Corresponding Author: Lisa Alphonsus, Master’s Student, Faculty of Nursing, University of Calgary Email: llfast@ucalgary.ca Journal of Applied Hermeneutics ISSN: 1927-4416 June 13, 2021 ©The Author(s) 2021 Weathering the Storm Together: How Emergency Nursing is an Interpretive Practice Lisa Leanne Alphonsus Abstract This paper was written for a hermeneutic research course in response to the statement: Emergency nursing is an interpretive practice. In it, I share from my own experience as an emergency department nurse, sharing deeply reflective and profound examples illustrating how I have come to understand the practice of interpretation. Drawing on other works within philosophical hermeneutics, I explore how emergency nurses bring our backgrounds and prejudices to work, and how we create meaning together with our patients. Gadamer’s description of the hermeneutic circle is used to explore how nurses move back and forth between the part and the whole, both as ourselves as nurses and how we care for our patients. The importance of emergency nurses remaining vulnerable, despite the acuity and chaos in which we are often surrounded, is emphasized, as well as supporting emergency nurses in our work, in our care for our fellow humans. Keywords Interpretive practice, philosophical hermeneutics, emergency nursing, hermeneutic circle, prejudices, vulnerability, compassion “I wish.” The words of man about to be intubated. 100% FiO2, 30L O2 through the high-flow nasal prongs and non-rebreather mask, gasping for breath. The most amount of oxygen we can give without a breathing tube. COVID positive. Desperate eyes. Searching eyes. His entire body poised and pushing to take each breath. A respiratory rate of 40 breaths every minute. Neck taut. Alphonsus Journal of Applied Hermeneutics 2021 Article 7 2 Tired. “Sir, the ICU NP is wondering if you have been vaccinated?” “I wish.” His wife on speakerphone asks, “How do you feel about that?” She sounds uncertain. She is questioning whether he really needs to be intubated. “I want to get better” he snaps. It takes all his energy to get the entire sentence out and he goes back to focusing on his breathing. Silence. The hiss of the oxygen flowing into his lungs, the beep of the monitor alarming his oxygen is low. It was my idea to call her. His wife at home, also infected with COVID-19. I thought it a humane thing to do. It will be weeks before they may see each other again. If they do. I’m thinking of the future, of the recovery, and of my Grandmother. She passed away from COVID-19. It wasn’t pretty. At the end each phone call was painful, for each of us in different ways. But I treasured every word. And so, my gift to them, is a few more words. We tell him that to intubate him we will first put him to sleep, he says “Good…. I need… a good sleep.” He looks so tired. He is tiring. We spring into action, an intricately executed dance involving powerful drugs which paralyze the man we were just talking to, we oxygenate his lungs for him. A breathing tube down his throat. Unconscious. He will go to the ICU now to recover. Which he might. Or he might not. We do not know. I wish we did. But we have done our part. Yet it doesn’t end there. It never does. These things take their toll. We are left wondering. It affects us. Why else would I have written this? I am no poet. I am only human. And watching other humans suffer is no fun. Did he recover? I wish I knew. How many more people with COVID will I need to intubate? How is he doing? How is his wife doing? Are they OK? Am I OK? I wish. Emergency nursing is a profession like no other. It is a unique, beautiful, glorious, fulfilling, and altogether devastating professional line of work. Lives are saved, and lives are lost in the emergency department. Nothing is as straight-forward as it seems. Patients come and patients go. Alphonsus Journal of Applied Hermeneutics 2021 Article 7 3 It is a fast-paced, hectic, and stressful place to work, and amongst all of it, the hermeneutic practice of interpretation is at work. In this paper I will discuss what the statement “Emergency nursing is an interpretive practice” means based on my understanding of hermeneutic philosophy and my experience as an emergency department nurse. Using examples, I will explore how nurses bring our backgrounds and prejudices to work, how nurses and patients create meaning together, how we move back and forth between the part and the whole, both as ourselves in our nursing practice and how we care for our patients, and how we recognize and understand first- hand that our interpretations are never final. My hope for this paper is that it allows for aletheia, for something that that was closed, to be opened, for unconcealment (Moules et al., 2002) both for myself, the writer, and for the reader. Emergency Nursing The beep of monitors, ringing of phones, people calling out, patients passing by in the hall, residents and physicians answering pagers, overheard pages, it is a symphony of chaos, and embedded into all of this, are the emergency department nurses. Not only do we make sure that the department runs smoothly, the cogs behind the wheels, but we make meaning from our nursing interactions. Whether we may recognize it or not, we are continuously interpreting, continuously making meanings from the interactions and situations that are presented to us. We bring with us our backgrounds and our prejudices, which influence the interpretations that we make. Prejudice, as Gadamer described, refers to the fact that we never approach an experience as a completely blank slate, that we always bring existing understandings to a topic (Moules et al., 2015). Prejudice “certainly does not necessarily mean a false judgment, but part of the idea is that it can have either a positive or negative value” (Gadamer, 1960/2013, p. 283). These prejudices are important for us to understand and reflect on to the best of our ability. We must remain open to the possibility of “stumbling over our own prejudices or having someone else stumble on them and point them out to us” (Moules et al., 2015, p. 44). Our prejudices influence the interpretations and the meanings that we make when nursing, which consequently also influence our other areas of life, like a circle, playing a game of back and forth, serve and return. My prejudices affect my nursing care and experiences, which affect me, which affects all other aspects of me. The part of me that is a nurse, affects the whole of me as a person. This circular relationship, the hermeneutic circle, tells us that we must “understand the whole in terms of the detail and the detail in terms of the whole” (Gadamer, 2013, p. 302). As we move back and forth between the part and the whole, we move forward in our understanding. The hermeneutic circle helps us understand how emergency nurses make meaning from their experiences and also describes how they go about understanding the patients in their care. Going back and forth between the patient as a whole, and the details that are bringing the patient into the emergency department allows us to come to a deeper understanding of the patient. Both the whole and the part need to be understood as fully as possible in order to take the greatest care of the patient. Patients do not always clearly or explicitly say the “real” reason why they are coming into the emergency department, and although we will not be able to fully understand the entire whole of the patient, it is important to not get entirely caught up in the details only, but to Alphonsus Journal of Applied Hermeneutics 2021 Article 7 4 remember that there is a whole, a person who we are treating and not just the symptoms the patient presents to us. The nursing care that I, as a nurse, provide is not separated from the other aspects of me. It is an extension of myself, as a whole. I am not compartmentalized. I provide care not just as I was objectively taught in nursing school (this is how to insert an IV/foley catheter) but as a person who has life experiences. The manner in which I provide nursing care is influenced by my past experiences, starting from the way I was raised, all the way until an experience from the last shift I worked, or even as recent as a moment before I walked through the door of a patient’s room. I provide nursing care as a mother, a wife, a sister, a friend, a student, a daughter. All these aspects of my life influence how I provide care. My nursing care is also individualized both to the patient, the person, that I am providing care for, from me, the person, who is providing the care. For example, being a mother allows me to see things I was not able to see before I experienced becoming a mother. Recently I cared for a patient who was six weeks post-partum from a vaginal delivery, and although it was years ago, I remember what six weeks post-partum felt like. The patient was anxious and concerned about how her perineal stitches were healing, and I was present while the male physician conducted a pelvic exam. I stood at her side and kept a gentle hand on her knee during the exam because she seemed very anxious. I asked her how she was doing, and during a particularly painful part of the procedure her hand reached up and touched my arm. Just a few fingers on my forearm. I expected her to move her hand when the hardest part was over, but the fingers lingered, and stayed on my arm for the remainder of the exam. Through that touch, in that moment, there was communication back and forth. I need you; I am here for you. I cannot do this by myself; I will stay right here. I am scared; I know it is scary. In these types of moments, titles such as nurse and patient fade away, and what is left is just two people—two humans weathering a storm together. These moments are a private dance between patient and nurse. The conversation, the dialogue, where questions are asked and answered, where truth is searched for, that is private. It is not shared, it cannot be shared, with others. And even if we try, they will only be able to have a shadow glimpse of the moment that passed, the communication of what was said, and more importantly, how it was said—how a touch added an exclamation mark, how a look brought forth tears. This is nursing, this is interpretation. The practice of interpretation in emergency nursing requires vulnerability, openness, and compassion. Patients in the emergency department are some of the most vulnerable people and can be at a very vulnerable point in their lives. Nurses must also allow themselves to be vulnerable; they must allow themselves to be present in their work. A few months ago, I helped care for a patient who was ten days post-partum, but her baby had passed away at four days old. We have a protocol in the emergency department that allows any patient less than 14 days post-partum to go straight to the labour and delivery floor to be assessed by the obstetrician there. However, due to the devastating circumstance, the triage nurse exhibited compassion and told me she was putting the patient in my room because she thought the last place the patient would want to be was on the same floor her baby passed away and Alphonsus Journal of Applied Hermeneutics 2021 Article 7 5 surrounded by new mothers and their babies. I could not have agreed more. When I went in the room to do my initial assessment of the patient, I was concerned about how it would go, nervous that I may say the wrong thing, but also trusting myself to know how to proceed, and remaining open to where the conversation may lead. I started on as neutral ground as I could: What brings you in to the emergency department today? She explained about having a syncopal episode at home, and briefly mentioned that she had had an emergency caesarean section ten days ago at 28 weeks and her baby had passed away after four days. When she got to this part I said, “I am so sorry, that is awful.” She seemed open so I asked what her baby had passed away from. She explained what had happened, speaking quietly, gently, and matter-of-factly, almost as if she did not want to make a big deal of it. But I did not want to leave it there, I needed to somehow acknowledge in some small way what she had been through. So, I asked, “What was your baby’s name?” She started to cry. “Hannah.” Then I started to cry, because that is a beautiful name, and she was a beautiful person, and it was heart-wrenching to think of her losing her beautiful baby. She looked me in the eyes, “Thank-you so much for asking her name, that means so much to me.” Moments, or experiences, like these are special and sacred, these moments create meaning amongst the chaos. However, they only happen if we allow ourselves to be open and vulnerable. I could have offered my condolences and left it there, but I chose to go deeper—to allow myself to feel and to allow myself to experience the experience. This example glimpses sight of the finitude of experience, how “one cannot know what is coming” (Moules et al., 2015, p.45), and shows the importance of allowing ourselves to be led by the situation and the opportunities presented to us. It also exhibits the idea of hermeneutics as a “condition of being human, an inescapable immersion in making sense of the world, but always finitely, always open to re- interpretation” (Moules et al., 2013, p. 8). Nursing is more than surface level. A good nurse, an experienced nurse, gently reaches down past the surface to explore what needs to come up. The interpretations we make are unique to ourselves, flowing from our prejudices. The poem at the beginning of this paper exemplifies this. The poem references an experience that impacted me, and so I wrote a poem as a way to express myself. Everyone else in the same room would have written a different poem, or they might not have written a poem at all, but it goes to show that our interpretations are personal. Emergency nurses also understand that our interpretations are never final. Through an ever- evolving shifting of meanings and contexts and situations, we understand that “it is not our lot, as humans, to know once and for all” (Moules et al., 2013, p. 9). The interpretations we make are not conclusions; they are doorways that lead us further into our profession, further into our understanding of our patients, of each other, and of ourselves. Concluding Thoughts Emergency nursing is an interpretive practice. Whether nurses are aware of it or not, they constantly create meaning from their experiences. The hermeneutic practice of interpretation allows us to decide “how we might live well with others, how we might, given their lives, help them heal or learn” (Moules et al., 2017, p. 5). We move back and forth between the part and the whole as our prejudices affect our nursing care, and our nursing experiences affect us as a whole. Alphonsus Journal of Applied Hermeneutics 2021 Article 7 6 We create meaning together with our patients, understanding that our interpretations are never final. We experience moments of clarity and understanding when we allow ourselves to be open and vulnerable. Understanding the experience of the emergency nurse is crucial to ensuring they are supported in the work that they do. The work of caring, of compassion, of supporting and healing, of taking care of the patients in their care, the people in their care. We are, after all, just humans taking care of other humans. Weathering the storm together. Don’t only practice your art, but force your way into its secrets. For it, and knowledge, can raise men to the divine. Ludwig van Beethoven. References Gadamer, H-G. (1960/2013). Truth and method (J. Weinsheimer & D.G. Marshall, Trans.; 2nd rev. ed.). Bloomsberry Academic. Moules, N.J. (2002). Hermeneutic inquiry: Paying heed to history and Hermes. An ancestral substantive, and methodological tale. International Journal of Qualitative Methods, 1(3), 1-19. https://ejournals.library.ualberta.ca/index.php/IJOM/article/view/4597/3750 Moules, N.J., Jardine, D.W., McCaffrey, G.P., & Brown, C. (2013) Isn’t all of oncology hermeneutic? 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