The central questions for Paterson and Zderad were: How do nurses andpatients inleract? and How can nurses develop the knowledge base for theact of nursing? The humanistie practice nursing theory proposes that thenurse and the patient are significant eomponents in the nurse/patientsituation. The aet of caring inereases the humanness of both, They bothapproach the situation with experiences that influence the encounter. Nurses,therefore, should consider such encounters as existential experienees andshould describe them from a phenomenological perspective. The sum totalof aU these experiences will enhance the development o the science onursing. In seleeting existentialism and phenomenology as context andmethod for the development o nursing knowledge, they operate from severalpremises. The progress o nursing as a human scienee is hampered by themechanistic, deterministie, cause and effeet methods that have dominated it;in other words, they rejeeted the reeeived view, the logieal positivism viewo theory development (Paterson, 1971, p. 143). They were a decade ahead o

. aUthe literature in nursing that is now advoeating sueh a move. They havealso developed their ideas on the premise that the experiences of nurses inpractice supply the impetus for any useful theory for nurses. The preeoneeivednolions of persons color what is significant and determinately influence thedevelopment of knowledge; they should evolve from nursing practice.

Theory Descrlptlon

Josephine Paterson and loretta Zderad

is the focus, patients should be consulted in their own care, andents should be spared the distress and discomfort associated with hospitale. Patlents' behaviors should be a significant factor in nurses' reactionsvice versa. Although the patient was still viewed as helpless and the

deliberative process appeared to be always Intiated by the nurse, neverthelessmany of the assumptions of the theory are eongruent with social andprofessional values of today.

The theory is culturally bound. Patients in other parts of the world and[rorn other subcultures may not want to participa te in identifying their needs.They may prefer to rely on their significant others and the health eareprofessionals to do that for them. They may misinterpret the eontinuousvalidation proposed in this theory as lack of knowledge, expertise, or lack ofaccountability in the care process (Lipson & Meleis, 1983). The uniquenessof individuals assumed by the theory could counteract automatic responsesof nurses beeause even a nursing proeess dscipline.z delberative nursingprocess could turn into an autornatc response if the nurse forgets the basic. assurnptions guiding the theory.

On Interactians 247

From Paterson. J.G. and Zderad. L.T.1I9761 Humerstk:mmtnq. New York: Jonn Wlley & Sons: and rrorn Zd.rad. l.T. 119691Empathericnursng: Realizaron or a human capaoty. NUfsing Clinics of Nortt "'m~rica. 4. 655-662.

ImpllcJt Assumptlons- Nursing involves two human beingswho arewilling [O enter nto an existencial relationship with

eacn other.- Nurses and patlents as persons are unique and total biopsychosocial beings with the potential

for becoming through choice and intersubjettivity.- The present experiencesare more than tne !sum total of tne pastopresent. and the future. and

are influenced by the pastopresent, and ruture. In their totality they are tess than tne future.- Every encounter with another human being ls an open and profound one, with a great deal of

Intimacy tnar deeply and humanistically influencesmembers in the encounter,- Human beingsarefreeand areexpected to be involved in their own care and in decisionsinvolving

them.- AI/ nursing acts inuence the quality of a person's living and dying.- Nurses and patlenrs coexst: they are independent and interdependent.- A nurse has to "accept and betleve in the cnaos of existence as lived and experienced by eacn

man despte tne shadows he casts. interpreted as poise. control, creer, and joy" (Paterson&Zderad, 1976,p. 62).

- Human beings nave an innate force that moves them to know their angular views and other'sangular views of the world (Paterson& Zderad, 1976; Zderad, 1969).

Table 11-9. Assumptlcns-c-Paterson& Zderad

248 OUR DOMAIN ANO OUR PIONEERS

Nursing is a lived dialogue that incorpora tes an intersubjective trans-action in which a nurse and a patient meet, relate, and are tota11y present inthe experience in an existential way that ineludes intimacy and mutuality(Paterson and Zderad, 1970-1971). Nursing brings a person together with anurse because of the can of that person for help and the response of thenurse. The encounter is influenced by a11other human beings in the patient'sand nurse's lves and by other things, whether ordinary objects (such as :~,utensils, clothes, furniture) or special objects (such as life-sustaining equip--~ment). The dialogue occurs in a time frame as experienced by both partners.When there is synchronicity in timing, the intersubjective dialogue is en-hanced. Dialogue occurs in a certain space that is objective-the physicalsetting, or subjective-personal space, Paterson and Zderad's theory wasbased on a number of implicit assumptions (Table 11-9).

The theory has the potential for highly abstract propositions related to .nurse/patient interactions (Table 11-10). The level of abstraction does notrender propositions ready for testing. .

Concepts of the theory are we11delineated (Tablet t-t ): however, sorne.conceptual definitions are not complete in the theory [I-thou, I-it, We, a11at ;once), and others provide useful conceptual definitions such as empathy(Zderad, 1969) and nursology (Paterson, 1971). The theorists did not offeroperational definitions. Central nursing phenomena, such as environment o~well-being, are not defined and neither are central concepts of the thsuch as nurturance, comfort, ernpathy, and elinical process. Derived LUJl .....e.....the nursing dialogue, is more comprehensively defined in terms of meerelating, and presence than any of the primitive concepts (Table 11-12).

Wel/-beingMorebeingChOicesAuthentieity with ones self

Intellectual awarenessCommunity'Concepts for research

Authenticity with senNursology

AII at once

BecomingI-ThouI-ItWe

BetweenNurturingComfortBeing ano doingLived dialogue

NurturingIntersubjective transaction

MeetingRelatingPresence

IntimacyMutuality

Call and responseOther human beingsThings ITime

SynchronicitySpaee

rabie 11-11. Concepts-Paterson & Zderad

..,v,~vt-,ine G. Paterson, D.N.S. and Loretta T. Zderad, Ph.D. are employed asresearchers at the Veterans Administration Hospital in Northport, New

. Paterson (Diploma from Lenox Hill Hospital, B.S.N.E. from St. lohnsnversty M.P.H. from Iohns Hopkins University) received her D.N.S. from

the Boston University School of Nursing. Zderad (Diploma from St. Bernard's=",-ospital, E.S.N.E. from Loyola University, M.S.N.E. fram Catholic Universily)

received her Ph.D. from Georgetown University. Their interest in public'. health and psychiatric nursing respectively is complementary and well-represented in their theory. Their ideas evolved in 1960 while collaborativelyteaching graduate students. After completing their respective doctorates, theydeveloped a course on humanistic nursing at the Veterans Administration

._Hospital in 1972. In the process of teaching the course, their theory evolved.

EORY ANALYSIS

.Nursing's existentia! involvement in patient care is manifested in the active presence of the whole'nurse in time and space as viewed by lile patient.Nursing's goal of more weu-be.nq is enhanced by both nurse ano patient as they experience theprocess of making responsible ehoiees.Because nursing is involved with humans, its phenomena are man needing help ano man helpingIn nts own slruanon.Intimaey ario mutuaty in relationships enhance more well-being.

Proposltlons-Paterson & Zderad

On Interactions 249

_ .._ -..---.. _ ..-._ .. _----~--_..__.._--------_..~.

--: ...............1. j;

Paradlgmatlc OrlglnsIt is quite easy to determine the paradigmatic origins of Paterson and Zderad'stheory. The origin is explicitly identified as being existential philosophy fortheory development and phenomenology for research. Existentialism considersa person as a unique being and the sum o all undertakings. It does oot -purport to find 'out the "why" o a human experience, but just describes the

Their 1976 collaborativa book is a result o their teac~ing and observingclinicians in practica.

Nursing A human discipline involving one human being helping another in an in-terhuman and intersubjective transaction "containing all the human po-tennats and limitations of eacn uniquepartldpant" (1976. p. 21.IncorporatesaIJhuman responsesof a person needing another. "The ability to strugglewith otner man through peak experiences related ro health and sufferingin whictl tne participants in the nursing situation are and become inaccordance with their human potential" (1976. p. 7).

Goals of Nursing 1) Humanistic nursing itself is a goal.2) Help patients and self to develop their human potenttat and to come

toward. through choice and intersubjectiviry. wellbeing or more wel-being.Tohelp patienrs and self to increasepossibility ormaking responsiblechotees (1976. pp. 15-17).

Health More than absenceof disease: equared with more wellbeing. as much ashumanly possible (1976. p. 12).

Environment Objecrive world as manifested in "otner human beings" and trnnqs. Thesuojectlvemeaningof the people and things. Refersto nurses'and patient'senvironment (1976. pp. 34-36. 411.

Human Being A unique and "incarnate being always becoming in relation with men andthings in a world of rime and space" (1976. p. 191.Has the capacity toreect, value, experience to become more. One who asks for help andone who gives help.

Nursing Client Botn nurse and patient are the nursing cnents (incarnate men). who areunique. when they "meet in a goaldirected (nurturing wellbeing andmore weli-belnq] intersubjecrive transaction (being with and doing with]occurring in time and space (as measured and as lived by patent andnurse)" (1976. p. 231

Nursing Problem Seemingdiscomfort that prornpts a caIJfor help. A person with perceivedneeds related to the health/illness quality of living (1976. p. 19).

Nursing Process "Deliberare. responsible.conscious. aware. nonjudgmental extstenceof thenursein the nursing situation. foIJowed by disciplined. authentic renecuonand descnption" (1976. pp. 7-8). Basedon awarenesson the pan of thenurse.continuous assessment(p. 17).and developing the human potentialof the patient for responsible choosing between alternatives.

Nurse/Patient Relations The human dialogue is the essenceor nursing. interaction snursing. Nurse/patient experience ts an intersubjective transaction with empathy.

Nursing Therapeutics A human dialogue involves being and doing. nurturing. well-belnq or moreweIJbeing.and comforting. Existential involvemenr rh,1tis an active presoence besides the doing. to provide nurturing and comfort and involvesexperiencing. reecttnq. and conceptualizing (1976. pp. 13-251. Nursesoffer alrernauvesand support responsiblechoosing. shareself. knowledge.and experience.

Focus On the person's unique being and becoming (1976. p. 20).

Table 11-12. Deflnltlon 0' DomaJn Concepts-c-Paterson& Zderad250 OUR OOMAIN ANO OUR PIONEERS

Internar Dlmenslons

The purpose of the theory is to develop humanistic nursing and the humanmethod of nursology (the study of nursing aimed toward the development ofnursing theory). The theorists used a method to develop theory and thetheory is the method. The theorists arned to develop a theory, usingmethodology and proposing research, congruent with the nature of nursingas a human science. The theory evolved deductively from a philosophicalview-existentialism-but they used a phenomenological approach to induc-tively develop a theoretical conception of nursing. Because most of theconcepts are derived from existentialism, one can deduce that the theory ismore deductive than inductive. This is a highly abstract theory developedaround an inlerest in exploring interaction as a concept. The theory focuseson properties of the human encounter-the human situation that existsbetween nurses and patients; therefore, it is classified as a microtheory, withmore derived than primitive concepts. Its scope is narrow, describing oneaspect of nursing therapeutics or the nursing process-interaction-and oneaspect of interaction-human encounter. Therefore, it is a single-domaintheory. It deals with knowledge of process: how do people interact, particularlywhen one needs help and one is willing lo give help? The theorists use adialogue forrn for describing the "nursing dialogue." Therefore, McKeon(cited in Stevens, 1979) would consider their approach to theory developmenta dialectic one. They presented a whole, explaining the whole (humanistic

of lt. It views human existence as inexplicable and emphasizes the~dom of human choice and responsibility for their acts. Existential philos-

projects that rnan exists but lacks a fixed nature and is always in aof becoming.Phenomenology is the study of all aspects of a phenomenon in a1l itsness. al! its dimensions, in its entirety without attempting to separate thean experiences of any partners in the study (Stevens, 1979, p. 225). Thes is on the here and now. Nursing deals with mote than that; therefore,

any limitations in the theory are lrnitations of the paradigmalic origins.-, Paterson and Zderad relied heavily on su eh existentialist philosophers'. as Teilhard de Chardin, Martin Buber, Gabriel Marcel, and Frederick Nietzscheto develop their theory of nursing, and they al so relied on such phenome-nologists as James Agee. Both existentialism and phenomenology are com-

.' patible paradigms and allow the humanistic nursing theory to evolve. Stevens.. identified several advantages in the use of these paradigms to develop the

nursing domain. A person could be considered in totality, experience couldbe viewed as a whole, and knowledge for nursing could be viewed as morethan the sum total of dverse views from a variety of disciplines. Indeed,these paradigmatic origins give nursing its raison d'etre (Stevens, 1979, p.225). Existential nursing furthers a better understanding of the environmentof one's self.

On Interactions 251

,,:[..XII,~l~..

This is a method to find truths related to everyday practice irt nursing ',;':'jor as evolving out of nursing research. Though no research is repor~ed usng ',I'?~".Paterson and Zderad's method, there are numerous research findings that .: Ihave used grounded theory, modified phenomenological approaches, and \qualitative approaches to nursing research. Researchers have used these :\. ,concepts interchangeably to describe methodologies depicting part of each ~ ,J

The theorists, in proposing their htiinanistic theory of nursing, have alsoproposed a mthodology congruent with the assumptions of the theory todevelop nursing knowledge (Paterson, 1971)_ They use the logic of phenom-enological methodology and call it phenomenological nursology. The methodis aimed at the reality as experienced by the nurse and the patient subjectivelyand objectively. They propose the method for research and nursing practice.Existentialism is the context ofnursing, and concepts are utilized to developtheory. Phenomenology is the process for clinical nursing and for researchin nursing. Phenomenological nursology evolved out of nursing practice andis usable for nursing research.

The theorists proposed five phases of phenomenological nursology(Paterson, 1971):

1. "Preparation of the nurse knower for coming to know";this could be accomplished by total immersion in selectedand related literary work. Immersion includes reflecting,contemplating. and discussing.

2. "Nurse knowing of the other intuitively" by seeing theworld through the eyes of the subject or the patient.Become an insider rather than an outsider.

3. "Nurse knowing the other scientifically" by replaying thesubjective experiences, reflecting on them, and transcribingthe amalgamated view. The nurse considers relationshipsand analyzes, synthesizes, and then conceptualizes.

4. "Nurse complernentarity synthesizing known others" bycomparing and contrasting the differences of like nursingsituations to arrive at an expanded view.

5. "Succession within the nurse from the many to theparadoxcal one," evolving from the multiple realities to aninclusive conception of the whole that incorpora tes themultiplicities and contradictions.

THEORY CRITIOUE

nursing) through the parts (the various concepts) and the parts through thewhole. The unlqueness of this theory lies in the lack of boundaries betweenthe experence of the authors as nurses, theoreticians, methodologists. andwriters. Conceptslin the theory describe a11that, and a11experiences descripeconcepts. ,

252 OUR OOMAIN ANO OUR- PIONEERS

... ,

External Components of Theory

The theory may be incongruent with prevailing values of practice but morecongruent with emerging values surrounding research and knowledge development in nursing. Humanistic theory proposes understanding of humanbeings and their experiences as they exist rather than considering what theyought to be or rather than changing them. That goal of humanistic nursinpma:y then be in conflict with professonal values and goals, Stevens (1979)makes two points to illustrate such incongruences. The first deals with apatienl in pain and in need of help.

It is a common existential position that suffering serves to bring about

(Stern, 1980; Wilson, 1977). Paterson and Zderad have used the approach toarticula te concepts of empathy (Zderad, 1968, 1969, 1970), and comforl

; (Paterson & Zderad, 1976), but these reports appear to be clinical insights asa prelude to systematic research findings.

Research lo explore the theory propositions has potential after theconcepts have been operalionalized. For example, the concepts of authenticity,the "between", more we11-being, and all-al-once are abstract and lackdefinition to render them researchable. The potential of the theory to generateresearch is exemplified in this example: the use of the self (the nurse) anddifferent patterns of "presence" in the patient's "time-space spheres" may beexplored.

The theory depicls a way oflife, an attilude toward humanity, a goal 01actualization worth striving for on a11 levels of personal and professionaJlves. However, it is limited in Ihe form of guidelines for nursing practice.The only indication of the use of this theory in practice has been offered byPaterson and Zderad as occurring in the Veterans Administralion Hospital inNorthport, New York.

The theory is a philosophy and a methodology that purports to improvenot only the quality 'of ca re but also the quality of life for the nurse, theteacher, and the administrator. Objective criteria to measure outcomes are. antithetical to the theory and the methodology proposed. Therefore, thesubjectivejobjective assessment of each individual nurse is expected andaccepted; there are no valid or reliable criteria lo measure 'concepts nor arethey warranted within the philoscphical view that guides the theory.

This is a tautological theory; the process o humanistic nursing isdescribed by the goal of humanistic nursing, and the complexity of thcphenomenon it addresses stems from abstractness and lack of boundariesbetween its concepts. It appears lo focus on the nurse rather than the patientas becoming and actualzing in the course of nursing care. Stevens (1979, p.227) asked if what we need is really a holislic nurse, in which case theproper subject mal ter of existential nursing theory would appropriately bethe nurse rather than the palient. If that is one of the focuses of nursing, andDonaldson would agree (1983), then Paterson and Zderad have offered atheory that appropriately describes one of the nursing phenomena.

On Interactions

1 the.-veenand

cribe

singsingthatandhese.ach

llogy

also['y loiorn-thodively:lice.'elop-archand

Nursing to Travelbee is an interpersonal process between two humanone of whom needs assistance because of an illness situation and the

Theory Descrlption

'a state o self-awareness, thereby creating 'an "openness" to authentic expe-rence that the patient might not otherwise evnce. Suffering crea tes a statein which the person is brought face to face with his own being. Most nurses,however, seek to remove (alleviate) suffering. It might be very difficult tojustify nursing acts that remove a patient from the authentic being osuffering. ~p. 229) , I

Neither Travelbee nor Paterson and Zderad would advocate the removalof suffering. Nursing to them is to help patients articula te their perceptionsof the situation and the meaning of the suffering.

Stevens' second argument evolves out of the theoretical proposition thatnurse/patient encounters involve an open human dialogue that involves adegree of intimacy to enhance understanding of the subjective world of thepatient. How many such "meetings" can a nurse be involved in in the courseof her working day and is there potential for emotional drainage leading toburnout? Do all patients seek and approve of such genuine encounters? iPaterson and Zderad would argue that the higher levels of "being" gleaned 'from each encounter indica te rejuvenation rather than burnout.

The theory is congruent with that segment of society that espousessubjectivity and being, but patients may want to evolve their beingin genuine encounters within their own circle rather than with the nurs-ing staff.

When, in 1960, Paterson and Zderad were developing the seeds of theirtheory, they may or may not have anticipated the supportive literature ofthe 19805 that advocated phenomenology as the methodology most compatiblewith nursing. The 19805 witnessed an ernergng world view in nursingdenouncng the empirical positivist view (see Chapter 2) and supporting aphenomenological view (Menke, 1978; Munhall, 1982; Oiler, 1982). Moreimportantly, Paterson and Zderad advocated respecting nursing experiencesas sources o knowledge and, indeed, o wsdorn, providing nursing withnonmechanistic and nonpositvstc strategies for theory development andresearch (Paterson, 1978; Zderad, 1978). Nursing would do well to adopttheir views,

254 OUR OOMAIN ANO OUR PIONEERS

.Joyce Travelbee