CONNECTEDNESS
I was with J. tonight, and for the first time I enjoyed "authentic presence" with her. I am not so sure it was because I was less fatigued and more receptive to "what is" in her home, but because J. was clearly "different" tonight. She greeted me with her usual rush of activity and then startled me by asking me to "be with me, please," when she gave her son an injection and changed the injection site on his central venous catheter line. I had met her son before, but had never been invited to his room or the upstairs quarters. We spent a long time in A's room with J. and A. talking, sharing thoughts and feelings about (sister) K., frustrations of J. trying to do it all and still find a little peaceful time for herself, angry outbursts and feelings of shame and sadness, and J's desire to go to Mass on Sunday without feelings of extreme anger and despair because K. cries when J. leaves the house, and ending with J's stated determination to do the impossible task of being all things to all people at all times. The dialogue was really between mother and son, with questions directed toward me but immediately answered by J. and A. The conversation was sparkling with humor and piercing with honesty, and created in mind's eye a rich, colorful mosaic of years of love, beauty, and truth. Tonight I wish I were an artist so I could capture this vision on canvas.
1. asked me to stay with A. while she did a small chore in the kitchen, and I settled in a side chair for whatever might present itself. The I.V. pole in the corner of the room caught my attention and A. offered the name of the drug and its purpose. I honestly did not know that particular drug, and had nothing to offer, so I just nodded my head. A. looked at me, cleared his throat, and proceeded to tell me about a problem he is encountering. I interrupted him and told him that I know nothing about him other than his name and he is J's son, and that J. has not shared anything about him privately with me. He smiled, and then with his head bowed and eyes peering at me, told me that he has AIDS, worries about the stigma, and dreads the stance most health professionals assume when he encounters them as they interpret the name of his disease process. I sat very still and nodded my head. I wanted to acknowledge his pain and show acceptance of him and what appeared to be his need to connect with me. Together we reflected on the wonderfulness of the human spirit, the concept of personhood, and holistic beings with thoughts, feelings, wants, and needs. When A. was ready we ventured down the stairs and found J. sitting quietly in a rocking chair. It seemed she had finished her "task," and I wondered how long she had been sitting alone. I sensed that she had invited me into her private pain, and courageously shared another part of her life with me. I also knew intuitively that she did not want to talk about it.
J. had prepared the piano, and all of them asked me to play for them and expressed disappointment that I did not play the piano during my visit last week. So I played gentle, reflective songs interspersed with light melodic phrases. Requests were offered by each member of the family, and within minutes J. was sitting next to me on the piano bench, singing loudly and punctuating words with feelings and strength and lending incredible meaning to lyrics. "Old Man River," deep, low, rumbling of the piano and purposefully driving tempo was responded to in kind with J. stamping her food with each beat and pounding her knee with each word as she emphatically sang "He just keeps rolling along, he keeps on rolling along." It seemed to be cathartic for her as expressions seemed to come from the center of her being. We applauded ourselves when we finished and J. let me hug her. A. caught my eye and mouthed "thank you for helping my mother to smile." J. was quiet then, and I felt her exhaustion. We agreed that it was time to close the piano for another week, and I left. J. followed me to my car, and left me with "God bless you."
This was an exhausting visit to J's home, yet it was even more energizing because of the multiple caring moments I experienced with J. and her family. I have come to believe that caring moments are unique to each nursing situation and evolve naturally from the mutuality of authentic presence as the fullness of the nurse's personhood blends with the fullness of the other's personhood. Together they transcend the moment. The caring moment is connectedness between nurse and other and both experience moments of joy. (Kronk, 1992)
To characterize this nursing situation with a nursing diagnosis and to portray it as a linear process driven by the diagnosis or problem to be addressed with a pre-envisioned outcome would be to rob the situation of all the beauty of nursing. Because a story of a nursing situation is narrative, there is a temporal structure. However, this structure supports rather than destroys the "lived experience" character of the situation. The story of the nursing situation conveys the "all-at-once" as well as the unfolding. This approach permits us to conceptualize as well as contextualize the knowledge of nursing the story tells. Through story, the meaning for this nurse of knowing herself as caring person, as entering into the world of other(s) with authentic presence, is understood. The nurse knows other as caring person, and in that knowing attends to specific calls for caring with unique expressions of caring responses created in the moment.
The Nursing as Caring theory, grounded in the assumption that all persons are caring, has as its focus a general call to nurture persons as they live caring uniquely and grow as caring persons. The challenge then for nursing is not to discover what is missing, weakened, or needed in another, but to come to know the other as caring person and to nurture that person in situation-specific, creative ways. We no longer understand nursing as a "process," in the sense of a complex sequence of predictable acts resulting in some predetermined desirable end product. Nursing is, we believe, processual, in the sense that it is always unfolding and that it is guided by intention.
Nursing is a professional service offered in social contexts, most often in bureaucratically organized health services. Discussions of health services, overheard in boardrooms and legislative chambers, are languaged in impersonal, aggregate, disembodying, and perhaps more importantly, economic terms. In contrast to the accepted ritualization of such language, nursing has a very important role to play—to bring the human, the personal dimension to health policy planning, and health care delivery systems. Clearly, it is nursing knowledge itself, of human person, of person as caring, that has been missing. While other groups rightly bring in knowledge of efficient operation and financing, nursing's contribution to the dialogue on effective care has the potential to remind all players of the real bottom line, the person being cared for. We must remember that in most industrialized countries health service is viewed as a commodity delivery system, an economic exchange of goods and services. While this is not the only context for nursing, it is the most prevalent context. If nurses choose to participate in existing delivery systems, and most do, then ways must be created that preserve the service of nursing while responding to the appropriate requirements of the system. Ultimately, this would require of nurses that they become skilled in articulating their service as nursing, and connecting that service to the recording and billing systems in use. Although this same goal animated the nursing diagnosis movement of the 1970s, within the terms of that movement, the result was less than fortunate: nursing's effort to emulate the fee-for-service billing practices of medicine failed, and nursing contributions were neither communicated nor reimbursed.
When nurses tell the stories of their nursing situations, however, the service of nursing becomes recognizable. The unique contribution that nurses make, expressed in the focus of nursing, emerges across settings. The difference between a nursing story and a typical nursing case report is striking; the first conveys the nursing care given, the second reports the medical-assisting activities performed by the nurse. We have discovered in our work with nurses that while nursing care is usually given, it is frequently neither acknowledged nor communicated.
The nurse practicing within the caring context described here will most often be interfacing with the health care system in two ways: first, to communicate nursing in ways that can be understood; and second, to articulate nursing service as a unique contribution within the system in such a way that the system itself grows to support nursing.
The concept of profession is involved in the practice of nursing as caring. With the advent of the information and action technologies of the twenty-first century, the present concept of professions as repositories of esoteric knowledge employed by social elites is rapidly becoming outdated. As many nurses will attest, the patient often teaches the nurse about new medical technologies and about the management of them. In this regard, what will it mean, in the next century, to profess nursing? A renewed commitment to professional caring means that nurses would seek connectedness in all collegial relationships as nurses are open to discovering the unfolding meaning of human caring, with persons valued as important in themselves. Therefore, nurses forfeit assuming authoritative stances toward each other, the persons nursed, and other participants in the health care enterprise. More than ever, it will mean that nurses will, in relation with others, live out the value of caring in everyday life. Thus, the organized nursing profession would assume responsibility for developing and sharing knowledge of nurturing persons living caring and growing in caring.
The following story of a nursing situation, told in the form of a poem, exemplifies the reconceptualization called for in the practice of Nursing as Caring. In this situation, the nurse carried out a medically prescribed treatment, not as a form of medicine but as a form of nursing. The nurse communicates a knowing of the other as caring person, living courage and hope in the face of pain and fear. This example illustrates the meaning of knowing as a caring ingredient (Mayeroff, 1971), in the connectedness of the nurse with the patient.
The nurse's knowing both forms the intention to nurse and is formed by the intention to know other as caring person and nurture caring. A more typical recounting of this situation would focus on the specific procedure of the treatment being applied, in terms of the condition of the wound. In this poem, the nurse renders the meaning of nursing.
Heating—HIV +
Your wounds weeped
Purulent with the discharge of our
Pain and fear.
They tried to hide, only to reappear.
The treatment gentle, slow
A warm, loving balm to your soul.
Your stomach was fed the comfort
Food of your youth
And your lips drank in deeply all
You knew and understood.
The memories sweetened each moment
You stood, face to face with terror of
What might be mistook.
All inside shifted as slowly it came,
A gradual awakening; embracing of pain
As you conquered your demons
A lightness appeared
To stay forever and
Abolish all fears. (Wheeler, 1990)