Part I: Foundations for Practice
Chapter 3: Presence
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resence is an intervention integral to the administration of all complementary therapies and may be used in conjunction with or independently of other procedures. It is closely related to the therapy of active listening, and the two share many similar characteristics.Although presence has been recognized for centuries within nursing, research has only recently been initiated on this subject. This research has largely been conducted in conjunction with the concept of caring.
DEFINITION
Philosophical views of existentialism assisted with the development of the concept of presence for nursing. Sartre (1943/1984) described aware-ness as a means toward knowing a person and a way of presence. Sartre coined the term authentic self as bringing self to “being with” a person.
Heidegger (1962), in his philosophical teachings, introduced the term Dasein or “being there” for another. “Being” is the unique quality of a per-son and is experienced through sharing one’s authentic self (Heidegger, 1962). According to nursing author T. P. Nelms (1996), being is presence and the heart of nursing practice. Thus, being there and being with are core definitions of presence. Preliminary to developing a presence scale, Kostovich (2012) had 10 registered nurses validate the following definition of presence: “Nursing presence is an intersubjective human connected-ness shared between the nurse and patient” (p. 169).
The connection between philosophy and nursing regarding the con-cept of presence began to emerge in the 1960s. Vaillot (1962) used the
phenomenon of presence to describe therapeutic relationships as crucial to patient care. Two other pioneers in this field, Paterson and Zderad (1976), described presence as the process of being available with the whole of oneself and open to the experience of another through a recip-rocal interpersonal encounter. According to Paterson and Zderad (1976), presence is an intervention the nurse uses to establish a relationship with the patient.
Benner (1984) coined the verb presencing to denote the existential practice of being with a patient. “Presencing” is one of the eight competencies Benner identifies as constituting the helping role of the nurse. This view of presence in nursing was supported by Parse (1998), who characterized presence as
“the primary mode of nursing practice” (p. 40). More recently, McMahon and Christopher (2011) have developed a midrange theory of nursing presence in which they identified five variables that characterize presence: individual client characteristics, the characteristics of the nurse, shared characteristics with the nurse–patient dyad, the environment, and the intentional decisions of the nurse related to practice. Kostovich (2012) developed a model for pres-ence that includes antecedents and possible outcomes.
Presence may be reciprocal when both parties are connecting and may be meaningful to both the patient and the nurse. Melnechenko (2003) noted:
“to be invited to share in another’s unfolding health, to be asked to jour-ney with another through the process of moving and choosing, is without doubt an honor and privilege” (p. 24). The transactional characteristic of presence was emphasized by McKivergin and Day (1998). Hessel (2009), in a concept analysis of presence, noted that presence involves a spiritual con-nection that is felt when the nurse and patient share the experience of being together. In presence, the nurse is available to the patient with the whole-ness of his or her unique individual being. Presence can be characterized as an exchange in which meaningful awareness on the part of the nurse helps to bring integration and balance to the life of the patient (Snyder, Brandt, &
Tseng, 2000) and perhaps satisfaction and meaning for the nurse.
Two classifications of presence have been developed (McKivergin &
Daubenmire, 1994; Osterman & Schwartz-Barcott, 1996). The continuum in both classifications extends from merely being physically present with the patient to being available with the wholeness of self. Exhibit 3.1 describes the dimensions of presence and provides an example of each type of pres-ence. It is only the transcendent (Osterman & Schwartz-Barcott, 1996) or therapeutic presence (McKivergin & Daubenmire, 1994) that constitutes the complementary therapy designated as presence.
Presence is an intervention used by nurses but takes practice if used as a complementary therapy. Nurses may increase their use of transcendent presence by practicing journaling, mindfulness, active listening, unitask-ing, holding silence with a partner, focus on the breath, and purposeful activities such as smiling and centering. These activities enable a person to experience presence and evoke it as an intervention when needed.
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The universality of presence and caring has been documented (Jonsdöttir, Litchfield, & Pharris, 2004). Presence transcends cultures and modes of communication. The Buddhist way of life through mind-fulness implies one is attentive, aware, and fully present in the moment ( Kabat-Zinn, 1990). Even if the nurse and patient are unable to communi-cate verbally, the patient perceives the presence of a caring nurse. The psy-chological evidence of presence is apparent. According to Paulson (2004), presence requires an emotional, subjective interaction in which the nurse conveys genuine concern for patients, not just as patients but as human beings.
SCIENTIFIC BASIS
Paterson and Zderad (1976) recognized presence as an integral component of their theory of humanistic nursing. Presence implies openness, recep-tivity, readiness, and availability on the part of the nurse. Many nursing situations require close proximity to another person; however, that in itself does not constitute presence. To experience the lived dialogue of nursing, the nurse responds with an openness to a “person-with-needs” and with an “availability-in-a-helping way” (Paterson & Zderad, 1976). Reciprocity often emerges through the dialogue.
Nurse scientists have described presence as a subconstruct of the broad concept of caring (Nelms, 1996; Watson, 1985), but Melnechenko (2003) contends that presence is more than caring and active listening.
Presence involves the nurse as “co-participant” in the caring process (Watson, 1985). Caring requires the nurse to be keenly attentive to the
Exhibit 3.1. Dimensions of Presence
Dimensions of Presence example
Physical presence Nurse is competent in carrying out patient care; has minimal interaction with patient and is seemingly unaware of nonverbal communication; exits room without noting future plan of care.
Full presence Nurse enters room and greets patient by name; nurse carries out care while communicating with patient;
senses patient’s nonverbal communication; plans care in collaboration with patient.
Transcendent presence Before entering patient’s room, nurse centers self so entire focus will be on patient; greets patient by name and uses touch. During the time with the patient the nurse conveys complete interest and is responsive to patient’s holistic needs. This is done while providing competent care.
needs of the patient, the meaning the patient attaches to the illness or problem, and how the patient wishes to proceed. The use of presence helps lead the patient to heal, discover others, and find meaning in life.
Research on the expert practice of critical care nurses has demonstrated the importance of presence. Minick (1995) found that connectedness with the patient was important not only as a caring behavior but also because it assisted the nurse in the early identification of postoperative problems.
Therapeutic presence may help nurses to be more attentive and to detect subtle changes that may not be evident without it. Nurses lacking connect-edness were perceived by their patients as detached. Wilkin and Slevin (2004) further validated the fact that the importance of the critical care nurse being present to the patient was as essential a part of nursing care as were the skills needed to reach unresponsive and intubated patients.
Kostovich (2012), in developing a presence scale, identified the follow-ing as attributes of presence: teachfollow-ing, surveillance, concern, empathy, companionship, educated skillfulness, availability, responsive listening, coordination of care, spiritual enhancement, reassurance, and personal-ization of care (p. 169). Antecedents of presence found in studies include connection through personal stories, informal interactions, and empathic interactions (Evans, Coon, & Crogan, 2007). These factors are important in establishing real connection with a patient.
When presence is used as a complementary therapy, consequences or effects occur for the patient, family, and nurse. Easter (2000) reported a decrease in pain for the patient, an increase in satisfaction for the nurse, and improved mental well-being for the nurse through presence. According to Drick (2003), presence creates healing and changes the atmosphere in the nurse–patient relationship. Jonas and Crawford (2004) reported calcium flux at the cellular level and lower, more stable heart rates as a result of healing presence within minutes to hours of the intervention. Tavernier (2006) identified three consequences of presence: (a) relationship, (b) heal-ing, and (c) reward. The importance of presence in care has been recog-nized and valued as a key nursing intervention. A midrange theory of nursing presence, developed by McMahon and Christopher (2011), identi-fies presence as integral to the nurse–patient relationship. The nurse must have the ability to recognize the need for presence and be open to the invitation to be present. Further investigation on why and how presence plays a positive and vital role in health outcomes needs to be encouraged.
INTERVENTION
The description of presence related by Mitch Albom (1997) in Tuesdays with Morrie succinctly captures its essential elements. Albom is reporting how Morrie, a man with advanced amyotrophic lateral sclerosis, views presence:
3. Presence 31
I believe in being fully present. That means you should be with the per-son you’re with. When I’m talking with you now, Mitch, I try to keep focused only on what is going on between us. I am not thinking about something we said last week. I am not thinking about what’s coming up this Friday. I am not thinking about doing another Koppel show, or about medications I’m taking. I am talking to you; I am thinking about you. (pp.
135–136)
Centering
Presence entails conscious attention to the upcoming interaction with the patient. The nurse must be available with the whole self and be open to the personal and care needs of the patient. This process is called centering, a meditative state. The nurse takes a short time, sometimes only 10 or 20 seconds, to eliminate distractions, so that the focus can be on the patient.
Some people find that taking a deep breath and closing the eyes helps in freeing them of distractions and becoming centered. This may be done outside the room (or other setting) in which the encounter will occur.
Centering may also be as simple as the nurse pausing before contact with the patient and repeating the patient’s name to help focus attention on that person.
Technique
Exhibit 3.2 lists the key component of presence and the skills necessary for practicing it. Sensitivity to others requires the nurse to be an excellent listener and observer. (Therapeutic listening is addressed in Chapter 4.) Good observation skills assist nurses in identifying nuances in expres-sion and communication that may reveal the real concerns of the patient.
Presence often means periods of silence in which subtle interchanges occur. Continuing attentiveness on the part of the nurse is a critical aspect of this therapy. Both the nurse and the client experience a sense of union or joining for a moment in time. Focusing on the moment—not the past or the future—is inherent in being present.
Exhibit 3.2. Skills for Implementing Presence
Key Component Skills
Holistic attention to patient Centering Active listening Openness to others Sensitivity
Verbal communication that is at level of patient Use of touch when culturally appropriate Nonverbal demonstration of acceptance
Little is known about the length of a therapy session or when thera-peutic presence should be used. Often the nurse identifies it intuitively:
“It just seems like this patient truly needs me now.” Because of the intense nature of the interaction, the length of time the nurse is present to the patient may seem greater even though only 30 seconds or a min-ute may have passed. Although presence is often used in conjunction with another therapy or treatment, identifying when a patient needs someone to just be present for a few minutes may be the most effective technique.
Measurement of Effectiveness
Measuring outcomes of presence interventions involve both the patient and the nurse because of their reciprocal interaction. Comments from the patient about feeling cared for, being able to express concerns, and per-ceiving understanding are some outcome measures derived from patient satisfaction tools. McMahon and Christopher (2011) reviewed literature on presence and identified potential client outcomes. These are shown in Exhibit 3.3. The correlation between high patient satisfaction and excellent nursing care is well documented. Incorporating the effects of presence in patient surveys should be considered among the important outcomes indicating a positive health experience and healing. Because of the intan-gibles that often occur with the use of presence, finding words or indices to measure presence may be challenging.
A tool developed by Kostovich (2012) may be used to measure patient’s perceptions of nursing presence. The Presence of Nursing Scale is a 25-item scale measuring nursing presence. The internal consistency reliability using Cronbach’s alpha was 0.95. This tool showed a high cor-relation with patient satisfaction.
Exhibit 3.3. Possible Outcomes of Presence Patient feeling comforted and supported
Patient sensing that whole being is cared for Patient level of stress decreased
Patient feeling less lonely
Patient has an increased sense of peace and hope Patient feeling increased self-worth
Patient perceiving decreased pain Patient feeling motivated and encouraged
3. Presence 33 Precautions
The major precaution in the use of presence is to take one’s cue from the patient and not force an encounter. A true presence encounter consid-ers the wants and needs of the patient and is not for the nurse’s primary benefit. If the nurse is “available with the whole of oneself and open to the experience” of the client, as the definition states, the nurse will act in accordance with the wishes and needs of the patient.
A negative consequence of presence is that colleagues may be critical of the nurse who spends time “just being” with patients and/or families.
Certainly this should not be a deterrent to the use of presence, but rather a concern that should be discussed and resolved by nursing staff. Finfgeld-Connett (2008) stated that a supportive work environment that starts at the highest administrative level of the facility helps promote the use of presence.
Professional maturity has been identified as a factor having an impact on the use of presence. McMahon and Christopher (2011) noted that a nov-ice nurse may be so focused on the skill to be performed as to be unable to detect the subtle signs that the patient requires the intervention of presence.
USES
Presence can be used in any nursing situation. Persons struggling with a new diagnosis, an exacerbation of a condition, or a loss are especially in need of moments of presence. An and Jo (2009) found that a 30-minute nursing-presence intervention reduced stress in older adults in nursing homes. Use of presence is also important in patients in hospice settings.
Presence is needed with patients in critical care settings (Wilkin &
Slevin, 2004) and emergency departments (Wiman & Wikblad, 2004).
Patients and their families often feel lost in high-tech critical care settings.
The use of presence helps prevent critical care nurses from being viewed by their patients as emotionally distant and focusing only on the machines and technology. Other patient populations in which use of presence has been documented include women with postpartum psychosis (Engqvist, Ferszt, & Nilsson, 2010) and in midwifery practice (Hunter, 2009).
As health care and nursing encompass more technology, including telemedicine, as part of the modes for delivery of care, explorations of virtual presence are needed. Educators using distance teaching have been investigating the impact of the emotional presence of the instruc-tor on learners and the effect this has on learning outcomes. Sandelowski (2002) noted that people involved in designing technology and nurses are interested in creating environments for patients and nurses that produce
feelings of interaction that are immediate, intimate, and real. The rapidly increasing use of telephones, home monitoring, and other forms of tele-medicine challenge nurses to convey attentive care in these settings that includes presence. Nurses can ask themselves, “Am I truly listening; pres-ent to the patipres-ent who is invisible?”
CULTURAL APPLICATIONS
Culture is closely interlaced with nationality, race, ethnicity, social class, and even generations, and is important in considering the meaning of presence for the patient, family, and nurse. Presence may also hold a special interpreta-tion for the individual based on past experience or family influence. The key is to identify and acknowledge the meaning of presence for the patient and all family members in the relationship. Mitchell (2006) provides an exemplar of presence among young, middle-aged, and older adults. The themes of attentive presence and “being with” in the exemplar are apparent in each of the generations. As described by Mitchell, cultural connection is necessary in bringing meaning to life experience and is emotional and healing.
In addition, each person has a preference for a communication style, and that may be influenced by his or her cultural background. In several cultures, gestures of respect and knowing the person hold high impor-tance in establishing a relationship. In other cultures, too much eye con-tact may be seen as offensive. Communication and trust are shown to be the largest factors that create connection among Hispanic families (Evans et al., 2007). Conversational silence is important in some cultures as a mechanism to becoming present with another person or the environment.
Buddhists use silence as a respectful technique to being present and are comfortable with long periods of silence, whereas other cultures may not be. Mindfulness, being in the present moment and aware of everything around you—is the Buddhist way of life.
A nurse who trained in the Philippines gives her expert opinion on the meaning of presence in the countries where nurses received nursing degrees (Sidebar 3.1).
Sidebar 3.1. Use of Presence in the Philippines Zapora Burillo
Filipino’s believe that “presence heals the spirit.” In this culture, sick-ness and hospitalization of an individual is a family matter. Family members stay with the patient 24/7; they schedule coverage for 24-hour
(continued)
3. Presence 35
FUTURE RESEARCH
Nurses document assessments made and treatments administered, but rarely do they document the use of presence and the outcomes of this therapy. Despite the challenges in identifying and documenting outcomes of presence, current interest in complementary therapies provides an opportunity for nurses to validate the positive outcomes of the use of presence. Areas in which research is needed include the following:
■ Although every patient could benefit from presence, large case-loads often place restrictions on nurses’ time. What are assessments that would alert nurses to patients who most need the therapy of presence?
■ What are strategies that can be used to teach nursing students and other health professionals how to implement presence?
■ With the advent of telemedicine, how can virtual presence be intro-duced into these contacts with patients? Is physical presence essential or is presence a nonlocal phenomenon, like prayer?
■ What are the barriers to becoming present?
■ What needs to occur in the work environment for presence to have meaning for both the patient and the nurse?
■ What are the cultural differences in the meaning of presence, and how can a nurse identify those differences?
■ Is there a relationship between the quantity and/or quality of presence and patient outcomes?
Sidebar 3.1. Use of Presence in the Philippines (continued) vigils until the patient is discharged home or is fully recovered. The person who stays with the patient is called bantay, which translates as “watcher.” The presence of a familiar face at the bedside alleviates the fear and anxiety of the patient; it promotes an environment of trust and confidence. The nurse works collaboratively with the fam-ily member to provide physical and emotional comfort to the patient during the healing process. The nurse’s presence provides a sense of reassurance.
Nurses need to make an assessment of the cultural needs of patients before therapeutic presence can be attained. Presence has special mean-ing to the individual, dependmean-ing on culture and accordmean-ing to level of development. It is critical to understand how one connects with others and creates an intimate awareness.
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