Humanistic Nursing by Loretta T. Zderad (good short books TXT) 📕

In reflecting on nursing experiences, it becomes obvious that the call and response in the nursing dialogue goes both ways for nursing is transactional. Both patient and nurse call and respond. The pattern of the dialogue is complex. It continues over time, from moments to years, in an ongoing sequence that either patient or nurse may begin, interrupt, resume, or end. For instance, {30} the patient turns on his call light to ask for something. This is not only a call but also a response to the nurse's previously stated suggestion that he use the signal if he needs her help. Or again, a nurse may stop and talk with a patient during a chance meeting recalling that he previously had expressed feelings of loneliness, boredom, pain, or joy. Also, other persons or events may interrupt or end a nursing dialogue. For instance, the nurse is called away to help in another situation, the patient is discharged on the nurse's day off, the patient expires.

Furthermore, the call and response are not only sequential but also simultaneous. In this live dialogue both patient and nurse are calling and responding all at once. The patient's request, for instance, is a call for help and at the same time a response to the nurse's availability or offer to be of help. From the other side, the way a nurse responds to a patient's call is, itself, a call to him for a particular kind of response, a call for his participation in the dialogue.

Reflect for a moment on your own example. Was your response to the patient influenced by the value you placed on such factors as his independence, motivation, rehabilitation, growth, strengths, pathology; on time, on place; on agency policy? Here again goal-directedness affects nursing dialogue. Our interpretation of the patient's calls as well as our responses are colored by the aim of our practice. Our values are like calls within the calls. Or to state it differently, the values underlying our practice give meaning to the calls.

Viewing dialogical nursing as a particular form of call and response highlights its complexity. It reveals the intricacy not only of its patterns of flow but also of its means of expression. Nursing is a lived call and response reflective of every mode of human communication.

Much has been studied and written about verbal dialogue between patient and nurse. Examining verbal exchanges from the perspective of call and response could uncover even more about this aspect of the nursing dialogue.

It is more difficult to find written descriptions of nonverbal nurse-patient communication, although this aspect is generally recognized to be of equal significance. Here again the call and response framework could be a useful aid. For instance, what does a nurse's mere physical presence mean to a patient either as a call or response? Or from the nurse's standpoint, under what circumstances is a patient's presence experienced as a call and, even more, as a call for a particular nursing response? What prompts us to respond in terms of his posture, his color, his facial expression, his behavior, the appearance of his clothes? Are we almost unconsciously checking some kind of "vital signs" in the inter subjective realm?

Nursing dialogue is characterized by the unique feature of occurring through nursing acts. The dialogue is experienced in what the nurse does with the patient. A call and response of caring is lived through in nurse-patient transactions (nursing care activities) from the simplest, most basic acts of bathing and feeding to the most dramatic resuscitation. {31}

The nursing act itself contains a meaning for each person in the dialogue and the meanings may differ (for example, touching and being touched, feeding and being fed, bathing and being bathed). In addition, as a behavioral expression, the nursing act conveys a message, a reflection of the nurse's state of being (for example, anxious, hurried, troubled, absent, present, fully present). Furthermore, a nursing act may serve as an occasion, or even a catalyst, for opening or moving the dialogue in some direction on a verbal level (for example, bathing a patient may prompt his discussion of his body image or of his fear of disfigurement).

The complexity of possibilities in this unique feature of nursing dialogue (occurring through nursing acts) is staggering, especially so when one considers the additional factors associated with the effects of technological advances in nursing. Think, for instance, of the influence on your nursing dialogue of any technical nursing procedure. What happens between you and the patient when you place a thermometer into his mouth? Take his blood pressure? Give him an injection? Aspirate him? Do any form of monitoring, from the simplest to the most complex? Are the technical procedures and instruments bridges or barriers in the between?

It is necessary now to look again at dialogical nursing in a broader perspective, for by limiting the exploration to the nurse, the patient, and their between, the previous discussion grossly oversimplified the way the dialogue actually evolves in real life. In the above, it was as if nursing were a drama acted out by two characters on a specially designed stage where precisely placed props lay ready to serve the actors and the passage of time is controlled by the chiming of a clock or the dimming of lights. As it is actually lived, the nursing dialogue is subjected to all the chaotic forces of real life. Nursing takes place in a real world of men and things in time and space. In many cases, it is a special world, a health system world, within the everyday world.

Other Human Beings

The dialogue lived between nurse and patient is affected by their numerous other interhuman relationships. For a nurse to be genuinely with a patient involves her coexperiencing his world with him. His family, friends, and significant others are a very real part of this world whether they are physically present or distant. So to be open to the patient is to be open to him as a person necessarily related to other men.

Furthermore, in caring for a patient the nurse relates to him not only as an individual patient but also as one in a group of patients. The group may be physically present (for example, in a ward, in an intensive care unit, in a {32} waiting room, in a dining room, in a therapeutic group) or they may be present in the nurse's mind (for example, while caring for one she may think "I have three more patients to visit," "so and so needs his medication in five minutes," "I promised so and so I'd get back to him," "three other patients are waiting to be fed"). Even when the nurse is responsible for only one patient, she often views him in relation to other patients she has nursed.

The nurse herself also functions within complex networks of interhuman relationships that affect the nursing dialogue. As health care becomes more specialized, more groups of health care workers arise and the various groups become more diversified. So the nurse's intersubjective transactions with her patients occur within an intra- and interdisciplinary milieu of constantly changing personnel, functions, and roles. While her own role is expanding, extending, deepening, broadening, becoming more specialized, she must relate with others undergoing similar change. And here again, as with the patients so with her colleagues, the nurse is constantly faced with the possibility and necessity of relating to others in terms of their functions and as persons.

Finally, it should be recognized that while it is easy and common to think of "the nurse" as synonymous with the function "nursing," in real life the nurse is a human being necessarily related to others. She learns to focus on those present in her here and now work situation. But she too is her history and brings to her work world all that she is and all that she is not including her past experienced and future anticipated interhuman relationships. So each nurse affects her peopled nursing world and is affected by it in her own unique way.

>From the other side, the patient also enters into the nursing dialogue with his various networks of interhuman relationships. How he experiences his relationships with his family and significant others, with the patient groups of which he becomes a part in different degrees, with members of various disciplines and health services groups, with "the" nurse and "his" nurse, all influence the lived nursing dialogue. It is always colored by the patient's current mode of interpersonal relating. Of course, the current mode reflects his past, for example, learned habits of response, and his future, for example, concerns about anticipated changes in interpersonal relationships due to the effects of his illness. In some cases, the intersubjective behavior itself becomes the focus of the nursing dialogue as the area of the patient's greatest needs in attaining well-being and more-being.

Things

The nursing dialogue takes place in a real world of things, ordinary things of everyday living and all forms of health care equipment. Both types of objects affect the nurse-patient transactions and their influence varies for they may be experienced differently by nurse and patient.

Ordinary objects used everyday—eating utensils, clothes, furniture, books, television sets—are so familiar that one usually takes their use for granted. {33} However due to illness a person may be unable to manipulate a knife and fork, for example. They become frustrating objects. His tools are no longer extensions of himself but impediments and barriers. He feels handicapped. His world of things changes.

On entering a health care facility, the patient finds himself in a foreign world of strange objects. In place of his familiar possessions he is surrounded by equipment, machines, instruments, solutions, and so forth. He may experience these as bewildering, frightening, painful, supportive, soothing, life-sustaining. The nurse, on the other hand, may experience these same objects quite differently. To her they may be familiar tools, useful aids, complex machines, annoyingly defective equipment. Even in a situation that does not have special equipment, for instance in a home, the patient's world of things changes as the nurse converts ordinary objects into tools. Thus, while nurse and patient share a situation, the things in their shared world have different meanings for each. The things themselves as well as the persons' relations to them can serve to enhance or inhibit the intersubjective transaction of nursing.

Time

To view dialogical nursing as it is actually experienced in the real world, one must conceive of it as occurring in time, not simply measured time but also time as lived by patient and nurse. Certainly both participants are caught up in measured time and this influences their shared world, for example, eight-hour tours of duty, a day off, surgery scheduled at 8:00 a.m., discharge in two days, visit three times a week, clinic appointment in 30 days. Thus, to an extent, both patient and nurse must live by the clock and calendar.

However, equally important, or perhaps even more important, in the lived dialogue of nursing is the participants' experience of time. Some references were made to lived time in the section on call and response where it was noted how the nursing dialogue unfolds over time from moments to years. How the involved persons experience this continuity is an individual matter.

The nurse may conceive of herself as one of many persons contributing to a continuous stream of caring for the patient. So she will give and hear and write and read reports, note observations, keep records. She will carry an image of the patient in her mind continually adding to it or changing it with each interaction or report. Sometimes, after not seeing the patient for a time, on meeting him again she will "pick up where she left off," treating him as if he were the same person, as if days, months, years of living had not intervened. "Oh, it's him again." Or she may be startled by the visible changes and resume the dialogue from that point. Or even if change is not visible, she may be aware that it may have occurred and try to fill in the gap.

These possibilities may be mirrored from the patient's standpoint, for he likewise experiences continuity or lack of it in his care. And yet, the experience must be different for him. For instance, nurses may think of continuity of care in terms of "coverage" for a planned program of care. So it has often been {34} claimed that "the nurse is with the patient 24 hours a day." From the patient's point of view this