By: Patricia Benner
We are learning more and more about the positive outcomes of engagement and the deleterious effects of disengagement (Rubin, 2009). In studies of skill acquisition and clinical reasoning we found that nurses who had problems with engaging with patients, families, and the actual demands, resources and challenges of particular situations did not go on to become experts (Benner, Tanner, Chesla, 2009; Benner, Hooper-Kyriakidis , Stannard, 2011). Attunement, openness and curiosity are all essential to expert situated thinking and action. Openness and communication skills are hard-won and complex; in part because they are intertwined with the nurse’s own experiences with vulnerability, suffering, pain and anger.
If student nurses objectify patients in ways that prevent understanding, they may fail to protect themselves from the challenges and threats in the situation while preventing access to vital information from the patient/family. Closing off information and understanding also prevents the student’s access to coping and spiritual resources available in the situation.
Early in nursing school, student nurses must learn to meet the patient/family as other, but not wholly other. Student nurses caring for patients and families in various circumstances of vulnerability, coping, and suffering, must learn not to over-identify or sentimentally imagine that the suffering of the patient/family carries the same threats, challenges and vulnerability for themselves and their lifeworld nurse. Their caring boundaries are professional in that, they do not face the same situation as the patient/family is experiencing. Sentimentalism occurs when the person takes the emotions and threats of another person in as their own, and elaborates the emotion, as if it were their own problem or situation. This is the problem of not having clear self-other boundaries. To be present and helpful nurses must clearly separate the pain, emotions and vulnerabilities of the particular patient/family from their own vulnerabilities and challenges. This kind of boundary learning needs to occur early in the nursing program. But learning to form healthy self-other boundaries is only the first step in learning good skills of involvement.
Learning the skill of involvement with different patients and families is intertwined with the student nurse’s own self-understanding and even with past challenges and vulnerabilities. Learning good professional boundaries is learned experientially, hopefully, in role playing, in narrative journals, and reflection as well as the higher stakes learning where the student nurses finds himself/herself over-identifying, or objectifying and disengaging with the patient/family. I can’t imagine facing all the high stakes learning challenges in becoming a nurse without erring in relational skills of connection and attunement. This kind of personal learning (Polanyi, 1958) requires a consciousness-raising. We learn directly from doing better or worse, and feeling good when we relate in helpful attuned ways to patients and families. We have to be open to learning when we are not involved in a helpful way or when we are too disengaged to take in patient/family concerns. This is why reflecting on experiential learning is so crucial in simulations, in skills labs, and in actual clinical practice. Journaling also offers a superb way for students to explore their skills of involvement with the patient/family and with the clinical or community situation.
In addition to personal experiential learning through reflection and consciousness-raising, student nurses need to have grounding in psycho-social knowledge about growth and development across the lifespan, in skills of communication, and in stress and coping related to illness. For example, when a student learns to relate to a patient’s or family’s anger not as a social statement about the nurse, but rather with openness and curiosity to consider what threats, encroachments, or challenges are making the patient/family feel helpless. Anger is often the first defense against feeling helpless, and defusing, or even presencing oneself with the patient/family anger requires not taking the anger personally, and responding in kind, but rather finding a way to reach out to the angry person and better understand how to meet the fear or threat of helplessness. Sometimes acknowledging the anger is all that can be offered, but when empathy and emotional understanding is offered, the patient/family may not feel so alone or isolated in their sense of threat over being helpless to change the situation.
Research on pain experience and pain expression can help the student nurse understand the range of both the experience and expression of pain. Dealing with one’s own death anxiety, to the extent of developmental readiness throughout life, can be a journey begun in nursing school with seeds planted to acknowledge our finitude and our anxiety over that finitude. Knowledge acquisition about psycho-social skills of interpersonal and situational involvement with learning how to translate explanations and “learning about” coping into using that knowledge to better understand and meet the patient/family as fellow human beings who are not the same, and yet now wholly other. Intellectualization can offer a false sense of belief that we are attuned, and actually helping when in fact, we are detached and describing the other’s plight as an intellectual exercise. Human beings share a common humanity with common embodied threats of vulnerability, injury, disfigurement, and recovery/rehabilitation challenges. As nurses we cannot get beyond these common aspects of the humanity we share with patients, but we can learn how avoid common pathologies of helping, such as exaggerating common threats, imagining that we can be omnipotent rescuers, engaging in grandiosity about what we can or cannot change.
In the Carnegie National Nursing Education Study (Benner, et.al.) we found a curious silence in the classroom about focal caring practices of nurses, and about confronting vulnerability, injury, suffering and death. Students complained that there was little teaching learning focus on these harder skills of interpersonal involvement. Sometimes this is because faculty may not always have the language or background to address this range of interpersonal skills of involvement in difficult patient care situations. We found that faculty teaching in clinical practice areas were more likely to address interpersonal and communication skills around pain management, suffering, and fears of patients and families.
Faculty can enhance their pedagogical skills in teaching and learning the skills of involvement, and their understanding of stress and coping in illness and in confronting illness and vulnerability at different stages of growth and development. If this area of teaching and learning is not as strong as it needs to be, faculty workshops, and continuing education units should be used to further develop the ability to teach students how to learn attunement, responsiveness, openness and curiosity.
We might imagine that we just need to tell the students to “call the chaplain” or “social worker”; however, these are necessary, but insufficient strategies. In order to become expert nurses, the technical and interpersonal must be intertwined. In expert practice they are attunement, responsiveness and curiosity are inseparable from technical abilities and good clinical judgment. The nurse who lacks skills of interpersonal attunement will function with insufficient information for attuned care of patients. Every professional caregiver, including the nurse creates a relational disclosive space for themselves and the patient/family. By disclosive space, I mean a comfort zone, a mood, a climate of situated possibility. If the nurses are brusque, anxious, always hurried, and focused on efficiency alone, the disclosive space will shrink, and effectiveness, expertise, and patient safety will be at risk. Even the neonatal intensive care nurse has to learn when and how to ensure that a fragile infant experience human solace and comfort as well as astute pain management. All professionals must develop skills of engagement, and the nurse’s situatedness and potentially prolonged contact with patients/families during times of stress and crisis call for high level and compassionate skills of involvement.
Benner, P., Sutphen, M., Leonare, V..W., Day, L. (2009) Educating Nurses: A Call for Radical Transformation. San Francisco: Jossey-Bass & Carnegie Foundation for the Advancement of Teaching.
Benner, P., & Tanner, C. Chesla, C.A. (2010). Expertise in Nursing Practice, Caring Clinical Judgment and Ethics (2nd ed.). New York: Springer Publishing Co.
Benner P., Hooper-Kyriakides P., Stannard D. (2011) (Second Edition, first edition 1999) Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-In-Action Approach. New York: Springer Publishers
Polanyi, M. (1958) Personal Knowledge. Chicago: The University of Chicago Press.
Rubin, J. (1996) Impediments to the development of clinical knowledge and ethical judgment in critical care nursing. In P. Benner, C. Tanner, & C. Chesla (Eds.), Expertise in nursing practice, caring, clinical judgment and ethics (pp. 170-192).New York: Springer.