Response to "The Concept of Nursing Presence: State of the Science"

By Chase, Susan K. EdD, Rn, Bc | Scholarly Inquiry for Nursing Practice, January 1, 2001 | Go to article overview

Response to "The Concept of Nursing Presence: State of the Science"


Chase, Susan K. EdD, Rn, Bc, Scholarly Inquiry for Nursing Practice


I am pleased to have been asked to respond to the challenging work by Tom Smith, "The concept of presence: State of the science." His article offers a critical analysis of spiritual, philosophical, and research literature with the purpose of synthesizing work on the concept from many sources. My own comments will begin with a response to his final point. An analysis of the concept of presence is particularly important at this time when nurses everywhere are working with heavier caseloads of sicker patients, and are doing so with less support. If nursing as a profession is to survive and evolve, a careful examination of presence is essential. The fact that this topic is of interest to a nursing administrator who leads a complex health care system, such as Tom Smith, is heartening.

Mr. Smith begins his review at the source of the concept, which comes from religious and spiritual roots. This is indeed parallel to nursing's own evolution as a practice based in religious tradition and institutions. One key concept in considering presence in the Hebraic sense is that the symbol of the presence of God was the tabernacle. It was obvious to all observers that contact with that presence resulted in a changed appearance in the person who made contact. We can draw an analogy in present day times in that authentic presence between patient and nurse results in a transformation in both. Presence is a matter of consciousness and is reflected in the holistic beings that are both nurses and patients.

In the spiritual sense, we are reminded that a simple cause-and-effect model is not the way to conceive of presence, and I believe that an examination of the worldview assumed by each of the authors cited by Smith may offer some clarity in the analysis of the concept. The worldview of the phenomenologists encourages analysis of concepts such as presence that are not accessible to positivist methods of inquiry (Husserl, 1962). This awareness has implications for the types of research that will illuminate the concept of presence and for the implications that we can draw from analysis of the concept. Presence as described by the phenomenologists is an essential human experience. Cutting humans off from the experience of human presence results in humans no longer being human (Heidegger, 1972). Presence, like caring, is not unique to nursing in the larger sense, but nursing is unique in how caring and presence are enacted.

COMMONALITIES

An examination of the many sources that contribute to our understanding of presence reveals that several concepts underlie many or all of the authors Smith cites. One essential feature of nursing presence is that it is a reciprocal experience (Ferlic, 1968; Marcel, 1950; Peplau, 1989; Zaner, 1981). Presence occurs through an interaction that may be verbal, through touch or through quiet availability. In any case, presence is not a one-way intervention that the nurse chooses in isolation to use. Even when the patient is unresponsive by some definitions, the situation that the patient presents in itself suggests an invitation to interaction. An example of this would be the comatose patient or a deeply psychotic patient.

Another essential feature of presence is that it relates to wholeness and not particulars. Presence calls forth an examination for both patient and nurse of the meaning of a given situation. Presence goes beyond instrumental techniques. Paradoxically, presence may occur during a time of technical interaction, but in these cases, presence changes the manner in which the technical skill is completed. The nurse who offers presence attends to the person, not to the technique.

Several authors discuss the notion that presence is purposeful but can be seen as something different from instrumental and cause and effect in character. Purposefulness and intentionality mean that a transformation of the patient's situation either through expanded consciousness, empowerment, or acceptance can result from a shared meaning-making activity that presence enables (Marcel, 1950; Parse, 1995; Vaillot, 1966). …

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