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Parse's nursing theory and its application to families experiencing empty arms.

Introduction

Nursing theories offer a structure to the vision of the human and health, and from that create a foundation for nursing practice. In nursing programs, students study nursing theory to assist with understanding practice from an abstract perspective, and to understand how research is supported with a theoretical framework. Since nursing was considered a profession, theory has been part of understanding nursing care, goals, and roles (Im & Ju Chang, 2012),

Nursing Science has been historically classified as a natural science. Natural Science posits methodologies that consider quantitative data from observable phenomenon. Data reveals cause and effect relationships. This approach deals with the reduction of a phenomenon to parts and the parts are examined using a theoretical framework. The human being is approached from the study of parts. We, as humans, are more complex than parts; we are more than the sum of our parts. Parse's theory embraces the advantages of nursing viewed instead as a human science. Proficient understanding of Rosemarie Rizzo Parse's Theory of Human Becoming requires some comprehension of the philosophers and theorists that influenced her.

The Human Becoming Theory emphasizes the patient perception of the experience and their wisdom to make choices in their own health.

The Human Becoming Theory, considered a midrange nursing theory developed by Rosemarie Rizzo Parse, emphasizes the patient perception of the experience and their wisdom to make choices in their own health care. This theory fits well into ICEA's vision of empowering the family to make their own informed choices during the childbearing years (ICEA, 2016).

Parse was led to the assumptions that underlie her theory through a combination of other nursing theory work and readings of philosophers such as Kierkegaard, Heidegger, Merleau-Ponty and Sartre (Wallace & Coberg, 1988). Nietzsche and Dilthey are also referred to as having influences (Parse, 1998; Wallace & Coberg, 1988). Origins of the theory were cultivated from a unique combination of existentialism/ phenomenology and Rogerian science. Understanding of the theories and philosophies that evolved into Parse's theory of human becoming is essential to understanding the essence of her theory.

The Evolution of Parse's Theory

Rene Descartes (17th century), the father of modern philosophy, was looking to construct a secure system of knowledge supported by certainty (Osborne, 1992). He postulated that true knowledge must come from true reason alone, as the senses could not be trusted. Descartes is famous for his cogito ergo sum, "I think, therefore, I am" (Osborne, 1992). His strictly rational and systematic model of thought proposes to never accept anything except clear and distinct ideas. Descartes was influenced by Aristotle's strictly logical approach to scientific investigation of natural phenomena (Lavine, 1984). Natural science extracts quantitative data to reveal pure cause and effect relationships, and is adopted by physical sciences such as chemistry, biology, physics, and medicine (Lavine, 1984).

Nursing, under the umbrella of medicine, and as defined by Nightingale, was seen to be a natural science, but even Nightingale recognized that nursing was more comprehensive than medicine in both practice and theory (Charlie, 2015; Parse, 1992). She characterized nursing as caring for the patient regardless of state of health, rather than caring for illness. Nightingale perceived the patient as having both the ability and responsibility to care for themselves, and make changes. She altered the environment to improve health, and helped patients heal themselves. Nightingale abandoned Descartes idea that humans were parts to be examined, and recognized that humans were a blend of mind and body.

Soren Kierkegaard (1813-1855) was a Danish philosopher and a founder of the existentialist movement from which Parse's theory evolved (Lavine, 1984). The main underlying theme of Kierkegaard's works is the freedom of choice between the "aesthetic" life of living by only instincts and feelings, and the "ethical" life of choosing the good (Osborne, 1992). Kierkegaard felt that despair results from the failure to make choices and accept responsibility for how an individual is to live. The important point is not the choice between situational options, but rather the determination to make the choice itself.

Nietzsche (1844-1900), like Kierkegaard, also recognized that despair results from the individual's lack of taking charge of his life (Lavine, 1984). He believed in the supremacy of the human will in reaching self-actualization. In Nietzsche's Genealogy of Morals (1992), he writes:
   ... in short, the man who has his own independent protracted
   will and the right to make promises .... how this
   mastery over himself also gives him mastery over circumstances,
   over nature. (p. 495)


A related theme in Kierkegaard and Nietzsche is their focus on the individual, the free will, and the responsibility for life choices. The power of will creates the situation. They had brought the psychology of the individual into philosophical inquiry.

Focus on the self emerged as the primary starting point of philosophical inquiry. This led to what is probably the most important concept in existentialism. Existentialist inquiry tends to focus on the characteristics of modes of being, or ontology. Only an analysis of consciousness can provide an understanding of the phenomena one experiences, and hence lead to understanding of the human condition (Lavine, 1984).

Husserl, considered the father of phenomenology, searched for a certainty in philosophy, such as that found in mathematics. He searched for absolute, certain truth. The dominance of the natural sciences in the modern world was viewed as insufficient in itself to explain the human condition (Levine, 1984).

Martin Heidegger (1889-1976) began the integration of existentialism and phenomenology. Among his early writings were criticisms of Descartes (Cartesian duality) in philosophy. He opposed the use of reductionist logic to psychological processes. Heidegger was trying to find out the truth about being, a "science of being" that would explain existence. He believed one cannot reduce the essence of the human to predetermined parts. Rather freedom, choice and responsibility defines human essence (Osborne, 1992). Jean-Paul Sartre (1905-1980) is widely considered the most important of the modern existentialists (Lavine, 1984). Like Husserl and Heidegger, Sartre's philosophy developed from his rejection of strict empiricism and Cartesian reductionism as adequate methods to explain the human condition (Osborne, 1992). All investigations flow from the basic fact that one is a conscious, thinking being. Though Sartre covered a lot more ground, his concepts are grounded in these themes. He considered existentialism a "humanism" (Lavine, 1984). The lack of a standardized set of principles and values shouldn't detract from the essential humanistic flavor of existentialism, namely, that each individual is responsible for their own condition, and they have the freedom to change it. The patient, as an individual, must be considered a conscious being-for-itself, with ultimate responsibility for making health decisions and also responsible for their consequences. Meaning rises from the exchange of the human and the surroundings, and defines life's purpose. Humans are whole. They are interconnected with others and history.

This was a profound move away from nursing as a natural science to nursing as a human science. If nurses begin to embrace the human science paradigm, the philosophical perspective of nursing will change. Reviewing the past ten years of nursing science literature testifies that changes have already begun.

The Essence of Parse's Theory

Mid-range theories are considered narrow of focus, less abstract, and are intended to reflect practice. The Human Becoming Theory represents an alternative to both the traditional medical approach of reductionism, and to the bio-psycho-social-spiritual approach of most other nursing theories. While it can be criticized as being abstruse it is also a breakthrough in nursing.

Health is described as a process of becoming (Parse, 1998), and is defined as what is perceived to be health, by the individual. It is the lived experience. The goal of using Parse's theory in practice is to examine quality of life from the client's perspective. Quality of life and health are defined by each individual, from their own perspective (Glauce Araujo Ideiao, Kellermann, Moura, Ivone, Costa de, & Diniz dos, 2013). Meaning is found in what you create and perceive as real, that is also congruent with your values. Values are being re-examined with each new experience. The human becoming is structuring meaning on a multi-dimensional level while responding to the rhythms of the changing universe. We are moving towards what could be.

Presence

True presence is the genuine connection between humans, where the nurse enters the client's perception of the world with openness, and in a non-judgmental, unconditional and therapeutic way (Parse, 1998; Shields & Wilson, 2016;). The whole attention and being is with the client, focusing on the client's perception of the world. The nurse learns to set aside personal values. The dialogue is always client-led. The nurse is aware of the client's words, silences, stillness, and body language (Parse, 1998), while the client is aware of the nurse's genuine presence by expression of the shared feelings shown with facial expressions, touch, and words (Shields & Wilson, 2016). These actions confirm the shared meaning of the moment for both the client and the nurse. True presence is an intentional process and reflects the belief that the client knows their own way. The Parse nurse addresses spirituality with every dialogical engagement. Within the human becoming perspective, humans are unitary beings. The spirituality of an individual cannot be separated from what is the essence of the "self." With Parse nurses, by being truly open and non-judgmental, and by being truly present, the client will explore the meaning of spirituality in their own life.

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Application of Parse's Theory

The grieving family who has experienced a pregnancy loss, still birth, or neonatal death will be considered in relation to Parse's Human Becoming theory. Grieving is the process the human becoming experiences when confronted with any loss and is expressed as paradoxes of absence and presence as well as a reluctance to let go and desire to move forward and be past the grief. The Parse nurse would not seek to change the feeling experienced, but by while being truly present with the client, seek clarity of the situation from the family's perspective. The nurse would listen for paradoxes to emerge as the family explored the experience. The nurse would not offer advice but would rather dwell on the paradoxes that are revealed in discussion, as the nurse-client relationship becomes. The nurse would ask questions to help the family explore the paradoxes identified.

An individual experiencing empty arms may express overwhelming disappointment over lost potential while hope and possibilities for the future are being considered. They may have feelings of being unable to go on (staying still), while making plans for the future (moving forward). They express loss of options while considering possibilities. They may recognize a need for help but a reluctance to accept help. They might reveal the paradox that they yearned for their child all while wanting to move on by forgetting the experience. Those living the experience defined hope as moving on, past barriers. The barriers were paradoxes of comfort and discomfort in moving towards and away from others. Hope existed concurrently with no hope. For transcendence to occur, the family moved through the paradox of anticipating the possibilities of the future while treasuring remembered moments.

For the family experiencing empty arms, there are often very few treasured moments with the infant through the trauma of the event. Patterns common to this family are telling the story of the birth repeatedly when among supportive others. Families remember the trauma of the experience, combined with a few treasured moments. They consider the future with hope and experiencing disappointment in the present. The client might reveal reluctance to hold the baby at first (pushing away), then reluctance to let the deceased infant out of their arms (holding close). These paradoxes can be points of discussion with the family, giving them chance to further discuss their feelings and experience.

Many mothers have been under the care of the author while going through this experience, grieving even years later. The author assumed the role of a Parse nurse, adopted true presence, and sought to explore the meaning of the experience. The mothers were assisted to glimpse paradoxes revealed. For example, Susan (not her real name), who had an emergency caesarian section at seven months gestation 15 years ago for fetal distress delivered a baby girl. Susan is quoted below.

"I never got too big, but the HMOI was going to never seemed too concerned until towards the end. Then they decided it was important, sent me down to the hospital in the city for an amniocentesis. They didn't get that far, as they realized the baby was in distress. Emergency Csection, and subsequent testing proved she had triploidy, three chromosomes instead of pairs".

Susan reported that she did not hold her baby, though her husband did. Because of the emergency nature of the delivery and the use of general anesthesia, this mother did not feel emotionally up to holding the baby immediately postpartum. The opportunity was not offered again by nursing staff. This mother reported aching to hold her infant, and disappointment she did not take the opportunity to hold her when it was offered. Susan said her husband had described to her how difficult it was to hold the baby and then put her down. Paradoxically she later stated preference for not holding the baby.

"I am probably better off for not holding her, as it wouldn't have changed the grief any. It may have hurt more. Besides, there is no going back. "

The family might reveal behaviors of others that had been supportive, but not supportive. The Parse nurse would ask questions such as, What do you see as supportive about that behavior? and What did that mean for you?

For the family experiencing empty arms, there may be a desire to share intense moments of suffering, but instead they choose to keep quiet. One family experiencing empty arms expressed perceptions that significant others who were once supportive had changed behavior. They were now perceived as driving the client to move on from the grieving. The family reported feeling of resistance to that pushing, while simultaneously wanting to go on with life. The nurse will ask open-ended questions around what is important to the client now, at this moment in time. Questions such as, What would help you most right now? and What is your first priority? would be appropriate.

One mother experiencing empty arms reported feeling guilt over the loss but feeling powerless at the same time. The Parse nurse pointed out that this seemed two feelings that weren't harmonious, and could she expand on this further. When exploring the paradox, she said:

"The feelings of guilt over the death were overwhelming, but there really wasn't anything in my power I could have done differently. It's funny that the guilt stuck even though I knew, in my head, that I it wasn't my fault. The guilt is much less than it used to be, because it just doesn't make sense does it, and I need to move on. "

Exploring the feelings with the mother, without trying to change the feelings may be a difficult experience for a nurse or doula who traditionally tries to make people feel better.

The Parse goal in practice is to enhance the quality of life and health as experienced and defined by those experiencing empty arms. Provide the opportunity for exploration of the paradoxes that are identified. By recognizing and exploring the paradoxes experienced those grieving will recognize choices available to them and choose in a manner that best fits their values. Glimpsing the paradoxical is a way of transcending the moment in changing patterns of health (Parse, 1998). The Parse nurse facilitates this process with true presence. It is with true presence that the nurse embraces who the client perceives the self to be and transcending that image of the self to become more.

The Human Becoming Theory of nursing in practice envisions a goal as assisting the client towards recognizing choices. The process makes explicit the thoughts and feelings, and that, in itself leads to a new light, a new perspective. The articulation through body language, reflection, quiet presence, and words leads the client to connect those feelings to their relevance in the present. The unfamiliar perception becomes familiar. Within there is transcendence.

Conclusion

Parse's theory is a dramatically different perspective than the traditional view of nursing. The view of the human is different. Health or disease is not cause and effect, rather cocreated in the process of experiencing the universe, from the individual's perspective. The use of Parse's theory in practice will lead to important changes in health of the individual becoming. The focus is on quality of life as experienced and perceived by the client as defined by their meaning of experiences. The nurse or doula can apply Parse by being truly present while being cognizant of paradoxes the client shares. The change of the nursing paradigm to recognizing paradox has been escalating, and Parse's work is destined to make a major advancement in nursing as a human science.

The road to understanding Parse is difficult and presents a barrier to those beginning to explore the theory. For the beginning Parse nurse, the barriers of obfuscation are overwhelming, especially without a strong philosophical background. Philosophy is not a required course for nursing or doula, or any caring profession. Parse integrates ideas of the great thinkers of the past two centuries and the reader develops an appreciation for her depth of knowledge and creativity. Parse is a complex theory to grasp, but well worth the effort of those in practice today.

References

Charlie, D. (2015). Florence Nightingale. Salem Press Biographical Encyclopedia. Ipswich, MA: Research Starters.

Glauce Araujo Ideiao, L., Kellermann, A., Moura, P., Ivone, K., Costa de, & Diniz dos, R. (2013). Theory of Human Becoming in nursing ecology: Applying Meleis's evaluation method, Texto &Contexto--Enfermagem, 4, 1179. doi:10.1590/S0104-07072013000400037

International Childbirth Education Association. (2016). Our Mission. Retrieved March 18, 2016, from http://icea.org/

lm, E., & Ju Chang, S. (2012). Current Trends in Nursing Theories. Journal of Nursing Scholarship, 44(2), 156-164. doi:10.1111/j.1547-5069.2012.01440.x

Lavine, T. Z. (1984). From Socrates to Sartre: The philosophic quest. New York: Bantam.

Nietzsche, F. (1992). Basic Writings of Nietzsche (W. Kaunfman, Trans.). New York: Random House.

Parse, R. R. (1998). The human becoming school of thought: A perspective for nurses and other health professionals. Thousand Oaks, CA: Sage Publications.

Shields, D. & Wilson, D. R. (2016). Energy. Chapter in 7th edition of Holistic Nursing. Burlington, MA: Jones & Bartlett Learning; 7th edition: . lSBN-10: 1284072673 lSBN-13: 978-1284072679.

Dr. Wilson has been a nurse for over 35 years, is on faculty at Walden University and Tennessee State University, and a Parse nursing scholar. She sits on the board of Sharing of Middle Tennessee, a support group for families who have experienced loss of a child through stillbirth, neonatal death, and miscarriage and is the editor of our journal.
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Author:Wilson, Debra Rose
Publication:International Journal of Childbirth Education
Geographic Code:1USA
Date:Apr 1, 2016
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