1. Introduction
Nursing care is provided in specific situations. A situation is defined as “a direct relationship between a place, time, and people [1].”A relationship between a nurse and an individual in a situation has different and particular meanings to individuals [2]. To be precise, there is no situation in which a person has been before. In this sense, all situations are specific, practical, and experimental. Nursing care is participation or involvement in a situation with an individual.
In particular, a psychiatric nursing care situation represents “a direct relationship of a person with the world.” [1] .The fact that nursing care records have unique characteristics also supports this. The records should include detailed descriptions of the relationship between nursing care providers and patients’ behaviors and remarks. It is necessary to examine these nursing care situations for establishing practical psychiatric nursing. To examine the nursing situation or the phenomenon, which subjects should be targeted and what methods should be used? Heidegger attempted to explain the concept of existence on the basis of the phenomenon of language. In effect, Heidegger [3] explored language not by “speaking about language” but by concept of “being called by essence of the language and being guided toward this essence.” On the other hand, Merleau- Ponty examined the “child’s relations with others” [4] in everyday experiences and the phenomenon of “phantom limbs” [5] and elucidated their meanings while critiquing the related underlying theories. Moreover, Fink [6] investigated the phenomenon of play (Spiel), Buytendijk [7] investigated women, Bollnow [8] investigated mood, and Kuki [9] investigated “Iki (chic),” These studies shed light on the nature of each phenomenon. There are of course others who have explored real individuals and interpreted the meanings underlying their essence. Reports by the psychopathologists Binswanger [10] , Minkowski [11] , Tellenbach [12] , van den Berg [13] and the educator, Langeveld [1] have interpreted the essence of patients who visited them or of children they visited, on the basis of everyday experiences. None of these subjects were selected for the purpose of research. In brief, to achieve their goal of appropriate treatment for patients and independence for children, these professionals familiarized themselves with their subjects’ situations, and have tried to interpret the meanings underlying their subjects’ words. Accordingly, it is sufficient that subjects have an experience in psychiatric nursing for the maintenance and improvement of patient’s mental health to perform investigations using the phenomenological interpretation concept of “learning from situations as subjects.” The present study will clarify the type of meaning context an individual lives in on the basis of the phenomenological interpretation of direct relationships between individuals that emerge from a psychiatric nurse’s description of nursing care, i.e., interpretation of the language and events described.
2. Methods
2.1 Study design
This study took a qualitative, interpretive approach to the key research question of understanding nursing situation. Phenomenology is a philosophy and research methodology that seeks to describe experiences as lived. The essence of a particular phenomenon is identified and described. A phenomenological approach was most appropriate in enabling the examination of such human experience.
2.2 Participant
When investigating the situation of nursing care, it is best to use nursing practice as a subject for study. Therefore, the subject of the present study is the description of nursing practice in the words of a psychiatric nurse. A psychiatric nurse was chosen because among the different types of nursing care, the situation of psychiatric nursing care best represents the direct relationship of an individual with the world.
To avoid bias, the researchers decided not to attach conditions to these descriptions. Researchers should not use nurses’ descriptions for research because Heidegger [3] states that the nature of a phenomenological approach, i.e., intuition, is to “hear” from nurses’ descriptions of practice. Therefore, I asked a psychiatric nurse to describe nursing practice situations frankly and in detail.
Phenomenology does not view descriptions of experiences as subjective. Nurses’ experiences occur within a situation, and therefore occur simultaneously with the experiences of another. As was discussed by Merleau-Ponty [5], the phenomenological world is not a pure existence but rather the meaning that emerges from the entanglement of various experiences at the intersections between one’s own experiences and the experiences of others. Thus, phenomenology involves taking the direct relationship of an individual with the world as the subject of interpretation and not the attributes of the nurse providing the descriptions or the patient appearing in the descriptions. Merleau-Ponty similarly explained that one’s own existence does not originate from one’s own personal history or physical/social environment. In contrast, one’s existence approaches and supports one’s personal history and physical/social environment. The researchers therefore accept the descriptions as they are given and have selected psychiatric nurse’s descriptions of nursing practice as the subject of the present study.
2.3 Ethical considerations
The participants in the study received written explanation of the purposes, objectives, and methods of the study and the facts that that (he /she) has the right to refuse to participate in the study; acquired information will not be used for purposes other than research; personal information is strictly protected during the study and at the time of its publication; and research results may be published in scientific papers or at academic conferences. Following the explanation, (his / her) written consent was obtained to confirm (his /her) intention to participate in the study.
2.4 Data collection
After psychiatric nurses were given explanations of the purpose and methods of this study, one nurse gave consent to participate. A psychiatric nurse (Nurse A), who consented to the study, was asked to describe nursing care situations in detail, including the behaviors, remarks, expressions, feelings, and thoughts of patients and herself, as well as her experiences in her free time; no deadline was set. I received the questionnaire survey sheet directly from her. Because there were some descriptions of a direct relationship between a place, time, and people, and information, they were excluded in consultation with her.
2.5 Methods of phenomenological interpretation
2.5.1 Overcoming the method principle
The method principle is an assertion that without a method procedure, actual experiences cannot be clarified. However, to clarify direct relationships between individuals, i.e., the significance of situations, the situation stops conveying meaning when the method is proceduralized and applied to a subject. This is because, in proceduralized methods, information is not completely heard from subjects but extracted in part from subjects so that the overall situation cannot be observed.
Hearing information from subjects themselves is sympathetic. According to the accurate definition for sympathy by “Whitehead A.N. [14],” “The primitive element is sympathy, that is, feeling the feeling in another and feeling conformally with another.” The phenomenological method signifies experiencing feelings with other people rather than using a procedure based on logic.
2.5.2 The intuition of essences
Sympathy or feelings are intuition in the sense that they are not brought about by thinking. Husserl [15] spoke of “phenomenon intuition” and said that “intuition is not demonstrated or deduced.” Similarly, Binswanger [16] also stated that “the phenomenon itself leads to one reaching intuition.” Husserl [17] also stated that “although the phenomenon itself is not natural, it has the essence of being able to be grasped with direct intuition and the essence of being able to be completely grasped.” While criticizing the intuition described by Bergson [18] as “awareness that is definitively arrived at” and the “intuition of essences” described by Husserl [17], Merleauponty [4] also referred to the importance of intuition. Thus, “the specific sensations of experiences felt here were always an objective for the intuition of essences and as a preceding item for the intuition of essences, this was an objective enfolding this.” Therefore, “essence can ultimately only be approached through individual ‘situations’ that appear.” Accordingly, intuition can be calculated from an individual to specific situations or experiences and essence is exposed from the intuition in response to this.
Of course, intuition in phenomenology is not based on the assumption of subjectivity versus objectivity. With regard to intuition, Moore [19] once said “unless you are explaining this to people who already know what yellow is, there is no way that you can explain it.” This means that the color yellow can only be recognized by direct contact with the eyes. Intuition in phenomenology is essentially an experience of phenomenon and requires direct contact with the phenomenon itself. Furthermore, this phenomenon represents essence, which means language in the broader sense. Thus, as Heidegger repeatedly mentioned, it is best that we “hear and speak from language [3].” Therefore, Heidegger [3] said that “when speaking about language, most language cannot be unavoidable, leading to only one subject.” The subject referred to is the concept of subjectivity versus objectivity. Phenomenological interpretation is only generated from intuition of the phenomenon itself. Accordingly, as Merleauponty [4] cited from Husserl’s book “Ideen,” “All people are actually constantly looking at ideas or essence and are using these in their thought processes [20].”
Thus, intuition itself is the essence of phenomenology. However, despite the intuition of essences, this does not mean that boundaries such as “as the moon takes shelter in the rain, the moon does not become wet and the water is not broken [21],” are always possible. Therefore, sincerity to clarify the water of one’s heart and the effort of reflection are constantly required so as to be released from preconceptions. Merleau-ponty [4] did not require people to stop the effort of reflection because “Reflection is not confirming facts but the effort of trying to understand them. Reflection is not passively looking over one’s path of life but trying to draw out meaning from one’s experiences.”
Thus, the principle of the method was to learn from a situation as a subject. Therefore, the method aims to help you determine “what” a specific situation was and not “why” or “how” it occurred and to advise close observation while eliminating preconceptions.
3. Results
3.1 Descriptions of situations
The following are the descriptions provided by psychiatric nurse A. Patient P was one of my patients. She often visited our nurse station and complained saying “I do not know why, but I feel bad.” As usual, she could not explain why she felt bad and what she wanted us to do. She got excited and cried while nurses were listening to her. When a nurse advised her to think why she felt bad, she became upset and said “No matter how many times I said to them, ‘I do not know’, all nurses tell me to think for myself.” In response to advice from another nurse, she said “That will not work. It is a waste of time.” When a nurse allowed her to choose from multiple coping methods, she began to cry, saying “That is enough. You don’t care about me, do you? I have to take care of myself, right?”
Different nurses respond to patients in varying ways according to the situation. However, no matter who responded to this patient, her attitude was negative and did not change. No nurse could calm her down or reassure her.
When the patient visited the nurse station, complaining that she felt bad, I did not understand what she wanted us to do. Therefore, she responded to the patient in various ways, asking questions such as “What happened?” “Do you want to take some medicine and rest?,” and “I see. You feel bad. What do you think you should do?” however, the nurse explained, no matter how hard she tried, she never got the feeling she could help or satisfy the patient.
The nurse went on to say, “One night, the patient visited me at the nurse station as usual and said, ’I am not sure why, but I feel bad,' with a tearful expression. When I asked her, ’Were you thinking about something?’ The patient just said, ‘Not particularly.’ The patient often felt bad immediately after she’d argued with her mother or talked with her attending physician, just as she had done that day. I asked her, ‘Do you feel bad because you were thinking of something after consulting the physician?’ And she bluntly answered, ‘No, it is not the reason.’ I thought that I should stop trying to identify the cause. Wondering how she usually copes with that problem by herself, I asked her “How do you cope with it when you feel bad?” She thought for a while and said with a sulky expression “I consult a nurse, or, when it does not work, I have no choice but to tolerate it.” I tried to praise her for the way she had dealt with the situation, saying “I see. That is why you always come to us for consultation. It takes courage to consult someone.” However, she looked down, and said “No.” The way she talked led me to think that she had no confidence in herself. I tried to encourage her and said “You have the courage to say that you feel bad. I think you should be proud of yourself for that.” However, she started crying and trying to contain her anger, she said “Why do I have to work so hard? When I told you that, I have to continue struggling forever, don’t I?” I was very surprised with that because I did not mean to push her hard at all. It was the first time that one of my patients had become upset by what I had said with good intentions. I was lost for words and stopped talking. Soon, another nurse came at the end of the day’s work shift to take care of the patient. For the first time, I realized that some people get hurt even when they are complimented.
3.2 Interpretation
The patient always visits the nurse station and complains “I do not know why, but I feel bad.” If a nurse advises her to think why she feels so, she begins to cry, saying “No matter how many times I said to them, ‘I do not know’, all nurses tell me to think for myself.” What does she mean when she says “I feel bad?” Even healthy people sometimes feel bad in their daily lives. They then search for and identify the cause, e.g., they stayed up late at night, could not sleep well because something had worried them, did not have breakfast, or had a cold or fever. Once the cause is identified usually are careful not to repeatthe same mistake. Of course, they cannot always identify the cause. At any rate, healthy people attempt to identify the cause of why they feel bad. If the cause is identified, they will be relieved of anxiety and can learn how to cope with it. To identify the cause leads to resolving the problem.
The patient always says “I don’t know why, I feel bad” or “I am not sure why, but I feel bad.” When Nurse A tries to persuade the patient to reflect on why she feels so, she refuses to think for herself, saying “I said, I do not know!” The patient visits the nurse station, only saying “I do not know why” or “I am not sure why,” because she wants nurses to know the fact that she is in distress. She does not ask them to identify its cause and relieve her of it. When she complains that she somehow feels bad, she wants other people to understand that she feels distressed.
The patient often complains that she feels bad after arguing with her mother or talking with her attending physician. She does not feel comfortable when she interacts with her mother and attending physician. This means that “her distress” is caused by her interactions with people.
Judging from her attitude, the nurse thought that she should stop trying to identify the cause at that point. The nurse made a correct judgment, explaining that the patient feeling bad means it is hard for her to live in her personal relationships with others. The patient complains when she feels distressed because of her relationships or the situation. In other words, her distress is not attributed to herself. It originates from her relationships with her mother, attending physicians, and nurses.
The nurse thought that there was no point in continuing to try to identify the cause because she had identified the cause to be the patient herself and separated the patient from the situation. It was natural for the patient to say “I do not know,” when many nurses, including Nurse A, kept asking her, trying to identify the cause in turn.
The nurse who wants to know how the patient usually copes with her distress by herself asks her “How do you cope with it when you feel bad?” The patient thinks for a while and says with a sulky expression “I consult a nurse, or, when it does not work, I have no choice but to tolerate it.” This question is difficult for her to answer or it makes her feel bad.
The nurse continues, explaining how she tried to praise her patient for the way she copes with the situation by saying “I see. That is why you always come to us for consultation. It takes courage to consult someone.” However, the nurse relates, the patient looks down and says “No.” The nurse tries to encourage her and says “You have the courage to say that you feel bad. I think you should be proud of yourself for that.” However, the patient feels distressed even when she has to answer “I have no choice but to tolerate it.” Furthermore, the patient feels more pressure when she hears the term “work hard” than when she is told to “tolerate it.” To tolerate something, you are only required to be patient with the present situation. However, working hard requires you to improve the present situation further. When the nurse says “You are working hard,” the patient thinks that the nurse expects her to continue working hard, rather than acknowledging her efforts. If a person were told “You are working hard, “he or she would think, “They expect me to have the courage to take the first step andwork harder.” Therefore, the patient, crying and trying to suppress her anger, says “Why do I have to work so hard? When I told you that, I have to continue struggling forever, don’t I?”
The nurse says “You are working hard,” thinking that the patient feels “bad” because the cause is attributed to her-Patient P. Her distress is caused by her relationships with other people. When the patient complained “I feel bad,” the nurse should have said “I am sure you do” to accept her feeling. This is what the patient expects nurses to do. In other words, the patient wants to feel comfortable in her relationships with others.
4. Conclusion
In clinical nursing settings, we always learn from the situation. For example, when eating a meal, some elderly patients with dementia open their mouth only when they are fed with a pair of chopsticks and not with a spoon. Eating food with chopsticks is their long-established habit, and a pair of chopsticks is an extension of their hands. To them, eating is putting food into the mouth using chopsticks. Another example is a so-called phantom limb-a patient complains that his/her lost right leg hurts. Nurses think “The patient’s right leg cannot hurt as he/she does not have one” or “Why does the patient complain of pain” However, they also can tell the patient “I understand. It must be painful. I hope you get a good prosthetic limb as soon as possible.” The patient had had the right leg all through his/her life, and whatever he/she did, the patient used it. His/her right leg was and still is a part of him/her. Merleau-Ponty [5] stated “Both physiological and psychological explanations of the phenomenon of a phantom limb are incorrect. It can only be explained by the theory of ‘Being-inthe- world’.” A patient’s complaint of pain is considered as a means of identifying the prosthetic limb with the real leg.
Furthermore, some inpatients complain that it is hot. Nurses do not understand “why they feel hot when they do not have a fever and the room temperature is appropriate.” However, nurses may respond to the patient in a different manner by accepting the complaint and saying “I understand that you are hot. I will put away the blanket.” When patients say: “It is hot today,” they actually feel hot.
As the psychiatric nurse’s description shows, when Patient P complains that she feels bad, her distress is not attributed to a physiological or psychological cause. She simply cannot tolerate being in that situation. The patient complains how hard it is for her to live in this world. To the patient, there is nothing that could be done about this difficulty in living except to persevere. The verbal encouragement of “You are working hard” elicited anxiety and fear in the patient who could do nothing but persevere in the first place. That is what the nurse’s description means. This quickly led to a change in nursing practice. Thus, rather than viewing patients as objective subjects and rather than trying to work out the “why” and “how” of the patient’s language saying “I feel bad,” the nurse needs to work out “what” a specific situation is and “what” it signifies. Therefore, the nurse should accept the fact that the patient has been in a situation in which she feels bad, instead of asking her the cause of her distress.
As Van den Berg [13] said, “Phenomenology is one method. It could also be called attitude.” In clinical practice, phenomenologicalinterpretation requires that nurses interact with patients in a phenomenological attitude. Of course, a phenomenological attitude does not involve breaking down patients’ words and behavior, extracting codes, and categorizing them. This is already removed from actual practice. The phenomenology in nursing demands a certain attitude to be implemented in actual practice. In nursing, requests and possibilities are connected. Therefore, as long as nurses act in accordance with the essence of phenomenology, situations’ interpretation can be implemented in actual practice. In this sense, it is an index for determining the validity of whether what has been interpreted can be implemented in actual practice by nurses in clinical settings.
Incidentally, the fact that the patient’s complaint of “I feel bad” is a special situation makes the universality of its interpretation questionable. In response to this, phenomenological interpretation suggests the following: A patient who complaints that “I feel bad” is not special but “can approach other subjects through expressions [22].” This is because, as Van den Berg [13] said, “all patients are humans.” Therefore, the difficulty of living is experienced by all people just as death “is a general phenomenon that is applicable to all people with no exceptions and an absolute assumption for every one of us [11].”
Competing Interests
The author has no conflict of interest directly relevant to the content of this article.
Acknowledgments
The author would like to thank all the nurses who participated in this study. This work was supported by the Hamamatsu University School of Medicine.