reflection
| Chapter 12 |
the weak and the orphaned are deprived of justice all the foundations of the earth are shaken. Ps. 82.3–5 Leininger (1988) maintains that caring is the essence of humanity and is essential for human growth and survival. She contends that care is one of the most powerful and elusive aspects of our health and identity and must be the central focus of nursing and the helping and healing professions. Similarly, Roach (1987) claims that care is the basic constitutive phenomenon of human existence and thus ontological in that it constitutes man as man. She points out that all existentials used to describe Dasein’s self have their central locus in care. Roach states, “When we do not care, we lose our being and care is the way back to being. Care is primordial, the source of action and is not reducible to specific actions” (1987, p. 15). Although Roach (1984) claims that caring is the human mode of being, she wonders how convincing the view is that caring is the natural expression of what is authentically human when there is so much evidence of lack of caring, both within our personal experiences as well as in the society around us. Roach points out that we live in an age where violence is commonplace and where atrocities are committed against individuals and communities everywhere. To compound the effect of such violence on the broader social body, many incidents enter our living rooms through the press, radio, and television often as quickly as they occur. As a result, modes of being with another in our world involve both caring and uncaring dimensions. What, then, are the basic modes of being with another? By analyzing two of my own studies on clients’ (patients’ and students’) perceptions of caring and uncaring encounters (Halldorsdottir, 1989, 1990), as well as related literature, I have determined that there are five basic modes of being with another as follows: life-giving (biogenic), life-sustaining (bioactive), life-neutral (biopassive), life-restraining (biostatic), and life-destroying (biocidic) (see Figure 12.1 and Table 12.1). In this chapter, I describe the five basic modes of being with another through examples of caring and uncaring encounters in hospitals as experienced by former patients, my co-researchers in the former study (Halldorsdottir, 1989). The phenomenological perspective of qualitative research theory guided the methodological approach to the studies analyzed, involving the use of theoretical sampling, intensive unstructured interviews, and constant comparative analysis. TABLE 12.1 Five Basic Modes of Being With Another Life-destroying (biocidic) mode of being with another is a mode where one depersonalizes the other, destroys the joy of life, and increases the other’s vulnerability. It causes distress and despair and hurts and deforms the other. It is transference of negative energy or darkness. Life-restraining (biostatic) mode of being with another is a mode where one is insensitive or indifferent to the other and detached from the true center of the other. It causes discouragement and develops uneasiness in the other. It negatively affects existing life in the other. Life-neutral (biopassive) mode of being with another is a mode where one does not affect life in the other. Life-sustaining (bioactive) mode of being with another is a mode where one acknowledges the personhood of the other, supports, encourages, and reassures the other. It gives the other security and comfort. It positively affects life in the other. Life-giving (biogenic) mode of being with another is a mode where one affirms the personhood of the other by connecting with the true center of the other in a life-giving way. It relieves the vulnerability of the other and makes the other stronger and enhances growth, restores, reforms, and potentiates learning and healing. FIGURE 12.1 The caring/uncaring dimension or continuum. Nine former patients participated in the former study and data were collected through 18 in-depth, open-ended interviews. Nine former nursing students participated in the latter study and data were collected through 16 in-depth, open-ended interviews. In both studies, interviews were tape-recorded and transcribed verbatim for each participant. The excerpts used from the former study will be referred to as “modes of being with a patient,” and for the sake of clarity, the feminine will be utilized in reference to the nurse and the masculine in reference to the co-researcher/patient/client. In the text, however, “nurse” and “co-researcher/patient/client” can refer to both males and females. Evidence from literature, that has a bearing on this matter, will also be given. The life-destroying, or biocidic, mode is the most inhumane mode of being with another in the list as given and is represented by violence in all its forms. It means hurting, harming, or deforming the other. This destructive mode manifests in numerous ways as follows: making people dependent or fostering infantilism; being threatening; involving manipulation, coercion, hatred, aggression, and humiliation; involving various kinds of abuse; and often involving an evident lust for power, followed by dominance and depersonalization of the other. Hardheartedness or coldheartedness also may be present here. This mode of being with another most often changes the other to the worse, the harm done depending on the other’s strength to endure. It involves the transference of negative energy or darkness to the other. It is the frost the human flower has a hard time enduring without loosing its luster, petals, leaves, and life. In many respects, the history of humankind is not a positive affirmation of the sanctity of human life as Roach (1987) has rightly pointed out. There seems to be no end to how destructive and brutal the human being can be. Roach also argues that perhaps the greatest threat against human life in our age lies in the erosion of sensitivity toward its value, particularly where the taking of human life becomes part of everyday experience. Roach claims that the public at large has become less and less sensitive to all overt killings—genocide, fratricide, homicide, suicide, and feticide. As described, the life-destroying, or biocidic, mode of being with a patient is the most severe form of indifference to the patient as a person, involves harshness and inhumanity, and is characterized by various forms of inhumane attitudes. Although I will not tell their entire stories here, four out of the nine co-researchers in the study under discussion had a biocidic experience. Of those four co-researchers, three asked me whether I had seen One Flew over the Cuckoo’s Nest and claimed that their nurse was very much like nurse Rachet, as portrayed in that film. None of the co-researchers knew each other. Although all co-researchers held a unanimous perception that uncaring encounters with nurses were very discouraging and distressing experiences for them as patients, their reactions to such encounters were many sided. Several major themes were identified in their accounts as follows: initial puzzlement and disbelief, which is followed by anger and resentment. Because of the patient’s vulnerable circumstances, however, the patient is most often unable to act out the feelings of anger and resentment, and these strong negative feelings seem to develop into despair and helplessness. Being uncared for in a dependent situation develops feelings of impotence, a sense of loss, and a sense of having been betrayed by those counted on for caring. If, on top of that, the patient is treated by the nurse as somewhat less than human, the patient’s feelings soon develop into feelings of alienation and identity loss. The patient feels he has no value as a person, that he is indeed less than a person—“a side of beef,” “an object,” or “a machine.” Furthermore, experiencing uncaring increases the patient’s own feelings of vulnerability within the hospital setting. Numerous co-researchers alluded to the threat of dehumanization within today’s hospitals. It was their unanimous perception that they felt vulnerable and in need of caring when they were in the hospital. Some suggested that this makes patients more sensitive to caring and uncaring. One such former patient stated that, I would expect that people being ill makes them vulnerable, so that when they have an uncaring transaction, like someone treats them rudely, they are more deeply wounded in that circumstance than if they were healthy and walking the street and someone on the corner said something stupid or insulting. I mean that they can shrug off and ignore, but here they are sick and in need, and probably feel weak in spirit, and weak in body, and so it hits home harder, any such transaction hurts them more. Other co-researchers related that they perceived uncaring as a transference of negative energy that affected their well-being and delayed or even prevented their recovery. This perceived negative effect on well-being and healing is illustrated in time and again in their accounts. Furthermore, it was their unanimous perception that the uncaring encounters made such an indelible impression on them and had a longer lasting effect than caring encounters that they tended to be both acid edged and memorable experiences. Some co-researchers referred to the “memories of uncaring encounters” as scars, and although they seem to be trying to understand or make sense of the experience, they are most often still angry and even have nightmares about the nurses perceived to be uncaring. Some co-researchers identified how the uncaring experience prompted them to think about ultimate realities vis-à-vis death, affected their view of the hospital, and how it continued to even dictate their decisions within the health care system today. Although most co-researchers had tried to forgive the uncaring nurse, some co-researchers related that that was probably more a result of forgetfulness than forgiveness. These co-researchers sometimes expressed a longing to return and confront the uncaring nurse, if, for nothing more, than to relieve themselves of their anger. At the same time, however, they realized that the nurses perceived to be uncaring were probably unaware of their influences on the patients and would, therefore, not recognize their stories. Hildegard of Bingen, a remarkable 12th-century abbess, scientist, artist, poet, musician, and mystic, talks about the dryness of carelessness and injustice. She claims that dryness and coldness together make hardness of heart and that drying up destroys our creative powers, marking the end of all good works, and the beginning of laziness and carelessness. She maintains that if we lack an infusion of heavenly dew, we will be turned into dryness and our souls will waste away. From Hildegard’s point of view, the ultimate uncaring occurs when we become cold and hardened to injustice. Hildegard (1985) wrote to one churchman: “When a person loses the freshness of God’s power, he is transformed into the dryness of carelessness. He lacks the juice and greenness of good works and the energies of his heart are sapped away” (p. 64). The life-restraining, or biostatic, mode of being with another involves negatively affecting life in the other by restricting or disturbing the energy already existent in the other. It means being insensitive or indifferent to the other, causes discouragement, and develops uneasiness in the other. It often involves imposing one’s own will upon the other, dominating, and controlling the other. It sometimes appears as fault finding, anger, blaming, accusing, and being unfriendly. It is that very coldness and strong wind the human flower has a hard time enduring. The life-restraining, or biostatic, mode of being with a patient involves the patient feeling strongly that the nurse does not care and is blind to his feelings by way of negative feedback from nurse to patient. Here, the nurse often treats the patient as a nuisance, that is, if it were not for the patient, the nurse’s life would be a lot easier. The patient starts to feel that he is bothering the nurse when asking for help, finds the nurse often cold and unkind, and the nurse’s presence destructive in some way. This nurse approach is partly illustrated in the following accounts. The second one [uncaring nurse] was cold, and I can at least give her that much because I interacted with her enough. The first one, I would just say I was … what?, I don’t know, a piece of dust on the floor, I mean, I can’t, I was a bother … The people in that room were just beds, that’s all, you know, beds. She had prescriptions, she had a checklist of what she had to do, you know, your heart, etc., and that’s all it was, for everybody, not just for me, you know. I had experiences of being in another ward for three days, and there was a tremendous high percentage of noncaring nurses. Actually, this is a nice description saying noncaring nurses, they were completely like … cold … cold human beings, like computers. It’s like, sometimes I was worried, I was … was wondering if they really even noticed that I was there. Dossey (1982) asserts that a patient-as-object approach to care delivery is destructive because it violates the oneness and wholeness that are necessary for healthy, viable living systems. Similarly, Gadow (1985) has pointed out that in addition to the domination by apparatus and by experts that can accompany the use of technology, patients can be reduced to objects in a more fundamental way than by the use of machines in the view of the body as a machine. Gadow states, “such reduction occurs because regard for the body exclusively as a scientific object negates the validity of subjective meanings of the person’s experience. Those meanings are categorically nonexistent in the scientific object” (p. 36). Furthermore, Gadow (1988) has pointed out that the exercise of power always increases the vulnerability of the one over whom it is exercised, no matter what benevolent purpose the power serves. The life-neutral, or biopassive, mode of being with another occurs when one is detached from the true center of the other and when there is no effect on the energy or life of the other. This lack of response, interest, and affect derives from inattentiveness or insensitivity to the other. It refers to the lack of a positive or caring approach rather than the presence of something destructive. Although it has no real effect on the life in the other, it sometimes creates a feeling of loneliness, because there is no mutual acknowledgment of personhood, no person-to-person contact. Furthermore, many seem to experience this apathetic inattention not only as lack of care but as noncaring or uncaring. The fundamental characteristic of the life-neutral, or biopassive, mode of being with a patient is perceived apathy, which refers to the approach in which the nurse is perceived to be inattentive to the patients and their specific needs. The co-researchers emphasized that the nurse seemed to care about the routine, the tasks she was supposed to perform, but not about the patient as a person. The nurse is sometimes perceived by the patient as insensitive, absentminded, tired, dissatisfied in her job, or lacking in some caring quality, for example, warmth of voice. Furthermore, the co-researchers perceived these nurses as either unwilling or unable to connect with, or develop attachment to, the patient. The co-researchers’ perceptions of detachment are seen clearly in their accounts. In fact, one co-researcher stated, Aahm … the way she looked at you … like you are not a part of her world … or that she doesn’t want to attach—you can feel that there is no emotional attachment there. Bermejo (1987) asserts that a person is essentially characterized by a necessary openness to another. He contends that a person closed in upon and withdrawn into his or her self, hardly deserves the status of person, for this withdrawal, he argues, goes counter to the very core of man’s being, which is clamoring first for an opening, and then, based upon that opening, for a total gift of self to another. Bermejo states, “A rejection of this essential, radical opening and the ensuing personal communion would unavoidably have a crippling effect on the fulness of the human person. A man half open is only half a man” (p. 46). Hildegard of Bingen (1985) states in one of her many books that too often human actions are weak and lukewarm and emerge from people who are more asleep than awake. She claims that in this way people “make themselves weak and poor who do not wish to be busy about justice or about rubbing out injustice or about paying back their debts.” Commitment to justice, she insists, would wake people from their sleep and would put zeal back into their lives and work. Similarly, Matthew Fox (1985) has pointed out that the theme of spiritual maturity as wakefulness has been expressed in religious literature throughout the world. Hildegard also makes a connection between wisdom as wakefulness and folly as sleepfulness. In the Gospel parable, the wise virgins stayed awake and the foolish fell asleep. In Hildegard’s terms, we can never climb the mountain of healing, celebration, justice making, and compassion if we do not care, are not committed, are indifferent, and do not fight injustice. The life-sustaining, or bioactive, mode of being with another involves benevolence, good will, genuine kindness and concern, beneficence, and kindheartedness. It is protecting life, relieving suffering, keeping promises, respecting the other, and acknowledging the other’s humanhood. Thanking and praising and a contrary dislike of constraining others are involved here. Indeed, there exists the heartfelt wish to do no harm. Comforting, encouraging, consoling, strengthening the other, and continuing to support the energy already present in the other adds other dimensions to the bioactive mode. The life-sustaining, or bioactive, mode of being with a patient means that the nurse is skillful, knowledgeable, committed to the provision of personalized care, and knows how to safeguard the personal integrity and dignity of the patient. This special kind of nurse approach, which includes compassionate competence, genuine concern for the patient as a person, undivided attention when the nurse is with the patient, and sober cheerfulness, is what I call professional nurse caring (Halldorsdottir, 1990). When the nurse succeeded in giving this kind of professional caring, it promoted the feelings of trust in patients, which facilitated the development of attachment between patients and nurses. It is precisely this attachment that forms the basis of a life-giving presence where openness and the transference of positive energy, which affects the other in a profound way, predominates. This life-giving, or biogenic, mode of being with another is the truly human mode of being and is represented by healing love. This mode involves loving benevolence, responsiveness, generosity, mercy, and compassion. A truly life-giving presence offers the other interconnectedness and allows for the expansion of the other’s consciousness and fosters spiritual freedom. It involves being open to persons and giving life to the very heart of man as a person, creating a relationship of openness and receptivity, yet always keeping a creative distance of respect and compassion. The truly life-giving or biogenic presence restores well-being and human dignity. It is transforming personal presence that deeply changes man. For the recipient, there is an experienced inrush of compassion, often like a current. Regarding the life-giving, or biogenic, mode of being with a patient, one co-researcher said this about the fundamental difference between caring and uncaring: I’m not sure how to put it other than “personal relationship,” the sense is somehow that your spirit and mine have met in the experience. And the whole idea that there is somebody in that hospital who is with me, rather than working on me. Another co-researcher explained it this way: You know, there is that kind of bonding, that kind of feeling of … not intimacy but at least connection, there has been a connection made with that person, a connection which I could then follow-up on, you know, I would feel free to do so. From co-researchers’ accounts, it is apparent that this bonding or connection also involves a creative distance of respect and compassion, a dimension of professional attachment that has to be present to keep caring in the professional domain. It is also clear that dimensions in true professional caring depend on the depth of attachment developed. Professional attachment development can be conceptualized as a process involving the following five phases: initiating attachment, or reaching out; mutual acknowledgment of personhood; acknowledgment of attachment; professional intimacy; and negotiation of care (Halldorsdottir, 1990). This professional nurse–patient relationship is in many ways unusual. The following two accounts provide poignant illustrations: She fostered a working relationship between the two of us, as I said importantly as equals, and fostered a sense of independence for your own growth, your personal growth to the point where you didn’t need her in that role anymore. In most other relationships what you want is some sort of deepening of the ability to communicate or the commitments so that the relationship is ongoing, that is, you want to perpetuate the relationship whereas in nursing and teaching the ideal thing is like parenting, what you want to do is to enable the client to graduate, that is, to leave. The best thing that could happen is that the patient is able enough to stop being a patient. Well, that is a peculiar thing in a relationship, that is, you are hoping for it to stop, for it to be no reason to continue, and then to be able to say goodbye with blessings, so that makes it unusual, I think, as a relationship. The co-researchers’ accounts illustrate clearly their conceptions of how caring positively influences the patient’s ability to recover. Some co-researchers articulated the relief that they sensed when they felt cared for and how that diminished anxiety and gave them time to concentrate on getting better. Some co-researchers actually referred to caring as medicine of sorts. One said, The purpose of the friendliness and the caring is focused on a particular professional activity and a particular very short period in the life of the patient and designed to … it’s another form of medication of sorts. It’s part of the healing, part of the getting the patient better, and it’s creating the climate for the patient getting better. Some co-researchers emphasized that caring affected healing through the psyche of the person. One said, I think the effect on the psyche of a person is very much a part of the healing, because I believe in treating the whole person, treating them as body, mind, and spirit, not just the body alone but the three of them combined, and if their psyche is being damaged or uncared for, then how can their body get well? It is apparent from the data that the nurse–patient attachment is perceived by the patient as a therapeutic or healing relationship. It seems that professional caring makes healing more profound, more rapid, and better internalized if it is provided, and it definitely makes the patient feel better healed. In addition, the data make evident that the patient’s reactions to professional caring are quite positive. The professional nurse gets to know the patient as a unique individual and treats that individual accordingly. She communicates to the patient in a way that makes him feel fully accepted as a normal human being and legitimized as a person and as a patient. This helps the patient to feel all right about himself and his hospital stay. Professional caring also seems to give the patient a sense of hope and optimism, encouragement, and reassurance. To feel cared for also gives the patient a sense of security. All this decreases the patient’s anxiety, increases the patient’s confidence, and positively affects the patient’s sense of well-being and healing. From co-researchers’ accounts, it is evident that they were, and still are, very grateful for their caring encounters; even if the only one, it is a pleasant memory that they carry away from their hospital stay. Life flows through the life-giving person like a river and there is a transference of positive energy, strengthening, inspiring, comforting, enlightening, and invigorating the other, bringing joy, hope, trust, confidence, and peace. This life-giving presence is greatly edifying for the soul of the other. It involves dynamism, movement, and growth. It is a healing energy of unconditional love. It is the heavenly sunshine and nourishment the human flower needs to grow and develop, learn, and heal. Examined in theological perspective, this growth-promoting flow of positive energy from the very center of the life-giving person is a “divine” energy of love and light, which has its source in a personal, living, and life-giving God. Fox (1979) contends that compassion is a flow and overflow of the fullest human and divine energies born of an awareness of the interconnectedness of all creatures by reason of their common creator. The preciousness of the human being and the inherent dignity of each person is explained by Archimandrite Sophrony (1977) who states, “When our spirit contemplates in itself the ‘image and likeness’ of God, it is confronted with the infinite grandeur of man, and not a few of us—the majority, perhaps—are filled with dread at our audacity” (p. 44). He further contends that in the Divine Being, the hypostasis constitutes the innermost esoteric principle of Being. Similarly, in human being, the hypostasis is the most intrinsic fundamental. As Sophrony states, Persona is the hidden man of the heart, in that which is not corruptible … which is in the sight of God of great price (I Peter 3:4)—the most precious kernel of man’s whole being, manifested in his capacity for self-knowledge and self-determination; in his possession of creative energy; in his talent for cognition not only of the created world but also of the Divine world. Consumed with love, man feels himself joined with his beloved God. Through this union he knows God, and thus love and cognition merge into a single act. (1977, p. 44) Again from a theological perspective, those who have gained perfection in caring are called saints. Dumitru Staniloae (1987), a professor of dogmatic theology, provides a closer look at saints. He explains how the gentleness and firmness of the man of God, his power to comfort and incite, his nearness and yet his distance, are all things rooted in the transcendent love of God, which comes close to us in him. Staniloae claims that in the person of the saint, because of his availability, extreme attention to others, and by the alacrity with which he gives himself to Christ humanity is healed and renewed. Staniloae states, The saint always radiates a spirit of generosity, of forbearance, of attention and willingness to share, without any thought for himself. His warmth gives warmth to others and makes them feel they are regaining their strength, and lets them experience the joy of not being alone … the saint immediately creates an atmosphere of friendliness, of kinship, and indeed of intimacy between himself and others. In this way he humanizes his relationships and leaves on them a mark of genuineness, because he himself has become profoundly human and genuine. (p. 3) Staniloae concludes, The saint shows us a human being purified from the dross of all that is less than human. In him we see a disfigured and brutalised humanity set to rights; a humanity whose restored transparency reveals the limitless goodness, the boundless power and compassion of its prototype—God incarnate. It is the image of the living and personal absolute Being who became man that is re-established in the person of the saint. By being so truly human, he has reached a dizzy height of perfection in God, while remaining completely at home with men. The saint is one who is engaged in ceaseless, free dialogue with God and with men. His transparency reveals the dawn of the divine eternal light in which human nature is to reach its fulfilment. He is the complete reflection of the humanity of Christ. (p. 7) This life force, or heavenly sunshine, creates the ideal conditions for the human flower to germinate, sprout, bloom, and bear fruit. It is a positive creative energy through which humanity is healed and renewed.
ONE FAMILY Father of love fountain of life and source of light A dry seed that I am give that I may dwell in you and moistened by the dew from heaven become a fruit of your ever-living love. Mother of love venerable rose and queen of tenderness A hungry child that I am give that I may rest against your breast and nourished by your cherishing love become filled with loving kindness. Brother of love divine partner, guide and companion An unworthy sinner that I am flood my senses with the light of your love and sanctified by your gracious brotherliness give that I may flourish in you my most dulcet morning. Sister of love white lily in the cloister of kindness A mature woman that I am with love let me serve you and in our long white gowns let us in joy and purity of heart celebrate our sisterhood. Sigridur Halldorsdottir REFERENCES Bermejo, L. M. (1987). The spirit of life. Chicago, IL: Loyola University Press. Dossey, L. (1982). Care giving and natural systems theory. Topics in Clinical Nursing, 3(4), 21–27. Fox, M. (1979). A spirituality named compassion. Minneapolis, MN: Winston Press. Fox, M. (1985). Illuminations of Hildegard of Bingen. Santa Fe, NM: Bear and Company. Gadow, S. (1985). Nurse and patient: The caring relationship. In A. H. Bishop &. J. R. Scudder Jr. (Eds.), Caring, curing, coping: Nurse, physician, patient relationships. Tuscaloosa, AL: The University of Alabama Press. Gadow, S. (1988). Covenant without cure: Letting go and holding on in chronic illness. In J. Watson & M. A. Ray (Eds.), The ethics of care and the ethics of cure: Synthesis in chronicity. New York, NY: National League for Nursing. Halldorsdottir, S. (1989a). Caring and uncaring encounters in nursing practice: The patient’s perspective. Paper presented at the International Nursing Research Conference, Nursing Research for Professional Practice, held by Workgroup of European Nurse Researchers (WENR), Frankfurt/Main, Germany. Halldorsdottir, S. (1989b). The essential structure of a caring and an uncaring encounter with a teacher: The nursing student’s perspective. In J. Watson &. M. Ray (Eds.), The caring imperative in education. New York, NY: National League for Nursing. Halldorsdottir, S. (1990). Caring and uncaring encounters in nursing practice: The patient’s perspective. Unpublished manuscript. Hildegard of Bingen (1985). In M. Fox (Ed.), Illuminations of Hildegard of Bingen. Santa Fe, NM: Bear and Company. Leininger, M. M. (1988). Caring: An essential human need. Detroit, MI: Wayne State University Press. Roach, M. S. (1984). Caring: The human mode of being, implications for nursing (Perspectives in Caring Monograph 1). Toronto, Ontario, Canada: University of Toronto, Faculty of Nursing. Roach, M. S. (1987). The human act of caring: A blueprint for the health professions. Ottawa, Ontario: Canadian Hospital Associations. Sophrony, A. (1977). His life is mine (R. Edmonds, Trans.). Crestwood, NY: St. Vladimir’s Seminary Press. Staniloae, D. (1987). Tenderness and holiness. In D. Staniloae (Ed.), Prayer and holiness: The icon of man renewed in God. Fairacres, Oxford, UK: SLG Press.
QUESTIONS FOR REFLECTION Master’s 1. The advanced practice nurse asks the patient about his “chief complaint” with eyes on the computer screen as she enters data into the electronic health record (EHR). What mode is reflected in this behavior and what might the patient experience as a consequence of mode of being? 2. What is the evidence for Halldorsdottir’s classification? Describe and critique these research studies. 3. How can the nurse sustain a biogenic practice?
Smith RN PhD AHN-BC FAAN, Marlaine C.. Caring in Nursing Classics: An Essential Resource (Kindle Locations 5774-6072). Springer Publishing Company. Kindle Edition.
reflection
the weak and the orphaned are deprived of justice all the foundations of the earth are shaken. Ps. 82.3–5 Leininger (1988) maintains that caring is the essence of humanity and is essential for human growth and survival. She contends that care is one of the most powerful and elusive aspects of our health and identity and must be the central focus of nursing and the helping and healing professions. Similarly, Roach (1987) claims that care is the basic constitutive phenomenon of human existence and thus ontological in that it constitutes man as man. She points out that all existentials used to describe Dasein’s self have their central locus in care. Roach states, “When we do not care, we lose our being and care is the way back to being. Care is primordial, the source of action and is not reducible to specific actions” (1987, p. 15). Although Roach (1984) claims that caring is the human mode of being, she wonders how convincing the view is that caring is the natural expression of what is authentically human when there is so much evidence of lack of caring, both within our personal experiences as well as in the society around us. Roach points out that we live in an age where violence is commonplace and where atrocities are committed against individuals and communities everywhere. To compound the effect of such violence on the broader social body, many incidents enter our living rooms through the press, radio, and television often as quickly as they occur. As a result, modes of being with another in our world involve both caring and uncaring dimensions. What, then, are the basic modes of being with another? By analyzing two of my own studies on clients’ (patients’ and students’) perceptions of caring and uncaring encounters (Halldorsdottir, 1989, 1990), as well as related literature, I have determined that there are five basic modes of being with another as follows: life-giving (biogenic), life-sustaining (bioactive), life-neutral (biopassive), life-restraining (biostatic), and life-destroying (biocidic) (see Figure 12.1 and Table 12.1). In this chapter, I describe the five basic modes of being with another through examples of caring and uncaring encounters in hospitals as experienced by former patients, my co-researchers in the former study (Halldorsdottir, 1989). The phenomenological perspective of qualitative research theory guided the methodological approach to the studies analyzed, involving the use of theoretical sampling, intensive unstructured interviews, and constant comparative analysis. TABLE 12.1 Five Basic Modes of Being With Another Life-destroying (biocidic) mode of being with another is a mode where one depersonalizes the other, destroys the joy of life, and increases the other’s vulnerability. It causes distress and despair and hurts and deforms the other. It is transference of negative energy or darkness. Life-restraining (biostatic) mode of being with another is a mode where one is insensitive or indifferent to the other and detached from the true center of the other. It causes discouragement and develops uneasiness in the other. It negatively affects existing life in the other. Life-neutral (biopassive) mode of being with another is a mode where one does not affect life in the other. Life-sustaining (bioactive) mode of being with another is a mode where one acknowledges the personhood of the other, supports, encourages, and reassures the other. It gives the other security and comfort. It positively affects life in the other. Life-giving (biogenic) mode of being with another is a mode where one affirms the personhood of the other by connecting with the true center of the other in a life-giving way. It relieves the vulnerability of the other and makes the other stronger and enhances growth, restores, reforms, and potentiates learning and healing. FIGURE 12.1 The caring/uncaring dimension or continuum. Nine former patients participated in the former study and data were collected through 18 in-depth, open-ended interviews. Nine former nursing students participated in the latter study and data were collected through 16 in-depth, open-ended interviews. In both studies, interviews were tape-recorded and transcribed verbatim for each participant. The excerpts used from the former study will be referred to as “modes of being with a patient,” and for the sake of clarity, the feminine will be utilized in reference to the nurse and the masculine in reference to the co-researcher/patient/client. In the text, however, “nurse” and “co-researcher/patient/client” can refer to both males and females. Evidence from literature, that has a bearing on this matter, will also be given. The life-destroying, or biocidic, mode is the most inhumane mode of being with another in the list as given and is represented by violence in all its forms. It means hurting, harming, or deforming the other. This destructive mode manifests in numerous ways as follows: making people dependent or fostering infantilism; being threatening; involving manipulation, coercion, hatred, aggression, and humiliation; involving various kinds of abuse; and often involving an evident lust for power, followed by dominance and depersonalization of the other. Hardheartedness or coldheartedness also may be present here. This mode of being with another most often changes the other to the worse, the harm done depending on the other’s strength to endure. It involves the transference of negative energy or darkness to the other. It is the frost the human flower has a hard time enduring without loosing its luster, petals, leaves, and life. In many respects, the history of humankind is not a positive affirmation of the sanctity of human life as Roach (1987) has rightly pointed out. There seems to be no end to how destructive and brutal the human being can be. Roach also argues that perhaps the greatest threat against human life in our age lies in the erosion of sensitivity toward its value, particularly where the taking of human life becomes part of everyday experience. Roach claims that the public at large has become less and less sensitive to all overt killings—genocide, fratricide, homicide, suicide, and feticide. As described, the life-destroying, or biocidic, mode of being with a patient is the most severe form of indifference to the patient as a person, involves harshness and inhumanity, and is characterized by various forms of inhumane attitudes. Although I will not tell their entire stories here, four out of the nine co-researchers in the study under discussion had a biocidic experience. Of those four co-researchers, three asked me whether I had seen One Flew over the Cuckoo’s Nest and claimed that their nurse was very much like nurse Rachet, as portrayed in that film. None of the co-researchers knew each other. Although all co-researchers held a unanimous perception that uncaring encounters with nurses were very discouraging and distressing experiences for them as patients, their reactions to such encounters were many sided. Several major themes were identified in their accounts as follows: initial puzzlement and disbelief, which is followed by anger and resentment. Because of the patient’s vulnerable circumstances, however, the patient is most often unable to act out the feelings of anger and resentment, and these strong negative feelings seem to develop into despair and helplessness. Being uncared for in a dependent situation develops feelings of impotence, a sense of loss, and a sense of having been betrayed by those counted on for caring. If, on top of that, the patient is treated by the nurse as somewhat less than human, the patient’s feelings soon develop into feelings of alienation and identity loss. The patient feels he has no value as a person, that he is indeed less than a person—“a side of beef,” “an object,” or “a machine.” Furthermore, experiencing uncaring increases the patient’s own feelings of vulnerability within the hospital setting. Numerous co-researchers alluded to the threat of dehumanization within today’s hospitals. It was their unanimous perception that they felt vulnerable and in need of caring when they were in the hospital. Some suggested that this makes patients more sensitive to caring and uncaring. One such former patient stated that, I would expect that people being ill makes them vulnerable, so that when they have an uncaring transaction, like someone treats them rudely, they are more deeply wounded in that circumstance than if they were healthy and walking the street and someone on the corner said something stupid or insulting. I mean that they can shrug off and ignore, but here they are sick and in need, and probably feel weak in spirit, and weak in body, and so it hits home harder, any such transaction hurts them more. Other co-researchers related that they perceived uncaring as a transference of negative energy that affected their well-being and delayed or even prevented their recovery. This perceived negative effect on well-being and healing is illustrated in time and again in their accounts. Furthermore, it was their unanimous perception that the uncaring encounters made such an indelible impression on them and had a longer lasting effect than caring encounters that they tended to be both acid edged and memorable experiences. Some co-researchers referred to the “memories of uncaring encounters” as scars, and although they seem to be trying to understand or make sense of the experience, they are most often still angry and even have nightmares about the nurses perceived to be uncaring. Some co-researchers identified how the uncaring experience prompted them to think about ultimate realities vis-à-vis death, affected their view of the hospital, and how it continued to even dictate their decisions within the health care system today. Although most co-researchers had tried to forgive the uncaring nurse, some co-researchers related that that was probably more a result of forgetfulness than forgiveness. These co-researchers sometimes expressed a longing to return and confront the uncaring nurse, if, for nothing more, than to relieve themselves of their anger. At the same time, however, they realized that the nurses perceived to be uncaring were probably unaware of their influences on the patients and would, therefore, not recognize their stories. Hildegard of Bingen, a remarkable 12th-century abbess, scientist, artist, poet, musician, and mystic, talks about the dryness of carelessness and injustice. She claims that dryness and coldness together make hardness of heart and that drying up destroys our creative powers, marking the end of all good works, and the beginning of laziness and carelessness. She maintains that if we lack an infusion of heavenly dew, we will be turned into dryness and our souls will waste away. From Hildegard’s point of view, the ultimate uncaring occurs when we become cold and hardened to injustice. Hildegard (1985) wrote to one churchman: “When a person loses the freshness of God’s power, he is transformed into the dryness of carelessness. He lacks the juice and greenness of good works and the energies of his heart are sapped away” (p. 64). The life-restraining, or biostatic, mode of being with another involves negatively affecting life in the other by restricting or disturbing the energy already existent in the other. It means being insensitive or indifferent to the other, causes discouragement, and develops uneasiness in the other. It often involves imposing one’s own will upon the other, dominating, and controlling the other. It sometimes appears as fault finding, anger, blaming, accusing, and being unfriendly. It is that very coldness and strong wind the human flower has a hard time enduring. The life-restraining, or biostatic, mode of being with a patient involves the patient feeling strongly that the nurse does not care and is blind to his feelings by way of negative feedback from nurse to patient. Here, the nurse often treats the patient as a nuisance, that is, if it were not for the patient, the nurse’s life would be a lot easier. The patient starts to feel that he is bothering the nurse when asking for help, finds the nurse often cold and unkind, and the nurse’s presence destructive in some way. This nurse approach is partly illustrated in the following accounts. The second one [uncaring nurse] was cold, and I can at least give her that much because I interacted with her enough. The first one, I would just say I was … what?, I don’t know, a piece of dust on the floor, I mean, I can’t, I was a bother … The people in that room were just beds, that’s all, you know, beds. She had prescriptions, she had a checklist of what she had to do, you know, your heart, etc., and that’s all it was, for everybody, not just for me, you know. I had experiences of being in another ward for three days, and there was a tremendous high percentage of noncaring nurses. Actually, this is a nice description saying noncaring nurses, they were completely like … cold … cold human beings, like computers. It’s like, sometimes I was worried, I was … was wondering if they really even noticed that I was there. Dossey (1982) asserts that a patient-as-object approach to care delivery is destructive because it violates the oneness and wholeness that are necessary for healthy, viable living systems. Similarly, Gadow (1985) has pointed out that in addition to the domination by apparatus and by experts that can accompany the use of technology, patients can be reduced to objects in a more fundamental way than by the use of machines in the view of the body as a machine. Gadow states, “such reduction occurs because regard for the body exclusively as a scientific object negates the validity of subjective meanings of the person’s experience. Those meanings are categorically nonexistent in the scientific object” (p. 36). Furthermore, Gadow (1988) has pointed out that the exercise of power always increases the vulnerability of the one over whom it is exercised, no matter what benevolent purpose the power serves. The life-neutral, or biopassive, mode of being with another occurs when one is detached from the true center of the other and when there is no effect on the energy or life of the other. This lack of response, interest, and affect derives from inattentiveness or insensitivity to the other. It refers to the lack of a positive or caring approach rather than the presence of something destructive. Although it has no real effect on the life in the other, it sometimes creates a feeling of loneliness, because there is no mutual acknowledgment of personhood, no person-to-person contact. Furthermore, many seem to experience this apathetic inattention not only as lack of care but as noncaring or uncaring. The fundamental characteristic of the life-neutral, or biopassive, mode of being with a patient is perceived apathy, which refers to the approach in which the nurse is perceived to be inattentive to the patients and their specific needs. The co-researchers emphasized that the nurse seemed to care about the routine, the tasks she was supposed to perform, but not about the patient as a person. The nurse is sometimes perceived by the patient as insensitive, absentminded, tired, dissatisfied in her job, or lacking in some caring quality, for example, warmth of voice. Furthermore, the co-researchers perceived these nurses as either unwilling or unable to connect with, or develop attachment to, the patient. The co-researchers’ perceptions of detachment are seen clearly in their accounts. In fact, one co-researcher stated, Aahm … the way she looked at you … like you are not a part of her world … or that she doesn’t want to attach—you can feel that there is no emotional attachment there. Bermejo (1987) asserts that a person is essentially characterized by a necessary openness to another. He contends that a person closed in upon and withdrawn into his or her self, hardly deserves the status of person, for this withdrawal, he argues, goes counter to the very core of man’s being, which is clamoring first for an opening, and then, based upon that opening, for a total gift of self to another. Bermejo states, “A rejection of this essential, radical opening and the ensuing personal communion would unavoidably have a crippling effect on the fulness of the human person. A man half open is only half a man” (p. 46). Hildegard of Bingen (1985) states in one of her many books that too often human actions are weak and lukewarm and emerge from people who are more asleep than awake. She claims that in this way people “make themselves weak and poor who do not wish to be busy about justice or about rubbing out injustice or about paying back their debts.” Commitment to justice, she insists, would wake people from their sleep and would put zeal back into their lives and work. Similarly, Matthew Fox (1985) has pointed out that the theme of spiritual maturity as wakefulness has been expressed in religious literature throughout the world. Hildegard also makes a connection between wisdom as wakefulness and folly as sleepfulness. In the Gospel parable, the wise virgins stayed awake and the foolish fell asleep. In Hildegard’s terms, we can never climb the mountain of healing, celebration, justice making, and compassion if we do not care, are not committed, are indifferent, and do not fight injustice. The life-sustaining, or bioactive, mode of being with another involves benevolence, good will, genuine kindness and concern, beneficence, and kindheartedness. It is protecting life, relieving suffering, keeping promises, respecting the other, and acknowledging the other’s humanhood. Thanking and praising and a contrary dislike of constraining others are involved here. Indeed, there exists the heartfelt wish to do no harm. Comforting, encouraging, consoling, strengthening the other, and continuing to support the energy already present in the other adds other dimensions to the bioactive mode. The life-sustaining, or bioactive, mode of being with a patient means that the nurse is skillful, knowledgeable, committed to the provision of personalized care, and knows how to safeguard the personal integrity and dignity of the patient. This special kind of nurse approach, which includes compassionate competence, genuine concern for the patient as a person, undivided attention when the nurse is with the patient, and sober cheerfulness, is what I call professional nurse caring (Halldorsdottir, 1990). When the nurse succeeded in giving this kind of professional caring, it promoted the feelings of trust in patients, which facilitated the development of attachment between patients and nurses. It is precisely this attachment that forms the basis of a life-giving presence where openness and the transference of positive energy, which affects the other in a profound way, predominates. This life-giving, or biogenic, mode of being with another is the truly human mode of being and is represented by healing love. This mode involves loving benevolence, responsiveness, generosity, mercy, and compassion. A truly life-giving presence offers the other interconnectedness and allows for the expansion of the other’s consciousness and fosters spiritual freedom. It involves being open to persons and giving life to the very heart of man as a person, creating a relationship of openness and receptivity, yet always keeping a creative distance of respect and compassion. The truly life-giving or biogenic presence restores well-being and human dignity. It is transforming personal presence that deeply changes man. For the recipient, there is an experienced inrush of compassion, often like a current. Regarding the life-giving, or biogenic, mode of being with a patient, one co-researcher said this about the fundamental difference between caring and uncaring: I’m not sure how to put it other than “personal relationship,” the sense is somehow that your spirit and mine have met in the experience. And the whole idea that there is somebody in that hospital who is with me, rather than working on me. Another co-researcher explained it this way: You know, there is that kind of bonding, that kind of feeling of … not intimacy but at least connection, there has been a connection made with that person, a connection which I could then follow-up on, you know, I would feel free to do so. From co-researchers’ accounts, it is apparent that this bonding or connection also involves a creative distance of respect and compassion, a dimension of professional attachment that has to be present to keep caring in the professional domain. It is also clear that dimensions in true professional caring depend on the depth of attachment developed. Professional attachment development can be conceptualized as a process involving the following five phases: initiating attachment, or reaching out; mutual acknowledgment of personhood; acknowledgment of attachment; professional intimacy; and negotiation of care (Halldorsdottir, 1990). This professional nurse–patient relationship is in many ways unusual. The following two accounts provide poignant illustrations: She fostered a working relationship between the two of us, as I said importantly as equals, and fostered a sense of independence for your own growth, your personal growth to the point where you didn’t need her in that role anymore. In most other relationships what you want is some sort of deepening of the ability to communicate or the commitments so that the relationship is ongoing, that is, you want to perpetuate the relationship whereas in nursing and teaching the ideal thing is like parenting, what you want to do is to enable the client to graduate, that is, to leave. The best thing that could happen is that the patient is able enough to stop being a patient. Well, that is a peculiar thing in a relationship, that is, you are hoping for it to stop, for it to be no reason to continue, and then to be able to say goodbye with blessings, so that makes it unusual, I think, as a relationship. The co-researchers’ accounts illustrate clearly their conceptions of how caring positively influences the patient’s ability to recover. Some co-researchers articulated the relief that they sensed when they felt cared for and how that diminished anxiety and gave them time to concentrate on getting better. Some co-researchers actually referred to caring as medicine of sorts. One said, The purpose of the friendliness and the caring is focused on a particular professional activity and a particular very short period in the life of the patient and designed to … it’s another form of medication of sorts. It’s part of the healing, part of the getting the patient better, and it’s creating the climate for the patient getting better. Some co-researchers emphasized that caring affected healing through the psyche of the person. One said, I think the effect on the psyche of a person is very much a part of the healing, because I believe in treating the whole person, treating them as body, mind, and spirit, not just the body alone but the three of them combined, and if their psyche is being damaged or uncared for, then how can their body get well? It is apparent from the data that the nurse–patient attachment is perceived by the patient as a therapeutic or healing relationship. It seems that professional caring makes healing more profound, more rapid, and better internalized if it is provided, and it definitely makes the patient feel better healed. In addition, the data make evident that the patient’s reactions to professional caring are quite positive. The professional nurse gets to know the patient as a unique individual and treats that individual accordingly. She communicates to the patient in a way that makes him feel fully accepted as a normal human being and legitimized as a person and as a patient. This helps the patient to feel all right about himself and his hospital stay. Professional caring also seems to give the patient a sense of hope and optimism, encouragement, and reassurance. To feel cared for also gives the patient a sense of security. All this decreases the patient’s anxiety, increases the patient’s confidence, and positively affects the patient’s sense of well-being and healing. From co-researchers’ accounts, it is evident that they were, and still are, very grateful for their caring encounters; even if the only one, it is a pleasant memory that they carry away from their hospital stay. Life flows through the life-giving person like a river and there is a transference of positive energy, strengthening, inspiring, comforting, enlightening, and invigorating the other, bringing joy, hope, trust, confidence, and peace. This life-giving presence is greatly edifying for the soul of the other. It involves dynamism, movement, and growth. It is a healing energy of unconditional love. It is the heavenly sunshine and nourishment the human flower needs to grow and develop, learn, and heal. Examined in theological perspective, this growth-promoting flow of positive energy from the very center of the life-giving person is a “divine” energy of love and light, which has its source in a personal, living, and life-giving God. Fox (1979) contends that compassion is a flow and overflow of the fullest human and divine energies born of an awareness of the interconnectedness of all creatures by reason of their common creator. The preciousness of the human being and the inherent dignity of each person is explained by Archimandrite Sophrony (1977) who states, “When our spirit contemplates in itself the ‘image and likeness’ of God, it is confronted with the infinite grandeur of man, and not a few of us—the majority, perhaps—are filled with dread at our audacity” (p. 44). He further contends that in the Divine Being, the hypostasis constitutes the innermost esoteric principle of Being. Similarly, in human being, the hypostasis is the most intrinsic fundamental. As Sophrony states, Persona is the hidden man of the heart, in that which is not corruptible … which is in the sight of God of great price (I Peter 3:4)—the most precious kernel of man’s whole being, manifested in his capacity for self-knowledge and self-determination; in his possession of creative energy; in his talent for cognition not only of the created world but also of the Divine world. Consumed with love, man feels himself joined with his beloved God. Through this union he knows God, and thus love and cognition merge into a single act. (1977, p. 44) Again from a theological perspective, those who have gained perfection in caring are called saints. Dumitru Staniloae (1987), a professor of dogmatic theology, provides a closer look at saints. He explains how the gentleness and firmness of the man of God, his power to comfort and incite, his nearness and yet his distance, are all things rooted in the transcendent love of God, which comes close to us in him. Staniloae claims that in the person of the saint, because of his availability, extreme attention to others, and by the alacrity with which he gives himself to Christ humanity is healed and renewed. Staniloae states, The saint always radiates a spirit of generosity, of forbearance, of attention and willingness to share, without any thought for himself. His warmth gives warmth to others and makes them feel they are regaining their strength, and lets them experience the joy of not being alone … the saint immediately creates an atmosphere of friendliness, of kinship, and indeed of intimacy between himself and others. In this way he humanizes his relationships and leaves on them a mark of genuineness, because he himself has become profoundly human and genuine. (p. 3) Staniloae concludes, The saint shows us a human being purified from the dross of all that is less than human. In him we see a disfigured and brutalised humanity set to rights; a humanity whose restored transparency reveals the limitless goodness, the boundless power and compassion of its prototype—God incarnate. It is the image of the living and personal absolute Being who became man that is re-established in the person of the saint. By being so truly human, he has reached a dizzy height of perfection in God, while remaining completely at home with men. The saint is one who is engaged in ceaseless, free dialogue with God and with men. His transparency reveals the dawn of the divine eternal light in which human nature is to reach its fulfilment. He is the complete reflection of the humanity of Christ. (p. 7) This life force, or heavenly sunshine, creates the ideal conditions for the human flower to germinate, sprout, bloom, and bear fruit. It is a positive creative energy through which humanity is healed and renewed. ONE FAMILY Father of love fountain of life and source of light A dry seed that I am give that I may dwell in you and moistened by the dew from heaven become a fruit of your ever-living love. Mother of love venerable rose and queen of tenderness A hungry child that I am give that I may rest against your breast and nourished by your cherishing love become filled with loving kindness. Brother of love divine partner, guide and companion An unworthy sinner that I am flood my senses with the light of your love and sanctified by your gracious brotherliness give that I may flourish in you my most dulcet morning. Sister of love white lily in the cloister of kindness A mature woman that I am with love let me serve you and in our long white gowns let us in joy and purity of heart celebrate our sisterhood. Sigridur Halldorsdottir REFERENCES Bermejo, L. M. (1987). The spirit of life. Chicago, IL: Loyola University Press. Dossey, L. (1982). Care giving and natural systems theory. Topics in Clinical Nursing, 3(4), 21–27. Fox, M. (1979). A spirituality named compassion. Minneapolis, MN: Winston Press. Fox, M. (1985). Illuminations of Hildegard of Bingen. Santa Fe, NM: Bear and Company. Gadow, S. (1985). Nurse and patient: The caring relationship. In A. H. Bishop &. J. R. Scudder Jr. (Eds.), Caring, curing, coping: Nurse, physician, patient relationships. Tuscaloosa, AL: The University of Alabama Press. Gadow, S. (1988). Covenant without cure: Letting go and holding on in chronic illness. In J. Watson & M. A. Ray (Eds.), The ethics of care and the ethics of cure: Synthesis in chronicity. New York, NY: National League for Nursing. Halldorsdottir, S. (1989a). Caring and uncaring encounters in nursing practice: The patient’s perspective. Paper presented at the International Nursing Research Conference, Nursing Research for Professional Practice, held by Workgroup of European Nurse Researchers (WENR), Frankfurt/Main, Germany. Halldorsdottir, S. (1989b). The essential structure of a caring and an uncaring encounter with a teacher: The nursing student’s perspective. In J. Watson &. M. Ray (Eds.), The caring imperative in education. New York, NY: National League for Nursing. Halldorsdottir, S. (1990). Caring and uncaring encounters in nursing practice: The patient’s perspective. Unpublished manuscript. Hildegard of Bingen (1985). In M. Fox (Ed.), Illuminations of Hildegard of Bingen. Santa Fe, NM: Bear and Company. Leininger, M. M. (1988). Caring: An essential human need. Detroit, MI: Wayne State University Press. Roach, M. S. (1984). Caring: The human mode of being, implications for nursing (Perspectives in Caring Monograph 1). Toronto, Ontario, Canada: University of Toronto, Faculty of Nursing. Roach, M. S. (1987). The human act of caring: A blueprint for the health professions. Ottawa, Ontario: Canadian Hospital Associations. Sophrony, A. (1977). His life is mine (R. Edmonds, Trans.). Crestwood, NY: St. Vladimir’s Seminary Press. Staniloae, D. (1987). Tenderness and holiness. In D. Staniloae (Ed.), Prayer and holiness: The icon of man renewed in God. Fairacres, Oxford, UK: SLG Press. QUESTIONS FOR REFLECTION Master’s 1. The advanced practice nurse asks the patient about his “chief complaint” with eyes on the computer screen as she enters data into the electronic health record (EHR). What mode is reflected in this behavior and what might the patient experience as a consequence of mode of being? 2. What is the evidence for Halldorsdottir’s classification? Describe and critique these research studies. 3. How can the nurse sustain a biogenic practice? Smith RN PhD AHN-BC FAAN, Marlaine C.. Caring in Nursing Classics: An Essential Resource (Kindle Locations 5774-6072). Springer Publishing Company. Kindle Edition.
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