Journal of Nursing Education

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Beyond Behavioral Skills to HumanInvolved Processes: Relational Nursing Practice and Interpretive Pedagogy

Gweneth A Hartrick Doane, PhD, RN

Abstract

ABSTRACT

This article argues that the teaching of behavioral communication skills may interfere with the learning of humanistic nursing practice. By inviting readers to consider moving beyond a method approach, the author discusses the pedagogical value of interpretive inquiry for the teaching-learning of relational practice. The author asserts that, as a "nonmethod," a pedagogy of interpretive inquiry can create opportunities for nursing students to learn and experience the transformetive power of reletionship, gain confidence in their cepacity for relational being and a sense of trust in their ability to be with people in ways that are authentic and meaningful, and develop their overall ability to enact humanistic, relational nursing.

Abstract

ABSTRACT

This article argues that the teaching of behavioral communication skills may interfere with the learning of humanistic nursing practice. By inviting readers to consider moving beyond a method approach, the author discusses the pedagogical value of interpretive inquiry for the teaching-learning of relational practice. The author asserts that, as a "nonmethod," a pedagogy of interpretive inquiry can create opportunities for nursing students to learn and experience the transformetive power of reletionship, gain confidence in their cepacity for relational being and a sense of trust in their ability to be with people in ways that are authentic and meaningful, and develop their overall ability to enact humanistic, relational nursing.

In 1976, Peterson end Zderad published their classic book. Humanistic Nursing. Describing nursing as "an experience lived between human beings" (Paterson & Zderad, 1976, p. 3), these nurse theorists inspire nurses to move beyond the technical "doing" of nursing and open up to the feeling end "being" of nursing. Underscoring that the nursing concern goes beyond the well-being of patients to the "more-being" of both patients and themselves, Paterson and Zderad (1976) described the pivotal role of relationship end relational practice in the humancentered process of nursing.

However, Paterson and Zderad (1976) recognized the challenge of actualizing humanistic nursing in the face of the hectic demands of everyday nursing practice. They emphasized that although no nurse may be able to live humanistic nursing in every moment of practice, it is "a goal worth striving for; an attitude that strengthens one's perseverance toward attaining the difficult goal; or fundamentally, a major value shaping one's nursing practice" (Paterson & Zderad, 1976, p. 15).

As a nurse educator, I have been greatly influenced by this humanistic nursing value. Not only has it made the development of relational practice a central project of my working life, but it has inspired me to spend many hours contemplating how to create opportunities for nurses to:

* Learn and experience the transformative power of relationship.

* Gain confidence in their capacity for relational being and a sense of trust in their ability to be with people in ways that are authentic and meaningful.

* Develop their overall ability to enact humanistic, relational nursing.

Humanistic nursing is not merely about finding a better way to practice. Rather, the humanistic, relational value is the essential core of nursing practice. As I have come to understand how significant this value is in shaping the practice of nursing, I have begun to wonder why the dominant curriculum discourse emphasizes the acquisition of behavioral communication skills as the foundation for the teaching-learning of interpersonal/relational practice. It seems that teaching behavioral methods of communication actually may interfere with the learning of humanistic, relational nursing. Behavioral skills not only fail to include essential elements of the human, relational process, but override nurses' spontaneous ability to be in caring human relationships. By focusing on performing the skills, nurses often fail to experience the spontaneous flow of relationships and their human capacity to meaningfully relate in an authentic manner.

My experiences as en educator have led me to move ewey from the teaching of communicetion skills and toward a pedagogy of inquiry. As it became clearer to me that relational practice is in essence a humanely involved process of respectful, compassionate, and authentically interested inquiry into another's (and one's own) experiences, I began to understand how interpretive inquiry also may serve as the pedagogical foundation for the teaching-learning of relational practice. As Paterson and Zderad (1976) purported, "nursing practice when studied.. .will only become available for conceptualization if the study methods are appropriete to its nature" (p. 65). This article highlights the affinity between interpretive inquiry and relational, humanistic nursing and discusses the pedagogical value of interpretive inquiry for the teaching-learning of relational practice. Through this discussion, I invite readers to consider moving beyond the teaching of behavioral skills and back to the human involved process of relational nursing practice.

THE CONSTRAINTS OF METHOD

In nursing there is a strong emphasis on the importance of practicing from a theoretical/scientific foundation. In developing a theoretical base for interpersonal practice, nursing has borrowed concepts and principles from the social sciences (Arnold & Boggs, 1995; MarrinerThomey, 1994). This borrowing occurred during ß time when mainstream psychology wes governed by behavioral science (Hartrick, 1997). Consequently, many of the dominant conceptualizations of interpersonal practice have emphasized the behavioral performance of nurses. These conceptualizations have been appealing because they have provided prescribed methods and outlined discrete and concrete behaviors for nurses to enact (Hartrick, 1997). However, there are a number of inherent constraints within this "method" approach of relational practice (Hartrick, 1997). In particular, prescribed method may hinder the spontaneous flow of human relationships and relational nursing practice.

As a nurse educator, I have pondered why we emphasize teaching and developing methods of relational practice. Caputo's (1987) discussion of reason and method has been helpful in articulating my growing concern with the method approach to relational practice. Caputo (1987) contended that nurse educators' grasping at method arises from our metophysicel belief thet there is a "master key" that somehow can still the flux of life and control its course. However, as Varela, Thompson, and Rosch (1993) described, we are at the point in Western science of realizing the impossibility of the existence of ß solid foundation of truth. In addition, nurse educators' progressive disenchantment and alienation with ourselves and our world reveal the constraints that arise through looking for a method (Berman, 1981; Caputo, 1987; Spretnek, 1991). There is no key to human "being" and "becoming.'' Human affairs cannot be formalized and "reasoned" into explicit rules or decision-making procedures (Caputo, 1987). According to Caputo (1987), as we "try to nail things down," we become bound by the rule of fixed technique- "...method rules instead of serving, constrains instead of liberating, and fails conspicuously to let science be" (p. 213).

Tanner (1988) described some of the deleterious effects formalized methods have had in nursing. The formalization becomes deified as identical to the original concern (Tanner, 1988). For example, behavioral communication skills are formalized as the substance of relational practice (Hartrick, 1999). Similar to Caputo's (1987) contention that formalized method serves to constrain science, Tanner (1988) maintained that formalized methods of nursing practice place limitations on nursing. According to Tanner (1988), at best, the prescribed methods are incomplete, and at worst, they may entirely miss the target.

Emancipating Ourselves from the Constraints of Method

According to Caputo (1987), the assumption that method is the reasonable and rational way to proceed evolves from disciplined values and beliefs called science. Science has become equated with the deductive model of rational thought. In exploring the roots of modern science and reasoned rationality, Berman (1981) emphasized that these ideas did not succeed in history because of their truth, but rather the socie! end economic milieu of modern Europe served to sustein this perticuler way of thinking. This deductive-rational model of reason has placed the gestalt sensibilities and feelings of interrelatedness beyond the bounds of relevance (Capra, 1976/1991; Spretnak, 1991). As such, the play and free movement of both science end reason have been arrested. The rational principle of reason dictates what is reasonable science and reasonable being. Consequently, reason has become an instrument of discipline, rather than a mark of freedom.

Caputo (1987) described how this socially constructed view of reason has been used to exclude voices that have been criticized as "primitive," "passionate," or "emotional" in the march of "enlightenment" and "progress." Those who dissent from the ruling standards of reason are declared irrational and required to somehow prove they are neither mad nor unknowledgeable.

Caputo (1987) argued for our ability to emancipate ourselves and others who live within reason's sphere of influence. He reminds us that the best way to respond to things is in the way they are:

If things are in flux, in undecidable drift and slippage, and if reason is to respond to things, to keep up a correspondence with them, according even to the most classical demand of metaphysics of truth, reason must play it loose, be capable of unexpected moves, of paradigm switches, of following up unorthodox suggestions. The most reasonable view of reason denies that you can write a handbook about the way reason works (Caputo, 1987, p. 228).

Rather than making humanness subservient to reason and method, «describing reason makes reason and method subservient to humanness. Drawing from Heidegger, Caputo (1987) suggested replacing method with a deeper appreciation of methodos, which is "the way in which we pursue a matter" (p. 213). Methodos reveals a way of moving when it seems there is no way to go. According to Caputo (1987), science (and I would add humanistic, relational nursing) makes its way by a "free and creative movement whose dynamic baffle the various discourses on method" (p. 211).

Letting go of method does not leave us stranded. Similar to Newman's (1986) suggestion, we are grounded through our consciousness. This grounding consciousness is different from a ground of solid theory and method. Through our "consciousness," nurse educators simultaneously are reasoned practitioners and participants in the shifting ground of human life and relationships. By consciously participating and inquiring into people's experiences in the moment, the barrenness of the isolated intellect is brought into relationship with emotional, practical, aesthetic, and spiritual rigor (Reason, 1993).

RECONCEPTUALIZING RELATIONAL PRACTICE

In freeing myself from the constraints of method, I have reconceputalized relational practice as similar to Csikszentmihalyi's (1993) description of a flow experience. During flow experiences, one is acting spontaneously, as if carried away by the tide of a current (Csikszentmihalyi, 1993). There is a unified consciousness in which one's self and one's actions are merged. One becomes so concentrated the supposed dualism of self and action disappears. There is a loss of self-consciousness, a self-abandonment (Paterson & Zderad, 1976) where concerns about oneself move out of focus. This lack of self-consciousness does not mean one is not aware of oneself but rather that energy is concentrated on oneself in relation to, as opposed to the separateness of, self and action.

An important distinction is that being in the flow of relationship is not equivalent to purposeless drifting. Rather, relational practice is a skilled action of inquiry. However, skill in this sense is contrasted with the tra· ditional idea of becoming skilled by gaining new methods and techniques (e.g., communication skills). The skillfulness of relational practice entails removing known habits. Varela et al.'s (1993) analogy of being born "already knowing how to play the violin and practicing with great exertion only to remove the habits that prevented one from displaying that virtuosity" (p. 251) captures how relational skillfulness is developed. As one becomes skillful in conscious participation, the automaticity of known patterns that seek to still the flux of human life and relationships is diminished. The spontaneous compassion that arises when one is not caught in habitual patterns is released. The heart is awakened.

Relational Practice: A Process of Interpretive Inquiry

Conscious participation involves the process of being in relation with and inquiring into human life. As such, it requires a transformed relationship to action. Similar to interpretive inquiry, one acts with awareness of the complexity and ambiguity of life, rather than the certainty of method. There is a participatory consciousness (Berman, 1981) that requires one to turn to an experience and open oneself up to its fullness and depth, to participate in the awe, zest, and passion of the experience (Reason, 1993). As Peterson and Zderad (1976) described, it involves being a "knowing place." Nurses approach people openly without deciding what to look for and are wiUing to be surprised and feel excitement, fear, uncertainty, or whatever emotions are sparked through the inquiry process (Peterson & Zderad, 1976).

Perhaps one of the most important skills of this conscious process of relational practice is the abiUty to "let be." Situated in, and constituted by, powerful nursing discourses of "problem solving," "alleviation," and "change," nurses experience tremendous anguish at the thought of being with people as they are- of letting be. The habit of striving to alleviate the "problem" is a difficult one to move beyond.

As I have attempted to learn the skill of letting be and worked with students who also are involved in this learning endeavor, I have found that moving beyond the dual ism of either letting be or changing is helpful. For exam ple, many students interpret letting be to mean everything remains the same, and things are not changed When we step out of duaUstic thinking, nurses open up to the possibility of seeing letting be as the most powerful way in which change is promoted. Letting be can be redefined as being open to know what is. As nurses join others as they are and let be, they are invited to open up to that which they are at that moment. Inner movement occurs when life can be received as it is, without asking it to be something else (Desmarais & Hamel, 1996). Experiences open up, begin moving, and changes occur.

Perhaps one of the most concrete examples of letting be was provided to me by an emergency room nurse. This nurse said that as she receives a patient from an ambulance, she consciously reaches out to be in relation with the person lying on the stretcher. She has found throughout her 20 years of emergency room nursing that by joining people in their experiences and "letting be to know what is," people's level of anxiety and pain seems to decrease. At the same time, letting be enables nurses to know and respond to what is most pressing.

A PEDAGOGY OF INQUIRY

Reconstituting relational practice as a nonmethod has raised many pedagogical questions. Some of these have included:

* How, pedagogically, do I "live the value" of humanistic, relational nursing?

* How do I, as an educator, foster the expression of students' natural caring and compassion?

* How do I teach the "unlearning" of patterns and habits?

* If I do not teach method and techniques (e.g., communication skills), what content do I teach?

* Although students bring their natural human capacity to be in relation, do they not require some foundational knowledge as well?

Once again I have found it helpful to step out of the duahstic choice of either teaching some defined method or letting students swirl in the abyss of nothingness. However, in between these two extremes, the question becomes, "How pedagogically may I help students experience and participate in the spontaneous flow of relationship and simultaneously support the learning of skilled relational practice?"

As I have considered this question and continued to read and reflect on it, I have begun to draw on the principles of interpretive inquiry (Denzin, 1997; Eisner, 1991; Lincoln, 1985) to help me in the teaching-learning of relational practice. In realizing that relational practice is in essence a process of interpretive inquiry, it has seemed to me that perhaps the most reasonable way to teach it is through the seme process (i.e., es a nonmethod, interpretive inquiry may not only give rise to rigorous and reasoned relational practice, but may serve as a rigorous and reasoned relational pedagogy).

Interpretive inquiry involves a process of intense reflection on events and experiences in which the inquirer is part of a relational process of interpreting. Denzin (1997) described how interpretive inquiry "refuses theoretical closure" (p. xvii) end authoritative eccounte of the life processes being examined. This inquiry process clarifies the openended messinese of human life by including the many discourses and voices that exist within a given social space.

Essentially, I have invited students to become inquirers into their own and others' relational experiences. I have attempted to provide the freedom for learners to be who they ere and to move the spotlight of learning away from nurses' performance and on to the relational connection between "self and other." As such, learners are freed to "play" (Caputo, 1987). They are free to explore, unearth, and create their own spontaneous, thoughtful, caring humanness. Unhempered in the ideas and content that can be brought to the situation, how we play with that content, what interpretations we make, and perhaps most important what questions we raise, the content becomes whatever arises through the inquiry process. That is, it is the learners' relational experiences that serve as the substratum for the development of new knowledge and skills. This process provides an opportunity for learners to authentically connect with their "self in relation" and move beyond the self and other dualisms.

As learners inquire into their relational experiences and practices through reflection, dielogue, enectments, and reenactmente, they reexperience and reexamine their relational practices. Through an interpretive inquiry process, they individually and collaboratively interpret and reinterpret their experiences and construct new knowledge and skills. For example, in one class, a learner who was feeling very frustrated in her work with a patient chose to reenact a recent relational experience. During the reenactment, she played the patient's role, and a clessmate played her as the nurse. As the reenactment occurred, the learners inquired into the relational experience. Through this inquiry process, the student's relational experience was radically transformed, as she experienced the relationship from a different perspective. At the same time, the inquiry process highlighted and informed the learners' developing understanding of relational theory, end we used theory end literature to enhance understanding of the relational experience. "Known habite" that had constrained the student's relational experience were revealed, and the opportunity to transform her future relational practice was created.

In essence, the teaching-learning of relational practice through a pedagogy of inquiry is a praxis process. As such, it ensures methods or theories are not superimposed on and do not override the human-relating process. The interpretive inquiry process allows relational practice to be reappropriated back to the human domain (i.e., it is moved out of a prescribed, detached method and beck into the realm of human flux). Similarly, a pedagogy of inquiry serves to open learners to the mystery of being human and to the fears and vulnerabilities that lie within relational nursing practice. By restoring the flux (both reletionally and pedagogically), students have the opportunity to move beyond roles and methods to experience authentic human relating in all its complexity. In addition, the possibility of learning to live in the inherent messinese end flow of humanistic nursing is created.

LIVING A PEDAGOGY OF INQUIRY

Living a pedagogy of mquiry has meant that as an educator I bear continual witness to the challenge of engaging in the practice of relational being. Each time I teach a course in relational practice, I watch the students struggle to cope. As I encourage them to let be, they most often reply by asking, "How do I do that?" Overall, Caputo's (1987) metephor of swimming in the ebyss mirrors the process of whet teeching-learning to be and let be entails- "the way one learns to float only by surrendering every attempt to swim end by remaining perfectly still. That takes practice and a bit of courage; it is simple but hard" (p. 224).

Being a teacher of humanistic, relational nursing requires a similar learning process. As studente are learning to let be, I walk the fine line of supporting them and simultaneously ensuring I am not hindering their learning to float on their own. For example, just as people learning to float sometimes find a gentle hand at their beck helps them relax in the water, at times I reach out to let students know they are not alone in the abyss. In addition, similar to learning to float, students sometimes suddenly become very conscious that they are "in the water" and begin to panic. At those times, I and the other learners ensure they do not sink.

Any conceptual position can become a method or constraining ground (Caputo, 1987). However, I have found myself at times inadvertently using interpretive inquiry pedagogy as a method to teach the "truth" of relational practice. Faced with the angst and uncertainty of the students in their learning process, I have pulled out my knowledge of relational practice and offered it to them as an anchor (i.e., I have put my hand on their back when they perhaps were ready to float on their own). Similarly, faced with my own worry about whether the students are "getting it," I have rushed to offer advice or show them. Although this offering of my knowledge is in and of itself not a problem (and in fact providing knowledge at times is essential), it is my underlying habit of providing knowledge and trying to change students' relational practice that is problematic. As I sUp into providing my knowledge to encourage students to change their relational practice, my relational participation in their inquiry process is circumvented, as is their own inquiry. At these times, it is my need to control their panic and my own worry about their learning that overrides the pedagogical need for freedom and play.

Subsequently, I find my biggest chaUenge as a teacher is to live what I am teaching (i.e., to Uve the value of humanistic, relational nursing by being a conscious participant in a relational pedagogy of inquiry). Rather iban teaching about interpretive inquiry as a method of relational practice, I strive to consciously participate in relation with students' inquiry processes. This conscious intent guides the knowledge I introduce, when I introduce it, and how I introduce it. Similarly, this intent directs the learning activities and what we do together in class. I attempt to join students in the water, to be the supportive hand in the background as they learn to float with consciousness and confidence and take up their own relational way of being.

Doll's (1993) description of pragmatic doubt has been particularly helpful in meeting the chaUenge of conscious participation. Pragmatic doubt is doubt that originates when one accepts the indeterminacy of human experience. Because there is no one truth or one best, we can never be certain. Consequently, we are obUgated to retain an open vision. Because we lack the certainty of preordained method, strategies, and master plans (Caputo, 1987; Doll, 1993), we must develop local strategies for local action. With a faith of pragmatic doubt, we are compelled to dialogue and be in relation with others so we can make particular decisions, which we hope may be veritable for a local time and place. As I engage in a living pedagogy of inquiry and continue to question and explore my own experiences, my understanding and skill continue to develop. Throughout this process, a faith of pragmatic doubt is my guide (i.e., I constantly remind myself that pragmatic doubt is a far more "reasonable" pedagogical resource than any current truth or method of relational practice).

CONCLUSION

According to Moccia (1988):

When we get past our science and theories, our technical prowess, our titles and positions of influence, it is this shared moment of authenticity- between patient and nurse- that makes us smile and allows us to move forward in our own life projects (p. iv).

Similarly, it is the relational moments I have experienced with students that have been the most influential in propelling me past the method and techniques of relational practice and pedagogy. It is these moments of authentic, relational connection with other learners that have fostered my belief in the value of interpretive inquiry as a pedagogy for humanistic, relational nursing practice.

REFERENCES

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  • Capra, F. (1991). The tao of physics. London, England: HarperCollins. (Original work published 1976)
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  • Tanner, C. (1988). Curriculum revolution: The practice mandate. In Curriculum revolution: Mandate for change (pp. 201-216). New York: National League for Nursing.
  • Varela, F.J., Thompson, E., & Rosch, E. (1993). The embodied mind. Cognitive science and human experience. Cambridge, MA: The MIT Press.

10.3928/0148-4834-20020901-08

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