Only a whisper away. A philosophical view of the awake patient's situation during regional anaesthetics and surgery

In this study the awake patient's intraoperative situation and experiences during regional anaesthetics and surgery are reflected upon by using the work of the French philosopher Maurice Merleau‐Ponty. Merleau‐Ponty's phenomenological idea of the body as being at the centre of the world highlights the patient's embodied position and bestows significance onto the body as a whole, as a lived body. A case, based on the findings from a previous interview study, is presented as a contextual starting point where a patient goes from having a familiar body recognized as her own to having a partially anaesthetized body experienced as an unknown object. The intraoperative caring space is described in this context as the mutual ground where the awake patient and the nurse anaesthetist (NA) can interact to create meaning. The NA can act as the patient's bodily extension to bridge the gap between the patient's experiences and the situation. This calls for the NA's proximity and genuine presence in order to meet and understand the patient's awake experiences. Learning from the patient's situatedness gives information that is valuable for NAs to share with patients who are less experienced with this contextual situation. The challenge for the NA is not to perform routine‐based care, but to acknowledge every patient's lifeworld and uniqueness thus enabling the patient to move easily along the mind–body–world continuum. The core of intraoperative care is to provide support and promote well‐being of awake patients in the intraoperative environment. The use of a philosophical perspective is relevant for nurses who work in an intraoperative setting where patients undergo regional anaesthetics. This study shows how nursing research using phenomenological philosophy can help uncover new meanings known only to the patients living the experience.     

Exploring a hermeneutic perspective of nursing through revisiting nursing health history

In this article, the nursing health history is revisited with a hermeneutic lens to uncover means by which this tool can better serve nursing practice. It is argued that further distanciation from the developmental and medical model is necessary to accurately uncover health and history in the nurse–client encounter. Based on the works of prominent hermeneutic philosophers, such as Heidegger, Gadamer, Merleau‐Ponty, Ricoeur, and Taylor, four orientations to health history and nursing are explored: orientation to caring, orientation to narrative, orientation to time, and orientation to the body. The nursing health history is used as a vehicle for illuminating the usefulness of a hermeneutic perspective in everyday nursing practice. This article reveals views of health, history, and health history that are already known to nurses and the nursing milieu but are concealed by more dominant outlooks. The hermeneutical perspective presented in this article can help to reveal the important dimensions of everyday nursing practice and foster a richer attunement with the complex health experiences of individuals.     

Philosophic reflections on the meaning of touch in nurse–patient interactions

In this paper I examine the meaning of physical touch as it occurs in the nurse–patient interaction. There are two aspects of the nurse–patient relationship that are found in most nurse–patient interactions which together have profound implications for nurses as practitioners and as individual human persons. The first is the clinical intimacy of the nurse–patient relationship where nurses touch, rub, smooth, clean, dress and otherwise physically interact with patients. The other is the existential crisis, the possibility of loss, suffering and death that lurks at the horizon of most, if not all, healthcare encounters. Edmund Husserl, Merleau‐Ponty and more recently Robert Sokolowski argue that tactile sensations and resultant perceptions are fundamental to all sensory perception. Further, they argue that tactile sensation is fundamental for the ongoing constitution of ‘my’ self as a person and for the development and exercise of human intersubjectivity. If tactile interaction is crucial to the development of our very selves as persons and a significant aspect of our interaction with patients includes direct or observed tactile sensations and if further these sensations occur around the context of existential crises for our patients, then nurse's very selves as persons are being challenged by these interactions. Here, then I examine the philosophical argument for the role of tactile sensations in our human development and briefly look at contemporary neurophysiologic research that supports this philosophical account. I then suggest ways such physical intimacy can lead to a strengthening or weakening of the person of the nurse and the nursing interaction and end with some thoughts about ways to support nurses in these activities.     

Reconciling conceptualisations of the body and person‐centred care of the older person with cognitive impairment in the acute care setting

In this article, we sought reconciliation between the “body‐as‐representation” and the “body‐as‐experience,” that is, how the body is represented in discourse and how the body of older people with cognitive impairment is experienced. We identified four contemporary “technologies” and gave examples of these to show how they influence how older people with cognitive impairment are often represented in acute care settings. We argued that these technologies may be mediated further by discourses of ageism and ableism which can potentiate either the repressive or productive tendencies of these technologies resulting in either positive or negative care experiences for the older person and/or their carer, including nurses. We then provided examples from research of embodied experiences of older people with dementia and of how nurses and other professionals utilized their inter‐bodily experiences to inform acts of caring. The specificity and individuality of these experiences were more conducive to positive care experiences. We conclude the article by proposing that the act of caring is one way nurses seek to reconcile the “body‐as‐representation” with the “body‐as‐experience” to mitigate the repressive effects of negative ageism and ableism. The act of caring, we argue, is the essence of caring enacted through the provision of person‐centred care which evokes nurses to respond appropriately to the older person's “otherness,” their “variation of being” while enabling them to enact a continuation of themselves and their own version of normality.     

Reinstating the marginalized body in nursing science: epistemological privilege and the lived life

Abstract For nursing, the presence of bodies, the body of the patient and the body of the nurse are self‐evident. Illness, pain and disability are essentially constituted as embodied experiences. Similarly, the nurse herself, in her body, is the primary and essential instrument of her practice. What is to be refuted, is the way in which the body is taken up in nursing discourse, the way in which the body of the patient and the body of the nurse are objectified, sanitized and stripped of embodied emotion and physicality. The authors propose that the ‘scientification’ of nursing limits what counts as nursing knowledge. This limitation undermines the central experience of nursing: the subjective and embodied experience of care. A number of factors contribute to the marginalization of the body and of embodied experience in nursing science. By privileging objective data and placing subjective experience outside the brackets of dominant scientific knowledge, practice disciplines such as nursing can become marginalized. To combat this marginalization, nursing and other professions have sought to situate themselves within the dominant frameworks. The result is that bodies are objectified, and person, practice, and embodied experience are subordinated to rational empirical intervention.     

Phenomenology as research method or substantive metaphysics? An overview of phenomenology's uses in nursing

In exploring phenomenological literature, it is evident that the term ‘phenomenology’ holds rather different meanings depending upon the context. Phenomenology has been described as both a philosophical movement and an approach to human science research. The phenomenology of Husserl, Heidegger, Gadamer, and Merleau‐Ponty was philosophical in nature and not intended to provide rules or procedures for conducting research. The Canadian social scientist, van Manen, however, introduced specific guidelines for conducting human science research, which is rooted in hermeneutic phenomenology and this particular method has been employed in professional disciplines such as education, nursing, clinical psychology, and law. The purpose of this paper is to explore the difference between the phenomenological method as described by van Manen and that of other philosophers such as Husserl, Heidegger, Gadamer, and Merleau‐Ponty. In so doing, the author aims to address the blurred boundaries of phenomenology as a research method and as a philosophical movement and highlight the influence of these blurred boundaries on nursing knowledge development.     

The use of photography in perceiving a sense in life: A phenomenological and existential approach in Mental Health Care

This article is about the therapeutic use of photography in mental health care. We will first describe the intelligent nature of perception as we understand on the basis of neurobiological research findings. We will link our interpretation of visual perception with the phenomenology of perception from the theory of Merleau‐Ponty.. Then we will discuss how patients in mental health care with mental health problems may profit by an experiential approach that is concomitant with the existential reality described by Merleau‐Ponty. The experiential approach we go into more detail is Focusing. We will demonstrate the limitations and feasibility of Focusing in the procedures of working with photography as a therapeutic medium.     

From discipline to control in nursing practice: A poststructuralist reflection

The everyday expressions of nursing practices are driven by their entanglement in complex flows of social, cultural, political and economic interests. Early expressions of trained nursing practice in the United States and Europe reflect claims of moral, spiritual and clinical exceptionalism. They were both imposed upon—and internalized by—nursing pioneers. These claims were associated with an endogenous narrative of discipline and its physical manifestation in early nursing schools and hospitals, which functioned as “total institutions.” By contrast, the external forces—diffuse yet pervasive—impacting upon contemporary nursing more closely align with the power dynamics explored in Gilles Deleuze's concept of the Society of Control. The example of sensor technology and telemetric monitoring of nurses’ locations in the clinical setting exemplifies the intense presence of surveillance, performance metrics and the “rationalization” of nursing practice. It falls upon nurses to recognize, accept or challenge these dynamics in order to shape the future of nursing practice into a discipline which embodies our values and priorities.     

Client attrition in the Nurse‐Family Partnership®: Revisiting metrics of impact in a home visitation program in the United States

The Nurse‐Family Partnership^® (NFP) is an evidence‐based home‐visiting program for low‐income, first‐time mothers. NFP^® has demonstrated benefits for reducing child maltreatment and improving parenting, child development and families' economic self‐sufficiency. It is now implemented widely in the US where, despite the use of home visits, which generally reduce barriers to program participation, only 35% of clients nationwide complete the 2.5‐year program. This concurrent mixed‐methods study was conducted in 2013 in an urban northeastern US NFP site and included administrative program data, surveys (n = 56), in‐depth interviews (n = 14) with nurse home visitors, and focus groups with nurse supervisors (n = 13). We explored associations between nurses' attrition rates and their perspectives on client attrition and retention strategies. We further conducted an inductive thematic analysis of the qualitative data. Findings indicate that nurses' attrition rates were not significantly associated with their views and strategies to retain clients. Nurses and supervisors noted that clients' competing priorities and ‘chaotic lives’ primarily explained attrition. They thought that clients often left the program upon receiving enough information and skills or achieving key milestones, which may reflect reaching a saturation point, albeit prior to the full completion of the program. We offer recommendations to assess performance based on client accomplishments rather than whether they participated until the prescribed endpoint.     

Reconciling economic concepts and person‐centred care of the older person with cognitive impairment in the acute care setting

Person‐centred care is a relatively new orthodoxy being implemented by modern hospitals across developed nations. Research demonstrating the merits of this style of care for improving patient outcomes, staff morale and organizational efficiency is only just beginning to emerge. In contrast, a significant body of literature exists showing that attainment of person‐centred care in the acute care sector particularly, remains largely aspirational, especially for older people with cognitive impairment. In previous articles, we argued that nurses work constantly to reconcile prevailing constructions of time, space, relationships, the body and ethics, to meet expectations that the care they provide is person‐centred. In this article, we explore key concepts of neo‐liberal thought which forms an important back‐story to the articles. Economic concepts, “efficiency” and “freedom” are examined to illustrate how nurses work to reconcile both the repressive and productive effects of economic power. We conclude the article by proposing a new research agenda aimed at building a more nuanced understanding of the messy actualities of nursing practice under the influences of neo‐liberalism, that illuminates the compromises and adaptations nurses have had to make in response to economic power.     

New graduate nurses as knowledge brokers in general practice in New Zealand: a constructivist grounded theory

Practice nursing in New Zealand is not well described in the literature. One survey illustrated that most of the New Zealand practice nurses sampled did not know of the country's two premier evidence‐based health websites. A recent review compared general practice in the UK, New Zealand and Australia and found that whereas there had been significant developments in empowering the practice nurse workforce to run nurse‐led clinics in the UK, New Zealand and Australia lagged behind. The aim of this reported constructivist grounded theory study was to investigate practice nurses’ use of information. Conducted in Auckland, New Zealand, data were collected through ethnographic techniques in one general practice between September 2009 and January 2010 to enhance theoretical sensitivity to the area of information use. Subsequently, six experienced practice nurses (one twice after moving jobs) and five new graduate nurses from five different general practices were interviewed, using open‐ended questions, between January 2010 and August 2011. Concurrent data collection and analysis occurred throughout the study period. The use of memos, the constant comparative method, data categorisation and finally, data abstraction resulted in the final theory of reciprocal role modelling. Experienced practice nurses role modelled clinical skills to new graduate nurses. Unexpectedly, new graduate nurses were unconscious experts at sourcing information and role modelled this skill to experienced practice nurses. Once this attribute was acknowledged by the experienced practice nurse, mutual learning occurred that enabled both groups of nurses to become better practitioners. Graduate nurses of the millennial generation were identified as a resource for experienced practice nurses who belong to the baby boomer generation and generation X.     

Reinstating the marginalized body in nursing science: epistemological privilege and the lived life

Abstract For nursing, the presence of bodies, the body of the patient and the body of the nurse are self-evident. Illness, pain and disability are essentially constituted as embodied experiences. Similarly, the nurse herself, in her body, is the primary and essential instrument of her practice. What is to be refuted, is the way in which the body is taken up in nursing discourse, the way in which the body of the patient and the body of the nurse are objectified, sanitized and stripped of embodied emotion and physicality. The authors propose that the 'scientification' of nursing limits what counts as nursing knowledge. This limitation undermines the central experience of nursing: the subjective and embodied experience of care. A number of factors contribute to the marginalization of the body and of embodied experience in nursing science. By privileging objective data and placing subjective experience outside the brackets of dominant scientific knowledge, practice disciplines such as nursing can become marginalized. To combat this marginalization, nursing and other professions have sought to situate themselves within the dominant frameworks. The result is that bodies are objectified, and person, practice, and embodied experience are subordinated to rational empirical intervention.     

Dysfunctional grieving related to childbearing loss: A descriptive study

The purpose of this qualitative study was to analyze client cases with the nursing diagnosis of dysfunctional grieving. Such research is in congruence with the American Nurses’ Association's definition of nursing as cited in Nursing: A Social Policy Statement and the call for diagnostic and case study research from the National Group for Classification of Nursing Diagnoses. A Grounded Theory, case study methodology was used to discover, categorize, and evaluate defining characteristics and strategies of assessment and counseling for the diagnosis. These cases include spontaneous abortion, stillbirth, infant death, and birth of severely handicapped and premature infants. Findings led to the development of a nursing counseling model, which highlights a creative nursing process of assessment and intervention that has not been identified in the literature. The assessment strategies of this model include the grief behavior paradox, mental imagery, and the diminutive therapeutic effect. Counseling strategies include dream baby identification, communication mapping, therapeutic use of humor, cultural and behavioral sensitivity, emotional time out, building self‐esteem, nurse authenticity, and self‐help groups. These findings describe advanced nursing practice that supports the position that nurses diagnose and treat “human responses to actual or potential health problems.”;     

Development and Initial Testing of an Instrument to Establish Eating Profiles of Clients in Nursing Homes or Elderly Homes

ABSTRACT

“Eating profiles” can be defined as types of clients distinguished by combinations of food preferences, consumption patterns, and preferences for ambiance. The purpose of this article is to describe the development and initial testing of an instrument to establish eating profiles of residents of nursing homes or elderly homes. We constructed a 35-item, 4-subscale questionnaire. This self-administered, usable instrument derived five eating profiles from clients' perspectives. Insight in eating profiles is important for facility managers to ascertain that the food, dinner service, and ambiance are adequately tailored to the residents' preferences.     

It happens when the stage sets collapse1

Sally Gadow's tenure as professor of nursing at the University of Colorado Health Sciences Center during my doctoral studies radically changed my view on science, nursing, relationships, and most importantly, the world. In this paper, I use ideas stimulated by Gadow's classes to argue that recognizing ambiguity through an attitude of metaphysical revolt can free nurses to form relationships with patients who are complex subjects rather than objects to be treated. I will first discuss Camus’ ideas of absurdity from the Myth of Sisyphus, comparing the awake passions of Don Juan and the maniacal (and fatal) love of Romeo and Juliet (1955). Merleau‐Ponty's (1962) work on the dialectic of human sexuality sheds light on the intrinsic bodily ambiguity of human existence as seen through sexual attraction. de Beauvoir (1948) further lends insight into ideas of ambiguity, relationship, and freedom. Finally, I will argue that recognition of the intrinsic ambiguity of existence coupled with an attitude of metaphysical revolt may free nurses and patients from external frameworks that limit experience, impose meaning, and in the process, sever human relationship.     

Siblings at birth: Professional philosophy and preparation

Increasingly more families are searching for caregivers and organizations that will accommodate their expectations to have siblings participate more actively in the childbearing experience. Family‐centered organizations need to translate their philosophy into flexible protocols that can facilitate family interaction and particularly sibling presence during labor and delivery. The authors articulate a professional practice philosophy and offer guidelines that can help nurses prepare clients for a family labor and delivery experience. It is the professional nurse who assumes the pivotal position in health care settings since she is charged with the responsibility of meshing nursing surveillance activities with organization and client values. The professional nurse must take the lead in developing family‐oriented education programs for the variety of clients that the organization serves. The presence of siblings at birth must be addressed by individual professionals and organizations, resolved as a contemporary controversy, and when sought by clients considered part of family‐centered care. Adult‐child interaction during the birth of a sibling may safeguard families from some introgenic effects of traditional hospital birth practices.