Are you looking for the perfect gift for a nurse on your holiday list? Or, are you looking for a book that is entirely consistent with the vision of the NurseManifest values and ideals? Are you still struggling to clearly answer the nagging question: what is nursing? Or do you just need inspiration? Look no further this book is the perfect choice – How to Nurse: Relational Inquiry with Individuals and Families in Shifting Contexts. I reviewed this book for this blog back in January, but I continue to be inspired and encouraged by this book and decided that now is a perfect time to once again bring this book to the attention of NurseManifestors! Right at the outset, the authors Gwenneth Hartwick Doane and Colleen Varcoe explain what they mean by the term “relational,” and in so doing reveal the close connection with NurseManifest values:
When we use the word “relational” and speak of a relational inquiry approach to nursing practice, many people think we are merely emphasizing the touchy-feely, emotional side of nursing and particularly “nurse–patient” relationships. However, relational inquiry is far more encompassing than that. Although relationships between people are certainly part of relational inquiry, in this book, the term “relational” refers to the complex interplay of human life, the world, and nursing practice. Specifically, relational inquiry involves highly reasoned, skilled action. Relational inquiry requires (a) a thorough and sound knowledge base; (b) sophisticated inquiry and observational and analytical skills; (c) strong clinical skills including clinical judgment, decision-making skills, and clinical competencies; and knowledge and skills. Rather, a relational consciousness highlights the interplay of a number of factors affecting the point-of-care . . . . This heightened awareness enables more informed decisions and more effective action.
Overall, a relational consciousness
• Sensitizes us to the relational complexities that affect what happens at the point-of-care
• Directs attention toward the “relational transactions” that are occurring within and among people and contexts
• Enables us to be very intentional and consciously choose how to act in response to these complexities and transactions
Specifically, relational consciousness is the action of being mindfully
aware of the relational complexities that are at play in a situation and
intentionally and skillfully working in response to those relational complexities.
(Doane, Gweneth Hartrick; Varcoe, Colleen (2013-12-30). How to Nurse (Page 3-5). LWW. Kindle Edition.)
I cannot recommend this book highly enough! In addition to this kind of explanation of the principles on which nursing is based, the book is loaded with examples and real-life activities that emphasize what this means in very practical terms.
Let’s start a lively discussion here about the insights that this book offers, and add more insights related to the connections between the perspectives this book offers and our own NurseManifest vision!
4 thoughts on “How to Nurse”
Hmmmm, as always, I am led to inquire how the book addresses the issues of clinical and financial management of care in contexts where each patient arrives with different benefits available? How does the book address the circumstances in which otherwise clinically indistinguishable clients arrive with severe financial constraints on care, when some clients arrive with very sparse benefits, while some arrive with quite generous benefits? Clearly this translates to different lengths of stay, different treatment protocols, different pharmacological options, different post-acute care options (LTC, Rehab and Home health options) and markedly different outcomes.
As well, how does the book address the more complicated economic and clinical implications of insurance risk transferring health care finance mechanisms (Capitation-like health care finance mechanisms, the Medicare/Medicaid Prospective Payment Systems and Profit/Risk sharing agreements that place these relational inquiring nurses, and other health professionals, in roles as their patients insurance benefit claims agents?
Can relational inquirers succeed in the absence of understanding and specifically addressing how health care finance mechanisms impact care at the national, state, local, facility, division, unit and individual nurse level?,
I have been looking for an Index or Table of Contents to satisfy my curiosity – perhaps you can add one to the thread?
Thank you for raising the questions you have. A central premise of relational inquiry is that patient well-being, nurse well-being and system well-being are intricately connected and thus attention to all three is vital. One of the central goals of our book is to bring attention to ‘context’ and the very real inequities that both disadvantage people in their everyday lives and shape the quality of health care they receive. Relational inquiry is, in its very essence, a process that intentionally focuses attention on how contextual structures (such as ‘health care finance mechanisms’) shape what happens at point-of-care (and impacts the intrapersonal and interpersonal levels). As you say, an understanding of the impact of structural mechanisms at the varying levels is crucial. Thus, throughout the book we offer tools to enable nurses to develop this understanding so it can inform their clinical decision-making and action in specific situations.
Within your own American context you are identifying structures in health insurance funding that lead to inequitable access and care. While these structures vary in other countries (for example, in Canada we have publically funded health care) attention to economic values/structures is most definitely part of the relational inquiry process since those structures will, in some way, always impact the care patients receive, the resources and limitations nurses experience, etc.. However, throughout the book we emphasize the specific and ‘situated’ nature of relational inquiry since, for example, structural mechanisms such as health care funding mechanisms are unique to specific contexts (e.g. country, state, municipality). Thus, while you won’t find a general analysis of “ implications of insurance risk transferring health care finance mechanisms” you will find tools that draw explicit attention to how structures such as local, state, and global political economies shape health care.
Basically the relational inquiry process and tools are intended to be used by nurses in their own specific circumstances to enhance their understanding and also their ability to act as responsively and as response-able as possible in light of the very real limitations in their specific contexts of care. Within contemporary health care milieus nurses can feel very powerless to affect what happens for patients especially when inequities and structural limitations exist. Relational inquiry is intended to enable them to access the power and choice they actually do have to navigate and hopefully impact well-being at all levels.
Overall relational inquiry is offered as a pragmatic tool that nurses can ‘put to work’ to help them navigate complex situations and discern responsive action. In that pragmatic spirit, the worth and usefulness of the tools can only be determined by the person enlisting them. The evaluative question is the extent to which they result in more responsive action and aid in changing realities (James, 1907). Along that line, this term I have been using the book in an on-line course with RN students from across Canada who are pursuing their BSN degree. The course is structured as a ‘practice inquiry’ where they try out the ideas/tools in their current clinical work. Each time I teach this course I find myself amazed at the imaginative capacity nurses have to envision and affect change. Basically relational inquiry simply helps them tap into that imaginative capacity. There are four frequent things that are said to me at the end of the course (once they have had a chance to play with the tools, try them out a bit and experience their own imaginative capacity and the possibilities within their own power). First they find themselves amazed at what they have never taken into consideration before (for example, how they were blind to inequities, the capacity they do have affect what is happening for patients, the importance of contextual elements etc). Second, they often comment how relational inquiry has helped them to reconnect with why they became a nurse (reconnect with their nursing values and imperatives and what matters). Third, most feel a renewed confidence and ability to intervene in impactful ways—in fact many actually experience doing so in their clinical context while in the course. Fourth, they feel committed and able to make their actions count in some way so that at the end of the day they can go home feeling they have somehow ‘done good.’
James W. (1907). Pragmatism. A New Name for Some Old Ways of Thinking. New York: Longmans, Green & Co.
Do you consider Relational Inquiry a mid-range Nursing theory? or a nursing theory at all? and how would you compare it Peplau’s Interpersonal Relations theory?
This reply from Gwenneth Doane:
Thank you for your thoughtful questions. The question of whether I consider relational inquiry a theory is an interesting one. While we explicitly articulate our perspective of person, health, environment and focus/purpose of nursing and thus it might be viewed as a theory, relational inquiry is grounded in a pragmatist orientation in which theorizing is a living process. Colleen and I have outlined our pragmatic orientation to theorizing relational inquiry in a 2005 ANS article titled “Toward compassionate action: pragmatism and the inseparability of theory/practice” (Vol. 28, No. 1, pp. 81–90). That paper explains how we view theory and how that translates in terms of relational inquiry. Personally I think of relational theory as a heuristic that can inform and guide practice and that is how I teach it and how I seek to enact it. For example, educationally it is the heuristic that informs my work as a teacher whether that be teaching undergraduate students, graduate students at different levels, doing faculty development and so forth. In essence it is a way of orienting and directing attention in such a way that opens and expands one’s view and offers potential actions that will foster well-being while honoring and addressing the complexities of a situation. One example of how I do that is In a third-year undergraduate nursing theory course where I actually introduce students to relational inquiry and we use it as a heuristic to critically examine and analyze various nursing theories in light of their practice goals and aspirations. In this process I invite students to bring actual situations they have experienced and/or observed during their nursing program—situations where they had great concerns about what happened or did not happen for a patient, situations where what they had been taught about ‘good’ nursing did not line up with what happened, situations that still haunt them, situations they felt powerless or lacking the ‘know-how’ to address, etc. Through a relational inquiry orientation we simulate the situations and ‘think through’ how different theories might orient and inform their nursing practice. So the students have the opportunity to translate and work in a very practical way with the theories (again this is a pragmatist orientation here) and to consider how theory might inform their own nursing actions. It also offers the opportunity for students to develop their higher order thinking, ground their practice in inquiry (knowing/not knowing) and experience how the relational inquiry process can provide a foundation for informed improvisation.
With regard to Peplau’s theory there are resonances in terms of shared concerns and some shared premises. Perhaps one aspect that is distinct is that Peplau focuses on the interpersonal domain while we have very purposefully and explicitly sought to bring a three-dimensional inquiry orientation (intrapersonal, interpersonal, contextual) and a critical analytic lens that considers the interplay between them. I hope this is helpful in answering your questions.