HUMANISTIC NURSING THEORY

By:
MARY JOHN L. RENONG, RN August 10, 2013

HUMANISTIC NURSING THEORISTS

Dr. Loretta Zderad

Dr. Josephine Paterson

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. 3

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

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 nursepatient 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 5

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, 19701971). 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 patients and nurses 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 nurses 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.

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 Zderads 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 persons living and dying. 7. Nurses and patients coexist; they are independent and interdependent. 7

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 others 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 8

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 goaldirectedness 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, 9

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 intersubjective 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. 11

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 12

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 13

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. 8889), which was obtained through the unbiased being with the 14

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 nurses 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 nurses general impressions are in a dialogue with her unbracketed view (see Figure 114). Nurse Knowing the Other Scientifically This phase incorporates the nurses 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 nurses 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 persons 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 17

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 18

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 ones 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 patients environment (1988, pp. 3133, 37).

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V: CONCEPTUAL FRAMEWORK
It is easy to determine the paradigmatic origins of Paterson and Zderads 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 for human ones choice and

responsibility

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 ones 20

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 patients 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 21

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 ones 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 noneffective 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 persons 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 entiretywithout attempting to separate the human experiences of any partners in the study (Kant, 1953, pp. 8090). 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 endof-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 26

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 researchers 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: 'Ive 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. 29

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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