Relational inquiry approach for developing deeper awareness of patient suffering

Abstract

To practice compassion, the recognition, understanding, and alleviation of patient suffering are of utmost importance. Nursing literature provides ample guidance about the nature and meaning and patients’ views about compassion and physical and psychological suffering. However, missing is the discussion about how nurses can achieve a deeper awareness of patients’ suffering to practice compassion. This paper aims to describe the relational inquiry nursing approach and illustrate how this approach can enable nurses to develop a deeper awareness of patient suffering. The relational inquiry approach encompasses two components: a relational consciousness and inquiry as a form of action. Relational consciousness requires the nurses to focus on the concrete situations and relationships as well as recognize the intrapersonal, interpersonal, and contextual factors affecting the situations. The interpersonal factors are among and between the individuals, intrapersonal factors are within the individuals, and contextual factors are the hidden factors influencing the individuals and situations. Inquiry as an action requires a critical analysis of the experiences of individuals, situational contexts, and knowledge to inform the nursing care modalities and actions. This approach encourages nurses to use the philosophies of hermeneutic phenomenology, critical theory, and pragmatism. The phenomenological worldview allows nurses to interpret their own and patients’ experiences, the critical theory worldview allows nurses to examine the influence of social and cultural factors, and pragmatism allows nurses to question their prior knowledge and develop new knowledge in each situation. The relational inquiry approach allows nurses to develop a deeper understanding of patient suffering through building a therapeutic and trustworthy relationship, active listening, focusing on the details, and engaging in broad and situations specific inquiries to understand the patient narrative of suffering. Two case exemplars are shared to demonstrate how relational inquiry allowed nurses to move beyond recognizing physical suffering and understand patients’ emotional and psychological suffering.

Keywords

Compassion nurse-patient interaction nursing theory relational capacities relational inquiry suffering

Introduction

In recent years, a greater emphasis is placed on compassionate nursing care.^1
–3 Compassion is defined as “the sensitivity shown to understand another person’s suffering, combined with a willingness to help and promote, the well-being of that person, to find a solution to their problem” (p. 605).⁴ On the other hand, suffering is defined as “an unpleasant or even anguishing experience, severely affecting a person at a psychophysical and existential level” (p. 1).⁵

In order to be compassionate, the recognition, understanding, and alleviation of patient suffering are of utmost importance.^6,7 Recognizing suffering allows nurses to build a therapeutic relationship with the patients and listen to their concerns, which can ultimately assist them in understanding suffering and developing a patient-centered plan to alleviate the suffering.^6,8 If patients’ suffering is not fully understood, the response to the suffering can be inadequate that may contribute to worsening the suffering.⁹

The nursing literature provides ample guidance about the nature of compassion^10
–12; nurses, students, and patients views of compassionate care^8,13
–15; strategies to foster compassion^7,16; the nature of suffering^17

–20; and the meaning of physical and psychological suffering for patients with chronic and acute conditions.^9,21,22 What seems to be missing is the discussion about how nurses can achieve a deeper awareness of patients’ suffering to practice compassion. Few approaches are offered to recognize and alleviate patient suffering. Cassell^23,24 offered a holistic approach that calls for a recognition of individuals as holistic beings. Therefore, individuals’ suffering must be recognized and alleviated after considering the mind, body, spirit, and the interplay of all three. Angelo,²⁵ based on the holistic view of beings, offered empathetic understanding as an approach that focuses on supportive communication with individuals who are suffering. Empathetic understanding requires the use of imaginative competence (i.e. placing oneself imaginatively in the sufferer’s world). Dempsey and Mylod²⁶ offered a compassionate care framework for mitigating inherent suffering. This framework is also based on the holistic view and calls for providers’ individual and group preparation to mitigate suffering. The individual-level preparation entails recognizing personal fears and anxiety, developing self-confidence and empathetic skills, and involving sufferers’ relatives in care. The group preparation involves collaborating and consulting with others and delivering care with courtesy. All of these approaches recognize the holistic nature of individuals and emphasize the importance of patient narrative and experiences as crucial to understand and alleviate suffering. This paper offers the relational inquiry nursing approach as a tool for developing a deeper awareness of patient suffering. The proposed approach aligns with the holistic view of nursing care and recognizes the significance of patient experiences. However, this approach also advances the crucial role of personal knowledge and awareness of complex situations and the influential role culture, social, political, and emancipatory factors on human suffering.

Purpose

The purpose of this paper is to describe the relational inquiry nursing approach and illustrate how this approach can enable nurses to develop a deeper awareness of patient suffering. First, the nature of compassion and its connection with suffering is briefly described. Second, the nature of and factors affecting suffering are described. Finally, the relational inquiry nursing practice approach is described, and its usefulness for developing a deeper understanding of patients’ suffering is demonstrated using previously published case exemplars.

Compassion and suffering

In Cambridge Dictionary,²⁷ compassion refers to the feelings of sympathy and sadness for others’ suffering. This definition is consistent with the Buddhist definition that compassion is the “noblest feeling of the human heart that trembles in the face of suffering” (p. 144).²⁸ From the Islamic perspective, Allah is compassionate and advises his followers to practice compassion with other living beings such as humans, animals, and birds and care for their physical and emotional needs.²⁹ In Christianity, compassion is a virtuous character of God, and the people of God practice compassion and love to others in suffering. This practice of compassion is reflective of the story of the Good Samaritan.³⁰ In Judaism, too, God is merciful and compassionate, and Jews are asked to imitate and model God’s compassion toward fellow beings.³¹ Most of the literature conceptualizes compassion as a multi-textured response that entails kindness, suffering, caring, sympathy, empathy, and generosity.^32,33 In the health and nursing literature, compassion is theorized as a relational, intentional, and ethical response to recognize, understand, and alleviate patients’ suffering.^4,6,7,33,34 The various accounts and definitions of compassion indicate that compassion and suffering are integral to each other, and compassion is always related to individuals’ suffering.³⁵ Therefore, compassionate care is promoted and fostered if a deep understanding of patients’ suffering can be achieved. However, it should also be acknowledged that nurses’ personal factors, and the organizational and cultural factors can interfere with their ability to develop a comprehensive understanding of patient suffering.³⁶

Nature of and factors affecting suffering

Suffering is intrinsic to human lives and experiences.³⁷ In the health care literature, suffering is described as a behavioral and emotional response,²⁴ an “anguishing experience, severely affecting a person at a psychophysical and existential level” (p. 1),⁵ and “undesired experience of a negative physical or affective state” (p. 58).³⁸ Suffering is so complex and multidimensional that it could be difficult for the sufferer to completely express and articulate.³⁹ Suffering is expressed and articulated differently by individuals; therefore, it must not be “reducible to any generalizable frame of understanding” (p. 1).⁴⁰

In the nursing literature, suffering is described using many metaphors such as a disappointment, “struggle, despair, longing, and being cut off from a relation” (p. 1356).⁴¹ Suffering is a personalized and multifaceted experience during which people assign negative meanings to different events and perceived threats.⁴² Morse,¹⁷ in her praxis theory of suffering, articulated suffering as a behavioral state encompassing enduring (emotional suppression) and emotional suffering. Ferrell and Coyle⁴³ described that in nursing literature, suffering is conceptualized as multidimensional pain, discomfort, distress, anxiety, worry, depression, and grief. Smith et al.,⁴⁴ offered a holistic view of suffering that entails the individuals’ awareness, beliefs, perceptions, and interactions with others.

The common theme across all of the above conceptualizations is that suffering is a negative response and a multifaceted experience that can threaten individuals’ physical, emotional, and psychological well-being. It is not sadness or depression, but it can lead to those states.³⁸ Suffering can affect individuals’ well-being and is affected by the duration and nature of undesirable events and threats. Since suffering is an experience, it is also affected by different contexts, situations, time, belief systems, values, personal, social, and spiritual support systems, coping strategies, temperaments, and adaptation problems, and the responses of individuals who are interacting with the sufferer.^5,38,42,45 If any or all of the above-listed factors are altered and/or are perceived as unfavorable and pose a threat to individuals’ integrity of self can lead to both physical and psychological suffering. Therefore, suffering often occurs due to “actions of oneself, the actions of others, and brokenness of the world” (p. 62).³⁸ Given that suffering is affected by self and others, it is apparent that an understanding of individuals’ suffering can be achieved from both emic (from the sufferer’s account) and etic (from the observer’s view) perspectives. Therefore, the suffering of individuals should not only be observed and understood, but it should be heard with authentic presence (i.e. being genuinely present and open to listen in the moment of interacting with individuals).⁴⁶

Relational inquiry nursing approach

Relational inquiry is a nursing practice approach developed in the Canadian Context as a reflexive and reverential approach to guide the nursing practice. This approach aims to achieve nurse, patient, family, and health care system well-being through recognition of their interconnected elements. Relational inquiry recognizes the dynamic intricacy of nursing care experiences for the patients, nurses, and the families of the patients. This approach calls for relating to patients and their families, nurses, and other care providers involved in a nursing practice situation. This approach brings to the attention that providing effective patient care requires an awareness of relational complexities in a practice situation.⁴⁷ Relational inquiry prompts nurses to engage in a critical inspection of and gain a comprehensive understanding of different nursing situations and patient transactions within complex health care and nursing contexts. This approach encompasses two core components: “a relational consciousness and inquiry as a form of action” (p. 3).¹² Relational consciousness requires the nurses to look beyond the observable and concrete situations and relationships to recognize three types of factors affecting the situations and relationships. These factors are as follows: interpersonal (factors among and between the individuals), intrapersonal (within the individuals), and contextual factors (hidden factors influencing the individuals and situations). Inquiry requires a critical examination of the relational experiences of individuals, situational contexts, and knowledge to inform the nursing care modalities and actions. Relational inquiry approach also encourages nurses to use five ontological capacities such as compassion, curiosity, commitment, competence, and correspondence during each nurse-patient interaction. Among all of these capacities, compassion is a vital capacity that humbles nurses by relating to others’ suffering.¹²

Philosophical worldviews guiding relational inquiry

In order to realistically examine the nursing situations, identifying the intrapersonal, interpersonal, and contextual factors, and recognizing the interplay of nursing situations and these factors, Doane and Varcoe¹² encourages nurses to use the tenets of the philosophies of hermeneutic phenomenology, critical theory, and pragmatism.

Hermeneutic phenomenology

Hermeneutic phenomenology focuses on the nature and experience of beings (i.e. Dasein) and how their experiences are shaped and influenced by their internal worlds.⁴⁸ The Hermeneutic phenomenology worldview focuses on the relationship of individuals with their own lifeworld and underscores that individuals living in different contexts are situated and constituted by their contexts.⁴⁹ Individuals are assumed to understand themselves and their experiences in relation to their lifeworld, even if they may not be explicitly aware of their understanding. Hermeneutic phenomenology inquiry seeks to understand the concealed complex experiences and disentangle the multiple layers of individuals’ experiences.⁴⁸ Therefore, the Hermeneutic phenomenology worldview highlights the shared and unique meanings that nurses, patients, and their families have of their experiences. The Hermeneutic phenomenology lens brings to the attention how our interpretations of nursing situations are affected by our previous experiences and how similar nursing situations are interpreted differently by different people. This worldview urges nurses to deeply understand the experience in a nursing situation from the viewpoint of the individual who experiences it. Therefore, the Hermeneutic phenomenology lens permits nurses to explore the intrapersonal and contextual factors and how patients and their families make meaning of nursing practice situations.¹²

Critical theory

The critical theory worldview posits that truth is socially and culturally constructed.⁵⁰ The critical theory focuses on recognizing the influence of social and cultural traditions and norms on individuals’ experiences and directs our attention to the power dynamics, oppression, emancipation, and social change in society.⁵¹ Habermas⁵² argued that an extensive understanding of individuals’ experiences is gained through recognizing the influence of social, cultural, historical, and political environments. Therefore, the critical theory focuses on exploring the more deep-seated social and cultural assumptions and how they may constrain individuals to understand the social world.⁵¹ In the nursing context, critical theory invites nurses to recognize the effect of the supremacy of views and roles, cultures, financial, social, and structural conditions, and inequalities in the healthcare and nursing systems on individuals’ experiences and nursing situations. It emphasizes the inquiry at intrapersonal, interpersonal, and contextual levels to recognize structural, social, and political conditions that shape nurses’ as well as patients' thinking. By drawing attention to these conditions, it calls for an expansion of thoughts beyond previous assumptions and biases, and make informed choices to care for patients and their families.¹²

Pragmatism

Pragmatism rejects the idea of an absolute and certain knowledge (i.e. thoroughgoing fallibilism) and advocates for the pluralism of perspectives, cultures, ideas, beliefs, and philosophical orientations.⁵³ Personal experiences and beliefs are central to pragmatism,^54,55 and our beliefs and experiences affect and influence our interpretation of any available knowledge and the practical aspects of the knowledge for everyday living.⁵⁵ Pragmatism posits that all knowledge is fallible because our experiences continuously influence its relevance to and practicality for our actions.⁵⁵ In the nursing context, the pragmatic worldview urges nurses to consider their knowledge about patient and nursing situations to be indefinite and fallible. Therefore, they must engage in an intentional, responsive, continuous process of discovering more about themselves, the individuals, and the situations. Through such discoveries, it invites nurses to develop their theories that are pertinent to determine practical nursing actions in their situations. The pragmatic worldview in relational inquiry invites nurses to prioritize the most relevant and useful knowledge to understand the situation and the essential knowledge that is required to discern and implement nursing care modalities. With the application of this worldview, nurses can discern the most practical and useful nursing actions that are essential for effective care of not only patients and families, but their self-care.¹²

How can relational inquiry approach enable a deeper awareness of patient suffering?

Developing a deeper awareness of patient suffering requires the development of a therapeutic nurse-patient relationship, which entails active listening, focus on the details, and both broad and situations specific inquires to understand the patients and their needs.⁵⁶ Such a type of relationship allows nurses to recognize the suffering of patients and intentionally understand the nature, extent, and consequences of their suffering on their well-being, and act compassionately to alleviate that suffering.⁵⁷ In order to develop a deeper understanding of patient suffering, health care providers must actively explore patient narrative.²⁵ The relational inquiry approach allows nurses to develop a relationship with the patients and their families and inquire about their needs at a deeper level using the Hermeneutic phenomenology worldview.¹²

When nurses examine their interpretations of patients suffering and consider themselves less knowledgeable about the nature and extent of patient suffering, they are better positioned to engage with patients and inquire about their suffering.^12,26,58 With compassion as the core ontological relational capacity, the relational inquiry naturally focuses on gaining a deeper understanding of patient suffering through the analysis of intrapersonal, interpersonal, and contextual factors. Integrating relational inquiry into practice can enable nurses to challenge their prior assumptions about patients and their suffering and recognize what is truly at stake in each practice situation.¹² Herein, I demonstrate how the use of relational inquiry allowed nurses to gain a deep understating of patients suffering and discern the best possible actions to alleviate the suffering.

Case 1: the suffering of a patient with dermatitis and diabetes mellitus

Zou⁵⁹ described the story of an 81-year-old woman who was admitted to the hospital after a fall in a bathtub. She had to stay in the tub for 48 hours because she was alone in the house and could not call the neighbors for help. When she was brought to the hospital, she was diagnosed with dermatitis. To her surprise, the medical team also diagnosed her with diabetes based on her blood work and past medical history. The nurse who cared for this woman taught her about self-care, particularly about self-administration of insulin. The nurse was excited to learn some new skills while caring for this patient and found the patient to be cooperative and eager to learn. However, a few days before the woman was to go home, the nurse found out that the woman would not administer insulin after going home. This situation prompted the nurse to inquire more about the woman’s life story and focus on the details. Therefore, using her therapeutic rapport, the nurse conducted a comprehensive inquiry that revealed the following observations.

The woman was depressed because she lived alone, her family died when she was 60 years old, and her son seldom visited or called her. Therefore, the woman thought it would be better to wait for the time of death, rather than engaging in more self-care. The woman indicated that she wished she had a daughter because daughters take care of their parents.

The woman indicated that she was disappointed because her old neighbors with whom she had a very good relationship moved out. Therefore, she cannot rely on anyone during the times of her need.

Through this relational injury, the nurse recognized that the patient’s actual suffering was not dermatitis, fall-related injury, and diabetes. However, it was the emotional suffering that resulted from loneliness, and death of loved ones, and loss of friends. The nurse described that her health care organization wanted nurses to focus on the physical needs and illness of the patient; therefore, she did not explore the contextual factors that were affecting the woman’s situation. If the nurse had not engaged in this relational inquiry, she would not have gained a deeper understanding of the woman’s situation. Based on her new learning, the nurse, after seeking permission from the woman, consulted hospital social workers to help her arrange home care services. The nurse also spent extra time with the woman and assisted her in recognizing the meaningfulness of her life and how she can effectively manage the stress.

Case 2: the suffering of a non-complaint patient with coronary artery bypass grafting

Younas⁶⁰ described a case of a 43-year-old man admitted with non-ST elevation myocardial infarction. The man underwent an angioplasty three weeks ago, but did not comply with the treatment and diet plan. Therefore, he developed further complications and was scheduled for coronary artery bypass grafting (CABG). Despite the importance of CABG for his well-being, he refused the procedure and insisted on a second angioplasty. In this situation, the unit nurses, doctors, and the management labeled him as a non-complaint and a difficult patient. However, the nurse who was assigned to the man realized that there was more to his story. Therefore, he used the relational inquiry approach and examined the intrapersonal, interpersonal, and contextual factors influencing this situation. The nurse used his therapeutic rapport and engaged in a more in-depth conversation with the patient, his wife, and the son. This inquiry revealed a complex interplay of various social, personal, economic, and religious factors. The newer observations were:

The man belonged to a middle-class family. He refused CABG for several reasons: (1) he did not have adequate finances and (2) he wanted to use the available finances for buying the medications for his wife who had diabetes and for paying the tuition for his son’s education.

He wanted to do things for his family because he did not want to go against that social norms: (1) the man is the bread earner of the family and should provide for his family in every situation and (2) the wife of a good man would never work to earn a living for the family. Due to these reasons, he fought with his wife, who wanted to work and share the financial burden.

This practice situation was much more than an account of a non-complaint patient. The man was willing to sacrifice his own needs and health for the well-being of his family. On the other hand, the wife was willing to sacrifice her health for the well-being of her husband, and the son was willing to study in a public school where they would not have to pay a large amount of tuition. The relational inquiry revealed that the man had physical, emotional, and psychological suffering that should have been recognized. The nurse recognized this suffering, understood it, and intervened to alleviate it after collaborating with the patient and his family as well as the health care team. The nurse advocated for the patient and the manager, and the doctor was able to arrange some funds to add to money that the man borrowed for the CABG. The man agreed for CABG because he realized that if he died, his wife and the son would be left alone. His sacrifice would go in vain. Therefore, he promised his wife that after they go home, he would allow her to work to share the financial burden.

Discussion

The shared exemplars demonstrated that the relational inquiry approach could play an essential role in developing an effective relationship with the patient and the family and explore their suffering at a deeper level. The nurses were able to recognize the complex interplay of intrapersonal, interpersonal, and contextual factors. These nurses moved within the space of knowing/not knowing (pragmatic lens), explored the issues of social, cultural, and power relations and their impact on patients’ needs and suffering (critical theory lens), and explored and interpreted the experiences of their patients from the patients’ perspective (Hermeneutic phenomenology lens).¹² The utilization of all three worldviews enabled nurses to move beyond their preconceived biases. For example, Zou⁵⁹ noted that she assumed that, like all white people, the woman was independent, autonomous, and superior in social status. Younas⁶⁰ indicated that, like all other health care providers, he assumed that the man was financially capable of having CABG, but was non-complaint. The nurses’ accounts illustrated that they focused on the physical suffering of their patients. The patients’ physical suffering was apparent from their medical diagnosis and their specific behaviors. However, the use of relational inquiry allowed them to expand their perceptual view⁴⁷ and recognize the implicit suffering of their patients. This implicit emotional and psychological suffering was due to the contextual factors and was aggravated by the interpersonal and intrapersonal factors and physical suffering. The nurses were able to identify the contextual factors after using the pragmatic, Hermeneutic phenomenology, and critical theory lenses. The pragmatic lens encouraged them to consider their prior knowledge about patients as fallible and inquire more about their suffering. Nurses used the Hermeneutic phenomenology lens to explore and understand patients’ suffering from the patients’ and their relatives’ viewpoints. They interpreted the patients’ experiences in line with the social, cultural, and political factors and discerned the contextual factors.

The relational inquiry approach also aligns with relational ethics, which focuses on developing a connection with patients and identify their most essential needs. Relational ethics requires nurses to focus on mind, body, and spirit (embodiment); develop a mutual relationship with the patients (mutuality); connect with patients with open hearts and minds and genuineness (engagement); do not force personal choices and opinion onto patients (non-coercion), and offer then to choose their alternatives to a specific approach to caring.⁶¹ Zou⁵⁹ and Younas⁶⁰ deliberately worked to develop a meaningful connection with their patients, and they overcame their personal biases and prejudices to collaborate with patients and choose the best possible and ethical nursing actions. With the use of the critical theory worldview, the relational inquiry approach calls for recognition of oppressive and unethical social and cultural practices and their effect on patients. Therefore, it emphasizes nurses to effort for the emancipation of their patients through ethical care during suffering.

Hueso Montoro et al.,⁶² suggested that to understand patient suffering, health care providers must build a trustworthy relationship with their patients because patients are comfortable sharing their implicit suffering and the factors that influence that suffering. The relationship inquiry approach offers a toolkit that can enable nurses to develop trust and learn more about their patients. In the described case exemplars, the patients were able to share their suffering because they felt trusted and respected and were treated in a respectful, caring, and compassionate manner by the nurses.^59,60 To understand suffering, the health care providers must acknowledge patient suffering and make themselves available to learn about the patients.⁶³ The relational inquiry approach directs nurses to do so through an intentional desire to ascertain patient suffering. This approach enables nurses to move beyond controlling and handling physical illness and aim at gaining a deeper understanding of patient needs and sufferings. The Hermeneutic phenomenology, critical theory, and pragmatic lenses that guide relational inquiry allow nurses to view patients as an expert of their own needs, patients as human beings whose experiences are constituted by their relationships and environments, and patients as wholistic beings whose physical suffering is connected to their emotional and psychological suffering and vices versa.¹² The case exemplars showed that the nurses gained a much more inclusive understanding of patient suffering when they treated them as wholistic beings who had unique and shared meanings of their physical and psychological illness and suffering.

Conclusion

Developing a profound understanding of patient suffering and gaining insights into their felt needs is critical for effective nursing care that embodies compassionate actions and moments. Patient suffering is a personalized and variable experience that fluctuates across different situations and is affected by hidden factors. The relational inquiry approach is proposed as an instrument to develop a deep understanding of patient suffering. This approach emphasizes recognizing the intricacy of nurse practice situations and focuses on intentionally examining the complex intrapersonal, interpersonal, and contextual factors. By drawing nurses’ attention to the uniqueness as well as the interconnectedness of nurses, patients, and their families’ experiences, the relational inquiry approach can enable nurses to unravel the implicit factors that contribute to or worsen patient suffering. To recognize and understand suffering, nurses must never say, “I know what you are going through” (p. 248).⁶⁴ because this attitude blocks them from listening to the patient’s interpretations of their experiences. The relational inquiry approach prevents nurses from developing such an attitude of knowing more about patient experiences than the patients themselves. Therefore, this approach is essential for recognizing and understanding patient suffering in the real sense and then discerning the relevant actions to alleviate the suffering.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ahtisham Younas

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