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On Interactians

is the focus, patients should be consulted in their own care, and

ents should be spared the distress and discomfort associated with hospital
e. Patlents' behaviors should be a significant factor in nurses' reactions
vice versa. Although the patient was still viewed as helpless and the
deliberative process appeared to be always Intiated by the nurse, nevertheless
many of the assumptions of the theory are eongruent with social and
professional 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 eare
professionals to do that for them. They may misinterpret the eontinuous
validation proposed in this theory as lack of knowledge, expertise, or lack of
accountability in the care process (Lipson & Meleis, 1983). The uniqueness
of individuals assumed by the theory could counteract automatic responses
of nurses beeause even a nursing proeess dscipline.z delberative nursing
process could turn into an autornatc response if the nurse forgets the basic
. assurnptions guiding the theory.

Josephine Paterson and loretta


Theory Descrlptlon
The central questions for Paterson and Zderad were: How do nurses and
patients inleract? and How can nurses develop the knowledge base for the
act of nursing? The humanistie practice nursing theory proposes that the
nurse and the patient are significant eomponents in the nurse/patient
situation. The aet of caring inereases the humanness of both, They both
approach the situation with experiences that influence the encounter. Nurses,
therefore, should consider such encounters as existential experienees and
should describe them from a phenomenological perspective. The sum total
of aU these experiences will enhance the development o the science o
nursing. In seleeting existentialism and phenomenology as context and
method for the development o nursing knowledge, they operate from several
premises. The progress o nursing as a human scienee is hampered by the
mechanistic, deterministie, cause and effeet methods that ha ve dominated it;
in other words, they rejeeted the reeeived view, the logieal positivism view
o theory development (Paterson, 1971, p. 143). They were a decade ahead o
. aU the literature in nursing that is now advoeating sueh 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. The preeoneeived
nolions of persons color what is significant and determinately influence the
development of knowledge; they should evolve from nursing practice.



Table 11-9.

Assumptlcns-c-Paterson& Zderad


Nursing involves two human beings who are willing [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 pasto present. 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 influences members in the encounter,
Human beingsare free and are expected to be involved in their own care and in decisionsinvolving
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's
angular views of the world (Paterson & Zderad, 1976; Zderad, 1969).

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

Nursing is a lived dialogue that incorpora tes

action in which a nurse and a patient meet, relate,
the experience in an existential way that ineludes
(Paterson and Zderad, 1970-1971). Nursing brings

an intersubjective
transand are tota11y present in
intimacy and mutuality

a person together with a

nurse because of the can of that person for help and the response of the
nurse. The encounter is influenced by a11other human beings in the patient's
and 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 enhanced. Dialogue occurs in a certain space that is objective-the
setting, or subjective-personal
space, Paterson and Zderad's theory was
based 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 not
render 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 offer
operational definitions. Central nursing phenomena, such as environment o~
well-being, are not defined and neither are central concepts of the th
such as nurturance, comfort, ernpathy, and elinical process. Derived
the nursing dialogue, is more comprehensively defined in terms of mee
relating, and presence than any of the primitive concepts (Table 11-12).
LUJl .....

_ .._




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

.. ~.

On Interactions 249

& Zderad

.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 the
process of making responsible ehoiees.
Because nursing is involved with humans, its phenomena are man needing help ano man helping
In nts own slruanon.
Intimaey ario mutuaty in relationships enhance more well-being.


ine G. Paterson, D.N.S. and Loretta T. Zderad, Ph.D. are employed as

researchers at the Veterans Administration Hospital in Northport, New
. Paterson (Diploma from Lenox Hill Hospital, B.S.N.E. from St. lohns
nversty 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 wellrepresented in their theory. Their ideas evolved in 1960 while collaboratively
teaching graduate students. After completing their respective doctorates, they
developed a course on humanistic nursing at the Veterans Administration
._Hospital in 1972. In the process of teaching the course, their theory evolved.

rabie 11-11.


Being ano doing
Lived dialogue
Intersubjective transaction
Call and response
Other human beings

& Zderad
AII at once
with ones self
Intellectual awareness
Concepts for research
with sen

--: ...............


Table 11-12.



Goals of Nursing

Human Being

Nursing Client

Nursing Problem
Nursing Process

Nurse/Patient Relations
Nursing Therapeutics


0' DomaJn Concepts-c-Paterson & Zderad

A human discipline involving one human being helping another in an interhuman and intersubjective transaction "containing all the human potennats and limitations of eacn unique partldpant" (1976. p. 21.Incorporates
aIJhuman responsesof a person needing another. "The ability to struggle
with otner man through peak experiences related ro health and suffering
in whictl tne participants in the nursing situation are and become in
accordance with their human potential" (1976. p. 7).
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 welbeing. To help patienrs and self to increasepossibility or making responsible
chotees (1976. pp. 15-17).
More than absence of disease: equared with more wellbeing. as much as
humanly possible (1976. p. 12).
Objecrive world as manifested in "otner human beings" and trnnqs. The
suojectlvemeaningof the people and things. Refersto nurses'and patient's
environment (1976. pp. 34-36. 411.
A unique and "incarnate being always becoming in relation with men and
things in a world of rime and space" (1976. p. 191. Has the capacity to
reect, value, experience to become more. One who asks for help and
one who gives help.
Botn nurse and patient are the nursing cnents (incarnate men). who are
unique. when they "meet in a goaldirected (nurturing wellbeing and
more weli-belnq] intersubjecrive transaction (being with and doing with]
occurring in time and space (as measured and as lived by patent and
nurse)" (1976. p. 231
Seeming discomfort that prornpts a caIJfor help. A person with perceived
needs related to the health/illness quality of living (1976. p. 19).
"Deliberare. responsible.conscious. aware. nonjudgmental extstence of the
nurse in the nursing situation. foIJowed by disciplined. authentic renecuon
and descnption" (1976. pp. 7-8). Basedon awareness on the pan of the
nurse.continuous assessment(p. 17). and developing the human potential
of the patient for responsible choosing between alternatives.
The human dialogue is the essenceor nursing. interaction snursing. Nurse/
patient experience ts an intersubjective transaction with empathy.
A human dialogue involves being and doing. nurturing. well-belnq or more
weIJbeing.and comforting. Existential involvemenr rh,1tis an active preso
ence besides the doing. to provide nurturing and comfort and involves
experiencing. reecttnq. and conceptualizing (1976. pp. 13-251. Nurses
offer alrernauvesand support responsiblechoosing. shareself. knowledge.
and experience.
On the person's unique being and becoming (1976. p. 20).

Their 1976 collaborativa book is a result o their teac~ing and observing

clinicians in practica.


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

theory. The origin is explicitly identified as being existential philosophy for

theory development and phenomenology for research. Existentialism considers
a 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


On Interactions

of lt. It views human existence as inexplicable

and emphasizes the
~dom of human choice and responsibility for their acts. Existential philosprojects that rnan exists but lacks a fixed nature and is always in a
of becoming.
Phenomenology is the study of all aspects of a phenomenon in a1l its
ness. al! its dimensions, in its entirety without attempting to separate the
an experiences of any partners in the study (Stevens, 1979, p. 225). The
s 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 Nietzsche
to develop their theory of nursing, and they al so relied on such phenomenologists 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 could
be viewed as a whole, and knowledge for nursing could be viewed as more
than 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 environment
of one's self.
Internar Dlmenslons
The purpose of the theory is to develop humanistic nursing and the human
method of nursology (the study of nursing aimed toward the development of
nursing theory). The theorists used a method to develop theory and the
theory is the method. The theorists arned to develop a theory, using
methodology and proposing research, congruent with the nature of nursing
as a human science. The theory evolved deductively from a philosophical
they used a phenomenological
approach to inductively develop a theoretical conception of nursing. Because most of the
concepts are derived from existentialism, one can deduce that the theory is
more deductive than inductive. This is a highly abstract theory developed
around an inlerest in exploring interaction as a concept. The theory focuses
on properties of the human encounter-the
human situation that exists
between nurses and patients; therefore, it is classified as a microtheory, with
more derived than primitive concepts. Its scope is narrow, describing one
aspect of nursing therapeutics or the nursing process-interaction-and
aspect of interaction-human
encounter. Therefore, it is a single-domain
theory. It deals with knowledge of process: how do people interact, particularly
when one needs help and one is willing lo give help? The theorists use a
dialogue forrn for describing the "nursing dialogue." Therefore, McKeon
(cited in Stevens, 1979) would consider their approach to theory development
a dialectic one. They presented a whole, explaining the whole (humanistic


... ,



nursing) through the parts (the various concepts) and the parts through the
whole. The unlqueness of this theory lies in the lack of boundaries between
the experence of the authors as nurses, theoreticians, methodologists. and
writers. Conceptslin the theory describe a11that, and a11experiences descripe
The theorists, in proposing their htiinanistic theory of nursing, have also
proposed a mthodology 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 ofnursing, and concepts are utilized to develop
theory. Phenomenology is the process for clinical nursing and for research
in nursing. Phenomenological nursology evolved out of nursing practice and
is 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 selected
and related literary work. Immersion includes reflecting,
contemplating. and discussing.
2. "Nurse knowing of the other intuitively" by seeing the
world through the eyes of the subject or the patient.
Become an insider rather than an outsider.
3. "Nurse knowing the other scientifically" by replaying the
subjective experiences, reflecting on them, and transcribing
the amalgamated view. The nurse considers relationships
and analyzes, synthesizes, and then conceptualizes.
4. "Nurse complernentarity synthesizing known others" by
comparing and contrasting the differences of like nursing
situations to arrive at an expanded view.
5. "Succession within the nurse from the many to the
paradoxcal one," evolving from the multiple realities to an
inclusive conception of the whole that incorpora tes the
multiplicities and contradictions.


This is a method to find truths related to everyday practice irt nursing

or as evolving out of nursing research. Though no research is repor~ed usng
Paterson and Zderad's method, there are numerous research findings that
have 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




:\. ,

On Interactions


['y lo



(Stern, 1980; Wilson, 1977). Paterson and Zderad have used the approach to
articula te concepts of empathy (Zderad, 1968, 1969, 1970), and comforl
; (Paterson & Zderad, 1976), but these reports appear to be clinical insights as
a prelude to systematic research findings.
Research lo explore the theory propositions has potential after the
concepts have been operalionalized. For example, the concepts of authenticity,
the "between",
more we11-being, and all-al-once are abstract and lack
definition to render them researchable. The potential of the theory to generate
research is exemplified in this example: the use of the self (the nurse) and
different patterns of "presence" in the patient's "time-space spheres" may be
The theory depicls a way oflife, an attilude toward humanity, a goal 01
actualization worth striving for on a11 levels of personal and professionaJ
lves. 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 by
Paterson and Zderad as occurring in the Veterans Administralion Hospital in
Northport, New York.
The theory is a philosophy and a methodology that purports to improve
not only the quality 'of ca re 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
assessment of each individual nurse is expected and
accepted; there are no valid or reliable criteria lo measure 'concepts nor are
they warranted within the philoscphical view that guides the theory.
This is a tautological theory; the process o humanistic
nursing is
described by the goal of humanistic nursing, and the complexity of thc
phenomenon it addresses stems from abstractness and lack of boundaries
between its concepts. It appears lo focus on the nurse rather than the patient
as 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 the
proper subject mal ter of existential nursing theory would appropriately be
the nurse rather than the palient. If that is one of the focuses of nursing, and
Donaldson would agree (1983), then Paterson and Zderad have offered a
theory that appropriately describes one of the nursing phenomena.
External Components


of Theory

The theory may be incongruent with prevailing values of practice but more
congruent with emerging values surrounding research and knowledge devel
opment in nursing. Humanistic theory proposes understanding
of human
beings and their experiences as they exist rather than considering what they
ought to be or rather than changing them. That goal of humanistic nursinp
ma:y then be in conflict with professonal values and goals, Stevens (1979)
makes two points to illustrate such incongruences.
The first deals with a
patienl in pain and in need of help.
It is a common existential position that suffering serves to bring about


'a state o self-awareness, thereby creating 'an "openness" to authentic experence that the patient might not otherwise evnce. Suffering crea tes a state
in 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 to
justify nursing acts that remove a patient from the authentic being o
suffering. ~p. 229)
Neither Travelbee nor Paterson and Zderad would advocate the removal
of suffering. Nursing to them is to help patients articula te their perceptions
of the situation and the meaning of the suffering.
Stevens' second argument evolves out of the theoretical proposition that
nurse/patient encounters involve an open human dialogue that involves a
degree of intimacy to enhance understanding of the subjective world of the
patient. How many such "meetings" can a nurse be involved in in the course
of her working day and is there potential for emotional drainage leading to
burnout? Do all patients seek and approve of such genuine encounters? i
Paterson 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 espouses
subjectivity and being, but patients may want to evolve their being
in genuine encounters within their own circle rather than with the nursing staff.
When, in 1960, Paterson and Zderad were developing the seeds of their
theory, they may or may not have anticipated the supportive literature of
the 19805 that advocated phenomenology as the methodology most compatible
with nursing. The 19805 witnessed an ernergng world view in nursing
denouncng the empirical positivist view (see Chapter 2) and supporting a
phenomenological view (Menke, 1978; Munhall, 1982; Oiler, 1982). More
importantly, Paterson and Zderad advocated respecting nursing experiences
as sources o knowledge and, indeed, o wsdorn, providing nursing with
nonmechanistic and nonpositvstc strategies for theory development and
research (Paterson, 1978; Zderad, 1978). Nursing would do well to adopt
their views,

.Joyce Travelbee



Nursing to Travelbee is an interpersonal process between two human

one of whom needs assistance because of an illness situation and the