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Nursing culture is situated within organizational culture that is further situated within the overarching culture of the health care system. Another critical component of this configuration is the client culture – a cross-cultural field of people from all walks of life, experiencing a variety of diverse health challenges, who are usually surrounded by and supported by their unique families and significant others. “Nurses, because of the nature of their work, have the rare opportunity to experience life in ways few have the privilege. They are present at birthing, birth, across the lifespan, in schools, homes, churches, neighborhood gatherings, work settings, and again at death and dying” (Wesorick, 2002, p. 31). This client field is the arena where nursing culture is ultimately performed; ideally as a dance of reciprocity between client and nurse; a dialogic partnership that forms as nursing care is delivered and received (Jonsdottir, Litchfield & Dexheimer, 2004). It is safe to say that the majority of nurses would prefer that these client-nurse relations be enacted in an atmosphere of calm, healing, caring, and respect, according to the client's preferences and needs. Unfortunately, the situation is often very different than the ideal.
“Traditional nursing culture with a focus on task orientation, rigid hierarchical structures and resultant disempowerment of staff is an impediment to delivery of patient-centered care. The rituals, routines, and cultures that have developed in nursing serve to prevent nursing from achieving this ideal model of care. Rigid hierarchical structures, disempowerment, the routinism of care combined with negative nursing attitudes, behaviours and language dehumanize nursing and reduce care to a series of tasks. Nursing cultures that allow nurses to nurse must center on the patient and their long-term needs and wishes” (Tonuma & Winbolt, 2000, p. 214). All too often, “patients are seen as problems to be corrected rather than mysteries to behold and attend to” (Jonsdottir, Litchfield & Dexheimer, 2004, p. 241).
The service delivery model that governs much of present day health care forces nurses to direct their focus on the management of treatments, and adhering to schedules rather than spending the time needed to develop a relational bond with clients, and creating space for clients to get in touch with their own feelings, experience, and ways of dealing with their illness or trauma. The biomedical approach that is still prevalent in most health care institutions limits client input into the construction, evaluation, and experience of their own illness experience. Biomedical approaches to illness decontextualize disease, making it very difficult to fully co-plan healing activities with clients, or move beyond the assembly-line approach so common in hospital unit schedules and procedure manuals (Faber, De Castell & Bryson, 2003). Nurses are educated and able to provide much more than pathophysiological care, but the context and situatedness of the caring space has to be conducive to this. Nurses need to join with clients in a process of collaboratively seeking meaning in their complex and often chaotic health circumstances, to adopt a participatory stance (Jonsdottir, Litchfield & Dexheimer, 2004).
Most nursing graduates who enter the world of present day nurses have been well versed in forming dialogic relations with their clients. They know how to be fully present with their clients, with full attentiveness, unconditional warm regard, be mutually responsive yet non-directive, stepping back and letting the client lead the dialogue to reach a deeper understanding of their health and the illness challenges that they are currently experiencing. Ideally, in a co-participant way, “The nurse, having no prescriptive agenda other than attending to what is going on for the patient in their health predicaments, embraces whatever emerges and goes with the conversational flow as new meaning unfolds” (Jonsdottir, Litchfield & Dexheimer, 2004, p. 243). Wesorick described five characteristics of relational dialogue that can be incorporated into nursing culture for peer and/or client communication:
This form of attentive dialogue and caring presence leads to insight as action, which allows the nurse to understand the meaning of health and the illness experience from the client's point of view. Actions are not predicted beforehand, but emerge from the dialogic relationship. “From a sociocultural standpoint, person and environment combine to create the action taking place and the agency by means of which it is accomplished – there is no such thing as a person in isolation” (Faber, De Castell & Bryson, 2003, p. 145). All too often, despite the best efforts of nurses to the contrary, clients are left out of the discourse that surrounds and officiates the planning of nursing care. Even the language used to describe the recipients of care is unsupportive in the hospital environment. Most nursing students are encultured to name these receivers as “clients” rather than “patients”. Yet, in the work culture common in Western society, most are still called “patients”. “All language has a cultural and historical base and the word patient is no exception. Few would argue that in this society patient denotes notions of ill health, passivity, pain, sadness, and someone in need of care. Being labeled as a patient affects both how people act and how others react to them. Thus, being in the position of patient is often negative and disempowering” (p. 148). 
Clients may lack the biomedical or pathophysiological “knowledge” about their health challenge, but all are acutely aware of their own experience of the event. Yet, this knowledge is not often acknowledged as part of the care discourse (Faber et al, 2003). “For the sick person, the potential to express experience and be listened to is a condition upon which trust in care provision is founded” (Skott, 2001, p. 249). The discourse concerning health challenges is localized in social relations and linguistic practice. Nurses are challenged to dissolve the barriers that separate “the socially established explanatory model (biomedicine), the mediating institution in which care takes place (the health care institution), and the individual's embodied experience of illness and nursing care – experience expressed in conversation and narrative” ( p. 249). 
Clients experience health challenges as painful disintegrations of both self and their personal world in everyday life. Most often, help is needed to heal this “lived disintegration of body, world, and self” (Skott, 2001, p. 249). Nurses need to listen to their client's narrative with a caring, professional and ethical approach that does not privilege biomedical knowledge. “The nurse is often required to take on a role as interpreter and mediator when the linguistic order of medicine meets the personal experience of sickness clothed in narrative language. Biomedical knowledge and personal experience represent two different arenas of knowledge, both of which are real and meaningful” (Skott, 2001, p. 250). 
Medical science and the biomedical approach often exhibited within nursing culture formulates the human body and illness in a culturally distinctive manner, and constructs the work world in a particular way. All too often, nurses and other health care professionals accept the objective biomedical “facts” as the reality of illness, but experienced illness is actually quite different. “For the nurse to provide holistic care even at its most elementary level, stepping outside the purely biomedical, objectifying and essentially modernist approach is essential” (Huntington & Gilmour, 2001, p. 906). The human body and disease are represented according to biomedical science as 'naturally biological' but biology does not exist outside culture (Skott, 2001, p. 250). Within the biomedical paradigm, client care is provided as if it were a commodity, thus suffering becomes a technical problem, “which utterly transforms its existential root. It is enacted within a context of power relations, and the experience of suffering is transformed: the political becomes the medical” (Skott, 2001, p. 251). This makes it very difficult to find both the time and space to fully engage in the client's personal experience of illness, since this experience is shaped in a specific context where social and cultural forces are integrated in a biomedical discourse, one that is foreign to most clients. 
Despite the harried pace of the common hospital context, it is important that nurses cultivate a cultural construction of sickness from the client's perspective (Skott, 2001). An important part of this cultivation is the assurance of caring, demonstrated by authentic caring presence. Caring presence is a state of being most readily observed through the bodily, sentient, enunciated caring behaviours demonstrated by nurses who ensure that they take the time to form a relationship with their clients.
“Caring presence is mutual trust and sharing, transcending connectedness, and experience. This special way of being, a caring presence, involves devotion to a client's well-being while bringing scientific knowledge and expertise to the relationship” (Covington, 2005, p. 169). Clients pick up cues from nurses and can perceive whether they are authentically present or merely performing the care tasks in a mechanical way. A client's whole lifeworld is altered with hospitalization, and they need and long for an attentive caring presence coupled with true compassion that allows them to explore and find meaning in their illness experience (Lindholm & Eriksson, 1993). Together, the client and nurse “shape and create multidimensional cultural structures” (Suominen, Kovasin & Ketola, 1997, p. 188).
Inherent to caring presence is an attitude of sensitivity, a sense of life, and attentive and alert mindfulness: the ability to be and to act in the here and now, being totally present for the client. (Hunt, 2004). “The modus operandi of a sense of life in action is awareness of and attention to the life one has before one. It is mindfulness of this person's life here and now. The carer is entering into someone's life, not just manipulating it “from the outside”” (Hunt, 2004, p. 200). The moral work of nursing includes helping clients find meaning in their health challenge experience. Through caring presence, nurses can facilitate client agency to develop or regain the capacity to initiate meaningful action within their own lifeworld. This can support them to regain a sense of normalcy, to feel like once again, they have a life and a sense of agency, and to masterfully reoccupy social, cultural and political space. (Mendyka, 2000). Nurses demonstrate caring presence by “being there” for clients showing a willingness to relate to their experience; “being with” to enable the feeling of comfort, and “being in tune” while creating the future (Wallace & Appleton, 1995). “When a nurse is "with" us, in the sense of being present, we feel the security of her protective gaze, we feel valued as a person, the focus of her attention. We know we do not need to hide behind the suffering we experience-what we say or how we look will not change this attitude. The nurse has learned to look for the indicators of disease and pain. We sense the nurse is close enough to feel with us, sharing the loss that accompanies the dis-ease we are experiencing in a sensitive, intimate way. Her understanding is more than an intellectual exercise. She understands. When a nurse is truly present, seeing and feeling all these things, we sense a kind of hopefulness. The presence of someone hopeful provides a moment of companionship, a moment of being "with." For a moment, we are not alone” (Bottorff, 2002, p.4).
Another important aspect of caring presence is the use of gnostic and pathic touch (van Manen, 1989). The probing gnostic touch entails a skilled, technically aware touch where each movement is deliberate and calculated, in a caring yet somewhat depersonalized way. The gnostic touch is usually linked to the medical culture, but nurses also use it to measure vital signs, skin conditions, and such: applying empirical biomedical knowledge to the interpretation of what is felt. On the other hand, the pathic caring touch is a skilled touch of another kind. “This hand does not touch a body of blood vessels, muscles, nerves, and bones, but rather, it touches the body of a living person. This pathic caring hand is guided by a knowledge of a sensitive kind, a knowledge which has as its end thoughtful, caring action” (p. 2). With it, nurses touch the man, woman, child, or infant themselves, not their anatomical parts. It is an intimate, soothing, highly charged touch that is distinct from the personal touch associated with sensual intimacy. Through it, touch conveys the essence of comfort, compassion, caring, and hopeful support. “Thus, the caring hand that gently supports a patient as she turns to find a new position in bed does not touch the skin which encloses a body, but this hand touches the woman herself. The gentle contact of the hand and the woman's body is a direct contact between two human beings, the nurse “with” the patient” (Bottorff, 2002, p. 5). 
In the past two decades, a greater emphasis on community health care has been cultivated within health care culture. More and more, clients are seeking and receiving health services in community based clinics, drop-in centers, in their own homes, on-line, or through other specialized community programs. Nurses with community health and development expertise, as well as advocacy and change agent skills, often practice within these community contexts, engaging with clients within their own community environments. Community care is ideally provided in response to the expressed needs of the community in question, as well as the individual clients who frequent the services. “Cultural and contextual circumstances necessitate a critical appraisal of the needs of the community and the corresponding attributes of those who provide health-care services” (McKinstry & Trainor, 2004, p. 235). 
Clarke and Mass (1998) described client reactions to a small community based Nursing Centre developed in Western Canada as a pilot project to demonstrate holistic, innovative nursing practice in a community context. “Clients reported great satisfaction, especially with the collaborative nurse-client relationship, changes in their health behaviours and status, and ability to make and act on their own choices. Collaboration and empowerment were deemed to be core concepts of the nursing centre” (Clarke & Mass, 1998, p. 217). Although not readily embraced by other health care professionals, particularly physicians, the community that accessed the centre valued the nurses' expertise, mode of relating, and services which spurred the move to acquire further funding so that the centre could continue past the two year development funding stage. This initiative not only ensured that the nursing centre would remain in the community, but also helped the community members involved to develop coalition-building, advocacy and political action skills. 
The nursing culture described promoted healthy work relationships with other nurses and allied health professionals open to the project. The nurses also felt comfortable and free to develop intimate nurse-client relations and to engage in “shared planning, decision-making, and responsibility” with their clients (Clarke & Mass, 1998, p. 219). As each client initiated service contact with the nursing staff, they were invited to tell their own story, which enabled the client to explore their health concerns within the context of their own life-space, and find personal meaning from this exploration. It was clear from the start that the 
client was entering a partnership where they were in charge of the decisions that needed to be made, and that the nurses were there to support them, as directed by the client. This Nursing Centre is one example of how nurses and clients can meet in truly collaborative relations, and the clients' knowledge and experience can become part of the discourse of health care culture. It is also an excellent example of how advanced nursing knowledge and research can help nursing move into a position of more autonomy where nursing culture can truly be enacted in a holistic, healing way that advances the professional image and mandate, as well as widen cultural acceptance of nurses in both health care and the community at large. © June Kaminski, MSN PhD Student - Contact 2006
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