REVIEW ARTICLE

On-call listening: an application of Humanistic Theory in the clinical nursing process

Alexandre Vicente da Silva^I; Iraci dos Santos^II; Célia Caldeira Fonseca Kestenberg^III; Célia Pereira Caldas^IV; Lina Marcia Miguéis Berardinelli^V; Lenilce Pereira de Souza da Silva^VI

^I Nurse. Professor. PhD student at the Postgraduate Program, Rio de Janeiro State University. Brazil. E-mail: alexvicentesilva35@gmail.com
^II Full Professor, Rio de Janeiro State University. Brazil. E-mail: iraci.s@terra.com.br
^III Nurse. Adjunct Professor, Rio de Janeiro State University, Brazil. E-mail celiaprofuerj@gmail.com
^IV Nurse. Associate Professor, Rio de Janeiro State University. Brazil. E-mail: celpcaldas@gmail.com
^V Nurse. Associate Professor, Rio de Janeiro State University. Brazil. E-mail: l.m.b@uol.com.br
^VI Nurse. Master's Degree by the Postgraduate Nursing Program, Rio de Janeiro State University. Brazil. E-mail: lenilcep.silva@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2018.33586

ABSTRACT

Objective: to think about the applicability of a listening service based on humanistic theory in the clinical nursing process. Method: this theoretical reflection on the metaparadigms and assumptions of Paterson and Zderad used in mental health nursing care for nursing residents at the Pedro Ernesto University Hospital, in Rio de Janeiro, Brazil, with a view to welcoming, listening to and contributing to experiences of this theory in the listening service. Results: the second phase of the clinical process – in which the nurse intuitively knows the other – was most notable. This is a phase of evaluation and intervention, because of the dialogic relationship and empathic understanding involved. Conclusion: using empathy as a vehicle for understanding and elaboration helps clients of care. It embodies therapeutic potential, providing comfort, broadening self-understanding, alleviating loneliness and anxiety, and boosting self-esteem. Above all, it helps to elaborate and find meaning in lived experience.

Descriptors: Nursing; theory; empathy; care.

INTRODUCTION

The "listening service" is a nursing care modality offered to mental health nursing residents from the Pedro Ernesto Teaching Hospital, in partnership with the Rio de Janeiro State University. Its goal is to welcome, help, listen, and help to elaborate the experiences lived by these residents. It started in 1990, being the unfolding of the extension project "living experiences" from the UERJ School of Nursing, which has been developing group activities for 26 years with undergraduate students from the last academic period, in order to know - to welcome the emotional demands of the student, because some students would request individual attention. Thus, the "listening service" emerged.

Since 2014, after requests from the nursing residency coordination, this procedure was implanted at the HUPE/UERJ, with the aim to assess and meet the emotional demands of some residents. The individual meetings, with duration of 60 minutes, started to happen in the nursing office of the mental health outpatient clinic. During the consultations, it was verified the need for a theoretical reference to support the clinical process established there.

From that point, the guiding question was formulated: what nursing theory will be able to support the "listening service"? It was assumed: the meeting, the dialogic relationship, and the presence, proposed by Nursing Humanistic Theory, that theoretically base the clinical process experienced in the consultations of the "listening service".

This assumption was very close to the work that was being done. Thus, it was possible to characterize the care within the nursing field, with validated concepts, specific to the profession, and facilitators of the construction of the therapeutic objectives.

Given the above, the objective was elaborated: to reflect about the applicability of the "listening service", based on the nursing humanistic theory and on the nursing clinical process.

THEORETICAL-METHODOLOGICAL REFERENCE

The Nursing Humanistic Theory arose in 1976, from the Paterson and Zderad's experiences in teaching and nursing care in psychiatry and mental health. Its content reveals the existentialist philosophy influence to understand life, its meaning and the possibilities of the humanistic choices, trying a broad vision about the human potential and phenomenology, seeking the meaning of what was lived from the perspective of the subject. The influence of these thought currents is perceived in the emphasis the authors gave to the meaning of life as it is lived, the nature of the dialogue and the importance of the perceptive field. They propose this profession to be developed as an existential experience.¹

Understanding of the metaparadigms of the theory

Human beings - seen as an existential structure of becoming-through choices. It is an individual being, relating to others in time and space. The human existence depends on the coexistence.¹

Health - understood as a matter of personal survival. It is more than the absence of disease. Individuals have the potential for stability, for being better, for becoming all that is humanly possible. Health is a process of finding meaning in life and it is experience in the lived world.¹

Nursing - involves a special meeting between people. This is the care response from one person to another, in a period of need aimed at the development of well-being and being better. It is a type of dialogue lived through an intersubjective experience.¹

Community - They are two or more people, fighting together the sudden living-dying. It is through the intersubjective sharing of meaning in community that human beings are comforted and cared for. It is where relationships happen.¹

The Humanistic Theory through its approaches

Nursing is considered a dialogue experienced between nurse and client; it harmonizes reason and sensibility, objectivity and subjectivity, care and comfort in the act of providing care. This dialogue is characterized by a creative relationship and it involves:¹

Encounter – a meeting of human beings. It is characterized by the expectation that there will be a nurse and someone to be cared for. In this encounter, some factors are influential, such as: feelings that emerge, the uniqueness of the participants and the decision to reveal and restrain oneself to others.¹

Relationship - refers to the process of being with one another and it occurs in two ways: when we relate as subject and object, we know others through abstractions, conceptualizations, categorizations and labels. The other way is the relationship between people. In this type of relationship it is possible to know the person in their unique individuality. The me - you relationship makes it possible to develop this unique potential.² Both relationships are fundamental to the nursing clinical process.

Being present - the quality of being open, receptive, ready and available to the other person in a reciprocal way. To open oneself up to the nursing experience. It often becomes a hard-to-reach behavior.¹

The call and the answer – are an indication of the complex nature of the dialogue experienced. They are transactional, sequential and simultaneous. Nurses and clients call and respond to each other within a framework of time and space. It happens verbally and / or not.¹

The purpose of nursing - nurture the well-being and the being-better in people. This nurturing is the ability to participate in nursing situations and to strive with others in their experiences of health and suffering in order to maximize their potential.¹

Help in caring - the nurse helps the client to get better from their particular condition. The nursing practice and its theoretical foundation are interrelated. To be a nurse is to develop this practice as a human being, who feels, values, reflects and conceptualizes. From the everyday life of this profession emerges an organized set of clinical knowledge.¹

METHOD

Theoretical reflection, carried out in 2016, about the meta-paradigms and assumptions of Paterson and Zderad,¹ used in mental health nursing care with the nursing residents of the HUPE/UERJ – Rio de Janeiro – Brazil, aiming to welcome, listen and contribute to the experiences of this theory in the listening service. The method has five phases:

Preparation for knowledge - the nurse seeks self-knowledge and, in this process, takes the risk of confronting their possible inability to perceive himself/herself and to make his/her thoughts and attitudes more human.³

The nurse intuitively knows the other - importing the knowledge one has about the other, the way it lives and sees the world. One seeks to insert themselves in the time, rhythm and mobility of the other, taking to an absolute, intuitive, inexpressible unique knowledge about the other. The nurse responds to the client's singularity, does not impose himself/herself, keeps his/her capacity for surprise, questioning and authentic presence.³

Scientific knowledge about the other - after intuitively experience it, the experience is conceptualized and expressed according to its human potential. A moment to reflect, analyze, sort, compare, contrast, relate, interpret, name and authentic categorization.³

The nurse synthesizes in a complementary way the known realities - time to compare and synthesize the multiple known realities to have an enlarged view. As knowledgeable, the nurse establishes relations between these realities and then interprets, selects and classifies them.³

Internal succession of the nurse from the multiple to the paradoxical unit - through reflections and considerations about the relations between multiple views, the nurse makes a comprehensive review and expands his/her own perception. The nurse goes beyond the multiplicities and contradictions and reaches an important conception for most or for all.³

It is emphasized that the phenomenological nursing methodology does not follow the conventional nursing process. Through the conceptualization and sharing, the methodology allows an advance in the process of construction of knowledge originated in the world experienced in this profession. The method uses a systematic approach of interaction with the client.³ In the listening service, it was emphasized the second phase of the proposed method of phenomenological nursing. The authors refer to that phase as being a moment of evaluation. However, it is understood that this is also a moment of intervention, because it is in this moment that the listening and the empathic understanding occurs.

RESULTS AND DISCUSSION

In the listening service, one works with the emergent. There is not a previously established agenda with days marked in this first moment. The coordination of the residency makes a telephone contact, directing the resident to the listening service. The moment of searching for help is very important, since the client is motivated and in a outspoken movement to elaborate their lived experience and should not be interrupted.⁴ This movement highlights the need for the nurse to have internal availability, readiness and openness to face the unexpected when providing care to this person. Dealing with the unpredictable is the nurse's great challenge in assisting the residents in the listening service. The aid relationship takes place in the present moment, in the here and now. The awareness of this temporal limit increases the care provision, favors the elaboration of the lived experience and facilitates processes already initiated.⁴ When arriving at the service, the client brings a complaint that can be anguish, stress, anxiety, doubts, sadness, a malaise or a difficult circumstance in life.^5,6 This is when the valuable work of sensitive listening begins.^7-9

What does the nurse listen to while listening to others? Listening is not a passive action. While listening, the nurse becomes available to pay attention and hear sensibly the meaning of the movement that the person is doing. Listening is a form of intervention that facilitates the other's taking a stand from some clarification in itself.^7-9 It is an invitation to draw the attention to oneself, to the way one pronounces the words, to the weight given to certain feelings as anxieties and desires. Listening can be a way of being present when it welcomes, resonates, silences, but above all, it accompanies the time, rhythm and movement of the client.^7,9 It begins even before the client begins to speak and is based on acceptance, in a silent presence, as well as in deep listening. To listen is also to begin the process of empathic understanding. Empathy and understanding are two of the essences (values and beliefs) present in the clinical process of the humanistic nursing. ¹ Empathy can be defined as the ability to put oneself in other person's shoes, sharing their way of being in a situation, resulting in a deep understanding of their perspective.^1,9

Some studies have evidenced the benefits of the empathy use from the perspective of another person, such as: activating feelings of compassion, affection, respect for the condition of another person. It makes possible building bond, solving interpersonal conflicts, helping reduce feelings of anger and sorrow, allowing forgiving, helping, negotiating, consoling, and validating each other's perspective.⁶ The tendency to reduce tensions promotes a sensible listening, to be accessory for conscious efforts to understand the reasons and feelings of another person.^7-10

In the humanistic nursing, it is not the job of the nurse to think about the client, it is necessary to think with the client, in a way that both can walk together in the world of the client's experiences, to always look for understanding the client with empathy. Nursing is an experienced dialogue. It is a creative way of nurse/client relationship. The meeting happens inside this dialogue, and it is the meeting between human beings and there is the expectation that it will be a nurse and someone who will be taken care of.¹ It is highlighted in this meeting the empathic ability as a resource capable of boosting the understanding process of the person.^9,11,12 The development of a careful, mindful, without judgment listening looks at building a differentiated dialogical relationship, which opens for a relationship of the You-Me ² type, as a real meeting.¹

From the company and true sharing of the nurse, the clients can expose themselves to dive into their own process and examine their own experiences. They will be welcomed and accompanied by the nurse who, being present and sensibly attentive, can contribute to their understanding, going beyond.¹ At this moment of immersion, the nurse must enter into the relationship and not leave the person alone with their own experiences. It is necessary to remain with the person in front of the pain that has been chosen to be presented and to have the courage to explore this pain with the client.¹³

Through listening, attention, being present, accepting, and showing empathy one can communicate to the client that it is worth to review the experience, the suffering, the distress, the contradiction, and the challenges, and answer to life itself. This way, he or she will be able to connect with themselves and find a meaning in their experiences. The client then moves and begins a journey in a search for bigger clarity and integration of oneself, thus, being open to changes. This reflexive and existential movement results in knowing oneself.^1,13,14 The empathic encounter acts as a powerful resource that contributes to the intuitive understanding of the being's essence, helps in the search for the meaning of their experience, and understands their experienced world.¹

To have the client's experience as the focus of the nursing experiences means to focus on the primary reality of the immediate experience, the world of the meanings, as it presents itself. This happens through empathy, where it is possible to penetrate in the perceptual world of someone else according to their world, the way they feel and perceive the experiences. ^1,10 The empathy enables the nurse not only to move into the client's world, but also to move in the client's company, seeking to understand their experience.

It is also possible that, in this journey of the therapeutic relationship, the nurse may realize, in the client's world, some aspects they could not realize until that moment. When the empathic understanding really happens and the nurse can perceive what happens in the client's internal world, how they feel and perceive the experiences, and this knowledge is verbalized, then the change may happen.^12,14,15

In the humanistic nursing, there is no concern about a behavior change, but about the meaning attributed to the experience lived by the client. There may be a change in the client's perspective regarding their experience, taking responsibility for their choices and to be able to find meaning for life. By doing this with a nurse, they will have the opportunity to confirm the human in this situation from their own perspective, which would result in personal growth, better living and well-being.^1,15-18 A continuous desire to empathically understand the person's experience can be extremely significant and bounding to the nursing/client therapeutic relationship, facilitating the elaboration of lived experiences.

CONCLUSION

The main goal of this study was reached, since there was reflection on the use of the Humanistic Nursing Theory, basing the actions of the listening service. The second moment of the humanistic nursing methodology - the nurse intuitively knows the other, referred to as a moment of assessment, allows to emphasize that this can also be considered as intervention, producing therapeutic results.

Empathy, as a vehicle for phenomenological understanding, helps the client to feel more understood and accepted. It brings in itself a therapeutic potential when it provides solace, comfort, enlargement of self-understanding, relieves pain, loneliness, anxiety and elevates the self-esteem, helping to elaborate and find meaning in the lived experience. A contribution of this work refers to the discovery that the application of the humanistic assumptions helps to add value to the clinical process of nursing and enables the exercise of the autonomy of the nurse.

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