Then I again reviewed my clinical recorded data to see what kinds of knowledge nursing with an aim to comfort would infer as necessary. Fifty-two items of knowledge were extrapolated from the clinical examples selected as representative of the twelve nurse behaviors. These items were categorized under broad cognitive and affective domains. This was an arbitrary point of separation. They were teased apart simply as an aid to conceptualization and understanding. If these knowledge domains had related to one another in a simple direct manner, I would have conveyed them in a table in which each would have been across from its mate. Their relationships to one another were far too complex to be handled in any such a way. The affective domain knowledge areas were a dynamic internalized synthesis of several knowledge areas from the cognitive domain. Thus, the expression of these affective knowledge areas was evidence of the practice of nursing as an artful form of expressing cognitive knowing.
In looking directly at the discomfort of long-term hospitalized psychiatric patients, I found myself faced with behaviors that resulted possibly from a muddle of many contributories. What in the behavior resulted from lifetime environmental influences and compounded responses that deepened scars? What resulted from long-term hospitalization? How many varieties of ills superimposed like layers on the above were expressed in what I saw as discomfort in these psychiatric patients? Diagnostic classifications are necessary for statistical economic planning reasons. Still, how naively and superficially they convey the human therapeutic care needs of each person.
At this point of construct development I saw a positive relationship in my thinking about comfort as a proper aim of psychiatric nursing and Viktor Frankl's description of his aim in logotherapy toward meaning. I had struggled with the idea of aiming at comfort while with patients who possessed ability and a favorable prognosis, often purposefully and deliberately asking them to consider ideas that caused them immediate greater discomfort. Frankl's quotes from Nietzsche and Goethe supported my altruistic intention. Nietzsche said:
"He who has a why to live can bear almost any how."[4]
Goethe said:
"When we take man as he is, we make him worse; but when we take man as if he were already what he should be, we promote him to what he can be."[5]
In conclusion to this stage of development of a synthetic construct of comfort as an aim of psychiatric nursing I can say: Comfort is an aim toward {103} which persons' conditions of being move through relationship with others by internalizing freedom from painful controlling effects of the past. These effects have inhibited their self-control, realistic planning, and prevented them from being all that they could be in accordance with their potential at any particular time in any particular situation. I would project this as an aim for nursing in all situations although the data for constructing this conceptualization were gathered in a clinical psychiatric setting.
CLINICAL: HOW
As a component of my doctoral examinations I was faced with having to rewrite a clinical paper. This led to my deliberately and personally choosing to conceptualize a synthetic construct of "clinical." This was my decision. It speaks well for the value of having had the experience of conceptualizing "comfort." Often it is said that man repeats that which he finds as meaningful and good. This choice also signifies a real overcoming of my resistance and ambivalence toward synthetic construct development in a year's time.
"Clinical" was developed as a synthetic construct in 1968. It was a conceptualized response to a dialectical process within myself. If I am a clinician, then "how" I am in the health-nursing situation would equate to "clinical." In conceptualizing this construct I teased out of my lived-nursing-world the "how" of my working toward my own and others' comfort.
Confusion, over what was meant when persons casually and currently popularly attributed the term "clinical" to situations and persons, called forth this conceptualization. It grew out of comparing and contrasting two nursing consultation experiences in the psychiatric-mental health area. Beginning this conceptualization I would have referred to both these experiences as "clinical." At the termination of the conceptualization they were both "clinical." They were very different experiences for me, and yet of equal value in my advancement toward my more of being. Prior to this conceptualization because my attending emotions were so disturbing and unacceptable to me in relation to one of these experiences, automatically I repressed part of them and found reasons to suppress the rest of them. Unfortunately, all else that was of value to me in having lived this experience was integrally enmeshed with these emotions. This, too, became unavailable to my conscious awareness. Conceptualization made recall and reflection a necessity. Clinical includes inherently a process of experiencing awarely and then recalling, looking at, reflecting on, and sorting out to come to knowing.
Before knowing how to approach the rewriting of my clinical paper as a partial requirement for receiving my doctoral degree I experienced a depression. I felt frightened, angry, and inadequate. The original clinical paper had been judged as more intellectual and scholarly than clinical. I could conceive of only two alternatives. Both seemed self-defeating. One, I could revise my former clinical paper into a more intellectual and scholarly paper that still {104} would not be clinical and would still leave my "I" out. Or, two, I could revise my former clinical paper, dump all my feelings in the situational experience, blame everyone else for these feelings, and culminate at least with my clinical passions visible. Conflict resulted from my considering pursuing either of these routes. I was immobilized for a time. A time limitation and time passing pushed me to begin somewhere. I began. Choosing the second alternative in the belief that at least through writing I would better understand what I had lived in the experience.
I could support the value of dredging up these old feelings and looking at them. Authentically letting myself be aware of what I had experienced, not necessarily communicating this or acting out in accordance with these redredged feelings; just really looking at them might allow me choice in how I wanted to live with them. One support for the value of looking at these old feelings was my own past three and one-half years in psychoanalysis in which I profited through such a process. The other support was my readings of the past two years. These included works of Russell,[6] Nietzsche,[7] Plato,[8] Popper,[9] Dewey,[10] Buber,[11] Bergson,[12] Cousins,[13] and de Chardin.[14]
As this experience became in shape and meaning through my writing, I began to view this product as like an existential play filled with blatant atrocities and absurdities that had to be nonrealities. This production, also, made visible beautiful raw data. As meaning in this clinical nursing consultation experience as a graduate student became evident, comparison of it with the meaning of clinical work experiences in nursing consultation situations flowed naturally. Then joy, it was like sunshine burst forth and warmed my spirit.
Before entering school, I was, for two years, a mental health psychiatric clinical nurse consultant to a staff of forty-five visiting nurses. I had become intrigued {105} with what I had come to understand about consultation related to clinical situations. I wrote a paper for publication on the subject. Busy in the process of returning to school, and awaiting the publication of two other papers—both of these proceedings feeling unreal and out of my control, not to mention self-exposing—I merely filed in my desk the typed submittable rendition of this consultation paper. Now, I dug it out. This meant that I had two conceptualized presentations of similar type personal experiences in nursing consultation to compare and contrast. From these, my conceptualization of clinical, and the values on which my clinical practice rests, could be extrapolated.
A Student Consultation Experience Becomes Clinical
In the graduate student nurse consultation experience I felt helpless, confused, unwanted, guilty, anxious, and unimportant. It was a passion-filled experience for me. As a nurse-student consultant among interdisciplinary nonstudent-consultants I experienced dependency for my being and doing on persons I viewed as anxious, critical, nonempathetic, and inadequate. We were attempting to offer consultation to a professional group of nonpsychiatric mental health oriented consultees who were anxious and felt inadequate in this area. I felt forced into an observer rather than participant mode of being, and my recorded data support this. Impotency comes to mind when I recall this experience, as well as a racking rage and suffering that obliterates feelings of love, good-will, tenderness, or hope. About that time I was reading Nietzsche's eternal recurrence phenomenon[15] and viewed it most pessimistically—all was awful, it would continue to be awful, life was just a vicious cycle of awfulness.
Defense or health, it is questionable. Suddenly, perhaps it was having hit feelings of rock bottom, I began to view Nietzsche's eternal recurrence phenomenon optimistically. Did the polarization of my negative feelings magnetically call forth my opposite feelings? All, now, contained the new, it would continue to contain the new, life was a series of similar and yet different cycles that always contained the new.
Now my reflections let in hope, positiveness, comradeship, good feelings, and progress made by myself and others in our year and a half together as consultants. During this period we met with the consultees for an hour once or twice a week. The group had continued over this period despite its components of psychiatric mental health professionals and nonpsychiatric mental health profession culturally, professionally, and historically having been quite alienated from one another. Attendance had improved some over time. Toward the end of the year and a half, during the last three months, the focus of discussion was on patients and their worlds for longer periods of time. There was less defensive acting out in which things, fees, time, and mechanics consumed the hour.
{106}
Toward the end of these sessions the consultant chief found more acceptable space in which to meet for the consultation. Eating lunch became part of the session. Food can be looked at in many ways. In this case it seemed to be a cohesive force, rather than a distracting, socializing force. Was this because of the underlying meanings food had for these people? Or was the meaning of food in this situation concrete? Now the consultees could have their lunch served to them while receiving consultation. This latter saved their time and meant money to them. This was a giving gesture on the part of the consultants even though the lunch monies did come out of the project funding source. The meaning of food was never discussed in the group. I wonder if this feeding was done with deliberate awareness or was just serendipitous.
During the last three months of meeting I began to feel related on a deeper level with a few of the participants, consultants and consultees. Individual to individual we began to communicate collaboratively with one another as professional colleagues. We discussed both patients' lived worlds and the meaning of psychiatric mental health terms and ideas. I can conceive, now, that this may have occurred between other group members before or after sessions. Initially there were often only two to three consultees to five or six consultants. Later the total group contained fifteen to sixteen people. Now I would project that the very existence of this group could influence future groups positively.
A Clinical Work Consultation Experience
In this work consultation experience my feelings were openness, reflectiveness, pain, helpfulness, alertness, searchfulness, appreciativeness, receptiveness, responsiveness, wantedness, competence, joy, and importance. It was both a passionate and a dispassionate experience. As a working consultant I met with consultees either alone or as part of a collaborating team of consultants. Often the situations the consultees presented which they struggled with and stayed in struck me with awe. They aroused my humility while making me feel whole and fulfilled in my participation with the consultees. In my explorations of and with the consultees my presence, thereness, and authenticity were all important. Buber would say that my aim in consultation was to "imagine the real" of what the consultee and the patients and families she discussed with me "could be."[16] This was my initial disposition. I aimed to be open to and accept the potentials of these others.
In initial receptiveness, grounded in my comfort, was the "key" to the "door" of the consultant-consultee "I-Thou" relation in which I could come to know intuitively the experience of this particular other nurse-in-her-lived-nursing-world. The consultees offered their lived-nursing-worlds each in their unique ways. Some discussed directly their pains, joys, adequacies, and inadequacies. Some discussed indirectly their panic, success, action, and immobilization. Some beyond being able to discuss their lived-worlds {107} spontaneously acted out their lived-worlds. For example, these often behaved toward me as their patients and families behaved toward them. These kinds of acted out lived-worlds I had to sense my way into to understand. When I began to wonder what it was that they wanted from consultation to take back to their lived-nursing-worlds, I would pull out of the "I-Thou" form of relating. This wonderment became my conscious clue. It was time to reflect and look at what my explorations had uncovered.
At this point transcending this "I-Thou" relation, I would look at "It." Seeing, now, what was within me, what the condition of my being was that I had intuitively taken on from the consultee, I would set it apart from myself, and see it as an empathic response. I knew that these feelings I experienced which I received existentially, globally through the compound of the consultee's words, tone inflection, volume, facial expression, posture, and positioning to me were what she experienced in her-nursing world. Verbalization of this empathized understanding fulfilled several purposes: (1) it conveyed my sympathy or joy with, and always my caring, (2) it validated that I saw it as it was for this nurse, and (3) it opened the door to our working through the possible meanings of the nurse's experience and to speculating about outcomes of alternative future nurse actions and behaviors.
Cognitively the range of these consultation discussions was broad. Some common themes were social and health histories of families, pertinent psychological growth and development factors of persons in the families of concern to the consultees, relationships between persons within the situations, resources available to the families, ways the consultees could relate with the parents and patients' families, friends, and other professionals in the situation, and the meaning of all these themes to the particular consultee.
This clinical consultation experience necessitated my being certain ways. It necessitated my being authentic with myself with regard to what responses were called forth in me in relating with a particular consultee. I viewed honesty with the consultee as a value necessary to the consultation process. In approaching the consultation I needed to be open to the consultee's angular view and predisposed toward an "I-Thou" relationship. The "I-Thou" relating necessitated subsequent scientific understanding extrapolated from it through reflection on it as "I-It." My hope in consultation was to offer both a cognitive, as well as, an ontic experience in which a mutual feeling apart from and toward the other would exist. This latter seemed most important to me. If the consultee experienced my being authentically present with her, she then would be apt to offer this type of relationship to the patients and families of concern to her.
Results of Comparison
The two clinical consultation experiences were juxtaposed, contrasted, questioned, related, and synthesized to envision their unified contribution to the construct of "clinical." The synthetic construct of "clinical" is not viewed as a mere juxtaposing, a disintegrating, or reconstructing of the contributions {108} to my knowing from either of these experiences. This comparison is viewed as a facing of the multiplicities they both present. The synthesis is an illumination of both experiences with each transfigured through their mutual presence in the "knowing place" of the comparer.[17]
In this comparison my appreciation grew of how I had uniquely implemented and conceptualized clinical consultation in my work experience. I recognized through the comparison that adequate clinical consultation demands both a passionate and dispassionate phase of "I-Thou" and "I-It" relating. Without either of these forms of consultant being-in-the-situation we degrade the term "clinical" if we employ it. Consultation lends itself naturally to a collaborative cooperative relationship. The consultant is dependent on the consultee for presentation of the specifics of particular situations. The consultee is dependent on the consultant for the tailoring of general knowledge to the consultees' particular situations. The relationship if appropriately called consultation is then of necessity interdependent. In being separate from the other while feeling with the other the consultant does not lose the ability to question. Passion undealt with or identification with the consultee inhibits the clinical purpose of the consultant and of the consultation. In identification one feels as if he were the other, rather than turning to the other and feeling with him. The degree of anxiety this provokes in the consultant can prevent looking at the consultation situation and issues in an "I-It" manner. The consultant loses the ability to question.
Through this comparison I was able to reflect on the graduate student nursing consultation experience in an "I-It" way. At this time it became a "clinical" experience for me. The lack of this reflective phase in this experience highlighted the reflective phase already existent in the working clinical consultation experience. The existence of this phase in the working clinical consultation experience highlighted its absence in the graduate student nursing consultation experience. My commonplace nursing world through this comparison became awarely meaningful and availed itself for conceptualization. A situation is not a "clinical" experience until the "would be" clinician can reflect, analyze, categorize, and synthesize it.
Clinical Is
A potentially clinical psychiatric mental health situation becomes "clinical" if the clinician relates to the helpee to awaken his unique potential or ontic wholeness, and noetically transcending this relating conceptualizes its meaning.
Clinician signifies a particular mode of being and a particular kind of cognitive knowledge. With all his human capacity the clinician relates with his clinical-world consciously and deliberately in "I-Thou," and "I-It."
Relating in "I-Thou" with the other in-his-clinical-world the clinician gives himself and receives back the other and himself in the sphere of "the between." {109} He knows the other and the more of himself in this relating. He is confirmed and confirms the other through the other's presence with him. Thus, he calls forth the other's actualizing of self through the clinical relationship. In accepting the other as he is the clinician imagines and responds to the reality of his potential for becoming, becoming according to his unique capacity for humanness.
Relating in "I-It" with his clinical world the clinician noetically transcends himself, objectifies himself, and studies his "I-Thou" knowing. He teases it apart. He classifies and studies it. He asks it questions. He compares and contrasts it to other clinical experiences. He discusses its many aspects in dialogue with his "inward," and possibly "outward" "Thous." He reorders its parts. He shapes, creates, plans from and for its clinical existence. Thus, he ever augments a world of heuristic knowing.
This "how" allows the clinical fulfillment of my nursing "why." Comfort is "why" I, as a nurse, am in the health-nursing situation. As conceptualized "comfort" is being able to freely control and plan for one's self, being fully in accord at a particular time, in a particular situation, with one's unique potential. Now, "what" is the nature of the nurse's world, the health-nursing situation?
ALL-AT-ONCE: WHAT
The term "all-at-once," arose within me as a construct that would metaphorically describe the multifarious multiplicities that exist within nursing situations. Completing my comparison of Gilbert's and Muller's written works to grasp how they viewed the nature of psychiatric mental health nursing I found myself mulling over and fussing.[18] Your question is probably, mulling and fussing over what? While I mulled over and fussed I believe I, too, was perplexed. Why was I unsatisfied?
I had compared Gilbert's and Muller's writing styles, their conceptions of man, approaches to nursing, nursing education, supervision, and consultation. Their similarities and differences were noted, and how each presented herself predominantly. Then I cited the nursing communities they sought to influence and those in which they were while writing. Through reviewing their bibliographies and biographies I indicated the sources that had influenced them.
Still I mulled over, fussed, and was perplexed. I awakened in the middle of one night in 1969 understanding what had been causing my struggle. The "all-at-once" was my answer.
The description of single constructs and single examples originally had felt unrelated to the reality of the nurse's world. They oversimplified its complexity. The nature of nursing was complex. It seemed to me that we needed, as a profession, constructs that simplified and allowed clear communications. We, also, needed constructs that conveyed the reality and complexity of the {110} worlds in which nurses nursed. Perhaps a description of what "all-at-once" expressed for me would convey to others the lived-unobservable-worlds of nurses.
Nurses relate to other man in situations of "all-at-once." The "all-at-once" is equated by me to Buber's "I-Thou" and "I-It" occurring simultaneously and not only in sequence as he expressed it. These two ways that man can relate to and come to know his world and himself demand sequential expression for clear communication. However, the responsible authentic nurse in the nursing arena lives them "all-at-once." Aware of the multifarious multiplicities of her responses to another and at once to the surrounding field of action, the nurse selects and overtly expresses her responses that actualize the purpose, values, and potential of the artful science of professional nursing.
Awareness of the multifarious multiplicities affecting the other and the self in the nursing arena is a component of "I-Thou" relating. Selectively overtly expressing concordantly with the purpose, values, and potential of nursing necessitates a looking at, which is a component of "I-It" relating, while acting and being. Therefore both "I-Thou and I-It" modes of being are "all-at-once."
This necessity for a nurse's duality in her mode of being came to my awareness through comparing Gilbert' and Muller's works, studying Buber's conceptions of man, and considering them in relation to my current and past lived-experiences in the nursing-arena. In my nursing world of "I-Thou" relating reflection is called forth prior to my overt response to allow response selection concordant with my nursing purpose. The very character of multifarious multiplicities of the nursing world undoubtedly has called for nurses to develop their human capacity for duality in their mode of being.
To make these "multifarious multiplicities" explicit I would like to offer a description of a recent, personal nursing experience. In a community psychiatric mental health psychosocial clinic, I sat across from and focused on relating with a psychiatric client. After long years of hospitalization he was now living in a community foster home and visiting the clinic three days a week. When there was no special clinic activity in progress and often even when there was, he sat by himself and played poker. He told me about his game many times, over weeks and months. He dealt out five poker hands. Each hand was dealt to a member of his family, long dead. He did not accept their deadness. One day while describing the poker games and his relatives, he intermittently expressed his fantasies which he projected on to a sweet cheerful 65-year-old community volunteer. She was somewhat deaf. His fantasies were angry. When he gestured toward her, she in a motherly way came over to him, put her arm around him, and her ear down to his mouth. It was a moment of possible client explosion. With my eyes I attempted to communicate with her. This, and the tone of the patient's voice warned her to move away. While this was occurring another patient jealous of my attentions to this patient walked up and down, and in passing negatively commented on the religious background of the man I was sitting with. In the rear of the room a dietician was conducting a group on obesity. And all of this was set to the {111} melodious, sanguine strains of "If I Loved You" being poorly beat out on a piano about ten feet away by another volunteer accompanied in song by a few clients. Meanwhile two staff nurses were observing my part in all this since I was labeled "expert." The client did support me that day and responded to my staying with him. Much to my surprise he began playing poker with me. He dealt me out a hand. This was, at this time, a new behavior on his part. It was movement toward his potential for relating to live persons in his current world. This, again, is just one example of the multifarious multiplicities of one very common type of nursing situation.
The inference from the above is that professional artistic-scientific nurses relate in "I-Thou, I-It, all-at-once" to the specific general, critical nonconsequential, and the healthy ill. This presents a paradoxical dilemma. Nurses, as human beings, have a highly developed capacity for living "all-at-once" in and with the flow of the multifarious multiplicities of their worlds. Nurses, as human beings, like all other human beings, are limited to thinking, interpreting, and expressing conceptually only in succession.
This metaphoric synthetic construct, "all-at-once," has allowed me to better convey how I experience the health nursing situation. It also has aided my understanding of the multifarious multiplicity of angular views expressed by several professionals in responding to and describing a similar situation. I can accept each description as truth for each responder. Each responds with his uniqueness in the situation. Comparing, contrasting, and complementarily synthesizing these multiple views inclusive of their inconsistencies and contradictions, none negating the other, allows a better understanding of man-in-his-world in the health situation than the so frequently presented oversimplifications. These oversimplified presentations usually deal only with what is occurring that is important to the particular interests of the reporter. And they are offered only after the selected material has been put through a process of interpretation and logical sequencing to emphasize the reporter's particular point. In such reporting the existent in the situation labeled unimportant, unacceptable, or unrelated is not considered. Such existents, nonetheless, may control the patients, the families, the nurses and health professionals generally. Their control may well be more powerful than any erudite oversimplification or its presentation.
Humanistic nursing practice theory in asking for phenomenological descriptions of the nurse's lived-world of experiencing proposes authentic awareness with the self of what is existent in the situation prior to conceptualization for dispersal. Unless nurses appreciate and give recognition to the dynamic meaningful breadth, depth, and future influence of their worlds the actualization of the potential thrust of the nursing professional will never be or become.
A THEORY OF NURSING
A human nurse nurses through a clinical process of "I-Thou, I-It, all-at-once to comfort." {112}
"I-Thou" is a coming to know the other and the self in relation, intuitively.
"I-It" is an authentic analyzing, synthesizing, and interpreting of the
"I-Thou" relation through reflection.
The "all-at-once" symbolizes the multifarious multiplicities of extremes (incommensurables, criticals, nonconsequentials, contradictions, and inconsistencies) as metaphorically representative of what exists in the nurse's world.
"Comfort" is a state valued by a nurse as an aim in which a person is free to be and become, controlling and planning his own destiny, in accordance with his potential at a particular time in a particular situation.
FOOTNOTES:
[1] Josephine G. Paterson, "A Perspective on Teaching Nursing: How Concepts Become," in A Conceptual Approach to the Teaching of Nursing in Baccalaureate Programs, a report of a project directed by Rose M. Herrera (Washington, D.C.: The Catholic University of America, School of Nursing, 1973), pp. 17-27.
[2] American Nurses' Association, Division on Psychiatric-Mental Health Nursing, Statement on Psychiatric Nursing Practice (New York: American Nurses' Association, 1967), p. IV.
[3] Plutarch, "Contentment," in Gateway to the Great Books, Vol. 10, Philosophical Essays (Chicago: Encyclopaedia Britannica, 1963), p. 265.
[4] Viktor E. Frankl, From Death-Camp to Existentialism (Boston: Beacon Press, 1961), p. 103.
[5] Ibid., p. 110.
[6] Bertrand Russell, The Autobiography of Bertrand Russell (Boston: Little, Brown and Company, 1968) and An Outline of Philosophy (Cleveland: The World Publishing Company, 1967).
[7] Frederick Nietzsche, "Beyond Good and Evil," trans. Helen Zimmern, in The Philosophy of Nietzsche (New York: The Modern Library, 1927) and "Thus Spake Zarathustra," trans. Thomas Common, in The Philosophy of Nietzsche (New York: The Modern Library, 1927).
[8] Plato, The Republic, trans. Francis MacDonald Cornford (New York, Oxford University Press, 1945).
[9] Karl Popper, Conjectures and Refutations (New York: Basic Books, Publishers, 1963).
[10] John Dewey, The Knowing and the Known (Boston: The Beacon Press, 1949) and "The Process of Thought from How We Think," in Gateway to the Great Books, ed. Robert W. Hutchins, et al. (Chicago: Encyclopaedia Britannica, 1963).
[11] Martin Buber, Between Man and Man, trans. Ronald Gregor Smith (Boston: Beacon Press, 1955); I and Thou, 2nd ed., trans. Ronald Gregor Smith (New York: Charles Scribner's Sons, 1958); The Knowledge of Man, ed. Maurice Friedman (New York: Harper & Row, Publishers, 1965).
[12] Henri Bergson, "Introduction to Metaphysics," in Philosophy in the
Twentieth Century, Vol. III, ed. William Barrett and Henry D. Aiken
(New York: Random House, 1962) and "Time in the History of Western
Philosophy," in Philosophy in the Twentieth Century, Vol. III, ed.
William Barrett and Henry D. Aiken (New York: Random House, 1962).
[13] Norman Cousins, Who Speaks for Man (New York: The Macmillan Company, 1953).
[14] Pierre Teilhard de Chardin, Letters from a Traveler, (New York: Harper & Row, Publishers, 1962) and The Phenomenon of Man (New York: Harper Torchbooks, Harper & Row, Publishers, 1961).
[15] Nietzsche, The Philosophy of Nietzsche, p. 441.
[16] Buber, The Knowledge of Man, Appendix, p. 168.
[17] Wilfrid Desan, Planetary Man (New York: The Macmillan Company, 1972), p. 77.
[18] Josephine G. Paterson, "Echo into Tomorrow: A Mental Health Psychiatric Philosophical Conceptualization of Nursing" (D.N.Sc. dissertation, Boston University, 1969).
{113}
APPENDIX
NURSE BEHAVIORS EXTRACTED FROM CLINICAL DATA
In pursuing the idea of conceptualizing comfort as a proper aim of psychiatric nursing I extracted 12 nurse behaviors from my clinical data that were used repeatedly to increase patient comfort. I quantified these behaviors for two months. The following are a list of these behaviors with a representative example of all but the first. The first was too general and continuous for example.
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 feelings of 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 on the belief that it was their life, and choice was their prerogative since they were their own projects.
Examples
(a) While drinking coffee with a few patients at the dining room table suddenly we could hear Sidney, in his customary way, wailing, moaning, and muttering in another room. It is a sad sound. I was about to get up and go to him as I often do, when Arthur, who was sitting next to me, face working, and tense posture-wise, aggravatedly said, "Sidney doesn't have to do that, he should control himself, the rest of us control ourselves." I said, "When others express how miserable they feel, it sometimes arouses our own feelings about our misery." This was an attempt to provoke 32-year-old Arthur to work on his own {114} feelings of misery and to deter his projection of anger at himself out onto Sidney. Arthur looked at me sharply, like he had gotten the message, and agreed by relaxedly nodding his head.
(b) Alice, diagnosed as manic depressive, has been depressed. This depression dates from her going out to a department store and asking for a job. She was hired for a five-day-a-week job. This was done on her own. Later her readiness for a five-day-a-week job and her participation in the unit were questioned. Then Alice became depressed.
Alice was sitting in the dayroom. I sat down next to her. She looked very sad, her eyelids as well as her mouth, drooped. Her mouth worked as if she wanted to talk, but she was quiet. I asked her about her job decision. She said that she had not taken it. I said, "You look so sad that I feel like holding your hand." Her hands were in her coat pockets, but she looked at me and smiled weakly. I said, "Sometimes a conflict of wanting to do two things at once in the present and not being able to can bring up the feelings of a past very much more important similar experience." Alice just shook her head up and down and looked at me. Alice is in her mid-forties. Later I was walking down the hall to leave saying goodbyes to various people. Alice came out of a side room, put both her hands out to me, and said, "goodbye and thank you." In a previous contact Alice had discussed her suicidal thoughts with me.
3. I verbalized my acceptance of patients' expressions of feelings with explanations of why I experienced these feelings of acceptance when I could do this authentically and appropriately.
Example
I met a new patient at coffee. Later she was the only patient in the dayroom when I went in. She had not spoken at coffee. Now she sat very stiffly in her chair. I sat down next to her and reintroduced myself. She looked scared but told me her name. Her shifting eyes reminded me of a cornered animal. She blurted out, "I don't believe I've met you." It was like she had said, "go away." I smiled at her and said, "We were introduced at coffee, but with so many new people it's hard to remember." Conversation continued to be tense. At one point Marion bolted from her chair toward the door. I thought she was going to leave. I stayed in my chair. She went to the fish bowl in the corner. We continued to talk about the fish. Marion came back and sat down a few seats away from me. I said that I felt I'd been asking her an awful lot of questions but that I was only trying to get to know her. Marion seemed to relax in her chair and gave a great deal of information about herself in a strange stiff sort of way often inserting a word that did not have meaning for me. I encouraged, supported and showed my interest. Finally she said that she {115} had been admitted to McLean in her third year of nurses' training just before her psychiatric experience. She had been in therapy there, one-to-one for a couple of years. I teased her about knowing the ropes, yet giving me a difficult time. This was an attempt to increase her feelings of adequacy by bringing out the similarities of the old situation which she knew and this new situation. For the first time she really grinned at me, almost laughed. Marion is in her early thirties.
4. When verbalizations of acceptance were not appropriate, I acted out this acceptance by my behavior of staying with or doing for when appropriate.
Example
Mary is a middle-aged patient who, on her first days in the unit, was liberally gobbling her food with alertness for only more to be had. Her only rather loud, irrelevant, smiling expression was about her daughter who was a go-go dancer, had three children, and whom she had visited twice by bus in California. This day she approached me and asked if I would file her nails. I said that I would but asked if she knew if there was a file in the unit. Another patient offered his. We sat down and I filed. The patient poured out a life story full of misery. This was a side of this patient that I had not perceived. I listened, nodded, and filed. The story started in the 1930s about her husband and mother-in-law's behavior; their marital separation; his being killed in World War II; their two children; their son, now thirty, was born with cerebral palsy, is blind and mute, and has been institutionalized since eleven months old; their daughter's husband left her with three children after fourteen years of marriage. I silently wondered what old feeling might have been aroused in her by her daughter's marital separation. Her daughter is so busy that she is unable to write regularly. She has told Mary not to worry if she doesn't hear from her. Mary then expressed concern over not receiving her usual letter this week from her mother, whom she visits. Mary had tried to reach her by phone and would again. I inquired if her mother lived alone. Yes, but next to relatives. She then related the drastic physical problems of a relative. I felt the sadness of this woman as she talked and empathized with the tough time she had had.
5. I expressed purposely, to burst asunder negative self concepts, my authentic human tender feelings for patients when appropriate and acceptable.
Example
I was sitting in a rather large group of patients in the dayroom. A casual conversation ensued about Thanksgiving as it had been and Christmas as it might be. There was talk of having been at home and plans for being at home. I supported and encouraged the discussion because of the meaningfulness of holidays, past and present. Snow was initiated as a {116} topic. I said, "It would be nice to have a white Christmas, but not too white." Vincent, a stiff, exact, ritualistic person who avoids stepping in an obvious fashion on thresholds, does little jiggle-like dance steps before sitting down, and again before settling in his chair, suddenly spoke. "Josephine, I beg your pardon, but I must take issue with you." I encouraged his unusual behavioral expression. He went on and on about the importance of a white Christmas. I let my mind flow with his jumbled discourse trying to decipher what he was getting at rather than each specific rapidly mentioned issue. He went from white to black, day to night, goodness to badness, love to hate, this side of the world to the other side of the world (Vietnam). I expressed that he seemed to keep mentioning two sides of things and that for some reason I could not help thinking of boys and girls. I said that he was over on that side of the world (room) and that I was over on this side of the world. I asked why he did not come over to my side, paused a minute, felt this was asking too much of this patient, and said, "Well I'll come over to your side then." When I sat down next to Vincent, he giggled as he does. Arthur, a younger patient, made a critical jealous type comment about Vincent's age (50ish). Arthur has done this before when I give attention to Vincent. Has Arthur a stereotype of father images and perhaps mother images? I said to Vincent "you have beautiful white hair, and big, brown, smiling Italian eyes." Vincent sat back smiling shyly but comfortably and the discussion of the group continued.
6. I supported patients' rights to loving relationships with others: families, other staff, and other patients.
Example
Alice M. said that she was sad to be back at the hospital after her weekend at home. Alice is a quiet, bland, soft-spoken person about fifty. She wears a worried expression even when she smiles and strikes me like she is "turned inside" herself. I encouraged her to talk about her time at home. She told me about how they had painted the living room with what for her was a show of real excitement. I said that her wish to be at home was very understandable. I did this because this patient almost whispers her wish to be at home and, generally, no one responds to it. Alice talked on with encouragement about the single sister whom she visits and the pleasure it gives her to be with this sister.
[I have other examples of this nurse behavior that indicate supporting of relationships between patients and between patients and other personnel.]
7. I showed respect for patients as persons with the rights to make as many choices for themselves as their current capabilities allowed.
Example
Discussion of group at coffee revolved around Carolyn's needing a new pair of shoes. The issues were where these might be gotten (Carolyn has {117} money), what kind she should get, and who and when someone would take her for them. It struck me as if Carolyn might not have been present. I asked Carolyn what kind of shoes she would like. Carolyn responded that she did not know whether she should buy regular shoes, or sneakers, or canvas shoes like Marilyn had gotten. She beamed. Since, she has come up to me several times and discussed the two pairs of different kinds of shoes she bought and why. Carolyn is a sweet, simple, retarded, deaf sixty year old whose behavior resembles an eight year old.
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.
Example
On my arrival after Christmas, Irene expressed anger at me in a laughing way for having been away. Then she moved from a seat in the corner of the room to a chair behind me at the coffee table. I moved to allow her to move up to the table, but she did not. After coffee Irene nonverbally with eyes and body movements told me to follow her. She led me into a small beauty parlor room and we both sat down. She closed her eyes. I said, "You seem to have some feelings about us all having been away." First she blurted, "I missed you," then in a quieter voice denied this, "It wasn't important that you weren't here." I said, "It could be helpful to you to talk about your present missing feelings as you had some very important losses of people when you were younger." Her eyes literally popped open and she again blurted, "You mean my parents?" I said, "Yes and your therapist could help you with this." I then asked if she ever had the opportunity to talk with anyone about such things. She replied, "No, well I had a social worker when I was a little girl." I tried at this point to transfer feelings of the past to the present. "Oh, for how long? What was she like?" "I don't remember," and Irene closed her eyes. In a few minutes Irene requested that I set her hair. She is capable of doing this herself. I set her hair, but discussed the question of what she was really asking for. I believe she was asking for concrete attention to test my ability to care for her. I was trying to say, concretely, by setting her hair, that people could care about her.
9. I encouraged patients' expression to come to understand better their behavioral messages to enable me to respond overtly as appropriately and therapeutically as possible.
Example
The previous time I was at the hospital Alice had not come to the unit. I was told that she felt too depressed to come down. I went to see her. She had looked surprised and impressed by my visit. She talked on at some length about her suicidal thoughts. I supported this on the basis that {118} verbal expression might make active expression unnecessary if she experienced empathy regarding how dreadful she felt. Then with little encouragement she had come down to the unit with me. Today, Alice was always near me, but nonverbal except for concise responses to questions that were offered with effort. I verbalized my reflections on her behavior and said that I was wondering about it. She said, "I like having you around; it takes me away from my thoughts." "How are your thoughts?" "The same, I wonder if I'll ever get better?" "You've gotten better before. I wonder if you're not more concerned about whether you can stay well." Alice, eyes watery, agreed with a nod. Irene, another patient, interrupted, "Don't expect too much from me, I've been here twelve years." I responded to them both, "But, I do expect a lot of you; things don't always have to be the same."
10. I verified my intuitive grasp of how patients were experiencing events by questions and comments, and being alert to their responses.
Example
Vincent's ritualistic behavior is associated in my mind with his exaggerated conscious expression of only the true, the good, and the beautiful. On this occasion we had just had a long talk about his weekend at home, his concerns about his family, and his food likes and dislikes. As we left a room he took his usual long step over the threshold. I noted this aloud and asked him if he knew why he did this. His expression became wide-eyed and smiling which indicates to me he consciously or unconsciously is selecting what he is going to say. We came to the next threshold. He stopped me by touching my arm and said, "Josephine, I almost grabbed you to prevent your bumping into that patient." In relation to my last question I focused on the "grabbed you" and said, "Vincent, to think about grabbing me is a pretty natural thought, and no reason to take a wide step over a threshold." He put his foot very deliberately if rather testily, right in the middle of this threshold. He stopped, looked at me with his hands together and giggled. Then he had to go to the bathroom.
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.
Example
My impression of Arthur, a thirty-two year old, is that he works at responding to me agreeably as he thinks I want him to, he frequently goes out of his way to make cutting comments to me about middle-aged men patients, and he responds with anger or teasing to a female patient his age. Arthur has a mother, father, and two older sisters. He obviously let me win at Ping-pong several times. I discussed this with him and asked if {119} he had ever talked with anyone about his responses to older women, people in general, or if he understood them. He said, "No, I have not been able to exactly figure this out yet." I repeated the talking it over. He said, "I haven't had much chance for that." Then staring at me he asked seriously, "Do you think talking it over would help?" I said, "I think that it would take a great deal of effort on your part, but I believe that it could help."
12. I supported appropriate patient self-images with as many concrete "hard to denies" as possible.
Example
Alice, a middle-aged woman, in the midst of a discussion of the difficulties of living outside the hospital, past relationships with nursing personnel, and her past practical nurse jobs suddenly said, "I worry about being sexually OK." This was kind of blurted out and she observed me closely. I said, "I thought that you had some concerns about this in relation to how you responded to my cutting the hairs on your face. I guess everyone worries at times about their adequacy in this area." She said, "I've never been able to have intercourse; I can just go as far as heavy petting. People say you can get a lot expressed if you have intercourse." I said, "Some people can, but if you have other standards that you've grown up with, (I suspect a rather religious, rigid Jewish background) it might cause difficulties to go against those standards." (Alice first became ill at sixteen, left school, and had some treatment in the community.) "It's pretty responsible not to be willing to bring a fatherless baby into the world, and I'm sure you'd have feelings about how your family might have responded to this sort of thing." Alice nodded and said "It's just that I don't know how womanly I am." I said with gestures and emphatically, "Well, Alice, if you have two things up here and no thing down here, then the fact is that you are a woman." Discussion pursued about her further talking about this topic with her therapist and the value of her working through her feelings in this area. This was a lengthy discussion and the first talking I had experienced Alice doing since her depression. {120} {121}
GLOSSARY
~angular view.~ An individual's unique vision of reality necessarily restricted by the angle of his particular here and now.
~authenticity.~ Genuineness; congruence with the self.
~(the) between.~ The realm of the intersubjective.
~bracket.~ Hold in abeyance.
~community.~ Two or more persons struggling together toward a center.
~existential.~ Of, relating to, or affirming existence; grounded in existence or the experience of living.
~existential dialogue.~ A unique individual person with the wholeness of his being is present, open to, and relates to the other seen in his unique individual wholeness; an exchange in which two persons transcend themselves and participate in the other's being; an interior unification; a mutual common union in being.
~existential experience.~ Contact with reality with the whole of one's being; involves all that a man is as opposed to experiencing through one or several faculties.
~existentialism.~ Philosophy based on phenomenological studies of reality; centers on the analysis of existence particularly of the individual human being, stresses the freedom and responsibility of the individual, regards human existence as not completely describable or understandable in idealistic or scientific terms.
~here and now.~ An individual's unique experience of his present spatial and temporal reality including his past experiences and expectations of the future.
~humanistic nursing.~ A theory and practice that rest on an existential philosophy, value experiencing and the evolving of the "new," and aim at phenomenological description of the art-science of nursing viewed as a lived intersubjective transactional experience; nursing seen within its human context.
~intersubjective.~ Pertaining to two or more human persons and their shared between; a relationship of two or more human beings in which each is the originator of human acts and responses. {122}
~lived dialogue.~ A form of existential intersubjective relating expressed in being with and doing with the other who is regarded as a presence (as opposed to an object); a lived call and response.
~lived world.~ The everyday world as it is experienced in the here and now.
~metanursing.~ A discipline designed to deal critically with nursing, ontological study of nursing; study of the phenomenon of nursing; a critical study of nursing within its human context.
~metatheoretical.~ Transcending theory; ontological inquiry from which theory may be derived.
~nursology.~ Study of the phenomenon of nursing aimed toward the development of nursing theory.
~phenomenology.~ The descriptive study of phenomena.
~phenomenon.~ An observable fact, event, occurrence or circumstance; an appearance or immediate object of awareness in experience. A phenomenon may be objective (that is, external to the person aware of it) or subjective (for example, a thought or feeling).
~prereflective experience.~ Primary awareness or perception of reality not yet thought about; spontaneous experience; immediate experience or perception.
~presence.~ A mode of being available or open in a situation with the wholeness of one's unique individual being; a gift of the self which can only be given freely, invoked, or evoked.
~transactional.~ An aware knowing of one's effect in a situation of which one is a part; an action that goes both ways between persons. {123}
SELECTED BIBLIOGRAPHY
In addition to the extensive discussions that have been generated since the initial publication of Paterson and Zderad's Humanistic Nursing, the work has been formally cited and or discussed in the nursing literature. This selected bibliography was compiled by Helen Streubert, MSN, RN doctoral candidate and research assistant in the Department of Nursing Education, Teachers College/Columbia University, New York.
BOOKS
Chenitz, W. C. (1986). From practice to grounded theory. Menlo Park,
California: Addison-Wesley.
Chinn, P. O., & Jacobs, M. K. (1983). Theory and nursing. St. Louis:
Mosby Company.
Duldt, B. W. (1985). Theoretical perspectives for nursing. Boston:
Little-Brown & Company.
Ellis, R. (1984). Philosophic inquiry. In H. H. Werley & J. J.
Fitzpatrick (Eds.), Annual review of nursing research (pp. 211-228).
New York: Springer Publishing Company.
Fitzpatrick, J., & Whall, A. (1983). Conceptual models of nursing:
Analysis application. Bowie, Maryland: Brady Company.
Kleiman, S. (1986). Humanistic nursing: The phenomenological theory of Paterson and Zderad. In P. Winstead-Fry (Ed.), Case studies in nursing theory (pp. 167-195). New York: National League for Nursing.
Leininger, M. (1985). Ethnography and ethnonursing models and modes of qualitative data analysis. In M. Leininger (Ed.), Qualitative research methods in nursing. Orlando, Florida: Grune & Stratton.
Meleis, A. I. (1985). Theoretical nursing: Development and progress.
Philadelphia: Lippincott. {124}
Moccia, P. (Ed.). (1986). New approaches to theory development. New
York: National League for Nursing.
Munhall, P. L., & Oiler, C. J. (1986), Nursing research: A qualitative perspective. Norwalk, Connecticut: Appleton-Century-Crofts.
Paterson, J. G. (1978). The tortuous way toward nursing theory. In Theory development: What, why, how? (pp. 49-65). New York: National League for Nursing.
Phipps, W. J., Long, B. C., & Woods, N. F. (1987). Medical-surgical nursing: Concepts and clinical practice (3rd ed.). St. Louis: Mosby Company.
Roy, C. (1984). Introduction to nursing: An adaptation model (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall, Inc.
Stevens, B. J. (1984). Nursing theory: Analysis, application, evaluation (2nd ed.). Boston: Little Brown Co.
Suppe, F., & Jacox, A. (1985). Philosophy of science and the development of nursing theory. In H. H. Werley & J. J. Fitzpatrick (Eds.), Annual review of nursing research (pp. 241-267). New York: Springer Publishing Company.
Zderad, L. T. (1978). From here-and-now to theory: Reflections on "how".
In Theory development: What, why, how (pp. 35-48). New York: National
League for Nursing.
ARTICLES
Bael, E. D., & Lowry, B. J. (1987). Patient and situational factors that affect nursing students' like or dislike of caring for patient. Nursing Research, 36 (5), 298-302.
Beckstrand, J. (1980). A critique of several conceptions of practice theory in nursing. Research in Nursing and Health, 3, 69-79.
Bottorff, J. L., & D'cruz, J. V. (1984). Towards inclusive notions of patient and nurse. Journal of Advanced Nursing, 9 (6), 549-553.
Braun J. L., Baines, S. L., Olson, N. G., & Scruby, L. S. (1984). Health Values, 8 (3), 12-15.
Brown, L. (1986). The experience of care: Patient perspectives. Topics in Clinical Nursing, 8 (2), 56-62.
Chenitz, W. C., & Swanson, J. M. (1984). Surfacing nursing process—A method for generating nursing theory from practice. Journal of Advanced Nursing, 9 (2), 205-215.
Drew, N. (1986). Exclusion and confirmation: A phenomenology of patients' experiences with caregivers. Image, 18 (2), 39-43.
Flaskerud, J. H. (1986). On toward a theory of nursing action skills and competency in nurse-patient interaction. Nursing Research, 35 (4), 250-252. {125}
King, E. C. (1984). Humanistic education: Theory and teaching strategies. Nurse Education 8 (4), 39-42.
Nahon, N. E. (1982). The relationship of self-disclosure, interpersonal dependency, and life changes to loneliness in young adults. Nursing Research, 31 (6), 343-347.
Oiler, C. (1982). The phenomenological approach in nursing research. Nursing Research, 31 (3) 178-181.
Rigdon, I. S., Clayton, B. C., & Dimond, M. (1987). Toward a theory of helpfulness for the elderly bereaved: An invitation to a new life. Advances in Nursing Science, 9 (2), 32-43.
Sarter, B. (1987). Evolutionary idealism: A philosophical foundation for holistic nursing theory. Advances in Nursing Science, 9 (2), 1-9.
Taylor, S. G. (1985). Rights and responsibilities: Nurse patient relationships. Image, 17 (1), 9-16. {126} {127}
INDEX
Abdellah, Faye G., 90
Agee, James, 8, 67
All-at-once, 4, 8, 44, 52, 55, 56, 68, 70, 73, 93, 96, 109-111
Analogy, 37, 54, 61, 83
Analysis, 72, 79, 82-84
Angular view, 5, 20, 37-38, 51, 65-67, 71, 74, 80-82, 84, 88, 95-98, 111
Art, 3, 7-8, 14, 17, 58, 60, 85-93, 111
Authenticity, 4-5, 14-15, 55, 56-60, 63, 104, 106, 111
Being and doing, 13-14, 17, 19, 26, 92
Bergson, Henri, 6, 68, 71, 72, 73, 104
Between, (the), 4, 7, 13, 21-22, 31, 44, 67, 82, 108. See also Dialogue; Intersubjective; Presence; and Transaction
Bracket, 38, 62, 80
Buber, Martin, 4, 6, 16, 23, 39, 44, 45, 47, 55, 69, 72, 73, 93, 104, 106, 110
Call and Response, 3, 5, 7, 24, 29-31
Choice, 4-6, 15-17, 20, 24, 37, 57, 69, 72. See also Confidentiality; Responsibility
Christoffers, Carol Ann, 89
Clinical, 65, 67, 92-93, 96, 103-109
Comfort, 65, 96, 98-103, 106, 111-112
Community, 7, 14, 37-48, 63, 84
Complementary synthesis, 3, 8, 36, 68, 73-74, 111.
See also Synthesis
Confidentiality, 53-56.
See also Choice; Responsibility
Cousins, Norman, 39, 47, 104
Cross-clinical, 20
de Chardin, Pierre Teilhard, 6, 39, 41, 104
Desan, Wilfrid, 16, 39, 73, 74, 108
Description, see Phenomenological description
Dewey, John, 72, 104
Dialogue, 21-36, 73, 77, 92-93. See also Between (the); Intersubjective; Presence; and Transaction
Durant, Ariel, 69
Durant, Will, 69
Existential, existentialism, 4-9, 14, 15, 23, 38, 47, 65-66. See also Phenomenology; Philosophy
Fahy, Ellen T., 91
Family, 38-45
Frankl, Viktor E., 6, 102
Garner, Grayce C. Scott, 88, 89
Gilbert, Ruth, 65, 96, 109, 110
Goethe, Johann Wolfgang von, 6, 67, 102 {128}
Heinlein, Robert A., 45
Here and now, 40, 41, 57, 68, 69, 80, 81
Hersey, John, 39, 89
Hesse, Herman, 6, 39, 40, 45, 69
Humanistic nursing, 3, 5, 14-20, 21, 85, 92-93
Humanistic nursing practice theory, 3, 6-7, 8, 17-20, 21, 55, 60, 62, 65, 70, 77-84, 95-112
Human situation, 11, 18-20, 87, 89
Husserl, Edmund, 56, 78, 79
Intersubjective, 13, 15-17, 21-22, 26-27, 31-32, 35-36, 68, 81, 90, 93. See also Between, (the); Dialogue; Presence; and Transaction
Intuition, intuitive, 19, 23, 52, 71-72, 73, 79-82, 96, 109
I-It, 27, 36, 44-45, 73, 106-112
I-Thou, 6, 27, 36, 44-45, 62, 72, 73, 92, 106-112
Jung, Carl G., 6, 58, 68
Kaplan, Abraham, 66
Kiell, Norman, 43
Laing, R. D., 17
Lemkau, Paul V., 54-55
Man, concept of, 5, 15-16, 18-19, 26, 38-45, 51, 52, 54-56, 67-71
Marcel, Gabriel, 6, 16, 23, 41
May, Rollo, 6
Meeting, 18, 24-26
Metanursing, 20
Metaphor, 54, 61, 84
Methodology, 65-75, 77-84, 95-112
Microcosm-macrocosm, 37-38, 40, 48
More-being, moreness, 4-6, 12, 16-17, 19, 29, 32, 36, 44-45, 48, 63, 69, 89, 92
Muller, Theresa G., 39, 65, 96, 109, 110
Nietzsche, Frederick, 6, 39, 40, 41, 46, 47, 54, 71, 102, 104, 105
Nursing, 3, 5, 7, 11-17, 21, 45-48, 57-58, 65, 69, 71, 72, 73, 74, 75,
90-92, 95-112.
See also Humanistic nursing
Nursology, 65, 67, 70, 72, 73, 74
Nurture, 13, 18-19, 25
Objective, see Subjective-objective
Paradox, 4, 39, 70
Phenomenological description, 3, 6-8, 13-14, 54, 60-62, 70, 77-84, 96, 111
Phenomenology, 6, 9, 60-62, 66, 67, 72, 78, 79
Phillips, Gene, 4
Philosophy, 17, 40, 66, 67, 75, 97. See also Existentialism; Phenomenology
Plato, 6, 37, 45, 67, 104
Plutarch, 101
Popper, Karl, 39, 104
Practice, see Humanistic nursing practice theory
Presence, 3, 5, 6, 13, 15, 16, 27-29, 47, 56, 58, 72, 106. See also Between, (the); Dialogue; Intersubjective; and Transaction
Proust, Marcel, 6
Research, 51-63
Responsibility, 3, 6, 16-17, 20, 28, 41, 53-55, 57, 63, 69, 70, 72, 110. See also Choice; Confidentiality
Rousseau, Jean-Jacques, 6
Russell, Bertrand, 70, 104
Science, scientific, 3, 6, 7, 8, 15, 17, 35, 45, 52, 53, 58, 60, 66, 68, 70, 72, 85-87, 88, 90, 93, 111 {129}
Socrates, 38
Space, 18-20, 34-35
Subjective-objective, 27, 35-36, 52, 67, 79, 81, 93
Synthesis, 72-74, 79, 82-84, 93, 95, 102, 103, 108, 111. See also Complementary synthesis
Theory, see Humanistic nursing practice theory
Time, 18-20, 29, 33-34
Transactions, 11, 12-13, 16-20, 21, 35-36. See also Between, (the); Dialogue; Intersubjective; and Presence
Trautman, Mary Jane, 87, 88
Uniqueness, 4, 7, 15, 23, 25, 26, 27, 32, 34, 35-36, 40, 45, 56, 68, 69,
72, 77, 111
Value, 6, 16, 17, 18, 30, 39, 46-48, 54, 56-57, 69, 71, 77, 79, 85, 97,
98, 104, 105
Well-being, 12, 16, 36, 89, 92
Whitehead, Alfred North, 6
Wiesel, Elie, 7, 96
Weymouth, Lilyan, 55
Words, 8, 60-62, 73, 81, 98
Wright, Edward A., 91
[Transcriber's Note: The following corrections have been made in this version.]