Presence

Healthy therapeutic relationships enhance wholeness and healing; they are the key to effective health promotion. Therapeutic nursing presence demonstrates caring, empathy, and connection, qualities required to build rapport and trust between nurse and patient. This concept analysis’ purpose was to illuminate the various forms of the meanings of presence and the value placed on them. The science of nursing often precedes the art and spirituality of nursing. This is due to focusing primarily on the high acuity of the patients being seen in conjunction with shortage of personnel and resources. Patient dissatisfaction continues to be a growing concern. The nursing shortage crisis continues along with more nurses experiencing moral distress, compassion fatigue, and/or burnout. In nurses’ haste to complete their duties, are we facing the risk of overlooking one of the original gifts of the nursing profession? This would be the gift of genuine presence. This concept analysis aims to identify the attributes that are essential to the concept of presence, and to clarify its nursing usage, by following the strategy suggested by Walker and Avant. It is important to reflect on various ways of providing presence in the clinical setting. By exploring the spiritual, literary, psychological, and nursing literature, there is a diverse yet similar interconnectivity of what presence may represent. Observations and experiences of a range of sensatory and kinesthetic perceptions are revealed to ascertain the attributes discerning commonalities and themes of presence. Nursing presence is considered to be an essential state of holistic nursing as well as a core competency in contemporary nursing. Clarifying the significance of presence in nursing invites the prospect of additional evidence-based research that may place the intrinsic value of presence as a continuing theoretical foundation.


Introduction
As society moves forward into the new millennium, emerging modes of communication allow nurses to practice beyond the bedside. This may include not meeting the patient face to face, yet maintaining a meaningful presence in patient care by the use of electronic technology. The multitude of technological advancements combined with decreased staffing creates concern of nurses becoming more focused on patients' data than the individual for whom they are called to care. The concept of presence goes beyond face-to-face contact with the patient. Presence in its multitude of meanings may be one of the greatest essential therapeutic components, indispensable to quality nursing care.
Walker and Avant recognize that the process of a concept analysis is necessary to clarify the defining attributes, antecedents, and consequences of nursing presence. The goal of this project is to make known significance of nursing presence for future use in the practice or research field (Walker & Avant, 2011). This analysis will examine the intrinsic worth that authenticity of presence in nursing holds today.

Use of the Concept
Barbara Dossey recognizes that honoring the importance of nurse self-care is a bridge to defining the presence of nursing (McKivergin, 2005). She has described presence as being with or in collaboration with a state of mindfulness.
In her expansion of presence Dossey encourages nurse to first recognize and embrace their own valuable presence, being aware of the here and now. As a holistic nurse, she recommends meditation, prayer, and/or creative outlets such as dance or poetry. These practices permit nurses to be still with themselves, thus enhancing the ability to be fully present with others.
The concept of presence varies according to one's personal history of belief, sensory experience, and truths. Defining characteristics include but are not limited to caring, empathy, listening, sensitivity, integration, and communion all moving toward enhancing evidence-based, improved outcomes of mental and physical well-being of the patient and the nurse (Finfgeld-Connett, 2008).

Spirituality
Divine presence addresses the belief of the omnipotent ability of a God or Gods to be present or in communion with humankind ("Divine Presence," 2010). This concept is shared by the majority of religions, each owning their unique theology and philosophy. Throughout the New Testament, Christians reveal through scripture the physical and metaphorical presence of God, both in the spirit and in the physical incarnation of the Father and the Son. "The earth shook; the heavens also dropped rain at the presence of God; Sinai itself was moved at the presence of God, the God of Israel." (Psalm 68:8, Bible Gateway, 1982A), and "Where can I go from Your Spirit? Or where can I flee from Your Presence?" (Psalm 138:7, Bible Gateway, 1982B; http://www.biblegateway.com/passage/ ?search=psalm%2068:8&version=NIV).
In Judaism, Shekhinah is the feminine principle identified as the Divine presence of God (Johansen, 2001). While Shekhinah is considered the essence of the presence of God, she is also considered to be tangible in all the beauty of this world. It has been avowed that modern Jewish feminism is centered throughout the Shekhinah. Kything, a term used in holistic nursing, is defined as the concept of spiritually manifesting oneself to another using no words, just being totally open and available to one another. Kything has been nicknamed "cherub talk." Holistic nurses have used kything therapeutically in meditation, sacramental communion, and prayer individually and with their patients (Dossey, 1997;Savary & Berne, 1988).
In parapsychology, spiritual presences are commonly characterized as apparitions or ghosts. These phenomena are normally witnessed by populaces who have known their apparitions, on occasion at the bedside of the dying individual (Williams, Ventola, & Wilson, n.d.). Their presence has been visual and/or auditory often accompanied by sensations of cold, wind, or touch. While scientific logic may infer paranormal enthusiasts having a broader imagination than the typical man, a 2005 Gallup poll revealed that almost one third of the 1,005 adult Americans surveyed believed that ghosts or spirits came back in certain situations.
Prior to imminent death, patients often state that they see people who were in their lives and are no longer living. Hospice nurses are frequently allowed the honor of patients sharing who they had seen: whom they perceive or actually had experienced the presence thereof. This presence is often portrayed as a loved one, waiting to greet them when they pass beyond this world, usually one of comfort and solace. Woven throughout all spiritual presence is the act of experiencing something outside of oneself that evokes a feeling of communion, be it rich and rewarding, or adverse and disturbing.

Literary
Literary presence, in all its genres, has the capacity to transcend us from infirmity and loss to hope and understanding of one another's views, evoking a sense of connection with those who have shared the story that has been told. Literary presence allows one to enter into the story that is being told by the artist by use of perception, emotional response, and thought process.
Studies conducted on the right temporal lobe, known as the "God-side of the brain," have found that highly creative people, such as artists, tend to experience more sightings of a presence or muse that can stimulate their poetic abilities (Platt, 2007). Platt reports that a stressed mind or electromagnetic stimulation has been shown to contribute to intense verbal or written prose or poetry. Intense meaningfulness is enhanced, creating a personal awaking and healing perceptions via the inspired artistic voice.
Presence in literature has no time restraints or boundaries. Various degrees of presence or lack thereof presence is a common theme in artistic form, whether written, sung, and/or on the stage. Bernard Duffy paid tribute to the poetry and prose of a literary American icon in his book A Poetry of Presence: The Writings of William Carlos Williams. The chapters are categorized into various forms of evoking a presence, or being present throughout Williams' prose. They represent the ambiance of kinesthetic actions, perceptions, and emotions. Williams prose invites one into the immediate proximity of the story being told via the imagination of the reader (Duffy, 1986).
Virtual technology is creating a greater depth of presence, evoking more lifelike illusion of presence through heightened arousal of kinetic stimulation of the senses. For example, when in 3D, the Oscar winning movie Avatar gave the illusion of being physically, emotionally, and kinesthetically present through the stimuli of the virtual cinematic experience ("Avatar," 2009).
The principle of presence is individual. It is created by the imagination of the people who immerse themselves in reading, watching, or listening to the literary form. The emotions evoked through imagination and sensory perceptions invite permission to escape immediate reality and enter into a multi-dimensional illusion of presence that coincides with each person's individual truths.

Psychology
Carl Rogers's psychotherapeutic model of client-centered practice argues that for constructive personality change to occur, the therapist must be attentive and empathetic, with an unconditional positive regard and sensory openness during the client's presence (Rogers, 2007). He recognizes therapeutic presence, as the quality of the therapist being fully in the moment, of extreme benefit to the client. Rogers does not indicate that there must always be willingness of the client; he has documented positive response with catatonic clients. Being present in the moment, practicing the act of a purposeful presence, originally leaned more toward psychoanalytical and philosophical genres.
Therapists may refer to presence in therapy as bearing witness to their client, co-creating empathy and cultivating therapeutic affirmation. This can be accomplished by merely being with the client and allowing them to express their fears and concerns. When applying this modality, patients experience a greater state of mindfulness, thereby enhancing communication and integration mutually between the client and the provider (Horovitz, 2005;Rutherford, 2007). David Childs emphasizes that mindfulness, as "being in the present on purpose," is one of the tools of clinical psychology to be used as an effective treatment method (Childs, 2007, p. 367). In his research, Childs reports empirical studies proving how this mindfulness can reduce the risk of lapse of depression. While some clinical researchers question these thoughts to be too esoteric to be respectable psychology, Childs concludes that the clinician's ability to be able to create presence, such as the Buddhists and other meditative traditions, offers enhancement of mental and physical health in the client (Childs, 2007).

Nursing
The affirmative aspect of nursing presence has been used since the beginning of modern nursing. Florence Nightingale established a nursing presence in the military hospital during the Crimean War in doing and in being (Dossey, 2000). Nightingale aided the soldiers with compassion and care. By dressing wounds, writing letters to their wives and mothers, and tending the dying; she provided a healing presence. It was noted that her calm voice, warm smile, and gentle touch conveyed hope, helping them to endure pain and suffering.
Nurses are not able to yield the patient from physical or emotional pain. Yet, by consciously being with the patient, displaying care and empathy, nurses can enhance healing. As nurse-patient loads increase, it is not unusual to observe a nurse attempting to meet the needs of a patient in a very rote fashion, with little or no therapeutic interaction. Genuine presence requires the nurse's agenda to set aside. Nursing presence, defined as genuine and meaningful exchange between nurse and patient, is believed by certain scholars to be the core of the nurse-patient relationship (Zyblock, 2010). Barbara Dossey perceives presence as the essential state or core in healing (McKivergin, 2005). Presence is a state of being. It is the shared experience of reciprocity, reflecting a mutual sense of well-being for the patient and the nurse. Dimensions of nursing presence include, physical presence, that is, body to body, using basic nursing activities, such as positioning or bathing a patient, or physical comfort, such as a gentle hug or healing touch. Psychological presence, mind to mind, is a cognitive awareness of being with the patient during communication. This bestows understanding and recognition of another's belief system in a non-judgmental milieu providing meaning to life's events. Dossey contends that it is essential for the nurse to actively listen, while remaining empathetic, understanding, and comforting toward herself and the patient (McKivergin, 2005). None of this has to be overly time-consuming; presence occurs by simply pausing to take a breath and address the patient with full attention in a kind manner. Doona, Chase, and Haggerty (1999) identified six features of nursing presence through a hermeneutic study. While gathering data on nursing judgment, the following features were defined: uniqueness, connecting with the patient's experience, sensing, going beyond the scientific data, knowing what will work and when to act, and being with the patient (Doona et al., 1999). They perceived presence not to be part of the problem-solving as nurses were originally taught. Instead they saw nursing presence as an immersion in the entirety of the situation, seeing beyond the moment of care and delving into the patient's perception of their greatest need at the time. An example was given of a psychiatric nurse sitting with a manic patient who had not been eating. The nurse chose to give him his favorite candy bar, a Milky Way, and continued to stay by his side, in lieu of checking his blood pressure, offering more medication, or other possible nursing tasks. Months later, he saw and thanked her, remembering her presence as a healing act of caring and kindness (Doona et al., 1999).
Patricia Benner was essential in developing the concept of presence in contemporary nursing (Benner, 1984). She denoted the verb "presencing" as one of the eight competencies of the helping role of the nurse. Benner explained that nurses are often trained to believe they are most effective when doing for a patient, failing to recognize that being with the patient can be equally, if not more, therapeutic overall. In Benner's theory, professional maturity, either innately or with experience, permits the nurse to immerse oneself in a more meaningful exchange (Benner, 1984). The novice nurse, lacking in this capacity, may need guidance or permission from an expert nurse prior to understanding the great significance of presence as a treatment modality. Nursing scholars have recently explained presence and its value in nursing as the ability to create space allowing the patient to be in deep contact with their suffering while sharing and assisting them to find their own way through their health care experience (Zyblock, 2010). Regardless of the time or the proximity, being present requires a meaningful exchange between the patient and the nurse.

Defining Attributes/Empirical Referents
The literature review displays the interconnectivity as well as the diversity of what presence may represent to the individual. It displays observations and experiences of a range of sensatory and kinesthetic perceptions to identify the attributes discerning the concept of presence. As often the case, the defining attributes and the empirical referents are identical (Walker & Avant, 2011).
Attributes of spiritual presence require a person or culture's need to cultivate an awareness of a higher power through relationship with deity and the communion of fellow believers. This includes the perception of comfort and hope by a presence that transcends human understanding. The antecedents are a personal belief system of awareness and acceptance often inherent from the individual's cultural religious customs indigenous to their heritage. One must choose to be open to the desire for a spiritual shared relationship and the need for a spiritual presence (Easter, 2000). Consequences are solace, hope, and a richer spiritual union with the human experience. Life is given a deeper sense of meaning with a feeling of the heart and mind open to the warmth of unconditional love and acceptance. Spirituality continues to evolve according to life experiences, environment, and maturing perceptions. Spiritual presence may be based or measured by sensory, emotional, or philosophical perceptions. Spiritual aspects of presence have been acknowledged as a human attribute, individually manifested and expressed as life is lived integrating mind, body, and spirit (Meraviglia, 1999).
Attributes of literary presence requires the participant's desire to take part in the experience to the degree they so choose. Thus, the perception or illusion of any presence is that which is transformed into reality by the artists who create and tell their story. Additional attributes of literary presence would be based on visual or auditory cues that impact the viewer's memory, emotion, observation, and beliefs. The antecedent is the willingness to immerse oneself into the given form, then emotionally engaging. This initiates the consequence; development of a personal relationship followed by an emotional response of knowing, being, or doing. A distinguishable literary consequence is the ability to allow the belief that one is currently, or has been somewhere, in the presence of people, objects, or emotions that do not actually exist. A willingness to allow one's imagination to go beyond the here and now in an acknowledged occurrence is well stated by Rilke written in a letter: "Ultimately there is only one poet, that infinite one who makes himself felt, here and there through the ages, in a mind that can surrender to him" Rilke's letter (as cited in Gass, 1999, p. 183). This evokes the impression of a resilient defining attribute of presence by the poet.
The attributes of presence in psychology includes physical and/or emotional proximity that is created by developing trust and rapport among the therapist and the client, evidenced by unconditional and positive regard from the therapist (Rogers, 2007). Antecedents are the client's need for help, and the clinician's willingness to immerse themselves into an empathetic understanding of the client's vulnerability. Psychological presence in therapy attributes toward the client's increased ability to cope thus improving a reciprocal sense of well-being and self-esteem for the client and the therapist.
The above model (see Figure 1) displays the primary implications for practice. Nursing presence is circular; it is complex and contextual, not a boxy structure with linear objectives. The circle is divided, yet is also whole. Each part of the circle interconnects; there is no beginning or end. Any portion is made more valuable when genuine presence occurs. The connecting boxes hold various words that add perception to, yet anchor the concept. Each word, each entity individually has the capacity to hold a solitary meaning. As a continuum, the model reveals the value of interconnectivity of nursing presence.
Nursing attributes may include, but are not limited to, self-giving and a healing connection with the patient. An awareness of the nurse and development of rapport is required. Certain authors addressed physical, emotional, and/or a spiritual need of another, in addition to patient openness to be antecedents needed to allow for nursing presence (Doona et al., 1999). Parse's view of nursing is that the client is the authority figure and by the nurse being an interpersonal guide, she or he maintains a loving presence with the patient to promote health and quality of life (Parse, 2002). Many others see nursing presence as a reciprocal act of mutuality lead by the need and willingness of the patient in congruence with the nurse's authentic commitment to be fully attentive.
This may include eye-to-eye contact, physical touch, listening, acknowledging, and respecting belief systems, and recognizing that the patient and their family are doing the best they can with their given situation. Assessing whether the patient's greatest need at the time is being with or doing for subsequently allowing for times of silence while sitting with the patient or praying/meditating with the patient may be equally therapeutic. An all-encompassing term for these may be empathy or caring.
Nursing presence has been recognized as one of the key components of quality health care by multiple nursing scholars, defining authentic presence as the ability to be in the moment with the patient. Mature nursing discernment is crucial to enact an innate sense of awareness beyond basic physical needs, creating a healing milieu for all. It is imperative that all components of presence be scrutinized as health care leaders plan for the future into a new paradigm of health care.

Personal Definition
Based on the research, genuine nursing presence consists of being with another individual, deeply listening, not conditional on what to do or say next, while remaining in the intimacy of the moment. Presence implies that the nurse permits oneself to be open and vulnerable to their patient, their patients' families and fellow nurses. It incorporates a vulnerability of sharing healing and suffering, joys and fears. It is making a connection through compassionate communion while tending to the patient's needs. Depending on the context of the nursing care, this could consist of a gentle pat, a nodding assurance or other forms that display a meaningful encounter toward the individual, all while being emotionally available. Presence in nursing is an integral and mutual exchange among nurses and patients that involves attentiveness, empathy, and the mature recognition of the nurse's and the patient's holistic needs.

Model Case
A nurse working in an outpatient diabetes center sees a man in his mid-50s with type 2 diabetes, hypertension, heart disease, and neuropathy to discuss initiating the use of insulin. This patient had been in a basic diabetes class 2 years prior to this visit. His wife was with him for the class but she was not at the most recent visit. During the class he presented as a jovial, confident person who was at the class "because his doctor sent the order and his wife wanted him to attend." He interacted with the other patients and the educators.
He stated that he and his wife had already begun making subtle lifestyle changes to improve their health. He was attempting to walk during his breaks at work and had lost five pounds by changing his regular soda to diet and bringing his lunch in lieu of eating out. He had made further positive goals and established a health plan of action with the diabetes educators by the end of the class and scheduled a follow-up appointment. The class evaluation said that he enjoyed the dialogue in the class and appreciated "not being nagged at." It appeared that rapport had been established.
The patient's scheduled follow-up appointment did not occur. He had lost his job and insurance; yet was encouraged to continue to call, email, or attend the monthly support group. He was lost to follow up until he was able to receive a scholarship through the local free clinic. On this visit he presented alone, sullen and withdrawn and very quiet. The nurse was aware through the patient's records that his wife had suddenly passed away soon after the class, and he had been unable to find employment. He had experienced a continuous decline in health with numerous emergency room visits documented since the last 9 months.
Prior to the nurse initiating instruction for the insulin administration, she asked him if there was anything else he wanted to discuss. Initially, he bowed his head. His face reddened and he placed his hands on the arms of the chair as if might be leave. The nurse sat in silence awaiting his next cue. He proceeded to tell the nurse how angry he was with himself and God and he was just waiting for her to be like the nurse in the emergency room who told him if he was not so "non-compliant" that he would not have to start on insulin. The nurse allowed him to vent then told him how sorry she was for all of his loss and misfortune. She conveyed she did not intend to place any judgment; she just wanted to know what might be most helpful for today's visit. He stated that he "just wanted to know how to feel better." The nurse asked if he might consider seeing a therapist. He did not feel he could afford this and was not aware of free services in his community until made aware by the nurse. He was also given a list of other health care resources available for uninsured patients. The nurse told him that there were other patients who had some of the same concerns at the diabetes support group and asked if it would be okay to enroll him for the next session. She then explained the progression of diabetes and its precipitators including stressors and asked if he was ready to learn about his insulin. He agreed stating that "he was not thrilled but would give it a try."

Consequences
Consequences included a greater sense of satisfaction and well-being for the patient and for the nurse (McKivergin, 2005). Presence facilitated holistic wellness, body, mind, and spirit. Both the nurse and the patient experienced a heightened sense of hope, motivation, and empowerment resulting in improved health for the patient and reduced incidence of moral distress, compassion fatigue, and burnout for the nurse.
This case includes defining attributes and the consequences of authentic nursing presence. The patient presented in need with rapport established in the prior visit. Being aware of the patient's distress, she sat attentively and listened to his concerns, making eye contact and nodding her head, yet remaining silent. While offering condolences without judgment, opportunity for a mutual and authentic sense of presence was established, allowing a therapeutic sense of comfort for the patient. These attributes aided with improved physical, emotional, and spiritual health, which in turn led to empowerment, hope, and improved health for the patient and the nurse. Had the nurse chosen to be inattentive, continuing with a regimented agenda, this could have easily become a contrary case.
Nursing scholars have identified physical, emotional, and/or a spiritual need of another, along with patient openness as antecedents to nursing presence. Parse's view of nursing is that the client is the authority figure, with nurses being an interpersonal guide, maintaining a loving presence with the patient to promote health and quality of life (Parse, 2002). Nursing presence is reciprocal act of mutuality led by the need and willingness of the patient in congruence with the nurse's authentic commitment to be fully attentive. The antecedent would be the nurse's recognition and intrinsic value of the patient's holistic needs (Zyblock, 2010).

Summary
As previously mentioned, there continues be fewer nurses available, who are often caring for much sicker patients. Value is often placed only on tasks that can be measured, leaving behind the authentic essence of nursing; this being the privilege of reciprocal, meaningful, and healing relationship. Holistic nurses have experienced the benefits of implementing presence as a valid and important nursing instrument (McKivergin, 2005). Clarifying the meaning and the value of presence in nursing invites the probability of additional evidence-based research that will place intrinsic value of presence as a theoretical foundation in all nursing realms.
There is increasing data validating that patient's emotional and spiritual health correlates with their physical health. In the report, Complementary and Alternative Medicine in the United States, the Institute of Medicine acknowledged that comprehensive care encourages a focus on healing, recognizing the importance of compassion and caring (Helming, Barrere, Avino, & Shields, 2014). They appeal that health professionals take into account emotional needs implementing strategies to enhance prevention and health promotion. As nursing moves forward, there is an opportunity to incorporate presence as a core value that enhances health promotion and restoration, integrating a relationship-centered modality of health promotion and restoration.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research and/or authorship of this article.