Part 15 (2/2)
11. I attempted to encourage hope realistically through discussing individual therapeutic gains that could be derived from patients' investment in therapeutic opportunities available to them.
12. I supported appropriate patient self-images with as many concrete ”hard to denies” as possible.
Each of these nurse behaviors was repeatedly evident in the months of recording patient-nurse interactions. For the conceptualization of the term ”comfort,” a representative clinical example was given to enhance the meaning of the behavior cited (see Appendix). When compiling materials for the conceptualization of this term, I found 12 a.s.sumptions about psychiatric nursing that I had written for the theory course in one of the first cla.s.s sessions. Although these a.s.sumptions were expressed in different words, their congruence with my 12 selected behaviors made me believe that these behaviors were somehow verified both in my conceptualized philosophy of psychiatric nursing and in my behavior while being a psychiatric nurse.
Next I struggled with an idealistic conception of comfort as opposed to a continuum of behavior which would indicate a person's degree or state of discomfort-comfort. Again, reflecting on and teasing out aspects of my data, I set up four behaviorally recognizable criteria for estimating a person's discomfort-comfort state:
1. Relations.h.i.+ps with other persons which confirm one as an existent important person.
2. Affective adaptation to the environment in accord with knowledge, potential, and values.
3. Awareness of and response to the reality of the now with understanding of the influence of and separation from the past.
4. Appreciation and recognition of both powers and limitations which enlighten the alternatives of the future.
These behavioral criteria, too, could each be spread on a continuum to evaluate the effects of this aim of nursing on a patient's actual comfort status at any particular point in time.
Considering the concept of comfort as a proper aim of psychiatric nursing brought forth the necessity of considering its opposite, discomfort, as a concept. Evidence for the existence of discomfort could be inferred in the absence of the above behavioral criteria. {101}
The basic foundation to justify the concept of comfort as a proper aim of psychiatric nursing would be both organic and environmental. In our culture, among the species man, we are moving toward being able to effect some organic conditions by genetic controls and surgical and chemical means. The professions have struggled long years to influence environmental deterrents to comfort. If an individual as a fetus, or as an infant, or young child never internalizes comfort of any kind from his environs, the probability of initiating a continuum within himself as an adult that is propelled toward comfort seems unlikely. Such individuals, lacking any potential capacity for comfort, I suspect are rare. There is evidence for the existence of this dormant seed of comfort in persons with schizophrenia in the hospital setting. Consider how repet.i.tively and ambivalently they ”reach out” to authority figures.
This dormant comfort seed requires nourishment of a high quality for testing whether it can develop and bear the fruits of health, growth, freedom, and openness.
When the development of this synthetic construct of comfort was discussed in the theory course a question was raised: Is a person who denies all feeling, presents himself as emotionally dead, comfortable?
If feelings are not relegated to the mind alone, as the effects of a peptic ulcer cannot be relegated to the stomach, if feelings are an essential of the nature of humanness, a human who denies this essential of his nature would not fit into this concept as comfortable. This synthetic construct of comfort, like its synonym contentment, described by Plutarch A.D. 46-120, does not imply pa.s.sivity, resignation, retirement, or a simple avoiding of trouble. Plutarch said, ”Contentment comes very dear if its price is inactivity.”[3] I would perceive of comfort or contentment as implying that a human being was all he could be in accordance with his potential at any particular time in any particular situation.
Continuing the aforementioned twelve nurse behaviors, observing behavior through the four established criteria and conceptualizing the construct of comfort, I began to wonder. Was I seeing what I had decided was the state of psychiatric patients' conditions of being? Was I projecting discomfort onto patients? I did not expect straight answers.
Nonetheless, I decided to ask patients about their discomfort-comfort states to verify my perception of the condition of their beings. All fourteen patients I asked a.s.sured me by their responses that I was not projecting or seeing discomfort where it did not exist.
Some described physical discomfort and sought the cause within and outside themselves (either another caused it, or another could cure it, pills would cure it), negatively viewed self-images, guilt based in their behaviors or thoughts. One patient defined comfort by a.n.a.logy and stated directly to my surprise that he seldom felt comfortable and that his excessive ritualistic behavior was his way of coping with his discomfort. One repet.i.tively stated a happy illusion that he seemed to hang on to for dear life. When I asked what he would do if this illusion was not truth, he said that he had never considered {102} this possibility. I knew he had been confronted with the truth of his situation many times in many ways. One patient merely looked directly at me and walked away.
Then I again reviewed my clinical recorded data to see what kinds of knowledge nursing with an aim to comfort would infer as necessary.
Fifty-two items of knowledge were extrapolated from the clinical examples selected as representative of the twelve nurse behaviors. These items were categorized under broad cognitive and affective domains. This was an arbitrary point of separation. They were teased apart simply as an aid to conceptualization and understanding. If these knowledge domains had related to one another in a simple direct manner, I would have conveyed them in a table in which each would have been across from its mate. Their relations.h.i.+ps to one another were far too complex to be handled in any such a way. The affective domain knowledge areas were a dynamic internalized synthesis of several knowledge areas from the cognitive domain. Thus, the expression of these affective knowledge areas was evidence of the practice of nursing as an artful form of expressing cognitive knowing.
In looking directly at the discomfort of long-term hospitalized psychiatric patients, I found myself faced with behaviors that resulted possibly from a muddle of many contributories. What in the behavior resulted from lifetime environmental influences and compounded responses that deepened scars? What resulted from long-term hospitalization? How many varieties of ills superimposed like layers on the above were expressed in what I saw as discomfort in these psychiatric patients?
Diagnostic cla.s.sifications are necessary for statistical economic planning reasons. Still, how naively and superficially they convey the human therapeutic care needs of each person.
At this point of construct development I saw a positive relations.h.i.+p in my thinking about comfort as a proper aim of psychiatric nursing and Viktor Frankl's description of his aim in logotherapy toward meaning. I had struggled with the idea of aiming at comfort while with patients who possessed ability and a favorable prognosis, often purposefully and deliberately asking them to consider ideas that caused them immediate greater discomfort. Frankl's quotes from Nietzsche and Goethe supported my altruistic intention. Nietzsche said:
”He who has a why to live can bear almost any how.”[4]
Goethe said:
”When we take man as he is, we make him worse; but when we take man as if he were already what he should be, we promote him to what he can be.”[5]
In conclusion to this stage of development of a synthetic construct of comfort as an aim of psychiatric nursing I can say: Comfort is an aim toward {103} which persons' conditions of being move through relations.h.i.+p with others by internalizing freedom from painful controlling effects of the past. These effects have inhibited their self-control, realistic planning, and prevented them from being all that they could be in accordance with their potential at any particular time in any particular situation. I would project this as an aim for nursing in all situations although the data for constructing this conceptualization were gathered in a clinical psychiatric setting.
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