Microsoft Word - Dhaliwal et al corrected proof.docx Corresponding Author: Sandip K Dhaliwal, RN, Master’s Student Faculty of Nursing, University of Calgary Email: sdhali@ucalgary.ca Journal of Applied Hermeneutics ISSN: 1927-4416 June 9, 2020 ãThe Author(s) 2020 New Realities and Tsunamis: A Nurse’s Interpretation of a Family Navigating Cancer Sandip K Dhaliwal, Nancy J Moules, & Graham McCaffrey Abstract This short paper was written for a hermeneutics research course from the perspective of the first author in response to the statement “Nursing is an interpretive practice.” A narrative account of caring for a young adult with hematologic cancer and his mother is provided to offer understanding on how cancer is an interpreted experience with a relational backdrop of family, and nursing is an interpretive practice situated within this relational complexity. Gadamer’s ideas around horizon of understanding, experience, and conversation are utilized to present a nurse’s interpretation of this family navigating the “new realities and tsunamis” and overturning of their lives by hematologic cancer. Given the interpretive nature of understanding in nursing work with families, it is proposed that hermeneutics, as an interpretive inquiry, offers a meaningful approach to understand family experiences of cancer in nursing research. Keywords interpretation, philosophical hermeneutics, relational complexity, oncology nursing, family nurs- ing Family is considered a significant part of an individual's psychosocial dimension in which illness is experienced (Quinn & Herndon, 1986). The context of family frames an important part of one’s Dhaliwal et al. Journal of Applied Hermeneutics 2020 Article 4 2 “being-in-the-world” and the experience of cancer is often interpreted within the relational com- plexities of family. As nurses, we are not outsiders but right there in the midst of the changing dynamics and relationships between family members. In this paper, I offer that cancer is an inter- preted experience with a relational backdrop of family, and nursing is an interpretive practice sit- uated within this relational complexity. I provide a narrative account (in italics) of two practice events with a young adult and his mother to illuminate the importance of interpretation in under- standing as an oncology, hematology, and blood and marrow transplant nurse. New Realities I was working in an outpatient blood and marrow transplant treatment clinic, and the next patient on my list was 28-year-old Ray (pseudonym) who was post-stem cell transplant for leukemia. His visit plan for the day was a routine bloodwork draw, and the time allocated for his visit was 15 minutes. I walked out to the waiting room, called his name, and a 5’8” man stood up and greeted me with a “good morning” and a warm smile. We walked to- gether from the waiting room to a clinic chair while making small talk about the weather and what he ate for breakfast. He took off his jacket and a bright red toque that revealed his bald head. He got comfortable in the clinic chair and lifted his shirt, as if it was second nature, so that I could access his central venous catheter line from which to draw blood. As I started to draw blood, I noticed he had a tattoo on his arm. “That is a cool tattoo, is it a guitar?” I asked. “Yeah it is” he responded. I noticed initials in the tattoo, “does it symbolize something for you?” I asked. The conversation that followed this simple question was profound and embedded with sto- ries about cancer and moments that were sad, happy, heartbreaking, and everything in- between. I came to learn that the tattoo was a tribute to Ray’s friend that passed away a couple years ago. The friend played guitar in a band of which Ray was a part; Ray played the electric keyboard. The band was a source of fun for Ray, but he had to stop being part of the band when he was diagnosed with cancer. He had also just finished receiving a heavy-duty equipment technician diploma and started a new job but then “cancer hap- pened.” He married his high school sweetheart and was looking forward to having a fi- nancially stable job so they could start to think about kids; those plans had to been inter- rupted and he had to move to a different city temporarily in order to get a stem cell transplant, but “at least” he banked his sperm for later. I learned that was not the way he imagined having kids, but he did not need to think about that right now. He needed to think about “being independent again” instead. He and his wife became dependent on his par- ents for financial support, which he admitted was hard for him. He was grateful to his family for being supportive, but he wished someone “understood” what he was going through. He did not want to be “a pessimist” with all the “cancer talk” though, “do you have any tattoos?” he shifted the conversation. I did not have any tattoos, but we found a common ground – a love for music – and continued the conversation talking about favour- ite bands and songs. The conversation between Ray and me was not one that was part of a care plan or within the allocated time frame of 15 minutes. Rather, the conversation had lasted well beyond 15 minutes. One might ask if having a “conversation” about a tattoo is really a nursing responsibility or priority. Dhaliwal et al. Journal of Applied Hermeneutics 2020 Article 4 3 At a glance, it may appear nursing work consists of vital signs, assessments, administering medi- cations, drawing blood, completing dressing changes, and charting before moving on to the next patient. Although these are important tasks of nursing work, I would argue that a caring presence, attentiveness to the particular, and interpretation are the heart of nursing. My initial question in relation to Ray’s tattoo was answered with a simple response from Ray, but I interpreted there was more to be said when I noticed Rays eyes had filled with emotion. Inter- preting the unsaid, I made the decision to probe, and although Ray could have ended the conver- sation, perhaps he had interpreted my inquisition as an invitation to express what he had hidden but lingered in his mind. There was something about the language he used – being a “pessimist” when it comes to “cancer talk” and wishing someone “understood” – that told me there was a conscious hiding of his feelings, emotions, and thoughts when it came to cancer. Perhaps for Ray, our conversation was simply the opportunity for him to share what was already at play in his mind, but this conversation became one of significant understanding for me and brought to light his ex- periences navigating cancer in relation to family. It is not surprising to think that our dreams, hopes, and understanding of experiences is based on “being-in-the-world” alongside those who help us construct meaningful lives. As Gadamer (1960/2013) stated, “long before we understand ourselves through the process of self-examination, we understand ourselves in a self-evident way in the family, society and state in which we live” (p. 289). Our “horizon of understanding” provides the familiar context in which we engage in understanding, and it is impossible to isolate our understanding from this horizon. Ray, as a young adult, was not only trying to understand his new reality of navigating hematologic cancer, but he was navigating what this meant for his relationship with his parents, on whom he was dependent again, and for his relationship with his wife who, with whom he was no longer having conversa- tions about having kids, but had now become his caregiver. Gadamer viewed experience “[as] an event over which no one has control and...in which every- thing is coordinated in a way that is ultimately incomprehensible” (Gadamer, 1960/2013, p. 361). Seemingly, the experience of hematologic cancer is an unpredictable one that throws families off a predetermined course and disrupts and shakes the dreams and hopes of those experiencing it. As a nurse, attempts to understand this experience is wrought with complexities, but these attempts may begin through conversation (or dialogue) and attention to the particular. Similar to experience, Gadamer suggested that understanding emerges from dialogue in the form of an unpredictable discovery rather than a controlled outcome. Of conversation, he stated: Rather it is generally more correct to say that we fall into conversation, or even that we become involved in it. The way one word follows another, with the conversation taking its own twists and reaching its own conclusion, may well be conducted in some way, but the partners conversing are far less the leaders of it than the led. No one knows in advance what will ‘come out’ of a conversation. (Gadamer, 1960/2013, p. 401) The conversation between Ray and me was not pre-planned with any specific intent, yet the “to and fro” of the conversation exposed what navigating hematologic cancer meant for him and his particular case. In this conversation with Ray, space was opened up for new understanding to occur, Dhaliwal et al. Journal of Applied Hermeneutics 2020 Article 4 4 and this newfound understanding became part of my interpretations in subsequent interactions I had with Ray and his family. Being Hit by A Tsunami Two months later, Ray was admitted to an inpatient hematology and bone marrow trans- plant unit for work-up to investigate abnormal blood counts, and I was assigned to care for him. I reviewed his chart and recent bloodwork before starting my day. Platelets, low; hemoglobin, low; white blood cells, low. I walked into his room for my initial round; his mother was in the room and Ray had his head back with a tissue shoved into his nostrils. Upon entering his room, I interpreted based on what I knew (his platelets were low) and what I saw (he was doing what most patients do when they have a nosebleed) and put together pieces of the puzzle. Ray was having a nosebleed. I introduced myself; Ray re- membered me. I instructed Ray to hold pressure to the bridge of his nose while I grabbed supplies to stop his nosebleed. I rested a cold pack to the nape of his neck and started rolling gauze to put up Ray’s nostril. Ray’s mother jumped in to guide me on the size of the gauze that works best, how many pieces of gauze are too thick for his nostril, and about how in the past, nurses would use the “sticky stuff” to wrap around the gauze so that the gauze holds its shape. (She was talking about Jelonet, a sticky adherence dressing). Ray rolled his eyes as she continued to guide me, and you could see the annoyance on his face. “Mom, seriously? She knows what she is doing, can you just leave?” he exclaimed. Ray’s mother left the room, and I allowed space for silence that had filled the room after she left. I attended to Ray, rolled up the gauze, secured it with Jelonet, and put it up his nostril that was bleeding. “I’m sorry, I know she is trying to be helpful,” he broke the silence, “Would you like to talk about it?” I asked. He did not want to talk right then. I walked out of the room to find Ray’s mother in the patient area directly outside his room, crying. It was a quiet crying where she was holding back in an attempt not to draw attention, but the tears rolling down her cheek were hard to miss (and dismiss). I sat down next to her, searching for the right words to say. Before I was able to find them, she explained, “I’m trying my best to help him and I wish he understood that.” I took a moment and thought back to the conversation I had with Ray in the clinic, “he appreciates having you, but do you think, right now, he just wants some control?” I asked. The words that I chose in response to Ray’s mother were not based on the singular event that had just occurred, but rather were interpreted in relation to the conversation I had with Ray months prior. I knew Ray loved and appreciated his mother, he told me this, but his world had been shaken up by cancer and seemingly, there was little of which he had control. Perhaps now that he was admitted back to inpatient care, there was even more uncertainty, fear, and a lack of control. I did not interpret Ray’s moment of frustration in which he asked his mother to leave as indicative of Ray being an unappreciative son but rather as one that his inner and hidden emotions had been revealed and expressed through anger. Dhaliwal et al. Journal of Applied Hermeneutics 2020 Article 4 5 Ray’s mother dabbed the tears streaming down her cheeks with a tissue and took a moment to respond, “I never thought about it like that.” I sat with her a while ruminating on the notion of “control” and listening to her story. Having a child diagnosed with cancer is like “being hit by a tsunami that knocks you off your feet” she explained. Tsunami is a Japanese word derived from tsu meaning “harbor” and nami meaning “waves” and is defined as “an extremely large wave caused by violent movement of the earth under the sea” (Tsunami, n.d.). For Ray’s mother, being “hit by a tsunami” was akin to being tumbled and tossed in the turbulent waters of uncertainty and fear that accompanies a diagnosis of hematologic cancer. Her experiences thus far had been filled with great waves of shock and fear followed by gentler waves of hope only to be followed by another tidal wave of fear. Seemingly, Ray and his mother were learning to navigate the changes to their relationship and the new realities while also trying to protect each other. That is, they both talked about wanting to be understood, and although they shared bits of their story with me, it was evident they did not want to burden each other. Perhaps sharing moments of happiness and sadness but also protecting one another is what being family means. In the case of cancer, which demands to be addressed and to be seen, the ability to protect is hindered and like when a tsunami hits, there is no protecting each other from the waves of fear, anger, and frustration that may follow. Concluding Thoughts One’s understanding of the world is “always already” situated within familial relationships. Nurs- ing practice, in relation to working with families, is not solely about acquiring and applying tech- nical expertise (techne), rather, it is about being immersed in situations and deciding the right thing to do in particular contexts (phronesis). In every particular situation, the “task of moral knowledge is to determine what the concrete situation asks of him [sic]—or put another way, the person acting must view the concrete situation in light of what is asked of him [sic] in general” (Gadamer, 1960/2013, p. 323). Facing the uncertainty and unfamiliarity of a particular situation does not re- quire ready-made rules, but it is still our responsibility to know and decide what to do. In the case of hematologic cancer, the patient becomes the family, and deciding what to do co-evolves through interpretation and understanding between the family and the nurse. Nurses strive to understand and interpret to understand; one could say nurses are already practicing hermeneutically. For nursing research work with families, hermeneutics as a methodology presents the ability to understand through interpretation. At the heart of hermeneutics is aletheia, which is described as unconcealedness (Aletheia, n.d.). Aletheia occurs when we open the portal to new understanding, when we enliven what was dead or taken-for-granted, and when we remember what was forgotten or concealed in darkness (Moules, McCaffrey, Field, & Laing, 2015). Hermeneutic inquiry, em- bracing aletheia, unlocks a path to inquiry that would allow families particular experiences with hematologic cancer to be brought to a presence and a place that calls for further questions, discus- sion, and need for understanding. References Aletheia. (n.d.). In Definitions.net. Retrieved May 17, 2020 from https://www.defini- tions.net/definition/aletheia Dhaliwal et al. Journal of Applied Hermeneutics 2020 Article 4 6 Gadamer, H-G. (1960/2013). Truth and method (J. Weinsheimer & D.G. Marshall, Trans.). Lon- don, UK: Bloomsbury Academic. Moules, N.J., McCaffrey, G., & Field, J.C., & Laing, C.M. (2015). Conducting hermeneutic re- search: From philosophy to practice. New York, NY: Peter Lang. Quinn, W.H., & Herndon, A. (1986). The family ecology of cancer. Journal of Psychosocial On- cology, 4(2), 45–59. doi:10.1300/j077v04n01_04 Tsunami. (n.d.). In Cambridge dictionary. Retrieved May 17, 2020 from https://dictionary.cam- bridge.org/dictionary/english/tsunami