Pause for a moment and try to think of a time when you are not in relation. If you think carefully, you will probably realize that regardless of whether you are seemingly alone in a solitary activity (eg, walking in a forest or shopping by yourself at the mall) or visibly interacting with other people you are always relating to yourself, to others, and to your surroundings in some way. Think of how, even at the physiological level, we are relationally interconnected. For example, breathing is a relational process—as we inhale and exhale, we are communing with whatever is in the air be it visible or invisible. Moreover, as we interact by breathing, we are being shaped by the air we inhale and affecting the air others breathe by what we exhale.
Simply put, as living, breathing beings, it is impossible to not relate.1 I begin my discussion with this simple observation because it has profound implications for how we understand relationships and health and what I am inviting you to consider as you ponder the articles in this Advances in Nursing Science issue on Relationships and Health. For example, if at our very core as human beings we live and exist relationally, would it not be vital to consider that relational interplay if we are to promote health? As nurses, might we need to move beyond the decontextualized, individualist orientation that currently dominates health care? Family offers a simple example. The field of family nursing has been developed on the basis of the understanding that families exert real effects on people and those effects can be positive or negative. However, when we consider family in light of the relational nature of human existence, it becomes evident that we need to go further than considering family in its literal sense. Given that family is a central organizing structure for society, people and their health experiences are highly influenced by their relational experience of “family,” regardless of the extent to which they are involved with any actual family.2–4
While it is vital to consider the relational world of the people/families we care for, I wish to focus my attention most concertedly on how nursing relationships have the potential to affect health. While the impact of decontextualized neutrality (central to Western neoliberal ideology) on nursing knowledge and practice has received a fair bit of attention and critique throughout the past decade, critically considering its legacy in shaping how we typically understand relational practice in nursing is crucial.4–6 For example, relational practice is most often understood within the confines of an individualist perspective that focuses on the interpersonal level of the nurse-patient relationship apart from the ideologies and norms of the larger health care context. Relational concepts such as trust, empathy, and presence are neither conceptually nor practically linked to issues of social justice, equity, ethics, or safe, competent practice.6,7 Moreover, there is the assumption that nursing relationships are health-promoting (at best) or neutral (at worst). However, interpersonal nursing relationships are anything but neutral, in terms of both experiential impact and health outcomes.5 They can have very real beneficial or deleterious effects on people's/families' health.
Yet, often we go about our nursing work in relational oblivion, ignoring relationships or assuming that they are somehow separate from other aspects of nursing. Relationships are often discussed and understood as the “soft” part of nursing—the touchy, feely stuff that one does when one has time. This understanding stands in stark contrast to the rich history of scholarship in nursing that illuminates how nursing is a skillful relational process (eg, the “all-at-once” of nursing so eloquently described by Josephine Paterson and Loretta Zderad8 and Margaret Newman's9 theory of health as expanding consciousness). How is it then that after 40 years of relational scholarship and discussion we still hear nurses say “I don't have time to relate to my patients?” Moreover, how is it that we nursing faculty are ourselves unclear about how relational knowledge is integral to every nursing action including the translation of any “hard, evidence-based, empirical” knowledge?
I believe that to consider relationships and health in nursing requires that we take an up close and personal look at how we relate. It also requires that we consider what is shaping and informing our understanding and enactment of relational practice in nursing. Importantly, we need to look beyond the interpersonal level to the interrelationship between intrapersonal, interpersonal, and contextual domains.4,7 We need to more consciously consider how meaning, intersubjectivity, and context are integrally related and how broader ideologies, norms, and discourses shape and influence relational action. Meaningful health-promoting nursing action can occur in any amount of time—it all depends on how you relate in the time you have. At its very core, skilled relational action is a practice of attention—honed, informed, conscious attention that involves the highly reasoned ability to simultaneously (a) enlist observational, analytic, and clinical skills to discern the most significant aspects of the situation, (b) enlist multiple forms of knowledge as we interact with patients/families across contexts of care, and (c) respond in an informed and compassionate manner.4,10
As you read the articles in this issue and seek to further your knowledge about relationships and health, I invite you to consider 2 basic contentions: (a) relating is not an option—it is a core function of every moment; and (b) how we relate shapes everything we experience, do, accomplish, and contribute in the moments we live (and practice as nurses). Who/what are you bringing to the relational moment? What assumptions about the nature of being and the nature of reality are embedded within you and shaping how you relate? What do you focus your attention on and privilege? Are you conscious of what, who, why, when, and where you are relating and whether your nursing actions are aligned to your health-promoting goals? Do you focus your attention on the interrelatedness of people's experiences—on how their health concerns are related to their personal aspirations and life situation? Do you notice how your responses and actions flow out of your own (intrapersonal) values, beliefs, and imperatives? How might your interpersonal actions be promoting/impeding health? Can you see how normative ideologies and systemic (contextual) forces are shaping you and the patients/families you care for?
As you ponder these relational questions of nursing, I invite you to join me in reimagining (and hopefully re-creating) current understandings of relational nursing knowledge/practice. What if we understood relating as the most fundamental, yet simultaneously advanced, aspect of nursing practice? What if we understood relating as an act that requires the skill to integrate and translate multiple forms of knowledge, discern what is most salient, and make the “best” clinical decisions? What if we understood the process of relating as the site where the art and science of nursing become one action? What if we understood relational practice as nursing competence in its fullest sense?4
Roach11 has described competence as having the knowledge, judgment, skills, energy, experience, and motivation to respond adequately. If nursing is seen as a relational practice, competence is clearly person/context-dependent and is determined by what relationally transpires in particular health care situations.4 In this view, reimagining relational practice requires that we both look beyond an individualist view of patients/families and reconsider our understanding of competent nursing practice. We are called to move out of relational oblivion and heighten our response-ability, becoming practitioners who continually scrutinize ourselves and our surroundings—including the knowledge and sensibilities we are drawing upon to enact ourselves as knowledgeable, compassionate, and competent nurses. Cultivating relational consciousness as the foundational intelligence that orients and guides us as nurses,10 we see that we do not have a choice about whether we relate. However, we always have a choice about how we relate. And those relational choices are perhaps the most impactful health-promoting decisions we will ever make as nurses.
—Gweneth Hartrick-Doane, PhD, RN
1. Hartrick G. Beyond interpersonal communication: The significance of relationship in health promoting practice. In: Young L, Hayes V, eds. Transforming Health Promoting Practice. Philadelphia, PA: FA Davis; 2002:49–58.
2. Hartrick-Doane G. Through pragmatic eyes: philosophy and the re-sourcing of family nursing. Nurs Philos. 2003;4(1):25–32.
3. Hartrick-Doane G, Varcoe C. Family Nursing As Relational Inquiry. Developing Health Promoting Practice. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
4. Hartrick-Doane G, Varcoe C. How to Nurse. Relational Inquiry With Individuals and Families in Changing Health and Health Care Contexts. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.
5. Brown H. The Face to Face Is Not So Innocent: Into Interpersonal Spaces of Maternal-Infant Care. Victoria, BC, Canada: University of Victoria; 2008.
6. Hartrick-Doane G, Brown H. Reconceptualizing learning in nursing: taking an ontological turn. J Nurs Educ. 2011;50(1):21–26.
7. Hartrick-Doane G, Varcoe C. Relational practice and nursing obligations. ANS Adv Nurs Sci. 2007;30(3):192–205.
8. Paterson JG, Zderad LT. Humanistic Nursing. New York, NY: John Wiley & Sons; 1976.
9. Newman MA. Health as Expanding Consciousness. 2nd ed. Sudbury, MA: Jones & Bartlett; 1999.
10. Hartrick-Doane G. Cultivating relational consciousness in social justice practice. In: Kagan PN, Smith MC, Chinn PL, eds. Philosophies and Practices of Emancipatory Nursing: Social Justice as Praxis. New York, NY: Routledge; in press.
11. Roach MS. The Human Act of Caring: A Blueprint for the Health Professions. Ottawa, ON, Canada: Canadian Hospital Association Press; 1987.