ourselves, to render a special service, to share in a work, we have humbly to acknowledge that we cannot conceive of this work in its entirety and that a fortiori we are incapable of knowing or imagining how it is destined to shape itself for the young will, it is our province to awaken to a consciousness of itself."[5] Think of this statement of responsible authority. How has it been evidenced in families and nursing situations of your nursing world? What are your expectations of your patients or nurses with whom you work?
Teilhard de Chardin, paleontologist, biologist, and philosopher, like Nietzsche, depicts man as lacking a fixed nature with his own mode of being as his fundamental project.[6] Initially, each person takes on a mode of being in his world dependent upon his degree of freedom and the how and what of the world as presented by his family and perceived by him. The world as presented is reflective of the family's culture, their provincial world view, their unique experienced "here and now," and the times. Metaphorically, the family's lived world, how they experience at this particular cross-section of their lives, can be symbolically described as a kaleidoscopic telescoping of its past and anticipated future. Now, this would be what was presented at any particular time. What would a child's perception do to this metaphorical symbol? The child's current human development and his narrow experience would be like a circus house mirror that would interpret the metaphorical symbol distortedly. Witness a three-year-old speaking questioningly and complainingly about her tension headache to her mute, nonperceptive doll, and asking her to please, please stop making such a mess and racket.
The earliest childhood views of family and community are influenced over time, gradually and abruptly, and grow in complexity. The child's puzzlement is aroused by others' comings and goings, happenings within the family, immediate neighborhood, and adjacent community, and the world presented through books and technologically, on radio, television, and tape recorder. Each child attends these presentations with varying measures of complacency, questioning, bafflement, and involvement.
{42}
For instance, for myself, as a child there was the excitement of the construction of a new house in the woods next door and meeting new neighbors. Initially my parents expressed their differences from ourselves. The differences they perceived were followed by negative projections on these unknown folk. Were these others really humanly different? I investigated; my family investigated. The folk became persons. They expressed themselves differently in volume and sometimes in language. They looked different. Yet they were not fearsome. They felt, cared, responded, and worried much as we did. Mutual knowledge allowed increasing closeness and liking.
Forbidden! This was the neighborhood across the tracks. I cried when an uncle teasingly proclaimed one day that my missing mother was over there. Later I attended school with both white and black children who lived over there. And again, each was different, yet not different; each was knowable, likeable, and loveable.
Adult family members whispered about a neighbor woman from across the street. She was apparently hospitalized permanently. When I inquired as to why, eyebrows were raised and strange looks were exchanged. I was told in a not believable way, "She broke her leg falling off the back porch."
A neighbor husband and wife frequently could be heard fighting both verbally and physically. Family talk at our house depicted the husband as "evil," the wife as a "poor soul." I did not enjoy being in these peoples' house. Perhaps the violence frightened me; perhaps I was uncertain when it might erupt? Perhaps I was concerned that I might one day somehow become part of such a situation? Now, looking back over the years, 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 and mysterious way. All expressed great sorrow for her always solitary and mysterious way. All expressed great sorrow for her elderly mother and father on her admission to the "State Hospital." Years later I wondered, and still wonder what happened to that girl, herself? What kind of an existence has she experienced?
During these early years there was also separation from and loss of close loved family members. When I was three and a half a great aunt who always appreciated my side of things moved out of our home due to a family argument. Perhaps most confusing of all during these preschool years, at four and a half, my father died suddenly. "They" said that he went to heaven, that God called him. Why did he go? Why would he leave us? Most important how could he leave me? What had I done wrong? Was it that 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 how should one act toward authority and power? The world didn't feel like a very safe place nor did persons appear to be dependable.
Then there was school. With additional authorities and peers there arose new 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 was at school? Could I depend on things being safe? In kindergarten I made an ash tray of clay for my already dead father.
In my child world there were books, radio, and the movies. Today children experience these, as well as television and record players. For me, books, radio, and the movies brought into my world new aspects of fear, excitement, joy, love, horror, violence, imagination, and suspense. They depicted at times the ideal and at times the abysmal. Sometimes, despite everything, good triumphed. At other times regardless of the effort invested all was lost. Where was the harmony of logical reason? Is our world absurd? Are we absurd to respond to it with an expectation of reason?
For each child there are very special, long-remembered events: being taught to swim by one's father, family picnics, trips into the world beyond city or country, going to the circus, a world's fair, a zoo or a fantasy land. There, also are the events of being loved and loving deeply, linked somehow with times of feeling unloved and unloving.
More than earlier, today there are multiple community groups for children where activities are guided and supervised. Within these situations and in the free play of neighborhood children, there is always the confusing, enlightening, and frequently distorted information gained 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 parental furor. Furor and different reactions from different involved parents lead to further child confusion and focus.
Within childhood peer relations there are games, play, and schoolwork that allow the child to come to know personally the meanings and feelings of competing, collaborating, fighting, winning, losing, destroying, building, aggression, passivity, constriction, freedom, and choice.
Then there is adolescence with all its moodiness, questions, fears, and experimenting related to adult modes of being. The moods are a mystery and the questions often unanswerable or the answers contradictory. Norman Kiell in The Universal Experience of Adolescence says that as adults we forget the intensity, turmoil, and concretes of this period and that perhaps we have to.[7] Yet, it is not possible that the instability and discomfort of spirit lived in adolescence does not leave its ingrained tracing as part of our eternal presents.
When the focus of our responsibility shifts from play to work, during these early years of becoming, depends on our particular circumstances and abilities. For most persons there is a tipping of the balance between these. Hopefully neither extreme is the master. Fortunately, in many instances, as the child's work as been to play; the adult's work world, his world of responsibility is lived, experienced by him, to an extent as play—it gives satisfaction and pleasure.
{44}
Some adults select another and are chosen by this other for a sharing of their worlds. Some go it alone. Some procreate new beings; some create in other ways; some give-take and exist; some just lean. These last appear to be, and yet to not be, "all-at-once."
MAN BECOMES EVER MORE
Buber perceives man becoming more through his human capacity to relate to other being in all forms from the materialistic to the spiritual in "I-Thou," "I-It," and "We" ways.[8] Gestation, with the closeness of mother and child, has left man with an ingrained knowing of the experience of closeness. Thus, throughout man's life his condition of existence is affected by and desires relationship with and closeness to other being. The closeness of the conditions of gestation is never again possible, hence existential loneliness. Yet because of this prenatal experience Buber conceives of man as born with a "Thou"—another—before he is conscious of himself, his "I." With growing consciousness he sorts out his "I" from his "Thou." You can see the late infant doing, acting through, this separation. During this growing phase, often to the care-taking adult's frustration, he repeatedly, intensely, and excitedly throws his toys or bottle out of the crib, carriage, or playpen. Often he runs away from his "Thou," his parental security source, to a safe distance with intense awareness of what he is doing. While internalizing these and subsequent "Thous" as part of his "I," his knowing place, paradoxically, he sorts out who he is, and who and what is other than himself. So with ever more relationship, ever more experience, he becomes ever more the person he has the human capacity to be. He becomes more 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 always necessitating an "I," a man, capable of recognizing self as at a distance, apart from otherness. Therefore, his "I-Thou" relating, a merging of beings, is not like the psychological defense, unconscious identification. Buber's "I-Thou" relating emphasizes awareness of each being's uniqueness without a superimposing, or a deciding about the other without a knowing. Such relating is a turning to the other, offering the other authentic presence, allowing the authentic presence of the other with the self, and maintaining one's capacity to question. It is not then identification or an idealization of the other. Within this mysterious happening of "I-Thou" relating, when both participants are human, each becomes more. Buber refers to the event of this merging of otherness, of man with other being, as "the between." Humanistic nursing is concerned with "the between" of nurses and their others. Their others, the {45} microcosms of their communities, would be patients, patients' families, professional colleagues, and other health service personnel.
Buber describes man's ability to come to know and relate in "I-It" as man looking back, reflecting on his past "I-Thou" relations. Looking back these "I-Thou" relations are viewed as an object to be known, as "It". "I-It" relating allows man to interpret, categorize, and accrue scientific knowledge.
Finally man relates with others as "We." This permits the phenomenon of community and of adult unique contribution. So man becomes through relating with family, others, and community, like Hesse's onion or a being 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 sense each unique person might be viewed as a community of the beings with whom 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 together supposedly for a common purpose. Since time began, man in community has been experienced by man as chaotic. Thus Plato wrote The Republic.[10] This presentation depicted an impossible scheme for developing an ideal community. As a classic, The Republic continues to be a thought provoking thesis. Its antiquity makes one realize that this desire to control, our continued concern with genetic planning, is a part of the very nature of man. And yet, considering man's ever existing recognition of 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 of the individual's existence in accordance with his particular potential for development to fulfill the needs of his ideally conceptualized community. Today Heinlein, a science fiction novelist, still writes of breeding for longevity in man, as we breed animal stock for the greatest amount of meat and profit.[11] Giving Plato his due, he recognized at the end of his book concern and doubt as to whether men so carefully mated and reared would fulfill their designated responsibilities. He wondered if things could, would, or would not go in accordance with his plan. He then logically indicated the process and kinds of community deteriorations which could ensue. Plato had a concept of an ideal community, of ideal types of necessary men, and of ideal male-female breeding relationships. He viewed our present-style family as one that saps the {46} strength of community and does not support this concept. He conceived of communal living more like the communal living of our present-day communes. However, Plato's communes would have been regulated by the plan as he conceived it. Existence in these communes was to be predetermined and very determined.