Humanistic Nursing

by Josephine G. Paterson; Loretta T. Zderad

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}