Phenomenology Online

A Resource for Phenomenological Inquiry

The Nursing Moment

 

Hawley, Patricia

 

In “Nursing the finest art: An illustrated history”, Donahue (1996) includes a photo of a poster created by Melody Chenevert of a Victorian crazy quilt with the caption “Nursing-a career not measured in years but in moments”. She writes:

A Victorian crazy quilt. A nursing career. What is it they have in common? Rich fabric. Fragmented. Held together by heart and hand.

Elaborately embellished with unforgettable moments. Fine art. Painstakingly executed. A work in progress, often unfinished. Chaotic yet controlled. And synergy – the whole is greater than the sum of its parts. In the end we will not remember the years we spent in nursing. We will only remember the moments. (p. 473)

A nursing moment …?

 

A moment of understanding

I have a patient, Bob, a high school teacher and soccer coach. He is 29 years old. He was admitted to our neurosurgical ICU with a broken neck. It was the last day of school. The teachers were having a party at the principal’s cottage at the lake. Bob dived into shallow water.

 

One day an independent, active man, whole and mobile. The next, he lies in a hospital bed, motionless. His head suspended in traction. Mouth, face and eyes are the only body parts moving. Within hours of his admission his breathing became shallow and rapid, his breathing muscles getting progressively weaker. He required the support of a ventilator. No longer able to speak, blinking became his only means for communication-one blink for yes, two for no.

 

One day I sensed that Bob was having a rough time-I just knew. I could feel the tension. He was experiencing a lot of pent-up frustration. Just before leaving I bent over and said, “Bob, when I go for coffee … I’ll scream for you.”

When a person’s body is broken, his world is broken. In Bob’s case his world has narrowed to the bed he occupies and the people who move in and out of his field of vision. No longer an able-bodied man he is now suddenly, unexpectedly and permanently disabled. No longer independent, but totally dependent. Unable to do anything for himself, he is now restricted to having things done for him, including the most fundamental things: breathing, and yes, screaming. In traction and immobile, Bob’s body now is lame and muted. Unable to speak, he is bodily trapped: entrapped as a body, and entrapped in a body. What is this existence like? What does he feel? Minutes must seem like hours, hours like days. Which thoughts are most impossible to endure? Which tortures are most unbearable? Even people who are tortured can still do one thing: scream. Bob’s torture is that he cannot even do that.

 

It is easy for the nurse to forget all this. To forget to imagine what it must be like to be a patient like Bob. How can anyone know what this is like? And how does one know what to say or do if one does not really know what it is like to suffer like this? The nurse can perform her technical skills and use her knowledge to attend to the patient competently. But how does one help the patient make life endurable? liveable? Perhaps no amount of formal study, no theory, no body of knowledge can possibly tell one how to be there as a nurse. A different kind of knowledge is needed: communicative knowledge and understanding. To practice communicative understanding the nurse needs empathic intuition. Knowing on the spot what to say or do. Intuition derives from the Latin intueri, meaning, to see within (Skeat, 1980). Intuition involves an immediate and direct knowing without conscious reasoning (Webster-Merriam, 1992). It requires a sensitive ability to interpret inner thoughts, understandings, feelings, and desires from indirect clues such as gestures, demeanor, expression and body language (van Manen, 1991). Benner & Tanner (1987) suggest that knowing the patient or having a feeling of connectedness enhances the nurse’s ability to recognize subtle clues that facilitate the intuitive experience.

 

“I’ll scream for you.” What an odd thing to say. And yet, how perfectly appropriate did the nurse sense what was this person’s suffering predicament: the need to vocalize his feelings. Later, when Bob was breathing on his own, and able to talk again, he told this nurse, “I’ve been waiting all this time to tell you this: I was so grateful for your willingness to scream for me. This I will never forget! I had indeed the feeling that someone understood me. My desire to yell, scream, cry out of utter desperation.”

 

Perhaps Bob’s desire is not so difficult to understand. A desire of the body to express itself. What do we normally do when we are in real pain or deeply frustrated? We may slam a door, kick a garbage can, throw something, bang a fist, go for a run, etc. Or, we may resort to verbal activity: cry, moan, weep, yell. In Bob’s case he could do none of this. He could not move and he could not talk. Even if he could have talked, words might not have been enough to express the way he was feeling. Sometimes the body needs to scream-a primordial mode of expression of desperation or frustration. What the nurse did was lend the patient her voice, her throat.

 

A moment of being present

While sitting at the nurses’ station I heard one of the most desperate cries of my life coming from a woman who appeared “out of nowhere”. I jumped off my chair and approached her. I had no idea who she was, but knew that something awful must have happened.

 

Placing my arm around her I said, “Come with me.” I took her into the family room, grabbing a box of Kleenex on the way. I sat with my arm firmly around her shoulders and asked her to tell me her name and what happened. Connie had been attending her seriously ill father when he suddenly stopped breathing. “I’m afraid he has died. They’re all down therethe doctor, the nurse. But I just know he is dead!”

 

She was shaking from head to toe and breathing very rapidly along with the uncontrollable sobbing. I coached her to do some slow deep-breathing. Before long the shaking stopped and she was able to talk about the possibility that her father had indeed passed away and what that would mean to her. I had a gut feeling that if her father had died this woman would not be able to make sound decisions on her own or drive home by herself. I was even concerned that she might do something self-destructive considering that she had revealed to me a history of depression which precipitated hospital admission in the past. I continued to hold her and simply listen to her grief. Connie said, “My father is my life-line. He is my only reason to go on living. I have been looking after him since my mother died.”

 

Then the doctor arrived with the bad news. I stayed with her until family arrived and made sure that she was accompanied home. After her telling me that she was not close to her siblings, I sought the name and number of her social worker who I then called to ask to be there when she arrived home.

 

I remember thinking to myself that my “being there for this woman was more important than the chart reading I was supposed to do.” I felt that I was able to help someone in need without actually doing things.

 

Several weeks later, while on duty with nursing students, the pastoral care Sister approached me with a message. Connie had phoned to tell that she was doing okay. She asked the Sister to pass on her thanks to me for being there for her the moment her father passed away, and that my kindness, concern and understanding would never be forgotten.

Sometimes nursing is not so much a kind of doing but a kind of being: being present in a moment of crisis and need. What is presence? The word presence is of Latin and French origin. It derives from the words praesen from prae, meaning in front, and sens, meaning being. The same word as a verb, praesentare, means to place before, to hold out, to offer, from which the nouns gift and present evolved (Skeat, 1980). Doona, Haggerty, & Chase (1997) define nursing presence as an intersubjective encounter between a nurse and patient in which the nurse approaches the patient as a unique human being in a unique situation (p. 12). Patterson & Zderad (1976) say:

A genuine intersubjective encounter only occurs when there is a certain openness, a receptivity, readiness or availability. The open or available person reveals him/herself as “present”. This is not the same as being attentive; a listener may be attentive and still refuse to give him/herself. 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. Availability implies, therefore, not only being at the other’s disposal but also being with him/her with the whole of oneself. Furthermore, it involves reciprocity. The other is also seen as a presence, as a person rather than an object. (pp. 30, 31)

Although the nurse describes her presence as being there, Connie’s experience reveals that it is more than a sheer physical presence. Being there also connotes a “being with” the other, a living personal presence. The nurse, in being with this woman, responded openly, willingly, and listened attentively. Feeling the nurse’s presence this woman knew the nurse’s desire to help was authentic and that her well-being was a priority to the nurse. She felt protected and no longer alone. She felt comfortable and secure enough to share her pain. To this nurse she mattered.

 

A moment of comforting the discomforts

A couple of hours into what was a busy night, 23 year-old Brian started to wake up from the heavy sedation he had received during intubation after he suddenly, without warning, stopped breathing upstairs on the neuro unit. He was brought to our ICU and assigned to me. Because he was being ventilated he could not talk to me, but his eyes spoke volumes. Where am I? What has happened to me? Am I going to be all right?

 

Brian was obviously terrified. Right away I went up to his face and spoke to him in a soft calming voice. I told him who I was, where he was, what had happened, what was going on and what all the tubes were for. I tried to reassure him by telling him that I would be by his side all night. I told him some of the things that I would be doing to him: monitoring his vital signs, giving medication, turning him, bathing him, and suctioning him.

 

Suctioning is the most horrible thing to have to do to anyone and the most horrible thing to have done to you. Knowing that, I explained in detail what I had to do, why I had to do it, what it was going to feel like and that it would be over as quickly as possible. I also told him what he could do to help minimize the discomfort. It was amazing to see the change come over him. His vital signs returned to more normal but the most dramatic change was in his eyes: the fear had dissipated. He started to relax, was able to cooperate with my instructions and eventually was able to sleep in between interruptions.

All of us at one time or another have emerged from sleep or a strange dream and for a fleeting moment did not know where we were, or perhaps, what day it was. It didn’t take long to come to our senses but the interim feeling was not pleasant. Perhaps there might have even been a moment of alarm or panic. Confused or dazed we ask ourselves questions that help us to regain our orientation. Then all is well.

 

Now imagine waking up in a bed in the intensive care unit, not knowing how you got there. You feel groggy, disoriented. You see only strangers. There is unfamiliar machinery all around you. Strange noises, beeps, whooshing sounds, and alarms ringing. The room is very bright but you are not sure whether its day or night. You are even unsure of what day it is.

 

Imagine having no recollection of arriving there, trying to recall what you last remember. You feel a tube down your throat, you can’t swallow, and you can’t talk. Your body feels heavy, caught up in the web of lines and tubes that are protruding from your body. You feel confined. Your body appears connected to equipment but seems disconnected from your memory. The secure relationship you had with your body and your world is now insecure. This is the terror of a bad dream that is not a dream.

 

The eyes can speak volumes without any solicitation. Brian’s nurse was attentive, listening, observant. She knew that this patient needed answers to questions he could not pose. Some questions she could not answer. She knew that he needed to feel safe, secure, and protected from further harm. She knew that he needed to know that someone was looking out for him, watching over him, worrying about him. She also knew that she would have to hurt him to help him.

 

Nurses are supposed to alleviate discomfort, not inflict it. Nurses are supposed to protect patients from hurt, not cause it. If one were to ask a nurse, “when was the last time you hurt a patient?” she would probably startle. But then she would admit in all likelihood that she had to cause pain when she inserted the needle, passed the catheter, dressed the wound, suctioned the chest, turned the patient, and so forth. Nurses frequently must inflict pain in carrying out necessary nursing and medical interventions. How do nurses reconcile such role conflict? How do nurses reconcile this violation of another? Is it the knowledge that, ultimately, such acts will achieve a greater good?

 

Brian’s nurse provided as much comfort for the discomfort as she could. And she knew that Brian had a vital role to play. He needed to be involved. He needed to feel he had some control. She gave simple but thorough explanations. She gave sensation information. She spoke in a soft, calm yet confident voice. She reassured him.

 

The nurse instilled trust. The trust needed to sleep securely: that this nurse would be vigilant.

 

A moment of touch

Alice lives in a nursing home and suffers from chronic, crippling arthritic pain. Over the past few months Alice and I had been talking a lot. I don’t recall how we managed to get onto the topic of death, nevertheless we did. As we were talking, Alice’s voice started to quiver. She had been in a lot of pain for some time now and she had had enough. I was sitting on the bed beside her. Without thinking I grasped her hands in mine. Then, with a quivering voice, her eyes filled with tears, Alice spoke: “I want to go home. I am waiting for the Lord to take me home.” The tears filled my own eyes. I felt homeless like her. At this moment Alice and I were one. We sat there like that for quite awhile.

 

Some time later, Alice was in a bright mood. She told me that the Lord must have sent me. She told me that she loves me, that I am like a granddaughter she never had.

Nursing and nurses’ work in most settings presupposes a pervasive use of touch. Ongoingly, nurses touch patients in administering direct physical, hands-on-care. Yet, touch as it occurred in this nursing moment suggests a different kind of touch, a touch with a different purpose, and hence, a touch having a unique experiential quality for the recipient. Van den Berg (1974) describes this kind of touch as the contact of one human being with another, an immediate participating in each other. It is more than the touching of a physical body, but rather, the touching of a whole, embodied person. Whether it is in the form of a strong embrace, a grasp of the shoulders, or an enclasping of hands, caring is revealed. For Alice, through touch she discovered she was not alone. Someone had recognized the pain. Someone was there to share the pain. Someone was there to comfort. Perhaps, too, in the warmth of the nurse’s touch there was a transfer of strength, courage, and hope.

 

Van Manen (1996) also helps us to more deeply grasp the differing experiential quality of touch by making a distinction between gnostic and pathic touch. Gnostic touch is a touch that analyzes, anatomizes, dissects, and makes diagnosis and prognosis that tend to objectify or separate the patient from his or her body. It is a touch that is guided by an intellectual knowing. It is to some extent a depersonalized act. Even though there is contact, a distance exists between the one touching (e.g., palpating, percussing, etc.) and the one being touched.

 

In contrast, pathic touch is a touch that aims to support and comfort. It is a touch that is guided by a sensitive knowing. It is a healing touch. It may promote a physical healing such as that experienced during a bath, or a massage, or an emotional healing such as that experienced when one is able to share the pain of loneliness, loss or grief. It is a touch that recognizes the unique, whole embodied person. It is a touch that can enable a patient to heal, to strengthen, and to become whole again.

 

A moment of encouraging

Irene, a piano teacher, had suffered a mild stroke and was depressed over the weakness in her right hand. This particular day she refused to go to physiotherapy. The nurse tells the story:

I just sat down and listened and talked to her. I did not say that I wanted her to go to physiotherapy, but that was my intention. I said to her that she was showing some progress. “Think about two days ago; today you can move your fingers a little bit more. You have made progress because of the exercise. If you keep doing these exercises, I expect that you will be able to have more use of your hands.” I encouraged her-pointing out the positive things because she was only zeroing in on the negative and looking at how much she didn’t have. I reminded her that when she first came in that her arm was weak and that she needed a lot of help to eat. Now she is able to hold a cup by herself. Now she is able to move her fingers and raise her arm; she could even raise it over her head. I said, “Look, you couldn’t do that yesterday and you are able to do that today.” I just went through all the things that I could see that I hadn’t seen the day before. After our talk, she went to physiotherapy. (Adapted, Benner, 1984)

Respect for patient autonomy is something nurses cherish. Yet nurses, because of their expertise, often know what is best for a patient, despite what the patient thinks is best at the time. As existential advocates nurses are there to help patients to discover possibilities for becoming their best selves (Gadow, 1980). Nurses are there to help patients overcome their fears and doubts and help them regain the lost skills and abilities (or develop new skills and abilities) needed for becoming what they have the potential to be.

 

This nurse sat and listened. She heard Irene’s story before speaking. When she did speak she emphasized the positives. Small or slow gains perhaps but remarkable gains none the less. Cumulative gains and the potential for more with exercise. The nurse was successful in motivating Irene to persist in the battle. She did not coerce Irene. She encouraged Irene. She gave the gift of courage.

 

A moment of further reflection

We are used to thinking that nurses nurse the whole period they are on duty. Their tour of duty is filled with numerous nursing tasks to be executed. And yet, many nurses may agree that real nursing occurs not so much as a matter of duty but rather as a matter of moments of genuine encounters. In the nurse-patient relation there are moments when the nurse nurses: when she acts with tact, when she gives courage, when she comforts, when she applies that pathic touch. A nursing moment is a relational encounter in which the vulnerable other is experienced as a call. A call to be authentic, a call to be “present” as a nurse. In the recognition of the vulnerability the nurse may experience an appeal to respond responsibly to the patient’s need.

 

In a nursing moment, one is called to nurse. The word “nurse” is derived from the Latin word nutrire, to nourish (Skeat, 1980). To nourish is to sustain, to give life. The nurse gives hope, strength, courage, companionship, comfort and meaning in times of suffering or despair. The nurse fosters healing. The nurse helps the patient to recover a livable relation with his or her psychophysical being (van Manen, 1998).

 

Against the backdrop of the dramatic and heroic events characteristic of modern health care and technology, these activities of a nurse may appear trivial. To the eyes of the world they may even remain invisible or go unnoticed. They do not make headline or front page stories. Yet, these seemingly trivial acts of nursing may bring about profound change in the lived experience of patients. In the lived world of nurses, they may bring a sense of professional fulfillment and satisfaction. They are the acts that sustain nurses in their involvement with patients and families amidst suffering, pain, loneliness, loss, and grief. Perhaps that is why nurses cherish these moments. Perhaps that is why these moments are remembered.

 

 

References

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison Wesley Publishing Company.

Benner, P., & Tanner, C. (1987). How nurses use intuition. American Journal of Nursing, 87(1), 23-31.

Donahue, M. P. (1996). Nursing the finest art: An illustrated history. (2nd ed.) St. Louis, MO: Mosby.

Doona, M. E., Haggerty, L. A., & Chase, S. K. (1997). Nursing presence: An existential exploration of the concept. Scholarly Inquiry for Nursing Practice,,11(1), 3-16.

Gadow, S. (1980). Existential advocacy: Philosophical foundations of nursing. In S.F. Spicker & S. Gadow (Eds.), Nursing images and ideals: Opening dialogue with the humanities (pp. 79 – 101). New York, NY: Springer.

Paterson, J. G., & Zderad, L. T. (1976). Humanistic Nursing. New York, NY: John Wiley & Sons, Inc.

Skeat, W. W. (1980). An etymological dictionary of the English language. Oxford, Claredon Press.

Van den Burg, J. H. (1974). A different existence. Pittsburg: Dusquesne University.

Van Manen, M. (1991). The tact of teaching: The meaning of pedagogical thoughtfulness . London, ON: Althouse Press.

Van Manen, M. (1996). The gnostic and pathic hand. Paper presented at the Asian-Pacific Health Sciences Conference, Melbourne, Australia, December, 1995.

Van Manen, M. (1998). Modalities of body experience in illness and health. Qualitative Health Research, 8(1), 7-24.

Webster-Merriam. (1992). Webster’s new collegiate dictionary. Springfield MA: Webster-Merriam.