In the nursing world, as in the world at large, human encounters may range from the trivial to the extremely significant. Within a day's work, the nurse may experience many levels of intersubjectivity from the lowest level of being called on as a function or being used as an object, to the other end of the scale of being recognized as a presence or a thou in genuine dialogue.
Nursing activities bring a nurse and patient into close physical proximity, but this in itself does not guarantee genuine intersubjectivity in which a man relates to another person as a "presence" rather than an object. A presence cannot be grasped or seized like an object. It cannot be demanded or {28} commanded; it only can be welcomed or rejected. In a sense, it lies beyond comprehension and can only be invoked or evoked.
There is a quality of unpredictableness or spontaneity about genuine dialogue. A nurse may be going through her daily activities, functioning effectively, relating humanely, when suddenly she is stopped by something in the patient, perhaps a look of fear, a tug at her sleeve, a moan, a reaching for her hand, a question, emptiness. In a suspenseful pause two persons hover between their private worlds and the realm of intersubjectivity. Two humans stand on the brink of the between for a precious moment filled with promise and fear. With my hand on the doorknob to open myself from within, I hesitate—should I, will I let me out, let him in? Time is suspended, then moves again as I move with resolve to recognize, to give testimony to the other presence.
Thus, for genuine dialogue to occur there must be a certain openness, a receptivity, readiness, or availability. The open or available person reveals himself as "present." This is not the same as being attentive; a listener may be attentive and still refuse to give himself. Visible actions do not necessarily signify presence so it cannot be proven. But it can be revealed directly and unmistakably in a glance, a touch, a tone of voice. (I can only ask you to substantiate this statement with your own experience.) Availability implies, therefore, not only being at the other's disposal but also being with him with the whole of oneself. Furthermore, it involves a reciprocity. The other is also seen as a presence, as a person rather than an object, such as a function or a case.
As was discussed earlier, the nursing dialogue occurs within the domain of health and illness and has a purpose in the minds of the participants. Nursing is a lived dialogue (a being with and doing with) aimed at nurturing well-being and more-being. This fact of goal-directedness modifies or characterizes dialogical presence. As a nurse I try to be open to the other as a person, a presence, and to be available to the other. Yet, when I reflect upon my presence, I realize that my openness is an openness to a "person-with-needs" and my availability is an "availability-in-a-helping-way." By comparison, my experiences of openness and availability in social, family, or friend relationships and in nurse-patient relationships differ. In the later, I find myself responding with a kind of "professional reserve." While it is true that what I conceive of as "professional" and the degree of "reserve" has varied over the years and from patient to patient, nevertheless, it is always a factor influencing the tone of my lived dialogue of nursing.
It is the qualitative differences in the various experiences of presence that deserve, yet almost defy, description. For instance, the presence seems to have a different quality of intimacy. It is not experienced as less intense or less deep in the nurse-patient relationship, but as somehow colored by a sense of responsibility or regard for what is seen as the patient's vulnerability. At times I am aware of a shadow of "holding back" in terms of what I consider "nurturing" {29} or "therapeutically appropriate" at a given moment. As a nurse, I find my presence flows through a filter of therapeutic tact.
Or again, the mutuality of presence may be experienced in the nurse-patient situation. At times I become consciously and acutely aware of the reciprocal flow of openness in the dialogue. It is as strong, definite, immediate, and total as in other dialogical relationships and yet it is somehow different. It is felt as a flow between two persons with different modes of being in the shared situation. My reason for being there, to nurture, and his, to be nurtured, bob into my consciousness like buoys marking the channel of openness.
Often in nursing it is necessary to focus my attention on some aspect of the patient's body or behavior. The patient may or may not have the same focus of attention. At least momentarily then, or even for a prolonged period, I place some aspect of the patient before or opposite myself (that is, objectify it). And to the extent that this detail absorbs my attention, I lose my sight of and my relatedness to the whole person who happens to be the patient. While I know this focusing on details to be a necessary step in the nursing process, sometimes I find myself abruptly refocusing my attention on the whole person with almost a twinge of guilt for having abandoned him. (Patients have described this uncomfortable intersubjective experience as feeling "looked at" or "watched" by staff.) At other times, on reflection, I find my attention was oscillating between the detail and the person, or focusing on both relating one to the other. From these experiences it is evident that dialogical presence is complicated in the nursing situation. It is inhibited when the focus of attention (of one or both participants) is on the patient's body itself or on his behavior. Yet the body is an integral part of the person and his behavior is an expression of his mode of existence or his way of being in the world. Man is an embodied being, and the nurse, in nurturing the patient's well-being and more-being, must relate to him and his body in their mysterious interrelatedness.
Call and Response
The dialogical character of nursing may be explored further by considering it in the general sense of a call and response. Nursing is a purposeful call and response, that is, it is related to some particular kind of help in the domain of health and illness. A patient calls for a nurse with the expectation of being cared for, of having his need met. He is asking for something. A nurse responds to a patient for the purpose of meeting his need, of caring for him. The nurse expects to be needed.