The ‘R factor’ in nursing

Cheryl Dellasega and Jared M. Dougherty | 01/02/2019

R is for relationships, RA for its evil twin. (Republished from 2017.)

Two views of a woman's face The business of healthcare delivery has been under a microscope in recent years. Given the expense of the “product” we provide for patients and those who support them, greater accountability and transparency are expected on all levels. Closer examination of budgets and the cost of care has led to management methodologies such as Lean Six Sigma, which has been shown to reduce spending and improve quality by eliminating waste, encouraging more efficient teamwork, and instituting stable yet flexible processes. Our pediatric unit at Penn State Health Milton S. Hershey Medical Center recently discovered that using principles of Lean Six Sigma to restructure physician rounding enhanced a number of patient outcomes.

Cheryl Dellasega While methods like Lean Six Sigma have the potential to result in greater employee satisfaction, one factor that remains underestimated is the impact of relationships on the delivery of healthcare. Recently, at a talk by a high-level administrator at our institution, there was a discussion of metrics—how they are established and what influences them. However, there was no recognition of the human influence on metrics, or that even the most efficient system will fail if those working in it are not satisfied with their jobs. Relationships are what most often lead to job satisfaction. 

Nursing relationship intensive
This is especially relevant for nursing. Nurses find themselves at the center of more relationships during their work time than any other healthcare team professional. Clinical nurses have the most contact with patients and their families on a daily basis and over time. In addition, they have relationship-intensive dynamics with physicians, other providers, and immediate co-workers throughout the day.

Jared M. DoughertyThe relationships nurses establish at the bedside are some of the most profound and touching interactions one can have. The feeling of caring for a patient with a poor prognosis over many months, or comforting family members after loss of their loved one, or simply spending time with a patient who is scared and fearful as his or her life hangs in limbo cannot be compared to any other human experience.

Today’s nurses are charged with providing high-quality, cost-effective, and time-efficient care. They are also often on the emotional firing line: If a patient’s condition deteriorates and tensions rise, nurses are frequently at the intersection of relationship turmoil, acting simultaneously as advocate, peer, and caregiver.

An example of this situation at our facility took place when a 20-something patient was admitted to one of our intensive care units with pulmonary fibrosis requiring centrally cannulated, venovenous extracorporeal membrane oxygenation (ECMO) therapy. In addition to his critical illness and high-tech care, the young man was a long way from home.

As his stay extended into months, a deep and caring relationship was established between the patient and the nurses. When distance prevented friends and family from visiting frequently, the nurses attended to his emotional needs and found ways to calm his panic attacks. Their support gave him a reason to press onward despite setbacks. Knowing how much he enjoyed being active and outdoors, they arranged for daily activity and even short excursions outside.

 As plans were made for lung transplant surgery, nurses continued to put the patient first. Even when caught between multiple and often opposing goals, their creativity and care, expressed daily through their relationships with him and his team of providers, ensured the best possible situation for this young patient.

Nurses have a big job. We learn to promote the well-being of both patients and their loved ones. We are taught to leverage resources, interact with the medical system, and handle emergencies. What we are not taught is how to build and maintain healthy relationships with each other. 

Nursing theories R-factor deficient
None of the longstanding nursing theories allude to the importance of relationships for nurses. Virginia Henderson may advocate for the patient’s independence, and Patricia Benner may describe the knowledge level of nurses from novice to expert, but only Hildegard Peplau addresses what we call “the R factor” in nursing practice. Her interpersonal theory of nursing is just as it suggests, but tradition holds that her work is most relevant to psychosocial mental health nursing.

We contend that all nursing is mental health nursing; positive connections and interactions fulfill us and help our patients heal. Without them, a machine would suffice to perform all the mechanical tasks that, when done correctly, make a healthcare system effective. Nevertheless, we have yet to recognize the critical role of professional and patient relationships in healing and the potential strain it can put on nurses.

This is why discord and relational aggression (RA) can be harder for nurses to cope with. RA is use of relationships to hurt others. Within the nursing workplace, a special kind of betrayal and disappointment occurs when it happens. In the course of our work, which focuses on quality of work life for nurses, we have heard about RA behaviors that stretch across a continuum ranging from “mild” at one end to “extreme” at the other. “How can nurses claim to be so caring and yet be so cruel to each other?” one nurse asked at a recent presentation, and yet, this happens all too frequently.

Unlike horizontal violence, which refers to nurse-nurse aggression, relational aggression can and does occur across and within organizational levels. For example, a unit administrative assistant may play favorites, turning one nurse against another. A physician may excel at belittling all nurses in front of patients, and, of course, we have all heard the infamous “nurses eat their young” expression that seems almost universal. 

Resources to combat RA
We believe that helping nurses identify RA, compassion fatigue, and horizontal violence, along with other relationship issues, will give them resources to combat these concerns both personally and interprofessionally. For this reason, we have developed the Relational Nurse Champion Program to prepare trained Relational Nurse Champions (RNCs). Nurses who receive this training will be a 24/7 resource to enhance relationships among their co-workers.

Relationships are core to humans and especially those of us who are privileged to be nurses. As we invest our energy in healing patients, we must also focus on the “R factor,” which impacts every aspect of our professional lives. With nursing and medical leaders establishing clinical dyads in upper-level management, it is time to take that mentality to the bedside and foster collaborative, meaningful relationships among nurses and physicians to best benefit the patients we all serve. RNL

Cheryl Dellasega, CRNP, PhD, MFA, is a professor in the Department of Humanities at Penn State College of Medicine. Her books When Nurses Hurt Nurses and Toxic Nursing (with Rebecca Volpe) have been recognized for their insight on relational aggression and nurses. She speaks frequently to both adult and adolescent women on the importance of relationships.

Jared M. Dougherty, BS, RN, CCRN, is a clinical nurse and chair of the Department of Nursing Quality of Work Life Council at Penn State Health Milton S. Hershey Medical Center. Dougherty is also pursuing a dual Master of Science and Master in Business Administration degree at The University of Texas at Tyler. 

Editor's note: This article has been reposted because of technical problems with the 
RNL website when the article was first published on 9 March 2017.

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