NUSC 1P12: Week 5 Relational Inquiry PDF

NUSC 1P12: WEEK 5 RELATIONAL INQUIRY “HOW TO NURSE” Doane & Varcoe, 2021, Chapter 1 (pp. 1-29) (posted on Brightspace) Last week we talked about theories and ‘ways of knowing’. How do we know what we know? How do we see what we see? What knowledge does nursing value? Today we will focus on a relat...

NUSC 1P12: WEEK 5 RELATIONAL INQUIRY “HOW TO NURSE” Doane & Varcoe, 2021, Chapter 1 (pp. 1-29) (posted on Brightspace) Last week we talked about theories and ‘ways of knowing’. How do we know what we know? How do we see what we see? What knowledge does nursing value? Today we will focus on a relational inquiry approach and ‘how to nurse”. OBJECTIVES oUnderstand relational inquiry (RI) as an approach to nursing practice oConsider how relational inquiry can address and support nurse well-being, patient/ family well-being, and the wellbeing of the health care system (self + other + context) oAppreciate how RI can help us explore and navigate the complexities and uncertainties of nursing practice WHAT IS RELATIONAL INQUIRY? RI is a highly reasoned (thinking), skilled action (doing) that involves: o a relational orientation o o a thorough and sound knowledge base o o curiosity, asking questions, being attentive, taking in and processing information as a situation is unfolding strong clinical skills including clinical judgment, decision-making skills, and clinical competencies o o knowledge gained through our inputs and ‘ways of knowing’, competence in what we know) sophisticated inquiry and observational and analytical skills o o perspective of self+other+context) we only see what we know, competence in what we do) particular ways of being o how we show up: includes compassion; commitment, or knowing why we are there and being there; corresponding, or relating to and with people in a way that is meaningful to them TWO KEY COMPONENTS OF RI RELATIONAL ORIENTATION INQUIRING ACTION RELATIONAL ORIENTATION A way of thinking and focusing our attention (on what is going on at and between the intrapersonal (self), interpersonal (others), and contextual (context) levels of a health care situation). • Note this goes beyond the interpersonal level of what is happening between and among individuals. o Intrapersonally: what is going on within all involved o within you, your patient, family members, colleagues (what is everyone feeling, how are all the individuals showing up? Scared/ worried, sad, frustrated, distracted, tired…) o Interpersonally: what is going on among and between people o how people are acting, any tensions, expressions of caring, what matters to who, who has power, what voices are being heard and silenced, what/who is being ignored (conscious or unconscious blindspots) o Contextually: what is going on around the people and situation o structures and forces influencing the situation and everyone involved (in the care setting, and in life in general beyond the health care situation) RELATIONAL ORIENTATION A relational orientation enables us to look beyond the surface(s) of people and situations to consider the unseen and/or ignored elements shaping what is transpiring. Example from p. 5 of standing on a balcony watching a dance, observing, being positioned (on balcony) and guided to intentionally turn your attention to the details (looking onto the dance floor) at the people, their attire, how they are moving, the experience they are having, the music, the surroundings, the floor, the lights, the space they have around each other… ORIENTATION... LET’S PRACTICE Let’s pay attention and orientate ourselves relationally in this moment. • What is going on for you (intrapersonal, self)? • Are you warm, cold, worried, relaxed, comfortable, hungry, thirsty, tired, focused, distracted? • What is shaping that at the contextual level (around you)? • Time and duration of class, did you have time before this to eat and drink something, did your roommates keep you up last night? What about the position of this content/ topic in relation to your learning in other courses and future learning in clinical? • What is going on between you and others around you (interpersonal)? • Are you sitting beside someone you know, are you worried you still haven’t had a chance to meet anyone, are you looking at how someone else is taking notes and wondering if you should try that way, are others in the room distracting you or those not in the room texting you? Can you see and hear me, and am I explaining this concept in a way that you can understand? INQUIRING ACTION • What does it mean to ’inquire’, to be an ‘inquirer’? • Inquiry-based nursing practice offers a way to get a wider and deeper understanding of a situation, helping us to determine what is most important and determine what else we may need to know to move forward with the best course of action. • “Inquiring” does not just mean asking questions of other people, but also of yourself and about other people. INQUIRING ACTION Example: Asking someone about their pain o How might you feeling impatient, distracted, rushed, focused, etc. influence this assessment? o What might influence your patient’s answer (fear, not wanting to seem weak, family member present and not wanting to worry them)? o What about the context, how does this shape you, the person, and the exchange (a private room, the triage desk, they just woke up, they are palliative, they are hoping to go home today)? o Veteran example of expression of pain RELATIONAL INQUIRY + INQUIRING ACTION o Together, a relational orientation and inquiring action help you consider how you and others are focusing your attention and how you are applying knowledge, making clinical decisions, and determining the “right” actions. o Think of attention, intention, and action o Helps us see how people, situations, contexts, environments, and processes are connected and influencing or shaping each other o what is happening, “the dance” o Helps us see how we ourselves are showing up, being present, responding, and relating in a situation o how we are o Informs our practice and how we respond within the complexities of relational realities o how we act, what we do REVIEW A SITUATION THAT BUGGED YOU (‘Try it Out’ 1.2, p. 6) THINK – PAIR – SHARE Think of a situation in your personal life that has bugged you (yesterday, last week…). Think of any situation where you felt bad, uncomfortable, disturbed, or unsettled. Purposefully look through an ”individualist lens” - see if you can ascribe as much responsibility as possible to the people involved, yourself + others (make it personcentered, zoom in). Imagine “blaming” particular individuals. Next, look at the situation with relational inquiry in mind (zoom out) and consider the following: • If you look “relationally”, how does your view change? • As you look “relationally”, do your thoughts about responsibility shift? • What intrapersonal elements do you consider? What interpersonal dynamics stand out? • How were all the players interrelating? How were they all “positioned” in the larger system? • What competing obligations were at play? What priorities were held by different people, or the system? • How did the interrelationships between self+other+context shape the situation? How does this expand your understanding? • What questions arise for you? How might you have responded to affect the situation? KNOWLEDGE & RELATIONAL INQUIRY Knowing: consider our overview of knowledge and “ways of knowing” from last week • Recall empirical knowing, theories, and the medical approach to health care • Does nursing and health care favor and privilege objective knowledge and equate empirical evidence with truth? • A ”pragmatic” approach enlists all forms of knowledge (all the inputs and ways of knowing) and focuses on the value of any knowledge in terms of its desired consequence (what it can do or achieve or add to a situation). • In RI, we do not assume any knowledge is right or certain simply because it has been “proven”, we explicitly consider the limitations and fallibility of any existing knowledge, recognizing the need for continual examination • For example, you may know the action, recommended dose, side effects etc. of a prescribed medication, but you don’t know how that patient will react to the medication, if it is the best medication for them, which side effects (if any) you should anticipate, etc. KNOWLEDGE & CONFIDENCE “Perhaps the primary challenge of learning to be a nurse is that of developing confidence in oneself as a knowledgeable, competent practitioner” (Doane & Varcoe, 2021, p. 8) • We may privilege/prioritize our professional expertise (clinical knowledge, empirical knowing) over other forms of knowledge (other ways of knowing) and the knowledge and perspectives of the people we care for • This narrow view can lead to assumptions and create blind spots causing us to overlook other forms of knowledge or key pieces of information vital to informed clinical decision making and action (doing the right thing) • Having a somewhat less confident approach to knowledge/ knowing and putting more confidence in your ability to inquire gives rise to safe, responsive nursing practice • Never lose sight of the fact that no matter how much you know, there is always the unknown, and that unknown can affect what happens (not knowing and uncertainty are inherent features of nursing) • How do you feel when you are faced with uncertainty? • If you were given permission to “not know”, how would you feel? “Since it is impossible to know-it-all and/or be certain about any knowledge, focusing on becoming a confident questioner and knowing hwo to work between what you know and do not know is a much more effective grounding for knowledgeable, competent practice” (Doane & Varcoe, 2021, p. 9) Examples: text pp. 8-9 of Colleen focusing on cardiac and respiratory systems and missing signs of bowel obstruction; not seeing phone; patient safety literature and admitting diagnosis A NURSING STANDPOINT • RI rests in the assumption that nursing and nursing knowledge can make a profound difference to patient/family well-being, nurse well-being, and system well-being • Nurses can feel powerless and devalued o Are you clear on the unique and vital contribution nurses do and can make? o What drew you to nursing? o What did you imagine yourself doing as a nurse? o What images and understandings of nursing did you come with? A NURSING STANDPOINT CONT’D o If we look at healthcare situations and identify the nursing care needed in those situations, and what you as nurses need to know, be, and do to provide that care, you can see the situation from a nursing perspective. “this is a whole new way of looking at my practice- it is like how to nurse patients is the focus, not just biomedical treatments- and that totally changes how I look at things and understand my role”. o One Doane & Varcoe’s students stated o A nursing standpoint highlights how the health needs to which a nurse responds are more comprehensive than just disease treatment (it is bigger/ more than interventions, medications, etc.) FOCUSING ATTENTION • Intentionally focusing your attention is a powerful strategy to bring to your nursing work (and your life in general, especially as a student!) • Imagine watching a good movie or playing a video game and losing awareness of yourself and your surroundings… • We have the ability to focus our attention outwardly • Similarly, we can focus so directly on ourselves and our own experience that we are not aware of what is going on around us • A nursing standpoint is important because it directs how and why we focus our attention, and this shapes the way we act • Attention is dynamic, we have the ability to narrowly focus or broadly expand our attention (zoom in or zoom out) • Let’s say it is your first day of clinical, you may focus on specific things that create a sense of orientation (e.g. things that look familiar from lab, supplies, hospital beds, medication cart, charts) • As someone new to that unit, you are more conscious of your actions and relate to your surroundings differently compared to someone who has worked there for years (“fresh eyes”) ATTENTION: LET’S PRACTICE o Scan the room slowly until something grabs your attention… o Why has your attention rested on that particular thing? o What was it that drew you toward it? o Once you focused your attention on that one object, did you start to notice new details in the object (upon closer inspection or consideration)? o How did focusing closely on one object (zooming in) limit your ability to see other objects (reduce your peripheral vision)? NURSING REFERENCE POINTS • Remember last week when we discussed “worldview”? The lens through which we see the world? • We all develop “reference points” based on our social locations (where we are, where we are from, where we have been) and backgrounds (life experiences, people, family, upbringing, culture, SDOH) and these reference points profoundly impact how we interpret the world around us, the value and meaning we assign to something, and the choices we make. • As a first-year nursing student, your reference points may be your own experiences with the healthcare system (personal and/or someone close to you), clinic/ER/hospital admissions. Maybe your reference points are also from TV. • These inputs shape your reference points which shape your thinking and how you focus your attention. NURSING REFERENCE POINTS • Remember from week 1 the definitions of health? What did you take away from that and internalize as your own definition of health? That serves as a reference point and creates a way of orienting and focusing your attention . • For example, you may be inclined to ask your patient about their struggles and challenges, their goals, forces influencing their health, their illness, etc. • Reference points can be easier to see in an unfamiliar context because we are relying on them more, so they slide into the forefront. • Think about your recent life changes. Starting university, entering nursing school, maybe moving away from home. Can you identify reference points you are using? • Reference points can become automatized and act as “shortcuts” in thinking that can be both helpful and limiting (for ex., if I do x, then y will happen… what if it doesn’t? Will you notice?) • Questioning the reference points that are shaping your attention, choices, and action is vital to the practice of nursing (not allowing them to become blinders or lead to assumptions). Story of Artur “A Frustrating Man” (Doane & Varcoe, 2021, pp. 14-15) NURSING IN THE CONTEXT OF COMPLEX CARE SETTINGS How does a nurse determine what ”ethical”, “safe”, “competent” and “healing/health promoting” care looks like in any/all situations? • Nurses work between their values and the values of others, between competing interests and obligations, and between nursing ideals and health care realities as they strive to provide quality care • RI is a way of working between the real and the ideal • RI is not about having the time necessary to practice in the way we would like, but rather making conscious choices about how to spend the time we have (by intentionally focusing our attention) • A form of action through which we can be in and navigate through the complexities of everyday practice, provide high quality care to patients and families, care for yourself, and respond to the limitations and challenges of the system in which you work (self+other+context) RELATIONAL INQUIRY & WELL-BEING • An individualist, decontextualized approach dominates nursing in most health care settings • An individualist approach focuses on individual (unique) patients and the individual (autonomous) nurses caring for them without considering influences that shape their actions and possibilities • Think critically about the pros and cons of “patient-centered” care? • Nurses often feel responsible for ensuring good care for their patients, regardless of the care setting. Nurses may feel powerless when faced with contextual constraints limiting what they can do for patients. This discrepancy often leads to a focus on what has not been provided, and it has been shown to have a very demoralizing impact (nurses carrying guilt and shame, feeling like they weren’t enough or didn’t do enough). Patient well-being, nurse well-being, and health care system well-being are intricately interwoven o related and dependent on one another, part of the same relational whole) Let’s consider a story and then look more closely at each of these three… To Illustrate: “All is Not Well” (Doane & Varcoe, 2021, pp. 22-23) PATIENT/FAMILY WELL-BEING Remember our definitions of health, health promotion, well-being, disease, illness, etc… • A dominant understanding of health has come from biomedicine that understands health as the “absence of disease or infirmity”, suggesting our mission is to keep individuals free of disease (prevent), or cure and treat disease (correct problems) to maintain health or return people to health • Remember our medical approach to health care? • Another prominent understanding of health is that it is “more than the absence of disease” and includes physical and emotional well-being. This view includes health-promoting nursing practice based on a behavioural perspective and emphasis is placed on changing behaviours and lifestyle to decrease disease risk and maintain well-being • Remember our behavioural approach to health care? PATIENT/FAMILY WELL-BEING Remember the “tipping point of context”? Then came along the Ottawa Charter of Health Promotion and this marked a shift to health determinants o Remember the socioenvironmental approach to health care? o RI is situated in a socio-environmental understanding of health and health promotion (recall how we discussed this approach and SDOH through the lens of relational practice, and an appreciation of ‘context’?) o Remember empowerment? RI is oriented toward enhancing the capacity and power of people to live meaningful lives. Of course, this may involve treating and preventing disease or promoting certain lifestyles, the primary motivation is to enhance people’s well-being and the capacity and resources for meaningful life experiences (health is a sociorelational experience strongly shaped by contextual factors). NURSE WELL-BEING • Nurses’ well-being also requires a socio-environmental approach • Emotional distress can build over time when nurses are unable to provide the kind of care they were educated to provide (Chachula, Myrick, & Yonge, 2015) • “New graduates who work in the hospital setting consistently express frustration and a sense of demoralization as a direct result of the dissonance they experience between their perception of nursing and what they find nursing to ‘really’ be” (Duchscher & Myrick, 2008). • Duchscher & Myrick (2008) described how interrelated forces and normative patterns in North American health care settings. can serve to transform creative, vibrant nurses into disillusioned, exhausted practitioners. • RI practice includes strategies that can mitigate against the detrimental effects on you as a nurse and also offers skills for navigating through the often conflicting and competing interests and values inherent in health care settings HOW DO NEW GRADS FEEL ABOUT THIS? “Like this patient did not want a thoracentesis but because they did an emergency thoracentesis they were allowed to do it, which is awful. And it sucks not being confident enough to say like, this is my patient, no we’re not doing it. I feel like that’s something I should have done, but I don’t know how to explain that, you gain confidence as you work I guess.” (Participant “Magda”) “I don’t want to be a nurse robot like some people on our floor are. I never want to be that person that just, death is a regular thing. I feel that for my sake, I want to always just feel emotion. That’s something that for the rest of my career, I’ll always look back on and just remember that this is what I kind of promised myself.” (Participant “Magda”) SYSTEM WELL-BEING o Oriented to a business model: emphasis on efficiency, limiting use of resources to optimize profit, often without attention to short-term or longterm consequences o Increasing acuity in hospitals, health human resource challenges, stretched resources, increased staffing ratios, burnout, the pandemic, etc. all make practice situations more challenging for the delivery of good care o From a stance of RI, nurses can practice more effectively and with greater well-being and participate in conditions that are healthier for patients families, communities, and other nurses REFLECTING: LOOKING BACK (Try it Out 1.4, Doane & Varcoe, 2021, p. 26) Go back in your mind to the situation you were thinking about earlier (the one that bugged you) o How was concern for, or attention on, self, other, context guiding the situation? o Other than this focus, toward “what” were the actions in the situation oriented? To what extent was efficiency or urgency or emotion driving the situation? o What does your reflection suggest about what different actions might have been taken? YOUR RI TOOLBOX o To become an intentional, competent nurse, you must bring intellectual understanding (e.g. theory) together with embodied, emotional experience (e.g. personal experience + nursing practice experience in the many years to come!) o Let’s not forget about our knowledge of aesthetics (the art of nursing) and ethical knowledge from our “ways of knowing”… and emancipatory knowing! Some of this will come from theory, some from experience. o How do you draw upon, enact, and create knowledge in all aspects of your life? How do you relationally respond to others? What makes you curious about this as you embark on your journey of becoming a nurse? THE 5 WS OF RELATING: CHOOSING HOW YOU WILL RELATE (Box 3.1, Doane & Varcoe, 2021, p. 95) What are you relating to? • On what are you focusing your attention? What are you valuing (seeing) and not valuing (ignoring)? Who are you relating to? • On who are you focusing your attention? Whose voice are you hearing, from whom are you distancing? Why are you relating? • What is your purpose? What goals are driving and motivating you? When are you relating? • How do time and timing shape your relating practice? How is time a factor? Where are you relating? • How is context, setting, privacy, etc. shaping your relating practice? THE 5 CS: RELATIONAL CAPACITIES CENTRAL TO RI Being compassionate • “to share suffering”; to share something of ourselves and of what it is to be human; to be with Being curious • being interested, inquisitive, and open to the uncertainty that is part of disease and illness experiences, and nursing practice (capacity to work in between knowing and not knowing) Being committed • to actively and intentionally identify the values and concerns that orient your work as a nurse and continually monitor how your actions are aligning with those commitments (staying the course, staying true to your values and purpose) Competence • not just about you and the knowledge and skills you possess, is person/context dependent Corresponding to what is • relating to and with people in a way that is meaningful to them HOMEWORK: WATCHING THE RELATIONAL INTERPLAY Let’s find ourselves a “balcony” from which to watch the “dance”! Find a busy place with people who are sharing space, to whatever extent they are interacting. This could be the hallway before class, the cafeteria, the gym, the mall, waiting in line at Tim Horton’s… o Witness/observe the interplay of people, situations, and contexts. • Notice the people and their appearances and behaviours. What do you see? What is capturing your attention? What curiosities arise? What are the sights, smells, sounds? Who is talking to whom? How are the people, contexts, and situations shaping each other? • How do you feel watching? What are you thinking and wondering? o Reflection/ analysis: • Do you find yourself experiencing some people’s actions more favorably than others? Why might that be, and what does that tell you about your own thinking? • What was going on among people? How were they influencing each other? Did anything surprise you? How did the physical setting influence what was happening?