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.