Research and Theory for Nursing Practice: An International Journal, Vol. 23, No.

4, 2009

A Theory of the Relational

Work of Nurses
Daniela Terrizzi DeFrino, MS, RN
Loyola University, Chicago

The subject of nurses relational work articulates a reality that exists but is not seen.
However, it is the awareness of this reality that leads to the discovery of where nurses
hold their professional power. A theory of the relational work of nurses is the derived
theory presented in this article from the parent theory of the relational work of women
(Fletcher, Jordan, & Miller, 2000). The new theory exposes the relational work of
nurses as the source of their power and value. It explains the relational dynamics of
nurses work, its inherent value, and the need for it to be explicitly recognized as the
process by which nurses achieve positive patient and professional outcomes. The
new theory proposes that because relational work is institutionally disappeared,
nurses therefore demonstrate lack of caring, patient detachment, and burnout. This
theory, if tested, would be an attempt to articulate and make valuable the skills and
strengths that nurses enact to get their job done.

Keywords: nursepatient relationship; relational work; theory derivation;

burnout; power; patient outcomes; professional satisfaction; gender

urses power results from the relational work that they do with patients. The
relational work exists but is, as a general rule, taken for granted as nice
and not valued as the skillful and effective process that it is. It is valued
neither by nurses explicitly nor by management in general. Without relational work,
are nurses technicians? The theory presented in this article moves beyond nurses
care. This theory identifies that power and knowledge lie in relational work and
that without the ability to engage in it, patient outcomes are poorer and nurses are
professionally dissatisfied. It is particularly relevant to bedside hospital nurses, where
the majority of the profession practices. The theory of relational work of nurses is
derived from Fletcher, Jordan, and Millers (2000) theory of relational work to make
explicit the unrecognized but vitally necessary relational work of nurses.
The theory of the relational work of nurses is derived from a psychodynamic
theory of the relational practices of women and the workplace. This article is
organized according to Walker and Avants (2005) process of theory derivation.
It is a process whereby a set of interrelated concepts is moved from one field to

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2009 Springer Publishing Company

DOI: 10.1891/1541-6577.23.4.294

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another and adapted to fit the new field. Theory derivation is useful when a theorist
has a number of concepts that are related to each other but no structural manner
to represent the linking of the concepts (Walker & Avant, 2005). This article will
present Fletchers theory and its derivation to the new nursing theory. The theory
statements of the new theory are presented with supporting literature. The article
concludes with the importance of the derived theory to the profession of nursing
and its potential uses.
The exploration of this topic stems from the work of Manojlovich (2007), who
stated that relational theory may have a greater relevance to the development of
empowerment in nursing than either workplace (Kanter, 1993) or motivational views
of empowerment because of the nature of nursing work. This topic also stems from
the work of Fletcher et al. (2000), whose relational theory articulates a revised vision
of valuing womens relational practices that are overlooked as real work.
It should be noted at the outset that the derived theory views nursing work as
having been structured as a job held by woman. While there are increasing numbers of men in nursing, it has been shaped and continues to exist according to a
female gender perspective of relational practices. This is not a weakness but in
fact an overlooked power of the role. Therefore, both women and men in the role
of nurse engage in relational behaviors in order to achieve nursings outcomes
for their patients, the organization, and themselves professionally. Nursing is the
profession that feminism forgot and still ignores through all its changing lenses
of gender, race, class, and so forth. The derived theory explicitly recognizes the
uniqueness of nursing as a profession largely of women. Gender is the source of
understanding the relational work of nurses. It is embedded in the structure of
the role. Ignoring the formative imprint of gender on the profession ignores the
skills and achievement made because of relational practicea role shaped by
women.

PARENT THEORY
The parent theory chosen for derivation is the theory of relational work of women
as detailed in an article by Fletcher et al. (2000). This theory, from the field of
psychoanalysis, discusses the psychodynamics of women and the workplace. Its
aim is to describe the relational practices of women at work. Relational practice
is defined as a way to achieve goals and getting the job done using skills such as
listening, mutuality, reciprocity, and sensitivity to the emotional context (Fletcher,
2001, p. 1).
The parent theory was chosen for derivation because it speaks directly to how
nurses work with others, specifically patients and health care team members, in
the workplace in order to reach goals and to succeed. The parent theory studied
female engineers and their interactions with others at work. Their study yielded a
description of the skills of relational work that the women used to arrive at collective accomplishment. The framework and cycle of the relational work of the parent
theory is analogous to the work nurses do with others in order to reach outcomes

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for both patient and organization. Nurses have individual responsibilities but must
engage relational practices and work collectively in order to succeed.
The parent theory was developed from womens experiences that led to thoughts.
It did not arise from other, existing theories. The theory rejects the emphasis on
development of a separate self (Fletcher et al., 2000, p. 245). It moves the focus
from the individual to the collective, understanding people in context and relationship. The theory proposes changes to work culture that focus on using gender to
re-vision the workplace rather than assimilating women into it. Instead of trying
to fix women to fit into the workplace, focusing on how women are discriminated
against at work, or valuing how women are different from the norm (White men),
they re-vision the workplace itself by putting the focus on gender.
The theory makes explicit what is already occurring and makes it visible by
naming it. Womens relational practices are to be viewed as skills, not attributes,
that are not merely nice and natural but also effective methods for achieving
desired work outcomes (Fletcher, 2001, 2007). Relational activities of women are
not viewed as female traits rooted in womens greater emotional needs (Fletcher,
2001, p. 2). Relational practice is a skill and a strength. The theory takes the myth
of independence that shapes workplaces and makes visible the large network of
relational connections that actually sustains it. Men are taught to deny relational
growth and needs, while women are taught to quietly sustain these. Additionally,
these relational skills are not acknowledged by society.

ASSUMPTIONS OF THE PARENT THEORY

The assumptions of the theory are the following. The first is that growth, achievement, and effectiveness occur best within a network of connection and support.
Workers are responsible for the whole. Severed relationships are an obstacle to
future growth and achievement. The second is that interdependence is something
to strive for. Mutual reliance on others is powerful and productive. Interdependence
is not a deficient state. The third is that important work outcomes include what
one achieves oneself but also what one enables others to achieve. The definition
of outcome includes outcomes embedded in others (Fletcher, 2001).

CATEGORIES OF THE PARENT THEORY

Fletcher et al. (2000) observed female engineers in a workplace with men and
women. They describe four relational behaviors of women that were observed. The
four categories are preserving, mutual empowering, self-achieving, and creating
team. These behaviors are relational because they are based in relational beliefs
about what kinds of work practices are effective (Fletcher et al., 2000, p. 251).
Preserving. There is a focus on task. The person shoulders responsibility for
the whole in order to preserve the life and well-being of the project through the
following actions: resolves conflict, anticipates problems, takes action to prevent
problems, does whatever it takes, and places project needs ahead of individual
career concerns.

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Mutual Empowering. There is focus on the other. The person enacts an expanded
definition of outcome to include outcomes embedded in others, such as increased
knowledge or competence: teaches with an awareness of the learners needs and
barriers, shares information, facilitates connections, supplies relational skills, gives help
without making the receiver feel guilty, and eliminates barriers and cuts slack.
Self-Achieving. There is focus on self. The person uses relational skills to enhance
ones ability to achieve goals: recognizes and accepts responsibility for breaks in
the relationship that could impede achievement, uses feelings as source of data
to understand and anticipate reactions and consequences, responds to emotional
data in order to strategize appropriate response, and asks for help in a way that
takes helpers needs and likely responses into account.
Creating Team. There is a focus on team. The person creates the background
conditions in which group life can flourish and the feeling of team can be experienced: affirms individual uniqueness through listening, respecting, and responding
and facilitates connections among individuals by absorbing stress, reducing conflict,
and creating structural practices that encourage interdependence.

DISAPPEARING DYNAMIC OF RELATIONAL PRACTICES

The theorys second half discusses how these relational behaviors are disappeared
in the workplace. The relational work is seen as womens work, where relational
practices are disappeared as real work and are constructed as something else.
These practices become personal, not task-related objectives and consequences
(Fletcher, 2001). The theory first validates the existence of womens relational
practices. It subsequently demonstrates how their accomplishments that are
achieved with the use of relational practices are then disappeared because they
are seen from a gendered perspective of nice, natural, and caring. The relational practices are not seen as the deliberate strategic intentions that they are
(Fletcher, 2001).
In the workplace, words used to describe the logic of effectiveness, such as
skill, intelligence, achievement, or outcome, are defined such that these
specifically exclude relational practices as real work (Fletcher, 2001). Fletcher
describes enactment of relational practices being confused with femininity. In fact,
women who enact relational practices at work are pathologized with gender stereotypes. The statements in describing women at work as compliant or wanting
to be liked or nurturing minimize and trivialize valuable and effective ways of
working. While the workplace benefits from relational practices, it does not adjust its
norms about valuable work and valuable practices (Fletcher, 2001). Then, because
these relational practices are not recognized and acting male does not work for
women, women will continually try to enact relational practice. In fact, it is quite
damaging to the mental health of women to not be recognized for the contribution
they make to work (Fletcher et al., 2000). Women often see themselves in conflict at
work because their relational practices are devalued and misunderstood. One of the
results of misinterpretation of motives is that they leave the workplace. The disappearing dynamic of relational practices in the workplace is shown in Figure 1.

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Figure 1. Disappearing dynamic of relational theory.

Note. From Fletcher, Jordan, and Miller (2000, p. 258).

PARENT THEORY TO DERIVED THEORY

Relational theory is an excellent window through which to view nursing expertise,
power, and effectiveness ( J. Fletcher, personal communication, June 27, 2008). There
is not a theory in nursing that brings explicit acknowledgment of gender, relational
practices, and workplace value together through which a fuller understanding of the
dynamics of nurses work functions. Nurses work with others, specifically patients
and health care team members, in the workplace in order to reach goals and to
succeed. The effectiveness of the relational practice, the benefits of professional
satisfaction, the constraints of the current health care environment, the invisible
work of nurses, and the disappeared achievements of nurses are all present in the
literature. Fletchers theory of relational work pulls it together and presents it as a
whole. It is obvious once it is made clear through her theory and easily translates
to a new theory proposed in this article: a theory of the relational work of nurses.
The derived assumptions, concepts, and structure have been altered such that
they have become relevant to nursing (Walker & Avant, 2005). The derivation
of concepts and structure requires both creativity and knowledge. The concepts
are modified in such a way that [they become] meaningful in the theorists field
(Walker & Avant, p. 151).

ASSUMPTIONS OF DERIVED THEORY

The theory of relational work of nurses has three assumptions. The first is that
growth, achievement, and effectiveness, between the nurse and others, occur

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best within a network of connection and support. Workers are responsible for the
whole. Severed relationships are an obstacle to future growth and achievement.
The second is that interdependence between the nurse and others in the workplace is something to strive for. Interdependence is not a deficient state. The third
is that it is both professionally and clinically powerful to be reliant on one another.
Valuable work outcomes include what the nurse achieves alone but also what the
nurse enables those the nurse works with to achieve.

CATEGORIES AND DEFINITIONS OF DERIVED THEORY

The four derived categories can be visualized as relational behaviors that each link
directly to the creation of successful relational practice of the nurse (see Figure 2).
The parent theory categories and definitions and the derived categories and definitions are essentially the same. The word nurse is inserted as the subject of the
categories. Nurses engage in relational work with health care team members as
well as with patients. These four categories of relational practice are preserving
work, mutual empowerment, self-achievement, and creating team.
Preserving Work. The nurse shoulders responsibility for the whole (manages stay
in the hospital, advocates for patient among disciplines) in order to preserve the
well-being of the patient and meet outcomes of the organization. The nurse focuses
on detailthe small things that make a difference. Detail orientation is preserving work. The nurse anticipates problems and takes action to prevent problems.
The nurse extends the job beyond defined boundaries to do whatever it takes to
achieve goals. The nurse extends responsibility beyond tasks or technical definitions of the job. The nurse places the patients and organizations needs ahead of
individual concerns.
Mutual Empowering. The nurse enacts an expanded definition of outcome to
include outcomes embedded in the patient such as increased knowledge or competence. The nurse enacts an expanded definition of outcome to include outcomes
attributed to physician action, for example, that occur because of knowledge passed
to the physician by the nurse. The nurse teaches with an awareness of the patients

Figure 2. Relational practice of the nurse. Nurses use

relational practice to achieve outcomes.

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needs and barriers. The nurse shares information with the patient and with health
care team members. The nurse facilitates connections with the patient and health
care team members. The nurse supplies relational skills when working with the
patient and health care team members. The nurse gives the patient help without
making them feel guilty or inadequate. The nurse eliminates barriers to achievement for the patient as well as other health care team members.
Self-Achievement. The nurse looks to self to modulate and reflect in order to
achieve goals. The nurse recognizes and accepts responsibility for breaks in the
relationships with patients and other health care team members that could impede
care. The nurse will reconnect with the patient or health care team member after
a disconnection or misunderstanding. The nurse reflects on own behavior in
order to work with others effectively. The nurse uses feelings as a source of data
to understand and anticipate reactions and consequences to care and helps the
patient and other health care team members strategize an appropriate course. The
nurse teaches the patient in such a manner that takes patients needs and likely
responses into account.
Creating Team. The nurse creates the background conditions in which unit work
and outcomes can flourish and feelings of relational competence and teamwork
can be experienced. The nurse affirms individual uniqueness through listening,
respecting, and responding. The nurse facilitates connections with others by
absorbing stress, reducing conflict, and creating structural practices that encourage interdependence.

DISAPPEARING DYNAMIC OF RELATIONAL PRACTICES

Just as Fletchers theory defines relational practice and then demonstrates how it is
disappeared as the real work that it is, so does the derived theory. Relational work is
seen as nurses work where relational practices are disappeared as real work and
constructed as something else. These practices become personal, not task-related
objectives and consequences (Fletcher, 2001). The dynamic of relational practice
needs to be put into context at the workplace in order to appreciate how all the
nurses hard work is disappeared (see Figure 3). The nurse is expected to use, has
the skills to enact, and believes in relational practice. To that end, nurses enact
relational practice with patients as well as with other health care team members.
Here, if the nurse is permitted to engage in relational practice because the work
environment supports it with time and validates its necessity professionally, the
nurse is able to experience positive professional rewards. The nurse sees worth
in being valued and stays in the profession. This is where the potential lies to
value nurses relational work with a transactional assessment by the institution.
However, because relational work is invisible knowledge work, it is devalued and
disappeared within the biomedical model. A disempowered and devalued nurse
focuses on tasks, makes it through the shift, experiences moral distress, and burns
out. The nurse either leaves the profession or, because of the belief in relational
practice, will try again and enact relational practice. The disappearing dynamic
repeats itself.

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Figure 3. Disappearing dynamic of the relational practices of nurses.

THEORY STATEMENTS
The literature was reviewed for a broad understanding of aspects of relational practices
of nurses. Nurses engage in relational practices with patients and health care team
members. Relational work is largely invisible and systematically ignoredtermed
disappearedas a valuable achievement in health care. This portion of the article
discusses five main theory statements of the derived theory and the literature that
supports them. The theory statements are the following:
1. A significant amount of the nurses knowledge of the patient comes from relational work with the patient.
2. Relational work creates positive professional rewards for the nurse.
3. Relational work is invisible knowledge work.
4. Relational work is devalued and disappeared in a biomedical model.
5. A disempowered nurse focuses more on tasks, experiences moral distress, and
burns out.

THEORY STATEMENT 1
The first theory statement is that a significant amount of the nurses knowledge of
the patient comes from the relational work with the patient.

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NURSEPATIENT RELATIONSHIP THEORIES

The literature was reviewed for the existence of a theory of relational work of
nurses. No theory was found. However, the topic of relational work extends to
the discussion of the nursepatient relationship. Elements of the parent theory
are congruent to nursing theories of the nursepatient relationship, for example,
working as a whole, relational encounter generating knowledge, work as a series
of relationships not just tasks, and lack of relational engagement leading to professional dissatisfaction.
A starting point for the understanding of the nursepatient relationship is Ida Jean
Orlandos nursing process theory. Her theory made obvious the significance of the
nursepatient situation. There are two assumptions of her theory that describe the
nursepatient relationship. The first is that the nursepatient situation is a dynamic
whole. The second is that the phenomenon of the nursepatient encounter represents a major source of nursing knowledge (Schmieding, 1995). Her work was the
initial acknowledgment of the nurses role beyond physical care tasks ordered by
the physician.
Perhaps more explanatory of the nursepatient relationship is the work of the
psychiatric nurse Hildegard Peplau and her interpersonal nursing theory (Forchuk,
1995). Peplaus theory focuses on the interpersonal processes that occur between
the nurse and patient. In fact, her theory identifies the therapeutic nursepatient
relationship as the crux of nursing. The relationship gives knowledge to the nurse
about how to provide nursing care to the patient. The nurse works to teach the
patient based on what the patient already knows (Peplau, 1997). Peplau stressed
the importance of relationships between people to confirm self-worth and connectedness and to support self-esteem.

NURSEPATIENT RELATIONSHIP AS SOURCE OF KNOWLEDGE AND WORK

The core of the first theory statement is that nursing practice takes place within
the context of a relationship with a patient (Evans, 2007; Jacques, 1993) and in the
details of the relationship (Miner-Williams, 2007). The value of the nursepatient
relationship is that this relationship is work and that the social understanding
and relationship with the patient make up the site of work (May, 1992b). The
nursepatient relationship joins hand in hand with medical interventions serving as the intervention through which comfort, emotional support, and real care
can be facilitated (Foster & Hawkins, 2005). Nursing is the proficient manner in
which physical tasks are completed, but it is argued that nursing is, in fact, much
more than this work. Nursing, as a discipline, has as its phenomena people and
their health. To this end, it is in fact the professional duty of the nurse to know
the patient more than as an object of clinical attention but to understand him or
her as a subject (not an object) with a social history. This understanding greatly
impacts how the nurse can most effectively deliver care (May, 1992a, 1992b). The
attachment that occurs between the nurse as active listener and a patient is in fact
part of the recovery of the patient. The relationship itself is a potentially powerful
intervention (Evans, 2007).

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The literature acknowledges the value of the nursepatient relationship that

exists for nursing work. In order for nursing practice to be effective in attending to
the patients health as well as healing needs, a relational space for a context of
understanding needs to be created (Doane & Varcoe, 2007). It is through the context
of listening and understanding the patient that the nurse can promote outcomes
of as well as beyond physical healing. While the nurse accomplishes tasks, there
is an extension to understand the patient as well as the patients relatives and
friends. Communication emerges from getting to know a patients perspective,
work accomplished through the work of the nursepatient relationship (Doane &
Varcoe; Finch, 2005).

THEORY STATEMENT 2
The second theory statement is that relational work creates positive professional
rewards for the nurse.
Not only is the relational practice of the nurse a vehicle through which the patient
reaps benefits of the nurses care and the organization meets its goals, but the nurse
gains professionally as well. The nurse experiences satisfaction of having connected
with a patient and made a difference (Deppoliti, 2008; Foster & Hawkins, 2005;
Mitchell, 2007). This satisfaction has been given numerous names, one of which
is outgrowth. Outgrowth is defined as a natural consequence of the nursepatient
relationship. For the patient, the outgrowth of the relationship may be comfort, for
example. For the nurse, the outgrowth is often professional growth (Miner-Williams,
2007). The energy gained from the nurse knowing that he or she has been helpful in
caring for the patient and being recognized by health care team members as having
been effective has been cited as a source of the nurses power as well (Chandler,
1992; Jacques, 1993). The professional value has also been cited not as an emotional
drain on the nurses but as one of growth and vitality (Miner-Williams, 2007). This
satisfaction of having entered and affected through the relational practice is often
the reason that nurses can endure and thrive in high-pressure care environments
like a pediatric intensive care unit (Curley, 1997; Morse, Bottorff, Anderson, OBrien,
& Solberg, 1992).
Interestingly, a formal grounded theory of caring that examines womens role of
caring in society mirrors much of the discussions in relational work literature. One
parallel is that, among other outcomes, the woman experiences caring rewards.
Caring rewards refer to the sustenance received from caringand bolsters the
woman in the face of the burden of further caring (Wuest, 2001).

THEORY STATEMENT 3
The third theory statement is that relational work is invisible knowledge work.
As Manojlovich (2007) stated, A lot of nursing work is done in private, behind
drawn curtains (p. 2). A direct line can be drawn from the invisible work of nurses
to mothers. Taking care of others is an integral part of womens work in society.
The gender-based characteristics of womens work, like those of nursing, devalue
the work and make it invisible (Brush & Vasupuram, 2006; Im, 2000). The persistent

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invisibility of nursing work makes it immeasurable and intangible to the group with
power that organizes what counts through the biomedical framework of health
care. There is no external, measurable value to nurture.
Visible activities are important but easily replaceable work that can be delegated
to an aide. This visible work is that which stereotypes the nurses work. The visible
work is feeding the patient, moving the patient, giving medication, doing IV work,
taking specimens, cleaning, and giving treatments. But the invisible work is the
relational knowledge work. This is the procuring of clinical information, teaching,
giving information, communicating with the patient, rapport talk, and the work
that connects knowledge to a larger picture that makes the whole process occur
( Jacques, 1993; Liaschenko, 2002; Maben, Latter, & Clark, 2006). If knowledge work
is invisible, then the nurses knowledge is invisible. A profession is marked by its
relationship to the knowledge it has in its domain. If the professions knowledge is
hidden and not explicit, it has no assigned external value. If the relational, hidden
connecting work of nurses is not quantified or recognized, it is invisible.
Relational/emotional work of nurses is often seen as natural womens work. It
has been called emotional labor. Emotional labor is as invisible in the workplace
as it is in the domestic domain (May, 1992b). Invisible social work is, for example,
when a nurse is seen as friendly or chatty. This is not just being nice; it is part of
how a nurse uses skill to create the nursepatient relationship and connects in
order to work toward a better rapport with the patient (McCabe, 2004). The nurse is
increasing her or his knowledge about the patient and will be able to create better
patient outcomes because of this knowledge.
Invisible work is work that is private. Miner-Williamss (2007) grounded theory
study demonstrated the essence of invisible, private work through the stories
patients told of interactions with nurses. One patient detailed all the difficult times
the nurse saw her suffer through. At the conclusion, she said, I guess maybe I dont
want it to seem trivial and to most people it would be and it is too personal for
me. . . . Most people dont want to know the behind the scenes details (p. 1228).
But the nurse was there, witnessed it, reacted, cared, and connected. It is private
invisible work.

THEORY STATEMENT 4
The fourth theory statement is that relational work is devalued and disappeared in
a biomedical model.
The understanding of the nurse as a worker that exists as an extension of the
organization it works within is vital to understanding how the organization and
worker accomplish outcomes together (Liaschenko & Peter, 2004). The understanding of the health care environments impact on the ability to engage in relational
work with the patient and with health care team members leads to the following
question: If relational practice is a valuable process for the patients well-being,
the organization meeting its goals, as well as for the nurse professionally, why is it
left unprotected, in fact ignored, as nursings major contribution to the care of the
patient and sustenance of the working of the health care system? The literature of

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nursing, as well as that of gender studies in organizations, attempts to highlight the

systematic devaluation of relational work of women. For nursing, from the structure
of the organization to the organization of the individual staff nurses day to what is
measured and held up as the generated positive outcome of the nurses practice,
all collude to paper over the reality of the intense relational work that nurses do to
achieve patient, organizational, and professional goals.
Disappeared achievement refers to work that is accomplished, but the visible
outcome is either systematically ignored or credited to someone else. For example,
the nurse, based on background social knowledge of the patient, brings clinical
information to the attention of a physician; the physician then changes an order
based on the information, and the result of the action is a medical action or outcome
( Jacques, 1993; Mantzoukas & Jasper, 2004). The connecting work of the nurse is
not measured or visible, and the credit of change is to the physician.
Disappeared achievement takes the position that the reason nurses are friendly
and close to patients is that it makes relations with the patient more enjoyable to
the nurse (May, 1992b). Further, nurses interaction with patients that is called casual
familiarity is reconstituted as work (May, 1992b). These kinds of observations view
nurses niceness and friendliness not as a skill to use in caring more effectively for
the patient but as a gendered silliness that makes nurses work easier. It is an incorrect assumption (Foster & Hawkins, 2005). Interestingly, feminists (and the feminist
movement) who critically examined women in all aspects of public and private life
turned their backs on the caring work of women, including nurses, thereby disappearing their accomplishments. Many feminists are in fact hostile to the domain of
caring (Bowden, 2000; Crittenden, 2001; Wuest, 2001). By effectively shutting the
door on the large body of work of caring that women do, there is no way to account
for, analyze, and promote a major activity that sustains society (Wuest, 2001).

THEORY STATEMENT 5
The fifth theory statement is that a disempowered nurse focuses more on tasks,
experiences moral distress, and burns out.
A disempowered nurse who is unable to engage in a relational practice detaches
from the patient, focuses on tasks, and burns out. Without engaging in relational
practice, the nurse is positioned at a distance from the patient and attends not to the
person but to the technical aspects of care. Liaschenko (2002) stated that nurses
are farther from the patients, which they profoundly resent (p.70). When this occurs
and the tasks occur but the relational practice does not, vital communication and
emotional connection to the patient is missing (Foster & Hawkins, 2005).
There are two arguments surrounding the sustainability of the existence of
the nursepatient relationship in the face of health care environment changes.
The increase in technology that the nurse uses to monitor the patients as well
as the decreasing length of hospital stay and the increased number of patients
the nurse has to care for as a result of a general nursing shortage all threaten the
nursepatient relationship and the ability of the nurse to engage in relational practice. The first argument, which is the stronger, is that the nursepatient relationship

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cannot survive. These environmental constraints force the nurse to focus attention on tasks, and the patient becomes the object on which tasks are performed
(Evans, 2007; Finch, 2005; Foster & Hawkins, 2005). The second argument is that
length of time is not as important to the creation of a nursepatient relationship,
but competence is needed in order to engage the patient in the face of the brevity
of time. Both arguments agree, however, that the nursepatient relationship is vital
specifically because of the rushed, computer-dominated, nonhuman orientation
that gives nurses less time to be with the patient and more time to monitor, record,
program, and generally have distance from the patient.
As Peplau stated (1997), Human relationships will be more essential than ever
before (p. 165). Nurses cannot work toward outcomes beneficial to patients without
having adequate information about the patient as a person (Peplau, 1997). In the
face of a changing model of health care where value and preoccupation is placed
on that which is technical and measurable, primary care physicians stated that they
found meaning in their relationships with patients. In a qualitative study, professional satisfaction and professional morale were found in the interpersonal aspects
of their work (Fairburst & May, 2006). In fact, one article reviewed the growing
number of models of centeredness toward the social and psychological sensitivities
of human encounters in health care (Hughes, Bamford, & May, 2008). The trend of
recentering has occurred, the authors argue, as a response to the increased push
toward a narrower biomedical view of health care overall.

MORAL DISTRESS
Moral distress is a response to the nurses inability to enact their moral values
because of a restriction in their practice environment (Began & Ells, 2007; Corley,
Elswick, Gorman, & Clor, 2001; Kopala & Burkhardt, 2005; McCarthy & Deady, 2008).
When nurses cannot do what they think is right, their experience of moral distress
leaves a moral residue (Corley, 2002, p. 636) in which conflict with those closely
held beliefs and values embedded in the nurses mind exist. Moral distress can also
be understood as compromised integrity (McCarthy & Deady, 2008).
Proximity to patients magnifies the nurses experience of moral distress. Moral
distress is also akin to moral suffering. Peter, Macfarlane, and OBrien-Pallas (2004)
described moral suffering by nurses as emotional exhaustion, feelings of abandonment by their organizations and lack of a sense of respect and belonging . . . moral
suffering accompanied their belief that their values had been seriously compromised
(p. 360). There is, not surprisingly, the voice of skepticism. Paley (2004) stated that
moral suffering is an example of nurses playing victim and the oppressed Other,
mistakenly focusing on emotion rather than pragmatic action.

CONSEQUENCES OF MORAL DISTRESS

As a result of experiencing moral distress, the nurse experiences feelings of powerlessness and devaluation. Unresolved moral distress or the moral residue of it leads
to burnout and leaving the profession (Began & Ells, 2007; Corley, 2002; Sumner &
Townsend-Rocchiccioli, 2003). The path that leads nurses to leave the profession

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starts at entering with a commitment to caring, to help others, but finding institutional barriers and practices that conflict with their ability to carry out their values
and care for the patient in a holistic manner, for example. The nurse works within
or under a number of systems. The nurse receives orders from physicians, is an
employee of an institution, and is the in-between between the physician and
patient and bureaucracy of the institution and the patient.
One of the results of the effects of moral distress, over time, is emotional detachment. In one study, women were found to not confront others when difficulty or
problems arose but were quiet, termed self-silencing, in order to get along and not
be seen as unfeminine (DeMarco, Roberts, Norris, & McCurry, 2007). Detachment is
protective to the nurse in that she or he avoids the internal conflict resulting from
moral distress, but it is also the barrier to experiencing compassion and empathy
which are deeply held values of good nursing work (Began & Ells, 2007). If moral
distress eventually forces nurses to avoid patients, then nursing care suffers, and
patients may suffer as well because their needs are not met because of the avoidance (Corley, 2002).

POTENTIAL USE OF DERIVED THEORY

It is the intent of this derived theory to do what Meleis (2007) described: create theory
based on an independent view of a phenomenon that is not currently revealed in
a theory in nursing literature and describe it by labeling it and connecting ideas.
Derived theories, however, are constructed in the context of discovery (Walker
& Avant, 2005, p. 155). In order for this theory to have validity, it must be subjected
to empirical testing.
The skills of relational practice are enacted by nurses every day. The dynamic
of disappearing nurses achievement is institutionalized by the structure of health
care. Nurses strive for professional power, but it is elusive because the relational
work they do is not seen. This theory illustrates what happens in the space between
idealism and professionalism and the actualization of the practice environment. All
the growth in connection with patients and health care team members that occurs
because of their relational practices is ignored by what has been made to count. Our
society values the myth of independence as well as leaders who see the big picture
and are not mired in the so-called trivial details (Fletcher et al., 2000). Therefore,
helping others, attending to details, and connectivity are excised as lacking real
value. This is as true in society at large as it is in hospitals.
Women do not view relationships and activities as mutually exclusive (Chandler,
1992). Neither do nurses. As Chandler (1992) explained, The nurses and patients
are moving through an interaction of connection (p. 69). The relational work of
nurses, where nurses connect, negotiate, and renegotiate within their socially
located work between patients, families, and physicians, is work carried out with
skilled and nuanced interaction (Peter & Liaschenko, 2003). This theory highlights
the importance of viewing relational work as existing within a network of relationships necessary . . . to the attainment of multiple agendas in complex environments

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(Liaschenko & Peter, 2004, p. 494). This theory, when tested, will be an attempt to
articulate and make valuable the skills and strengths that nurses enact to get their
job done.
In order for the quotidian to become valuable, for the niceness to become a genuine
recognized path to power, there has to be a meeting of the feminine and the feminist. As Bowden (2000) argued, the feminist recognition of the moral significance
of institutional structures of power (p. 37) are antithetical to feminine care ethics,
or the relational work of nurses. In other words, how does interpersonal (feminine)
work meld with political (feminist) necessity in order to expose the powerful but
disappeared work of nurses (Bowden, 2000)? The ethic of care, mutuality, helping,
caring, and all the other niceties need to be not only reunderstood as the power
for those receiving care but also restated as the power for those doing the caring
work. A feminist approach to valuing this relational work demands, as ethicist and
philosopher Margaret Urban Walker (2007) stated, attention to diversities of social
positions, stations, or identities constituted by unshared and unequal powers within
communities (p. 28). Without the relational work of nurses in the community of
interest here, the hospital, patient outcomes are poorer. This theory of the relational
work of nurses shines a bright light on their work and demonstrates that this is where
the power is, the work that creates positive professional and patient outcomes. The
power is exactly where hospitals do not look because it is the feminine.
This theory does not assume the position that the nurse is oppressed or a victim
or holding a slave mentality as in Paleys (2002) critique of nursings ideology of caring. It assumes just the opposite. This theory does not reject science, the objective
necessity of science, or the importance of the technicalities of empiricism. It does not
define itself as the opposite of science. However, this theory does reject the stance
that power exists only in the objective medical model and that much of nursings
power exists in the relational, contextual work that it does. That is, nursings power
is in that which has been externallyand internally to the professionviewed as its
weakness, that is, the relational work of nurses with patients and health care team
members. Interestingly, the feminization of medicine is seen as a positive change
in delivering primary care. For female physicians, spending more time with patients
and listening more effectively or enacting relational practices is a benefit, not a
weakness, of women in health care (Phillips & Austin, 2009). This theory exposes
the powerful relational work in attempt to take future steps to support its value for
the patients health and the nurses professional satisfaction.
How does the nurse work within the medical model? As has been stated, this
theory does not reject science, but it demonstrates relational work that occurs in a
positivist, reductionist setting that venerates evidence-based outcomes and disappears achievements of relational work. Monetary value on relational work is an
eventual goal of this theory. The splitting of professionalism needs to first be recognized (Hall & Schneider, 2008). How can we make the relational transactional?
In a transactional model, care is constrained by the rules that govern a business.
In a relational model, care is a part of the relationship that the nurse enacts. Is the
outcome of relational work, for example, to comfort a dying patient when the nurse,
because of the nursepatient relationship created, honors the patients request to

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stay with her as she dies, an outcome that is given explicit, concrete, monetary
value? The absence of this relational, emotional work lays bare an inhumane health
care system (Liaschenko, 2002). It is professionally valuable to the nurse to honor
the patients wishes. But is it explicitly recognized by the institution as having
value? Workers with commodified knowledge are necessary to an organization
(Liaschenko, 2002, p. 70). Nursing work is invisible, and therefore organizations
do not validate nursings work.
In order for the relational to be recognized as work, numerous assumptions need
to be confronted. Is it distasteful in our society to hold up the private, relational work
for economic value externally? Who maintains it as being wrong, as being distasteful to pay to nurture, to care, and to connect? Who says that nurture cannot have a
price? This is the feminist working for the feminine. This theory says that caring is
work, that relational work is valuable, and that it should be validated as such.

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Acknowledgments. I would like to acknowledge and thank my professor, Dr. Lee Schmidt, of
Loyola University, for his guidance in theory derivation and his review of my work. I would
also like to thank Dr. Milisa Manojlovich, of the University of Michigan, for her review and
guidance of my work.
Correspondence regarding this article should be directed to Daniela T. DeFrino, MS, RN, Loyola
University Chicago, Niehoff School of Nursing, 618 South Spring Avenue, LaGrange, IL 60525.
E-mail: d.frino@sbcglobal.net

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