It is necessary now to look again at dialogical nursing in a broader perspective, for by limiting the exploration to the nurse, the patient, and their between, the previous discussion grossly oversimplified the way the dialogue actually evolves in real life. In the above, it was as if nursing were a drama acted out by two characters on a specially designed stage where precisely placed props lay ready to serve the actors and the passage of time is controlled by the chiming of a clock or the dimming of lights. As it is actually lived, the nursing dialogue is subjected to all the chaotic forces of real life. Nursing takes place in a real world of men and things in time and space. In many cases, it is a special world, a health system world, within the everyday world.
Other Human Beings
The dialogue lived between nurse and patient is affected by their numerous other interhuman relationships. For a nurse to be genuinely with a patient involves her coexperiencing his world with him. His family, friends, and significant others are a very real part of this world whether they are physically present or distant. So to be open to the patient is to be open to him as a person necessarily related to other men.
Furthermore, in caring for a patient the nurse relates to him not only as an individual patient but also as one in a group of patients. The group may be physically present (for example, in a ward, in an intensive care unit, in a {32} waiting room, in a dining room, in a therapeutic group) or they may be present in the nurse's mind (for example, while caring for one she may think "I have three more patients to visit," "so and so needs his medication in five minutes," "I promised so and so I'd get back to him," "three other patients are waiting to be fed"). Even when the nurse is responsible for only one patient, she often views him in relation to other patients she has nursed.
The nurse herself also functions within complex networks of interhuman relationships that affect the nursing dialogue. As health care becomes more specialized, more groups of health care workers arise and the various groups become more diversified. So the nurse's intersubjective transactions with her patients occur within an intra- and interdisciplinary milieu of constantly changing personnel, functions, and roles. While her own role is expanding, extending, deepening, broadening, becoming more specialized, she must relate with others undergoing similar change. And here again, as with the patients so with her colleagues, the nurse is constantly faced with the possibility and necessity of relating to others in terms of their functions and as persons.
Finally, it should be recognized that while it is easy and common to think of "the nurse" as synonymous with the function "nursing," in real life the nurse is a human being necessarily related to others. She learns to focus on those present in her here and now work situation. But she too is her history and brings to her work world all that she is and all that she is not including her past experienced and future anticipated interhuman relationships. So each nurse affects her peopled nursing world and is affected by it in her own unique way.
>From the other side, the patient also enters into the nursing dialogue with his various networks of interhuman relationships. How he experiences his relationships with his family and significant others, with the patient groups of which he becomes a part in different degrees, with members of various disciplines and health services groups, with "the" nurse and "his" nurse, all influence the lived nursing dialogue. It is always colored by the patient's current mode of interpersonal relating. Of course, the current mode reflects his past, for example, learned habits of response, and his future, for example, concerns about anticipated changes in interpersonal relationships due to the effects of his illness. In some cases, the intersubjective behavior itself becomes the focus of the nursing dialogue as the area of the patient's greatest needs in attaining well-being and more-being.
Things
The nursing dialogue takes place in a real world of things, ordinary things of everyday living and all forms of health care equipment. Both types of objects affect the nurse-patient transactions and their influence varies for they may be experienced differently by nurse and patient.
Ordinary objects used everyday—eating utensils, clothes, furniture, books, television sets—are so familiar that one usually takes their use for granted. {33} However due to illness a person may be unable to manipulate a knife and fork, for example. They become frustrating objects. His tools are no longer extensions of himself but impediments and barriers. He feels handicapped. His world of things changes.