HUMANISTIC HUMANISTIC NURSINGNURSING THEORYTHEORY

By:By:

MARY JOHN L. RENONG, RNMARY JOHN L. RENONG, RNAugust 10, 2013August 10, 2013

Dr. Loretta Zderad Dr. Josephine Paterson

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HUMANISTIC NURSINGHUMANISTIC NURSING THEORISTSTHEORISTS

I. BIOGRAPHY

Josephine Paterson was born on the 1st of September of 1924 in Freeport, New York. Loretta

and Josephine spent their early school years during the depression of the 1930's.

Josephine G. Paterson was also learning the role of a nurse as well as work responsibilities

during this same time period. She had graduated in August of 1945 with a diploma from Lenox Hill

School of Nursing in New York. She finished a couple of years earlier than Loretta Zderad and within a

year of WW II ending.

Nine years later (1954, August) Josephine Paterson graduated with her Bachelor's Degree in

Nursing Education from St. John's University in Brooklyn, New York. After moving to Baltimore,

Maryland she completed in June, a year later, with her Master's in Public Health from the John Hopkins

School of Hygiene and Public Health.

While Paterson was starting her Bachelor's and Master's programs, Loretta Zderad completed her

Master's in Science in Nursing Education with a psychiatric nursing major from Catholic University in

June of 1952.

It was during the 1950's and 1960's that Zderad and Paterson did their formative nursing work,

the basis from which they would draw from in formulating their Humanistic Nursing Theory and further

refinement in the 70's and 80's.

Paterson worked in the public and mental health field and Zderad in psychiatric health with

leanings toward philosophy.

Zderad received a PhD in Philosophy in 1968 from Georgetown University and Paterson her

DNS in 1969 from Boston University with her specialty of psychiatric mental health.

Several of their students have gone on to further Paterson and Zderad's theory and add to the

theoretical base.

Paterson and Zderad presented and published most of their work in the decades of the 1960's and

1970's.

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Dr. Josephine Paterson is originally from the east coast and Dr. Loretta Zderad is from the mid-

west. They both were graduates of diploma schools and subsequently earned their bachelor's degree in

Nursing Education. Dr. Paterson did her graduate work at Johns Hopkins and Dr. Zderad did hers at

Catholic University. In the mid-fifties they were both employed at The Catholic University and were

assigned the task of working together to create a new program that would encompass the community

health component and the psychiatric component of the graduate program. Subsequently they developed

a collaboration and dialogue and friendship that have lasted for almost 40 years.

In 1971, Paterson and Zderad's career paths led them to the Veterans Administration Hospital in

Northport, New York. Both theorists used a three-pronged approach that integrated clinical practice,

education, and research. Their theory of humanistic nursing presented a method for nurses in clinical

practice to examine their experiences. They believed that by examining these experiences they could be

analyzed, synthesized, and subsequently formulated into theoretical propositions which can become

resourceful guides for nursing practitioners (Zderad, 1978, p. 4)."

Subsequently Paterson and Zderad began to integrate the concepts of Humanistic Nursing into a

series of courses that they conducted around the country. During these courses they encouraged other

nurses to articulate and describe their experiences of nursing. It is from these descriptions that the

eleven essences, awareness, openness, empathy, caring, touching, understanding, responsibility, trust,

acceptance, self-recognition, and dialogue, emerged. Humanistic nursing theory proposes that these

clusters of phenomena can be ordered as common beliefs-values to nursing practice for these nurses.

Josephine Paterson and Loretta Zderad retired in 1985 and moved South where they are currently

enjoying life. Although they are no longer active, they are pleased at the on going interest in their

theory.

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II. INTRODUCTION

Humanistic Nursing Theory, formulated by Josephine Paterson and Loretta Zderad, aims at the

development of nursing theory through the study of the existence and reality of nursing. Humanistic

Nursing Theory is based on the idea that nursing is an inter-subjective transactional relationship between

a nurse and a patient who are human beings existing in the world. The conceptual framework of the

theory is existentialism and it presents a phenomenological method of inquiry that can be used by nurses

to examine and understand their everyday practice. The theory serves as a vehicle to describe the

essences of everyday nursing experiences. It is an inductive approach to theory building through

exploration and description.

Paterson and Zderad (1988) addressed three central questions: What is the meaning of nursing?

How do nurses and patients interact? How can nurses develop the knowledge base for the act of

nursing? The humanistic-practice nursing theory proposes that the nurse and the patient are significant

components in the nurse–patient situation. The act of caring increases the humanness of both. They both

approach the situation with experiences that influence the encounter. Nurses therefore, should consider

such encounters as existential experiences and should describe them from observing “the thing itself,”

the phenomena of nursing as they occur in the world. They use a phenomenological perspective as the

basis for a dialogue about lived experiences to uncover answers to the questions. The sum total of all

these experiences will enhance the development of the science of nursing.

In selecting existentialism and phenomenology as context and method for the development of

nursing knowledge, Paterson and Zderad operate from several premises. The progress of nursing as a

human science is hampered by the mechanistic, deterministic, cause-and-effect methods that have

dominated it; in other words, they rejected the received view, the logical positivist view of theory

development (Paterson, 1971, p. 143). Paterson and Zderad were a decade ahead of the literature in

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nursing that later advocated such a move. They have also developed their ideas on the premise that the

experiences of nurses in practice supply the impetus for any useful theory for nurses. However, they also

warned us that preconceived notions influence what is significant and determinately affect the

development of knowledge.

Nursing is a lived dialogue that incorporates an inter-subjective transaction in which a nurse and

a patient meet, relate, and are totally present in the experience in an existential way that includes

intimacy and mutuality (Paterson and Zderad, 1970–1971). Nursing brings a person together with a

nurse because of the call of that person for help and the response of the nurse. The encounter is

influenced by all other human beings in the patient’s and nurse’s lives and by other things, whether

ordinary objects (such as utensils, clothes, furniture) or special objects (such as life-sustaining

equipment). The dialogue during these encounters occurs in a time frame as experienced by both

partners. When there is synchronization in timing, the inter-subjective dialogue is enhanced. Dialogue

occurs in a certain space that is objective, the physical setting, or subjective, personal space. In their

theory, the nurse is expected to know “the nurse’s unique perspective and responses, the others’

knowable responses, and the reciprocal call and responses, the in-between, as they occur in a nursing

situation” (Paterson and Zderad, 1988, p. 7).

III. THEORETICAL ASSERTIONS

FOUNDATIONS OF HUMANISTIC NURSING

Nursing is a response to the human situation. It comes into being under certain conditions--one

human being needs a kind of help and another gives it. The meaning of nursing as a living human act is

in the act itself. To understand it, therefore, it is necessary to consider nursing as an existent, a

phenomenon occurring in the real world.

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THE PHENOMENON OF NURSING

The phenomenon of nursing appears in many forms in the real lived world. It varies with the age

of the patient, the pathology or disability, the kind and degree of help needed, the duration of the need

for help, the patient's location and his potential for obtaining and using help, and the nurse's perception

of the need and her capacities for responding to it. Nursing varies also in relation to the socio-cultural

context in which it occurs. Being one element in an evolving complex system of health care, nursing is

continuously appearing in new specialized forms. As professionals, we are accustomed to viewing

nursing as we practice it within these specialty contexts--for example, pediatric, medical, rehabilitation,

intensive care, long-term care, community. There seems to be no end to the proliferation of

diversifications. Even the attempts of practitioners to combine specialties give rise to new specialties,

such as, community mental health nursing and child psychiatric nursing.

Paterson and Zderad’s theory is based on a number of implicit assumptions:

1. Nursing involves two human beings who are willing to enter into an existential relationship with

each other.

2. Nurses and patients as human beings are unique and total biopsychosocial beings with the

potential for becoming through choice and intersubjectivity.

3. The present experiences are more than the sum total of the past, present, and the future, and are

influenced by the past, present, and future. In their totality, they are less than the future.

4. Every encounter with another human being is an open and profound one, with a great deal of

intimacy that deeply and humanistic influences members in the encounter.

5. Human beings are free and are expected to be involved in their own care and in decisions

involving them.

6. All nursing acts influence the quality of a person’s living and dying.

7. Nurses and patients coexist; they are independent and interdependent.

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8. A nurse has to “accept and believe in the chaos of existence as lived and experienced by each

man despite the shadows he casts, interpreted as poise, control, order, and joy” (Paterson and

Zderad, 1988, p. 56).

9. Human beings have an innate force that moves them to know their angular views and other’s

angular views of the world (Paterson and Zderad, 1976; Zderad, 1969).

HUMANISTIC NURSING: A LIVED DIALOGUE

The meaning of humanistic nursing is found in the human act itself, that is, in the phenomenon

of nursing as it is experienced in the everyday world. Therefore, the interrelated practical and theoretical

development of humanistic nursing is dependent on nurses experiencing, conceptualizing, and sharing

their unique angular views of their unique lived nursing worlds. An open framework suggesting

dimensions for such exploration was derived from a consideration of the phenomenon of nursing within

its basic context, namely, the human situation. The elements of this humanistic nursing framework

include incarnate men (patient and nurse) meeting (being and becoming) in a goal-directed (nurturing

well-being and more-being), intersubjective transaction (being with and doing with) occurring in time

and space (as measured and as lived by patient and nurse) in a world of men and things.

Nursing implies a special kind of meeting of human persons. It occurs in response to a perceived

need related to the health-illness quality of the human condition. Within that domain, which is shared by

other health professions, nursing is directed toward the goal of nurturing well-being and more-being

(human potential). Nursing, therefore, does not involve a merely fortuitous encounter but rather one in

which there is purposeful call and response. In this vein, humanistic nursing may be considered as a

special kind of lived dialogue.

Meeting

The act of nursing involves a meeting of human persons. As was noted above, it is a special or

particular kind of meeting because it is purposeful. Both patient and nurse have a goal or expectation in

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mind. The inter-subjective transaction, therefore, has meaning for them; the event is experienced in light

of their goal(s). Or in other words, the living human act of nursing is formed by its purpose. Its goal-

directedness colors the attributes and process of the nursing dialogue.

When a nurse and patient come together in a nursing situation, their meeting may be expected or

planned by one or both or it may be unexpected by one or both. In any case, the goal or purpose of

nursing holds. Even in a spontaneous interaction where they have met only by chance, in a health care

facility or any place where one is identified as patient and the other as nurse, there is an implicit

expectation that the nurse will extend herself in a helpful way if the patient needs assistance. If the

meeting is planned or expected, this factor influences the dialogue. Each comes with feelings aroused by

anticipation of the event, for example anxiety, fear, dread, hope, pleasure, waiting, impatience,

dependence, hostility, responsibility.

The patient and the nurse are two unique individuals meeting for a purpose. In the existential

sense, each of these persons is his choice, each is his history. Each comes to meet the other with all that

he is and all that he is not at this moment in this place. Each comes as a particular incarnate being. Each

is a specific being in a specific body through which he affects the other and the world and through which

he is affected by them. This nurse who uses her eyes, ears, nose, hands, her body, this way here and now

meets this patient whose body in this condition serves him this way here and now.

Although the nurse and the patient have the same goal, that is, well-being and more-being, they

have different modes of being in the shared situation. One's purpose is to nurture; the other's is to be

nurtured. This difference in the perspectives from which they approach the meeting is reflected in the

kind and degree of their openness to each other.

Relating

As a human response to a person in need, the nursing act is necessarily an inter-subjective

transaction. Or to put it in other words, regardless of the complexity of need and/or response, when

nurse and patient meet in the event of nursing both have "to do" with each other. Since both are human,

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their doing with means being with. Men can do with and be with each other because they are able to see

others and things as distinct from themselves and enter into relation with them. What distinguishes the

human situation is that men can enter into a dialogue with reality. They have a capacity for internal

relationships, for knowing themselves and their worlds within themselves, they can relate as subject to

object (for example, as knower to thing known) and as subject to subject, that is, as person to person.

Both types of relationships are essential for genuine human existence.

It is natural, in fact unavoidable, for man to relate to his world as subject to object. How could a

person survive even one day without knowing and using objects? Therefore, man's abilities to abstract,

objectify, conceptualize, categorize, and so forth, are necessary for everyday living. Even beyond this,

the human capacity for relating to the other as object is basic to the advancement of mankind for it

underlies science, art, and philosophy. It is simply one way of being human.

Another mode of relating is open to men. Whenever two persons are present to each other as

human beings, the possibility of inter-subjective dialogue exists. Since both are subjects with the

capabilities for internal relationships, they can be open, available, and knowable to each other. They can

know each other within themselves. Furthermore, they can be truly with each other in the inter-

subjective realm because while maintaining their own unique identities, they can participate in an

interior union. Inter-subjective relating is also necessary for human existence. For it is through his

relationships with other men that a person develops his human potential and becomes a unique

individual.

Nursing, being an interhuman event, has within it possibilities for various types and degrees of

relationships. Both nurse and patient can view themselves and the other as objects and as subjects or in

any variation or combination of these ways. A person can view and relate to another person as an object,

for instance as a mere function ("patient," "nurse," "supervisor," "medicine nurse," "admitting nurse,"

"administration") or as a case or type ("schizophrenic," "cardiac," "outpatient," "readmission," "bed

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patient," "wheelchair patient," "total care patient," "terminal patient"). Such subject-object or "I-It"

relationships differ essentially from subject-subject or "I-Thou" relationships.

As the derivation of the term indicates, an object is something placed before or opposite; it is

anything that can be apprehended intellectually. Through objectification the object is de-individualized

and therefore made replaceable for the purpose of study by any other object with the same properties. It

is indifferent to the act by which it is thought and, therefore, the subject studying the object may also be

replaced by a similar subject.

Although it is possible to view a person as an object, persons and things are necessarily different

kinds of objects. A thing, as object, is open to a subject's scrutiny, while a person, as object, can make

himself knowable or set up barriers to objectification. He can keep his thoughts to himself, remain silent,

or deliberately conceal some of his qualities.

Through the scientific objective approach, that is, subject-object relating, it is possible to gain

certain knowledge about a person; through inter-subjective, that is, subject-subject relating, it is possible

to know a person in his unique individuality. Thus, both subject-subject and subject-object relationships

are essential to the clinical nursing process. Both are integral elements of humanistic nursing.

Presence

In the nursing world, as in the world at large, human encounters may range from the trivial to the

extremely significant. Within a day's work, the nurse may experience many levels of inter-subjectivity

from the lowest level of being called on as a function or being used as an object, to the other end of the

scale of being recognized as a presence or a thou in genuine dialogue.

Nursing activities bring a nurse and patient into close physical proximity, but this in itself does

not guarantee genuine inter-subjectivity in which a man relates to another person as a "presence" rather

than an object. A presence cannot be grasped or seized like an object. It cannot be demanded or

commanded; it only can be welcomed or rejected. In a sense, it lies beyond comprehension and can only

be invoked or evoked.

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There is a quality of unpredictableness or spontaneity about genuine dialogue. A nurse may be

going through her daily activities, functioning effectively, relating humanely, when suddenly she is

stopped by something in the patient, perhaps a look of fear, a tug at her sleeve, a moan, a reaching for

her hand, a question, and emptiness. In a suspenseful pause two persons hover between their private

worlds and the realm of inter-subjectivity. Two humans stand on the brink of the between for a precious

moment filled with promise and fear. With my hand on the doorknob to open myself from within, I

hesitate--should I, will I let me out, let him in? Time is suspended, then moves again as I move with

resolve to recognize, to give testimony to the other presence.

Thus, for genuine dialogue to occur there must be certain openness, a receptivity, readiness, or

availability. The open or available person reveals himself as "present." This is not the same as being

attentive; a listener may be attentive and still refuse to give himself. Visible actions do not necessarily

signify presence so it cannot be proven.

Call and Response

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.

“Call and response” encapsulate the core

themes of this quite elegant and very profound

theory. Through this paradigm, Josephine

Paterson and Loretta Zderad have presented a

vision of nursing that is amenable to variation

in practice settings and to the changing patterns of nursing over time. There is a call from a person, a

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family, a community, or from humanity for help with some health-related issue. A nurse, a group of

nurses, or the community of nurses hearing and recognizing that call respond in a manner that is

intended to help the caller with the health-related need. What happens during this dialogue, the “and” in

the “call and response,” the “between,” is nursing.

A common misconception that nurses have is that it asserts that the nurse must provide what it is

that the patient is calling for. The response of the nurse must be guided by all that she is. This includes

his or her professional role, ethics, and competencies. A particular nurse may not actually be able or

willing to provide what is being called for, but the process of being heard, according to this theory, is in

itself a humanizing experience.

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.

PHASES OF PHENOMENOLOGIC NURSOLOGY

Dr. Paterson and Dr. Zderad describe five phases to their phenomenological study of nursing.

These phases are presented sequentially but are actually interwoven, because as with all of Humanistic

Nursing Theory, there is a constant flow between, in all directions, and all at once emanating toward a

center that is nursing. The phases of humanistic nursing inquiry are: 1.) preparation of the nurse knower

for coming to know, 2.) Nurse knowing the other intuitively, 3.) Nurse knowing the other scientifically,

4.) Nurse complementarily synthesizing known others 5.) Succession within the nurse from the many to

the paradoxical one

Phase I: Preparation of the Nurse Knower for Coming to Know

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This method engages the investigator as a risk taker and as a "knowing place." Risk taking

necessitates decision. This process of accepting the decision to approach the unknown openly is

experienced as an internal struggle and we become consciously aware of our rigidity and satisfaction

with the status quo. Conforming to the usual, in this case positivism, gives a security that is not easily

relinquished despite the advantages of actualizing our unique responsible freedom.

In the first phase, the inquirer tries to open herself up to the unknown and to the possibly

different. She consciously and conscientiously struggles with understanding and identifying her own

“angular view.” Angular view involves the gestalt of the unique person mentioned earlier. It includes the

conceptual and experiential framework that we bring into any situation with us, a framework that is

usually unexamined and casually accepted as we negotiate our everyday world. Later in the process

angular view is called upon to help make sense of and give meaning to the phenomena being studied. By

identifying our angular view we are then able to bracket it purposefully so that we do not superimpose it

on the experience we are trying to relate to. When we bracket, we intentionally hold our own thoughts,

experiences, and beliefs in abeyance. This “holding in abeyance” does not deny our unique selves but

suspends them, allowing us to experience the other in his or her own uniqueness.

Even temporarily letting go of that which shapes our own identity as the self, however, causes

anxiety, fear, and uncertainty. Labeling, diagnosing, and routine add a necessary and very valuable

predictability, sense of security, and means of conserving energy to our everyday existence and practice.

It may also make us less open, however, to the new and different in a situation. Being open to the new

and different is a necessary stance in being able to know of the other intuitively.

Phase II: Nurse Knowing the Other Intuitively

Knowing the other intuitively is described by Dr. Paterson and Dr. Zderad as “moving back and forth

between the impressions the nurse becomes aware of in herself and the recollected real experience of the

other” (Paterson & Zderad, 1976, pp. 88–89), which was obtained through the unbiased being with the

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other. This process of bracketing versus intuiting is not contradictory. Both are necessary and

interwoven parts of the phenomenological process. The rigor and validity of phenomenology are based

on the ongoing referring back to the phenomenon itself. It is conceptualized as dialectic between the

impression and the real. This shifting back and forth allows for sudden insights on the nurse’s part, a

new overall grasp, which manifests itself in a clearer, or perhaps a new, “understanding.” These

understandings generate further development of the process. At this time, the nurse’s general

impressions are in a dialogue with her unbracketed view (see Figure 11–4).

Nurse Knowing the Other Scientifically

This phase incorporates the nurse’s ability to be

conscious of herself and that which she has taken in,

merged with, and made part of herself.

“This is the time when the nurse mulls over, analyzes,

sorts out, compares, contrasts, relates, interprets, gives a

name to, and categorizes” (Paterson & Zderad, 1976, p79).

Nurse Complementarily Synthesizing Known Others

At this point the nurse personifies what has been described

by Dr. Paterson and Dr. Zderad as a “noetic locus,” a “knowing

place” (1976, p. 43). According to this concept, the greatest gift a

human being can have is the ability to relate to others, to wonder,

search, and imagine about experience, and to create out of what

has become known. Seeing themselves as “knowing places”

inspires nurses to continue to develop and expand their community of world thinkers through their

educative and practical experiences, which then become a part of their angular view. This self-

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expansion, through the internalization of what others have come to know, dynamically interrelates with

the nurse’s human capacity to be conscious of her own lived experiences.

Succession within the Nurse from the Many to the Paradoxical One

This is the birth of the new from the existing patterns, themes, and categories. It is in this phase

that the nurse “comes up with a conception or abstraction that is inclusive of and beyond the

multiplicities and contradictions” (Paterson & Zderad, 1976, p. 81) in a process that corrects and

expands her own angular view. This is the pattern of the dialectic process, which is reflected throughout

Humanistic Nursing Theory. In the dialectic process there is a repetitive pattern of organizing the

dissimilar into a higher level (Barnum, 1990, p. 44). At this higher level, differences are assimilated to

create the new. This repetitive dialectic process of humanistic nursing is an approach that feels

comfortable and natural for those who think inductively.

The pervasive theme of dialectic assimilation speaks to universal interrelatedness from the

simplest to the most complex level. Human beings, by virtue of their ability to self-observe, have the

unique capacity to transcend themselves and reflect on their relationship to the universe. This dialectic

process has a pattern similar to that of the call-and response paradigm of Humanistic Nursing Theory.

This paradigm speaks to the interactive dialogue between two different human beings from which a

unique yet universal instance of nursing emerges. The nursing interaction is limited in time and space,

but the internalization of that experience adds something new to each person’s angular view. Neither is

the same as before. Each is more because of that coming together. The coming together of the nurse and

the patient, the between in the lived world, is nursing. Just as in the double helix of the DNA molecule

(where this interweaving pattern is what structures the individual), in the fabric of Humanistic Nursing

Theory this intentional interweaving between patient and nurse is what gives nursing its structure, form,

and meaning.

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THE CONCEPT OF COMMUNITY

The definition of community presented by Drs. Paterson and Zderad is: “Two or more persons

struggling together toward a center” (1976, p. 131). In any community there is the individual and the

collective known as the “community.” Plato points to the microcosm and the macrocosm and proposes

that the one is reflective of the many. Humanistic Nursing Theory similarly proposes that the interaction

of one nurse is a reflection of the recurrent pattern of nursing and is therefore worth reflecting upon and

valuing. According to Humanistic Nursing Theory, there is an inherent obligation of nurses to one

another and to the community of nurses. That, which enhances one of us, enhances all of us. Through

openness, sharing, and caring, we each will expand our angular views, each becoming more than before.

Subsequently, we take back into our nursing community these expanded selves, which in turn will touch

our patients, other colleagues, and the world of health care.

So for a health-nursing community to truly be actualized each nurse would prepare to be all it

was possible for her to be as a nurse. Then, through exploration there would be recognition of the reality

of the existent community. Over time a merger of the values of the nurse and of the existing community

would be reflected as moreness in each. The nurse would be more through her relation with the

community; the community would be more through its relation with the nurse. Each would make an

important difference in the other. The macrocosm, the community, would reflect the nurse's quality of

presence. The microcosm, the nurse, would reflect the presence of the community with her. Each unique

man becomes in community through communication with other uniquely different men.

IV. THE NURSING METAPARADIGM

MAN

Man is an individual being necessarily related to other men in time and

space. As every man is beholden to human existence is coexistence. The

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deeper significance of this truth has been recognized and elucidated by many

thinkers, especially those in the existential stream. Over and over, their writings

reveal the paradoxical tension of being human: each man is, at once,

independent, a unique individual and interdependent, a necessarily related

being. To know myself as "individual" is to experience myself as this particular

unique here-and-now person and other than that there-and-now person. Or in

other words, to know myself as me is to see myself in relation to and distant

from other selves.

Human being is a unique and “incarnate being always becoming in relation with men and

things in a world of time and space” (1988, p. 18). Has the capacity to reflect, value, experience to

become more. They are the one who asks for help and one who gives help.

NURSING

Nursing, as seen through Humanistic Nursing Theory, is the ability to

struggle with another through “peak experiences related to health and

suffering in which the participants are and become in accordance with their

human potential” (Paterson & Zderad, 1976, p. 7). The struggle evolves

within a dialogue between the participants, illuminating the possibility for

each to “become” in concert with the other. According to Josephine Paterson

and Loretta Zderad, in nursing, the purpose of this dialogue, or

intersubjective relating, is, “nurturing the well-being and more-being of

persons in need” (1976, p. 4).

Nursing, being an intersubjective transaction, presents an occasion for both

persons, patient and nurse, to experience the process of making responsible

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choices. Through living this process in nursing situations, the nurse develops

her own potential for responsible choosing. The satisfaction, often in the

form of a sense of vitality and strength, that is felt in making responsible

competent professional judgments reinforces the habit. In personally coming

to experientially appreciate the growth promoting character of responsible

choosing, the nurse may more readily recognize the value of such

experiences for any person, including the one currently labeled "patient."

HEALTH

Health as defined in Humanistic Nursing Theory, is, a matter of personal

survival. It is a process of experiencing one’s potential for well-being and

more-being, a quality of living and dying.

Health is valued as necessary for survival and is often proposed as the goal

of nursing.

Health an existential view of health that focuses on symbolism and the

place of the self in an intricate web of relations among objects and subjects

COMMUNITY

Community as presented by Drs. Paterson and Zderad is: “Two or more persons struggling

together toward a center” (1976, p. 131).

Objective world as manifested in “other human beings” and things. It is the subjective meaning

of the people and things.

Refers to nurses’ and patient’s environment (1988, pp. 31–33, 37).

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V: CONCEPTUAL FRAMEWORK

It is easy to determine the paradigmatic origins of Paterson and Zderad’s

theory. The origins are explicitly identified as being existential philosophy for

theory development and phenomenology for

research. Existentialism considers a person

as a unique being and the sum of all

undertakings. It does not purport to find out

the “why” of human experience, but just

describes the “is” of it. It views human

existence as inexplicable and emphasizes

the freedom of human choice and

responsibility for one’s acts. Existential

philosophy projects that a person exists but lacks a fixed nature and is always in a

state of becoming.

Humanistic nursing is a moving process that occurs in the living context of

human beings, human beings who interface and interact with others and other

things in the world. A person becomes a patient when he or she sends a call for

help with some health-related problem. The person hearing and recognizing the

call is a nurse. A nurse, by intentionally choosing to become a nurse, has made a

commitment to help others with health-related needs. It is important to emphasize

that in humanistic nursing theory, each nurse and each patient is taken to be a

unique human being with his or her own particular gestalt. Gestalt, representing all

that particular human beings are, which includes all past experiences, all current

being, and all hopes, dreams, and fears of the future that are experienced in one’s

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own space-time dimension. As illustrated, this gestalt includes past and current

social relationships, as well as gender, race, religion, education, work, and

whatever individualized pattern for coping a person has developed. It also includes

past experiences with persons in the health-care system and a patient’s images

and expectations of those persons.

Our gestalt is the unique expression of our individuality as incarnate human

beings who exist in this particular space at this particular time, with circumscribed

resources and in a physical body that senses, filters, and processes our

experiences to which we assign subjective meanings. Accordingly, a nurse

and a patient perceive and respond to each other as a gestalt, not just as the

presentation of a sum of attributes. In humanistic nursing we say that each person

is perceived as existing “all at once.” In the process of interacting with patients,

nurses interweave professional identity, education, intuition, and experience with

all their other life experiences, creating their own tapestry, which unfolds during

their responses. One has only to observe nurses going about their nursing to see

this process of interrelating as subjective human beings.

VI. CRITIQUE

Paterson and Zderad relied heavily on such existentialist philosophers as

Teilhard de Chardin, Martin Buber, Gabriel Marcel, and Frederick Nietzsche to

develop their theory of nursing, and they also relied on such phenomenologists as

James Agee. Both existentialism and phenomenology are compatible paradigms,

allowing the humanistic nursing theory to integrate their assumptions and

concepts and to evolve from both traditions. Barnum identified several advantages

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in the use of these paradigms to develop the nursing domain. A person could be

considered in totality, experience could be viewed as a whole, and knowledge for

nursing could be viewed as more than the sum total of diverse views from a

variety of disciplines. Existential nursing furthers a better understanding of the

environment of one’s self. To use the accepting nature of existentialism is

antithetical to the advocacy needed to make changes in intolerable and oppressive

situations that are mitigated by illness or by other social or political conditions.

Existential nursing may provide the rationale for accepting an unhealthy and non-

effective status quo. And it provides no guidelines for releasing patients from

suffering (Barnum, 1998).

The theorists, in proposing their humanistic theory of nursing, have also

proposed a methodology congruent with the assumptions of the theory to develop

nursing knowledge (Paterson, 1971). They use the logic of phenomenological

methodology and call it phenomenological nursology. The method is aimed at the

reality as experienced by the nurse and the patient, subjectively and objectively.

They propose the method for research and nursing practice. Existentialism is the

context of nursing, and concepts are used to develop theory. Phenomenology is

the process for clinical nursing and for research in nursing. Phenomenological

nursology evolved from nursing practice and is usable for nursing research.

The theory depicts a way of life, an attitude toward humanity, a goal of

actualization worth striving for on all levels of personal and professional lives.

However, it is limited in the form of guidelines for nursing practice. The only

indication of the use of this theory as a framework for practice has been offered by

Paterson and Zderad as occurring in the Veterans Administration Hospital in

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Northport, New York. However, the theory is used in discussions of research

findings related to a person’s relationship to time and space, such as hospital

rooms or the meaning of waiting for particular procedures.

The theory is a philosophy and a methodology that claims to improve not

only quality of care but also the quality of life for the nurse, the teacher, and the

administrator. Objective criteria to measure outcomes are antithetical to the

theory and the methodology proposed. Therefore, the subjective/objective

assessment of each individual nurse is expected and accepted; there are no valid

or reliable criteria to measure concepts, nor are they warranted within the

philosophical view that guides the theory.

The theory is based on several sets of ideas: that the person possesses

autonomy, free will, and many opportunities for choosing among available options.

However, the options and choices are considered relative and are perceived

subjectively. An absolute reality does not exist for those who follow the

existentialist school of thought. This theory allows nurses to use knowledge

processed through their own lenses and experiences. There is total freedom to

create, enhance, determine, and act. Existential philosophy emphasizes a

complete sense of responsibility for all actions, and Paterson and Zderad based

their theory on this stance.

Their theory also has roots in phenomenology. Phenomenology is the study

of all aspects of a phenomenon in all its richness, in all its dimensions, in its

entirety—without attempting to separate the human experiences of any partners

in the study (Kant, 1953, pp. 80–90). The focus is on the here-and-now. Nursing

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deals with more than that; therefore, any limitations in the theory are limitations of

its paradigmatic origins.

VII: IMPLICATION OF THE THEORY

NURSING EDUCATION

Training nurses in a humanistic approach to caring for patients with dementia

Author: Leonard L. Sarff

January 2013

Abstract:

This study applied a humanistic perspective to nursing care for people with dementia. A formal training

program was designed to help Registered Nurses, Licensed Practical Nurses, and Certified Nursing

Assistants understand the etiology and progression of dementia, followed by hands-on training

addressing the behavioral challenges in these residents. This training taught the nurses to explore not

only the medical aspects of dementia but more importantly to see the person suffering from dementia as

a whole person who had a life of experiences, dreams, loves, and aspirations for their lives, and what has

made the resident a unique individual. The principal question this exploratory case study examined was:

Does training nurses to use a humanistic approach lead to a higher quality of care and improve the

personal experiences of the caregiver? A semi-structured interview with one Registered Nurse, one

Licensed Practical Nurse, and one Certified Nursing Assistant, a subset of those who attended the

training, supplemented a survey of 16 participants as well as observations of staff-patient interactions by

the investigator. A survey completed by the participants asked them to compare their own work

orientations before training with changes following the training. Training the staff to use a humanistic

approach led to 15 out of 16 participants reporting that their participation in the program contributed to

one or more aspects of improved personalized care for their patients, benefiting not only the residents

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but themselves as well. Participants reported feeling more satisfaction with the work they were doing

and an increased ability to have a greater impact on the lives of the residents they were treating.

NURSING PRACTICE

Humanistic Nursing Theory: application to hospice and palliative care.

Wu HL, Volker DL.

Nursing Department, Meiho University Neipu,

Pingtung, Taiwan.

2011 Jul 20

Aim: This article presents a discussion of the relevance of Humanistic Nursing Theory to hospice and

palliative care nursing.

Background: The World Health Organization has characterized the need for expert, palliative and end-

of-life care as a top priority for global health care. The specialty of hospice and palliative care nursing

embraces a humanistic caring and holistic approach to patient care. As this resonates with Paterson and

Zderad's Humanistic Nursing Theory, an understanding of hospice nurses' experiences can be

investigated by application of relevant constructs in the theory.

Data Sources: This article is based on Paterson and Zderad's publications and other theoretical and

research articles and books focused on Humanistic Nursing Theory (1976-2009), and data from a

phenomenological study of the lived experience of Taiwanese hospice nurses conducted in 2007.

Discussion: Theoretical concepts relevant to hospice and palliative nursing included call-and-response,

inter-subjective transaction, and uniqueness-otherness.

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Implications for Nursing: The philosophical perspectives of Humanistic Nursing Theory are relevant

to the practice of hospice and palliative care nursing. By 'being with and doing with', hospice and

palliative nurses can work with patients to achieve their final goals in the last phase of life.

Conclusion: Humanistic nursing has some serious advantages over traditional nursing. Terminal

patients in particular appear to be far more receptive and responsive to humanistic nursing over

traditional nursing, and live longer and more content lives when nursed in this manner. Often,

relationships are what give people the strength to heal in the face of major adversity, so a humanistic

nurse can dramatically improve a chronically ill patient's odds for survival if he is receptive to this type

of treatment.

Use of core concepts from Humanistic Nursing Theory can provide a unifying language for planning

care and describing interventions. Future research efforts in hospice and palliative nursing should define

and evaluate these concepts for efficacy in practice settings.

NURSING RESEARCH

Care of Client with Panic Disorder: A Humanistic Nursing Approach

Domino Butron Puson

Cebu Normal University

Philippines (December 2013)

ABSTRACT:

This study aims to apply the Humanistic Nursing Approach in the care of clients with Panic Disorder as

basis for the proposed desensitization program. Based on the findings of this study, the lived experience

with the client was able to generalize that the Paterson and Zderads Humanistic Nursing Theory could

be utilized as a care model to develop a Panic Disorder Anxiety Desensitization Program as evidenced

by the clients responses in the nurse-patient relationship. The holistic and humanistic approach of this

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theory could be used to explore the overall condition of the client and lead an open relationship of the

client and the researcher wherein both especially the client is able to reflect on the basis of learning from

self experiences and of the researchers experiences. Furthermore, the researcher’s self-made Nursing

Humanistic Assessment Tool patterned in the Humanistic Nursing Theory obtained in depth information

about the client and can be used as an adjunct to conventional psychiatric assessment forms. Finally, the

practice of humanistic nursing in clients with Panic Disorder furnish better outcomes in terms of nursing

care and the development of new insights by the client to reach her optimum human potential.

VIII: APPLICATION OF THE THEORY

COMMUNICATION

The call and response of an authentic dialogue between a nurse and patient

has great power--the power to change the lived experiences of both patient and

nurse, to change the situation, to change the world. It is the same authenticity we

search for in relationships with our friends and lovers. The person who really

listens to what we are saying, who really tries to understand our lived experiences

of the world and who asks the same from us. When found, it brings the same

exhilarating feeling of self-affirmation and the comforting feeling of well-being.

Nursing is a lived call and response reflective of every mode of human

communication.

Without exception, patients’ experiences are influenced by how care is delivered. Through

communication, a patient can: be reassured; be put at ease; be taken seriously; understand their illness

more fully; voice their fears and concerns; feel empowered; be motivated to follow a medication

regimen; express a desire to have treatment (or not); be given time and treated with respect.

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Communication is therapeutic. Building relationships is the cornerstone of nursing work,

particularly with patients with learning disabilities; communication is a prerequisite to that process. It

can also be life-saving. If a patient is informed about what symptoms to mention, a cancer is more likely

to be diagnosed and treated in time.

Nurses who are comfortable with listening for and discussing existentially related concerns may

be in a better position to promote the patient's psychological adaptation.

Too often, health care providers are solely focused on treatment and disease management. The

types of death-related concerns that people experience and strategies to help resolve the normal but often

distressing psychological responses in the early post-diagnostic and treatment period.

"With a nurse's help, if a patient can resolve the issues that impact quality of life during early treatment,

it may greatly improve their outlook," she said. "It is difficult for patients to focus on learning about

anti-cancer treatment if they are overwhelmed with anxiety and distressing thoughts."

PERSONAL AND PROFESSIONAL DEVELOPMENT

Nursing is a continuous learning process of knowledge, skills, and attitude both scientific and

humanistic in terms of health care management. In Humanistic Nursing Theory, the nurse and the patient

are mutually learning from each other thus provides personal and professional growth not only for the

nurse herself but also to the patient. Here is an example of expanding the nursing practice by learning

from patients.

Student nurse Natasha Thompson learned that although cognitive ability may not appear to be

there after a stroke, it does not mean patients do not understand.

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In my first year as a nursing student I worked on a ward for older people for six months. Other

students would say: 'Poor you, it is hard work.' But I loved it.

I looked after a lovely blue-eyed woman called Jane, who, following a stroke, was fully

dependent on nursing staff. The doctors were not sure of her cognitive abilities. She was unable to

speak, and did not appear to understand what was said to her. Jane had a peg feed in situ and every time

I came to change the feed, I felt she was trying to say something with her eyes. I often talked with her,

and she responded by smiling.

Jane's daughter was concerned that her mother was suffering and wanted it to end, so the doctors

decided to discontinue the feed. Jane was transferred to a nursing home and was expected to die in a

matter of weeks. All the staff were sad to see Jane go and felt uneasy about the decision.

A year later, I was allocated to a community placement in a large nursing home. The sister took

me round the home to meet all the residents. She stopped in front of one and said: 'I want you to meet

our lovely Jane.' I stood there, not believing my eyes. The same Jane, who was discharged to die, was

sitting in bed smiling at us.

She had lost a great deal of weight, but her eyes looked even more beautiful. The sister said she

could not let her die - they had continued to feed her, despite the doctors' advice.

To my amazement, Jane had improved and was able to speak short sentences. She enjoyed

listening to music and looking at the trees outside. The staff at the home often said: 'Jane knows her own

mind.' Every time I came to see her, she would smile and say: 'I’ve been looking for you.' She also loved

holding my hand.

After her stroke, Jane's quality of life diminished greatly, but I believe if she had been asked she

would have said she wanted to continue living. The smile on her face was the proof of her contentment.

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We need to understand more how people's minds are affected by stroke. Cognitive ability may

not appear to be there, but it does not always mean patients do not understand. I have realized that,

despite some patients' inability to communicate, there is a possibility that they may have a level of

understanding.As nurses we should always remember this and where possible allow patients to make

their own choices. Sadly Jane died recently, but this time she was ready.

IX. BIBLIOGRAPY:

Butts, J.B. & Rick, K.L. (2010). Philosophies and Theories for Advanced Nursing Practice.

Malloy, Inc.

Parker, M. E. (2005). Nursing Theories & Nursing Practice 2nd Edition. F. A. Davis

Company

Paterson, J. & Zderad, L. (2007). Humanistic Nursing (Meta-theoretical Essays on

Practice) The Project Gutenberg eBook

Sarff, L.L. (2013). Training nurses in a humanistic approach to caring for patients with

dementia. http://udini.proquest.com/view/training-nurses-in-a-humanistic

goid:761130528/

Volker D.L. & Wu H.L. (2011). Humanistic Nursing Theory: Application to hospice and

palliative care. http://www.bioportfolio.com/resources/pmarticle/210941/

Humanistic-Nursing-Theory-application-to-hospice-and-palliative-care.html

Puson, D.B. (2013). Care of Client with Panic Disorder: A Humanistic Nursing Approach

http://jes-lcup.com/abstract-details.asp?r=86

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