HUMAN CONDITION OF BEING: NURSE RESEARCHER
Initiation of a Nurse Researcher
The nurse student, recently arrived in her experiential world, is awed with the need to be cognizant of multitudinous factors. At this initial introductory phase one could say her "being" as a nurse is programmed or imprinted with: It is your responsibility to report and attend all the things that influence the response and comfort of those for whom you care. This programming supports and is supported by any already existing tendencies within the nurse student toward unrealistic, perfectionistic expectations of self.
Then in research courses, usually positivistically geared, her programming jams. Her system is fed: Select out, isolate, focus down on a single question, limit your variables, establish a protocol of operation, control for reliability and validity, tunnel your vision, and safeguard objectivity. The jamming is the result of the human nurse's capacity to see relationships between the part and the whole. Human intelligence, as a condition of humanness, demands this relating of one thing to another. Often such relating is intuitive, human, based on much thinking for purposes of understanding and solution. Yet, often it cannot be substantiated fully and conceptualized logically at specific times, therefore it is subjective.
To highlight the obvious in the above I attempted facetiousness. Many nurses acutely aware of the complexities, contradictions, and inconsistencies of their nursing worlds have struggled and used the positivistic method in research studies. Hence, they have isolated a researchable question, stated their basic assumptions, hypothesized outcomes, selected samples, established experimental and control groups, formulated methodologies, searched out and utilized appropriate findings, and have made recommendations. Usually these research efforts have advanced scientific knowing and knowledge of existents within the health-nursing situation. And yet, often these efforts have discouraged the research wonderment of the nurse interested in the nature and meaning of the nursing act and how the event of nursing is lived, experienced, and responded to by the participants. These positivistic research methods have made available answers. Still, they have not answered the questions most relevant to nursing practice and to nurses.
These nurses were certain that man generally could not be prescribed for interpersonally; he was not predictable, not yet an automaton. Faced with alternatives men often surprised. Consequently these positivistic approaches to studying human events, unless one forced one's data crowbar style, always terminated with a kind of miscellaneous category. Man's undeterminedness makes him all-at-once frustrating to study, impossible to distinctly categorize, and excitingly mysterious and the most worthy focus of nursing research. {53}
A Nurse Researcher's Presence in the Nursing-Health Setting
The existent, a nurse labeled researcher, in the health world brings a disquiet that has to be understood and endured. Necessities for scientific study in the nurse's world of the nursing event or situation are wonderment, concern, and responsibility. Open adherence to such qualities frequently startles others into speculating about the researcher. She, herself, becomes an oddity. Persons ponder the possibility of her study's having a hidden agenda that involves them. Over time these persons generally accept or reject the searcher's efforts. If rejected the searcher is often labeled a worthless nosey troublemaker. Subtly it is conveyed among those involved that she is to be interfered with often by mechanisms of ignoring or forgetting or righteously setting "patient's needs" above conforming to the study plan. For instance, how often have research nurses met with responses from staff at the time of their planned arrival on a unit to work with a patient, "Oh, he seemed to need activity, he was restless, I forgot you were coming, I sent him to the gym," or "Oh, (surprise) did you want to give the patient his morning care? That was done a while ago; we give care early." If accepted the searcher is often labeled an interested, interesting person whose efforts are to be fostered because her findings will enhance situation nursing. The distinction frequently is based in staffs' responses to the searcher's personality more than in the value of the issues of the investigation.
Significant to negative staff responses toward a nurse searcher is the necessity for her to withhold information. This withholding may be necessary to protect the study results. For example, it is necessary when a special type of patient care is being tested against usual patient care or when confidentiality is an issue. Confidentiality requires a nurse, searcher or not, to censor communications when personal knowledge of individuals make them identifiable. The need for confidentiality can be determined by the nurse's considering the knowledge gained in view of whether it will or will not influence the over-all treatment plan. If it will affect the plan, there is reason to reveal it; then it must be related in a manner that insures the patient's continued protection and, if possible, with his permission. If over-all treatment is not influenced, one must censor the knowledge gained to check one's own free communications. Would the patient want it revealed; is it knowledge of a quality that brings ridicule, is looked at negatively or nonacceptably in our particular culture generally? Is it of a sensitive nature and therefore knowledge we do not just reveal to anyone?
Other patient care givers may sense this withholding by the nurse searcher. They may reasonably accept it or unreasonably not accept it. The researcher may or may not be aware of or concern herself with her colleagues' sensitivity. This would depend on the searcher's usual modus operandi and on the importance she associates with her colleagues' sway in her investigation. The latter can be much greater than is obvious. {54}
Confidentiality—Description: Humanistic Nursing
Humanistic nursing practice theory proposes phenomenology, a descriptive approach to participants in the nursing situation as a method for studying, interpreting, and attesting the nature and meaning of the lived events. Humane nursing is not humanistic nursing within this theory unless that which becomes visible to the nurse in the nursing situation is shared in a durable form with colleagues.
Confidentiality, then, becomes an important issue in humanistic nursing. No scientific methodology of research is affixed with "ought" or "should" virtues regarding knowledge gained. In nursing, a professional helping realm, a practitioner or researcher is wed to "ought" and "should" virtues. The knowledge gained "ought" to be dispersed to colleagues for their increased understanding. It "should" enhance the constructive force of the profession. To so enhance it "must" be communicated in a manner that allows understanding while protecting distinct individuals and groups. Words and conceptualized ideas are the tools of phenomenology. Protection of distinct persons and meaningful communication can be augmented through the utilization of abstractions, metaphors, analogies, and parables. So humanistic nurses, as practitioners and researchers, are inherently responsible for their manner of being, responding, and consciously sculpturing knowledge into words.
Responsibility When Sharing: Understanding of Man
How does a nurse searcher, who wonders, notices, relates, and comes to know, become humanly responsible? Nietzsche's philosophical works would direct a nurse searcher to look at her values. The values known through looking at what determines her actual behavior considering how these values correlate with her privilege of calling herself, nurse. Empathy, knowing how another experiences, when coupled with the title, nurse, dictates a performance that encompasses no harm to others and hopefully benefits them. Despite the human excitement of discovery, disciplined effort and rigorous evaluation enter into preparing knowledge of man for dispersal. Revelation should not merely shock; rather, professionally we use shock to awaken surprise, a fundamental, for human constructive movement toward moreness. The former, mere shock, needs to be guarded against. The latter, shock to awaken surprise needs to be exactingly, uncompromisingly attended for the communicability of knowledge and the actualization of the phenomenon, nursing.
In considering confidentiality and the quality of knowledge of man available to me, as nurse, my consciousness is confronted with my former mentor, and internalized "Thou," Paul V. Lemkau, M.D., psychiatrist. He {55} emphasized repeatedly that the professional person, as he increasingly understands man, should take on increasing responsibility to man, one's self and one's others. Buber says, "As we become free … our responsibility must become personal and solitary."[1] One can extend this and say that to help others struggle for freedom one must realize that others must responsibly decide and that although they do this through and in the authentic presence of a nurse, these others are alone in deciding. And nurses in deciding what and how to convey of their knowing must decide freely, responsibly, personally, and alone.
The nurse in deciding what and how to convey, considering the professional necessities of both confidentiality and dispersion of knowledge, can be guided by a conception of the nature of man-in-his-world. Man in humanistic nursing practice theory is viewed as a conflictual, contradictory, inconsistent dilemma. One horn of the dilemma is ideal spirituality that wrestles against the other horn, protective materialistic animalism. This "all-at-once" struggling, stretched, mixed nature of man needs recognition. Recognition of man's nature, as such, supports greater self-acceptance. Self-acceptance and this view of man-in-his-world, like a magnifying glass, unmasks for a nurse her possible responses, motivations, and alternatives. Cognizant of these, she can responsibly select what knowledge to disperse to protect individuals and to continually shape and conceptually actualize the nursing profession. Utilizing this magnifying glass on self in humanistic nursing practice theory to let one's existing mixed, varied, struggling responses, motives, and alternatives into self-awareness is an axiom referred to as authenticity with self.
Acceptance of the others' human nature or human condition of being is usually easier than acceptance of our own. Usually each man is his own severest judge. Lilyan Weymouth, R.N., clinical specialist, my past teacher and present friend, in sympathetic moments, speaking of suffering others, often says, "the poor devils." Once, feeling anxious and annoyed, I responded, "we are all poor devils." She retorted, "I am glad you recognize that." Stopped short, I found myself continuing to ponder the phrase, "poor devils." Man's dilemma is that he is neither saint nor devil. He is a "poor saint" and a "poor devil," and by his nature he is pushed and pulled in both directions, "all-at-once." Our human existence in the world calls for an enduring with our virtues and vices, our energy and our laziness, our altruism and our selfishness, in a word with our humanness.
What meaning does this conception of man have for humanistic nursing practice theory? This theory necessitates a nurse who accepts and believes in the chaos of existence as lived and experienced by each man despite the shadows he casts interpreted as poise, control, order, and joy.
Labeled mental patients in therapeutic situation, in the sun beyond the shadows, express how they set themselves apart from the rest of the community {56} of man. They express how they experience themselves. They view themselves as the worst, the noblest, the unhappiest, the most maligned, and the most afraid. It comes out as if these superlative distinctions are their only claims to fame. In my humanness I appreciate the awesome dreads they live. They need to know that they exist in their unique distinctness. And yet, the separation and loneliness with which they adorn themselves and which professionally we have fostered with fear engendering diagnostic labels seem a heavier than necessary burden. In the light of existential loneliness, a part of each human existence, often I invite them to see themselves as not so unlike other men and as suffering the turmoil of existence as part of the human community, such as it is. One usually can note their surprise and disbelief of my view. Then, momentarily at least, tension seems to visibly fall from their faces and forms. When this idea of them is heard by them, its effect corresponds to how I experienced the technique in sensitivity group of literally being allowed to dance into what felt like the circle of man, our group.
To hear opportunities for humanistic nursing acceptance and support nurses, too, need to question their self-nurse-image within the nursing and health community. Do they know that they make and have real potential for making a difference, an important difference? Do they accept themselves as nurse? To me, a nurse is a being, becoming through intersubjectively calling and responding in her suffering, joyous, struggling, chaotic humanness, always trying beyond the possible while never completely free from ignoble personal human wants. And, through her presence it is possible for other persons to be all they can be in crisis situations of their worlds. For the nurse to be humanistic it is necessary for her to live her human condition-in-her-nursing-world proudly with all its vulnerability and all its wonders. As man, the nurse can recall and reflect on her "I," on her past "I-Other" experiences, and she can come to know and accept more and more of herself, as she becomes more. In humanistically recalling and reflecting a nurse will understand and respond empathetically and sympathetically to both her own humanness and the other's. She will recognize both self and other as "poor devil" and "poor saint," all-at-once.
On the other hand, if a nurse denies her own struggling humanness, she self-righteously will be apt to accuse either self or her other. This way of being denies, suppresses, and represses one's own and the other's ability to be, to be as much as potentially possible. Understanding man through this conception of him is important to the possibility of augmenting the implementation of humanistic nursing practice theory.
Authenticity With The Self: For Actualization of Nursing's Potential
Husserl, the father of phenomenology, suggested the study of our lived worlds, our experience, a return to the study of "the thing itself." Looking at the lived worlds of nurses one is confronted with conflicts and multiple {57} values. In their nursing worlds nurses often risk themselves in their commitment to good for their patients. They come to know aspects of their own and others' unique natures. These are often different from and frequently in conflict with generally accepted cultural values and/or institutional policies and rules. If confidentiality is an issue, does this dictate a suppression of nurses' complete knowing? Or does this call for a recognition of as complete a knowing as possible followed by responsible selection and revelation of that knowing which will advance knowledge and understanding of man? Understanding of man can change a person's way of being with other man and his way of existing in and responding to his world. I suggest the latter, as complete knowing as possible followed by responsible selection and revelation, with occasional risk taking to deepen the level of accepted cultural knowledge of man. Always, the nurse would protect an individual other man. This dispersion of knowledge, then, requires not only responsible being in the nursing situation but also mulling, pondering, assessing, and judging prior to disclosure.
As complete a knowing as possible, in humanistic nursing refers to its axiom, authenticity with the self. When I, nurse, respond in the arena of my lived nursing world, I respond to a particular person in this "here and now" with all my background and all my anticipation of the future. By respond, I do not mean to indicate that I overtly deliberately communicate or verbalize my total response. Rather I mean that I strive for awareness of my total response within myself to a particular person in a particular "here and now" viewed through my particular past and anticipated future. It is a struggle to grasp how I perceive and respond within all my capacity of human beingness. To attain the highest possible level of authenticity with the self requires later recollection of ongoing perceptions of the other and reciprocal responses, selected communications, and actions by the self. These recollections now become raw data available for analyzing, questioning, relating, synthesizing, hypothetically considering, and ongoing correcting. Sometimes sharing such recollections with a trustworthy confidant (clinical specialist, consultant) for purposes of reality testing is helpful. Often this can broaden the professional meaning base I attribute to both my perceptions and my responses. On return to the arena of my nursing world I then verify my perceptions. I can let the other know how I perceived his actions and be open to his further expression of how this world is for him. In professional nursing this kind of experiencing, searching, validating, utilizing of one's human potential capacity must be based in the ideals on which nursing rests. Primarily for me, I see myself, nurse, as comforter or being nurse in such a way that my other is helped to be all that he can humanly be in this particular "here and now" considering his unique potential.
So, being authentic with the self, is not an acting out of a nonthought through response or merely a doing of what one feels like doing. Rather it is the very opposite of this. It is a thought through responsible choosing of overt response based in knowledge and on nursing values. It must correspond positively with one's belief that searching and sharing in one's nursing world will promote both the nursed and the nurse to be more. If it is merely a {58} peeking in on, an exploitation of the other, for selfish learning purposes, it desecrates the very concept of nursing. One has the broad human potential of feeling like doing many things, all-at-once, that extend into all kinds of living. And this is true in, as well as outside, a nurse world. In recollecting and reflecting on perceptions and responses in all these extremes one becomes freer to select from within one's self the values to be chosen, actualized, and potentiated in one's nursing practice. Authenticity with the self calls forth confrontation of the self with one's motivations and alternatives. This permits a purposeful selection and an aware actualized overt response based on one's nursing value criteria artfully tailored to a particular situation.
I consider each nurse a scientific-artist: classical, modern, primitive, cubic, or interpretive. My inference here is that we express artfully in accordance with our uniqueness. Many nurses given the same data would accomplish with the same or a similar degree of adequacy through use of their particular distinct selves. Therefore, though the function called for might be the same, each nurse would approach the function and the patient differently. How one actualizes the result of thinking, and being authentic with one's self recalls what Jung said about art.
"Art is a kind of innate drive that seizes a human being and makes him its instrument. The artist is not a person endowed with free will that seeks his own ends, but one who allows art to realize its purpose through him. As a human being he may have moods and a will and personal aims, but as an artist he is "man" in a higher sense—he is "collective man"—one who carries and shapes the unconscious, psychic life of mankind."[2]
Through the years, over and over, I have met nurses so driven, motivated, and expressive in their nursing worlds.
I called this section "authenticity with the self: for actualization of nursing's potential." In it I have been trying to say, the more of ourselves we are able to awarely include, the more of the other we can be open to and with. A capacity for presence with others allows us to share ourselves. Through this sharing others become more. They are able to internalize us as "Thou." This happening occurs in the reverse, too, and we become more.
In a nursing situation the quality of being authentic with the self is to be striven for. It is a taking advantage of and appreciating of our human ability and spirit. It fosters our pursuit of inquiry, improves our caring for others, the contributing of our unique knowing, and it allows us to shape ever further a scientific-artistic profession of nursing.
Authenticity With the Self: Potentiated in Lived Experience
This example is offered to support the claims for authenticity with the self made in the last paragraph of the prior section.
{59}
As clinical supervisor and thesis advisor to a young graduate nursing student in her twenties the benefits of authenticity with the self were again brought home to me. She was taping her therapy sessions with two patients. These taped materials were to become her thesis data.
One of her patients was not much younger than herself. The other was a divorced woman in her forties, around my age. This young graduate nursing student was receiving clinical nursing supervision as a necessity in her particular situation not by personal choice or awareness of need.
>From the onset of her clinical supervision with me I was aware that it aroused her feelings about dependence. At her age this had meaning since she was still struggling for independence and interdependence. This is a difficult time. Her response to me was "respectful," sweetly and unawarely hostile, and she made it apparent that I was another nurse authority to be appeased, manipulated, and outsmarted. This behavior had been successful for her with past authorities. She was bright and had been able to complete intellectual requests and assignments at the last minute with little effort. During the initial phase of our relationship awareness of her struggle, her difficulties and her assets, allowed me to maintain a supportive kind of being with her.
In listening to her therapy tapes I realized that another clinical supervisory approach was called for. She was defending against relating to her older patient by behaving toward her as she probably felt toward her own mother, and often toward me. Also, she was defeating her therapeutic purpose with her younger patient by viewing her as if the patient were herself. The older suicidal, depressed patient was begging her for an understanding therapeutic relationship. She needed terribly to share her suffering. This woman did not need a "rejecting daughter" working hard to outwit her. The younger patient needed to share her angry feelings and sense of worthlessness.
Through the tapes and through weekly sessions with the graduate student, I came to know and understand her existing nursing situations. At this time neither the student's need to understand nor the patients' therapeutic needs were being met. The student, too, was aware of this in a sort of suppressed way. Indirectly, in responding to her patients, knowing I would be listening to the tape she would take a "sweet swipe" at me which placed the responsibility of all our efforts on my shoulders. So if there were no beneficial outcomes, obviously the blame could be placed.
During the initial phase of my relationship with the graduate student and during the initial phases of her relationship with her patients I came to understand. I listened, got into the rhythm of these other spirits, reflected on what I had come to know, and out of this experience assessed and planned.
Later, taking what I had come to know, as just how it was for all of us, I shared my knowing with the graduate student and budding first-rate therapist. Together we explored the implications of the above. She became invested, involved, and excited about herself becoming more. We, myself and each of her patients, become for her more whom we essentially were. Most important to her and to me, this graduate student grew in her recognition and acceptance {60} of herself and her ability as an adult nurse therapist. The thanks and meaningful praise she received from both her patients on termination of therapy made this apparent. It brought tears to both her eyes and mine. I felt joy in being with a now-respected colleague, as opposed to the earlier being with a person who felt like an unasked for "awe struck defensive daughter."
Authenticity with myself, and this graduate student's ability for authenticity with herself allowed these patients' progress to occur. It allowed a realistic articulation in this student's phenomenological master's thesis of her lived nurse experience. From such articulation will a theory and scientific-artistic profession of nursing ever mold, flow, and form.