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Bearing witness: a moral way of engaging in the nurse–person relationship

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Abstract

For nursing, the idea of bearing witness is of utmost importance. Nurses are present with persons who experience changes in their health and quality of life and who live intense and profound moments of struggling, questioning, and finding meaning. Nurses are also with persons from moment to moment as their lives unfold, and when joy, serenity, contentment, vulnerability, sadness, fear, and suffering are experienced. In this paper, it is proposed that bearing witness is a moral way of engaging in the nurse-person relationship. Based on Levinas's ethics of the face, it is claimed that bearing witness is enacting one's moral responsibility, which arises from the encounter with the other. Drawing on Parse's human becoming theory, ways of witnessing and bearing witness are defined and discussed. It is suggested that bearing witness is a human-to-human way of being-relating, a mode of human coexistence. Bearing witness is being present and attentive to the truth of another's experiences. Moreover, in this paper, the ways nurses enact their moral agency and bear witness to others placed in their care, or turn away, are explored. Nurses' moral agency is located in the constrained moral space of contemporary health care. Hence, the creation of a moral space, which allows nurses to enact their moral responsibility of bearing witness to other persons' experiences of health and quality of life, is called for. In doing so, it is suggested that the act of bearing witness needs a specific nursing knowledge base and a recognition that being present and being with another is a valuable nursing practice that is utterly meaningful for persons who are living through difficult times.

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... This article by Naef [38] had me thinking after just reading the title. Thinking of bearing witness as a MORAL way of engaging is a wonderful concept. ...
... Another student wrote: What I found to be particularly insightful about her (a nurse author Naef,) story [38], was despite the fact that she was unable to get her patient's pain adequately managed, the patient, in all his suffering, was able to utter the words, "it's just enough that you are here". This was my "aha moment" because I think that we can probably all relate to a time in our career when we felt helpless. ...
... I think the YouTube clip also stresses the importance of taking the time to bear witness to our patients. As so powerfully demonstrated in her story, bearing witness can sometimes be the most courageous and respectful response to alleviate suffering, aloneness, and vulnerability [38] (Course Section 2). ...
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This paper describes the kind of engagement and emergent learning that happened in three different sections of a graduate nursing course. Three nursing educators used an e-learning platform called Daagu that was developed by faculty guided by complexity pedagogy. A total of 43 students were enrolled in the full credit foundations course in theory and philosophy. Authors describe two specific instances of emergent learning: one was expressed by students in relation to a particular resource (article, TedTalk, YouTube, Poem) or discussion, and the second is in relation to specific “aha moments” or shifts in understanding that changed student attitudes and actions. Quotes of emergent learning provide a source of narrative data for conversing about and developing quality e-learning platforms for students and educators.
... Närståendes utsatthet, i samband med vård av en sjuk familjemedlem, kan ses ur ett allmänmänskligt perspektiv. Den utsatta situation närstående befinner sig i kan beskrivas dels som "att bevittna", vilket är ett mänskligt sätt att relatera, att samexistera, att lyssna till och att respektera en annan människa och ett etiskt tvång (Naef 2006). Närståendes utsatthet skulle även kunna beskrivas utifrån Levinas" filosofi om ett etiskt ansvar i mötet med en annan människa och på känsligheten för en annan människas sårbarhet (Levinas 2006). ...
... Närståendes utsatthet skulle även kunna beskrivas utifrån Levinas" filosofi om ett etiskt ansvar i mötet med en annan människa och på känsligheten för en annan människas sårbarhet (Levinas 2006). Naef (2006) menar även att möjligheten finns att vägra "bevittna", vilken skulle kunna vara ett sätt att dra sig undan ansvaret, eller ta ett mindre ansvar, av olika skäl. ...
... Studier visar att vårdpersonal är utsatta på ett unikt sätt, t.ex. i situationer av närhet med främmande personer och genom att bevittna det pågående lidandet i ett sjukdomsförlopp (Travelbee 1971, Naef 2006, Carel 2009). Detta beskrivs som en form av sårbarhet som kan uppstå i mötet med extraordinär sårbarhet (jfr Sellman 2005), som i vården av sjuka människor (Carel 2009). ...
... Bearing witness is [a way of] being with and relating to others that is based on values and beliefs that give rise to a commitment to attend to, honour, and stay with persons' truths, perspectives, priorities, hopes, and dreams; that is, their lived experience [it] is a distinct way of being and relating with persons because of the ontological view about human beings and health that underlines it [48] (p. 149). ...
... Bearing witness is grounded existentially through the recognition of human dignity. It is, for example, a means of "enacting one's moral agency in nursing" [48] (p. 152). ...
... Bearing witness requires, first and foremost, recognition of the survivor as a person, grounding the relationship in mutual being-ness. "Bearing witness is enacting the moral responsibility arising from the encounter with the other, and it is a form of ethical resistance because when we bear witness, we acknowledge the other as other and turn towards him or her" [48] (p. 149). ...
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Written from a standpoint of religious ethics, this article interprets the work of trauma response and recovery in transcendent and moral terms not always apparent to the practitioner or institution. This article provides a broad understanding of spirituality, transcendence, and faith as these concepts relate to Judith Herman’s stages of trauma healing and the characteristics of trauma-informed response articulated by the Substance Abuse and Mental Health Services Administration. These features are then mapped onto specific modes of transcendence and moral themes identifiable in a wide range of religious traditions. The connective framework for this mapping is provided by utilizing the concept “bearing witness,” as synthesized from a wide range of disciplinary perspectives, to describe the work of trauma-informed response. This article concludes by recognizing bearing witness as a form of social action, a moral response with implied if not explicit religious dimensions and spiritual implications, for which an understanding of religious ethics is a helpful ally. Thus, this article concludes that religious ethics can be a valuable resource and partner in addressing the personal, systemic, and political aspects of trauma response and recovery, enabling attention to spiritual well-being of both the trauma survivor and the one responding to the survivor.
... O respeito ao ser humano é o princípio máximo do qual devem emanar os preceitos éticos de tudo e todos que com esse ser lidam (20) . A responsabilidade moral a favor do respeito pela autonomia das pessoas é definida como um imperativo categórico da consciência moral, é o agir de tal maneira que a máxima de tua vontade possa valer sempre (21) . No caso do enfermeiro, é permitir que a família mantenha-se fortalecida e autônoma na situação de crise, desenvolvendo um cuidar que envolva as dimensões éticas. ...
... Nessa perspectiva, o enfermeiro como um ser responsável moral por suas ações, independente e participante ativo na equipe de saúde (21) , tem o dever de garantir o direito à autonomia do paciente e família. De acordo com essa premissa, o enfermeiro deve oferecer condições à família para as tomadas de decisão, por meio de informações e conhecimento a respeito da situação da criança, a fim de permitir que esta faça suas próprias escolhas de maneira livre e esclarecida, consolidando o princípio da autonomia. ...
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Rev Esc Enferm USP 2011; 45(4):825-32 www.ee.usp.br/reeusp/ RESUMO Este estudo buscou compreender a experiên-cia de vulnerabilidade da família da criança internada em Unidade de Cuidados Inten-sivos Pediátricos (UCIP). O Interacionismo Simbólico e o Conceito de Vulnerabilidade da Família foram utilizados como funda-mentação para a compreensão dessa expe-riência. A Análise Qualitativa de Conteúdo foi o referencial metodológico aplicado. Os dados foram coletados por meio de entrevis-ta e observação com 11 famílias de crianças hospitalizadas em uma UCIP de um hospital universitário, do Município de São Paulo. Emergiram seis categorias analíticas da expe-riência da família que, ao serem comparadas às categorias conceituais da Vulnerabilidade da Família, revelam os elementos definidores do conceito nesse contexto. Para a família, a internação de um filho em UCIP desencadeia sofrimento intenso, pois remete a possibili-dade de uma perda definitiva. Assim, o poder e a autonomia da família em relação ao filho são diminuídos, intensificando o sentimento de vulnerabilidade. ABSTRACT The objective of this study was to under-stand the vulnerability experienced by the family of children hospitalized in a Pediat-ric Intensive Care Unit (PICU). The Symbolic Interactionism and the Concept of Family Vulnerability were the frameworks used to understand this experience. Qualitative Content Analysis was used. Data was col-lected through interviews and observation with 11 families of children hospitalized in a PICU of a university hospital in São Paulo. Six analytical categories regarding the family experience emerged. The cat-egories were compared to the conceptual categories of Family and Vulnerability, and revealed the elements that defined the concept within this context. The child's hospitalization in a PICU triggers intense suffering within the family, as it refers to the possibility of losing their child. Thus, the power and the autonomy of the family in relation to their child are reduced, inten-sifying the feeling of vulnerability.
... Defining a "difficult patient" presents challenges, as individuals and nurses perceive patients differently. Michaelsen (2012) indicated that the difficulty does not lie with the patient, rather between the nurse and the patient and their relationship. Accordingly, difficult patients include those who do not cooperate with what staff asks them to do, those who ask too many questions, and those who interrupt daily routines. ...
... However, "wishful thinking," denial, and avoidance were not positive coping strategies in dealing with the stress that often accompanies providing care for a dementia patient. In a qualitative hermeneutic study, Michaelsen (2012) explored strategies used by nurses to handle difficult patients, where persuasion, compromise, and avoidance emerged. Avoidance was used by nurses who did not recognize the severity of the problem patients were suffering from. ...
Article
Background For some nurses, providing altruistic care to difficult patients is a challenge, leading to the use of negative coping strategies such as anger or avoidance, leaving the nurse frustrated and patients feeling rejected. Yet other nurses can deal positively with difficult patients. Purpose To study how the stress of caring for difficult patients affects the level of altruism and use of negative coping strategies in their care and to find out what positive coping strategies and interventions could be used. Design/Method A mixed-methods design was used. A survey tested the level of altruism, the use of negative coping strategies, and several demographics. Thematic analysis examined narratives generated by participants to three questions regarding how to provide altruistic care to difficult patients. Findings A purposive sample of 67 registered nurses (RNs) participated. The average level of altruism used by RNs with difficult patients was 99.7/120 points. An inverse relationship was found between the level of altruism and use of negative coping strategies ( r = −0.577, p < .001). Qualitative analysis of narratives identified three themes—Developing Psychological Hardiness, Bearing Witness, and Fending for Oneself. Conclusions This study provides insight into the experiences of RNs caring for difficult patients and how to ensure altruistic caring.
... Witnessing can be understood as a personal experience, "the direct, personal apprehending of something in the moment" (Cody, 2001, p. 289). This is extended further by Cody (2001), Naef (2006 and Webb (2016) to the concept of bearing witness or "attesting to the veracity or authenticity of something through one's personal experience" (Cody, 2001, p. 289 , 2015). Compassion fatigue is a recognised source of suffering among critical care nurses, but the field of study remains lacking in terms of both conceptual clarity and theoretical grounding as to how to best identify and respond to this (Webb, 2016). ...
... ).Naef (2006) argues further that such presence is a central concept in nursing. The data from this study show that nurses chose to bear witness rather than to not bear witness but with the consequential effect of emotional disquiet for some. ...
Article
Aim To discern and understand the responses of nurses to the survivorship needs of patients and family members in adult critical care units. Background The critical care environment is a demanding place of work which may limit nurses to immediacy of care, such is the proximity to death and the pressure of work. Design A constructivist grounded theory approach with constant comparative analysis. Methods As part of a wider study and following ethical approval, eleven critical care nurses working within a general adult critical care unit were interviewed with respect to their experiences in meeting the psychosocial needs of patients and family members. Through the process of constant comparative analysis an overarching selective code was constructed. EQUATOR guidelines for qualitative research (COREQ) applied. Results The data illuminated a path of developing expertise permitting integration of physical, psychological and family care with technology and humanity. Gaining such proficiency is demanding and the data presented reveals the challenges that nurses experience along the way. Conclusion The study confirms that working within a critical care environment is an emotionally charged challenge and may incur an emotional cost. Nurses can find themselves bounded by the walls of the critical care unit and experience personal and professional conflicts in their role. Nurses bear witness to the early stages of the survivorship trajectory but are limited in their support of ongoing needs. Relevance to Clinical Practice Critical care nurses can experience personal and professional conflicts when caring for both patients and families. This can lead to moral distress and may contribute to compassion fatigue. Critical care nurses appear bounded to the delivery of physiological and technical care, in the moment, as demanded by the patient's acuity. Consequentially this limits nurses’ ability to support the onward survivorship trajectory. Increased pressure and demands on critical care beds has contributed further to occupational stress in this care setting. This article is protected by copyright. All rights reserved.
... Nurses can be troubled by their awareness of irresolvable competing or contradicting moral imperatives. 6 There is ongoing interest and a growing need to develop practical models aimed at improving moral agency in health care, 7 yet there are relevant methodological challenges. Traditionally, investigating ethical issues and decision making in health care was unacceptable and not researchable when various approaches, such as qualitative inquiry, were evaluated within the strenuous framework of the positivistic paradigm. ...
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Moral stress, moral climate and moral sensitivity among psychiatric professionals
... However, it may be hard to be present due to workload, tiredness and competing demands affecting concentration [19]. Likewise, taking a mechanistic approach to care, focusing on technology and technical skills, may put HCPs at risk of disengaging from the patient before them [20], resulting in staff doing for rather than being with patients [21]. ...
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Background Compassion in healthcare represents an ideal way of interacting with patients. It entails an active response to suffering, distress or discomfort that can be associated with people seeking health related support or treatment. However, reports from within healthcare highlight that compassionate care (CC) is not always achieved. It may be especially problematic when trying to work with a patient who seems unwilling or unable to engage with advice provided by a healthcare professional (HCP).
... However, it may be hard to be present due to workload, tiredness and competing demands affecting concentration [19]. Likewise, taking a mechanistic approach to care, focusing on technology and technical skills, may put HCPs at risk of disengaging from the patient before them [20], resulting in staff doing for rather than being with patients [21]. ...
Article
Aim To explore healthcare professionals' views of measuring compassionate care. Method As part of a grounded theory study participants, who were healthcare professionals involved in the care of patients with type 2 diabetes, were invited to discuss the topic of compassionate care measurement through semi-structured interviews and focus groups. Results Measuring compassionate care was regarded as problematic because of its complex nature. Categories identified in the data that reflect this difficulty include distinguishing compassionate care from other concepts, relying on informal indicators, making the subjective objective, incorporating external influences and putting a measurement tool to use. Conclusion Findings highlighted the complexities associated with measuring compassionate care, and how attempts to do this by managers could be problematic.
... Other theoretical frameworks may offer similar, competing or different findings. For instance, Naef (2006) and Delmar (2008), respectively, offer comment about choices we have in the process of human engagement (of becoming involved) and that different people generate degrees of easiness or difficulty for us in entering the relational aspects of care. The findings of this research need extension and challenge from other theoretical perspectives if they are to help consumers and health professionals to probe, reflect and modify their connections and responses to each other as they occupy different positions in their care roles. ...
Article
Aims and objectivesTo understand how people who present on multiple occasions to the emergency department experience their health professionals' moral comportment (ethic of care and duty of care); and to understand the consequences of this for ‘people who present on multiple occasions’ ongoing choices in care.Background People (n = 34) with chronic illness who had multiple presentations were interviewed about the role that emergency departments played within their lives and health–illness journey. Unprompted, all participants shared views about the appropriateness or inappropriateness of the care they received from the health professionals in the emergency departments they had attended. These responses raised the imperative for specific analysis of the data regarding the need for and experience of an ethic of care.DesignQualitative description of interview data (stage 3 of a multimethod study).Methods The methods included further analysis of existing interviews, exploration of relevant literature, use of Tronto's ethic of care as a theoretical framework for analysis, thematic analysis of people who present on multiple occasions' texts and explication of health professionals' moral positions in relation to present on multiple occasions' experiences.ResultsFour moral comportment positions attributed by the people who present on multiple occasions to the health professionals in emergency department were identified: ‘sustained and enmeshed ethic and duty of care’, ‘consistent duty of care’, ‘interrupted or mixed duty and ethic of care’, and ‘care in breach of both the ethic and duty of care’.Conclusions People who present on multiple occasions are an important group of consumers who attend the emergency department. Tronto's phases/moral elements in an ethic of care are useful as a framework for coding qualitative texts. Investigation into the bases, outcomes and contextual circumstances that stimulate the different modes of moral comportment is needed.Relevance to clinical practiceFindings carry implications for emergency department care of people who present on multiple occasions and for emergency department health professionals to increase awareness of their moral comportment in care.
... Each of the participants, with his or her own areas of professional expertise and experience, was bearing witness to Nouredinne's story and suffering. It was an act of moral responsibility grounded in the recognition of ''otherness'' and in the acknowledgement of the authenticity of another's truth (Levinas 1979(Levinas , 1998Poland 2000;Naef 2006). In therapeutic encounters, there are two main aspects to bearing witness: the medical-therapeutic and the sociopolitical aspects. ...
Article
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Illegal immigration in Canada is characterized mainly by non-status immigrants who legally enter Canada and stay after their legal status expires and by failed refugee claimants. For these persons, immigration status or its absence plays an important role in determining the degree of access to Canadian health care. This article situates the clinical setting as a site of contention and negotiation of citizenship and care in social networks as well as pragmatic and discursive strategies. Drawing on the case of a patient who faced imminent deportation and became suicidal, in this article I depict how psychiatrists and other health practitioners embrace "bearing witness" as an ethical practice, which intersects the medical and legal spheres.
... During the face-to-face encounter of the disability assessment process, doctors 'bear witness' not only to the disablement of a patient but to the vulnerability and suffering of another human being. This may create feelings of responsibility and moral obligation towards patients (Olthuis, 1997;Raef, 2006), which could affect how they treated them. According to Swartz and Schneider (2006: 243), "it is difficult to apply principles of distributive justice when one is faced with the reality of poverty". ...
... Witnessing is a person to person way of being and relating a mode of human coexistence. Bearing witness is being present and attentive to the authenticity of another's experiences [12]. Such action takes into account the metaphysical healing of the patient, validating that the body and spirit of the person are interwoven and inseparable through a shared affirmation of an inevitable human event. ...
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Disclosure on ClosureBowed head swallows truthShared secrets loud and clearUncertain unwavering calmTo quench sereDried and withered. http://www.merriam-webster.com/dictionary/sere sufferingShared secrets loud and clearWeightless, heavy in the airTo quench sere sufferingCompassion cloaks questionsWeightless, heavy in the airTruth, suspended, flickersCompassion cloaks questionsWondering on wordsTruth suspended flickersUncertain unwavering calmWondering on wordsBowed head swallows truthAs I worked on this paper, I composed the poem above as a pantoum. The pantoum is a poetic form originating in Malaysia and appreciated for the subtle shifts in meaning that are achieved through repetition of lines in a prescribed sequence. Revisiting the experience giving of bad news, this poem contemplates the mutual reluctance in telling and the hearing the news.I was interviewing Thembi Zulu*, a volunteer home-based caregiver in rural KwaZulu-Natal, South Africa to understand what made it possible for ...
... Nurses can be troubled by their awareness of irresolvable competing or contradicting moral imperatives. 6 There is ongoing interest and a growing need to develop practical models aimed at improving moral agency in health care, 7 yet there are relevant methodological challenges. Traditionally, investigating ethical issues and decision making in health care was unacceptable and not researchable when various approaches, such as qualitative inquiry, were evaluated within the strenuous framework of the positivistic paradigm. ...
... Nortvedt (2001), for example, draws on Lévinas' thought to describe the inseparability of ethical sensitivity and clinical nursing knowledge. Papers by Naef (2006), Wynn (2002), and SmithBattle (2009) shed further light on the ethical responsibilities that are grounded in first knowing the person. ...
Article
Doctoral programmes in nursing are charged with developing the next generation of nurse scholars, scientists, and healthcare leaders. The American Association of Colleges of Nursing (AACN) endorses the inclusion of philosophy of science content in research-focused doctoral programmes. Because a philosophy course circumscribed to the natural or social sciences does not address the broad forms of knowledge that are relevant to nursing practice, we have developed and co-taught a course on the philosophy of knowledge that introduces students to competing claims regarding the nature of knowledge, truth, and rationality. In addressing broad themes related to science and knowledge of the body, health and illness, and ethics, the course equips students to tread the rough and shifting ground of nursing scholarship and practice. Providing doctoral students with this philosophical footing is intended to give future scholars, researchers, and healthcare leaders the intellectual skills to critically reflect on knowledge claims, to challenge the hegemony of science, and to recognize the disciplinary forms of knowledge that are left out or trivialized. Our pedagogical approach to knowledge development does not denigrate scientific knowledge, but elevates forms of inquiry and notions of clinical knowledge that are too often marginalized in doctoral education and the academy in general. © 2014 John Wiley & Sons Ltd.
... Therefore, freedom is connected to both responsibility and guilt, where for a nurse, the existential responsibility could be to truly acknowledge the patient's experiences and perceptions (cf. Naef, 2006). Kierkegaard (1980) argued that as humans we are free to choose in a deeper sense, i.e. our choices reveal what is meaningful. ...
Article
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Aim: The aim of this study was to illuminate and clarify the concept of existential issues in relation to nursing research and nursing practice. Methods: This article is a theoretical analysis of existential issues in relation to nursing. Results: Existential issues are becoming more commonly discussed and investigated in nursing research. Thus, it is important to clarify the concept. Conclusions: A clarification of existential issues may contribute to health care quality by increasing awareness of what existential issues are and drawing attention to the importance of discussing and reflecting on these issues, since practitioners in a caring profession will most likely encounter them.
... 21(p505) The relationship of presence and commitment is also strongly reflected in the writings of Parse, Naef, and Bunkers. [38][39][40] For Parse, being with and bearing witness to persons as they lived changing health patterns was "true presence". 38 Naef argued that "bearing witness was enacting one's moral responsibility, which arises from the encounter with the other". ...
Article
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Advances in health care and communication technology have expanded nursing practice to nontraditional environments that preclude the physical presence of the nurse for a caring encounter. An increasing number of nurses are creating and maintaining nurse-patient relationships and practicing in a diverse range of specialties in virtual/distance environments. Can nursing presence as a caring modality be "real" in a virtual/distance environment? A new ontology of nursing presence is offered that transcends people, place, space, and time.
... Emotional, psychological and spiritual support will be provided to all of the team members by elders and senior members of the project team throughout the process to assist them with any struggles they may have as a result of the content area. Prior to commencing the reading and the analysis, team members will also receive specific training on the possible personal costs associated with bearing witness to accounts of human suffering (Naef, 2006;Salgado, 2017). ...
Article
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There is a dearth of research on student-to-student abuse in Canada’s Indian Residential School System despite the fact that the legacy of this violence continues to negatively impact Indigenous communities. This paper proposes an approach to dealing with this difficult subject matter by using creative practice as a means of working collectively with community leaders, scholars, artists and students to develop shared understandings of the abuse and its continued legacy. This paper outlines the rationale for work in this area and the beginnings of the development of hybrid Indigenous and non-Indigenous methodology that brings survivors’ stories to audiences through a series of collectively authored theatrical performances that promote understanding and dialog. This paper is of interest to scholars, artists, playwrights, community leaders, and front line social workers who are working to bridge academic research and community engagement, particularly as it relates to artistic practice. © 2017 The Author(s). This open access article is distributed under a Creative Commons Attribution (CC-BY) 4.0 license.
... For example, some studies include healthy people for whom lifestyle changes lead to favourable physical consequences, examining physical, medical and economical aspects of the change (8)(9)(10)(11). Other studies examine the existential and ethical aspects of lifestyle changes necessitated by diseases (12)(13)(14)(15)(16)(17), including how nurses can be involved in these lifestyle changes (18). Although these constitute a promising beginning, Løgstrup's concepts could represent a useful framework for further studies. ...
... In coordinating a MAiD program, I heard stories every day, ripe with emotions of suffering or expressions of gratitude that landed on me and I let linger, sink in. I was bearing witness (Naef, 2006) to a unique time in history and to one of the most profound moments in a life, that being death. I established a practice of journaling each evening, of entering a safe place that became my way of telling. ...
Article
Accessing medical assistance in dying (MAiD) became legal in Canada in June, 2016. This marks a unique time in our history, as eligible persons can now opt for an assisted death and health care professionals can be involved without criminal repercussion. I used an autoethnographic approach to explore and describe my experience of implementing and coordinating a new MAiD program in a local health authority. Part I is a self-reflexive narrative based on journal entries about my immersion in this practice role over a 6 month period. In Part II, I share five emergent storylines: coming to the role (the calling), embodiment (becoming the face of), immersion in clinical practice, interactions with those seeking MAiD, and self survival (sense making). The created story and storylines shine a light on new ethical practice realities, enhance understanding about MAiD as it continues to unfold, and hopefully inspire human centered, compassionate care.
... There is no doubt that critical care is a complex and demanding clinical area where nurses work alongside patients and families who are exposed to the prospect of death and dying. 1 Within this complex milieu, nurses manage challenging end-of-life situations on a daily basis 2 and are therefore well placed to make a significant difference to the care of patients who will not survive their critical illness. ...
... Mothers ID:p0105 are no exception: they seek human connection with the LC for its own sake, and not only as part of a service sought. Watson's (2008) theory of care highlighted similar aspects (Clark, 2016), while Naef (2006) stressed the role of this relation within the therapeutic process, as did Monbiot (2017), when assessing the benefits of connection stressed the damaging effects of isolation. ...
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Background Every encounter in lactation care should aim to set the ground for an emerging human connection between the lactation consultant (LC) and the breastfeeding mother. Cultivating connection is as important as adequate clinical competencies and effective communication skills. Methods The article proposes a hermeneutics of care that articulates elements that enhance the understanding between the LC and the circumstances and realities of the breastfeeding dyad in the context of diagnosis, management, and healing. These elements can be best described by Martin Buber's (2013) I–Thou approach, which we use to enter into a relationship. Results When the LC has the courage and humility to convey her full presence for that mother and her circumstances, connection has been primed. The quality and depth of the LC– breastfeeding mother relationship, in turn, enhances diagnosis and healing options, particularly in chronic cases. Conclusions The “alchemy of connection” opens the ground for a relation of mutual trust between the LC and the mother and her world, which supports better breastfeeding care.
... Nurses, for instance have always accompanied people during birth, death, illness, and life transitions. Presence refers to "bearing witness to other people's lives" [84]. Bearing witness through research is a natural extension of the nurse's role. ...
... All disciplines should engage in healing relationships with patients and families during their time of potentially extreme vulnerability, sadness, and fear, "our consciousness, our intentionality, our presence, makes a difference for better or for worse" [30]. When clinicians are unable to be present or turn away from the lived reality of the patient, moral responsibility is abandoned, and quality care and patient safety are undermined [31,32]. ...
Article
“The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk on water without getting wet. This sort of denial is no small matter”1The concept of trauma and traumatic stress emerged in the field of mental health over forty years ago and is a widespread public health concern. The paradigm of trauma-informed care acknowledges that trauma and traumatic stress overwhelm an individual’s ability to cope while simultaneously changing their biology with both short term and lifelong implications for health and wellbeing. The Substance Abuse and Mental Health Services Administration (SAMHSA) was the first to implement a trauma-informed care framework which “(1) realizes the widespread impact of trauma; (2) recognizes the signs and symptoms of trauma in clients, families, staff, and others; (3) responds by fully integrating knowledge about trauma into policies, procedures, and practices; and (4) actively seeks to resist re-traumatization.”2
... Nurses can be troubled by their awareness of irresolvable competing or contradicting moral imperatives. 6 There is ongoing interest and a growing need to develop practical models aimed at improving moral agency in health care, 7 yet there are relevant methodological challenges. Traditionally, investigating ethical issues and decision making in health care was unacceptable and not researchable when various approaches, such as qualitative inquiry, were evaluated within the strenuous framework of the positivistic paradigm. ...
Article
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Research on ethical dilemmas in health care has become increasingly salient during the last two decades resulting in confusion about the concept of moral distress. The aim of the present paper is to provide an overview and a comparative analysis of the theoretical understandings of moral distress and related concepts. The focus is on five concepts: moral distress, moral stress, stress of conscience, moral sensitivity and ethical climate. It is suggested that moral distress connects mainly to a psychological perspective; stress of conscience more to a theological-philosophical standpoint; and moral stress mostly to a physiological perspective. Further analysis indicates that these thoughts can be linked to the concepts of moral sensitivity and ethical climate through a relationship to moral agency. Moral agency comprises a moral awareness of moral problems and moral responsibility for others. It is suggested that moral distress may serve as a positive catalyst in exercising moral agency. An interdisciplinary approach in research and practice broadens our understanding of moral distress and its impact on health care personnel and patient care.
... 226). Naef (2006) contended that "bearing witness is a human-tohuman way of being-relating, a mode of human coexistence. Bearing witness is being present and attentive to the truth of another's experiences" (p. ...
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This column explores the meanings of presence from philosophical, theological, psychological, and nursing perspectives. The eye of the needle is used as a metaphor to emphasize the capacities required for living presence. The humanbecoming concept of true presence is emphasized and examples are given of living true presence in nursing.
... Being with dying people is an integral part of nursing, yet many nurses feel unprepared to accompany people through the process of dying [1]. Bearing witness, listening and staying present as the patients' suffering unfolds can be emotionally challenging because it exposes the nurses to their own vulnerability and finitude [2,3]. Western society's fast-paced healthcare environment conditions us to view death as a physiological event and a failure [4,5] rather than a natural part of the human lifecycle and a sacred passage of a life [1,6]. ...
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This article begins with an overview of some of the late Bill McWilliams's key contributions to probation research and scholarship, focusing in particular on how his work helps us think about how people experience supervision, and about how the practice of supervision should be conceived and constructed. In the sections that follow, three of the co-authors respond to these ideas from their different perspectives as service user, as frontline probation officer, and as probation manager. In the conclusion, we summarise the discussion by focusing on the role of values, of relationships and of evidence in the reform and development of probation.
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In this chapter, we explore the concept of bearing witness in nursing practice. We examine the description of bearing witness in the nursing literature, particularly that offered by William Cody who suggests that bearing witness results in the limited moral obligation of “true presence.” We then turn to Lorraine Code’s work on testimony, drawing parallels between the concepts of testimony and bearing witness. Code’s analysis of epistemic injustice complicates understanding of the practice of bearing witness, suggesting that since testimony itself entails social practices of knowledge-conveying among people, we need to be concerned with the effects of socially constructed patterns of knowing. More than mere presence, Code’s work suggests that an ability to receive testimony—or bear witness—requires analysis of the ways that social structures and identities influence understanding. We discuss these ideas in relation to a Canadian exemplar of witnessing: the Truth and Reconciliation Commission of Canada’s work to understand and address the historical injustices done to Indigenous peoples in Canada. Here we focus on the Commission’s definition of witnessing and highlight the experience of Shelagh Rogers who served as an honorary witness. As an outcome of our analysis, we suggest that bearing witness in nursing practice is most usefully conceptualized as a social practice as well as both a moral and a political obligation. Implications for nursing practice are suggested, including first, the need to critically examine our own understandings of power and privilege in order to authentically bear witness and avoid being complicit in injustice, and second, the concomitant responsibility to take action to challenge injustice once we have borne witness to it.
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In this paper I argue that the metaphysical ethics of Emmanuel Levinas captures some essential moral intuitions that are central to health care. However, there is an ongoing discussion about the relevance of ethical metaphysics for normative ethics and in particular on the question of the relationship between justice and individualized care. In this paper I take part in this debate and I argue that Levinas' idea of an ethics of the Other that guides politics and justice can shed important light on issues that are central to priorities in health care. In fact, the ethics of Levinas in seeking the foundation of normativity itself, captures the ethical core and central values of health care.
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This manuscript offers a new view of old and timeless values: the essential ethic of love, informed by contemporary European philosophies, and caring theory, as well as ancient poetry and wisdom traditions. It integrates some of the philosophical views of Levinas and Logstrup with Watson's Transpersonal Caring Theory. The metaphysics, metaphors, and meanings associated with "ethics of face," the "infinity of the human soul," and "holding another's life in our hands" are tied to a deeply ethical foundation for the timeless practice of love and caring, as a means to sustain, not only our shared humanity, but the profession of nursing itself.
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This manuscript offers a new view of old and timeless values: the essential ethic of love, informed by contemporary European philosophies, and caring theory, as well as ancient poetry and wisdom traditions. It integrates some of the philosophical views of Levinas and Logstrup with Watson's Transpersonal Caring Theory. The metaphysics, metaphors, and meanings associated with “ethics of face,” the “infinity of the human soul,” and “holding another's life in our hands” are tied to a deeply ethical foundation for the timeless practice of love and caring, as a means to sustain, not only our shared humanity, but the profession of nursing itself. Let us fall in love again And scatter gold dust all over the world. Let us become a new Spring And feel the breezes drift in the heaven's scent. Let us dress the earth in green, And like the sap of a young tree Let the grace from within sustain us. Let us carve gems out of our stony hearts And let them light our path of Love. The glance of love is crystal clear And we are blessed by its light. —Rumi 1(p117)
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Nursing science: the transformation of practice World-wide transformations in nursing practice are evolving as more nurses are embracing extant nursing theories and frameworks in order to fortify their unique contributions to the healthcare system. This article specifies the importance of and the ethical considerations arising when using nursing knowledge from within the school of thought of the discipline to guide practice. The ideas set forth are in stark contrast to the general nursing process with its medical model-driven diagnostic systems now proliferating in nursing practice in the global healthcare community. Both challenges and opportunities are present in the transformation of practice to a nursing knowledge base.
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"Knowing the patient" is an emerging concept in nursing that appears to be a central aspect of practice. "Knowing the patient" encompasses the complex process whereby the nurse acquires understanding of a specific patient as a unique individual, which subsequently enhances clinical decision-making, selection of optimal nursing interventions, and patient outcomes. Despite these heralded benefits, "knowing the patient" is severely undervalued in contemporary health care. Organizational arrangements, economic restraints, and efficiency of healthcare systems currently are of top priority. The potential effect on nursing practice is disconcerting; the effect on the discipline and the patient potentially devastating. This article explores the specific bureaucratic obstacles that impinge on "knowing the patient" within the context of nursing practice. It is hoped that illumination of the issues will beget viable alternative solutions, facilitating the transformation of awareness into action.
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This study explored the meanings of the lived experience of nursing students as they care for patients who are suffering. In this interpretive phenomenological study, 13 nursing students participated in conversational interviews and wrote narratives about their experiences of being with someone who was suffering. Embedded in the students' stories are the ways they came to understand suffering in the context of learning to practice nursing. The metatheme of bearing witness to suffering emerged from the analysis of the students' reflections. Bearing witness was exemplified with the subthemes of grappling with suffering, struggling with the ineffable, getting through, being with suffering patients, embodying the experience of suffering, and seeing possibilities in suffering. Bearing witness to suffering patients called students to an awareness of their own vulnerability. A concern for learning amid suffering was present throughout the students' texts. The call to care can be sustained through a pedagogy of suffering that acknowledges the need for support through a caring community.
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This paper considers the spatial dynamics of nurse-patient relationships within hospitals, primarily in the USA, under conditions of organizational restructuring, and situates them within social theoretical perspectives on space. As a human practice to which relationship is considered essential, nursing depends upon sustaining an often taken-for-granted proximity to patients. But hospital nursing, I argue in this paper, is increasingly constrained by spatial-structural practices that disrupt relationship and reduce or eliminate such proximity. Three kinds of proximity are threatened: physical, narrative, and moral. Examining these proximities through a place-space lens suggests that nursing is increasingly "distal" to patient care. There are potentially dangerous implications in this loss of proximity.
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There are occasions when persons find themselves faced with a difficult choice to be with one or more persons as they live intense experiences that often involve pain and suffering. It is proposed in this column that the experience of choosing to be with others during these times calls forth a risking of self. That fleeting moment when people choose to engage with others or to turn away from that opportunity is explored through personal experience and as portrayed in poetry and film. The authors use the metaphor of an abyss to explore the lived experience of risking being with the truth of human connectedness. It is suggested that nurses know the abyss and that they have opportunities to be with persons as they live truth in human becoming.
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This paper investigates the possibility of understanding the rudimentary elements of clinical sensitivity by investigating the works of Edmund Husserl and Emmanuel Levinas on sensibility. Husserl's theory of intentionality offers significant reflections on the role of pre-reflective and affective intuition as a condition for intentionality and reflective consciousness. These early works of Husserl, in particular his works on the constitution of phenomenological time and subjective time-consciousness, prove to be an important basis for Levinas' works on an ethics of alterity and infinite responsibility for the other person. In fact, it is difficult to understand the core of Levinasian ethics, of vulnerability as proximity, of ethical sensitivity as passivity and a suffering for the suffering of another, without understanding the influence from Husserl's work. Crucially, the paper will, on the basis of Levinasian ethics, establish an understanding of sensibility as vulnerability and receptivity that is fundamental also for understanding significant intuitions in clinical nursing. Clinical sensitivity and carefulness in nursing are shaped by the concrete and also bodily expressions of vulnerabilities in a receptivity that is pre-reflective and pre-ontological.
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The physical nearness, or proximity, inherent in the nurse-patient relationship has been central in the discipline as definitive of the nature of nursing and its moral ideals. Clearly, this nearness is in service to those in need of care. This proximity, however, is not unproblematic because it contributes to two of the most prolonged difficulties, both for individual nurses and the discipline of nursing--moral distress and moral ambiguity. In this paper we explore proximity using both a moral and geographical lens and offer some insights regarding this practice reality. We examine the effect of proximity to patients on nurses' moral responsiveness, particularly as it affects nurses' moral distress. Proximity is paradoxical in this regard because, while it propels nurses to act, it can also propel nurses to ignore or abandon. Likewise, we argue that nursing's tendency to define itself in relation to the closeness of the nurse-patient relationship leads to problems of moral ambiguity. Our recommendations include moving others closer to the bedside and thus to the work of nursing in the literal and theoretical sense.
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The purpose of this article is to reflect on pediatric critical care nurses' experience of grief by focusing on the meaning of the stories that haunt them. It is suggested that these stories are the nurses' attempt to find ways to journey through their grief and to live with the mystery of life and death. It is also the task of these stories to throw light on their experiences, a task that is never entirely finished. Dwelling with the stories that haunt them helps to provide nurses with a moral structure of critical care nursing practice. Their reflections upon the meaning of their experiences of grief can lead to a view of death that is not always perceived as an evil to flee, but is upheld as a source of value and revelation as critical care nurses strive to build who they are and how they practice the art of nursing.
The Art of Human Becoming
  • R R Parse
  • Eifried S.