The concept of nursing situation is central to every aspect of the
theory of Nursing as Caring. We have claimed that all nursing knowledge
resides within the nursing situation (Boykin & Schoenhofer, 1991). The
nursing situation is both the repository of nursing knowledge and the
context for knowing nursing. The nursing situation is known as shared
lived experience in which the caring between the nurse and the one
nursed enhances personhood.
It is to the nursing situation that the nurse brings self as caring
person. It is within the nursing situation that the nurse comes to know
the other as caring person, expressing unique ways of living and growing
in caring. And it is in the nursing situation that the nurse attends to
calls for caring, creating caring responses that nurture personhood. It
is within the nursing situation that the nurse comes to know nursing, in
the fullness of aesthetic knowing.
The nursing situation comes into being when the nurse actualizes a
personal and professional commitment to the belief that all persons
are caring. It should be recognized that a nurse can engage in many
activities in an occupational role that are not necessarily expressions
of nursing. When a nurse practices nursing thoughtfully, that nurse
is guided by his or her conception of nursing. The concept of nursing
formalized in the Nursing as Caring theory is at the very heart of
nursing, extending back into the unrecorded beginnings of nursing
and forward into the future. Acknowledgement of caring as the core
of nursing implies that any nurse practicing nursing thoughtfully is
creating and living nursing situations because, whether explicit or
tacit, the caring intent of nursing is present.
Remember that the nursing situation is a construct held by the nurse,
any interpersonal experience contains the potential to become a nursing
situation. In the formal sense of professional nursing, the nursing
situation develops when one person presents self in the role of offering
the professional service of nursing and the other presents self in the
role of seeking, wanting, or accepting nursing service.
The nurse intentionally enters the situation for the purpose of coming
to know the other as caring person. The nurse is also allowing self
to be known as caring person. Authentic presence, like most human
capacities, is inherent and can be more fully developed through
intention and deliberate effort. Authentic presence may be understood
simply as one's intentionally being there with another in the fullness
of one's personhood. Caring communicated through authentic presence
is the initiating and sustaining medium of nursing within the nursing
situation.
The nurse, with developed authentic presence and open to knowing the
other as caring, begins to understand the other's call for nursing.
A call for nursing is a call for specific forms of caring that
acknowledge, affirm, and sustain the other as they strive to live caring
uniquely. We must remember as well that calls for nursing originate
within the unique relationship of the nursing situation. As the
situation ensues, the call for nursing clarifies. The nurse comes to
know the one nursed more and more deeply and to understand more fully
the unique meaning of the person's caring ways and aspirations for
growing in caring. It is in this understanding that the call for nursing
is known as a specific situated expression of caring and a call for
explicit caring response.
The nursing response of caring is also uniquely lived within each
nursing situation. In the nursing situation, the call of the nursed is a
personal "reaching out" to a hoped-for other. The nursed calls forth
the nurse's personal caring response. While the range and scope of human
caring expression can and must be studied, the caring response called
forth in each nursing situation is created for that moment. The nurse
responds to each call for nursing in a way that uniquely represents the
fullness (wholeness) of the nurse. How I might respond to such a call
would and should reflect my unique living of caring as person and
nurse. Each response to a particular nursing situation would be slightly
different and would portray the beauty of the nurse as person.
The nursing situation is a shared lived experience. The nurse joins in
the life process of the person nursed and brings his or her life process
to the relationship as well. In the nursing situation, there is caring
between the participants. Further, the experience of the caring within
the nursing situation enhances personhood, the process of living
grounded in caring. Each of these components of the construct of
the nursing situation raises questions for immediate and continuing
discussion.
How can an unconscious patient be a participant in a nursing situation?
Can "postmortem care" be considered nursing? How can the nurse know that
the other is truly open to nursing--can the nurse impose self into the
world of the other? What about an unrepentant child rapist or a person
responsible for genocide, can we say that person is caring, and if not,
can we nurse them? Does the nurse have to like the person being nursed?
Does the nurse seek enhancement of personhood in the nursing situation?
If so, might the goals of the nurse be imposed on the one nursed? If the
nurse gains from the nursing situation, isn't that unprofessional?
In part, these legitimate questions raise larger issues about the
uniqueness and scope of nursing as a discipline and professional service
in society. Certainly the study of these questions adds clarity to the
purpose of nursing actions. To nurse, situations in a general sense
are transcended and transformed When they are conceptualized as nursing
situations. From the perspective of the Nursing as Caring theory, the
study of these questions would require that the nurse transcend social
or other situational contexts and live out a commitment to nurture the
person in the nursing situation as they live and grow in caring.
Persons with altered levels of consciousness, measured on normative
scales developed for medical science purposes, can and do participate
in nursing situations. Nurses committed to knowing the unconscious as
caring person can and do describe their ways of expressing caring and
aspirations for growing in caring. Nurses speak of the post-anesthesia
patient as living hope in their struggle to emerge from the deadening
effects of the anesthesia; as living honestly in fretful, fearful
thrashing. Nurses help these persons sustain hope and extend honesty
through their care. The profoundly mentally disabled child lives
humility moment-to-moment and calls forth caring responses to validate
and nurture that beautiful humility. Nurses speak of caring for their
deceased patients as nursing those who have gone and are still in some
way present. The nurse, connected in oneness with the one known
and nursed, holds hope for the other as the other's expression of
hopefulness lives on in the consciousness of the nurse. Thus, a sense
of connectedness does not dissipate when physical presence ends, but
remains an active part of the nurse's experience.
Nursing another is a service of caring, communicated through authentic
presence. Nursing another means living out a commitment to knowing the
other as caring person and responding to the caring other as someone of
value (Boykin & Schoenhofer, 1990, 1991). In its fullest sense, nursing
cannot be rendered impersonally, but must be offered in a spirit of
being connected in oneness. "To care for" seems to require that the
caregiver see oneself as caring person reflected in the other (Watson,
1987). The theoretical perspective of Nursing as Caring is grounded in
the belief that caring is the human mode of being (Roach, 1984). When
a person is judged by social standards to be deviant and even
evil, however, it is difficult to summon caring. This points to the
contribution nursing is called upon to make in society. When we speak
of nursing's contribution here, we are invoking earlier discussions of
discipline and profession. Each discipline and profession illuminates a
special aspect of person--in effect, what it means to be human. The light
that nursing shines on the world of person is knowledge of person as
caring, so that the particular contribution of nursing is to illuminate
the person as caring, living caring uniquely in situation and growing in
caring. In nursing, practiced within the context of Nursing as Caring,
the person is taken at face value as caring and never needs to prove
him or herself as caring. The nurse, practicing within the context of
Nursing as Caring, is skilled at recognizing and affirming caring in
self and others. Being caring, that is, living one's commitment to this
value "important-in-self" (Roach, 1984), fuels the nurse's growing in
caring and enables the nurse I turn to nurture others in their living
and growing in caring. The values and assumptions of nursing as caring
can assist the nurse to engage fully in nursing situations with persons
in whom caring is difficult to discover.
Nursing knowledge is discovered and tested in the ongoing nursing
situations. Once experienced, nursing situations can be made
available for living anew, with new discovery and testing. Aesthetic
representation of nursing situations brings the lived experience into
the realm of new experience. Thus, the knowledge of nursing can be made
available for further study. Re-presentation of nursing situations
can occur through the medium of nursing stories, poetry, painting,
sculpture, and other art forms (Schoenhofer, 1989). Aesthetic
re-presentation conserves the epistemic integrity of nursing while
permitting full appreciation of the singularity of any one nursing
situation (Boykin & Schoenhofer, 1991). Here, then, is one nurse's story
of a shared lived experience in which the caring between nurse and the
one nursed enhanced personhood. This story is offered as an example
of nursing situation, re-presented as an open text, available for
continuing participation by all who wish to enter into this shared lived
experience of nursing. In fact, we invite the reader to enter into this
nursing situation, which may then be used in classroom or conference
settings to stimulate general or specific inquiry and dialogue.
CONNECTIONS
One night as I listened to the change of shift report, I remember the
strange feeling in the pit of my stomach when the evening nurse reviewed
the lab tests on Tracy P Tall, strawberry-blonde and freckle-faced,
Tracy was struggling with the everyday problems of adolescence and
fighting a losing battle against leukemia. Tracy rarely had visitors.
As I talked with Tracy this night I felt resentment from her toward her
mother, and I experienced a sense of urgency that her mother be with
her. With Tracy's permission I called her mother and told her that Tracy
needed her that night. I learned that she was a single mother with
two other small children, and that she lived several hours from the
hospital. When she arrived at the hospital, distance and silence
prevailed. With encouragement, the mother sat close to Tracy and I sat
on the other side, stroking Tracy's arm. I left the room to make rounds
and upon return found Mrs. P. still sitting on the edge of the bed
fighting to stay awake. I gently asked Tracy if we could lie on the bed
with her. She nodded. The three of us lay there for a period of time and
I then left the room. Later, when I returned, I found Tracy wrapped
in her mothers arms. Her mothers eyes met mine as she whispered "she's
gone." And then, "please don't take her yet." I left the room and closed
the door quietly behind me. It was just after 6 o'clock when I slipped
back into the room just as the early morning light was coming through
the window. "Mrs. P," I reached out and touched her arm. She raised her
tear-streaked face to look at me. "It's time," I said and waited. When
she was ready, I helped her off the bed and held her in my arms for
a few moments. We cried together. "Thank you, nurse," she said as she
looked into my eyes and pressed my hand between hers. Then she turned
and walked away. The tears continued down my cheeks as I followed her to
the door and watched her disappear down the hall.
Gayle Maxwell (1990)
This nursing situation is replete with possibilities for nurses, and
others, to understand nursing as nurturing persons living caring and
growing in caring. A dialogue ensues on the nursing situation that
allows participants an opportunity to experience both resonance and
uniqueness as personal and shared understandings emerge. As the reader
enters into the text, the nursing situation is experienced anew,
now within the presence of two nurses, not one. Though intentionally
entering the situation, the second nurse experiences d affirms being
connected in oneness with both nurse and nursed as caring lived in the
moment.
Gayle entered into Tracy's world that night open to hearing a special
call. Gayle's openness was partly a reflection of her use of the
empirical pathway of knowing, the data given in report, the comparison
of empirical observations against biological, psychological,
developmental, and social norms. Before discussing our understanding of
Gayle's response from the theoretical per-perspective represented,
it might be helpful to compare how the call for nursing may have been
interpreted if approached, for example, from a psychological framework.
If the nurse responded from a psychological framework, the problem
identified would perhaps be conceptualized as denial on the part of
Tracy's mother. It could be assumed that Tracy's mother was avoiding the
reality of the impending death of her daughter. Here, the nursing goal
would be assist the mother in dealing with her denial by facilitating
grieving. Denial is only one psychological concept that could be applied
in this situation; avoidance, anxiety, and loss are others. When nursing
care is based on a psychological framework, however, the central theme
of care is likely to be deemphasized in favor of a problem-oriented
approach. The perspective offered by a normative discipline requires
a reliance on empirical knowing. Using only the empirical pathway of
knowing, the richness of nursing is lost.
Gayle's personal knowing, her intuition, however, was the pathway
that illuminated the appreciation of this situation and prompted her
acknowledgement of a call. She heard Tracy's call for intimacy, comfort,
and protection of her mother's presence as she (Tracy) summoned courage
and hope for her journey. Gayle intuitively knew that the specific
caring being called forth was the caring of a mother. Gayle's caring
response also took the form of the courageous acknowledgement of a call
for nursing that would be difficult to sub-stantiate empirically. Beyond
telephoning Tracy's mother, Gayle continued her nursing effort to answer
Tracy's call for the presence of a mother as she supported Mrs. P. living
her interconnectedness, in being with Tracy. Gayle heard Mrs. P.'s calls
for knowing, knowing what to do and knowing that it would be right to
do it, for the courage to be with her daughter in this new difficult
passage. Her response of showing the way reflects hope and humility. The
caring between the nurse and the ones nursed enhanced the personhood of
all three, as each grew in caring ways. It is possible that the caring
between the original participants in the nursing situation and those of
us who are participating through engagement with the text continues to
enhance personhood.
REFERENCES
Boykin, A., & Schoenhofer, S. (1991). Story as link between nursing practice, ontology, epistemology. Image, 23, 245-248.
Boykin, A., & Schoenhofer, S. (1990). Caring in nursing: Analysis of extant theory. Nursing Science Quarterly, 4, 149-155.
Maxwell, G. (1990). Connections. Nightingale Songs, 1 (1). P.O. Box 057563, West Palm Beach, FL 33405.
Paterson, J., & Zderad, L. (1988). Humanistic nursing. New York: National League for Nursing Press.
Roach, S. (1984). Caring: The human mode of being, implications for nursing. Toronto: Faculty of Nursing, University of Toronto. (Perspectives in Caring Monograph 1).
Schoenhofer, S. (1989). Love, beauty and truth: Fundamental nursing values. Journal of Nursing Education, 28 (8), 382-384.
Watson, J. (1987). Nursing on the caring edge; Metaphorical vignettes. Advances in Nursing Science, 10, 10-18.
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