Humanistic Modelling

Nursing has long been an advocate of the embodiment of humanistic principles, with much of the nursing literature (Bevis, 1998; Mullholland, 1995; Nelson, 1995; Paterson and Zderard, 1976) describing humanistic nursing practice involving an approach in which nurses enter into an empathetic and therapeutic relationship with their patients as it facilitates the ‘development of human potential’ (Paterson and Zderard, 1976, p.63).

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The notion of Humanism can be located in the writings of the early Greek scholars, Socrates (470-399 BC), Plato (384-345 BC), and Aristotle (384-322 BC) who believed that by studying human social actions and interactions, particularly those concerning good or evil, an insight into human nature could be gained. In sociology, social action is the term used to describe an act which accounts for the actions and reactions of individuals, these actions can be goal orientated but with little thought to the consequences of the action or goal-instrumental where actions are planned and executed in relation to other goals and after careful consideration of the resulting consequences (Fadul and Estoque, 2010). Social interactions stem from social contacts, a pair of social contacts forms the basis of social interactions which in turn provide the medium for social relations (Fadul and Estoque, 2010).

The French Revolution (1789-1799) and the Enlightenment era of the 18th century led to a greater scientific understanding of disease and disability, and the formation of a medical model of health, which developed with the growth of the medical profession, and viewed health as the absence of disease (Porter, 1999). During this period a noticeable move away from religious authority to a faith in the workings of human rationality appeared (Traynor, 2009). This was more evident after the Second World War (1939–1945) when a strong restatement of humanistic values emerged in response to the Nazi horrors of the concentration camps which so devalued human life and worth. Following on from this in 1948 the newly formed United Nations composed its Universal Declaration of Human Rights. Article 1 states that:

“All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience”, (United Nations 1948 art.1, p.72).

In the same year the World Health Organisation boldly announced its definition of health as, ‘a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity’ (World Health Organisation, 2006, p.1). Despite the best efforts of WHO to dispel the philosophical beliefs of the medical model the notion of well-being remains firmly rooted in disease and illness, which is understandable when there is strong evidence that in times of ill-health people turn to medicine rather than at times when they are feeling well (Bury, 2005). A more recent scholar of humanism,

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Lamont (1997), suggests that the goal of life for any human is to work for the happiness of others.

The concept of humanism within the healthcare professions and in particular nursing is based more upon an ideal describing this form of humanism in a paralleled “contrast to medico-scientific reductionism and objectivity”, (Traynor, 2009, p.1560). Traditionally health care professions have formalised ethical statements relating to their basic values, committing to the maintenance of patient dignity, beneficence, individuality and the promotion of patient self-help, these values have been laid down for posterity in ‘Codes of Professional Practice’ and the infamous ‘Hippocratic Oath’ (General Medical Council, 2006).

Nursing has at all times concerned itself with the welfare of the individual but has done so within the confines of working within hierarchical and bureaucratic organisational structures (Playle, 1995) which have served to dehumanise the caring process. This dehumanising practice has been identified within medicine, the illness-cure model or medical model (Parse 1999; Playle, 1995), in which the physician adopts an authoritarian position in relation to the passive, dependent perspective of the patient. This is a fundamental assumption of the model; it is seen as necessary and to be expected. External social or psychological factors are generally ignored or de-emphasized making the disease condition of the patient of major importance thus dehumanising the individual to nothing more than an illness or disability (Bury, 2005; Lawrence, 1994; Porter 1999). In nursing, humanism has become a traditional valued belief of the profession recognized by some of the leading nursing figures of the last century such as Virginia Henderson (1964) and Florence Nightingale (2011). Nightingale claimed that the ability by the nurse to provide humane sensitive care was quintessentially nursing and Henderson (1964) concurred that the human element was naturally housed within nursing itself. It was Nightingale who recognised the importance of social and environmental contributory factors to health and well-being especially within the nursing environment.

Humanising care and caring may be difficult to implement in certain situations such as where injustice exists globally, and in situation where individuals are quite happy to place

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themselves in the ‘hands’ of health care professionals, announcing that ‘doctor knows best’ fervently feeding the medical model of care. In these circumstances the ability to empower individuals to take responsibility for their own lives and make their own decisions may well be an impossible task.

“Care…conceptualized as values and attitudes” (Symanski, 1990, p.138) is a particular feature of caring models where the authors advocate the presence of distinct caring values and attributes. Roach (1993) in his model the Five Cs of caring, lists these qualities as compassion, competence, confidence, conscience and commitment. Sherwood’s (1997) Therapeutic Caring Model reflects the work of Roach and includes behaviours which demonstrate commitment such as empathy, providing support and comfort, preservation of dignity, showing concern and providing a protective environment to facilitate healing interaction. These models were developed to provide nurses with a means of understanding what takes place during the act of caring, what that signifies to the patient and ultimately their effect on the nurse/patient relationship. Both models attach importance to creating an environment which values the inimitability of the individual whilst caring for them from a holistic and humanistic stance. On the whole caring theory is difficult to delineate tangibly. Caring models such as those described seek to illustrate what is effectively seen as the essence of professional caring; despite their efforts the concept remains elusive and open to investigation from nursing researchers who actively pursue new strategies aiming to generate data that will ultimately reveal the value of caring. Patricia Benner (1984, p.213) illustrates this point by asking us to consider the “power” of caring, she describes the caring role as involving the concepts of transformative power, advocacy, healing power, integrative caring, problem solving and participative/affirmative power. This in essence elevates the interpretation of professional care from the mere application of skill to one that acknowledges a humanistic, relational interaction. Fundamentally Benner’s model can be attributed to a naturalistic worldview (Sire, 1990).

In relation to humanistic research there has been a call amongst nursing writers for the embodiment of humanistic principles as evident in nursing practice to be reflected in nursing literature (Leininger, 1985; Morse and Field, 1996; Speziale and Carpenter,

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2007). Myers (2000) argues that qualitative research is conducive to understanding lived experiences such as caring, comfort and powerlessness with Basset (2004) arguing against the use of quantitative research to define and measure complex human emotions and attitudes citing unpredictability as the rationale. These arguments are assumptions arising from the use of evidence based practice to inform health care professional knowledge of patient care and care delivery. Wall (2008) suggests that the nursing profession has adopted a traditional, bio-medical approach to research use and evidence based practice, questioning whether this approach is trustworthy in identifying caring values. Wall builds upon the arguments of Mitchell (1997) who stated that this research focus does not serve nurses well in relation to caring and does not provide sufficient direction on how nurses can understand patient experience such as living with loss, struggle, despair, fear, concern or suffering. ‘The realities of practice involve nursing encounters with complex human beings who are living out experiences that cannot simply be changed according to findings from research’ (p.154). The cautions as presented by Mitchell and Wall are rational and logical, especially when considering that not all research findings are useful in practice when ethical or moral standards are applied. How then can any health care professional discover what they need to know in order to care? In a Canadian study, Estabrooks et al. (2005) found that when making decisions in clinical practice, nurses depended upon internal experiential and intuitive knowledge. This ‘knowing’ is accumulated through social interaction type learning activities such as informal consultations with peers and medical staff and structured lectures. The conclusions of this study were noteworthy in relation to receiving knowledge by listening to scientific findings (produced by experts); Estabrooks et al. found this to be an insignificant source of knowledge for nurses. Here the authors perhaps inadvertently, illustrate a certain bias towards nurses’ acceptance of research generated knowledge, giving the impression that empirical approaches to knowledge have yet to mature in the nursing profession.

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