[1] Josephine G. Paterson, "Echo into Tomorrow: A Mental Health Psychiatric Philosophical Conceptualization of Nursing" D.N.Sc. dissertation, Boston University, 1969.
[2] Josephine G. Paterson "From a Philosophy of Clinical Nursing to a Method of Nursology," Nursing Research, Vol. XX (March-April, 1971), pp. 143-146.
[3] Abraham Kaplan, Conduct of Inquiry (San Francisco: Chandler Publishing Co., 1964), p. 23.
[4] Plato, The Republic, trans. Francis MacDonald Cornford (New York: Oxford University Press, 1945), p. 45.
[5] James Agee, Let Us Now Praise Famous Men (New York: Ballantine Books, 1939), pp. 91-102.
[6] Johann Wolfgang von Goethe, "On Originality." In Great Writings of Goethe, ed. Stephen Spender (New York: Mentor Press, 1958), p. 45.
[7] C. G. Jung, Modern Man in Search of a Soul, trans. W. S. Dell and Cary F. Baynes (New York: Harcourt, Brace and World, 1933), p. 118.
[8] Henri Bergson, "Time in the History of Western Philosophy," in Philosophy in the Twentieth Century, ed. William Barrett and Henry D. Aiken (New York: Random House, 1962), p. 252.
[9] Will Durant and Ariel Durant, Lessons of History (New York: Simon and Schuster, 1968), p. 102.
[10] Hermann Hesse, Demian, trans. Michael Roloff and Michael Lebeck (New York: Harper & Row, 1965), p. 4.
[11] Martin Buber, Between Man and Man, trans. Ronald Gregor Smith (Boston: Beacon Press, 1955), p. 93.
[12] Bertrand Russell, The Autobiography of Bertrand Russell, 1914-1944 (Boston: Little, Brown and Co., 1968), p. 97.
[13] Frederick Nietzsche "Thus Spake Zarathustra," trans. Thomas Common, in The Philosophy of Nietzsche (New York: Random House, 1927), p. 239.
[14] Henri Bergson, "An Introduction to Metaphysics," in Philosophy in the Twentieth Century, ed. William Barrett and Henry D. Aiken (New York: Random House, 1962), pp. 303-331.
[15] John Dewey, How We Think (Boston: D. C. Heath & Co., Publishers, 1910), p. 105.
[16] Martin Buber, "Distance and Relation," trans. Ronald Gregor Smith, in The Knowledge of Man, ed. Maurice Friedman. (New York: Harper & Row, Publishers, 1965), pp. 60-82.
[17] Bergson, "An Introduction to Metaphysics," pp. 303-331.
[18] Martin Buber, I and Thou, 2nd ed., trans. Ronald Gregor Smith, (New York: Charles Scribner's Sons, 1958). pp. 3-34.
[19] W. D. Desan, Planetary Man (New York: The Macmillan Company, 1972), p. 77.
[20] Ibid.
[21] Ibid., p. 80.
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7
A PHENOMENOLOGICAL APPROACH TO HUMANISTIC NURSING THEORY
Humanistic nursing is dialogical in the theoretical as well as the practical realm. Just as the meaning of humanistic nursing is found in the existential intersubjective act, that is, in the dialogue as it is lived out by nurse and patient in the real world, so the theory of humanistic nursing is formed, in the dialogical interplay of articulated experiences shared by searching, abstracting, conceptualizing nurses.
The theory of humanistic nursing originates from and is continually revitalized and refined by actual nursing experience. But each nurse, as a unique human being, necessarily experiences the nursing dialogue and her nursing world in a unique way. So the development of humanistic nursing theory rests on the sharing of individual unique angular views. And the theory as a totality will become richer, more consonant with reality, as it represents more and more nurses' views.
So often nurses, even nurses who know that their clinical expertise grew out of their practice, hesitate to share their nursing experiences. They are apt to say deprecatingly, "Oh, that's only my personal experience." Yet that is precisely where the value lies, in the uniqueness of human experience. Since each nurse's description of her nursing experience is a glimpse of a real nursing world, the views cannot justifiably be judged as right or wrong; they simply are. Once the various views are expressed, they can be compared and contrasted, not for the purpose of accepting some and rejecting others but rather in the interest of clarifying each in relation to the other. Such a dialogue of experientially based conceptualizations can result in a complementary synthesis. The process calls for not only a true appreciation of personal experience by each nurse but also commitment to a collaborative effort of open sharing by a genuine community of nurses.
This view, that the development of humanistic nursing practice theory is a dialogical process, has led to our valuing (in fact, insisting on) the description {78} of nursing phenomena. We see phenomenological description as a basic and essential step in theory building. Indeed, considering the "state-of-the-art" of nursing theory development, it is the most crucial and immediate need.
Looking back at the historical evolvement of our humanistic nursing approach, it is obvious that we had been using and developing a phenomenological approach for a number of years before we graced our efforts with the impressive label, "Phenomenological Psychiatric Mental Health Nursing," in a course offered to a group of nurses at Northport Veterans Administration Hospital in April 1972. Although we were aware much earlier that our interests and work were flowing in the general stream of phenomenology, we usually refrained from using the label because it did little to clarify our position.[1] The term has grown less precise with the extension of its use in different disciplines and with variations in methodology.
When we began applying the term "phenomenological" to our work, we learned that to many persons it sounds strange, unpronounceable, foreign; to some forbidding; to others enticing. We later coined the title "humanistic nursing" as being more suitable for it encompasses our general existential bent. However, this change in title does not imply any abandonment of our phenomenological approach. The description of nursing phenomena is as highly prized now as ever. In humanistic nursing, phenomenological and existential currents interrelate. Having an existential view of nursing as a living dialogue influences which phenomena one becomes aware of, experiences, values, studies, and describes. Reciprocally, as one discovers and struggles to describe and develop meaningful ways of describing nursing phenomena, the lived nursing dialogue itself will be continually perfected.
It is more precise to speak of phenomenological methods (in the plural) rather than phenomenological method (in the singular), for, since Edmund Husserl's original work, the approach has been used by different disciplines. With its spread there has developed a corresponding variation in methodology. This, in a sense, is the beauty of phenomenology: it thrives on variety of perspective; it allows, perhaps requires, individual creativeness; it is always open. In this spirit, ideas are offered here with the hope of stimulating imaginative, critical response, and further development of methodology.
This chapter considers some of the more concrete details of phenomenological methodology as they relate to humanistic nursing. The general approach and procedures discussed below have been used, individually {79} and collaboratively, by Dr. Josephine Paterson and myself with individual and groups of nurses to explore and describe their nursing experiences. They have helped nurses in various levels and types of nursing service to take a fresh look at their practice and make desirable changes. We have lived through the process with graduate students in nursing, and it has led both the students and us to new conceptualizations and reconceptualizations of nursing phenomena. We have found this to be a fruitful research method when applied to clinical nursing phenomena personally experienced and/or reported in the literature. And we are currently exploring its potentials with interested nurses at Northport Veterans Administration Hospital.
A PHENOMENOLOGICAL APPROACH
The method may be characterized generally as descriptive but it is not a simple cataloguing of qualities or counting of elements. Basically, it involves an openness to nursing phenomena, a spirit of receptivity, readiness for surprise, the courage to experience the unknown. Equally important is awareness of one's own perspective and of personal biases. The methodological process is subjective-objective and intuitive-analytic. Besides subjective knowing or personal experiencing of the phenomenon, rigorous analysis also is required. This being-with (subjective, intuitive knowing and experiencing) and looking at (objective analyzing) the phenomenon all at once sparks a creative synthesis, a conceptualization from which emanates insightful description.
More specifically, the method entails an intuitive grasp of the phenomenon, analytic examination of its occurrences, synthesis, and description. In actuality, as the method is carried out, one does not necessarily recognize or focus on these processes as distinct phases or steps. In the flow of the experience, at times, some seem to occur simultaneously or in oscillation. Bearing this in mind, the processes will be considered in more detail.
Intuitive Grasp of the Phenomenon
Phenomenology is grounded in experience. It values the raw data of immediate experience. ("To the things themselves," was the slogan that inspired and guided Husserl and his followers.) So this approach requires, in the first place, attitudes of openness and awareness. It involves learning to become conscious of spontaneous perceptions, or in other words, getting in touch with one's sensations and feelings. It means capturing prereflective experience, that is, becoming aware of one's immediate impression or response to reality before labeling, categorizing, or judging it.
In this kind of a state of readiness to receive what appears, a phenomenon may be grasped intuitively. It is as if a particular bit of reality, a happening, flashes impressively into one's awareness. The intensity of the experience and the absorption of one's attention in the phenomenon vary over a wide range. There may be only a fleeting recognition of a phenomenon accompanied by {80} a half-formulated thought or judgment, such as, "hmm, that's interesting," with immediate dismissal from or replacement of it by something else in one's consciousness. The impression may, of course, be stored in memory and pop out again at a later time. Or the phenomenon may strike on one's consciousness more forcefully causing further pondering and wonder. Or the impression of the phenomenon may be so startling that it fills one's consciousness to the point of pushing all else out; a person is momentarily "stopped in his tracks."
In the intuitive grasp, regardless of its intensity or duration, the phenomenon appears clear and distinct. The intuitive grasp is an insight into reality that bears the certainty of immediate experience. No discursive process intervenes; one simply knows the phenomenon as it is experienced. Furthermore, the intuitive grasp provides a kind of definite and whole understanding, a gestalt, that allows recognition of the phenomenon in other situations. So when the person is faced with another event he can say, "Yes, that is the phenomenon under consideration," or "No, that is not it."
In order to be open to the data of experience in using a phenomenological approach, one strives to eliminate "the a priori" (that which exists in his mind prior to and independent of the experience). This is done by attempting to "bracket" (hold in abeyance) theoretical presuppositions, interpretations, labels, categories, judgments, and so forth. Granted, a person cannot be completely perspectiveless. Man is an individual; he is a unique here and now person. So naturally, necessarily, he has an "angular" view for he experiences reality from the angle of his own particular "here" and his own particular "now." Or, stated differently, as a knowing, experiencing subject, each man must have some perspective of the phenomenon being experienced. However, by recognizing and considering the particular perspective from which he is experiencing it, a person may become more open to the thing itself.
Furthermore, this kind of openness to one's own perspective can be developed through deliberate practice. Several approaches may be used. To begin with, a person can develop the habit of recognizing and exposing his own biases. This could involve something as basic as stating the actual physical situation or circumstance in which the phenomenon was experienced. For example: the phenomenon could be something seen from above or below, at a distance or nearby; something heard in a quiet room or above the din of background noise; a patient's behavior in a large group or in a small group, with his family, with on particular nurse, with his doctor; a patient's response while being fed, bathed, monitored.
Beyond this unavoidable bias of the angle of perception, the nurse's experience of her lived world may be dulled by habituation. It is necessary to break through the tunnel vision of routine. For instance, a nurse new to a situation may notice a patient's response to her and remark about it to another nurse. The second nurse, to whom the patient's behavior is familiar, may respond, "Oh, he's done that for years." Often this is the end of the dialogue; it should be the beginning, for the duration of a phenomenon is not {81} equal to its description or meaning, but rather, is an indication of its significance.
The mystery of the commonplace is hidden by veils of the obvious. To recognize one's biases means to put one's beliefs, one's cherished notions, out on the table. A helpful aid in reflecting on and articulating an experience is the question, "What am I taking for granted?" Commonly used terms, such as, "psychiatric patient," "orthopedic patient," "oncology unit," "uncooperative," "emotional," "chronic," "terminal," "hopeless," "outpatient," "ambulatory," "visitors," "family," "doctor," "nurse," "administration," "front office" have an aura of connotations that may correspond to or differ greatly from the actual immediate experience. It may be a case where believing is seeing. The habit of premature labeling may close a person to the full savoring of experience.
Another means of increasing openness to one's own perspective is to consciously note whether the phenomenon is being experienced actively or passively. For example, the phenomenon may be the motion of changing a patient's position in bed. Both experience the motion, but it is a different experience for the nurse who actively moves the patient and for the patient who is moved passively. Or again, many studies of the phenomenon of empathy have been reported in the literature. Almost exclusively, these are descriptions of empathizing with someone; only rarely are they concerned with the experience of being empathized with. Yet obviously, the active and passive experiences of the phenomenon of empathy are different. The same holds true for touching and being touched, bathing and being bathed, feeding and being fed, supporting and being supported, reassuring and being reassured, and many other phenomena in nursing.
Similarly, awareness of one's perspective may be increased by consciously realizing whether the phenomenon is being viewed objectively or subjectively. Consider for example, phenomena such as pain, anxiety, sleep, restlessness, boredom. Seeing evidence of pain in another person is not the same as feeling pain within myself. Recognizing objective signs of anxiety in another person differs from the subjective experience of feeling anxious myself. Sleeping and observing someone sleeping are two different experiences. The same hold true for restlessness, boredom, and so forth.
In view of nursing's dialogical character it may be assumed that many phenomena of major concern would be intersubjective or transactional. It is important then for nurses, attempting to develop openness to their own perspectives, to consider whether the phenomenon involves two subjects and their between. Does the action go both ways? Are both persons calling and responding to each other simultaneously? Take the phenomenon of "timing" for example. The nurse's verbal response to a patient depends not only on her perception of her own here-and-now and his perception of his here-and-now but rather it also involves their perceptions of their shared here-and-now situation. The nursing world is filled with intersubjective phenomena such as, eye {82} contact, touch, silence. To describe these fully the nurse must be open to her perspective, the patient's perspective, and their between.
Analysis, Synthesis, and Description
After a nursing phenomenon is grasped intuitively, it is desirable to find as many instances of it as possible for the sake of description. Keeping the phenomenon in mind and reflecting on it from time to time, the nurse becomes more alert to its occurrence in her lived world. The phenomenon may be experienced directly. In which case, it is described and reflected on and descriptions, reflections, and questions are recorded. When she observes the phenomenon in others, the nurse may ask them to describe it and verify her own observations. Some nurses have involved other staff members in discovering and describing instances of the phenomenon being studied. Similarly, one becomes more open to descriptions of it in the literature—any literature—or in any form of human expression, for example, poetry, drama, art, science. As many descriptions of the phenomenon are gathered from as many angles as possible, these are the data to be analytically examined, synthesized, and described.
The three processes of analysis, synthesis, and description are so interrelated and so intertwined in reality that it is simpler to discuss techniques in relation to all three. Some techniques are equally useful in the analytic examination and the description of phenomena. In a sense, a person does both at once. And often, it is during this process of shifting back and forth, analyzing and describing an experience that synthesis occurs. A person gets a sudden insight, "everything falls into place," "it clicks." One gets a gestalt, a whole, not necessarily a whole in the sense of complete and entire, but a whole frame, form, or structure that allows for further developing and filling in of details.
There are many ways of going about the analysis and description. The following are some that have been found useful in the explication of nursing phenomena.
Comparing and contrasting instances of the phenomenon lead to the discovery of similarities and differences. For instance, in studying patients' crying it was found that their crying was with or without tears; loud or silent; expressing pain, anger, fear, sorrow. Or again, silence may be defined simply as absence of sound. But silence as experienced in the real nursing world has other characteristics. It may convey anger, fear, peacefulness, and so forth. It is these nuances or qualities of silence that are significant cues for the nursing dialogue. They could be brought to light by comparing and contrasting descriptions of silence.
Various instances of the phenomenon being studied may be examined to discover common elements. Characteristics or elements seen in one instance are sought in the others. For example, when descriptions of interpersonal empathy were scrutinized, it became evident that in all cases there were physiological, psychological, and social components. Examining experiences {83} of reassurance revealed they had elements such as empathy, sympathy, reality orientation, feelings of hope and comfort.
One may determine which elements are essential to the phenomenon by imaginative variation, that is, by trying to imagine the phenomenon without a particular element. For instance, reassurance without empathy or sympathy would be false reassurance or, in other words, would not reassure.
The elements of the phenomenon can be studied to determine how they are interrelated. One may ask, is there a priority in time? Does one element develop from another? Consider the phenomenon of reassurance; does empathy precede sympathy? Or, to take another example, in the empathic experience, an openness to the other and an imaginative projection into his place lead to the vicarious experiencing of his situation.
For further clarification of its distinctive qualities the phenomenon may be related to and distinguished from other similar phenomena. For example, empathy is similar to and also different from identification, projection, compassion, sympathy, love, and encounter.
By considering what it has in common with other phenomena, the phenomenon being described may be classified as being subsumed in a broader category. Thus, empathy is a human response, a coalescent movement, a form of relating.
The phenomenon may be described by selecting its central or decisive characteristics and abstracting its accidentals. For instance, interpersonal empathy always involves movement into another's perspective and as a form of movement it has directions, dimensions, and degrees. It can occur between persons of difference age, education, experience, sex; these latter characteristics are accidental.
Some descriptions make use of negation. A phenomenon cannot be described completely by negation but it may be clarified to some extent by saying what it is not. For instance, empathy is not sympathy; it is not projection; it is not identification.
Analogy may be used to promote analytic examination and description. This involves a comparison based on partial similarity between like features of two things. For example, the movement of empathy is like the currents in the sea; the heart is like a pump. The advantage of using analogy is that the comparison raises questions about the nature of the phenomenon under consideration. However, since the similarity between the analogues is always partial, one must guard against overextending the comparison to unwarranted conclusions. The description must always be consonant with the phenomenon as it occurs in reality.
The use of a metaphor also may enhance description and analysis. A metaphor suggests comparison of the phenomenon with another by the nonliteral application of a word. For example, "the between is a secret place." The use of metaphor may be criticized in regard to its lack of precision. On the other hand, there are some (for example, Marcel, Buber) who hold that the intersubjective realm can be described only metaphorically because it is {84} beyond the level of objectivity. And to attempt to describe intersubjective phenomena in precise terms related to the physical world would tend to distort rather than clarify. Many of the nursing phenomena requiring description occur within the intersubjective realm. Metaphors could cast some light on these.
CONCLUSION
As a theory of practice, humanistic nursing is derived from individual nurses' actual experiences in their uniquely perceived but commonly shared nursing world. Its development, therefore, depends on the articulation of their angular views and also on the truly collaborative effort of a genuine community of nurses struggling together to describe humanistic nursing practice.
Since the description of nursing phenomena is recognized as a basic and essential step in theory development, this chapter presented an approach and detailed some techniques used by nurses to describe phenomena. It is hoped that these would be viewed critically and creatively; that they would be used, varied, combined adapted, and lead to new methods suited to the description of nursing phenomena. And if they are developed, it is hoped that they will be shared for the growth of humanistic nursing depends not only on using and sharing what we learn but also on describing how we come to know. Then humanistic nursing theory will grow in dialogue.
FOOTNOTES:
[1] Loretta T. Zderad, "A Concept of Empathy" (Ph.D. dissertation,
Georgetown University, 1968). Josephine G. Paterson, "Echo into
Tomorrow: A Mental Health Psychiatric Philosophical Conceptualization of
Nursing" (D.N.Sc. dissertation, Boston University, 1969). Loretta T.
Zderad, "Empathy—From Cliche to Construct," Proceedings of the Third
Nursing Theory Conference (University of Kansas Medical Center
Department of Nursing Education, 1970), pp. 46-75. Josephine G.
Paterson, "From a Philosophy of Clinical Nursing to a Method of
Nursology," Nursing Research, Vol. XX (March-April, 1972), pp.
143-146. Josephine G. Paterson and Loretta T. Zderad, "All Together
Through Complementary Synthesis," Image, Vol. IV, No. 3 (1970-71), pp.
13-16.
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8
HUMANISTIC NURSING AND ART
The term "humanistic nursing" often is interpreted as implying humaneness. Logically, humane caring must be one aspect (a major aspect) or a natural expression of humanistic nursing practice theory. But the term means more. According to the position being taken here, nursing may be described appropriately as humanistic since at its very base it is an inter-human event. As an intersubjective transaction, its meaning is found in the human situation in which it occurs. As an existential act, it involves all the participants' capacities and aims at the development of human potential, that is, at well-being and more-being. Our approach qualifies, then, as a form of humanism, according to the dictionary definition, being "a system or mode of thought or action in which human interests, values, and dignity are taken to be of primary importance."
In another sense of the word, our theoretical stance is humanistic by virtue of its regard for the humanities and arts. Philosophy, literature, poetry, drama, and other forms of art are valued as resources for enriching our knowledge of man and the human situation. They also are seen as suitable means for expressing or describing the lived realities of the nurse's world.
Contemporary nursing, being a true child of its time, reflects American society's high regard for "Science." Values of science are easily discernible in nursing and affect the character of its research, education, and practice. Consider, for instance, how the nursing dialogue is influenced by the prizing of objectivity, precision of language, operational definitions, scientific jargon, development of constructs and theories, methodology of scientific inquiry, emphasis on quantification and measurement.
There is much more written in our current literature about nursing as a science than about nursing as an art. Although slighted, the humanities have not been rejected. In fact, some nurses and educators are urging that the role {86} of the humanities and arts be recognized in nursing and that they be used more effectively in undergraduate and graduate nursing education.[1]
Turning to my own personal experience, I recall that one of the first definitions I had to learn in my basic nursing program began with the statement, "Nursing is an art and science…." (It is interesting that now, years later, this is all I can recall of the definition!) At that time, I accepted the statement at face value. I did not question it. Perhaps I had not thought enough about art and science and certainly I did not know enough about nursing to question the description. Yet over the years many experiences and insights have turned into questions that challenge this adopted cherished notion.
In the beginning I merely accepted the view that nursing is an art in the sense of being a skillful or aesthetic application of scientific principles. After all, we had a course in nursing arts (later called fundamentals of nursing). This had to do with bathing, feeding, making beds, and hundreds of other nursing procedures that were presented as "nursing arts," the doing of nursing. At the time I also had courses in the humanities and liberal arts. These courses were not related directly to nursing by either the teachers or myself, as I recall. I did not ask: In what way is nursing an art? What kind of art is nursing? Or, how does the art of nursing differ from other arts?
The notion (perhaps "conviction" would be more accurate) that nursing is an art in some sense other than an artful application of scientific principles has been with me for a long time. I do not know its origin nor even the form in which the view first appealed to me. I do recall having difficulty on several occasions in trying to express let alone explain, my idea. At these times, what I experienced subjectively as an intuitive flash of insight would end up objectified in an amorphous blob of words. Yet the theme returns over and over in a variety of questions and issues that demand response if not resolution. This chapter offers some further reflections on the relatedness of humanistic nursing and art.
USE OF ARTS
One of the most obvious ways in which nursing and art are related is in nursing's use of the arts. This may be seen in nursing education as well as in nursing practice.
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Liberalization
Usually, when arts and humanities are included in nursing education programs, it is for their humanizing effects. Traditionally they have been recognized as having a civilizing influence. So in nursing they are seen as supporting the elements of humaneness and humanitarianism. Furthermore, they are a necessary antidote for the depersonalization that accompanies scientific technology and mechanization.
The arts are valued also for their liberalizing effect. They stimulate imaginative creativity. They broaden a person's perspective of the human situation, of man in his world. For instance, depictions of suffering man or of other aspects of the human condition that are found in poetry, drama, or literature are far more descriptive and much closer to reality than those given in typical textbooks.
Current nursing practice reflects the educational preparation of nurses that is weighted heavily with scientific courses and the methodology of positivistic science. Arts and humanities are a necessary complement. Science aims at universals and the discovery of general laws; art reveals the uniqueness of the individual. While science strives for quantification, art is more concerned with quality. Strict conformance to methodology and replicability are prized in scientific studies, whereas freedom and uniqueness of style reign in art. Science, forever updating itself, opens the nurse's eyes to constant change and innovation; the classics promote a sense of the unchanging and lasting in man's world. Science may provide the nurse with knowledge on which to base her decision, but it remains for the arts and humanities to direct the nurse toward examination of values underlying her practice. Thus, humanistic nursing has both scientific and artistic dimensions.
Expression
Humanistic nursing and art are interrelated in another way. Some nurses who are also artists use their respective arts to express their nursing experience. Poetry is a good example.
In an article, "Nurses as Poets," Trautman notes that since the 1940s progressively greater numbers of poems about nursing have been published and since the 1960s the quality of these poems has improved considerably.[2] She believes that nurses' ability to express their feelings about nursing in poetry cannot be attributed entirely to a change in times. Rather, it is a reflection of change in nursing practice. For one thing, contemporary nursing requires a great deal of abstract thinking. It calls for an understanding involving mental and emotional investment, and imaginative feeling with the patient. The {88} nurse-poet puts aside technical terms, looks at her patient in a fresh and creative way and shares her view in a poem.
A second reason offered by Trautman is the increased emphasis in nursing education on communication and verbal skills. A nurse with a talent for writing may be moved by a particular experience to share it. Thus, "the sensitive nurse-writer may use poetic expression to work through a problem, to muse about a detail, or to record a profound experience."[3]
Finally, she states that some nurses write poetry about aspects of their work that defy scientific analysis and cannot be easily contained in technical papers. In this, then, nurses' poetry goes beyond the personal satisfaction accompanying expression; it preserves a unique angular view of nursing's lived world and adds to our store of clinical wisdom. As Trautman concludes:
"Poetry has trailed the profession for many years, probably because nurses were not encouraged in creative writing of any kind. Today, however, I think that poetry leads the profession because most of it never loses sight of human needs—both nurses' and patients'. Our poets lend a clear and vital voice to our profession. They cite their experiences, emotions, beliefs, and awareness in lieu of a science-oriented bibliography. They appeal to our common sense but, more importantly to our hearts. They tell us to observe honestly and to feel. Above all, our poets tell us to believe in our observations and to trust in our feelings—for patients, for ourselves."[4]
Some elements or aspects of nursing lend themselves to scientific exploration and discovery while others, equally important and likewise deserving expression, reveal themselves only through the artist's vision. So what has been said of poetry, therefore, may hold true in other arts. Each art has its own form of dialogue with reality. The painter, for example, feels with his eyes; he feels lines, points, planes, texture, and color.[5] What could the nurse-painter share? Or as Garner, a nurse-musician, suggests, nursing could be conceptualized along the schema of tones, texture, rhythm, meter, intensity, temperament.[6]
What nursing content would accrue if the various nurse-artists used their forms of knowledge, skill, and vision to explore nursing as the various nurse-scientists do? What can our poets, painters, musicians and dancers see, hear, feel in the nursing dialogue?
Therapeutics
There is a third way in which humanistic nursing and art are related. For many years, the arts have been used in nursing for their therapeutic effects, especially with psychiatric, geriatric, and pediatric patients. The nurse and a patient or a group of patients participate in an artistic experience together. These may be passive activities, such as, attending a concert or play or visiting {89} an art exhibit; or they may be active ones in which nurse and patients are involved in artistic expression or creation.
Music, poetry, painting, drama, and dance have been used effectively in various nursing situations. For instance, Christoffers, a nurse and dancer, emphasizes the importance of body language as communication and supports her view with clinical evidence. She urges nurses to become "physically literate—to develop an understanding and appreciation of the part played by body language in human relationships."[7] Or again, according to Garner, "Music, when carefully planned, can be used as a source of culture, nurturance, communication, socialization, and therapeusis."[8]
A major therapeutic value of art lies in the fact that it confronts one with reality. "Art is a lie which makes us realize the truth."[9] In his novel, The Conspiracy, Hersey has Lucan, a poet, write to Seneca:
"To me the ideal of a work of art is that each man should be able, in contemplating it, to see himself as he really is. Thus art and reality meet. This is the great healing strength of art, this is the power of art, … Art's power which nothing can challenge, is the blinding light of recognition."[10]
By using various art forms the nurse helps the patient experience, become aware of, and express his feelings. When the activity occurs in a group, the members have the additional advantage of sharing in others' expressions and of developing fellow-feeling. Increased socialization is another important therapeutic effect nurse-artists/art appreciators seek in the use of art. A corollary benefit is improved communication between the patient and the nurse or between the patient and others.
Obviously, self-knowledge and fellow-feeling are consistent with the aim of humanistic nursing to nurture well-being and more-being. A person develops his human potential and becomes the unique individual he is through his relationships with other men.
NURSING AS ART
Thus far, this chapter has been concerned with the relatedness of nursing and art. It was seen that nurses may study arts and humanities for a broader understanding of the human situation, may express their nursing worlds through various art forms, and may use the arts therapeutically. Now the question is raised whether nursing is an art, and if so, what kind of art.
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Artful Application
Even the most scientific nurses do not deny that nursing is, in some way, an art. But precisely how the art and science of nursing are interrelated is not clear. For example, Abdellah writes:
"The art of nursing must not be confused with the science of nursing. The former concerns itself with intuitive and technical skills (often ritualistic), and also the more supportive aspects of nursing; the latter concerns itself with scientific truths. Both are important. They are interwoven and complement each other."[11]
However, Abdellah gives no further elaboration of this point. Usually, when nurses are asked about the relatedness of the art and the science of nursing, the view expressed is that science has to do with general principles and laws that govern nursing and art has to do with the particular application of principles in individual cases. Furthermore, when a nurse describes some event as "beautiful nursing" and is pressed to elaborate, she usually describes nursing actions that were performed "artfully," "skillfully," "harmoniously." Thus, in some way, the art of nursing has to do with the nurse's response to human needs through actions that are purposeful and aesthetic.
Useful Art
In current usage, the term "art" is most commonly associated with the beautiful, that is, with aesthetics or the fine arts. Frequently, it is restricted even more to signify one group of the fine arts, namely, painting and sculpture. For instance, one refers simply to an "art exhibit" or an "art" museum but specifies further "a center for the performing arts."
However, historically the word "art" was related to utility and knowledge, and its traditional meanings still exist today. For example, we speak of "industrial arts" and "arts and crafts" through which useful things are produced. On the other hand, "liberal arts" (work befitting a free man) are those related to skills of the mind. We also refer to the art of medicine, of teaching, of nursing, of politics, of navigation, of military strategy, and so forth.
The word "art" can refer to both the effect of human work (works of art) and the cause of things produced by human work (the knowledge and skill of the artist). It is obvious that not only knowledge but also some form of work and skill are involved in all art, useful or fine. "Art" is the root of "artisan" as well as of "artist."[12]
Some arts, such as nursing, medicine, and teaching, may be considered useful, yet they differ from other useful arts, such as industrial arts, for they {91} do not result in tangible products. Nursing for instance, aims purposively for well-being, more-being, health, comfort, growth. These are the results of the art of nursing. As an artist, therefore, the nurse must know how to obtain desired effects and must work skillfully to get them. The nurse cannot make well-being or comfort or health as one can make a shoe or a painting or a speech. The art of nursing involves a skillful doing rather than a making. Furthermore, nursing is concerned with changes in human persons not merely with the transformation of physical objects. It is intersubjective and transactional, so the art of nursing must involve a doing with and a being with.
Performing Art
Along this vein, nursing may be viewed as a kind of performing art. Fahy, nurse-educator-actress, draws an interesting comparison between the process of nursing and acting in a drama.
"In a play the actors know certain things, there are a certain number of given circumstances: plot, events, epoch, time, and plan of action, conditions of life, director's interpretation. The technical things are also there: setting, props, lights, sound effects, and so forth. But it remains at the time of curtain for the actors to go on alone and produce. In the act of nursing there are some known facts that the nursing student or the nurse can pick up: name, age, religion, ethnic background, medical diagnosis, and plan of care (sometimes), her own background knowledge and experience, and her own unique personality. However, when she encounters other patients—watch it! The same thing happens in the teaching-learning process."
"Edward A. Wright in Understanding Today's Theater says about the actor and acting something which I believe about the nurse and nursing.
'… the actor … is his own instrument. His tools are himself, his talent, and his ability. Unlike other creative artists, he must work through and with his own body, voice, emotions, appearance, and his own elusive personal quality…. He uses his intelligence, his memory of emotions, his experiences, and his knowledge of himself and his fellow men—but always he is his own instrument.'"[13]
Here is another example of viewing nursing as a performing art. Once a nurse was trying to describe the nursing care she received from another nurse when she had been ill. She struggled with some details of finer points and then summed it up by saying, "I felt her nursing care was just like a symphony. That's the only way I can describe it."
These comparisons bring many aesthetic qualities to mind, for instance, harmony, rhythm, tone, feeling. Nursing is like music and drama in other ways. The nursing procedure, like a musical score or a play script, allows for individual interpretations, adaptations, and embellishments. Although nurses follow the same general principles, each can develop her own unique style. {92} If nursing really is viewed as a performing art, there are opportunities for creative exploration and development of the art of nursing. And furthermore, these individualized styles of nursing are worthy of description and sharing.
Another similarity is the ephemeral character of nursing, music, and drama. A particular nursing transaction, like a concert or play, is transitory, short-lived. Yet the effects may be long-lasting and remembered. There is this difference in nursing, I believe. Each nursing transaction may flow into a stream of nursing care extending continuously over 24 hours a day for weeks, months, years. And many individual nurses "get into the act." How does this affect the art of nursing? How is nursing like and unlike the other performing arts? The answers to these and similar questions must come from the nurse-artists.
HUMANISTIC NURSING AS CLINICAL ART
The relatedness of nursing and art, viewed existentially, is more basic, more fundamental than mere similarity of qualities and characteristics as discussed above. Both art and nursing are kinds of lived dialogue. In both, man responds to his world of men and things through distance and relation. They affect him and he affects them with the creative force of his relation.
In fact, one may say further that humanistic nursing is itself an art—a clinical art—creative and existential. This is evident when one returns again to the thing itself, to the nursing dialogue as it is lived in the everyday world.
In genuine meeting the nurse recognizes the patient as distinct from herself and turns to him as a presence. She is fully present to him, authentically with her whole being and is open to him, not as an object, but as a presence, a human being with potentials. In such a genuine lived dialogue, the nurse sees within the patient a form (that is, a possibility) of well-being or more-being (or comfort or health or growth, and so forth). Like a beautiful landscape inspiring a painter or poet, the form in the patient addresses itself to the nurse, a call for help demanding recognition and response. The form is clearer than experienced objects; it is not an image of her fancy; it exists in the present although it is not "objective." The relation in which the nurse (artist) stands to the form is real for it affects her and she affects it. If she enters into genuine relation with the patient (I-Thou) her effective power (caring, nursing skills, hope) brings forth the form (well-being, more-being, comfort, growth), just as the painter's or poet's power and skill create a painting or a poem.
Of course, there is this difference. The art of nursing, being goal-directed and intersubjective, is more complex than the arts of painting and poetry, for example. As a clinical art, it involves being with and doing with. For the patient must participate as an active subject to actualize the possibility (form) within himself. Perhaps the art of nursing could be described as transactional. Not only does the nurse see the possibilities in the patient but the patient also sees a form in the nurse (for example, possibility of help, of comfort, of support), and he responds in relation to bring it forth. {93}
Then the question logically may be raised: Is the patient's responses in relation (I-Thou) a necessary condition for the art of nursing? Or to state it differently: can there be any art of nursing the infant, the unresponsive, the comatose, the dying? I would answer that the art of nursing can exist even if the relation is not mutual. For as Buber writes,
"Even if the man to whom I say Thou is not aware of it in the midst of his experience, yet relation may exist. For Thou is more than It realises. No deception penetrates here; here is the cradle of Real Life."[14]
DIALOGICAL NURSING: ART-SCIENCE
Art and science, like nursing, represent angular views. Each is a view with a particular purpose. They are human responses to the everyday world in which man lives. Existentially speaking, each is a form of living dialogue between man and his human situation.
It is possible that there is in nursing a kind of human response to reality that is a combination, a true synthesis of art and science? The more one focuses on nursing as it is lived, on the intersubjective transaction as it is experienced in the everyday world, the more questions arise about it as art and science. Elements of both art and science are evident in nursing. The practicing nurse must integrate them in her mode of being in the situation.
While Dr. Josephine Paterson was developing a methodology of inquiry from a clinical nursing process and describing her construct of the "all-at-once," she was so intent on communicating the interrelated reality of the art and science elements in nursing, that she welded them together with a hyphen into one word, "art-science." And even then there is some dissatisfaction when the weld is interpreted merely as a seam. For the combination is more than additive; it is a new synthetic whole.
I experienced a similar difficulty in trying to describe the synthesis of art and science that takes place in the nursing process. The nursing dialogue reflects the orientations of art and science for it involves both the patient's and the nurse's subjective and objective worlds. I believe the synthesis of art and science is lived by the nurse in the nursing act. This is a phenomenon more readily experienced than described.
Yet if we truly experience nursing as a kind of art-science, as a particular kind of flowing, synthesizing, subjective-objective intersubjective dialogue, then nursing offers a unique path to human knowledge and it is our responsibility to try to describe and share it.
FOOTNOTES:
[1] New England Council on Higher Education for Nursing, Humanities and the Arts as Bases for Nursing: Implications for Newer Dimensions in Generic Nursing Education, Proceedings of the Fifth Inter-University Work Conference (Lennox, Mass: New England Council on Higher Education for Nursing, June, 1968). "Humanities, Humaneness, Humanitarianism," Editorial in Nursing Outlook, Vol. 18, No. 9 (September, 1970), p. 21. Charles E. Berry and E. J. Drummond, "The Place of the Humanities in Nursing Education," Nursing Outlook, Vol. 18, No. 9 (September, 1970), pp. 30-31. Marion E. Kalkman, "The Role of the Humanities in Graduate Programs in Nursing," in Doctoral Preparation for Nurses, ed. Esther A. Garrison (San Francisco: University of California, 1973), pp. 138-155.
[2] Mary Jane Trautman, "Nurses as Poets," American Journal of Nursing, Vol. 71, No. 4 (April, 1971), p. 727.
[3] Ibid., p. 728.
[4] Ibid.
[5] Chaim Potok, My Name Is Asher Lev (Greenwich, Conn.: Fawcett Publications, 1972), p. 105.
[6] Grayce C. Scott Garner, "Qualitative and Quantitative Analyses of Schizophrenic Verbal and Non-Verbal Acts Related to Selected Kinds of Music," Humanities and the Arts, p. 49.
[7] Carol Ann Christoffers, "Movigenic Nursing: An Expanded Dimension," Humanities and the Arts, p. 95.
[8] Garner, p. 40.
[9] Picasso as quoted in My Name Is Asher Lev.
[10] John Hersey, The Conspiracy (New York: Alfred A. Knopf, 1972), p. 82.
[11] Faye G. Abdellah, "The Nature of Nursing Science," Nursing Research, Vol. XVIII (September-October, 1969), p. 393.
[12] "Art," The Great Ideas: A Syntopicon of Great Books of the Western World I, Vol. 2, 1952, pp. 64-65.
[13] Ellen T. Fahy, "Nursing Process as a Performing Art," Humanities and the Arts, p. 124.
[14] Martin Buber, I and Thou, 2nd ed., trans. Ronald Gregor Smith (New York: Charles Scribner's Sons, 1958), p. 9.
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9
A HEURISTIC CULMINATION
This chapter presents an application of the humanistic nursing practice theory over time and an outcome. The outcome represents my present conscious conceptualization of my personal theory of nursing. It has grown out of my nursing practice experience, my reflecting, relating, describing, and synthesizing. This is heuristic culmination of much mulling over my lived world of nursing.
ANGULAR VIEW: PRESENT PERSPECTIVE
In 1971 after a presentation on concept development I heard myself in a chatty response to the audience declare my unique theory of nursing. It was based in constructs that I had developed and conceptualized. Previously I had viewed these constructs only as distinct entities. My synthesis of them surprised me. This was the first time I conveyed them as my why, how, and what of nursing. This synthesis may have emerged as a sequence to my reexamination and reflection on each of these constructs in preparation for this 1971 presentation.[1] Now it became evident that their sequential evolvement had a logic that had come from my being without my awareness.
Since 1971 I have planned to reflect on these synthetic constructs to better understand how they relate to one another complementarily. Why? To further the development of these constructs and to state them as propositions. Statements of propositions are movement toward nursing theory. Theory is considered here as a conceptualized vision teased out of my knowing from my nursing experience.
{96}
Like Elie Wiesel, the novelist and literary artist, I write to better understand and to attest to happenings. This chapter is the fruit of this endeavor.
The first term, "comfort," was developed as a construct in 1967. After recording and exploring my clinical experiential data, a conceptualized response emerged to my question: "Why, as a nurse, am I in the clinical health-nursing situation?" The second term, "clinical," was developed as a construct in 1968. It was a conceptualized response to a dialectical process within myself. I asked, "What is clinical?" I answered, "I am a clinician." I asked, "As a nurse clinician what do I do; what is the condition of my being in the nursing situation?" I answered, "This described would equate to clinical." Consequently I compared and contrasted two nursing experiences similarly labeled to properly grasp the principle of "clinical" for conceptualization. The third term or phrase, "all-at-once," arose intuitively within me as a construct in 1969 and was partially conceptualized. It arose after mulling over other nurses' published clinical data and asking, "What can you tell me of the clinical nursing situation?" "What do you perceive as the nature of nursing?" Therese G. Muller's, Ruth Gilbert's and my thought on the nursing situation merged into a view of these as multifariously loaded with all levels of incomparable data, the "all-at-once." Incommensurables relate to the nature of nursing and its concerns. How can one study unrelated appearances? Muller often used an historical approach while Gilbert emphasized individualization. In humanistic nursing practice theory a descriptive, intersubjective, phenomenological approach is proposed for greater understanding and attestation of the events and process of the nursing situation. The construction of "comfort, clinical, and all-at-once" I would now label as conceptualized phenomenologically. I view them as relevant phenomena to any nurse and this nurse-in-her-nursing-world.
Theory: Unrest, Beginning Involvement
This desire to develop nursing theory goes back to my years (1959-64) as a faculty member in a graduate nursing program. I fussed with the idea, did not know exactly what I was fussing about, and expressed my desire, interest, and concern poorly. Much, I am sure now, to others' dismay. Teaching in nursing was an offering of multitudinous theories developed in and for other disciplines using nursing examples. There were both similarities and differences in the many nursing examples in which attempts were made to describe the qualities of the participants' beings. Emphasis was placed on the observations by the nurse of the others' responses in the nursing situation. Nursing education was rife with lengthy repetitive examples utilized to focus on particular variations. I desired a unifying base applicable to all nursing situations. This was not a seeking for conformity nor an attempt to negate individuality. Certainly I did not want such a base to exclude individual nurses' talents. Rather this base, foundation of nursing indicative of the nature of nursing, would heuristically promote endless variations to flow, blossom, cross-pollinate, and evolve. {97}
In these observations and thinkings I was attempting to understand, sort out, and clarify the questions that underlay my puzzlement. This puzzlement arose out of my 18 years in nursing practice and education. In a theory course and a philosophy of science course, while in doctoral study, I recognized and learned to label my unrest and puzzlement as a recognition of the need for nursing theory.
In 1966 in discussing my purposes for doctoral study, I expressed this unrest and puzzlement. I viewed my varied past experiences in nursing as excellent. I sought time to reflect on the past 24 years of living nursing to see what it could tell me, and to come to better understand its meaning to the profession of nursing. The philosophical nature of these questions and what they express of myself is evident. Such personal revelation at this time is no risk, and withholding would only deprive myself and others of the answers that might be brought forth.
As in most school situations initially responding to class assignments and involvement in new clinical situations consumed my time and thwarted my personal, professional interests. When I commented on this my interests were interpreted to me as a desire to live in the past. Living in the present was recommended and terms like "up-to-date" and "progressive" were employed. I felt stopped cold. I had never viewed myself as old fashioned or non-progressive. Many of my past nursing experiences were still avant-garde as compared with general current practices.
There was something different though in recalling and reflecting on the past as opposed to current experiences. One's past would be visible in view of how one approached and experienced the present. Self-confrontation moved me beyond confining myself either to the past or to the present. In my writings one could detect a comparison of what had been known with what was coming to be known. It was as if a light of a different hue lit up the whole—past and present—as a different scene. Similarly I viewed and experienced my clinical experience differently. I gained awareness of a quality of my being that always had been there, but which I hid. Now I valued this part, struggled with it, and expressed it directly with courage, integrity, and pride. The power with which this self-actualization imbued me has been sculpturing my "I" into a form of my choosing ever more acceptable to me, and accepting of others.
Concept Development
In a nursing theory course the final assignment was: develop a concept relevant to nursing. Again I found myself struggling. The didactically stated importance of investing precious time and energy into constructing a synthetic conceptualization of a term eluded me. Time and energy spent to better understand man as he was known to me in the nursing situation seemed so limited. In these situations persons were expressing so many things at one time, how could the conceptualization of one term be relevant. Finally I understood: no one was saying that any one term could equate any particular or group of {98} nursing situations. They were saying that to communicate the nature or experience of nursing with words, to develop nursing theory, relevant terms needed clarification as to the meaning they conveyed and delineation as to their inclusiveness and exclusiveness.
As this struggle subsided I could hear, "a term could be developed as a concept or synthetic construct if one conceptualized its why, what, how, when, and where and how these interrelated." In approaching concept development the last but not least hurdle was, what term did I consider relevant enough in nursing to expend this precious time and energy on considering the many possibilities. The first term I began to intellectually play with was "ambivalence." Now, I would attribute my selection of "ambivalence" to my then existing ambivalence about conceptualizing a synthetic construct. Then, I based its selection only on its existence in my clinical nursing world. I was working therapeutically on a regular, individual basis with an ambivalent adolescent male labeled diagnostically as a paranoid schizophrenic. I began to consider my clinically recorded data of my sessions with Bob through ambivalence. What were the relationships between why, how, what, when, and where Bob expressed ambivalence?
Struggling with the term "ambivalence" involved and interested me in concept development. During this phase I overcame my fear of exposing my thoughts, I took the risk, and my courage had the upper hand. Nevertheless, another choice had to be made since now I was not willing to invest this much time on conceptualizing "ambivalence" as so relevant to nursing. Perhaps this signified that my own ambivalence had dissipated. And again, I faced the question, what term would I want to develop as a synthetic construct?
The next question that occurred to me was, what term would indicate why, as a nurse, I am in the clinical health-nursing situation? Did I view my value mainly as growth, health, freedom, or openness promotion? I worked for a while with each of these terms and eventually discarded them. Some long-hospitalized persons with whom I was working on a demonstration psychiatric unit to prepare them for a more independent and appropriate form of community living would never be stably balanced in health, growing, freedom or openness. For many, these could be only flitting memorable beautiful moments. Still I believed I was very much there in the nursing situation for these persons, as well as for those who moved into the community and found work and social satisfactions. Something occurred between all of these 15 patients and myself—and that was nursing.
COMFORT: WHY
While considering what construct to conceptualize, I was in the process of recording my three-hour, twice a week interactions in the demonstration unit. I reflected on these interactions and waited for the data to reveal to me the major value underlying my nursing practice. Then the term "comfort" came {99} to mind. Perhaps at this point I became comfortable in this unit, or perhaps the unit, itself, became a more comfortable setting. When I had first begun my experience with this demonstration unit, it was still being planned and the hospital was new to me. However, the term "comfort" has long been associated with nursing. One can find it as a historical constant throughout the professional nursing literature. The term had been used recently in an ANA publication.[2] When I considered the idea of comforting in nursing practice I felt such experiences had fulfilled and satisfied me, made me feel adequate. I could recall specific experiences that went back to my initial nursing practice settings. I could conceive of comfort as an umbrella under which all the other terms—growth, health, freedom, and openness—could be sheltered. Some of my contemporaries scoffed and viewed this term as much too trivial.
Now, again reviewing my months of gathered clinical data, I sorted out 12 nurse behaviors that I viewed as aiming toward patient comfort. They were:
1. I focused on recognizing patients by name, being certain I was correct about their names, and using their names often and appropriately. I also introduced myself. Names were viewed as supportive to the internalization of personal identification, dignity, and worth.
2. I interpreted, taught, and gave as much honest information as I could about patients' situations when it was sought or when puzzlement was apparent. This was based in the belief that it was their life, and choice was their prerogative as they were their own projects.
3. I verbalized my acceptance of patients' expressions of feeling with explanations of why I experienced these feelings of acceptance when I could do this authentically and appropriately.
4. When verbalizations of acceptance were not appropriate, I acted out this acceptance by staying with or doing for when appropriate.
5. I expressed purposely, to burst asunder negative
self-concepts, my authentic human tender feelings for patients
when appropriate and acceptable.
6. I supported patients' rights to agape-type love
relationships with others: families, other staff, and other
patients.
7. I showed respect for patients as persons with the right to make as many choices for themselves as their current capabilities allowed.
8. I attempted to help patients consider their currently expressed feelings and behaviors in light of past life experiences and patterns, like and unlike their current ones. {100}
9. I encouraged patients' expression to better understand their behavioral messages and to enable me to respond overtly as therapeutically as possible.
10. I verified my intuitive grasp of how patients were experiencing events by questions and comments and being alert to their responses.
11. I attempted to encourage hope realistically through discussing individual therapeutic gains that could be derived from patients' investment in therapeutic opportunities available to them.
12. I supported appropriate patient self-images with as many concrete "hard to denies" as possible.
Each of these nurse behaviors was repeatedly evident in the months of recording patient-nurse interactions. For the conceptualization of the term "comfort," a representative clinical example was given to enhance the meaning of the behavior cited (see Appendix). When compiling materials for the conceptualization of this term, I found 12 assumptions about psychiatric nursing that I had written for the theory course in one of the first class sessions. Although these assumptions were expressed in different words, their congruence with my 12 selected behaviors made me believe that these behaviors were somehow verified both in my conceptualized philosophy of psychiatric nursing and in my behavior while being a psychiatric nurse.
Next I struggled with an idealistic conception of comfort as opposed to a continuum of behavior which would indicate a person's degree or state of discomfort-comfort. Again, reflecting on and teasing out aspects of my data, I set up four behaviorally recognizable criteria for estimating a person's discomfort-comfort state:
1. Relationships with other persons which confirm one as an existent important person.
2. Affective adaptation to the environment in accord with
knowledge, potential, and values.
3. Awareness of and response to the reality of the now with
understanding of the influence of and separation from the past.
4. Appreciation and recognition of both powers and limitations which enlighten the alternatives of the future.
These behavioral criteria, too, could each be spread on a continuum to evaluate the effects of this aim of nursing on a patient's actual comfort status at any particular point in time.
Considering the concept of comfort as a proper aim of psychiatric nursing brought forth the necessity of considering its opposite, discomfort, as a concept. Evidence for the existence of discomfort could be inferred in the absence of the above behavioral criteria. {101}
The basic foundation to justify the concept of comfort as a proper aim of psychiatric nursing would be both organic and environmental. In our culture, among the species man, we are moving toward being able to effect some organic conditions by genetic controls and surgical and chemical means. The professions have struggled long years to influence environmental deterrents to comfort. If an individual as a fetus, or as an infant, or young child never internalizes comfort of any kind from his environs, the probability of initiating a continuum within himself as an adult that is propelled toward comfort seems unlikely. Such individuals, lacking any potential capacity for comfort, I suspect are rare. There is evidence for the existence of this dormant seed of comfort in persons with schizophrenia in the hospital setting. Consider how repetitively and ambivalently they "reach out" to authority figures. This dormant comfort seed requires nourishment of a high quality for testing whether it can develop and bear the fruits of health, growth, freedom, and openness.
When the development of this synthetic construct of comfort was discussed in the theory course a question was raised: Is a person who denies all feeling, presents himself as emotionally dead, comfortable? If feelings are not relegated to the mind alone, as the effects of a peptic ulcer cannot be relegated to the stomach, if feelings are an essential of the nature of humanness, a human who denies this essential of his nature would not fit into this concept as comfortable. This synthetic construct of comfort, like its synonym contentment, described by Plutarch A.D. 46-120, does not imply passivity, resignation, retirement, or a simple avoiding of trouble. Plutarch said, "Contentment comes very dear if its price is inactivity."[3] I would perceive of comfort or contentment as implying that a human being was all he could be in accordance with his potential at any particular time in any particular situation.
Continuing the aforementioned twelve nurse behaviors, observing behavior through the four established criteria and conceptualizing the construct of comfort, I began to wonder. Was I seeing what I had decided was the state of psychiatric patients' conditions of being? Was I projecting discomfort onto patients? I did not expect straight answers. Nonetheless, I decided to ask patients about their discomfort-comfort states to verify my perception of the condition of their beings. All fourteen patients I asked assured me by their responses that I was not projecting or seeing discomfort where it did not exist.
Some described physical discomfort and sought the cause within and outside themselves (either another caused it, or another could cure it, pills would cure it), negatively viewed self-images, guilt based in their behaviors or thoughts. One patient defined comfort by analogy and stated directly to my surprise that he seldom felt comfortable and that his excessive ritualistic behavior was his way of coping with his discomfort. One repetitively stated a happy illusion that he seemed to hang on to for dear life. When I asked what he would do if this illusion was not truth, he said that he had never considered {102} this possibility. I knew he had been confronted with the truth of his situation many times in many ways. One patient merely looked directly at me and walked away.