Understanding How Nursing Students Experience Becoming Relational Practitioners: A Narrative Inquiry

Abstract

Background

Teaching nursing students to become relational practitioners requires theoretical approaches and strategies that engender personal and aesthetic knowing. These qualities closely parallel those that define relational practice. The use of creative self-expression in supporting the development of student capacity for relational practice offers a viable approach.

Purpose

To learn how nursing students’ engagement in creative self-expression activities may impact the construction of their professional identity and capacity for relational practice as novice nurses.

Method

Clandinin and Connelly's narrative inquiry approach was used to explore nursing students’ experiences of learning how to become relational practitioners. Four new nurse graduates engaged in a follow-up focus group using Schwind's narrative reflective process to discuss the impact of a relational practice workshop series.

Findings

Bronwyn's story became the composite of the four participants. Two key narrative patterns emerged: being in service of others and being knowledgeable collaborative leaders. These entailed an intentional engagement in relationships with patients, which required attention to the co-constructed relational space. The creative approaches used to facilitate students’ learning informed their awareness that led to their transformation.

Implications

Educating future nurses who are relational, person-centered practitioners requires a holistic approach to teaching/learning which also includes creative self-expression.

Teaching how to be in a relationship with people in our care is a significant challenge for nurse educators. We use the metaphor of a camera on a tripod (Schwind, 2008) to represent nursing curricula, where two tripod legs of theoretical knowledge and clinical practice are respectively pulled out to the highest standards. However, the third tripod leg of teaching students how to be caring compassionate practitioners in person-centered relational practice is often left to chance of the role-modeling by educators or simply being subsumed in various theoretical courses (Schwind et al., 2015). Considering that nursing is both an art and a science, we became curious to further explore how nursing students develop into relational practitioners, those who act in caring compassionate ways when interacting with patients.

Funded by the Registered Nurses Association of Ontario in collaboration with Associated Medical Services, this inquiry was dedicated to exploring how focused attention on relationality through a workshop series, using an adaptation of the narrative reflective process (Schwind, 2008, 2016), a creative self-expression approach, could facilitate the internal movement of students’ ways of becoming relationally compassionate practitioners. The outcomes of this narrative inquiry have the potential to inform nursing curricula, and specifically nursing pedagogy.

Background

According to Doane and Varcoe (2015), each person “has a unique, personal, socio-historical location that shapes a person's identity, experience, interpretations, and ways of being in the world” (p. 15). Engaging relationally involves values, intent, knowledge, commitment, decision-making, and actions (Doane & Varcoe, 2015). Within the context of relationality, nurses and patients holistically enter into a shared space for dialogue and collaboration. What happens within this co-constructed space becomes the essence of nursing care and a patient's illness experience. It is within the therapeutic relationship, space between nurse and patient, that the potential for healing becomes possible.

Doane and Brown (2011) claim that a focus on relational practice shifts nursing education from the attention on knowledge acquisition and generation (epistemology) to a deliberate consciousness of being (ontology). For educators, a clear understanding of the nature of what it means to be a nurse is essential in this curricular focus. To center learning on relationality requires a particular type of relationship that calls to mind authentic engagement with self and with the other, where dialogue in multiple forms becomes the medium for communication (Gergen, 2009; Schwind et al., 2014). In this context, the intent is to become aware of one's self, that is, to enhance personal knowing (Carper, 1978; Chinn & Kramer, 2015; Schwind & Manankil Rankin, 2020). When we enhance our personal knowing, we gain the opportunity to understand in an embodied way who we are as “instruments of care” (Schwind et al., 2012), and with that awareness, the position of the other. Being in relation with the other (e.g., patient, student, and colleague) involves enacting this embodied understanding through the five relational capacities: commitment, curiosity, compassion, competence, and corresponding (Doane & Varcoe, 2015).

For nurses, the movement toward being requires intentional activities that promote embodied experiences. For teachers of student-nurses that calls on revisioning the curriculum in such a way that it includes both the theoretical knowledge and the lived experience of relational practice. Utilizing various creative self-expression tools, such as the narrative reflective process (Schwind, 2008, 2016), enhances future practitioners’ development of personal knowing. Furthermore, Doane and Varcoe (2015) propose interpretive inquiry as a pedagogy in which the nurses inquire into the lived experience of patients, while donning a critical perspective toward the context of their therapeutic encounters. As such, nurses need to shift toward approaches that focus on building relational capacities (Hartrick, 1997). Embracing the caring values and focusing on relationship as the center of caring practice can be accomplished by creating opportunities for learners. Thus, learners need to engage in humanistic interactions that evoke confidence and trust in one's ability to be with others in relational, authentic, and meaningful ways (Doane, 2002).

In contemporary health care settings, it is becoming increasingly challenging for nurses to build effective therapeutic relationships that embody the core values and goals of our profession (Doane & Varcoe, 2007, 2013, 2015). As our world and health care evolve with globalization, technology, and science, so does the very essence of quality nursing care and what is considered meaningful nursing practice. It is crucial to dig beyond the surface of the one-to-one encounters and to consider what shapes those connections to act with intention to build trust, compassion, and respect (Doane & Brown, 2011; Doane & Varcoe, 2007, 2015).

McGovern et al. (2013) propose the use of Carper's patterns of knowing as a framework for teaching nursing students how to recognize relational cues in high fidelity simulations. These authors believe that without framing the experience through this lens, the potential for preoccupation with a psychomotor acquisition could become more prominent. Another fear is that if we focus solely on competency-based achievement, which is prevalent in many nursing schools, the emphasis would be on a technicality rather than on relational practice development (Scott, 2008). Mirza et al. (2019) agree that to be “practice-ready” entails not only the knowledge and the skill, but also the relational competence in caring for patients. It is evident that a curricular focus on the technicalities of care has made implicit the humanistic, person-centered relational practice competency, particularly essential to new graduates.

Relationality involves an invitation to a particular type of relationship that calls to mind authentic engagement with the “other” where dialogue in multiple forms becomes the medium for communication (Gergen, 2009; Hersted & Gergen, 2013; Schwind, 2016). Bohm and Nichol (1996) claim that dialogue takes place in an open space where judgment is suspended. In the context of relationality, intent is set to understand the standpoint of the other. Doane and Varcoe (2015) introduce the term synchrony, meaning that there is attunement with the other. It is this synchronous collaboration between nurse and patient that facilitates the opportunity for expanding consciousness that enables the potential for wisdom (Newman, 2008), and opens the space for healing.

Increasing self-awareness and knowledge of the self as a person, informs who nurses are as professionals (Lindsay, 2008; Schwind et al., 2012). Coparticipating in creative self-expression activities, such as the narrative reflective process (Schwind, 2008, 2014, 2016), enhances exploration of various dimensions and connections between self-as-person and self-as-professional. In a study of South Asian senior women who live long term with heart illness, Schwind et al. (2015) shifted from using only traditional interviews to also including creative self-expression of storytelling, drawing, and metaphors, all part of the narrative reflective process. By including both approaches, researchers successfully unearthed knowing that is often hidden or lost through a question–answer approach, alone. They obtained a more holistic picture and understanding of how these women live and the challenges they encounter within the community. Such an artful inquiry helps to illuminate the depth and breadth of understanding that would otherwise be missed by words alone (Schwind, 2003; Schwind & Lindsay, 2016).

In terms of professional development of practitioners, Schwind et al. (2012) used the metaphor of self-as-instrument-of-care with nurse-teachers to help them increase their self-awareness and personal knowing to develop their own agency as part of their teaching–learning relationships within educational contexts. A similar creative self-expression was used with mental health nurses to help them explore their own personal knowing as it unfolds within therapeutic relationships (Schwind et al., 2014). By engaging in artful activities, nurses are thus able to authentically examine their lived experiences (ontology) to uncover a deeper co-constructed understanding of who they are as practitioners in relationship with those in their care. Through such creative processes, they deepen their personal knowing, being, and doing.

Relational practice is an entry to practice competency for Registered Nurses in Ontario (College of Nurses of Ontario, 2018). Understanding how the use of creative self-expression strategies influences the personal transformation of nursing students to novice relational practitioners is a significant piece of information that may inform curriculum development. Scholars have suggested that gaining the competency of how to care in a relationship benefits patient experience (Bourque Bearskin, 2011). We add that relational practice also includes the nurse, and thus would benefit both the nurse and the patient (Lindsay & Schwind, 2015; Schwind et al., 2014). In this narrative inquiry, we explored how nursing students, who engage in guided creative activities, coconstruct their identity and their capacity as novice relational practitioners.

Method

Narrative inquiry assumes that people live storied lives and that studying the experiences of life offers the possibility for reconstruction that expands options for future ways of encountering life (Clandinin & Connelly, 2000). Narrative inquiry is about understanding the situated lives of people through reflection and reconstruction of experience, using stories as the foundational basis for such an understanding (Clandinin & Connelly, 1994; Pinnegar & Daynes, 2007). It aligns with philosophical assumptions of the subjective and multiple natures of reality (Creswell, 2007).

Connelly and Clandinin (1990) point out the interrelationship between the phenomenon and method in narrative inquiry. According to the authors, a narrative is both a phenomenon and a method, where the former represents the life being studied and the latter refers to the process with which a researcher studies the phenomenon and engages in the act of retelling (Connelly & Clandinin, 1990). The following assumptions guide the narrative inquiry research process: life is narratively composed; reflection on the stories is critical; stories and analysis are coconstructed and autobiographically informed; and reconstruction of experience is the aim of the inquiry (Clandinin & Connnelly, 1994, 2000; Connelly & Clandinin, 1990, 2006).

Ontologically, narrative inquiry is interpreted as transactional, meaning that the researcher, through inquiry, coconstructs a new relation between the person and the social environment that enables a renewed and awakened perspective from the original narrative (Clandinin & Rosiek, 2007). Epistemologically, knowledge claims become discernible through the reconstruction of experience, which often takes shape in creative representations (Clandinin & Rosiek, 2007).

The act of studying experience narratively requires that the researcher engages in self-inquiry. Autobiographical writing becomes the means by which a researcher makes visible their interpretation of the experience under study anchored within the context of the researcher's larger life story (Connelly & Clandinin, 2006). A researcher engages in a constant reformulation of the inquiry through consistent introspection into their life and social context, which reveals the perspective of multiple selves, multiple “I's” in qualitative research (Clandinin & Connelly, 2000; Denzin & Lincoln, 2005). This methodological consideration addresses the multiple levels of experience embedded in the analysis and frames the personal, practical/professional, and social justifications of the study (Clandinin & Connelly, 1994).

Narrative patterns emerge from a deeper analysis of the account, using the three-dimensional space of experience (person, place, and time) as the analytical framework that facilitates the movement of the inquiry forward into the circles of justification (personal, practical, and social) (Clandinin & Connelly, 1994; Lindsay & Schwind, 2016). Analysis continues addressing all circles of justification (personal, practical/professional, and social) to compose the final research text (Clandinin & Connelly, 2000).

The inquiry puzzle for this narrative study was: How does engagement in creative self-expression activities as nursing students, impact the construction of their professional identity and their capacity for relational practice as novice nurses?

Data collection process

The workshop series, offered during the academic year 2017–2018, was intended to enhance our understanding of how senior nursing students in a second-degree accelerated nursing program learn about and enact relational practice. The workshop series consisted of one 8-h in-person full-day session, followed by six virtual meetings that reinforced the learning and further focused on building relational capacities.

The workshop series was offered as a voluntary extracurricular activity to senior students. Fourteen students participated. For personal–professional development, three faculty members and two preceptors from the program also joined the first in-person workshop. This full-day session involved dialogue on relational practice, mindful breathing, and an artistic self-expression activity, where the participants were invited to visually express what it means to be a relational practitioner.

The virtual meetings focused on linking students’ lived experiences with the literature on relational capacities in practice. Here, the students were asked to think about their clinical experience, read an article, or watch a YouTube video related to one or two of the relational capacities and discuss how relational practice and leadership may be informing their emerging nursing identity.

Four participants accepted the invitation to participate in this inquiry, which serves to qualitatively evaluate the impact of the workshop series on their clinical practice and emerging nursing identity. At the time of this follow-up meeting, fall of 2018, the participants had passed their licensing exam and had been practicing nursing for approximately four months.

At this follow-up meeting, using the narrative reflective process, specifically the metaphoric reflection, participants were asked to consider the value of engaging in the workshop series, as well as to explore how they experienced becoming relational practitioners. In this inquiry, to protect the anonymity of the participants, a composite story was constructed to represent a collective story of how engaging in creative self-expression activities as nursing students, impacted the construction of their professional identity and their relational practice capacity as novice nurses. A composite story is a data analytic device that allows the weaving of the narrative resonant threads within each individual narrative account into a story that encompasses the voice of the participants (Lindsay et al., 2012; Manankil-Rankin, 2016; Schwind et al., 2015). The composite story becomes the collective story and the text from which the circles of justification materialize, creating the final research text, the narrative analysis of the story (Lindsay & Schwind, 2016). Thus, in our inquiry, to protect the identity of our coparticipants, we selected Bronwyn (personal pronoun they/them) to represent the four students’ experiences and responses.

Bronwyn's story

I see endless potential in what I can do as a nurse. Sometimes, I need to be a vessel that is filled with a lot of different resources that I collected over time in school and in personal life experiences to symbolize my values that guide my practice. I want to show that I am trying to be real as a health care professional. I enjoy being able to see whatever my patients are facing. I think this enables me to care. I believe that a nurse brings things together, such as a chain: one that does not break when there is a patient setback. I am there to provide support and navigate the treacherous waters. As a patient advocate and leader, I move change on policy within the health care system. There are times I feel like a telescope allowing myself to be curious about my patient's story and responding with competence based on gathered information.

One of the things I have had to come to accept is to trust other health care professionals. I trust policies and structures that are there to cover my patients. As a nurse, I feel like I have to reach out to other professionals, whether it be processing an order with a pharmacy or consulting with a dietitian. It is like the chain metaphor, bringing everything together, mobilizing so that the patient gets the care they need to get better. So, I need to be quick thinking, fluid, dynamic, moving, and always on my toes.

From my experience, the way I see compassion manifest itself is through keeping in constant communication and correspondence with my patients and their families. I do this by talking with them, always letting them know what I am doing. We have some patients who are intubated, so I do not assume that they cannot really understand things. I see competence as knowing what is of concern.

Being within that nurse–patient relationship is to know what it is that they seek. It is to make that connection with what they are going through and be able to point them in the right direction. I try to instill hope by helping them move toward something greater than what they are going through. It is being a star that a sailboat follows, as a navigational point for helping patients become aware of beauty and hope in their patient journey.

In terms of the workshop series, it helped me internalize knowledge. It is nice to realize how the actions I was taking correspond with what the theory was saying. I found reflecting on relationality and my relationships very helpful in understanding myself and how I naturally relate to people. It encouraged me to use it more in practice. I also think about collaboration with other nurses and health care professionals. It is looking at how I work with others and relate to the rest of the health care team to be able to provide better care to my patients.

I also think that using art in practice might allow patients to feel not so intruded upon with questions. I think it would also help nurses with self-care. I find that learning about the patient's history, where they come from, provides my practice with color. It helps me appreciate where my patients are coming from while understanding how our goals and values interconnect.

Personal justification

Reading and rereading the composite story, we are struck by the metaphoric representations that embody different aspects of nurses’ professional selves. Different contexts bring forth different qualities that reflect the holistic human engagement in service of another. Reading and rereading Bronwyn's story in light of our inquiry puzzle, we discern the following narrative threads: internalized knowledge, filled with resources, values that guide my practice, instilling hope, understanding myself, understanding how our goals and values are interconnected, nurses bring everything together, connection, and collaboration.

As we further immerse ourselves into the composite story and deepen our understanding through reflective dialogue, we sort the selected narrative threads into two key narrative patterns: being in service of others (compassion for self and other and commitment to patient), being knowledgeable collaborative leaders (interprofessional practice, sound knowledge and skill, and competence).

Practical Justification

Being in Service of Others

The pattern that expresses serving others was developed from Bronwyn's engagement with the creative and theoretical elements of relationality. The creative self-expression process of the narrative reflective process, in which Bronwyn engaged, both in the workshop series and the focus-group interview, allowed them to access that part of themselves “unreachable by words” (Schwind, 2003, p. 25), thus giving rise to imagination of potential possibilities. It fueled their abilities to develop their relational capacities. The capacities of competence, compassion, curiosity, correspondence (communication), and commitment arouse from the vessel of their experience.

Through the creative activities and reflective dialogue, Bronwyn was able to identify metaphors that represented their view of how they see themselves in relation to their patients. The vessel was not empty but rather filled with the relational capacities they developed over time. Their heightened sensitivity to relational ideas facilitated the embodying of a framework for relational practice within themselves, as these were brought to their consciousness/awareness through creative and reflective activities.

The selected metaphors (vessel, chain, telescope, star, and sailboat) depict ways to respond to patients through relationships. Through the relational space created by nursing students with their patients, they express a response that depicts the internally driven nursing obligations that compel them to act intentionally with attentiveness as part of narrative competence. Doane and Varcoe (2015) claim that an underpinning in the relationship of inquiring into the life of the other, in this case, the patient, is to act intentionally within the relationship. It means using the nurse's knowledge and skill to address the critical issue(s) relevant to the patient. Charon (2005, 2007), in the model of narrative medicine, states that attentiveness is a response of a health care provider made possible through empathetic listening to the patient. Although Charon’s (2006) work stems from medical education, it has been used interprofessionally to discuss patient experiences through a common conceptual lens.

Charon (2005) emphasizes listening as an essential component of hearing and reading the issue that the patient presents. Doane and Varcoe (2015) highlight the significance of the revered space created between the nurse and the patient for the work inherent in a therapeutic relationship. Intentionality comes to bear in response to the patient in the act of hearing their voice and seeing the person. Bronwyn's story foregrounds this point well, “I enjoy being able to see whatever my patients are facing. I think this enables me to care. I believe that a nurse brings things together, like a chain: one that does not break.” There is something that is powerful in seeing what the patient is seeing. For us, it brings to mind the irreducibility of the person (Irvine, 2005). Perhaps, it is seeing the totality of the other through their lens that facilitates the engagement of compassion as a foundational capacity in relational practice. More importantly, a sense of commitment emerges from the nurse to the patient that is driven by this particular perspective, and as such these novice nurses through Bronwyn's story describe metaphors relevant to how they see themselves as authentically engaged nurses in the practice setting.

The relational space that is created by the nurse and the patient through intentional engagement is where co-constructed knowledge emerges (Schwind & Manankil-Rankin, 2020). The space opens the nurse to possibilities of opening to the liminality of knowing and not knowing. Doane and Varcoe (2015) call this potential curiosity a capacity for being relational. To be curious is to be satisfied with uncertainty as part of knowing. To allow certainty and uncertainty to permeate in one's state of implying a coconstruction that is fluid. This was how Bronwyn conceptualized qualitative data from their patients.

The assumption around the fluidity of information is a significant element of the transformation into relational practitioners. The attentive response to the changing data that emerges from the patient's story allows for the emergence of responsive care. If data are fluid and depict movement, then being relational means to open oneself to the movement of information both in the fields of what is known to unknown to grasp the essence of the patient's experience. Bronwyn narrates the experience clearly, “It is like the chain metaphor, bringing everything together, mobilizing so that the patient gets the care they need to get better. So, I need to be quick thinking, fluid, dynamic, moving and always on my toes.”

The elements we just discussed are significant in reflecting on the transformation of nursing students into relational practitioners. They make explicit assumptions about “being”—grounded on person-centeredness. This sense of person-centeredness is an organizing value for interaction with the patient. Bronwyn claims, “I need to be a vessel that is filled with a lot of different resources that I collected over time in school and in personal life experiences to symbolize my values that guide my practice. I want to show that I am trying to be real as a healthcare professional.”

Another significant element in the transformation of nursing students to relational practitioners refers to the role of the creative process. The creative self-expression of the narrative reflective process allowed the reflection to emerge and for solutions to surface. The development into a relational practitioner was not imposed upon the students but offered for the taking through the multiple exposures of aesthetic strategies and reflections over time throughout the workshop series. The creative process offered the potential for possibilities by opening the space for personal knowing that led to claiming the professional that they intended to be. As instruments of care, the nursing students gained insight into the utility of the use of art in direct practice and as a way to care for themselves. This is reflected in Bronwyn's words, “I also think that using art in practice might allow patients to feel not so intruded upon with questions. I think it would also help nurses with self-care.”

By engaging in relational practice and using creative self-expression, Bronwyn's personal knowing is deepened thus allowing for responsive and imaginative actions that attend to patients’ unique stories and the interconnection of common goals. “I find that learning about the patient’s history, where they come from, provides my practice with colour. It helps me appreciate where my patients are coming from, while understanding how our goals and values inter-connect.”

Being knowledgeable and collaborative leaders

The attention to the whole person with past, present, and future demonstrates that human beings cannot be reduced merely to a presenting problem of the day. The metaphor of the chain alludes to this notion of circularity with the inclusion of the expanding network of the interprofessional team as part of person-centered relational practice. For us, the chain metaphor also denotes the influence of the team as part of the social conditions within the hospital that impact the personal/health conditions of the patient. Nurses are part of a collective humanity within a clinical setting. As such, astute attention to understanding the patient is essential to bring forth the knowledge to the health care team necessary to facilitate the best care. Bronwyn discussed the attention to collaboration from this light.

This narrative thread also foregrounds the idea of making a particular nurse, who responds to the needs of their patients with intention, suggesting the focus on “being” as the core for action. As Bronwyn claimed, the vessel that they depict is one that bears intentional responsive action toward the patient, instead of merely remaining a receptacle. The attention in the development of “being” sheds light on the embrace of knowledge and action. Thus, if to be relational is to be intentional, then intentionality is a deliberate action that brings knowledge and action together. Bronwyn claimed, “In terms of the workshop series, they helped me internalize knowledge. It’s nice to realize how the actions I was taking correspond with what the theory was saying.” In other words, to be relational necessitates deliberative dialogue to demonstrate knowledge-translated action (Plamandon & Caxaj, 2018). As Doane and Varcoe (2015) describe, competence is possessing the knowledge, skill, and judgment inherent in being a nurse.

Social justification – How does relational practice matter?

Looking at the health care landscape on which this inquiry is situated, we ask the question of how this inquiry matters to the healthcare system, including education, practice and research, and beyond to the greater community. Why is preparing students to engage in relational practice important? We turn our gaze toward nursing education, practice, research, and the community at large and ask how nurse educators may facilitate the embodiment of relational practice in their students from these perspectives.

Nursing education

It was clear in the inquiry that the transformation of nursing students into relational practitioners involves a deliberate engagement of students with the concepts of relational practice using reflective creative self-expression. If the intent is toward an ontological premise in education, then the strategy would need grounding in the cultural, historical, contextual, and personal elements of both the students and the teachers (Doane & Brown, 2011).

Using Dewey’s (1938) notion that an experience not reflected upon may be miseducative, we recommend that learning activities involve opportunities for reflection and reconstruction of experience that is at the same time scholarly and personally meaningful. One such way of making this happen is to introduce the use of creative self-expression tools, such as the narrative reflective process, for eliciting thoughts and feelings for which words are not always easily accessible (Schwind & Manankil-Rankin, 2020). Engaging in a creative reflective dialogue to explore issues more deeply calls on imagination and provides students an opportunity to develop both their personal and aesthetic knowing (Schwind & Manankil-Rankin, 2020).

The use of imagination in the context of thinking about how to engage in a relationship with self and others opens the possibility of making particulars concrete (Greene, 1995). This means that when we represent experience using creative self-expression, such as a metaphor, connections among and across experiences become discernible, making it possible to capture the inherent learning within the experience (Greene, 1995; Schwind, 2009). This new insight becomes a source for dialogue that may fuel nuanced changes within nursing students’ forming practice habits.

As we saw in Bronwyn's response to the workshop series, the dialogue and the activities embedded within the facilitation promoted the connection between theory and practice. The workshop created the space that invited Bronwyn to get to know themselves, thus facilitating the interior movements that fuelled the process for transformation. Bronwyn observed, “They helped me internalize knowledge. It’s nice to realize how the actions I was taking correspond with what the theory was saying. I found reflecting on relationality and my relationships very helpful in understanding myself and how I naturally relate to people. It encouraged me to use it more in practice.” Bronwyn's comment suggests that the creative process they were engaged in, motivated them to continue in awareness and intention to bring together theory and practice in a relational and meaningful way.

Nursing practice

A consistent offering of workshops in developing personal knowing and self-as-instrument of care is one way to create the relational space for nurses to intentionally interact with self, while considering relationships with their patients, as well as their colleagues. Rodney et al. (2013) claim that nurses are dialogical and relational in nature. The exploration of experience through creative self-expression and reflection allows for continual engagement with difficult situations in practice rather than its avoidance. It renews the commitment to alleviate the struggle in practice, while allowing new insights to emerge supporting nurses to try again. Lindsay (2001) would label this process as living anew.

Bronwyn stated, “I also think that using art in practice might allow patients to feel not so intruded upon with questions […] It helps me appreciate where my patients are coming from, while understanding how our goals and values inter-connect.” Strategies that renew commitment, curiosity, compassion, competence, and corresponding (communication) with patients in the lives of nurses enable the strengthening of these relational capacities that help nurses live out the nursing obligations of acting with intention, being comfortable with suffering, and using one's voice at all levels of the organization (Doane & Varcoe, 2007, 2015).

Awareness of these relational matters orients nurses to working responsively with patients (Manankil-Rankin, 2015). In such a fashion, nurses move toward a coordinated practice with those they serve, thus opening the space for responding, relating, and solving problems (Gergen, 2009; Tanner, 2006). The relational focus in practice allows for the intersection of the five ways of knowing: emancipatory, empirical, ethical, personal, and aesthetic in the formation of nurses into person-centered relational practitioners.

Nursing research

A focus on how the interior movement within the self plays a role in the formation of nurses is important to investigate. In this inquiry, we found that creative self-expression and reflective dialogue facilitated the opening of imagination that led to a deeper understanding of the experience. The metaphors participants created told the story of their values, showing how they view their role in relation to patients and how they use this perception of themselves to respond to those in their care. This is consistent with Dewey’s (1934) claim that past experiences and thoughts surface into form through reflection, which then informs present understanding resulting in an act of expressing embodied action.

What is particularly essential to foreground is the sustenance afforded by emotions when we engage in the spontaneity embedded in the creative self-expression as an art form. In creating a poem, a drawing, or any artistic creation, we engage in “complete absorption on the subject matter that is fresh, a freshness that holds and sustains emotions” (Dewey, 1934, p. 73). The focus on the freshness that emotions bring to awareness is what may lead to the unfastening of possibilities and expand the dream of potentialities. As Bronwyn claims, “I see endless potential in what I can do as a nurse […] I think that using art in practice might allow patients to feel not so intruded upon with questions […] I find that learning about the patient’s history, where they come from, provides my practice with colour.” The impact of emotions and art as avenues for nursing research needs further unlocking.

Community at large

Relational practice matters to the community, as we all may one day take on the role of a patient. Establishing connectedness with people in our care enhances the quality of their illness experience. Patients desire the presence of their care providers during their times of anxiety (Ross, 2017). They need their caregivers to provide more holistic and rewarding experiences for them and their family. Leotin (2020) suggests that patients yearn for a hospital experience that acknowledges the holistic human experience of illness. Without this relational candor, patients feel the stress more deeply. Patients seek empathy, kindness, and a sharing of humanity. These acts of relational practice lighten an already heavy emotional load of illness (Leotin, 2020). As Doane and Varcoe (2007) claim, the nursing obligations embedded in the thirst to be relational are to be intentional and to be with those who are suffering. Bronwyn caringly expressed this as “…being within that nurse–patient relationship is to know what it is that they seek. It is to make that connection with what they’re going through and be able to point them in the right direction. I try to instil hope by helping them move toward something greater than what they’re going through. It is being a star that a sailboat follows, as a navigational point for helping patients become aware of beauty and hope on their patient journey.”

Denouement: Connecting the process of becoming a nurse, relational practice, and imagination

Lindsay (2006) reminds us that the process of “becoming a nurse” is autobiographically informed. A nursing student's emerging nurse identity is layered by multiple stories and plot lines that reflect patterns that shape the storied life (Lindsay, 2006). Carefully narrated stories of unfolding events in a professional life are deeply intertwined with personal experiences. Schwind (2003) acknowledges the same phenomenon in her narrative inquiry into the illness stories of nurse teachers. Both authors reinforce the role of reflection and reconstruction of experiences that make apparent the insights that inform the future ways of being, thinking, and doing. Using reflection, both critical and creative, is an effective approach to teaching and learning, and enactment of the development of nursing identity.

Clandinin and Connelly (1994) add another element to the mix. They claim that the professional landscape, fuelled by relationships between and across events, people, and things is a moral one. Theory and knowledge that are applied in the practical world have a moral orientation. This suggests that particular nursing knowledge becomes valued and creates what Clandinin and Connelly (1994) refer to as, sacred stories (those that take supremacy over other stories). These stories become embedded in the theory–practice realm, where nursing students absorb them and enact them in the professional landscape.

The challenge in nursing education then becomes a way to question the notion of what constitutes nursing knowledge. What matters in the care of patients? What does the reciprocity of the nurse–patient relationship look like? How are educative experiences reinforced over time in the educational field? Manankil-Rankin (2015) states that nurses value responsive relationships born out of day-to-day interactions with patients. Stories that reflect the value of person-centered care emerge as sacred stories to commit and practice by Manankil-Rankin (2015, 2016). These nurse–patient stories that surface from reflecting on the interaction at the bedside depict what nurses’ desire. They construct their care based on the dialogue that happens within the relationship (Manankil-Rankin, 2015).

If relational practice matters and reflection and reconstruction of experience provide a process by which nursing students may develop their identity, then the way in which these strategies and concepts are facilitated in a nursing curriculum also matter. Engaging nursing students in creative self-reflection and reflective dialogue highlights the unearthing of the authentic self through personal knowing. Schwind and Manankil-Rankin (2020) suggest that strategies, such as the narrative reflective process, facilitate the emergence of stories of experiences for the telling and re-telling of nuances for examination. A creative use of metaphors, art, and/or poetry about experiences opens the space and imagination that bring forth the tacit knowing for exploration and analysis, leading toward an eventual transformation (Schwind & Manankil-Rankin, 2020).

Greene (1995) claims that the nurturance of imaginative capacity promotes the ability to view circumstances through different lights that lead to new perspectives. Wood (2014) further observes that empathy toward the patient is the fuel that triggers the imaginative capacity in nursing practice. Taken into the context of the nurse–patient relationship, the relational space created between the nurse and the patient during the caregiving interaction becomes a space for potentialities where a sense of humanity, sensitivity, and compassion could be shared for the purpose of arriving at a constructive (Scott, 1995), and we add, empathetic way to care.

A nurse whose knowledge is nested in the importance of the personal world when analyzing patient stories is a particular practitioner with an added dimension of relational connectedness. The use of creative self-expression grounded on the value of relational practice creates a unique nursing practice. The commitment toward this approach to fostering nursing students’ growth into relational practitioners reconstructs the professional landscape to deepen its value for personal knowing, as exemplars of nursing's sacred stories. Valuing our personal knowledge along with its intended outcome of empathy provides the potential for imagining the coordination of actions between oneself and the other.

The opportunity to reflect on one's story (nursing student) in relation to the context of others (patients) makes visible what nursing students can bring to the relationship. As this inquiry has found, reflecting and reconstructing experiences with patients facilitated student-nurses’ growth toward intentionality in care, a sense of purposeful caring. In the relationships that emerge between nurses and patients, they recognize how their capacities to be relational, brought forth by ongoing exposure to creative self-expression and reflective dialogue promote in them a uniqueness that sheds light on why they became a nurse. As working novice nurses, these students have come to know that their lives as persons and nurses are mutually informing.

Epilogue

We have come to the end of this inquiry. We shared a Narrative Inquiry that addresses the inquiry puzzle of “How does engagement in creative self-expression activities as nursing students, impact the construction of their professional identity and their capacity for relational practice as novice nurses?” We shared the story of Bronwyn, a composite narrative of the four participants in the study. This was intentional to protect participant anonymity. In keeping with narrative inquiry, we engaged in the circles of justification (personal, practical, and social) to further illuminate the told stories. The denouement was an opportunity to extend the reflection on the stories.

At this stage, we wonder about how we, as educators, are informed and moved by our discoveries within this narrative inquiry. How are we now different? This question brought us back to a piece of writing from an earlier study by Manankil-Rankin (2015), where she expressed her commitment as an educator of the new generations of nurses to do her part in supporting the emergence of an “awakened nurse”.

I’ll trust I’ll do my part in education I’ll teach in ways that will help future nurses Think, Reflect, Reconstruct Together we’ll build a better future One that makes visible Our moral Horizon As Awakened Nurse (p. 168)

The ode is a mantra that is a promise to our past, present, and future students. We will teach so that our students may discover and examine for themselves the stories of their interior lives and how these contribute to creating who they are as nurses.