Toward Conceptualizations in Nursing: Harbingers From the Sciences and Humanities AGNES

M.

AAMODT,

Conceptualizations of care and caring generated from ethnographic study of Tohono O’odham children, Norwegian-Americans, elderly clients in nursing clinics, preschoolers, children with cancer, and gender differences is outlined. Where research questions came from during life experiences of the author, a journey of nursing scholarship viewed from concepts of context development, transformation and care, and “Where do we go from here?” serve as the outline for a discussion of the generation of conceptualizations. A question for nursing research is proposed: What characteristics of care promote human responses for quality human experience? Suggestions for nursing research in the future emphasize the potential of human responses, variations in conceptualizations of care during the life cycles of human beings living in diverse cultural contexts, and changes in conceptualizations of care over time. (index words: Care; Conceptualization; Ethnography and research; Life experience; Nursing) J Prof Nurs 8:184-794, 7992. Copyright

F

0 1992

by W.6.

Saunders

Company

ROM BIRTH TO DEATH, human life is punctuated by experiences of health, illness, pain,

healing,

and dying.

Nursing

attends

to these experi-

ences in practice, research, and theory. Multiple complex developmenrs in conceptualization methodology

have emerged

in the growth

and and

of knowl-

PHD,

point

RN,

FAAN*

is myself,

tinguished

for in 1990 I was awarded

Nurse Research Lectureship

the Western

Institute

investigators

whose research

tained

of Nursing

and substantial

tradition

former awardee Ramona Quint nursing

research within

conversations,

getting

a context

a discussion

of

“Nursing Rewas the choice of dinner

ready for trips,

cleaning

table the

questions. Academia and practice showed me categories, formulae for problem solving, and an awareness of life experiences within a context of the sciences and humanities,

all providing

ways to seek for answers to

what became my burning questions. For me, ethnography, or learning the story of the others in the tradition of anthropology, was a major focus for my work: the stories of the clients of health care_Papago

perspective

caring for mothers,

184

by

house, and learning ways to be sick, to squabble, and to have fun contributed to a context for generating

women in Western

*Professor Emerita, College of Nursing, The University of Arizona, Tucson. Address correspondence to Dr Aamodt: College of Nursing, The University of Arizona, Tucson, AZ 8572 1. This article is a revised version of the Distinguished Research Lectureship “Toward Conceptualizations in Nursing, Harbingers from the Sciences and Humanities.” Communicating Nursing Research Volume 23, Nursing Research: Transcending the 20th Century (1990:2 l-32). Boulder, CO: Western Institute of Nursing. Copyright 0 1992 by W.B. Saunders Company 8755-7223/92/0803-0011$03.00/0

A

established

of life experiences

experiences

the elderly

the growth and development of ideas for use in a practicing profession such as nursing. The case in

been

T. Mercer (1988) and Jeanne

children,

This article

sus-

to nursing.

and the theme of an annual conference. search Transcending the 20th Century” for 1990. For me, early family

by

senior

have made

Benoliel (1989); that is, framing

American

on birth to death experiences.

efforts

had

edge as nurses have observed and recorded the nursing represents one view of the generation of conceptualizations of nursing. What I attempt to show is how personal development, academic experiences, and the real world of professional practice can contribute to

to recognize

contributions

for the lecture

the Dis-

established

in nursing children

clinics,

Wisconsin,

Norwegianpreschoolers

with cancer, and charac-

teristics of care from the view of men. Their stories have given direction to how I choose to think about nursing. Some of the questions I can trace in my work are: What

conceptualizations

in culture

and human

nature capture the essence of nursing! What are the variations in explanations used by human beings cross-culturally for birth, health, illness, pain, healing, and death, all sine qua non of the human condition? How can nurse scientists generate humanistic and/or scientific knowledge from the realities of nursing of the past and present for the future? To what extent should we adjust, alter, or change the beliefs and practices of clients as individuals, families, and communities! What conceptualizations characterize the promotion of human responses for quality human experience! For three decades questions such as these

Journal of ProfeessionalNwsing,

Vol 8, No 3 (May-June),

1992: pp 184-194

185

TOWARD CONCEPTUALIZATIONS

IN NURSING

have represented

one slice of my thought

at least

was learning

about rules within

a context

of ambigu-

ity and change.

world. This article attempts relationships

between

healing,

and

within

and

a high school term paper on coffee houses in England

that follow are: (1) Where

did

in the 18th century

come from in my life experiences?

(2)

generated

scholarship,

tions of context, formation

of ideas

research,

How did the questions nursing

and the development

health,

of nursing

The sections

the questions

culture,

A sense of history

practice,

care for the benefit theory.

to show how I have pursued

develop within specifically

development

of data with

care? (3) Where

the context

of

the conceptualiza-

and process,

consideration

and trans-

to the case of

can we go from here!

the context of conversation

where Samuel Johnson

ideas we live with today.

nursing

course,

I found

tures in the human tracheas,

drops, Beyond

drams,

chemistry,

ounces

intense

anatomy,

almost

supernatural

by aper-

eye sockets,

as ice, steam,

deand

focus on the physics,

and physiology

body I was absorbing,

Where the Questions Came From

Later, in my first

and millimeters,

and water

this

and others

myself preoccupied

body: nares, urethras,

grees of temperature, liquid.

came, in part, from

of the human

along with my classmates, sense of the nature

of human

be-

Learning to wonder, recognize patterning in the interrelationships of the social behavior of human be-

ings and the obligations toward patients.

ings and their environment, and getting a sense of the lexicon of nursing and anthropology absorbed a child-

nurse, and clinical

hood and early academic career. My earliest memories are of playing ball with a make-believe playmate

to a world of the mavericks in anthropology, which I was told was the most scientific of the humanities and

named

the most humanistic of the sciences. For me it still is! In a first course on cross-cultural religion I wrote a

Billy and making

up words for songs just be-

cause I liked the way they went together. Briggs

profile

tells me I am intuitive,

My Myersand it must

have been so then. Hanging clothes in Aunt Marie’s backyard meant lining up the dish towels on a separate line from pillow cases and sheets. Aunt Inga always put the butter on the top shelf of the icebox with the cream and milk. Today, more or less or better or worse matters

less than fit and how what I have put

together feels. Very early, it appears, I was ordering data into what I now call culturally relevant domains of meaning.

Very early, it appears, I was ordering data into what I now call culturally relevant domains of meaning.

With

three sisters I played

Anti-Anti

Over,

Kick

the Can, and furiously designed original Christmas presents. Mother helped us organize tree houses and set rules for our way of life, including drinking fluid and visiting the bathroom. Mother’s thought world of hallucinations from my age of 10 was an introduction to feeling comfortable with ambiguity. Dad was persistent in introducing us to new experiences. When I was 12 years old he stopped the car on the highwaywe were alone-and said “You drive now!” Thus, I

A series of experiences

brief paper giving

or commitment

an

I was to feel

as an Army nurse,

instructor

pediatric

over two decades led me

me direction

toward

how children

learn within the context of family life, and how rules for health care fit with family living and spirituality. The paper was entitled “How Papago Indian Children Learn Religious Beliefs and Practices.” Ruth Underhill had published “The Autobiography Woman,” and I quoted it as follows:

of a Papago

Early in the morning,

in the month of Pleasant Cold, when we had all slept in the house to keep warm, we would wake in the dark to hear my father speaking, ‘Open your ears for I am telling you a good thing. Wake up and listen. Open your ears. Let my words enter them.’ He spoke in a low voice, so quiet in the dark. Always our father spoke to us like that, so low that you thought you were dreaming (Underhill, 1936, p. 5).

Listening to such rhythm and sounds had to provide a setting for the transmission of cultural rules. Three and one-half years later I was seeking cultural scenes among children and their families in the village of Pisinemo in southwestern Arizona on the then Papago, now called Tohono O’odham Reservation. For a year I lived, slept, ate, and sat by the fire while making baskets, listening to jokes, and looking for patterns in how children learn about health and healing. Life stories are bounded by the freedom and direction of the actors surrounding us. Pearl Parvin Coulter and Katherine Hoffman first suggested a future for me

186

AGNES M. AAMODT

in anthropology.

Six weeks

cultural

religion

almost

breathless

sitivity

for diversity

and intuition

the cultural

the field work than-average

program

as primary

experience

sen-

tools, and

was marked skills,

within

the context

well--one

mem-

civility

during

cancer-a

unspeakable

processes

we must

a substantive of nursing.

culture

of childhood feel

a third.

useful to the art and science of

nursing in the 20th and 21st centuries are driven by systematic, and sometimes not so systematic, human inquiries into the sciences and humanities. Nurse theorists, clinical researchers, and practitioners of nursing depend on the language generated from a context of human discourse within and without the nursing community. The wholeness of what society has mandated as the mission of nursing somehow must be partitioned or divided into chunks of reality worthy of talk, labeling, validation, and application for practice. The conceptual patterns used by nursing for developing knowledge in the century surrounding the year 2000 are numerous and many sided, encompassing examples from such corners of inquiry as linguistics, biochemistry, herbalism, kinetics, hermeneutics, embryology, dialectics, aesthetics, and poetry in addition to society, the cell, the individual, and culture. I have chosen four concepts to provide a beginning framework within which to highlight some very

providing

consider

both

about

part of a path for

in any ethnographic

concept that represents Whereas

study,

culture

or

care, is

to me the essence

is the nucleus

for anthro-

the cell the heart of physiology,

society the core of sociology,

the

free and freeze the

research. The fourth concept,

and

care is the center of what

society mandates for nursing. As we become more introspective

in our search for

truth, what I have to say about generating a substantive concept, such as care, for nursing is a primitive but necessary

first step.

Mine

is an attempt

to em-

phasize a great need of nursing: identifying concepts illustrative of the realities of the responses of the human condition within the context of care or caringeg, health as expanding consciousness, selftranscendency, and help-seeking behaviors-all of which can lead us to a greater understanding of the central

core of nursing. CONTEXT

Conceptualizing From the Sciences and Humanities Conceptualizations

speaks

and evolutionary

lets us talk

tools that

of all

pological

time when the body and mind

pain-was

build-

development

in process, change,

the constraints

nonethnographic

have helped with

a shame

research and theory

a setting,

transformation

as he

of free spirit.

The culture

and

methodological

in your last paper as you start to write the next one. ” And another urged me on with “Do field work with at least two cultural groups in order to have a point of contrast.” As it turned out the Papago served

to the patterning

suggest

Later a colleague said, “Look to the

and the other a guilt culture.

in nursing provides

by the sym-

last paragraph

and Norwegians

trends

ing. Context

changes in the form of the data. These three concepts

all manner of research and writing. As examples, before entering the field, three unofficial advisers said, “Swing with the people, ” “Don’t talk about them,” and “Be yourself.”

present

Con-

illustrate

trends,

with respect for questions

Since then friends and colleagues

that are serving and have

well in its search for knowledge.

text, development or process, and transformation

by my less-

red vest of one committee

tinged

conceptualizations

served nursing

social

sketch of myself by another

members

primitive

before

settings,

saw me in the field, and by the gentle of scholarship

with

condition,

analytical

oral communication

of a cheerful

I was

are sprinkled

in the human

scenes. My oral examination

ber, by a penciled committee

on cross-

They were right.

carriers’ view of behavioral

scenes, or cultural

bolism

courses

and personality

with enthusiasm.

Images of my doctoral arguments

into

and culture

Where does the story for nursing research begin? What are the social scenes, the physiological contexts, the behavioral situations precipitating a nursing research question?

What

sorts of variety

repeat

with

enough regularity to be of interest to a nurse researcher? Inevitably other questions follow to be considered in the research: Where is the whole? Where are the boundaries of the scene or setting, ie, the context? What is the unit of analysis? The quark? The community? The system? The dyad of interaction? The importance of context to nursing research in the 20th and soon the 21st century is exemplified in our need, almost an obsession, for a conceptual framework or orientation in which to ground our research. In my conceptual orientation, culture, development, human response, health care environment, and care are related (Fig 1). In many ways culture transcends the other concepts. Culture helped me see the diversity in human interaction associated with health care experiences. Learning which cultural differences were useful to my research was difficub. Two stories about a preschool

TOWARD CONCEPTUALIZATIONS

Papago girl illustrate relevant

to me what could be culturally

patterning.

The first is about the time Jennie

told me how frightened myself and another and her mother,

she was of white people like

occurred Conchita,

O’odham Maakai

187

IN NURSING

(Papago

with the Garcia family. but I knew that Jennie

man) could do.

two months

We hardly

I had lived

knew each other,

liked to tease. As I sat at the Playing

using

She choked

any wits,

stuck

around

my finger

and breathed

out.

and I,

past

her

Her mother

feat had emerged:

The feat of all Native

domain cattier

concepts useful for developing of nursing

theorists

to practicing In time,

thought I had saved her life. On reflection, however, I knew we had been caught acting in a world where unconscious

care giving,

precise.

I do the language

within

the context

of a

into a lexicon of

paradigms

and explaining

of

from the

for the work

nursing

activities

nurses. the context

for my research became mote

and my research

question

It goes like this: “What

conceptualizing Cultural

and care teceiv-

of meaning,

scene, must be transformed

conceptual,

the family gathered

tongue.

cultural

I chased

a darker color than her already-brown

relevant

argot of the cultural

and caught her

the game,

her across out dirt floor. She stumbled

without

related to care eliciting, a culturally

an

my room and my things.

skin. In an instant

my focus was on my te-

ing. In the kind of ethnogtaphy

what

to the floor and tan toward

turning

eventually

when she was very sick

supper table she dropped

breath,

said,

told me about

medicine

The first story: For almost

formants

sponses from what I saw, heard, and felt that could be

care informs

knowledge represents

became

mote

cultural

knowledge

the behavior

of children?

a tradition

of semantic

ethnogtaphy embedded in a cognitive view of culture focusing on a system of symbols used in the social in this case children. Informs process whereby human be-

world of human beings, refers to an interpretive ings select consciously

and unconsciously

from a sys-

Americans for whites was played out in that moment. The second story: This story is about a time when Jennie became ill. For two weeks her bed had been

tem of cultural knowledge and translate this knowledge into behavior. For example, an examination of

placed in the kitchen

elderly woman alcoholics

close to the stove, and a monj&

to the context

of Friday night

find Jennie with nates, and glazed

girls Deborah Williams (1986) learned how becoming a woman can be captured in words, for example, “having a boy to hug and kiss” and “kissing under the sheets.”

supta sternal retractions, eyes. My pediatric nursing

flared back-

ground alerted me to a crisis. To be a researcher, however, meant wanting to find out how Conchita and Jennie played out their experience. self to say I did not like her breathing,

hospital bed. Conchita came to where I was waiting in the cat and said, “Well, that’s something an O’odham can’t do anything

about-pneumonia!”

One

month later Conchita called to me, “You remember that breathing Jennie had? That you didn’t like? Delores had that last week. They took her to the O’odham Maakai and the next day she was just fine.” In the context of stories like these I began derstand

culture

and the meaning

rules for drinking.

dances where she learned

From

mentally

retarded

the

preteen

I brought myand two hours

and fifty miles later Jennie had radiographs, inttavenous lines of electrolytes and fluids, oxygen, and a

Maakai

country

took a student

had been tied over her head and under her chin symbolizing, to me, illness. One afternoon I returned to

to un-

it had for my te-

search question. My sense of what ethnographic field work brought to my questions for nursing science grew. Moving from the setting of a rural Indian community to a Norwegian community to a nursing clinic and a cancer clinic broadened my view of context and how context, or in this case cultural boundedness, is both constraining and liberating. Additionally, the concepts of health care environment, human response, and care placed different boundaries on the cultural scenes I chose for analysis. Although I was interested in almost anything my communities did and my in-

Conceptualizations of development include the ideas of change, process, and evolution. A final consideration of the many complexities implied in the concept of context is: When have we gone fat enough? For indeed uncovering a first layer of context by one question exposes another layer and another layer. In other words, Where ate the boundaries? Where ate the edges? The limitations of a human life time ate such that we can see only a very small piece of the pie, and all any of us can do is raise mote questions. For me this is always cheery news because when we find all the answers human beings will have been reduced to robots and humanity will have lost is variety, ambiguity, and charm. DEVELOPMENT

Conceptualizations of development ideas of change, process, and evolution.

include the Patterns of

AGNES

188

change during

a life cycle provide

sion to nursing

care. Whereas

a somewhat

new frontier

the processional

of a sociocultural

known.

However,

or five-year-old

I can say something

this is different

out medicine

or hiding

they know

that.”

responses

behave”

emerging

about their nurses. who of-

the system by spitting

them

feel sicker than

when they

details

of a developmental

to show itself in two isolated of developing cyclical

settings:

the style of a fieldworker

responses

of child informants

to walk and talk “the Indian

to their

of development of the responses

chemotherapy

experiences,

cancer and the chemotherapy

as flies walked

people’s

Among the Norwegians, in contrast, I was accosted with “How can you say you are educated when you

KINK

dren

a conceptualization in our data analysis

knowing

as I talked about how I felt White

I

Finally, emerged

in the process to their cancer

I

and

development.

format

and in the

cre-

for growth

of knowing

talk came at me like a stream of bullets when I first came back from the reservation. I truly thought I was being shot down. They knew how that felt, too.

k/NK

an opportunity

of four stages

because I wasn’t O’odham, and giggled when two O’odham women heard me speak, chuckling with ap-

I

surroundings

in a cylindrical

across my wet face in the hot summer sun. I felt a piercing stab in my stomach as an eight-year-old boy said I could not have a lick of his ice cream cone

preciation

ates for any fieldworker

and bodily

unfamiliar

representations

way,” to drink Coke and

chips and be undisturbed

of feelings

in culturally

were patterned

experiences. In my fieldwork I began to see changes in myself as I felt and acted more like a Papago. I learned eat potato

The stimuli

process began

have ever felt before. Heuristic

(ie,

about a four-

pills under the mattress

it will make

I needed to

Committee

stuff than

and

was disturbing

Subject’s

“You just tell them we’re made of stronger

to be un-

from teenagers

ten look for ways of sabotaging

about a set of questions

our Human

to a Nor-

was told

a

What

from

and, when I reported

to your informants?),

within

frame continue

who says, “You gotta

wegian informant answer

of childhood,

of childhood

“Don’t mess ‘em up” when talking Furthermore,

can’t speak Norsk?”

dimen-

my work has focused on

of the culture

characteristics

context

a different

M. AAMODT

about

ences from the view of the child.

What

of chiland

(Fig

they

l), with and

not

experi-

we believe we

have captured is the sense of a developmental process that is repetitive and circular. We have labeled the four stages “so this is it,” “maintaining,” “choosing,” and “living with it.” Every child develops a different pattern

to fit with their individual

experiences,

but it

appears to us that a generalized pattern can be talked about and that it fits with the ideas undergirding process and development. Conceptual development in children, processes in the world of the field-worker, and processional characteristics in paradigmatic styles of nursing theory continue

to catch our attention

attempts

to link the real world with scientific

and help us in our sche-

mata. The notions of change within a context captured for a moment are intriguing for all scientists. Nursing has much to learn about behavior, and the

K,nk

K/nk

rpeclalions

I’ rperfences *

?esponses -Y

Stage IV Living with it

Figure

1. Cyclical responses of care and caring phenomena during cancer therapy experiences. k, small amount of knowing; NK, large amount of not knowing; K, large amount of knowing; nk, small amount of not knowing.

TOWARD CONCEPTUALIZATIONS

world of nursing the generation

189

IN NURSING

care provides

an elegant

of conceptualizations

ment and change are manifested

context

for

on how developin human

responses.

you itch,” elderly

In hazy, their

world

meaning

phrases

and the culturally

that give direction

thought cer,

amorphous

children

American

in nursing

women

the abstractions

contribute emerging

speech into conceptual

tell

relevant to their

world of Papago children,

patients

responses

“Treat

doesn’t matter what we don’t like. We have to do ‘em anyway. I’m sick you know (six-year-old boy).

clinics,

about

domains

behavior.

children and

to nursing

of The

with can-

Norwegianknowledge

as we transform

in

vernacular

labels for use in theory devel-

opment, and for organizing ideas for health providers to use as they ask these clients to tell about their

Pergrin,

me normal;

& Prosser,

when immobilization

to human

world of children

It

a view from the world of the

Aamodt,

and the handicapped usual

TRANSFORMATION

representing

(Porter,

feelings

Transformation of data in my work can on/y be a reflection of what I know and how I feel.

1981).

comes from the

with alopecia who ask not only to be

treated

as if they are the same but also treated

special

person

because

Grassl-Herwehe,

they

Farrell,

ality is, of course, a dilemma have it both ways, that

truly

hurt

& Hutter,

like a

(Aamodt,

1984).

Such re-

for all nurses who would

is, to treat patients

as they

always are and as special. Transformation reflection words,

of what

of data in my work can only be a I know

what contributes

direction

and how I feel. In other to my cognitive

to the way I transform

lationships

with informants

data.

viewed

map gives

Researcher

re-

and the research environ-

ment is a well-known phenomenon tions we can ask about the tabula Aquinas and John Locke in which

health care needs.

(Munoz,

treat me special”

1981)

prohibits

as a clean slate or a blank

reflecting quesrasa of Thomas the intellect is sheet of paper.

A

nurse clinical researcher carries an elaborate set of conceptualizations into every field setting. Thus, with good reason, what I may do with a piece of data may be different from what any one of you would do with it, except perhaps for the constraints put in place in

The protocol

for transformation

the work of James Spradley

(1979,

I follow is found in 1980). We trans-

formed our ethnographic data into domains of meaning, arranging them into sets of cover terms, with each cover term having a series of member terms. (Further details of a protocol for transformation is reported in Aamodt, 1989.) Examples of cover terms were “waiting in the clinic,” “things nurses do,” “stages in getting medicine,” and “kinds of kids with hair loss.” Member terms for kinds of kids with hair loss were: “total terms mants

“capers,”

“supercopers,”

“I’m

still

me,”

withdrawers,” and “no one knows.” Cover and member terms were reviewed with inforto insure

that

out

“transformation”

was in

keeping with what they wanted to say. The point, then, of our kind of ethnography was to tell stories of clients in a form usable by nurse scientists and practitioners. Additionally, we transformed our data into cultural themes. Whereas organized sets of domains of meaning come from the vernacular of the informant, a cultural theme is a moment of invention of the researcher and represents a whole of what is the reality to be transformed into nursing knowledge. For example, some of our themes have been: “The pits of dependency

is not being

able to scratch

yourself

when

the name of validity

and reliability.

My moments of insight, conscious and unconscious, are often closely akin to the A-thinking, or autistic thinking, of Joseph Chilton Pearce (197 1) as he writes in The Crack in the Cosmic Egg. To him, autistic thinking is unstructured, nonlogical, as distinct

from illogical,

dream-world, tial unfolds.

whimsical

left-handed

thinking-a

thinking

by which

kind

of

poten-

When my Aunt Inga and I were building a jigsaw puzzle she talked on and on and said “. . . but I miss my neighbors so.” Neighboring was a pearl in my Norwegian study, a context for the visiting, checking on, praying

for, and being there that formed the sub-

stance of neighboring as a caring-for-others phenomenon. When I was conversing with a chemistry professor about “care,” I was pressed to help him understand nursing’s problem in transforming care into a scientific-sounding conceptualization and said, “The problem is, care is not a limited good. It is available in all cultures and expressed in various ways. If it were oil or emeralds we would know a lot about it.” Thus, transformation is what we often do when we least expect to. For me it requires ambiguous and diverse data where seeking a new pattern is the challenge.

190

AGNES M. AAMODT

CARE

Care or caring

diabetes,

is a substantive

concept

in the last three decades through Madeleine clinical

Leininger

nursing

(1978,

research

ceptualizations

the pioneer efforts of

1984).

and colleagues

writings

of Leininger,

others).

In the late 19th century,

captured

Ray, Gaut,

model

for

theory on confollowed

in nursing

world(see the

Tripp-Reimer,

and

Heidegger

(1962)

the essence of care in his work on Dasein,

distinguishing “doing

Her

and nursing

of care is now being

wide by students

recognized

between

for” and “doing

“being” with.”

and “a thing” Later, Talcott

(1964) told us that care was what nursing My Papago

dissertation

one label of “taking

(Aamodt,

Parsons

was about.

197 1) contains

care of’ in approximately

pages of the ethnographic

report.

and

250

From a small num-

ber of ethnographic observations a beginning set of primitive conceptualizations emerged, For example, a short time after the dissertation,

in a classroom

set-

ting, Madeleine asked what major theme of care I could identify in my Papago data. I said “I have a story. ” A replay flashed before my eyes of a time during

the Wine

Feast with

a young

eagled on the grass and a younger him watching listening brightly turning

his breathing,

to his heartbeat.

boy bending

checking Although

boy spreadover

his eyes, and the sun shown

above, the young boy moved on without the boy’s face from the full view of the sun-

light. As I reported this event to a nursing research group we agreed that, conceptually, this linked with care as surveillance.

Over the years I have tested the

concept with other Papago data, and I continue to be impressed with the patterning in how people watch out for each other.

arthritis,

the cafe concept was now ‘firmly centered within any cultural system . . .

The traditional style of anthropological thought and methodology helped me to recognize patterns in the meanings of language, both tacit and explicit. For example, I began to identify nesting behavior in the speech and body movements of a two-year-old while readying him for a nap, or a nurse settling down to experience the insult of piercing skin and entering a vein. Care behavior in neighboring among Norwegian-American women was demonstrated by holding on to Dad’s thumb during cancer treatments, and working on acceptance of symptoms and treatments of

hypertension.

197Os, I wrote my initial O’odham children nursing

conference

1978b)

as a culturally

that organizes turally

of health

relevant

religion,

linked

The referent

with

systems

common

encounter

the client,

such as

nomencla-

was now firmly

system,

in a nursing

clinic

mother-preschooler

from the view of the child,

centered

and I began to look into

a world beyond the usual scenes of nursing: client

“cul-

a system

literature.

For me, the care concept any cultural

of meaning

placed care within

and kinship,

ture in anthropological within

domain

experience.

domain”

and healing

economics,

1978a) for a ttanscultural

and a first paper on care (Aamodt,

human

relevant

In the early

paper on care and Tohono

(Aamodt,

the nurse-

from the view of

interaction

and

care

and Norwegian-American

women and care of others (Aamodt, 1972, 1980, 1986). Clients told me thoughts like “We don’t come for things,” and “Today I’m not going to stroke out!” Preschoolers

told us “Well

the way I take care of my

mother is to wake her in the morning and then let her sleep ten minutes longer,” and Norwegian-American women showed me how to focus on a specific role within a cultural system of care, that is, neighboring. Norwegians

showed

us how to focus on “What

is

private?” (that is, where, when, and what is it that I pray for neighbors?) and “When is it too much caring?”

(for example,

when

has a new mother

been

given too many bowls of sot suppe {fruit soup is given to strengthen a new mother]). As my own projects

were developing,

master’s de-

gree students and a few doctoral students began to look with favor at the kinds of data coming from fieldwork experience and informants’ formal and informal interviews. With great assistance from staff in the larger nursing

.

and

community

and colleagues

in the

academic community, we began a series of ethnographic studies on fathers of children with cancer (Damler, 1979), teenaged girls with asthma (Mennen, 1979), family members in a waiting room of an intensive care unit (Sohl, 1979), a child’s view of a cystic fibrosis clinic experience (Gould, 1982), and a child’s view of a lumbar puncture (Dunscomb, 198 1). We learned about fathers whose control in the business world could not help with the life-threatening characteristics of their child’s illness. We learned about waiting in the clinic when you had asthma and the lethal consequences of peanut-butter breath. We learned that in outpatient waiting rooms family members did not want to break down, and for the nurse this meant the best caretaking would help family members maintain a poised demeanor. We learned from children that “doctors and nurses do things to

TOWARD CONCEPTUALIZATIONS

191

IN NURSING

my body and yet they still are my friends” waiting

and getting

“don’t

like surprises”

backs” during “hang

bored.

We learned

and “we can’t see behind

lumbar

punctures

not feeling

and about

and we were impressed

our

“not

but that it is good to

My own work took the direction

of children

Grassl-Herwehe,

(Aamodt,

1984).

The ethnographic

during

admissions

for treatments,

clinic

experiences.

Farreli,

and “it’s the

by self-care measures

and care-of-others

and Although

strategies

such as such as

hesitant

the time came when we had a

Center

about

be expected

to respond

we could place in our meth-

An award was made by the Na-

for Nursing

Research

for a study

View of Care During

enti-

Chemother-

apy.” Together

with research associate Isela Luna, we

visited,

with,

with

our

could

of trust

protocols.

tled “The Child’s

their

welcomed

we were still somewhat

tional

alrou-

following

children

odological

of times:

when explaining

at home

and the limits

and John

style of data collection

Finally,

sense of how children

& Hutter,

kids at all manner

to the clinic,

tines

conversations,

Fran Farrell,

Grassl-Herwehe,

lowed us to talk with

thinking”

and behave.”

in the

cancer clinic and their view of alopecia with the help Hutter

like that”

“Be good, don’t mess ‘em up! You gotta help ‘em out

onto Dad’s thumb.”

of Sue-Ellen

good and things

dying that’s hard. ” Some care ideas began to emerge,

that children

talked 17 children

interviewed,

and

spent

time

from 4 to 18 years of age. In our

view the research

question

had been

tested:

What

what we knew was a “captured audience” and what was truly fair to exploit. We knew children lived in

cultural knowledge informs the behavior of a child confronting the health care delivery systems of family

several worlds, and often what we were searching for may have been classified as private to them, but they

and community? Our conceptual framework (Fig 2), a three-layered set of 15 primitive concepts related to

liked to talk and talk they did. Shortly thereafter Sandra Ferketitch,

childhood, then

a doc-

toral student, asked me to describe my research questions, and for the first time I wrote on the blackboard

A “human

response”

recognize the American Policy Statement (1981),

phrase was added to

Cornelia work

Porter,

forward

with

a doctoral

human

(Porter,

health

care enon the of care

Of the conceptualizations suggest

patterns

reflective

tured my interest

in my research, of caring

that

several

have cap-

over the years. They are:

responses 1. So thi.r is it: This is the first of the four stages

student,

a study

response,

to our reviewers.

Nurses’ Association Social and it now reads like this:

What characteristics of care promote for quality human experience?

human

useful for middle-range nursing theory and the possibilities in an ethnographic protocol, was appealing

the question that continues to ground the work I do: What characteristics of care promote quality human experience?

culture,

vironment , and care, together with a statement ultimate objective of generating dimensions

moved 1983)

in our model of cyclical responses of children

our

receiving

of the

chemotherapy.

“So this is it” rep-

resents a time when children

child’s view of the pediatric oncology clinic. Stories with a heavy emphasis on the human response as a

recognize

what

they are in the middle of, a diagnosis of cancer after feelings of fatigue, restlessness, and

prelude to caring activity began to show up in our data. Children told us “we wait and wait for doctors,

unusual

bumps

make their way into their ev-

Level I.

II

Culture -

Culture

of -

chlldhood

Ill

Develop-

r

-

Health -

Human -

Care

ronment

ri!spo”se

Ic\

ChIldhood- Ambulatory-Human 1 health care responses delivery

Care -

Care

glvlng

receiving

In childhood

I

I

I

Culture -

Children -

Pedlatrlc -

Human

knowledge

3-18

Oncology

responses

of child with

years after birth

ambulatory health

during

cancer

Care ellclting

systems

care delivery system

-

Figure 2.

cancer therapy Tentallve

relak3nshq

-

Constructs for studying a child’s view of care in health care delivery systems.

92

AGNES

eryday human

experiences.

dren developed

elaborate

feeling,

for example

Often older chil-

explanations

“because

for this

I got stoned

put objects and events into play that provide rules

for communication

community

members.

among Coffee,

with those kids last fall” or “because I needed

tea, Papago beans, and Jewish

to get on the right path.”

has a special

2. Watch and don’t watch: These represent egies for learning and activities a metaphor

about managing

in a changed for all their

world of cancer therapy. become

experts

with

ritualistic

must

happen.

the children

the objects

monitoring

needle injections.

sleeping,

with

came from a and

for activity

together

watch”

messing

soup, of this

coffee is most often

a mediator

gather

fear associated with

The children

of playing,

“don’t

Fixing

of the

of what can and that

chicken

is

routines

Early in our interviews we learned

system.

the work of women,

or

English

for members

a social group as members

As they watch they

expectancy

cultural

meaning

family

like

within

life. The pattern

and move through

was one way of managing world

strat-

M. AAMOD

of a group

to plan and do.

5. Nurses give protective care and we get garbage, nurses as friends and enemies: “Garbage” idiom their

used by children chemotherapy.

Garbage

of

was garbage

because of what it did to their bodies: them feel rotten,

was an

for the medicine

made

lose their hair, get pudgy,

and just plain hurt. Children said it was so bad they did not know how to feel. Nurses

around, and they entered a world of hurts, unknown attacks on themselves and their

are linked with garbage in that needles, attend to the bandages

bodies. One strategy was to look or not look at the needle as the nurse and child identify

dwelling venous catheters, and give medicine. In the language of childhood nurses with

the

these tools are enemies. The dilemma for the nurse as well as the children is that nurses are

spot

When

and

the

needle

we ask youngsters

breaks

the

skin.

“how to do it” or

they insert around in-

“what do you know,” we are using “watch” and “don’t watch” in our problem-solving

also friends and neighbors. They give hugs, bring pillows, say encouraging words, tell

protocol

jokes, and just plain talk. Strategies for managing interactions with persons who are both friends and enemies are contrived out of feel-

for patient

care.

3. Working on acceptance: This was invented classroom setting Berg (1979). tocol with

with a student

in a

named Carol

She used the ethnographic

pro-

a woman from a nursing clinic to her, “I’ve had hypertension,

who said swollen feet and hands, diabetes, diverticulitis, a broken arm, headaches, toothaches,

and arthritis. People keep asking me if I am accepting what I have and I say ‘Well, not really but I’m working on it. ’ ” We feel that “working on acceptance” used by most of us as a self-care measure, refutes the classical dichotomy of compliance and noncompliance and continues

to need the attention

of self-

care advocates. 4. Fixing coffee: This came from a NorwegianAmerican community in western Wisconsin. Fixing coffee serves as a metaphor for the ritual activity put into play as a NorwegianAmerican community confronts a need for a new beginning, for example, during destruction of buildings, crops, and property by cyclones; during grieving or bereavement; during sickness and death; or during joy and celebration. The need is to be with others and

ing of hurt and pleasure, derstand

and we do not un-

all of the complexities

yet.

6. Having strategies for getting back keeps me going: To children complicated

the cancer experience appears as a tempestuous hurricane of bellig-

erent assaults coming from every direction, internally and externally. Without reason they identified objects and events to respond to in their environment. Being mean to siblings and parents, bugging the nurses, running the doctor’s shorts up the flag pole, telling jokes about cancer to the kids at school, and acting like a brat were ways of getting back to keep going. Older children often reflect on their escapades with the glee of a true delinquent, for example, “To fool the nurses I spread K-Y Jelly on the door knobs-they couldn’t open the doors and didn’t know why.” 7. Detachment, distancing, and not thinking are ways of pretending we are not there: How does one get out of cancer alive? This became a key question in the minds of our informants. Dis-

TOWARD CONCEPTUALIZATIONS

connecting

and separating all our

selves

out,

Children

especially

logic, and behavioralstill be a part of nursing’s

In some form or

informants

psyched

during

terms such as scientific, humanistic, bio-

Will

oneself from can-

cer was one of the answers. another

193

IN NURSING

nomenclature?

them-

procedures.

3. To what extent can changes in conceptualiza-

talked

about “starting to sweat,” “getting real hot, ” “watching the needle go in, ” “feeling it but then just going to sleep.”

transformation

Laughing

the essence of expanding

and

joking

was part

cancer. Soda Pop (14-year-old “In order

said, laugh

to survive

tions human

of handling

girl informant) cancer

of care encourage

you must

hood soothe

in its face.”

Will

Examples

Each of these primitive

concepts

cusing

tells something

a

working

on

fixing coffee, nurses as friends and eneacceptance, mies, strategies for getting back, and detachment em-

a more balanced

consciousness

in the

of our child-

care experiences?

researcher

of tomorrow

be a

of lullabies?

of questions

on feelings

behavior

of self-

we have captured

our intensive

for programs

search in our next century

little different about the care concept, suggesting new dimensions of reality ready for exploration at another time and place. So this is it: Watching,

Will

Will the lullabies

the nurse

collector

. . . we are members of a cultural system in which we strive for balance

and generate

experience?

21st century?

a process

leading

might

accompanying to unwanted

of nursing

re-

call for designs

fo-

rituals

of teenaged

pregnancies,

drug ad-

diction, and gang warfare. Adolescence is a complex time in the human life cycle. To search for domains of meaning in their language together with changes in their biochemistry,

within

ferences and caretaking, inspire roles for nursing

the context should both of the future.

A second set of questions might focusing on community participation recognize the wisdom of the elderly,

of cultural

dif-

enlighten

and

call for designs in health care to the bereavement

phasize the very real experience of maintaining balance in a world fraught with imbalance. Our informants appear to be saying we are members of a

of families after loss, and the perceptual pictures of survivors of cancer and other lethal diseases and ex-

cultural

periences,

system

in which

we strive

for balance

and

have much to say about how to try to achieve harmonious communication with our environment.

searching

for patterns

opment in human response-biologic and behavioral-within a context of nursing practice. A third set of questions cusing on the relationships

Where Do We Go From Here?

care; the characteristics If I were to begin

a nursing

research career today I

of change and devel-

might call for designs foof human responses and

of such subtle

behaviors

as

would choose questions leading to a focus on a synthesis of biologic and cultural units of analysis in the

whimpering, sighing, chuckling, blushing, itching, and comfort within the context of health care and the characteristics of being with/being alongside of and

context of physical anthropology. It is here that we will be able to find the conceptual pictures of that

helping out in the Heidegerrian sense of Dasien. Such a program of nursing research must seek to

whole that attracts so many of us to nursing today. My questions for nursing in the 21st century now

understand the potential of human responses and care and caring possibilities at both individual and collective levels of human behavior. To search for perfection in such an imperfect science as nursing will bring us

What caring human

are the variations in explanations of phenomena during the life cycle of beings

living

in diverse cultural

con-

texts? Will a process such as caring and care be our central area of concern rather than absolute death?

concepts

such as illness,

health,

and

How can we generate humanistic and scientific knowledge within the context of biologic and behavioral characteristics of care?

beyond

what

is human.

To know

and to allow

for

diversity will bring health care closer to an ideal of humane care that captures a sense of ethics, integrity, and compassion.

In Summary This article has addressed some of the complexities inherent in two questions having major impact on the development of conceptualizations for nursing sci-

194 ence:

AGNES M. AAMODT

What

and science? solving

What

activity

velopments world

are the

The question as described

is it that

of nursing

personal,

as humanity

care and caring

can add to the problem-

of the practicing

in the

of a nurse

realities

nurse

academic,

from and

tacular

the depractice

for nursing focuses

from emerging

in my research

on conceptualizations

but

of

whole

imperfect

characteristics

for quality

scientist?

above

What

and human

this

human question

and the parts

it is that

response

human

leading

experience

of care promote experience? can

of what

it is that

and

human

Given

nursing

the

attend

to specreads:

responses direction

to both

hurts

the

and what

comforts.

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