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Angela Bouwers
Registered Nurse/BsN |
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The concept of relational practice in nursing is one of the founding principles that our profession has been known for. Oftentimes, however, the psychomotor tasks that a nurse is expected to complete take precedence in the busy hospital setting. As nurse researcher G.A. Hartrick states “Nurses have the opportunity to make a profound difference in peoples' health and healing experiences. However, our emphasis and reliance on mechanistic models of relating often results in our failure to realize this opportunity (2008)”. This insight from Hartrick is very congruent to my own experience as a newly graduated Registered Nurse working in a small community hospital. I found to retain a balance between relational practice and completing the psychomotor tasks set before me, I had to be very self aware and intentional in my practice. I feel a competent, caring nurse is one that can use equally and in balance both a knowledge of the psychomotor skills and a relational focus within his/her nursing practice.
I received my Bachelor of Science in Nursing through the local college, North Island College, which is known for its focus on relational practice. While the psychomotor skills I learned within the curriculum provided a strong basis for my nursing practice, they did not take centre stage as to what was most important in patient care. Safe, competent practice was well-established by my nursing instructors with a reminder to practice ethically in remembering the person and fighting the temptation to allow the focus to be drawn to the skills that needed to be performed. The support from fellow students and instructors to take time to relate with a patient and really see them as a person with a context and journey, felt congruent to what I feel is the core of nursing. To be a caring nurse means to be able to see deeper than the monitoring of vital signs, the administration of medication, the laboratory values, the bandaging and casting, the IV fluids, and ECG monitoring. A caring nurse is able to see, really see, the person. It is to look into your patients eyes and see a reflection of your sister, your brother, your friend, your mother, your father, your grandmother, your grandfather…..yourself. If that relational, person-to-person connection can happen the psychomotor skills needed to support that persons healing become complementary.
However, once I graduated and entered the work force as a casual Registered Nurse in a small remote hospital, I came up against a huge pressure to place more emphasis on psychomotor skills than relational practice. The older and more experienced nurses would ask me where I did my nursing education and when they heard North Island College they would say “Oh you’re one of those nurses”. It appeared that nurses who graduated from a more technical and skill-focused institution were more highly valued than those institutions that have more of relational focus. I struggled to remember why relational practice was important in the face of the huge learning curve I was trudging through.
One day, I had an interaction with a patient in the emergency department who taught me yet again that while having the psychomotor skills to act competently and safely is incredibly important, a nursing practice that is relationally based is the first step to establishing a therapeutic and trusting relationship with the patient. I was on my first day orientation at small community hospital on the northern-most tip of Vancouver Island. The nurse (call her BA) I was partnered with felt the best way for me to be oriented to the hospital would be by placing me in the 5 bed emergency room and coming to check on me every once in a while. I was managing quite well through the day when the police brought in a severely intoxicated woman who had fallen and hit her head on the concrete bed in the police cells. Realizing the need for more support (as the other 4 emergency beds were also occupied), I asked my orientation nurse to come and help me. The Dr had asked us to start the woman on IV fluids so BA asked me if I could start the IV which I said I could do after I had talked with the woman and introduced myself. Not seeing the need for this step in the process, BA suggested that I hold the woman’s arm down while she started the IV. I felt a lot of tension internally at this point as I knew ethically I had to stand on my belief that relational practice is just as important as the psychomotor skills that needed to be completed in this scenario. Respectfully, I asked BA if I could have a minute with the patient before we started the IV. Shaking her head but remaining agreeable to this plan, BA went to collect the IV supplies. Meanwhile my patient was mumbling incoherently and trying to get out of the bed. Squatting down so that she could see my face, I told her my name, and asked her what her own name was. After this connection was made I asked the patient if she knew where she was. In her comprised mental state the patient replied “I think I am in the police cells and I think someone is trying to do something horrible to me!” Stunned by the implications of this patient’s perception about her whereabouts and safety, I gently put my hand on her shoulder and told her of the situation she was in and where she was. Understanding flickered in her eyes as I told her we would need to put an IV in her hand and asked her if this was ok. With a more peaceful look in her eyes the patient agreed and stayed still through the whole process. Afterwards, I thanked BA for giving me time to have that moment with the patient before she started the IV and after this encounter I noticed a more accepting attitude from this nurse.
I think students and new graduates in the nursing profession are presented with many challenges the minute they step onto the ward. One of these challenges is the decision that appears to need to be made to either be the clinically, medically minded nurse who is proficient at every psychomotor skill or it’s to be the relational, health and wellness, holistic nurse who can demonstrate the person to person caring aspect of nursing. As one very salient research article found it is difficult for many nursing students to see value in their practice because they become preoccupied with their perceived lack of knowledge and technical skills. Nurses and nurse educators should be aware of how this brands new graduates and informs their sense of developing professional identity (Beckett, Gilberson, & Greenwood, 2007). With the current state of a nursing shortage, it is easy for new graduates and students to decide to become more proficient in the skills aspect of nursing and consequently sacrifice the relational parts that are just as important to nursing as a caring profession. I have seen new nurses, under the pressure of high patient loads, increased acuity, and staffing shortages prioritize the relational piece of nurse-patient interaction to when there is time….of which there rarely is. I myself often felt the push towards skill development even at the cost of losing the relational development part of my practice. Yet, I found, as Beckett, Gilberson, & Greenwood (2007-Jan) research shows that despite their feelings of deficit in terms of skills and knowledge, it is clear that many nursing students are, in fact, effectively negotiating relational ethics.” To have this experience in emergency further enforced the importance to have a nursing practice that balances both the psychomotor skills and the relational practice. I hope that by sharing this experience nursing instructors, students, new nursing graduates and nurses will remember the importance of having a caring therapeutic nursing practice that takes time for the relational aspects of care in balance with psychomotor skill development.
Works Cited
Hartrick G.A. (28 June 2008). Relational capacity: the foundation for interpersonal nursing
practice. Journal of Advanced Nursing, 26 (3), 523-538.
Beckett, A, Gilbertson, S, & Greenwood, S. (2007, January). Doing the right thing: nursing
students, relational practice, and moral agency. Journal of Nursing Education, 46 (1), 28-
32. http://www.ncbi.nlm.nih.gov/pubmed/17302097 website accessed June 03/09.
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