Shirley Stephenson, RN, APN
ACCESS Community Health Network, Chicago, Illinois, United States
Photography by Mark Belokopytov
There are things that make us uncomfortable, such as public speaking or taking a seat on an airplane as coats, bags, or limbs spill over the border of armrest. We are uncomfortable for a moment when we first sit very close to a stranger. When addressing a group of people in a lecture hall or press conference, we are typically twelve feet or more away from others. A book titled The Fundamentals of Nursing1 tells us this distance is the public zone. The social zone is a bit closer—between twelve and four feet. The personal zone is four feet to eighteen inches, which is close. It is how near we are to a new acquaintance with whom we’re shaking hands, or to fellow diners.
The intimate zone is eighteen to zero inches, or actual touch. Out of all the people whose paths we cross in a day, there are not a lot to whom we get that close unless they are friends, lovers, family, or—ironically—total strangers toward whom we are forced to move in modes of transportation, elevators, theater lobbies. And in those cases, we typically acknowledge our transgressions, saying sorry if we bump an elbow or foot. It is startling, and possibly awkward, to touch a stranger.
The degree of discomfort varies among cultures. From the Latin cultura, the word culture has come to encompass elements of life ranging from ballet to bacteria. In the laboratory setting we culture (verb), as in look after, assist growth. Then we assess sensitivity. What makes a culture susceptible? This Petri dish process is not entirely different from the social experimentations humans undergo with any new journey or comfort zone. Perceptions of intimacy shift dramatically for those who enter the field of healthcare.
Imagine, for example, being among a group of new nursing students. You stand in a row with other adults whom you hardly know and demonstrate proper hand washing technique. How surreal. Then you are in a classroom together, learning (or not) how the body compensates for life-threatening acid/base imbalances. You watch one another pass or fail tests on mitered corners and mechanisms of action. Then you go as a group, united by the weeks of shared experience and nervousness, and enter a building full of people you know even less well, who lie nearly naked in bright corridors of vulnerability.
You may speak with the gowned strangers for a few minutes before moving within eighteen inches of their face to listen to their heart and lungs. You may clean them, and access their veins. You still do not really know these patients, but you know if they are in pain, and if they need anything—water, medicine, spiritual comfort, socks. You ask how they cope, and usually they tell you because you are seen as a safe deposit box, a neutral keeper and provider. They say, I cope by spending time with family. I cope with alcohol, prayer, pasta, heroine, jogging. And after only a few hours, you know aspects of these patients better than you know much of your own family. You touch their skin, and in many cases you reach, literally and figuratively, below it.
This all can make us uncomfortable, and yet at the same time trust often comes very naturally. It is part of what nursing is. It is bizarre and intense. It is an honor, it is invigorating, and it is draining. You do not have to be a nurse to experience this. Most of us, whether in healthcare or not, have had some moment of astounding intimacy with another person, be it through love, death, or an accident on the roadside. But what we do not all experience are the relationships and culture that form among students in healthcare.
I decided to become a nurse in my mid-thirties. Before that, I had been a writer, reporter, editor—each of which encourages investigation, but permits both physical and emotional distance. In the first few weeks of nursing, this removal was helpful because it allowed me to ease into what was, for all of us, a very different set of circumstances. It allowed me to consider my reactions.
My academic cohort consisted mostly of adults who already had a career in another field, and decided they wanted something deeper, something more. In the beginning of our endeavor, I did what I was accustomed to doing—I observed. I saw empathic, funny and adventurous people complain about the unflattering fit of our scrubs. I saw frustrated and tired people prepare for weekly exams and the "skills tests" we took with rubbery mannequins in our simulated basement hospital ward.
Then I began to see other things.
As I walked down the hall of an organ transplant floor during the first weeks of clinical rotations, I passed a room where a classmate was asking a man in his 50s—not a mannequin at all—if he knew what city he was in, or if he knew who the people were in the photo beside his bed. I saw a friend break into tears in the nurses’ locker room because she had spent the last six hours helping a family decide how best to make use of their dying teenage daughter’s organs. I watched with enormous respect and fondness as a classmate devised a way to give a child in the locked psychiatric unit a virtual hug, because imaginary hugs were the only allowable form of physical contact for this patient.
I saw classmates with their own children negotiate family life while going to class and clinical rotations. And I saw classmates dealing with personal illness and family crises while still making it to the hospital by 6:30 a.m. with ten pages of information about the pathophysiological, pharmacological, and sociocultural backgrounds of the patients they would care for that day. And I found myself crawling on the floor of a hospital room in order to reach an electrical outlet so that a woman could read by the light of her bedside lamp instead of the harsh overhead fluorescence. The woman, the patient, had a cancer that had eroded and enervated her body. When she said how much it meant to have a working bedside lamp after nine days in that room, it reoriented me. I felt that I was no longer reporting. I had left the public zone. I was no longer apart.
But I kept watching, bewildered and inspired as people would study together, complain together, and hold one another upright when they were exhausted and burned out. I saw classmates become friends quickly, and quietly congratulate one another when they had inserted a catheter for the first time, drawn blood, fed someone through a tube in their intestines, or helped a woman deliver her first child.
Gradually, I became less surprised by the unique intimacy of nursing, but more and more astonished by us. As with any group, we fragmented and found those with whom we felt most comfortable, but eventually we also became a “we.” Together we described the color and stench of the bodily fluids we had encountered that day, and together we sat to discuss, with grief and sometimes anger, the patients we had watched die. We came to recognize air hunger, understand how to unravel a contracted fist, know when a patient was catching her last glimpse of blue sky out the hospital window, and when to let language go silent, but remain present.
After only a couple months we could analyze lab results and describe the effects of a particular antibiotic on ribosomes. But what was equally fascinating is how the knowledge we had before studying nursing came into play. The culture of "us" was shaped by people who had filmed surgeries in New York City, or coordinated surgeries in Guatemala. My classmates could describe serving in the military, being an attorney, a sheriff, an environmentalist, a union organizer, software wiz, preschool teacher, kinesthesiologist, mathematician, sleep disorder specialist, improvisational dramatist, and social worker. They could share stories of their families from Japan, Greece, Nigeria, Thailand, and Ireland, and they knew about children with asthma, housing advocacy, bacon factories, cancer research, haikus, pharmaceutical trials, community work, and women in engineering. I believe the energy from this diversity reached, indeed still reaches, the individuals with whom we come in contact as nurses.
Nursing is contradictions—it is a privilege and a challenge. Incredibly rewarding, yet largely thankless. And depending where one works, it is a brutal reminder of economic and racial inequities. It is walking into a stranger’s room, entering their intimate zone, and suddenly knowing them, or rather, being allowed to suddenly know them because their life is in the midst of a profound change. And similarly, it is entering a group of fellow students and suddenly knowing them, because our lives also transform in inextinguishable ways. As we came close, as we touched, we discovered our sensitivities—that which broke down walls and made us as susceptible as the patients for whom we cared.
- Potter, P.A. & Perry, A.G. (2004). Fundamentals of Nursing. Philadelphia, PA: Mosby
SHIRLEY STEPHENSON, RN, APN, is a Family Nurse Practitioner at a clinic on the south side of Chicago. She previously worked in the ER. Prior to becoming a nurse, she worked as a communications and development professional in global health and arts nonprofit organizations. She received an Illinois Arts Council Artists Fellowship, and her degrees include an MFA in poetry and MA in Latin American and Caribbean Studies.