Mid-Grand Nursing Theory

AN INDEPENDENT VOICE FOR NURSING

Toward a Mid-Range Theory of Nursing Presence nuf_215 71..82

Michelle A. McMahon, MSN, RN, and Kimberly A. Christopher, PhD, RN, OCN Michelle A. McMahon, MSN, RN, is a Student in the PhD in Nursing Program, College of Nursing, University of Massachusetts Dartmouth, North Dartmouth, MA; Kimberly A. Christopher, PhD, RN, OCN, is Associate Professor, College of Nursing, University of Massachusetts Dartmouth, North Dartmouth, MA. Keywords Nursing presence, mid-range theory, nurse education, relational skills Correspondence Michelle A. McMahon, MSN, RN, Student in the PhD in Nursing Program, College of Nursing, University of Massachusetts Dartmouth, North Dartmouth, MA E-mail: [e-mail]
BACKGROUND. Presence is widely accepted as a core relational skill within the nursing profession. Nurse educators are challenged to ensure that the humanistic aspects of client care are included in the Bachelor of Science in Nursing (BSN) curriculum. Introducing and teaching presence skills early in the BSN curriculum will ensure the essential value of relational engagement with clients. Nursing literature, however, notes presence is a challenging concept for BSN students. Articulating a midrange theory of
nursing presence will facilitate students’ conceptual understanding of presence and guide nurse educators to teach presence skills. AIMS. To propose a mid-range theory of nursing presence. Within the theoretical model, identify development opportunities to improve student nurse use of presence as a relational skill. METHODS. An extensive literature review was conducted. Materials were synthesized and the mid-range theory was developed. DISCUSSION. Kim’s nurse-client domain provided the perspective that guided the parameters of the theory. Professional nursing presence is dependent upon the combination of five variables: individual nurse characteristics, individual client characteristics, shared characteristics within the nurse-client dyad, an environment conducive to relational work, and the nurse’s intentional decisions within the practice domain. The variables are described and the relationships among variables depicted in the model. Specific nurse-sensitive points during a nurse-client interaction determine or influence the nurse presence intervention and dose. Areas designed to teach or improve relational skills are identified for the BSN educator. CONCLUSION. A mid-range theory of presence contributes to our understanding of the relational aspects of nursing practice within the contemporary healthcare environment. Identifying strategies to teach BSN students presence skills will facilitate the incorporation of the humanistic aspects of client care in the undergraduate curriculum.

Presence as a concept is widely accepted as a core relational skill within the profession of nursing (Covington, 2003; Gardner, 1985; Gilje, 1992). In the contemporary healthcare setting—characterized by economic and time constraints, nursing shortages, agency expectations, and accreditation mandates— nursing’s relational work is at risk (Cohen, Hausner, & Johnson, 1994; Doona, Haggerty, & Chase, 1997; Finfgeld-Connett, 2008; Melnechenko, 2003). The

scope of nursing practice continues to expand and practicing nurses are challenged to prioritize the humanistic aspects of nursing care as they integrate increasing numbers of technical and scientific expectations. In addition, nurse educators are challenged to ensure that the humanistic aspects of client care are included in the baccalaureate curriculum (Kleiman, 2007). Current baccalaureate education emphasizes integration of informatics (Quality and Safety
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Education for Nurses, 2010; Technology Informatics Guiding Education Reform, n.d.) and simulationbased learning strategies (Simulation Innovation Resource Center, n.d.) designed to promote skill acquisition and fact-based knowledge. Both are valuable tools which help prepare students for professional practice. However, if these methods predominate, then this focus could potentially undermine students’ opportunities to learn interpersonal and relational skills. The Essentials of Baccalaureate Education document discusses patient-centered care, including “listening to . . . communicating with” and development of the “. . . nurse-patient partnership” (American Association of Colleges of Nursing, 2008, pp. 7–8), professional expectations which are consistent with the concept of presence. Introducing and teaching presence skills early in the baccalaureate nursing curriculum will stress the essential value of relational engagement with clients. To facilitate conceptual understanding of presence, a mid-range theory is proposed. Based on the theory, potential opportunities to teach relational skills such as presence to baccalaureate students are identified. Background Presence has its roots in both religion and existential philosophy. Specifically, Gabriel Marcel (1889– 1973), drawing from the work of Martin Buber (1958), discussed the reciprocal and interactive nature of presence (as cited in Smith, 2001). Nurse theorist Sister Madeleine Clemence Vaillot is credited with the early discussions of presence in the nursing discipline (Vaillot, 1966). In addition, several nursing theories and philosophies integrate presence as a major component, including Parse’s (1992) Human Becoming Theory, Watson’s (1988) Theory of Human Science and Human Care, and Paterson and Zderad’s (1976) Humanistic Nursing. Although these theories differ, each has a conceptualization of nursing that includes presence as an intersubjective, interpersonal, and mutual experience between the nurse and client (Doona et al., 1997; Finfgeld-Connett, 2006; Paterson & Zderad, 1976). Nurse scholars have attempted to fully depict the nurse actions during presence. Authors have described a number of nurse behaviors, communication styles, and emotional attitudes that the nurse incorporates during presence. Behaviors include physical closeness, eye contact, and appropriate touch (Dochterman &
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Bulechek, 2004; Finfgeld-Connett, 2006; Fredriksson, 1999). Communication styles include a quiet tone of voice, carefully chosen words, and attentive listening (Easter, 2000; Fredriksson, 1999; Hessel, 2009; Hines, 1992). Emotional attitude includes intimacy, sensitivity, and acceptance (Dochterman & Bulechek, 2004; Finfgeld-Connett, 2006; Fredriksson, 1999). Scholars also hypothesize that during presence, the nurse and client experience a range of emotions such as a feeling of belonging, reciprocity (Curley, 1997), sense of mutual openness, yet separateness (Tavernier, 2006), vulnerability (Melnechenko, 2003), respect and trust for the other (Finfgeld-Connett, 2008), and transpersonal connectedness (Hines, 1992; Osterman & Schwartz-Barcott, 1996). In addition, several authors have expanded upon the familiar conceptualization of presence as physically “being there” and psychologically “being with” the patient by describing presence as having numerous levels. For example, McKivergin and Daubenmire (1994) describe three levels of therapeutic presence, Osterman and Schwartz-Barcott (1996) describe four ways of being there, Easter (2000) describes four modes of presence, and Godkin (2001) describes a three-stage hierarchy of healing presence. A summary of these authors’ level descriptions, including selected nursing behaviors associated with the levels, and identification of potential positive client outcomes after presence are illustrated in Table 1. Multiple conceptualizations of presence make this concept difficult to understand. In this mid-range theory, the definition of presence is based on the widely cited work of Dochterman and Bulechek (2004) and McKivergin and Daubenmire (1994). Presence is defined as a nursing intervention that takes the form of “being with another, both physically and psychologically, during times of need” (Dochterman & Bulechek, 2004, p. 580) and has three levels: physical (body to body), psychological (mind to mind), and therapeutic (spirit to spirit) (McKivergin & Daubenmire, 1994). McKivergin & Daubenmire’s term, therapeutic presence, is consistent with other authors’ similar terms including Osterman & Schwartz-Barcott’s (1996) transcendent being there, Godkin’s (2001) healing presence, and Easter’s (2000) holistic and spiritual modes. Of note, although the leveling of presence is described in a hierarchical manner, this does not mean that one level is better than the other, but rather with certain client scenarios there is increased opportunity for the nurse giving of self and deeper nurse–client

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Table 1. Summary of Presence Levels, and Nursing Behaviors and Potential Client Outcomes Associated with Presence
Literature reference Differentiations of presence Nurse behaviors (selected examples) Potential beneficial client outcomes “Being there” for the client— routine care needs met “Being with” the client— helped, comforted, supported Whole being care needs met—mind, body, emotions, and spirit ↓ stress—another physical body present ↓ stress, equipment maintenance Alleviate distress or human problems in the moment Transformative effects, ↓ loneliness, ↑ spiritual peace, hope, and meaning ↑ self worth, feel heard, encouraged and motivated, and ↓ loneliness/isolation Feelings of support, hope, and comfort with ↑ coping ↑ health and healing↓ anxiety, ↓ pain, and ↓ diastolic blood pressure Self-affirmation, courage, and
self-forgiveness

Levels of therapeutic Physical (body to body) Seeing, touching, hearing presence McKivergin & Daubenmire, Psychological (mind to mind) Actively listen/counsel, 1994 accept non-judgmentally Therapeutic (spirit to spirit) Intentionality, intuitive knowing, connecting Intrapersonal, self-absorbed, no interaction Object/task-oriented, partial interaction Interactive yet role-bound (dyad)—eye contact, open body language, and listening attentively Holistic approach, relationship without roles or boundaries (monad) Seeing, touching, hearing, hand shaking, use of body language Use of empathy, attentive listening, unconditional regard blended with nurse clinical expertise Uses simultaneity practice to discover client rhythms/ patterns Transcendent awareness in nurse–client dyad—may use meditation or prayer

Four ways of being there Osterman & SchwartzBarcott, 1996

Presence (physical) Partial presence (physical) Full presence (physical and psychological) Transcendent (physical, psychological, and metaphysical)

Four modes of presence Easter, 2000

Physical (body to body— requires proximity) Therapeutic (mind to mind—psychological and psychosocial) Holistic (mind, body, and spirit) Spiritual (spirit to spirit)

Hierarchy of healing presence Godkin, 2001

Bedside presence (beyond physical) Clinical presence (beyond psychological)

Healing presence (beyond therapeutic)
↑, increased; ↓, decreased.

Physically available “being ↑ comfort, motivation, and there”—see client as hope unique and aim to connect/gain rapport Psychologically “being Holistic needs met with”—sensing from the unconditionally client perspective and going beyond the scientific data Knowing what will work and Clients viewed as subjects when to act—reaching not objects—receive mutual presence individualized care

engagement. The nurse determines the level of presence required after the synthesis of all relevant client data. Because presence is an intervention, it is equally appropriate to consider presence in terms of

the dose provided rather than the level provided. Level and dose are closely related. The assessment process determines the level (or type) of presence, i.e., physical, psychological, or therapeutic, needed or
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Toward a Mid-Range Theory of Nursing Presence
Figure 1. Mid-Range Theory of Nursing Presence

M. A. McMahon and K. A. Christopher

that the nurse can deliver at that time. When the presence intervention is initiated, the nurse provides a dose of presence, i.e., physical, psychological, or therapeutic. In addition to determining the necessary dose of presence, the delivery form must also be determined. To date, the majority of literature describes presence interventions delivered with the nurse and client physically proximal to each other. Kaiser (2005) addresses physical embodied presence and disembodied presence. She notes that with advances in healthcare services and healthcare technology, delivering or providing presence interventions through forms of disembodied practice such as telehealth, phone triage, or electronic consultation should be further explored (Kaiser, 2005). Specifically, she suggests that new and future healthcare scenarios will require a revisitation of how physical nursing care and being with a client is interpreted (Kaiser, 2005). In the future, client–nurse dyads may successfully engage in presence either proximally (body to body), approximately (by intercom or phone), or virtually (web-based). Therefore, the consideration of various forms of delivering presence is also needed.
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Introduction to the Model Although the nursing literature identifies elements of presence, a comprehensive view of the components of presence, the variables impacting presence, and potential outcomes of presence has yet to be described. To organize a framework for nursing presence, the authors build on Kim’s (2000) nurse–client domain to guide the parameters of the theory. Specifically, nursing presence is dependent upon the combination of individual nurse characteristics, individual client characteristics, shared characteristics within the nurse–client dyad, an environment conducive to relational work, and the nurse’s practice decisions (Figure 1). There are crucial points during a nurse–client interaction which determine the eventual dose of presence delivered. Specifically, the nurse draws on clinical expertise and previous experience with presence, interprets both the client’s subtle cues and obvious requests for presence, considers the environmental factors, and then pauses and decides the most appropriate dose of presence at that particular time. Identifying these nurse-sensitive points within the theoretical model will facilitate nurse educators’ ability to

M. A. McMahon and K. A. Christopher identify opportunities to improve students’ use of presence as a relational skill. Nurse Characteristics There are several individual nurse characteristics which influence clinical judgments during relational work. As a nurse progresses from novice to expert clinician (Benner, 1984), these characteristics related to professional, moral, relational, and personal maturity evolve in a developmental manner. Professional maturity is the first characteristic integral to a nurse’s potential to offer presence. The professionally mature nurse draws upon empirical, esthetic, personal, and ethical knowledge during the nurse–client interaction (Carper, 1978). Hence, the professionally mature nurse recognizes when the client is in need of, and open to, presence. This recognition is followed by the nurse’s deliberate engagement in presence rather than task-oriented and routine care (Doona, Chase, & Haggerty, 1999; Melnechenko, 2003). During this process, with conscious awareness (Covington, 2003, emphasis added) and intention, the nurse chooses the dose of presence he/she can or will offer in that moment. The nurse’s choice of dose of presence is based on an amalgamation of complex factors related to the client, the nurse–client dyad, environmental factors, and practice considerations. These extrinsic factors are crucial, yet the nurse’s conscious intention to become involved (Ferlic, 1968), his/her level of commitment (Doona et al., 1997; Vaillot, 1966), and his/her open availability (Doona et al., 1999) may be the most persuasive influences on the eventual dose of presence actually provided. Tavernier (2006) notes the importance of the nurse’s knowledge and skill as antecedents for presence. Professional maturity assumes that an experienced nurse, who has sound theoretical knowledge and is comfortable practicing, has an advantage when faced with a clinical scenario in which presence is indicated. The ability of an experienced nurse to physically and psychologically “be with” a client, while simultaneously completing necessary tasks, is the hallmark of expert nurse practice (Hanneman, 1996). Moreover, the more expert the nurse is, the more likely he/she is to see the value “being present” has on clients (Benner, 1984). This expert process depicts the seamless nursing care that ensues when the nurse has gained mastery, and practice appears natural and effortless. The professionally mature nurse is able to blend psychomotor ability, intuitive knowl-

Toward a Mid-Range Theory of Nursing Presence edge, and therapeutic communication skill with an authentic intention to intersubjectively connect with a client. Conversely, a less clinically proficient nurse may be so preoccupied at the time with the tasks that he/she is unable to identify the client’s subtle signals of a need for nursing presence intervention. Consequently, the novice nurse may not be able to blend or prioritize relational responsibilities when these responsibilities coexist with complex cognitive situations and psychomotor tasks, and this may undermine a client’s relational needs. Expanding on Doona and colleagues’ (1999) work with presence, Godkin (2001) supported the progressive and developmental nature of presence skills when she proposed a hierarchical model that depicts presence in conjunction with novice-to-expert trajectory (Benner, 1984) and nonexpert and expert nurse practice (Hanneman, 1996). Godkin’s postulation that greater experience correlates with increased potential to be maximally present with clients illustrates the progression that a developing professional nurse makes to incorporate nursing science knowledge and artistry into relational care with clients. Doona et al. (1997) note that experienced nurses can facilitate the development of presence skills in less experienced nurses. If practicing nurses’ presence skills can be refined over time, it is logical that with role modeling and structured learning opportunities, students’ presence skills can be developed over time. Presence is also influenced by moral maturity, the second nurse characteristic in the model. The term commitment, originating from existential philosophy, entered nursing literature in the 1960s (Smith, 2001). Sister Madeleine Clemence Vailott described the “committed nurse” as one who chooses to engage with clients rather than detaching herself during care (Vaillot, 1966). Vaillot’s position that the committed nurse has a responsibility to accept professional obligations implies a required unconditional willingness to be available to the client. This professional obligation to be available to the client makes presence a moral imperative for nursing. Ferlic (1968), influenced by Marcel’s existential philosophy, referred to commitment as “an intrinsic characteristic of the truly professional nurse” (p. 30). This statement assumes a subjective variation in nurses’ level of commitment within practice as each nurse brings into the profession a value and belief system which influences practice decisions. It is possible that moral maturity evolves in a similar developmental manner that Godkin (2001) proposed for nursing presence. Potentially, the more morally
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Toward a Mid-Range Theory of Nursing Presence established and committed the nurse is to the profession, the more likely that nurse is to relationally engage with clients. In addition, moral maturity potentially motivates the nurse to strive to deliver the appropriate dose of presence to clients regardless of barriers found in the clinical setting. The idea of moral maturity developing as a complementary yet separate entity from professional maturity may explain why some long-term practicing nurses are less skilled at being fully present with their clients, while also accounting for some novice nurses who easily assimilate relational work alongside clinical hands-on skills. When combining an authentic intention with knowledge and skill, the nurse makes a moral commitment to engage in presence with a client. This assertion of a moral component related to a nurse’s ability to be present is supported in Finfgeld-Connett’s (2006) meta-synthesis of the presence literature. This literature describes moral underpinnings as a nurse antecedent in the process of presence. In addition, Watson (1999) posits a nurse’s authentic presence during transpersonal caring as a moral ideal. Levine (1977) also posited a nurse’s willingness to engage with clients as a moral responsibility and went further to liken a nurse’s moral commitment to excellence in practice. Some may argue whether moral maturity is an appropriate benchmark measurement for the nurse at entry-level practice. However, the expectation of a moral component within the profession is supported by the “Good Moral Character” licensure requirement established by some state registration boards (Executive Office of Health and Human Services, 2007). This requirement for initial licensure and licensure reciprocity supports the long-standing moral expectations within the profession of nursing. The third nurse characteristic impacting presence is relational skill maturity. A relational skill set includes a nurse’s ability to recognize a client’s therapeutic communication needs. Specifically, the relationally skilled nurse has the ability to use the right words and gestures (Vaillot, 1966), and capacity to be available as needed through behaviors such as attentiveness (Tavernier, 2006), active listening (Doona et al., 1999), quiet availability (Chase, 2001), and touch (Fredriksson, 1999). Presence is viewed by some scholars as a key component to the relational process (Covington, 2003; Gilje, 1992), and by others as the actual “core of the nurse-patient relationship” (Gardner, 1985, p. 316). Because presence is a mutual two-way process (Chase, 2001), the nurse and client must connect in some sense if presence is to occur. The
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M. A. McMahon and K. A. Christopher nursing literature describes therapeutic use of self (Peplau, 1952), creative use of self (Ferlic, 1968), use of self as an instrument (McKivergin & Daubenmire, 1994), and gift of self (Osterman & Schwartz-Barcott, 1996) as methods the nurse uses to build rapport when engaging in a relational encounter. The relational skill set a nurse brings to practice varies; therefore, experiential opportunities that improve professional communication proficiency are needed to improve the nurse’s ability to be present with clients. Personal maturity, the fourth characteristic of the nurse, includes self-awareness and self-knowing. These qualities facilitate the nurse’s ability to compartmentalize personal issues and disallow any external stressors that interfere with his/her capacity to provide patient-centered care (Tavernier, 2006). The ability to discern and set aside outside influences, and deliberately focus on practice, is indicative of a personally mature nurse. A personally mature nurse who is able to balance personal and professional obligations and remain free from burnout, compassion fatigue, tiredness, or preoccupation is best situated to provide presence during client care (Finfgeld-Connett, 2008; Karl, 1992). In addition, Finfgeld-Connett’s (2008) work notes that the nurse engaging in presence in the practice setting also exhibits spiritual and psychological wholeness. Hence, the nurse who lives a healthy lifestyle, for example one with physical, psychological, or spiritual integrity, will maximize his/her potential to be fully available to or “be there or be with” the client.

Client Characteristics During a clinical encounter, the dose of nursing presence is also based on the client’s expectations and requirements. Therefore, client characteristics are identified in the model. These client characteristics determine the request for and level of presence needed during the encounter, and include the client’s openness, level of perceived vulnerability during illness–wellness state, the trust and rapport with the nurse at hand, and previous history with nursing presence. The first client-initiated step toward a mutual exchange is the openness of the client to nursing presence and the client’s subsequent invitation to engage. Prompted by an unmet need and potentially demonstrating physical, psychological, and/or spiritual distress, the client signals either openly or subtly a need for the nurse to be there or be with him/her (FinfgeldConnett, 2006, 2008). This initial step is a critical point

M. A. McMahon and K. A. Christopher and the nurse must interpret a client’s cues for an invitation for nursing presence. The second client characteristic is perceived vulnerability, which is likely influenced by illness state such as acute versus chronic status or curative versus terminal outcome. The more vulnerable a client feels, the more he/she may seek nurse presence. This is consistent with Doona et al.’s (1997) description of presence as the “antidote for the depersonalization of health care” (p. 14); hence, a client’s need for nurse presence is likely intensified by the degree of threat a client feels to his or her personhood. In addition, certain situations or medical conditions potentially require doses of presence which are more spiritual and metaphysical in nature, for example at end of life (Nelms, 1996), the experience of intrauterine death (Engebretson, 2000), mechanical ventilation (Doona et al., 1999), and severely disabled long-term care patients with chronic illness (Osterman & SchwartzBarcott, 1996). Therefore, it is reasonable to assume that a client may seek or require an increased dose of nursing presence when facing a catastrophic event or terminal illness. The third client characteristic is the degree of trust and rapport the client has with the nurse. Trust is a precursor for nurse presence to occur (FinfgeldConnett, 2006). In addition, increased level of trust is noted to be a positive outcome associated with presence (Tavernier, 2006). Interestingly, in DuisNittsche’s (2002) study of nurses’ perceptions of presence, nurses reported that knowing patients’ unique needs and intuitively responding was an integral characteristic of nursing presence. Duis-Nittsche’s study also reported that understanding individual clients’ needs and providing subsequent offers of presence hastened the development of trust. Therefore, it is reasonable to suggest that as a client begins to trust the nurse, he or she may be more likely to request and benefit from presence. The client’s previous history with nursing presence and nonpresence is the fourth characteristic. The literature suggests that clients who have previously experienced positive nursing presence may actually have less need for, but a greater openness to, presence in future encounters (Finfgeld-Connett, 2006). Decreased client need for presence may be related to the lingering effects of a previous encounter, or because of the client’s improved well-being and functioning. The nurse’s acknowledgment of the client’s decreased need for presence would be important to interpret in order to determine the correct dose of

Toward a Mid-Range Theory of Nursing Presence presence needed, or equally important, allow the client to decline nurse presence if he or she so chooses. Nurse–Client Dyad Characteristics In addition to individual characteristics of the nurse and client, the commonalities and differences within the dyad must be considered. Variables which potentially influence the nurse–client dyad include age, gender, culture, spirituality, and a previous nurse– client relationship. Currently, there is no literature specifically discussing the impact of age or generational differences on the presence encounter. Therefore, it is unknown to what extent having the nurse and client of a similar age or generation enhances the relationship. It is plausible that nurse–client pairs with similar age may share common life experience, values, and attitudes that facilitate a relationship. Although the nurse-caring literature has identified that gender impacts caring, for example, male nurse’s apprehension with use of touch (Keogh & Gleeson, 2006), to date the presence literature has not explored the impact of gender on presence. The exploration of nurse gender influence on presence ability, as well as any differences between male and female clients’ desire, elicitation, or interpretation of presence, is needed. Equally unknown is the effect that sharing cultural backgrounds has on presence. One could postulate that a client is more likely to initiate or accept the nurse’s offer of self if the client believes that the nurse is aware of cultural norms. Possibly, the nurse viewing a client situation from an emic perspective may be able to interpret client clues and adjust dose of presence more appropriately. Presence as a concept has rich religious overtones and inferences to theology (Chase, 2001; Doona et al., 1997; Smith, 2001). A similar level of spirituality shared by the nurse and client may improve the rapport between them. Spiritual compatibility may enhance the presence experience, particularly when a spiritual and metaphysical level of presence is needed. These higher levels of presence require the nurse and client to connect as two intertwined subjects, which may be facilitated when the nurse and client experience a common sense of spirituality. The fifth dyad characteristic is the effect a previous nurse–client relationship has on level of presence. Consistent and extended interactions are natural predecessors to relationship building. Opportunities for nursing presence are enhanced when clients are familiar with their caregivers (McKivergin & Daubenmire, 1994) and when nurse–client assignments are
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Toward a Mid-Range Theory of Nursing Presence maintained throughout hospitalization (Cohen et al., 1994). However, a first time client–nurse encounter is not necessarily less amenable to presence. Tarlier (2004) notes that although there is a unique temporal component to certain relationships including those originating in the emergency or operating room, relationship building and therefore nursing presence can develop despite a limited timeframe. Clinical situations involving shortened interaction time emphasize the need for personally and professionally mature nurses who can intentionally engage with clients. Finfgeld-Connett’s (2006) meta-synthesis suggests that presence could be experienced beyond the actual interaction time. Specifically, Finfgeld-Connett describes presence “as a process that is enacted in moments or over days, weeks and years” (2006, p. 710) . . . which allows for recognition of “rhythmic patterns” to emerge over “extended periods of time.” This description suggests that reflecting upon a previous encounter may provide a client with a sense of nurse presence. Conceptualizing presence beyond a specific moment in time potentially expands its therapeutic value. And interestingly, this conceptualization is also consistent with Parse’s (2003) term, lingering presence. The possibility of the therapeutic benefits of presence continuing beyond the original encounter is intriguing and needs further investigation. Environmental Factors Although environment is presented as a separate entity within the proposed theory, environment should be viewed as a dynamic force that continuously affects nursing presence. Nurse, client, and nurse– client dyad characteristics are influenced by the environmental atmosphere of the healthcare delivery setting. Moreover, a nurse’s practice decisions are heavily influenced by the physical setting and professional tone of the workplace. Recent syntheses of presence literature identify several environmental factors—working conditions, management philosophy, physical plant—that facilitate a proper milieu for presence to occur (Finfgeld-Connett, 2006, 2008). Additional literature stresses the importance of proper staffing. Proper staffing, including appropriate numbers of nurses with appropriate skill mix, will promote collaborative working relationships on the unit (Doona et al., 1997; Finfgeld-Connett, 2006, 2008; Tavernier, 2006). Also, a management philosophy that values nursing may likely strive to ensure that nurses are supported in clinical practice.
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Environmental issues influencing level of nursing presence include agency contextual factors. As previously noted, a supportive work environment sets the stage for and can improve the likelihood that presence will occur (Finfgeld-Connett, 2008). The nurse’s ability to engage in presence is highly dependent upon the culture of the unit or setting in which the nurse practices. It is reasonable to posit that a nursing unit which values the relational aspects of nursing practice would promote strategies that encourage staff to engage in presence. Chase (2001) strongly supports environmental opportunities for nurses to be present with clients and goes further to infer that the profession of nursing risks “becom[ing] irrelevant to the health care system” (p. 326) without presence. To date, there is limited literature regarding how agency factors can promote or discourage presence. However, some agencies may be more likely to promote presence than others; for example, magnet institutions, which are associated with greater nursing support, more highly educated nurses, and foster an atmosphere promoting excellence in care, are more likely to endorse presence as a nursing practice expectation. Understanding the impact an agency milieu has on presence will potentially lead to resources that will create an environment conducive to providing presence interventions. Exploring additional agency contextual factors, for example, various inpatient or community-based settings, type of specialty unit, educational preparation of the nursing staff, and nursing staffing mix (full-time, part-time, float, contract), may increase our understanding of how these factors impact nursing presence. Time constraint is the second environmental factor. Nurses report that time constraints impact their ability to be present with clients and limited time potentially compromises client care (Cohen et al., 1994; Melnechenko, 2003). Adequate time is purported as a prerequisite for presence (Finfgeld-Connett, 2006). Nurses continually confront the dilemma of allocating time to be present with clients and allocating time to required tasks and technology (Melnechenko, 2003). Opportunities for presence should not be scheduled or fit in as an afterthought because presence is best provided when “interwoven and interconnected” into care (Duis-Nittsche, 2002, p. 8). Although some authors describe a relationship between availability of time and presence, other authors stress that the willingness of a nurse to engage during presence is more important than available time (Chase, 2001; Pettigrew, 1988). This ability to rise above time restrictions and

M. A. McMahon and K. A. Christopher make a concerted effort to engage with clients supports the premise that presence is largely controlled by the nurse’s authentic intention. A third environmental factor which potentially interferes with presence interventions is the increasing use of technology in the clinical setting. In the contemporary healthcare setting, there often seems a competition between attending to the client during presence and attending to the equipment. Specifically, Finfgeld-Connett (2006) discusses the challenge of fulfilling technological tasks while ensuring psychological and spiritual concerns are met. Godkin (2001) reports on nurse dissatisfaction within environments where technological tasks have priority over the human aspects of practice. Therefore, as more technology demands fill the nurse’s clinical responsibilities, it is essential that presence skills not be undermined. Nurses must decisively assimilate presence into technological care as appropriate. This requires purposeful intention by the nurse. Practice Considerations The final area of the model addresses the nurse from the perspective of Kim’s (2000) practice domain. The practice domain represents the point when the nurse pauses to assess a client situation, and makes professional decisions about the dose and mode of delivery of presence. Decisions within this domain are dependent upon the nurse’s conscious prioritization of a client’s need for presence. Duis-Nittsche’s (2002) qualitative study found that nurses make this conscious decision when choosing to be present with patients, regardless of other nursing responsibilities at the time. This suggests that the nurse is the most critical determinant of the dose of nursing presence during an interaction. Specifically, the nurse determines whether he/she will only physically “be there” observing the event from a distance, or if he/she will extend beyond the physical realm to “be with” the patient and partake in the moment. Curley (1997) describes these choices of “being there” or “being with” as the nurse choosing to act as witness in the former and as privileged participant in the latter. As previously noted, the nurse with professional, moral, relational, and personal maturity is best prepared to determine the appropriate physical, psychological, or therapeutic level of presence needed and then provide the appropriate dose. What happens in that moment when the nurse identifies the client’s invitation to be present? Why

Toward a Mid-Range Theory of Nursing Presence does one nurse choose to engage the invitation and another does not? This period of contemplation when the nurse considers how to proceed is the nurse pause (Bottorff & Varcoe, 1995; Watson, 2002). This pause, consistent with Watson’s (2002) view of intentionality in practice, occurs during purposeful and directed consciousness toward the client. An example of this process is when the nurse temporarily dwells on a client’s need for presence and then refocuses attention to provide the appropriate dose of presence, often needing to overcome competing demands. Godkin (2001) notes the impact of nurse volition when the nurse intentionally chooses to engage with clients and extend care beyond taskoriented behaviors. Pilkington (2005, p. 102) describes Parse’s use of the term intentional as complimentary to “deliberate” or “reflectively chosen way of being.” This inference of the nurse applying purposeful actions to situations while considering the uniqueness of the client situation is what occurs during the nurse pause. Specifically, during the pause the nurse takes time to consider the complexity of the situation. The nurse assesses the invitation from a client, weighs the subjective and objective data, and makes accommodations for the environment. All these considerations are unconsciously influenced by degree of intention to be present, combined with the nurse’s professional, moral, relational, and personal maturities. Once all these considerations are assimilated, a decision to act is made.

Nurse-Sensitive Points in Model Within the proposed model, there are identified areas denoted with an asterisk which are critical nurse-sensitive points which determine eventual nurse dosing of presence. Specifically, a nurse must recognize a client’s invite or request for presence, draw upon ability and previous experience, interpret a client’s obvious and subtle cues, allow for mitigating environmental factors, and pause to reflect upon a range of options and determine the appropriate dose of presence. The identification and utilization of these nurse-sensitive points provides an opportunity to facilitate the presence process. In regard to nurse characteristics, as theoretical and experiential knowledge increase, one’s potential to be present increases. Both professional and relational maturities can be fostered in nurses and students.
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Particularly, as a student nurse matures and has broader clinical opportunities, the student is more able to recognize client patterns and draw upon previous relational encounters with clients. As nurse skill develops, nurse deliberation to intervene, including ability to determine type and dose of presence needed, is enhanced. With advanced proficiency or expertise, the nurse is better able to anticipate client needs, including being proactive in purposeful offering of self. Creating opportunities for students to hone these pattern recognition skills and act with intention would facilitate presence. Client factors also offer teaching opportunities. Complimentary to the previously mentioned pattern recognition is nurse identification of potential client vulnerability. An ability to see client prompts for professional nurse presence despite eliciting only subtle signals is an artful skill that could be cultivated in a teaching setting. Designing curriculum activities which foster detection of a client’s threat to personhood can increase awareness of situations which may indicate an increased dose of presence. Furthermore, opportunities to build rapports with clients in the clinical setting are essential. However, equally important is to ensure that simulation scenarios and clinical skill laboratory experiences incorporate opportunities for therapeutic skill building. Fostering students’ ability to assimilate client interaction alongside technical skills will reduce compartmentalizing the concept of presence from hands-on tasks. Discussions regarding the negative effect environmental barriers may have on client outcomes during presence, including time constraints, competing clinical demands, and a nonpresence-supportive setting, is vital to preparing students for a successful transition from student to practitioner. Opportunities to practice time management ability and role play delegation skills may help with future mitigation of contextual environmental factors that challenge nurse ability to be present. Finally, the most crucial nurse-sensitive point, which develops over time, is the nurse pause. During this pause, nurse volition is combined with nurse, client, dyad, and environmental factors which determine the nurse’s clinical practice decision of presence or nonpresence. Students can be assisted in reflective activities which allow for deconstructing the complex process by which a nurse determines appropriate dose and delivery mode with each opportunity for nursing presence.
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M. A. McMahon and K. A. Christopher
Incorporating Presence Skills in Undergraduate Nursing Curriculum Nursing presence is a challenging concept for nursing students to grasp and utilize (Rankin & DeLashmutt, 2006) for several reasons. Students begin their nursing education with varying levels of relational skill ability. There are multiple definitions of presence and this leads to confusion and misunderstanding. Moreover, most of these definitions are associated with obscure and vague language which makes teaching and evaluating presence skills very difficult. To date, there is no agreement among nurse educators as to whether students can be taught presence skills; however, some educators propose that relational skills, in particular presence, can be developed across the undergraduate curriculum (Doona et al., 1997; Easter, 2000; Mardsen, 1990; Smith, 2001). Specifically, all levels of clinical education are an opportunity to develop students’ presence skills and increase the likelihood that students will be present with clients when providing clinical care. Ensuring that students understand the importance of nurse presence intervention and increasingly develop presence skills are consistent with the goals and policies of the profession (Dochterman & Bulechek, 2004; American Nurses Association [ANA], 2001 Code of Ethics; ANA, 2003 Nursing Social Policy Statement; and ANA, 2004 Scope and Standards of Practice) and should be an educational outcome in baccalaureate programs.

Conclusion This article synthesizes a collection of literature on the concept of presence and proposes a mid-range theory aimed at facilitating presence work within the clinical setting. Ensuring that nursing presence is valued in clinical practice is essential to maintaining the essence of the discipline’s relational work with clients. In addition, facilitating the development of presence capacity in baccalaureate students is critical as they establish the foundations of nursing practice. The model depicts components of individual nurse characteristics, individual client characteristics, shared dyad characteristics, environmental factors, and nurse practice domain considerations and their interrelationship. Of particular importance is the nurse pause. This crucial point, in which the nurse, influenced by degree of intention to be present, considers the complex interplay of client needs, nurse ability, and

M. A. McMahon and K. A. Christopher contextual environmental factors that determine the eventual dose of presence delivered. Nurse educators, whether clinical or academic, are encouraged to focus on the asterisked areas of model when planning activities to further develop presence skills. For example, opportunities which would help with identifying and proactively responding to client need for presence, sensing client openness via cues, buffering environmental obstacles to presence, and skillfully assimilating presence while attending to other psychomotor tasks may likely enhance the delivery of nursing presence. Acknowledgment. The authors would like to acknowledge and thank Dr. Nancy Dluhy, Director of PhD in Nursing Program at the University of Massachusetts Dartmouth, for her assistance with developing the model. Visit the Nursing Forum blog at http://www. respond2articles.com/NF/ to create, comment on, or participate in a discussion.
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