Humanistic Nursing Part 15

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 cla.s.s a.s.signments 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 fas.h.i.+oned 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 a.s.signment 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 relations.h.i.+ps 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 a.s.sociated 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 relations.h.i.+ps 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.

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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 a.s.sumptions about psychiatric nursing that I had written for the theory course in one of the first cla.s.s sessions. Although these a.s.sumptions 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. Relations.h.i.+ps 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 repet.i.tively 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 pa.s.sivity, 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 a.s.sured 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 a.n.a.logy 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 repet.i.tively 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.

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 relations.h.i.+ps 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 cla.s.sifications 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 relations.h.i.+p 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 relations.h.i.+p 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.