Notes on Nursing: The “Real Work” of Nurses, Relational Practice

In her 2009 article, A Theory of the Relational Work of Nursing, author and nurse Daniela DeFrino writes: “Nurses’ power results from the relational work that they do with patients. The relational work exists, but is, as a general rule, taken for granted as ‘nice’ and not valued as the skillful and effective process that it is.” I have thought of those words many times since reading them. Relational practice is a distinctive nuance of the work performed by nurses. But because is visible to only patients and nurses, it has no measurable value to the healthcare industry, third-party payers, or lawmakers. 

But without the provision of this type of care, the practice of nursing becomes simply tasking and charting. Relational work does not require a doctor’s orders, but without it there is no humanity in the delivery of patient care. Nurses who do not have time to deliver relational care can become unfulfilled, disappointed with their work, and burned out—the altruism for which many of them entered the profession gone. 

Patients and nurses are intimately aware of the exchange of behaviors required to secure their mutual bond for the benefit of the greater good. Trust between nurses and their patients is essential to the provision of relational care. The patient freely places their trust and welfare in the nurse upon entering the nurse’s care. This trust initiates the nurse-patient relationship. There is a vulnerability in this type of trust, making the relational bonds more sacred. 

Although originally considered inherently female in nature, relational practice in the nursing profession has no gender—as evidenced by the increasing number of men entering the profession. The relational care provided by all nurses is the reason the profession enjoys such an admired and positive reputation. In fact, for the 20th year in a row, a national Gallop survey has found nursing to be the most trusted profession in the United States. 

Relational practice in nursing can take many forms, including: 

• Anticipation of/Intuition about patient needs 
• Presence: Bearing witness to a patient’s condition and experience
• Empathy: Affirming patients’ experience as they perceive and express it 
• Advocacy: Protecting your patients’ rights and values
• Goodwill: Establishing common work and goals based on shared values
• Altruism: Giving self in service to another: “I will help you” 
• Beneficence: Communicating to your patients that what is best for them is a priority for you
• Honesty: Being thoughtful in disclosures to patients
• Authenticity: Sincerity in words and deeds
• Caring: Investing emotionally in the condition of your patients.

Patient satisfaction with their healthcare experiences reflects their satisfaction with the nursing care they receive. Nurses who engage in consistent and frequent use of relational practices positively impact not only their patients, who enjoy better health outcomes, but also themselves as they realize meaning in their work. Healthcare systems perceived as having trustworthy and caring nurses enjoy more organizational success and economic growth, and they generate less risk. 

A Profession Under Duress 

With today’s increased patient acuity and nurse staffing issues further aggravated by a worldwide pandemic, there is much less time for relational nursing. This threatens patient-centric care and the identity of professional nurses—possibly even the future of nursing itself. Ask any nurse the reason they became a nurse, and most will say that they wanted to help people. Wound care, medication administration, surgical prep, physical assessments, and monitoring are all actions nurses take to help patients heal. The nurse with barely enough time to do leaves even less time to be a nurse, and, ultimately, less time to relate to patients. 

High-intensity, high-pressure extended workdays, during which nurse-patient ratios threaten patient safety, may be tolerable when it is the exception rather than the rule. However, research shows that if this is the only type of work experience nurses have, they will quickly become disillusioned, disconnected, uninvested, and more likely to leave the profession altogether. 

Likewise, in an overly strained healthcare environment without adequate resources, patients can feel abandoned, helpless, and unsure of who is protecting them in their vulnerable state. Strategies and initiatives that promote and support the relational work of nurses as real work can help ensure the delivery and receipt of high-quality, holistic, patient-centric healthcare and prevent the institution of nursing from becoming a technical vocation. 

Relational Care at Work 

One night on my ward, I observed two daughters sitting with their dying mother in the dark. I listened as the daughters spoke with pride of their upbringing under this matriarch’s care and how she guided the whole family in the important decisions of life. The daughters had been by her side all day and were tired. They asked if I thought it would be okay if they went home for the night. What they really were asking was, “Will mother die soon? Should we stay?” It was my belief that death was near, although their mother lay quiet and still, breathing slowly and shallowly much as she had done all day.

I encouraged them to stay and to give their mother their permission to leave. In the early morning hours, their mother died. The daughters were asleep at her bedside, one holding her mother’s hand. I awakened them gently with the news of their mother’s passing. A quick gasp was quickly followed by an outpouring of love as they hugged one another and kissed their mother. They were the most upset that they’d “missed it,” but they also were convinced that she had heard their promise—that they and their family would be okay. 

While all of nursing engages in relational practice, a patient’s death can make its impact more evident. Bearing witness to the suffering and needs of another and meeting them in that time of need strengthens the bonds of trust in what becomes a covenant among the patient, the nurse, and the healthcare system. EM Marshall describes this trust as “an important imperative in life, affecting human conduct in all kinds of settings.” Such trust, says Marshall, “is based on biological need, psychological requirements, emotional well-being, feelings of self-respect, and it is foundational to the human relationship.”

In cancer care, victory can take multiple forms. When surviving cancer is not one of them, families will tell you that despite this outcome, what matters most is how the nurses made them feel—relational work, remembered. 

Robin Atkins, RN, OCN, is a symptom management triage nurse with Virginia Oncology Associates in Norfolk. She is a self-identified southern Virginian and proud baby boomer. Atkins graduated from Riverside School of Professional Nursing in 1985, where she received her RN, and has worked in outpatient oncology since 1988. She and her husband have two adult children, seven grandchildren, and two cats, Gracie and Annie. She enjoys the serenity of living in the country, RV camping with friends in Virginia’s state parks, and canoeing.

More From Robin's Notes on Nursing Series:

• Learning From a Noble Expert
• Staying a Nurse