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?