Part 5 (1/2)
Other Human Beings
The dialogue lived between nurse and patient is affected by their numerous other interhuman relations.h.i.+ps. 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 relations.h.i.+ps 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 antic.i.p.ated interhuman relations.h.i.+ps. 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 relations.h.i.+ps. How he experiences his relations.h.i.+ps 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 antic.i.p.ated changes in interpersonal relations.h.i.+ps 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 partic.i.p.ants 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 partic.i.p.ants' 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 s.p.a.cing 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, antic.i.p.ating, 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.
s.p.a.ce
By exploring the dialogue of nursing as it is lived in the real world the factor of s.p.a.ce becomes apparent. Here again the dialogue is influenced by s.p.a.ce as it is measured and s.p.a.ce as it is experienced by nurse and patient. When thinking of health care facilities, ”s.p.a.ce” 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 s.p.a.ce may be even more important.
s.p.a.ce 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 s.p.a.ce 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 att.i.tude toward and experience of a particular place may be affected by his mental a.s.sociation 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 s.p.a.ce. It is personalized s.p.a.ce. 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 s.p.a.ce, in his here and now.