When a nurse

Encounters a patient

Something happens

What occurs

is never

a neutral event

A pulse taken

Words exchanged

A touch

Resuscitation

Two persons

Are never

The same1

Nurse-patient interactions are not neutral events. So it is with nursing presence, as described in the accompanying article by Anderson.2 Anderson eloquently describes the use of nursing presence by advanced practice nurses (APNs) in a home-based community case management program for patients with heart failure and contends that the program's success is, in large part, due to the therapeutic relationship that develops between the nurse, the patient, and the patient's loved ones. She provides a compelling case for the power of "being present" with patients with heart failure and the resultant positive outcomes for both patient and nurse.

I would bet that most clinicians would agree with this-that much of what we do does indeed depend on the relationships we develop with patients and their significant others. On a regular basis, we accompany patients on their journey along the trajectory of their illness, but we likely have not labeled this as "presence," as this author has taken the time to do. That is why this article makes us stop to examine what it is we do with patients and take a closer look at the concept of presence.

Presence is a complex concept that is difficult to clearly define, has unclear boundaries, and has often been combined with other concepts such as caring.3 Anderson provides the following definition of presence: "presence is an intersubjective encounter between a nurse and a patient in which the nurse encounters the patient as a unique human being in a unique situation and chooses to spend her/himself on the patient's behalf."2 Presence is a process that is enacted in moments or over days, weeks, and years.3

Finfgeld-Connett,3 in a recent review of the concept of presence, notes that several antecedents are needed for presence to be implemented: (1) the patient's need for and openness to presence, as well as the nurse being willing to engage in intentional presence; (2) the nurse being personally and professionally mature enough to enact presence; and (3) the existence of a conducive work environment. Each of these is discussed below in relation to Anderson's article and to current cardiovascular clinical practice.

Patient's need for presence. The patient's need for presence is evidenced by physical and psychological distress.3 All of the cases mentioned in Anderson's article clearly had physical and/or psychological distress, as would most heart failure patients that we as clinicians care for on a regular basis. However, also included in this requirement is the patient's openness to presence, and although the patients in the first 2 cases in the article were open to the presence of the APN, clearly, the patient in Anderson's third case study was not initially open to visits from the APN. But the APN persisted with other interventions, and eventually, her "presence" became accepted-again, often a situation we encounter with our patients and families who are chronically ill.

In addition, the nurse must be willing to intentionally engage in presence-and in this article, the APN certainly was-but do we always feel we have the time for this? Are we "present" while doing other tasks? Does the idea of "being present" for someone even cross our mind when we are doing it or is it done automatically? Furthermore, if a nurse is not willing to be present, does something else take place, such as compassion or nurturing?3

Nurse personally and professionally mature. To be truly present, nurses must know and accept themselves and have the appropriate clinical competence and expertise.3 The APNs as described in Anderson's2 article clearly have met this attribute, as evidenced in the author's text and in the list of advanced practice nursing skills given in Table 4 of the article.

In day-to-day clinical practice, however, we likely have nurses with variable levels of clinical competence caring for patients. In this model for presence, can a less experienced nurse be truly "present" for a patient? Or can a novice nurse enact presence, if the support of a mentor is available?4 Furthermore, could an expert nurse make presence work even when the patient is not initially open to it or, as noted below, if the work environment is not conducive to it?

Conducive work environment. Elements of a conducive work environment include supportive colleagues, adequate time and staffing, and attention to technology and tasks and psychological concerns.3 All of these elements are present in the situation described in Anderson's article and are likely a major reason for its success. But again, these particular elements are often not present across all clinical settings, and the question arises as to how to enact presence in an unfavorable environment. Do our nursing and nonnursing colleagues understand and support this somewhat abstract concept? How would we explain it to them in a clinically meaningful way? How do we focus on interventions to make the best use of what is usually a limited amount of time with patients?

Finfgeld-Connett's3 literature synthesis found no evidence that presence results in negative consequences, and she suggests that if negative consequences do occur, a temporal phenomenon other than presence has arisen. Although presence has been cited as a positive phenomenon, some questions remain about the implementation of this intervention in today's clinical setting.

First, as Anderson alluded to in her article, how do we measure presence in the clinical setting? We have no tools for it. If we say that this is an important, powerful intervention (and, yes, I believe it is), there will need to be a way to somehow measure or describe it so that it is seen as valued by nurses and nonnurses alike.

Second, as presence is seen as being performed by mature clinicians, how do we teach this skill to new nurses (or to established nurses who need further education)? Or can we? Is it a skill seen only in the "expert" nurse as opposed to the "novice" or "advanced beginner" nurse, as per Benner's criteria?5

Third, and one of the biggest contemporary issues for the implementation of presence, is the emergence of telehealth and remote monitoring of patients. Do the nurse and the patient have to be in close physical proximity for presence to unfold? Given the wide use of telemonitoring in the field of heart failure, this warrants further study. Savenstedt et al6 studied videoconferencing with elders, and their findings suggest that presence via this method is possible using the same techniques used in face-to-face settings.

A final consideration of the power of presence involves, of course, the issues of cost and practicality. The system followed by Anderson and her colleagues is a program that is provided free of charge. Not all healthcare systems would be willing to do such a venture, even if downstream revenue were generated, unless certain outcomes were achieved. There have been generalized reports of presence making patients feel safe and secure and have decreased stress and enhanced coping strategies, and nurses have also reported improved mental well-being with the use of presence.3 However, in general, the literature is lacking in this area, and until presence or a surrogate marker of presence is shown to affect key outcomes, programs may not actively pursue its use.

REFERENCES