Copyright (C) 2007 by Josephine Paterson and Loretta Zderad.

Humanistic Nursing

(Meta-theoretical Essays on Practice)

by Josephine Paterson and Loretta Zderad

Copyright (C) 2007 by Josephine Paterson and sLoretta Zderad all rights reserved except as follows. This e-text may be freely copied for academic and scholarly work with the copyright notice clearly affixed to all copies. No commercial use may be made of any part of the text without the express permission of the copyright holders.

This e-text version of the classic text "Humanistic Nursing" is made available with the kind permission of the authors and copyright holders, Josephine Paterson and Loretta Zderad. The book was originally written to define the Humanistic Nursing Theory which presented a way for each nurse to become-more as a person and to extend that becoming-more to the community of nurses in which he or she practices. The offering of this book in the "free" e-text format reiterates the continuing contribution of these two nurses long after their retirement from practice. It is their hope that nurses everywhere will take their vision for nursing and expand on it and integrate it into their nursing practice. At the request of the authors this e-text version is complete with the original 1976 Front Matter.

Susan Kleiman

For more information or questions about the subject of Humanistic nursing or this e-text you may contact Professor Susan Kleiman, PhD, RN, CS, NPP at: susank@humanistic-nursing.com. Alternatively you may visit the web site: www.humanistic-nursing.com. The Humanistic Nursing Inquiry web site provides context for the major initiatives of humanistic nursing, which celebrate the enduring and immutable ideals of Humanism that give us insight into the fundamental truths of being in the world of nurses, patients, families, colleagues, and students.

FOREWORD to the 1976 Edition

These essays will evoke different reactions from different readers. "Well, I know that," for example, may be the reaction of a beginner in nursing; "I wouldn't have said it that way but I knew that is really nursing." "Since they've given us a methodology," perhaps from one more experienced in nursing; "I'll give it a try." Others with still more or different kinds of experience may respond, "It's about time nurses put that into words; it's about time."

Timely as these essays are I would prefer not to use up the foreword with a listing of the crises, the "eco-spasms," and scientific triumphs that would document their timeliness. It is my pleasure, rather, to use this opportunity to relate the six elements of my own reaction:

Nursing has a solitariness until we find it has many companions in philosophy, science, and art. It has a steadiness about its pace yet holds a potential for flights to higher elevations. It is constantly changing yet has an enduring component of permanence. Good is the word we use every day; our vision, however, is of excellence. Its tasks often have the appearance of homeliness until we glimpse that kind of beauty that is humanness. Nursing even sings very softly because our ears are attuned to "a different drummer."

Lilyan Weymouth, R.N., M.S. Northampton, Massachusetts October 1975

PREFACE to the 1976 Edition

Out of necessity nursing, as a profession, reflects the qualities of the culture in which it exists. In our culture for the past quarter of a century nursing has been assailed with rapid economic, technological, shortage- abundance, changing scenes' vicissitudes. In the individual nurse these arouse turmoil and uncertainty. These cultural stirrings inflame that part of the nurse's spirit capable of chaotic conflict and doubt. Often she questions her professional identity. ''Just what is a nurse?" Her nurse colleagues, other professionals, and nonprofessionals freely, directly and indirectly-on television, in the theater, through the news media and the literature-pummel her with their multitudinous varied views.

As searching, wondering, reflecting, relating microcosms within this perplexing health nursing world for longer than a quarter of a century, we present this book. Descriptively we view the chapters as hard-wrung, philosophical foundations, synthesized extracts from our lived experiences. These metatheoretical essays on practice present an existential alternative approach for a professional nurse's knowing and becoming.

These conceptualized existents are available because Miss Marguerite L. Burt, formerly Chief of Nursing Service, Northport, N.Y. Veterans Administration Hospital called them forth from us. These chapters are our response to her call. In 1972 Miss Burt requested us to develop a course for the professional nursing staff at Northport V.A.H. This book has evolved from the original presentations offered to the ten participants in the first course. While we taught and worked with five subsequent groups, we learned and continually revised and clarified our conceptualizations. The course is entitled Humanistic Nursing.

Fifty-three nurses have been involved in this course. Interest, appreciation, wonderment, effort, and investment characteristically depict their response. They convey that the humanistic nursing practice theory reflects what nursing means to them. Their hungry approach to the suggested readings has both surprised and pleased us. Our amazement persists over the participants' ability to concentratedly discuss abstract theory and concrete nursing practice for weekly day-long sessions over six-to nine-month periods. Presently requests to participate in the next humanistic nursing course are mounting from nurses both within and outside the Northport complex.

The course, the theory, and this book are the fruits of our individual and collaborative efforts. While sharing seminar responsibility for graduate students in 1960, we began to dialogically and -dialectically struggle with professional and /clinical nursing issues. Discussing and searchingly questioning ourselves and our students became a value. Through conveying, struggling for clarification, openness to honest argument, we grew in our awareness that each was moved beyond her beginning thoughts. Through reflection we have come to view, describe, and distinguish our dialogues as struggles with, and not against, others' ideas. Differences in response are valued for what they can tell us of our chosen area-nursing. So dialectical dialogue has gradually become our predominant teaching method. We convey our ideas, are open to others' questions, struggle to clarify and really communicate, and question ourselves, and others. In the process of the humanistic nursing course, using this methodology, which is deliberate and, yet, natural and authentic for us, we and our professional nursing staff students have learned and become more human, more questioning, more clinical, and just, more.

We value our moreness. Appreciating and valuing the effects of our actualizing selves as human beings, we must attest to our existential modes of nurse being; our inner mandate is: share. Hence, Humanistic Nursing has come into being.

To find the meaning of nursing we have returned "to the thing itself," to the phenomenon of nursing as it occurs in the everyday world. Our reflections on nursing as a lived experience flowed into the realm of metanursing. Obviously, these thoughts are only a beginning. They are offered in the hope of stimulating response and further development. Dialogue may be difficult at first because humanistic nursing represents one of our discipline's less articulated streams. Yet, it is a stream traceable to nursing's foundation and, as such, is related to nursing's artistic, scientific, and technological currents. It is not being, cannot be, developed in opposition to them.

Science and art are forms of human responses to the human situation. They are valued in genuine humanism. Thus, the humanistic nursing approach does not reject advances in nursing technology, but rather it tries to increase their value by viewing their use within the perspective of the development of human potential. The same holds true for scientific, artistic, and clinical developments in nursing practice. They are the necessary means through which and in which humanistic nursing (a being and doing) is experienced and developed.

At this time when serious concern is being expressed about the survival of nursing as a profession, humanistic nursing offers a note of optimism. By examining the values underlying practice, it focuses on the meaning and means of nursing's particular' mode of interhuman caring. It increases respect for that caring as a means of human development. Nurses have the privilege of being with persons who are experiencing all the varied meanings of incarnate being with men and things in time and space in the entire range from birth to death. They not only have the opportunity to co-experience and co-search with patients the meaning of life, suffering, and death, but in the process they may become and help others become more-more human.

Beyond this, the humanistic nursing approach respects nursing experience as a source of wisdom. By describing and conceptualizing the phenomena experienced in nursing situations, nurses could contribute to the development of nursing as a discipline. Even more, they could add to the knowledge of man.

Humanistic nursing, then, is neither a break with nor a repetition of nursing's past. It is neither a rejection of nor a satisfaction with nursing's present. Rather it is an awakening to the possibilities of shaping our nursing world here and now and for the future.

Thanks to Miss Marguerite L. Burt are in order for she provoked our conceptualizations of our lived nursing worlds. Dr. Frederick H. Wescoe, while Chief of Nursing Service, Northport, N.Y., VAH administratively facilitated the time and the means for our compiling these materials into a manuscript. Past nursing students challenged and grappled with our ideas and theirs insisting always on our forwarding our thinking. Our consultants, Miss Lilyan Weymouth and Miss Rose Godbout, were marvelous resources and counselors.

Immediately we are most grateful to the participants in the six humanistic nursing courses taught here at the Northport VAH. As nurses, they received and accepted our expressed ideas to the extent of testing them in the fires of their real lived nursing practice settings. While struggling with our ideas and us, they gave to us. They were supportive, loving, and truly present with us in the community of nurses at Northport, VAH. Miss Sue McCann, clinical nurse specialist, one of our first course participants, has read and reviewed our materials. More than this Miss McCann has been a counselor, resource person, and a dependable friend in our humanistic nursing effort of the last three years. We hope our chapters give back to others, at least just a part of what we have received from them in our travels in the nursing world.

J.G.P L.T.Z.

[Transcriber's Note: to the 1988 Edition

Italic text has been marked as text.
Bold text has been marked as ~text~.
Obvious punctuation errors in the original have been corrected.
Other corrections are noted at the end of the text.
The original page numbers have been retained, e.g. {1} marks the start
of page 1 in the original text.]

HUMANISTIC NURSING

Josephine G. Paterson, DNSc, RN Loretta T. Zderad, PhD, RN

PREFACE

Somewhere there's a child a crying
Somewhere there's a child a crying
Somewhere there's a child a crying
Crying for freedom in South Africa.[1]

But until someone hears the cry and responds, the child will continue to suffer the oppression of the current South African regime; and the world will continue to be less than it could be. To cry aloud when there seems no chance of being heard, belies a hope—perhaps an inherently human trait—that someone, somewhere, somehow will hear that cry and respond to it.

This same hope, that someone would hear and respond, allowed existential psychologist Viktor Frankl to survive the systematic torture and degradation in Nazi death camps. As Frankl and others sought their way, they found meaning and salvation "through love and in love;" and by choosing to believe that "life still waited for him, that a human being waited for his return."[2]

There is power in the call of one person and the potential response of another; and incredible power when the potential response becomes real. There is the power for each person to change as she becomes more than she was before the dialogue. There is the power to transcend the situation as two people engage the events that are whirling around them and together try to make sense of their worlds and find a meaning to their existence. When the call and response between two people is as honest as it can be, there is the revolutionary power which the poet Muriel Rukeyser speaks of:

What would happen if one woman told the truth about her life?
The world would split open.[3]

{iv}

The call and response of an authentic dialogue between a nurse and patient has great power—the power to change the lived experiences of both patient and nurse, to change the situation, to change the world. It is the same authenticity we search for in relationships with our friends and lovers. The person who really listens to what we are saying, who really tries to understand our lived experiences of the world and who asks the same from us. When found, it brings the same exhilarating feeling of self-affirmation and the comforting feeling of well-being.

For, if as holistic beings we are the implicate order explicating itself, as suggested by Bohm[4] and Newman[5] among others, then the responsibilities of those who would help (e.g., nurses) include making sense out of the chaos that can occur as illness disrupts past order and as the ever-present threat of non-being disrupts all order. When we are successful in helping patients and their loved ones make sense of their lives by bringing meaning to them, we make sense of and bring meaning to our own.

And when we help create meaning, it is easier to remember why we chose nursing and why we continue to choose it despite what an underpaid and undervalued job it has become in today's marketplace. These are the moments when by a look or a word or a touch, the patient lets us know that he understands what is happening to him, what his choices are, and what he is going to do; that he knows we know; and that each knows that the other knows. When we get past our science and theories, our technical prowess, our titles and positions of influence, it is this shared moment of authenticity—between patient and nurse—that makes us smile and allows us to move forward in our own life projects.

Nurse educators who seek such authentic exchanges with their students enjoy similar moments. The same can be said of deans of schools of nursing, administrators of delivery systems, executives and staff of nursing and professional organizations, and colleagues on a research project. It is the authentic dialogue between people that makes any activity worthwhile regardless of whether or not it is called successful by others.

When Josephine G. Paterson and Loretta T. Zderad first published their book Humanistic Nursing in 1976, society was in the midst of the new women's movement and nurses were going through the phase of assertiveness training, dressing for success, and learning to play the games that mother never taught us. Since then, nurses have moved into many sectors of society and have held power as we have never held it before. We have proved ourselves as politicians, administrators, researchers, and writers. We have refined our abilities to assess, diagnose, treat, and evaluate. We've raised money and balanced budgets. We've networked, organized, and formed coalitions.

Yet, individually we are uneasy and collectively we are unable to articulate a vision clear enough so that others will join us. This re-issue of Paterson and {v} Zderad's classic work will help to remind us of another way of developing our power. Perhaps we can, once again, look for and call for authentic dialogue with our patients, our students, and our colleagues. Paterson and Zderad are clear in their method: discuss, question, convey, clarify, argue, and reflect. They remind us of our uniqueness and our commonality. They tell us that it is necessary to do with and be with each other in order for any one of us to grow. They help us celebrate the power of our choices.

Is it ironic and fortunate that Humanistic Nursing should be re-issued now when it is needed even more than it was during the late 1970s? Then, humanitarianism was in vogue. Now, it is under attack as a secular religion.

Today, the technocratic imperative infiltrates an ever-increasing number of our lived experiences; and it becomes more difficult to ignore or dismiss Habermas's analysis that all interests have become technical rather than human.[6] As health care becomes increasingly commercial the profound experiences of living and dying are discussed in terms of profit and loss. Life itself is the focus of public debates about whether surrogacy involves a whole baby being bought and sold or only half of a baby, since one half already "belongs" to the natural father and so he cannot buy what he already owns.

We have many choices before us: to adopt the values of commerce and redesign health care systems accordingly; to accept competition as the modus operandi or insist on other measures for people in need; to decide who will be cared for, who won't, who will pay, and how much?

Perhaps it is time for us to turn away from the exchange between buyers and sellers, providers and consumers; and turn back to an exchange between two people trying to understand the space they share. Perhaps it is time for a shared dialogue with patients for whom the questions are most vital? Perhaps we need to hear their call and respond authentically. Perhaps they need to hear ours? For only then, as Paterson and Zderad have made quite clear, will our lived experiences in health care have any real meaning.

Patricia Moccia PHD, RN
Associate Professor and Chair
Department of Nursing Education
Teachers College Columbia University

FOOTNOTES:

[1] Azanian Freedom Song. Lyrics by Otis Williams, music by Bernice Johnson Reagon. Washington, DC: Songtalk Publishing Co., 1982.

[2] Frankl, Viktor. Man's Search For Meaning. Boston: Beacon Press, 1959.

[3] Rukeyser, Muriel. "Kathe Kollwitz," in By a Woman Writ, ed. Joan Goulianos. New York: Bobbs Merrill, 1973, p. 374.

[4] Bohm, David. Wholeness and the Implicate Order. London: Ark, 1980.

[5] Newman, Margaret. Health As Expanding Consciousness. St. Louis: C. V. Mosby Company, 1986.

[6] Habermas, Jurgen. Knowledge and Human Interest, (trans. J. Shapiro.) Boston: Beacon Press, 1971.

CONTENTS

PART ONE

THEORETICAL ROOTS 1

1 Humanistic Nursing Practice Theory 3 2 Foundations of Humanistic Nursing 11 3 Humanistic Nursing: A Lived Dialogue 21 4 Phenomenon of Community 37

PART TWO

METHODOLOGY—A PROCESS OF BEING 49

5 Toward a Responsible Free Research Nurse in the Health Arena 51 6 The Logic of a Phenomenological Methodology 65 7 A Phenomenological Approach to Humanistic Nursing Theory 77 8 Humanistic Nursing and Art 85 9 A Heuristic Culmination 95

Appendix 113
Glossary 121
Bibliography 123
Index 127

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Part 1

THEORETICAL ROOTS

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1

HUMANISTIC NURSING PRACTICE THEORY

Substantively this chapter introduces two aspects of the humanistic nursing practice theory: first, what this theory proposes and, second, how the proposals of the theory evolved.

Concisely, humanistic nursing practice theory proposes that nurses consciously and deliberately approach nursing as an existential experience. Then, they reflect on the experience and phenomenologically describe the calls they receive, their responses, and what they come to know from their presence in the nursing situation. It is believed that compilation and complementary syntheses of these phenomenological descriptions over time will build and make explicit a science of nursing.

HUMANISTIC NURSING: ITS MEANING

Nursing is an experience lived between human beings. Each nursing situation reciprocally evokes and affects the expression and manifestations of these human beings' capacity for and condition of existence. In a nurse this implies a responsibility for the condition of herself or being. The term "humanistic nursing" was selected thoughtfully to designate this theoretical pursuit to reaffirm and floodlight this responsible characteristic as fundamentally inherent to all artful-scientific nursing. Humanistic nursing embraces more than a benevolent technically competent subject-object one-way relationship guided by a nurse in behalf of another. Rather it dictates that nursing is a responsible searching, transactional relationship whose meaningfulness demands conceptualization founded on a nurse's existential awareness of self and of the other. {4}

EXISTENTIAL EXPERIENCE

Uniqueness—Otherness

Existential experience infers human awareness of the self and of otherness. It calls for a recognition of each man as existing singularly in-his-situation and struggling and striving with his fellows for survival and becoming, for confirmation of his existence and understanding of its meaning.

Martin Buber, philosophical anthropologist and rabbi, expressed artfully this uniqueness, struggle, and potential of each man. He said:

"Sent forth from the natural domain of species into the hazard of the solitary category, [man] surrounded by the air of a chaos which came into being with him, secretly and bashfully he watches for a Yes which allows him to be and which can come to him only from one human person to another."[1]

With such uniqueness of each human being as a given, an assumed fact, only each person can describe or choose the evolvement of the project which is himself-in-his situation. This awesome and lonely human capacity for choice and novel evolvement presents both hope and fear as regards the unfolding of human "moreness." Uniqueness is a universal capacity of the human species. So, "all-at-once," while each man is unique; paradoxically, he is also like his fellows. His very uniqueness is a characteristic of his commonality with all other men.

Authenticity—Experiencing

In humanistic nursing existential awareness calls for an authenticity with one's self. As a visionary aim, such authenticity, self-in-touchness, is more than what usually is termed intellectual awareness. Auditory, olfactory, oral, visual, tactile, kinesthetic, and visceral responses are involved and each can convey unique meaning to man's consciousness. In-touchness with these sensations and our responses informs us about our quality of being, our thereness, our degree of presence with others. The kind of "between" we live with others depends on both our degree of awareness and the meaning we attribute to this awareness. This awareness, reflected on, sometimes shared with a responsible other for reality testing, offers us opportunity for broadening our meaning base, for becoming more—more in accord with our potential for humanness.

Perhaps a statement made by Dr. Gene Phillips, professor of education at Boston University, will clarify the importance I attach to each nurse becoming as much as she can be. He said, "The more mature we are the less it is necessary for us to exclude." Presently I would paraphrase this statement {5} and say, the more of ourselves we do not have to exclude, the more of the other we can be open to. Our self-awareness, in-touchness, self-acceptance, actualization of our potential allows us to share with others so they can become in relationship with us.

In this kind of existential relating, presence with another, a nurse is confronted with man as singular in his own peculiar angular, biased, or shaded reality. It becomes apparent that each has his very own lived world. So one might describe human existence as man-world as some refer to man as mind-body, using a hyphen rather than "and." Man's universal species commonality and peculiar perplexing noncommonality, has this manness, affect and constantly interplay with one another. This arena of interplay is complicated further by man's capacity for nondeterminedness, his ability for envisioning and considering a variety of alternatives and choosing selectively. Often these alternatives are experienced as contradictory and inconsistent. Humanistic nursing calls forth in the nurse the struggle of recognizing the complexity of men's relating in the nursing world as "just how man is" and his nature, his human condition, as searching, experiencing, and an unfolding becoming.

Moreness—Choice

How can a nurse let herself know her human responses and the breadth and depth of the possibilities called forth by the other? How can she be, search, experience, become in an accord with the calls and responses of her lived nursing world? It is a chosen, deliberate life-long process. The process itself is generative. One experience opens the door for the next. In humanistic nursing practice theory we call this kind of experiencing authentic, genuine, or "letting be what is." It is man conscious of himself, not necessarily acting out, but aware of his human responses to his world and their meanings to him. This quality of personal authenticity allows one's responsible chosen actions to be based in human knowledge rather than human defensiveness. Man is a knowing place. From education and living experience one assumes an initial innate force in human beingness that moves man to come to know his own and others' angular views of the world. Humanistic nursing is concerned with these angular views, these differences being viewed by nurses responsibly and as realities that are beyond the negative-positive, good-evil standard of judgement. Or, for example, nursing is concerned with how this particular man, with his particular history, experiences being labeled with this general diagnosis and being admitted, discharged, and living out his life with his condition as he views it in-his-world.

Man has the inherent capacity to respond to other man as other man. Only each unique nurse faced with the chaos of her alternatives in a situation can then choose either to relate or not to relate and how to relate in-her-nursing-world to others. Choosing to and how to relate or respond cannot be superimposed on man from the outside by another. A person, to a degree, can be coerced to behave outwardly in a certain way. For example, physically, in a spatial {6} sense, a nurse can be ordered into parallel existence with another. Being existentially and genuinely present with another is different. This human mode of being is chosen and controlled by the self. It takes responsible self-ordering that can arise only in the spirit of one's own disciplined being.

Value—Nonvalue

To offer genuine presence to others, a belief must exist within a person that such presence is of value and makes a difference in a situation. If it is a value for a nurse, it will be offered in her nursing situation. Libraries, concrete buildings bursting with words of great thinkers, support the value of genuine presence and authentic dialogue between persons. Consider the literary works that have conveyed or reflected this message throughout the existence of intellectual man. Plato, Rousseau, Goethe, Proust, Nietzsche, Whitehead, Jung, May, Frankl, Hesse, de Chardin, Bergson, Marcel and Buber effortlessly come to mind.

Many nurses are genuine presences in the nursing situation. Some have tried to share their experiences; some have not. And, there are those who are not genuine presences in the nursing situation. One wonders if this has influenced the distinctions nurses have made over the years with certainty when considering their nurse contemporaries. Often one hears, "she is a good nurse, a natural." These positive critics are often up against it when asked, "why, how, what?" Descriptive literary conceptualizations of nursing that reflect this quality of nurse-being (presence, intersubjectiveness) call for nurses willing to search out and bring to awareness, the mysteries of their commonplace, their familiar, and to appreciate the unique ideas, values, and meanings fundamental to their practice. Conceptualization of these qualities by practicing nurses is basic and necessary to the development of a science and an actualized profession of nursing.

PHENOMENOLOGICAL DESCRIPTION

Phenomenology directs us to the study of the "thing itself." The existential literature, descriptions of what man has come to know and understand in his experience, has evolved from the use of the phenomenological approach. In the humanistic nursing practice theory the "thing itself" is the existentially experienced nursing situation. Both phenomenology and existentialism value experience, man's capacities for surprise and knowing, and honor the evolving of the "new."

What Does Humanistic Nursing Practice Theory Ask the Nurse to Describe?

Nurses experience with other human beings peak life events: creation, birth, winning, nothingness, losing, separation, death. Their "I-Thou" empathetic {7} relations with persons during these actual lived experiences and their own experiential-educational histories make "the between" of the nursing situation unique. Through in-touchness with self, authentic awareness and reflection on such experiences the human nurse comes to know. Humanistic nursing practice theory asks that the nurse describe what she comes to know: (1) the nurse's unique perspective and responses, (2) the other's knowable responses, and (3) the reciprocal call and response, the between, as they occur in the nursing situation.

Why Does Humanistic Nursing Practice Theory Ask That Existential Nursing
Experience Be Described Phenomenologically?

There are many reasons. Philosophically and fundamentally the reason relates to how humanistic nursing perceives the purpose and aim of nursing. It views nursing as the ability to struggle with other man through peak experiences related to health and suffering in which the participants in the nursing situation are and become in accordance with their human potential. So, like Elie Wiesel, the novelist, who states in One Generation After that he writes to attest to events of human existence and to come to understand, humanistic nursing proposes that human forms of existence in nursing situations need attestation and that through describing, nurses will understand better and relate to man as man is. Thus the profession of nursing's service contribution to the community of man will ever become more.

The reasons for phenomenologically describing nursing are complex, interinfluential, and their ramifications are far reaching. Sequentially, the study and description of human phenomena presented in nursing situations will affect (1) the quality of the nursing situation, (2) man's general knowledge of the variation in human capacity for beingness, and (3) the development and form of the evolvement of nursing theory and science.

How Can Nurses Begin to Describe Humanistic Nursing Phenomenologically?

The process of how to describe nursing events entails deliberate responsible, conscious, aware, nonjudgmental existence of the nurse in the nursing situation followed by disciplined authentic reflection and description.

There are obvious common lived human experiences which if considered and wondered about, can advance a nurse's ability for phenomenological description. These experiences are easily cited, yet not easily plumbed. Often experiences such as anger, frustration, waiting, apathy, confusion, perplexity, questioning, surprise, conflict, headache, crying, laughing, joy are quickly theoretically and analytically interpreted, labeled, and dismissed. Examining, reexamining, mulling over, brooding on, and fussing with the situational context of these experiences as nonlabeled, raw human lived data can yield {8} knowledge. Knowledge of the nurse's and her other's unique human existence in their on-going struggle becomes explicit. Superficial treatment of such human clues results in nonfulfillment of the realistic human possibilities of artful-scientific professional knowing and nursing.

Words are the major tools of phenomenological description. They are limited by our human ability to express, and yet they are the best tools we have for expressing the human condition. The novelist James Agee, in Let Us Now Praise Famous Men, says that though man or human relatedness never could be described perfectly it would be the greater crime not to try. This, too, is a basic premise of the humanistic nursing practice theory.

The words we use to describe and discuss this theory are easy words, everyday English words. We all know them. We, at times, narrow a word's meaning or make it more specific. Some problem is presented by words we are accustomed to using and hearing. Habit and our human fallibility can promote only superficial comprehension. Thoughtful awareness of the meaning of these same sequentially expressed words can convey the complexity of the never completely fathomable "all-at-onceness" of lived existence. This theory is expressed in terms like "existence confirming," "striving," "becoming," "relation," and "reflection." We intend such words to express the grasp with acceptance and recognition of human limitations while awesomely pondering the open-ended scope of each man's potential.

In time, with disciplined authentic reflective description, themes common and significant to nursing situations become apparent. They are then available for compilation, complementary synthesis, and on-going refinement. A nursing resource bank accrues: Not a bank that offers a map of how and what to do but rather one that further stimulates nurses' exploration and understanding.

THE EVOLVEMENT OF HUMANISTIC NURSING PRACTICE THEORY

Since 1960 Loretta T. Zderad and myself in dialogue, together, and with groups of nurses in graduate schools and in nursing service situations have reflected on, explored, and questioned our own and others' nursing situational experiences. Over this period we have come to value and appreciate the meaningfulness of these situations to man's existence. This constantly augmented our feelings of responsibility for contributing to these situations beneficially. Therefore, we looked at them for their tractability to research methodology. Their loadedness with variations, changes, uncontrollables, and our negative feelings about the implications of viewing human beings as predictable left the strict scientism of positivistic method wanting at this stage of man's knowing. We saw objectivity in nursing situations or our questions, nursing questions, in the realm of needing to now how man experienced his existence. This objectivity, or man's real lived reality paradoxically is subjectively ridden, man-world.

The existential literature dealt with substantive themes encountered in nursing experiences. As I previously stated this literature evolves from a phenomenological {9} approach to studying being and existence. This approach to studying, describing, and developing an artistic science of nursing became Dr. Zderad's and my long-sought haven. All along existentialism and phenomenology had been ours 'and many nurses' "what" and "how." Now we had labels that were acceptable and reputable to many—most of all to ourselves.

FOOTNOTES:

[1] Martin Buber, "Distance and Relation," trans. Ronald Gregor Smith, in The Knowledge of Man, ed. Maurice Friedman (New York: Harper & Row, Publishers, 1965), p. 71.

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2

FOUNDATIONS OF HUMANISTIC NURSING

Nursing is a response to the human situation. It comes into being under certain conditions—one human being needs a kind of help and another gives it. The meaning of nursing as a living human act is in the act itself. To understand it, therefore, it is necessary to consider nursing as an existent, a phenomenon occurring in the real world.

THE PHENOMENON OF NURSING

The phenomenon of nursing appears in many forms in the real lived world. It varies with the age of the patient, the pathology or disability, the kind and degree of help needed, the duration of the need for help, the patient's location and his potential for obtaining and using help, and the nurse's perception of the need and her capacities for responding to it. Nursing varies also in relation to the sociocultural context in which it occurs. Being one element in an evolving complex system of health care, nursing is continuously appearing in new specialized forms. As professionals, we are accustomed to viewing nursing as we practice it within these specialty contexts—for example, pediatric, medical, rehabilitation, intensive care, long-term care, community. There seems to be no end to the proliferation of diversifications. Even the attempts of practitioners to combine specialties give rise to new specialties, such as, community mental health nursing and child psychiatric nursing.

So it is difficult to focus on the phenomenon of nursing as an entity without having one's view colored by a particular clinical, functional, or societal context. Yet, if we can "bracket" (hold in abeyance) these adjectival labels and the preconceived viewpoints they signify, we can consider the thing itself, the act of nursing in its most simple and general appearance. {12}

Well-Being and More-Being

In this most basic sense, then, disregarding the particular specialized forms in which it appears, the nursing act always is related to the health-illness quality of the human condition, or fundamentally, to a man's personal survival. This is not to say that all instances of nursing are matters of life and death, but rather that every nursing act has to do with the quality of a person's living and dying.

That nursing is related to health and illness is self-evident. How it is related is not so apparent. "Health" is valued as necessary for survival and is often proposed as the goal of nursing. There are, in actuality, many instances of nursing that could be described as "health restoring," "health sustaining," or "health promoting." Nurses engage in "health teaching" and "health supervision." On the other hand, there are instances in which health, taken in its narrowest meaning as freedom from disease, is not seen as an attainable goal, as evidenced, for example, in labels given to patients such as "terminal," "hopeless," and "chronic." Yet in actual practice these humans' conditions call forth some of the most complete, expert, total, beautiful nursing care. Nursing, then, as a human response, implies the valuing of some human potential beyond the narrow concept of health taken as absence of disease. Nursing's concern is not merely with a person's well-being but with his more-being, with helping him become more as humanly possible in his particular life situation.

Human Potential

Since nursing involves one human being helping another, the notion of humaneness has been associated traditionally with nursing. Nursing practice is criticized justifiably when it is not humane and is taken for granted or praised when it is. The expectation of humaneness is so ingrained in the concept of nursing that some nurses are surprised when it is acknowledged by patients. If a patient thanks them for their kindness, patience, or concern, these nurses reply, in their embarrassment, "Oh, that's part of my job."

However, to equate nursing's humanistic character solely with an overflowing of the milk of human kindness is a serious error of oversimplification. Such a limited view, in fact, is a dehumanizing denial of man's potentials. As a human transaction, the phenomenon of nursing contains all the human potentials and limitations of each unique participant. For instance, frustration, discouragement, anger, rejection, withdrawal, loneliness, aggression, impatience, envy, grief, despair, pain, and suffering are constituents of nursing, as well as tenderness, caring, courage, trust, joy, hope. In other words, since nursing is lived by humans, the "stuff" of nursing includes all possible responses of man—man needing and man helping—in his situation.

Intersubjective Transaction

Looking again at the phenomenon of nursing as it occurs in the real lived world, obviously it is always an interhuman event. Whenever nursing takes {13} place two (or more) human beings are related in a shared situation. Each participates according to his own mode of being in the situation, that is, as a person nursing or as a person begin nursed. Since one is nursing and the other is being nursed, it follows that the essential character of the situation is "nurturance." In other words, the phenomenon of nursing involves nurturing, being nurtured, and a relation—the "between" in which or through which the nurturance occurs.

On reflection, it is obvious that nursing is an intersubjective transaction. Both persons, nurse and patient (client, family, group), necessarily participate in the proceedings. In this sense, they are _inter_dependent. Yet, they are both subjects, that is, each is the originator of human acts and of human responses to the other. In this sense, they are _in_dependent. The intersubjective transactional character of nursing cannot be escaped when one is experiencing the phenomenon, either as nurse or as patient. Consider for example, some of the most common nursing activities, such as, feeding and being fed, comforting and being comforted, giving and taking medications. Although this intersubjectivity is unmistakably known in experience, it is extremely difficult to conceptualize and convey it to others. It rarely is found in descriptions of nursing, and to the unfortunate extent that it is missing, the descriptions are not true to life.

In real life, nursing phenomena may be experienced from the reference points of nurturing, of being nurtured, or of the nurturing process in the "between." For instance, the nurse may describe comfort as an experience of comforting another person; the patient, as an experience of being comforted. However, while each has experienced something within himself, he also has experienced something of the "between," namely, the message or meaning of the "comforting-being comforted" process. This essential interhuman dimension of nursing is beyond and yet within the technical, procedural, or interactional elements of the event. It is a quality of being that is expressed in the doing.

Being and Doing

As an intersubjective, transactional experience, nursing necessarily involves both a mode of being and a doing of something. The being and doing are interrelated so inextricably that it is difficult, even distorting, to speak of one without the other. Descriptions of nursing, however, often focus primarily (sometimes exclusively) on the doing aspect of the process, on the nursing techniques or procedures. The observable acts are more easily discerned and discussed. They can be measured, counted, and charted. Yet, in the actual interhuman experience of nursing the weight of being is felt. Presence and the effect of one's presence can be known much more vividly than they can be described. Still, not to attempt to describe them is to present only a half, or perhaps less than half, of the nursing picture.

When a nurse refers to a nurse-patient interaction during which a change in the patient's condition or behavior was noted, one hoping to get a description of nursing may ask, "What did you do?" Often the answer is a description of a {14} manual action or a verbal interchange. Sometimes the nurse responds, "Nothing, I was just there." Perhaps it is the question that is wrong. The respondent usually interprets "doing" in a limited sense. In reality, everything the nurse does is colored by the character of her being in the situation. The nursing act itself is a behavioral expression of the nurse's state of being, for example, concerned, fatigued, hurried, confident, hopeless.

Furthermore, there is a kind of being, a "being with" or a "being there," that is really a kind of doing for it involves the nurse's active presence. To "be with" in this fuller sense requires turning one's attention toward the patient, being aware of and open to the here and now shared situation, and communicating one's availability.

Whether the nursing act is verbal, or manual, or both, a silent glance, or physical presence, some degree of intersubjectivity is involved and warrants recognition. To become more aware of and explore more fully this essential constituent of nursing we need to focus on the participants' modes of being in the situation. Rather than ask the nurse, "What did you do in the nurse-patient situation?" we ought to ask, "What happened between you?"

HUMANISTIC NURSING

When the meaning of nursing is sought by scrutinizing the phenomenon, that is, by examining the nursing event itself as it occurs in real life, one finds nursing embedded within the human context. As a nurturing response of one person to another in need, it aims at the development of human potential, at well-being and more-being. As something that happens between people, it reflects all the human potential and limitations of the persons involved. As an intersubjective transaction, it holds the possibility for both persons to effect and be affected, the possibility for both to become more. At its very base, then, nursing is humanistic. It is, at once, man's expression of and his striving for survival and further development in community.

In a way, to specify nursing as humanistic seems redundant. In view of its source and goals how could it be otherwise? However, the term "humanistic nursing" was coined thoughtfully and used purposely here to designate a particular nursing approach. Not only does the term signify full recognition of nursing's human foundation and meaning but it also points the direction for nursing's necessary development. What is proposed here is the enrichment of nursing by exploring and expanding its relations to its human context.

Authentic Commitment

When it is genuinely humanistic, nursing is an expression, a living out, of the nurse's authentic commitment. It is an existential engagement directed toward nurturing human potential. The humanistic nurse values nursing as a situation in which the necessary conditions for such human actualization exist and is open to the possibilities in the intimately shared nurse-patient here and now. {15}

Humanistic nursing calls for an existential involvement, that is, an active presence with the whole of the nurse's being. This involved presence is personal and professional. It is personal—a live act stemming from this unique, individual nurse. It is a chosen human response freely given; it cannot be assigned or programmed. The involvement is professional—goal directed. It is based on an art-science; it is held accountable.

Anyone familiar with typical hectic nursing situations could justifiably question the actual attainability of such an existential involvement. It goes without saying that it would be humanly impossible for a nurse to be wholly present to numerous patients for eight hours a day. But any nurse who has experienced moments of genuine presence in the nurse-patient situation will attest to their reality and to the fact that it is these beautiful moments that give meaning to nursing. In terms of actual practice, then, it is more realistic to think of humanistic nursing as occurring in various degrees. It may be more useful, in fact, to consider humanistic nursing a goal worth striving for; or an attitude that strengthens one's perseverance toward attaining the difficult goal; or fundamentally, a major value shaping one's nursing practice.

Process—Choice and Intersubjectivity

For the process of nursing to be truly humanistic it must bear out, that is, be a lived expression of, the nurse's recognition and valuing of nursing as an opportunity for the development of the human person. To this end, humanistic nursing process echoes existential themes related to a person's becoming through choice and intersubjectivity.

Existentially speaking, man is his choices. This does not mean that a man can be anything he chooses. Naturally, each individual is unique, having his own particular potentials and limitations. Nor is this view a denial of the forces of unconscious motivation and habit. It does not imply that all of a person's actions result from totally conscious deliberations. By saying, "I am my choices," I mean I am this here and now person because in my past life I took particular paths in preference to others; of the possibilities open to me, I actualized certain ones.

In this sense, I am my history, I am what I am, what I have become. But I am also what I am not, what I have not become. I am a nurse, this unique here and now nurse with particular experience, knowledge, skills, and values; without other experience, knowledge, skills, and values. Through self-reflection I know that I have changed, I have experienced growth from within. I know myself as a being capable of becoming more, capable of actualizing my possibilities, my self. So I am my choices not only in terms of my past but also in regard to my future, my possibilities.

Man is an individual being necessarily related to other men in time and space. As every man is beholden to other men for his birth and development, interdependence is inherent in the human situation. In this sense, human existence is coexistence. The deeper significance of this truth has been recognized and elucidated by many thinkers, especially those in the existential stream. Over {16} and over, their writings reveal the paradoxical tension of being human: each man is, at once, independent, a unique individual and interdependent, a necessarily related being. As Wilfrid Desan says, referring to man as subsistent relation, "He is towards-the-other but he is not-the-other."[1]

Furthermore, as Martin Buber and Gabriel Marcel maintain, it is actually through his relations with other men that a man becomes, that his unique individuality is actualized. To know myself as "individual" is to experience myself as this particular unique here-and-now person and other than that there-and-now person. Or in other words, to know myself as me is to see myself in relation to and distant from other selves. As Buber so beautifully states, "It is from one man to another that the heavenly bread of self-being is passed."[2]

Logically, it follows that the possibility for self-confirmation exists in any intersubjective situation. However, in everyday life this self-confirmation is experienced to different degrees or on different levels in interhuman relating. Since both persons are independent subjects acting with their human capacity for disclosing or enclosing themselves, there is no guarantee that the availability and presence necessary for a genuine confirming encounter will come forth. Presence, the gift of one's self, cannot be seized or called forth by demand, it can only be given freely and be invoked or evoked.

Since man becomes more through his choices and the aim of nursing is to help man toward well-being or more-being, the humanistic nursing effort is directed toward increasing the possibilities of making responsible choices. Such choice involves, in the first place, an openness to and an awareness of one's own situation. A choice is a response to possibility. Therefore, one must first recognize that possibilities or alternatives exist. This openness to options is experienced as a freedom to choose as well as a freedom from the bonds of habit and stereotyped response, from routine, from the veils of the obvious. It means getting in touch with one's experience, one's subjective-objective world. As one becomes more acutely aware of his personal freedom of choice, there arises concurrently an awareness of the quality of choice, of the responsibility that is always implied in the freedom. Then follows reflective consideration of one's unique situation with its possible alternatives and an examination of the values inherent in them. Finally, the act of choosing is expressed in a response to the situation with a willingness to accept the responsibility for its foreseeable consequences. Through this experience the person becomes aware of himself as an individual. As a subject choosing freely and responsibly, he knows himself as distinct from and yet related to others.

Nursing, being an intersubjective transaction, presents an occasion for both persons, patient and nurse, to experience the process of making responsible choices. Through living this process in nursing situations, the nurse develops her own potential for responsible choosing. The satisfaction, often in the form {17} of a sense of vitality and strength, that is felt in making responsible competent professional judgments reinforces the habit. In personally coming to experientially appreciate the growth promoting character of responsible choosing, the nurse may more readily recognize the value of such experiences for any person, including the one currently labeled "patient." The humanistic nurse, therefore, is alert to opportunities for the patient to exercise his freedom of choice within the limits of safe and sound practice. She is constantly assessing his capabilities and needs and encourages his maximum participation in his own health care program. Through coexperiencing and supporting the process in the patient's experience from his point of view, the nurse nurtures his human potential for responsible choosing. Both patient and nurse become more through making responsible choices in the intersubjective, transactional nursing situation.

Theory and Practice

The term "humanistic nursing" refers to a kind of nursing practice and its theoretical foundations. The two are so interrelated that it is difficult, in fact even somewhat distorting, to speak exclusively of either the practice or the theory of humanistic nursing. When, for the sake of clarity or emphasis, discussion is focused on either the practical or the theoretical realm, thoughts of the other realm cast their shadows on the fringes. For in our view, for the process of nursing to be truly humanistic means that the nurse is involved as an experiencing, valuing, reflecting, conceptualizing human person. From the other side, the theory of humanistic nursing is derived from actual practice, that is, from being with and doing with the patient. "Theory," says R. D. Laing, "is the articulated vision of experience."[3]

Humanistic nursing is not a matter solely of doing but also of being. The humanistic nurse is open to the reality of the situation in the existential sense. She is available with her total being in the nurse-patient situation. This involves a living out of the nurturing, intersubjective transaction with all of one's human capacities which include a response to the experienced reality. Man is able to set his world at a distance as an independent opposite and enter into relation with it. In fact, according to Buber, this is what distinguishes existence as human. It is man's special way of being.[4] For nursing to be humanistic in this full sense of the term requires being and doing in the situation and subsequently setting the experienced reality at a distance (that is, objectifying it) and entering into relation with it. The nurse's reflective response to her lived world may take the shape of any form of human dialogue with reality, such as, science, art, or philosophy.

Viewed existentially, every nursing event is unique, a live intersubjective transaction colored and formed by the individual participants. Although the event is ephemeral, the resultant experiential knowledge is lasting and cumulative. So {18} from the nurse's daily commonplace grows a body of clinical wisdom. The need for describing nursing phenomena, for expressing and conceptualizing lived nursing worlds, is basic to the theoretical and actual development of humanistic nursing. In summary, we contend that humanistic nursing practice necessarily involves the conceptualization of that practice and an examination of its inherent values and that humanistic nursing theory must be derived from nurses' lived experience. The interwoven theory and practice are reciprocally enlightening.

Framework—The Human Situation

It is easy to recognize the intrinsic interrelatedness of humanistic nursing theory and practice and the consequent necessity for their concurrent development. It is even quite easy to take the next steps of valuing such development and committing oneself to the task. But then the question arises: Where to begin?

Humanistic nursing is concerned with what is basically nursing, that is, with the phenomenon of nursing wherever it occurs regardless of its specialized clinical, functional, or sociocultural form. So its domain includes any or all nursing situations. And within this domain, since humanistic nursing is an intersubjective transaction aimed at nurturing well-being and more-being, its "stuff" includes all possible human and interhuman responses. To conceive of so limitless a universe for study is at once exhilarating and overwhelming. How can one get a handle on the nursing universe? Is it possible to envision an inclusive frame that would allow an orderly, systematic, and hopefully productive approach to the development of humanistic nursing?

The key is to return again to the source, to look at the phenomenon of nursing as it occurs in real life. From this perspective, the human situation sets the stage where nursing is lived. The major dimensions of humanistic nursing, then, may be derived from this situation. Existentially, man is an incarnate being always becoming in relation with men and things in a world of time and space. The nursing situation is a particular kind of human situation in which the interhuman relating is purposely directed toward nurturing the well-being or more-being of a person with perceived needs related to the health-illness quality of living. The elements of the frame, based on this view of humanistic nursing, would include incarnate men (patient and nurse) meeting (being and becoming) in a goal directed (nurturing well-being and more-being) intersubjective transaction (being with and doing with) occurring in time and space (measured and as lived by patient and nurse) in a world of men and things. In other words, the inexhaustible richness of lived nursing worlds could be explored freely, imaginatively, and creatively in any direction suggested by the dimensions of this open framework. It allows for a variety of angular views.

For example, in terms of man as incarnate, it is certainly not new for nurses to focus on man's bodily existence. Naturally, one of nursing's basic concerns always has been care of people's physical needs. To view nursing from the perspective of the human situation, however, is to see beyond physical care, {19} beyond the categorization of man as a biopsychosocial organism. The focus is on the person's unique being and becoming in his situation.

Every man is inserted into the common world of men and things through his own unique body. Through it he affects the world and the world affects him. Through it he develops his own unique personal private world. When a person's bodily functions change during illness the world and his world change for him. The nurse needs to consider how the patient experiences his lived world. Ordinary things which nurses simply take for granted, such as, hospital noises or odors, touching, bathing, feeding, sleep or meal schedules, may have very different meaning for individual patients. They may or may not be experienced as nurturing in a particular person's lived world.

In the humanistic perspective the nurse also is viewed as a human person, as a being in a body rather than merely as a function or a doer of activities. Conscious recognition of this fact opens many areas for exploration. Obviously, the nurse's actions (her being with and doing with), that affect the patient's world, are expressed through her body. How is nurturance communicated and actually effected through nursing activities? From the other side, consider the nurse as being affected by the world through her body. What depths of "nursing content" could we fathom if we accepted the existential dictum that "the body knows?" Would we dismiss so lightly those gems of clinical wisdom nurses attribute disparagingly to "gut reaction," "unscientific intuition," or "years of experience"? Would we value serious exploration and extraction of these natural resources in the nursing world?

The framework suggests, further, the possibilities of exploring the development of human potential, both patient's and nurse's, as it occurs in the unique domain of nursing's intersubjective transactions. What human resources are called forth in the shared situations during which nurses coexperience and cosearch with patients the varied meanings of being and becoming over the entire range of life from birth to death? How does it occur? What is the process? What promotes well-being or becoming more when facing life, suffering, death? For the patient? For the nurse? What knowledge gained through the study of nursing, a particular form of the human situation, could be contributed to the general body of human sciences?

Finally, within this framework, all the phenomena experienced in the nursing situation could be explored in relation to their attributes of time and space. More specifically, from an existential perspective, the focus would be directed toward the significance of lived time and space, that is, time and space as experienced by the patient and/or the nurse, and as shared intersubjectively. For example, waiting, silence, chronicity, emergency, positioning a patient in bed, moving through space in a wheelchair, crutchwalking, pacing, could be considered from the standpoint of the patient's experienced space and time, or from the nurse's, or as a shared event. Explorations of this kind could provide valuable insights into important nursing phenomena, such as, presence, empathy, comfort, timing. {20}

The human situation, then, is the ground within which nursing takes form. As such, it provides a framework for approaching the study and development of humanistic nursing. As an angular view, it holds the focus on the basic question underlying nursing practice: Is this particular intersubjective, transactional nursing event humanizing or dehumanizing?

CONCLUSION

This chapter explored the foundations of humanistic nursing. The discussion flowed naturally, perhaps unavoidably, into the realm of meta-nursing. "Naturally," for the humanistic nursing approach is itself an outgrowth of the critical examination of nursing as an experienced phenomenon. From this existential perspective of nursing as a living human act, the meaning of nursing is found in the act itself, in nursing's relation to its human context.

Reflection on nursing as it is lived in the real world revealed its existential, nurturing, intersubjective, transactional character. The process of humanistic nursing stemming from the nurse's authentic commitment is a kind of being with and doing with. It aims at the development of human potential through inter subjectivity and responsible choosing.

The actualization of humanistic nursing is dependent on the concurrent development of its practice and theoretical foundations by practicing nurses. An open framework derived from the human situation was offered to suggest possible dimensions of humanistic nursing practice that could be described and articulated into a body of theory.

Nurses who have considered this humanistic nursing approach in terms of their daily practice have felt at home in the ideas. The conceptualizations fit their personal nursing experience. If there is any strangeness in the approach, it is perhaps that it does not follow the contours of the clinical specialties to which we have grown so accustomed that they may be more ruts than roads. This is not to say that humanistic nursing is opposed to clinical specialization in nursing. In fact, clinical nursing, as it exists in any form, is its very heart and base. Humanistic nursing is not compartmentalized into clinical (or functional, or sociocultural) specialties because it applies in all clinical areas. It is, in the most basic sense, cross-clinical. This may be the great advantage of humanistic nursing. By orienting its explorations ontologically, it may foster genuine cross-clinical studies of nursing phenomena. If nurses with highly developed abilities in particular forms of nursing would struggle together in collaborative cross-clinical studies of nursing phenomena, specialization would serve to advance rather than fragment all nursing.

FOOTNOTES:

[1] Wilfred Desan, The Planetary Man, Vol. I, A Noetic Prelude to a United World (New York: The Macmillan Company, 1972). p. 37.

[2] Martin Buber, "Distance and Relation," trans. Ronald Gregor Smith, in The Knowledge of Man, ed. Maurice Friedman (New York: Harper & Row, Publishers, 1965), p. 71.

[3] R. D. Laing, The Politics of Experience (New York: Ballantine Books, 1967), p. 23.

[4] Buber, The Knowledge of Man, p. 60.

{21}

3

HUMANISTIC NURSING: A LIVED DIALOGUE

The meaning of humanistic nursing is found in the human act itself, that is, in the phenomenon of nursing as it is experienced in the everyday world. Therefore, the interrelated practical and theoretical development of humanistic nursing is dependent on nurses experiencing, conceptualizing, and sharing their unique angular views of their unique lived nursing worlds. An open framework suggesting dimensions for such exploration was derived from a consideration of the phenomenon of nursing within its basic context, namely, the human situation. The elements of this humanistic nursing framework include incarnate men (patient and nurse) meeting (being and becoming) in a goal-directed (nurturing well-being and more-being), intersubjective transaction (being with and doing with) occurring in time and space (as measured and as lived by patient and nurse) in a world of men and things.

The framework offers a little security by providing some reference points for the exploration. However, what is gained in clarity by conceptual abstraction is lost from the flavor of the actual experience. Like a weather map that statically represents major factors and currents in their interrelatedness, the framework discloses a nexus of elements. But it is as far from the real phenomenon of nursing with its pains and suffering and comforting and joys and hopes as the weather map is from real weather with its wind and rain and heat and cold. This chapter is concerned with the same basic framework of humanistic nursing but seen in an enlivened form. To inspirit its constructs the search must return again to the existential source, to the nursing situation as it is lived.

When I reflect on an act of mine (no matter how simple or complex) that I can unhesitatingly label "nursing," I become aware of it as goal-directed (nurturing) being with and doing with another. The intersubjective or interhuman element, "the between," runs through nursing interactions like an underground stream conveying the nutrients of healing and growth. In everyday practice, we are usually so involved with the immediate demands of our "being with and {22} doing with" the patient that we do not focus on the overshadowed plane of "the between." However, occasionally, in beautiful moments, the interhuman currents are so strong that they flood our conscious awareness. Such rare and rewarding moments of mutual presence remind us of the elusive ever-present "between."

>From these epiphanic episodes in our personal nursing experience, we have certain and immediate knowledge of intersubjectivity. Through our experience, too, we know that both humanizing and dehumanizing effects can result from human interactions. Therefore, it is essential for the development of humanistic nursing to explore and describe its intersubjective character.

Although many nurses have agreed in principle about the importance of this work, they also have expressed the feelings of frustration and discouragement attending it. There are real difficulties involved in attempting to describe something so real yet so nebulous as "the between." The descriptions must be derived from our own real nursing experiences. This means that we must develop habits of conscious awareness of experience, of recall, and of reflection. Then we must struggle with our language finding the words in our physically and technologically oriented vocabularies, perhaps even creating terms, to convey the substance and flavor of the experience of intersubjectivity.

Furthermore, description of the intersubjective quality of nursing is difficult because of its peculiar pervasiveness. Whether it is consciously recognized or not, it is part of every nursing transaction. However, to consider and explore intersubjectivity solely as a component or constituent of nursing, even a necessarily inherent or an essential one, would be to see it out of true perspective. The "between" is more than a factor or facet of nursing; it is the basic relation in which and through which nursing can occur. So the question remains. How can our experiences, our angular views, our glimpses of this foundation, this necessary means of nursing, be conceptualized and shared?

Once while reflecting on the nature of nursing against a background of notions about intersubjectivity drawn from experience and literature and testing them against my own real life experiences of nursing, I suddenly saw that nursing itself is a particular form of human dialogue. This insight occurred to me with clarity, conviction, and all the force of a brand new idea. It was so obvious, so distinct, so simple, so clearly a central intuition that could illuminate the phenomenon of nursing from within. I experienced the idea as fresh and excitingly full of promise.

Yet, when I said it out loud, "Nursing is dialogue," the words seemed too meager to convey the true meaning of the idea and its real significance. There was, furthermore, an annoying shadow of familiarity lurking about it. It was almost as if I had expressed something similar previously. At first, I hesitated to share this insight with others for fear they would extinguish it by saying, "of course, everyone knows that," or "I've heard you say something like that before." Still, I experienced it as an idea I had to express. Moved by the pressure of feelings of responsibility and desire to share, in 1973 I wrote a paper, "The Dialogue Called Nursing." {23}

In retrospect, that paper has the marks of a hesitant beginning, restrained by cautious statements and supposedly protective references to existential literature. Dissatisfaction with it prompted further rethinking and revision. Searching through my files during this process, I found, to my great surprise, some notes on the dialogic nature of nursing written by myself three and six years previously. In fact, a three-year-old note contained the very title, "Dialogue Called Nursing"! Now, how is it possible to grasp a truth and then "forget" that one knows it and later meet and grasp the old truth again as new? The difference in these experiences of knowing, for me at least in this case, is that now I know as if from the inside out that nursing is dialogical. The idea seems to have sprouted out of the lived phenomenon, to have broken forth from the ground of experience, as opposed to having been concluded in my earlier "intellectual," "theoretical," or "philosophical" ponderings. But how did the earlier idea, the conclusion that nursing is dialogical, become a live option for me? Why did it appeal to me? How did it come to make sense in the first place if not because of my experience?

The concept and the actual experience revitalize each other. Perhaps this is the value of an existentially grounded insight; it has a kind of durability resulting from its continuous rejuvenation by the interplay of experiencing and conceptualizing. Some old ideas are always new. In this spirit, this chapter looks again at humanistic nursing as lived dialogue.

LIVED DIALOGUE

The central insight (intuition or idea) from which this exploration grows is this: nursing itself is a form of human dialogue. I mean that the phenomenon of nursing, that is, the nurturing, intersubjective transaction, the event lived or experienced by the participants in the everyday world, is a dialogue.

Much has been written about dialogue and, as the word is now in vogue, it is being used in different ways. Here, the term "dialogue" is used to denote a broader concept than the typical dictionary definition of dialogue as "a conversation between two or more persons or between characters in a drama or novel." It is used in the existential sense. It implies an "ontological sphere," in Buber's terms, or the "realm of being" to which Marcel refers. Here it refers to a lived dialogue, that is, to a particular form of intersubjective relating. This may be understood in terms of seeing the other person as a distinct unique individual and entering into relation with him. In other words, nursing is a dialogical mode of being in an intersubjective situation.

As in common usage, here also, the term "dialogue" implies communication, but in a much more general sense. It is not restricted to the notion of sending and receiving messages verbally and nonverbally. Rather, dialogue is viewed as communication in terms of call and response. {24}

Nursing implies a special kind of meeting of human persons. It occurs in response to a perceived need related to the health-illness quality of the human condition. Within that domain, which is shared by other health professions, nursing is directed toward the goal of nurturing well-being and more-being (human potential). Nursing, therefore, does not involve a merely fortuitous encounter but rather one in which there is purposeful call and response. In this vein, humanistic nursing may be considered as a special kind of lived dialogue.

NURSING VIEWED AS DIALOGUE

These considerations of the dialogical character of nursing will be more fruitful if they are related to some concrete nursing experience. Reflect for a moment on your daily nursing practice. Recall an encounter, a specific interaction with a patient (client). Try to remember the details. Where were you? What time of day was it? Who was present? What was your state of being—what were you feeling, thinking, doing? How did the interaction begin? What happened between you? What was felt, said, done? What was left unsaid, undone? How did the interaction end or close? How long did the flavor last? Now keep this concrete instance of your lived nursing reality in mind and let it raise its questions in the following exploration.

Meeting

The act of nursing involves a meeting of human persons. As was noted above, it is a special or particular kind of meeting because it is purposeful. Both patient and nurse have a goal or expectation in mind. The inter subjective transaction, therefore, has meaning for them; the event is experienced in light of their goal(s). Or in other words, the living human act of nursing is formed by its purpose. Its goal-directedness colors the attributes and process of the nursing dialogue.

When a nurse and patient come together in a nursing situation, their meeting may be expected or planned by one or both or it may be unexpected by one or both. In any case, the goal or purpose of nursing holds. Even in a spontaneous interaction where they have met only by chance, in a health care facility or any place where one is identified as patient and the other as nurse, there is an implicit expectation that the nurse will extend herself in a helpful way if the patient needs assistance. If the meeting is planned or expected, this factor influences the dialogue. Each comes with feelings aroused by anticipation of the event, for example anxiety, fear, dread, hope, pleasure, waiting, impatience, dependence, hostility, responsibility.

Another factor experienced in their meeting is the amount of choice or control either nurse or patient had over their coming together. In today's complex health care systems, a nurse may be assigned to care for a particular patient, or for persons in an area or unit, or may be called into service through a registry, {25} or may be approached directly by a patient. From the other side, the patient also experiences varying degrees of control over his meetings with nurses depending on the system in which the health care is offered, his location, his financial means, and so forth. So when a patient and nurse do meet in a given instance, each comes to the situation bearing remnants of feeling of having caused or not having caused this encounter with this particular individual. (Of course, even in the most de-individualized systems the nurse and/or patient can still control their meetings to some extent, for example, avoidance by the nurse being too busy or avoidance by the patient feigning sleep.)

The patient and the nurse are two unique individuals meeting for a purpose. In the existential sense, each of these persons is his choice, each is his history. Each comes to meet the other with all that he is and all that he is not at this moment in this place. Each comes as a particular incarnate being. Each is a specific being in a specific body through which he affects the other and the world and through which he is affected by them. This nurse who uses her eyes, ears, nose, hands, her body, this way here and now meets this patient whose body in this condition serves him this way here and now.

Furthermore, both the patient and the nurse have the human capacity for disclosing or enclosing themselves. So they have some control over the quality of their meeting by choosing how and how much to be open with and to be open to the other. Their openness is influenced by their views of the purpose of the meeting. In general, the patient expects to receive help and the nurse expects to give it. However, their views may differ on the precise need and the kind of help to be given.

Also, although the nurse and the patient have the same goal, that is, well-being and more-being, they have different modes of being in the shared situation. One's purpose is to nurture; the other's is to be nurtured. This difference in the perspectives from which they approach the meeting is reflected in the kind and degree of their openness to each other.

In describing their experiences nurses often have revealed that they are open to patients in a certain way. This is evident when nurse and patient meet. The nurse may have prior knowledge of the patient, perhaps even an image of him drawn from case history, charts, tour of duty reports, and so forth; or she may meet him as a total stranger. But when they come together, the nurse sees "the patient as a whole." This global apprehension is not experienced as an additive summation but rather as a gestalt. It may result in a very clear "picture" of the patient's condition with nursing action initiated almost before the picture registers in full conscious awareness. Or the perception may be imprecise yet strong that "something is wrong." From these experiences one may infer that a nurse's openness involves being open to what is and to what is not in the patient's state of being as weighed against some notion (or standard) of what "ought" to be, with the intention of doing something about the difference. Thus, the nurse is open-as-a-helper to the patient. This kind of openness is a quality that characterizes the humanistic nursing dialogue. Of course, every nurse-patient meeting differs, for each participant comes to the situation as the {26} unique individual he is, with his own expectations and capacities for giving and taking help.

When these factors are considered in terms of an actual personal nursing experience (for instance, the example recalled above by the reader), they highlight a tension in the lived nursing world. The meeting through which the nursing dialogue is initiated and consequently is possible is, to a certain extent, out of the nurse's control. She is assigned to approach or she approaches the patient in terms of her function. In this sense, "the nurse" is synonymous with the function "nursing." Yet she experiences each meeting as herself—a unique individual person, this here-and-now being in this body responding in this situation. She is at once a replaceable cog in a wheel of an incomprehensibly complex system and a unique human being sharing most intimately in another's search for the meanings of suffering, living, dying. Can these two world views be reconciled? How can they be lived in the nursing dialogue?

Relating

As a human response to a person in need, the nursing act is necessarily an intersubjective transaction. Or to put it in other words, regardless of the complexity of need and/or response, when nurse and patient meet in the event of nursing both have "to do" with each other. Since both are human, their doing with means being with. (Reflect for a moment on the personally experienced patient encounter you recalled at the beginning of this exploration. Relive it and see clearly again that the nursing dialogue involves being with and doing with the patient.)

Men can do with and be with each other because they are able to see others and things as distinct from themselves and enter into relation with them. What distinguishes the human situation is that men can enter into a dialogue with reality. They have a capacity for for internal relationships, for knowing themselves and their worlds within themselves, they can relate as subject to object (for example, as knower to thing known) and as subject to subject, that is, as person to person. Both types of relationships are essential for genuine human existence.

It is natural, in fact unavoidable, for man to relate to his world as subject to object. How could a person survive even one day without knowing and using objects? Therefore, man's abilities to abstract, objectify, conceptualize, categorize, and so forth, are necessary for everyday living. Even beyond this, the human capacity for relating to the other as object is basic to the advancement of mankind for it underlies science, art, and philosophy. It is simply one way of being human.

Another mode of relating is open to men. Whenever two persons are present to each other as human beings, the possibility of intersubjective dialogue exists. Since both are subjects with the capabilities for internal relationships, they can be open, available, and knowable to each other. They can know each other within themselves. Furthermore, they can be truly with each other in the {27} intersubjective realm because while maintaining their own unique identities, they can participate in an interior union. Intersubjective relating is also necessary for human existence. For it is through his relationships with other men that a person develops his human potential and becomes a unique individual.

Nursing, being an interhuman event, has within it possibilities for various types and degrees of relationships. Both nurse and patient can view themselves and the other as objects and as subjects or in any variation or combination of these ways. A person can view and relate to another person as an object, for instance as a mere function ("patient," "nurse," "supervisor," "medicine nurse," "admitting nurse," "administration") or as a case or type ("schizophrenic," "cardiac," "outpatient," "readmission," "bed patient," "wheelchair patient," "total care patient," "terminal patient"). Such subject-object or "I-It" relationships differ essentially from subject-subject or "I-Thou" relationships.

As the derivation of the term indicates, an object is something placed before or opposite; it is anything that can be apprehended intellectually. Through objectification the object is de-individualized and therefore made replaceable for the purpose of study by any other object with the same properties. It is indifferent to the act by which it is thought and, therefore, the subject studying the object may also be replaced by a similar subject.

Although it is possible to view a person as an object, persons and things are necessarily different kinds of objects. A thing, as object, is open to a subject's scrutiny, while a person, as object, can make himself knowable or set up barriers to objectification. He can keep his thoughts to himself, remain silent, or deliberately conceal some of his qualities.

Through the scientific objective approach, that is, subject-object relating, it is possible to gain certain knowledge about a person; through intersubjective, that is, subject-subject relating, it is possible to know a person in his unique individuality. Thus, both subject-subject and subject-object relationships are essential to the clinical nursing process. Both are integral elements of humanistic nursing.

Presence

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.

In reflecting on nursing experiences, it becomes obvious that the call and response in the nursing dialogue goes both ways for nursing is transactional. Both patient and nurse call and respond. The pattern of the dialogue is complex. It continues over time, from moments to years, in an ongoing sequence that either patient or nurse may begin, interrupt, resume, or end. For instance, {30} the patient turns on his call light to ask for something. This is not only a call but also a response to the nurse's previously stated suggestion that he use the signal if he needs her help. Or again, a nurse may stop and talk with a patient during a chance meeting recalling that he previously had expressed feelings of loneliness, boredom, pain, or joy. Also, other persons or events may interrupt or end a nursing dialogue. For instance, the nurse is called away to help in another situation, the patient is discharged on the nurse's day off, the patient expires.

Furthermore, the call and response are not only sequential but also simultaneous. In this live dialogue both patient and nurse are calling and responding all at once. The patient's request, for instance, is a call for help and at the same time a response to the nurse's availability or offer to be of help. From the other side, the way a nurse responds to a patient's call is, itself, a call to him for a particular kind of response, a call for his participation in the dialogue.

Reflect for a moment on your own example. Was your response to the patient influenced by the value you placed on such factors as his independence, motivation, rehabilitation, growth, strengths, pathology; on time, on place; on agency policy? Here again goal-directedness affects nursing dialogue. Our interpretation of the patient's calls as well as our responses are colored by the aim of our practice. Our values are like calls within the calls. Or to state it differently, the values underlying our practice give meaning to the calls.

Viewing dialogical nursing as a particular form of call and response highlights its complexity. It reveals the intricacy not only of its patterns of flow but also of its means of expression. Nursing is a lived call and response reflective of every mode of human communication.

Much has been studied and written about verbal dialogue between patient and nurse. Examining verbal exchanges from the perspective of call and response could uncover even more about this aspect of the nursing dialogue.

It is more difficult to find written descriptions of nonverbal nurse-patient communication, although this aspect is generally recognized to be of equal significance. Here again the call and response framework could be a useful aid. For instance, what does a nurse's mere physical presence mean to a patient either as a call or response? Or from the nurse's standpoint, under what circumstances is a patient's presence experienced as a call and, even more, as a call for a particular nursing response? What prompts us to respond in terms of his posture, his color, his facial expression, his behavior, the appearance of his clothes? Are we almost unconsciously checking some kind of "vital signs" in the inter subjective realm?

Nursing dialogue is characterized by the unique feature of occurring through nursing acts. The dialogue is experienced in what the nurse does with the patient. A call and response of caring is lived through in nurse-patient transactions (nursing care activities) from the simplest, most basic acts of bathing and feeding to the most dramatic resuscitation. {31}

The nursing act itself contains a meaning for each person in the dialogue and the meanings may differ (for example, touching and being touched, feeding and being fed, bathing and being bathed). In addition, as a behavioral expression, the nursing act conveys a message, a reflection of the nurse's state of being (for example, anxious, hurried, troubled, absent, present, fully present). Furthermore, a nursing act may serve as an occasion, or even a catalyst, for opening or moving the dialogue in some direction on a verbal level (for example, bathing a patient may prompt his discussion of his body image or of his fear of disfigurement).

The complexity of possibilities in this unique feature of nursing dialogue (occurring through nursing acts) is staggering, especially so when one considers the additional factors associated with the effects of technological advances in nursing. Think, for instance, of the influence on your nursing dialogue of any technical nursing procedure. What happens between you and the patient when you place a thermometer into his mouth? Take his blood pressure? Give him an injection? Aspirate him? Do any form of monitoring, from the simplest to the most complex? Are the technical procedures and instruments bridges or barriers in the between?

DIALOGICAL NURSING IN THE REAL WORLD

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.

On entering a health care facility, the patient finds himself in a foreign world of strange objects. In place of his familiar possessions he is surrounded by equipment, machines, instruments, solutions, and so forth. He may experience these as bewildering, frightening, painful, supportive, soothing, life-sustaining. The nurse, on the other hand, may experience these same objects quite differently. To her they may be familiar tools, useful aids, complex machines, annoyingly defective equipment. Even in a situation that does not have special equipment, for instance in a home, the patient's world of things changes as the nurse converts ordinary objects into tools. Thus, while nurse and patient share a situation, the things in their shared world have different meanings for each. The things themselves as well as the persons' relations to them can serve to enhance or inhibit the intersubjective transaction of nursing.

Time

To view dialogical nursing as it is actually experienced in the real world, one must conceive of it as occurring in time, not simply measured time but also time as lived by patient and nurse. Certainly both participants are caught up in measured time and this influences their shared world, for example, eight-hour tours of duty, a day off, surgery scheduled at 8:00 a.m., discharge in two days, visit three times a week, clinic appointment in 30 days. Thus, to an extent, both patient and nurse must live by the clock and calendar.

However, equally important, or perhaps even more important, in the lived dialogue of nursing is the participants' experience of time. Some references were made to lived time in the section on call and response where it was noted how the nursing dialogue unfolds over time from moments to years. How the involved persons experience this continuity is an individual matter.

The nurse may conceive of herself as one of many persons contributing to a continuous stream of caring for the patient. So she will give and hear and write and read reports, note observations, keep records. She will carry an image of the patient in her mind continually adding to it or changing it with each interaction or report. Sometimes, after not seeing the patient for a time, on meeting him again she will "pick up where she left off," treating him as if he were the same person, as if days, months, years of living had not intervened. "Oh, it's him again." Or she may be startled by the visible changes and resume the dialogue from that point. Or even if change is not visible, she may be aware that it may have occurred and try to fill in the gap.

These possibilities may be mirrored from the patient's standpoint, for he likewise experiences continuity or lack of it in his care. And yet, the experience must be different for him. For instance, nurses may think of continuity of care in terms of "coverage" for a planned program of care. So it has often been {34} claimed that "the nurse is with the patient 24 hours a day." From the patient's point of view this is not true. A nurse may be with him but each nurse is different. The function of nursing may be continuous, but individual nurses come and go; the day nurse, the evening nurse, the night nurse are each unique individuals. And the nursing dialogue as lived, intersubjective transaction occurs between a particular nurse and a particular patient.

When we speak of a nurse and a hospitalized patient spending a day together, we usually are referring to eight hours out of a 24-hour day. They may both experience the spacing of this time by functions or activities such as meal time, medicine time, visiting time. Yet the measured minutes and hours are experienced differently by each in their different modes of being in the situation. Nurses often express feelings of not having enough time to give the care they want to give; of having too many demands on their time; of trying to "make time" for patients who ask "do you have a minute?" Patients live their time in relation to boredom, pain, loneliness, separation, waiting. The nursing dialogue runs its course in clock time but both nurse and patient live it in their private times.

When the nursing dialogue is genuinely intersubjective, it has a kind of synchronicity that is evident in the nurse's being with and doing with the patient. This kind of timing is related to the transactional character of nursing and to its goal of nurturing the development of human potential. It is experienced in openness, availability, and presence, as well as in nursing care activities. The nurse feels in harmony with the rhythm of the dialogue and, sensing the timing of its flow, she paces her call and response to patient's ability to call and respond in that moment. So, as a nurse, you may find yourself almost unconsciously or intuitively waiting, holding back, anticipating, urging the patient. This kind of synchronization or timing is intersubjective for the clues or reasons for encouraging or waiting are not found solely in the patient's behavior nor only in the nurse's knowledge or experience. "Good" or "right" timing somehow involves the "between." It implies that nurse and patient share not only clock time but private, lived time.

Space

By exploring the dialogue of nursing as it is lived in the real world the factor of space becomes apparent. Here again the dialogue is influenced by space as it is measured and space as it is experienced by nurse and patient. When thinking of health care facilities, "space" may be synonymous with such things as beds, waiting rooms, interview rooms, treatment areas, size of patient's room, visiting areas, a quiet place, a private place. Naturally, the physical setting, whether in a hospital, home, anywhere in the community, can serve to enhance or impede the nursing dialogue. However, the person's experience of the space may be even more important.

Space is lived in terms of large and small, far and near, long and short, high and deep, above and below, before and behind, left and right, across, all {35} around, empty, crowded. These perceptions and experiences of space may be influenced by the effects of illness, for example, changes in vision or locomotor ability. Thus, a patient's spatial world may change, expand or diminish, become unmanageable or manageable day by day. Furthermore, a patient's attitude toward and experience of a particular place may be affected by his mental association to it (for example, oncology ward, psychiatric unit), his previous experience in it (for example, emergency room, operating room), or a desire to be somewhere else (for example, "This is a nice hospital but I'd rather be home").

Place is a kind of lived space. It is personalized space. One says, for example, "Come to my place" meaning to my home. Or even more personally, it relates to where I feel I belong or am, for instance, "he put me in my place; I felt put down." The patient may feel "out of place" in the health care setting, while it may be commonplace to the nurse. There may be areas in the setting that the patient experiences as his territory, for example, his bed, his room, his ward; while other areas are "theirs" or "restricted to authorized personnel." So a nurse and a patient may be in a place together, yet one feels at home and the other does not. For the nurse to be really with the patient involves her knowing him in his lived space, in his here and now.

Lived space is interrelated with lived time. Patients hospitalized for a long time often express a proprietary attitude toward the hospital. The same holds true for personnel. With time and familiarity a feeling of reciprocal belongingness grows. The person belongs in the place and the place belongs to the person. On the other hand, when a person finds himself in a new place he may feel the discomfort of not belonging. This is as true for the nurse in an unfamiliar setting as for the patient. Again in this regard, the lived nursing dialogue is enhanced by the nurse's awareness of not only her own experience of space but the patient's as well.

CONCLUSION

This chapter explored the basic view of humanistic nursing as a phenomenon in which human persons meet in a nurturing, intersubjective transaction. Beginning with the central intuition that nursing is lived dialogue, the examination turned to its existential source, the nursing situation as it is lived. Reflection on actual experience clarified the phenomena of meeting, relating, presence, and call and response as they occur in humanistic nursing. Dialogical nursing was then reconsidered in broader perspective as it actually evolves in the real world of men and things in time and space.

As scientific advances multiply in the health field, nursing is swept along in the tide. Continuous technological changes, ever increasing specialization, emphasis in nursing education and research on scientific methodology all have marked influence on the development of nursing. Science (with a capital S) colors the nursing world. At every turn it permeates the nurse's being with and {36} doing with the patient. It offers a certain security by providing a consistent and effective approach to some problems and questions, and, in some cases, results in general laws to guide practice. At the same time, in the lived nursing world the nurse experiences a reality that is not open to the scientific approach, a reality not always verifiable through sense perception, a reality of individuality. The uniqueness of individuality (her own as well as the patient's) pervades the nursing dialogue.

The ever-present individual differences may be regarded as intractable elements to be conquered for the sake of the efficiency of the system (for example, fit the patient to the treatment program). Or they may be valued as indicators of the inexhaustible richness of human potential to be developed. In their daily practice, nurses are drawn toward the two realities—the reality of the "objective" scientific world and the reality of the "subjective-objective" lived world. This tension is lived out in the nursing act. Doing with and being with the patient calls for a complementary synthesis by the nurse of these two forms of human dialogue, "I-It" and "I-Thou." Both are inherent in humanistic nursing for it is a dialogue lived in the objective and intersubjective realms of the real world.

In the highly complex health care system nurses experience many demands from many directions. Their clinical judgments in daily practice must be made within a continuous stream of decisions about priorities of investment of their time and efforts. Sometimes, survival in the system reduces the nurse to following the line of least resistance, that is, responding to the immediate or to the loudest demands. However, even with their total commitment this course of response does not guarantee that nurses are making their greatest possible contribution to health care. This can happen only if we are able to see demands and opportunities in relation to our reason for being—nurturing the well-being and more-being of persons in need.

Humanistic nursing, viewed as a lived dialogue, offers a frame of orientation that places the center of our universe at the nurse-patient inter subjective transaction. Insightful recognition of the lived nursing act as the point around which all our functions revolve, could require a Copernican revolution of orientation of some nurses. It does provide, for all nurses, a true sense of direction that can be actualized by each unique nurse through creative human dialogue. {37}

4

PHENOMENON OF COMMUNITY

Humanistic nursing creates, happens within, and is affected by community. This chapter will discuss the abstract term "community." To stimulate thought on a nurse's influence on community, consideration will be given to three points: (1) my angular view of community and its evolvement, (2) how man has considered community over time, (3) how a human being comes to be through community.

MY ANGULAR VIEW

One can view members of a family, a student class, a hospital unit, a hospital staff, several related hospital staffs, health services organizations within a geographic area, a profession, a town to a world or universe as community. Man's mind, my mind, determines where I superimpose the limits or lift the limits or relate components. In The Republic Plato depicted a community as a macrocosm.[1] Its nature was conditioned by the kinds of men, the microcosms, that composed it. The macrocosm was a reflection of its microcosms.

So each human person, each nurse, as a microcosm, could make a difference. Reflecting on the lived worlds of nurses, their communities, if we use Plato's philosophical analogy of macrocosm-microcosm, despite the varieties of situation, we can make meaningful a basic concept of community. Such a concept utilized by a nurse to view her particular ongoing changing world can help her to understand more realistically, survive within, and strugglingly participate as a quality force.

To be a quality force within community a nurse must open her being to the endless innovative possibilities and unattempted choices available to her. {38} The ability to thus open one's self requires our exposing our biases, the shades through which we regard the world, to the sunlight. In nursing our shades often are closed categories, labels, diagnoses, trite superficial hackneyed expressions learned by us, taught to us as fact, taken in unexamined, and left unreexamined despite other changes in ourselves and our situations. Socrates said, and it still holds, that the unexamined life is not worth living. Our shades can be cherished concepts, beliefs that guide us automatically rather than thoughtfully. Whether they are entirely myth or partial truths, they can cause us agonizing dilemma because they obscure the obviously relevant and the possibilities beyond. A concept of community, if grasped and if a nurse is truly consciously aware, can help her to understand how her nursing world has evolved, is presently, and how she can be, to shape its future in accordance with her values.

As nurses one of our shades is often the confining labels we give to ourselves as doers in service giving profession. I would like to go on record as most respectful of this aspect of my world. I regret, nonetheless, that we have not always similarly crystallized and floodlighted the discovery and creative possibilities in our communities. In our very personal, intimate, involved professional nursing relations with other man we are privileged to be included in human happenings open to no other group. As nurses, we have had and are having emphasized to us the importance of facts handed to us. Can we actuate the importance of the knowledge of man that becomes part of us through our nursing worlds? It is hard to honor the significance of the everyday, the commonplace, the intimately known? It has been said that one could know of the whole universe if one could make every possible relationship starting from a piece of bread. Think of a "simple" or "routine" nursing situation. Think of its true complexity and how it can trigger puzzlement, wonderment, and thinking. As learning situations, nurses' situations are existentially priceless. Returning now to Plato's conception of community understood through the terms macrocosm and microcosm, what can the nursing world situation reveal to us of community? What are the qualities of the participants, the microcosms, and how are these qualities reflected in our nursing communities?

HISTORY: THE SHADES OF MY WORLD, BRACKETED

In years past as a public health mental health psychiatric nurse I have structured facts about man, family, and community precisely for presentation. Approaching the data sociopsychologically I framed it in the public health model of promotion of health, prevention of illness, treatment, rehabilitation, and maintenance. I thought of family sociologically as nuclear, procreative, and extended. In accordance with the psychoanalytic model, family members were oral, anal, oedipal, latent, homosexual, adolescent, heterosexual, and/or mature. Community, like person and family, was considered according to a {39} closed paradigm, ranging from ideal to abysmal, from the smallest to the largest unit in which persons congregated for common purposes. I selected from experience nursing examples to make these sociopsychological public health constructs meaningful. I did not start from nursing experiences to come up with nursing concepts of man, family, and community. I denied my particular self as a source of knowledge of these areas. Had education programmed me to value only others' ideas gleaned in the classroom or from books? I projected this devaluation of my own ideas onto my colleagues and until I really knew them gave them what I thought they wanted, others' ideas. Presently I prize my uncertainty about the nature of man in family and community and my striving toward an ever explorative process of being and becoming, available for surprise. Paradoxically, I believe it was these very same capacities, uncertainty and striving, that compelled my superimposing on my colleagues with certainty other persons' and other professions' views. Actually, my certainty about the conundrums: man, family, community come only in particulars and only in fits and starts, and my certainty is at once a truth and a nontruth. I see my aim as ever striving toward certainty while constantly wrestling with the discomfort of uncertainty.

EACH NURSE: A NOETIC LOCUS[2]

Each nurse is a "knowing place." It feels as if my greatest talents, as a human nurse person, awaited my acceptance that came through as I related to the existentialist thinking of persons like Martin Buber, Teilhard de Chardin, Frederick Nietzsche, Karl Popper, Hermann Hesse, Wilfrid Desan, and Norman Cousins. Now when I think of the phenomena—man, family, community—Theresa G. Muller, nurse educator and clinician, who quoted Hersey from his novel, A Single Pebble, comes to mind.[3] He said, "I approached the river as a dry scientific problem; I found it instead an avenue along which human beings moved whom I had not the insight, even though I had the vocabulary, to understand." I consider my greatest gifts as a human being nurse my ability to relate to other man, to wonder, search, and imagine about my experience, and to create out of what I come to know. My ever developing internalized community of world thinkers dynamically interrelated with my conscious awareness of my experienced nursing realm allows my appreciation of my human gifts and the ever enrichment of myself as a "knowing place."

NURSE: EXPERIENCE INTERNALIZED

Nursing experience taught me that each man, each family, each community was at once alike and different. Hesse, an existential novelist, in Steppenwolf, {40} describes each man who has become in family and community as like an onion with hundreds of integuments or a texture with many threads.[4] Then man's differences would be in the quality of his integuments and their development or in his threads in their preponderance. Contemplating the struggles in community regarding mutual understanding, I expanded Hesse's conception of man and found my vision of community to be a salad tossing or a patchwork quilt tumble drying.

Valuing the complexity of this conception of man and therefore of community I find myself smiling at the naivety of the earlier more static frames of order I superimposed on these phenomena. These oversimplifications maintained the shade through which I viewed my world. The shade was: others are knowing places, they are responsible; therefore if I quote authority from outside of myself, I can speak with certainty about what I know and believe and no one can attack me. And yet, my unique knowledge was not given and so my defense, my clutching at security foiled my human need for conceptualization of and expression of my own nurse vision of reality. This defeated the development by me of nursing theory.

Now I realize how I underestimated the potentialities of my nursing effect, of the difference I made, and could make. Just consider the given human uniqueness of each participant in the nursing situation whose familial potential goes back to an origin of thinking being or consciousness, and forward to his anticipation of the future, his eternity.

In the nursing literature, it is rather infrequent that we philosophically share our innermost thoughts, dreams, ideals, and strivings without a strong overlay of indoctrination or conversion. Nietzsche presents philosophy as autobiographical, such sharing does not offer maps. It could offer relevant resources and stimulate other nurses to influence the shape and becoming of the profession.

This chapter attempts to discuss ideas of community, the macrocosm, by considering man, the microcosm, as he develops in family and community. The ideas represent my "here and now" as it reflects my past and anticipated nursing world, including my hopes and expectations.

Man's Experience

Each human being carries a view of persons, families, and communities shaded by the views of his nuclear family. The past usually is corrected; it is never erased. So in his family of origin man internalizes ideas of "right-wrong," "appropriate-inappropriate," "expected-unexpected." Each family's shaded world echoes its procreators' familial, psychosocialeconomic, religious and experiential breadth, closely resembled or distorted. Two persons, perhaps more, usually husband and wife, bring shaded views together in some combination or balance that becomes the "stuff," the authority, of {41} their children's worlds. Thus, children see their early worlds through the complementariness and conflict of this initial home view, acting at times with it; at times against it.

Adults, in response to and through one another, procreate new sensitive beings whom they want and/or do not want and whom they may and/or may not experience as their responsibility in varying degrees. Marcel, a French existentialist philosopher, views procreation and responsible parenthood as quite different. My past nursing experience substantiates this. Marcel expresses my bias about responsible parenthood, and this statement is also worthy of consideration by nurses in positions of authority to others. He says, "We have to lay down the principle that our children (or those for whom we care) are destined, as we are ourselves, to render a special service, to share in a work, we have humbly to acknowledge that we cannot conceive of this work in its entirety and that a fortiori we are incapable of knowing or imagining how it is destined to shape itself for the young will, it is our province to awaken to a consciousness of itself."[5] Think of this statement of responsible authority. How has it been evidenced in families and nursing situations of your nursing world? What are your expectations of your patients or nurses with whom you work?

Teilhard de Chardin, paleontologist, biologist, and philosopher, like Nietzsche, depicts man as lacking a fixed nature with his own mode of being as his fundamental project.[6] Initially, each person takes on a mode of being in his world dependent upon his degree of freedom and the how and what of the world as presented by his family and perceived by him. The world as presented is reflective of the family's culture, their provincial world view, their unique experienced "here and now," and the times. Metaphorically, the family's lived world, how they experience at this particular cross-section of their lives, can be symbolically described as a kaleidoscopic telescoping of its past and anticipated future. Now, this would be what was presented at any particular time. What would a child's perception do to this metaphorical symbol? The child's current human development and his narrow experience would be like a circus house mirror that would interpret the metaphorical symbol distortedly. Witness a three-year-old speaking questioningly and complainingly about her tension headache to her mute, nonperceptive doll, and asking her to please, please stop making such a mess and racket.

The earliest childhood views of family and community are influenced over time, gradually and abruptly, and grow in complexity. The child's puzzlement is aroused by others' comings and goings, happenings within the family, immediate neighborhood, and adjacent community, and the world presented through books and technologically, on radio, television, and tape recorder. Each child attends these presentations with varying measures of complacency, questioning, bafflement, and involvement.

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For instance, for myself, as a child there was the excitement of the construction of a new house in the woods next door and meeting new neighbors. Initially my parents expressed their differences from ourselves. The differences they perceived were followed by negative projections on these unknown folk. Were these others really humanly different? I investigated; my family investigated. The folk became persons. They expressed themselves differently in volume and sometimes in language. They looked different. Yet they were not fearsome. They felt, cared, responded, and worried much as we did. Mutual knowledge allowed increasing closeness and liking.

Forbidden! This was the neighborhood across the tracks. I cried when an uncle teasingly proclaimed one day that my missing mother was over there. Later I attended school with both white and black children who lived over there. And again, each was different, yet not different; each was knowable, likeable, and loveable.

Adult family members whispered about a neighbor woman from across the street. She was apparently hospitalized permanently. When I inquired as to why, eyebrows were raised and strange looks were exchanged. I was told in a not believable way, "She broke her leg falling off the back porch."

A neighbor husband and wife frequently could be heard fighting both verbally and physically. Family talk at our house depicted the husband as "evil," the wife as a "poor soul." I did not enjoy being in these peoples' house. Perhaps the violence frightened me; perhaps I was uncertain when it might erupt? Perhaps I was concerned that I might one day somehow become part of such a situation? Now, looking back over the years, I would guess that both this husband and wife were "poor souls" struggling with their humanness as best they could.

An adolescent girl lived down the block. She was labeled as "strange," "peculiar," "odd," "crazy." Often one saw her talking to herself, skipping and rotating as she moved along in her always solitary and mysterious way. All expressed great sorrow for her always solitary and mysterious way. All expressed great sorrow for her elderly mother and father on her admission to the "State Hospital." Years later I wondered, and still wonder what happened to that girl, herself? What kind of an existence has she experienced?

During these early years there was also separation from and loss of close loved family members. When I was three and a half a great aunt who always appreciated my side of things moved out of our home due to a family argument. Perhaps most confusing of all during these preschool years, at four and a half, my father died suddenly. "They" said that he went to heaven, that God called him. Why did he go? Why would he leave us? Most important how could he leave me? What had I done wrong? Was it that I had not loved him enough? Been good enough to him? Was he angry? What kind of God is God, anyway? Is he benevolent, malevolent, indifferent? Is he real: is he believable? What can one expect and how should one act toward authority and power? The world didn't feel like a very safe place nor did persons appear to be dependable.

Then there was school. With additional authorities and peers there arose new wonderment and expectation. The way one was to be in school was {43} different from at home. And what was happening at home while I was at school? Could I depend on things being safe? In kindergarten I made an ash tray of clay for my already dead father.

In my child world there were books, radio, and the movies. Today children experience these, as well as television and record players. For me, books, radio, and the movies brought into my world new aspects of fear, excitement, joy, love, horror, violence, imagination, and suspense. They depicted at times the ideal and at times the abysmal. Sometimes, despite everything, good triumphed. At other times regardless of the effort invested all was lost. Where was the harmony of logical reason? Is our world absurd? Are we absurd to respond to it with an expectation of reason?

For each child there are very special, long-remembered events: being taught to swim by one's father, family picnics, trips into the world beyond city or country, going to the circus, a world's fair, a zoo or a fantasy land. There, also are the events of being loved and loving deeply, linked somehow with times of feeling unloved and unloving.

More than earlier, today there are multiple community groups for children where activities are guided and supervised. Within these situations and in the free play of neighborhood children, there is always the confusing, enlightening, and frequently distorted information gained through discovering your relationship with both boys and girls. Exploration by children into their sexual similarities and differences, a healthy pursuit, in the past more than today often aroused parental furor. Furor and different reactions from different involved parents lead to further child confusion and focus.

Within childhood peer relations there are games, play, and schoolwork that allow the child to come to know personally the meanings and feelings of competing, collaborating, fighting, winning, losing, destroying, building, aggression, passivity, constriction, freedom, and choice.

Then there is adolescence with all its moodiness, questions, fears, and experimenting related to adult modes of being. The moods are a mystery and the questions often unanswerable or the answers contradictory. Norman Kiell in The Universal Experience of Adolescence says that as adults we forget the intensity, turmoil, and concretes of this period and that perhaps we have to.[7] Yet, it is not possible that the instability and discomfort of spirit lived in adolescence does not leave its ingrained tracing as part of our eternal presents.

When the focus of our responsibility shifts from play to work, during these early years of becoming, depends on our particular circumstances and abilities. For most persons there is a tipping of the balance between these. Hopefully neither extreme is the master. Fortunately, in many instances, as the child's work as been to play; the adult's work world, his world of responsibility is lived, experienced by him, to an extent as play—it gives satisfaction and pleasure.

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Some adults select another and are chosen by this other for a sharing of their worlds. Some go it alone. Some procreate new beings; some create in other ways; some give-take and exist; some just lean. These last appear to be, and yet to not be, "all-at-once."

MAN BECOMES EVER MORE

Buber perceives man becoming more through his human capacity to relate to other being in all forms from the materialistic to the spiritual in "I-Thou," "I-It," and "We" ways.[8] Gestation, with the closeness of mother and child, has left man with an ingrained knowing of the experience of closeness. Thus, throughout man's life his condition of existence is affected by and desires relationship with and closeness to other being. The closeness of the conditions of gestation is never again possible, hence existential loneliness. Yet because of this prenatal experience Buber conceives of man as born with a "Thou"—another—before he is conscious of himself, his "I." With growing consciousness he sorts out his "I" from his "Thou." You can see the late infant doing, acting through, this separation. During this growing phase, often to the care-taking adult's frustration, he repeatedly, intensely, and excitedly throws his toys or bottle out of the crib, carriage, or playpen. Often he runs away from his "Thou," his parental security source, to a safe distance with intense awareness of what he is doing. While internalizing these and subsequent "Thous" as part of his "I," his knowing place, paradoxically, he sorts out who he is, and who and what is other than himself. So with ever more relationship, ever more experience, he becomes ever more the person he has the human capacity to be. He becomes more through his relations with others, never the same as these others, though he does internalize these others as part of himself.