Defining the “Relational Aspects” of Award Winning Care

DAISY paper coverI recently had the honor of collaborating with DAISY co-founder Bonnie Barnes and DAISY Executive Director, Cynthia Sweeney to create a resource designed to help clinicians recognize their use of the therapeutic practices of attuning, wondering, following, and holding in their daily work.

Our hope for this paper is two-fold:

1)  That nurses in DAISY organization will use this resource to write DAISY nominations that overtly articulate the high degree of relational proficiency of each nurse nominated, and

2)  That caregivers in all organizations will use this resource as a basis for demystifying and better understanding the practices that comprise therapeutic relationships.

We believe that culture is created, in part, by language. Once the language of attuning, wondering, following, and holding becomes a part of the culture, relationship throughout the organization are positively affected!

Click here to read the white paper, “Inspiring Nurses to See the Extraordinary in their Ordinary.”

Mary Koloroutis

The Practice of Wondering

Friend, colleague, and See Me as a Person workshop facilitator, Dan Kopp, M.D., shares a recent experience of rapturous wonder. We are moved by this beautiful expression of deep curiosity about a fellow human being and think this post stands as an example of how, over time and with intention, one’s propensity for wonder can become second nature.

~ Mary and Michael

farmer hands (2)I first noticed his gnarled right hand as he slid into the seat across the aisle of the 737 to Seattle. Tall and thin, he appeared to be in his mid-eighties. Sparse white hair and a bushy gray mustache framed a gaunt face that held a somewhat confused expression. A short and stout fifty-something woman was already settled into the middle seat beside him. She was obviously his daughter by the bits of conversation I overheard. Their exchanges suggested he most likely suffered from some type of dementia. She reminded him to put the ticket stub for the jet-way-checked bag into his wallet so he wouldn’t lose it. As he stood to comply, he removed a dark, slightly stained tweed jacket, revealing a well-worn plaid long-sleeved shirt. He sported camouflaged suspenders over stooped shoulders that apparently helped a wide brown belt secure his faded jeans.

It was his hands, though, that were mesmerizing. There was all the evidence of the countless tasks I imagined they’d performed over eight decades. Though there was little meat in or around the long, slender fingers, prominent purple veins tented his thin skin. Nicotine had stained the tips of the first two fingers of that right hand, as it did the lower edge of his mustache, correlating with the pungent odor of tobacco clinging to his clothes.

The woman continued to attend and speak with him more as a grandchild than the man she called Dad. I further imagined how those hands might have held her a half century ago, soothing her when she cried. I suspected he was a farmer and had worked long and physically demanding years in his fields, though there were no certain clues for that. My hunch was he’d been a good provider for his family, but don’t ask me why. Perhaps it was the soft expression of love I saw in his daughter’s eyes as she held a cell phone at arm’s length announcing she wanted a “selfie” of just the two of them.

He seemed oddly curious at seeing their faces together on the device. She was obviously pleased to have captured the moment. I smiled when he then interrupted the young flight attendant on seat belt patrol. She seemed confused to observe him holding his right hand up in the air until he moved it back and forth. He apparently wanted to “high five” her, something he undoubtedly did often with his children and grandchildren over the years, and she finally graciously obliged.

I saw worry lines deepen on his daughter’s face and wondered if she was dreading this long flight to the northwest coast. I suspected she was considering how many times he might need to use the bathroom, or what he might say that could offend another passenger who didn’t understand how polite and appropriate he had always been before those hands grew gnarled. I continued to wonder about the many tasks they had performed. How often had they swung a hammer, guided a rip saw, or caressed his wife’s face? Had they aimed a rifle in combat? Was the slight tremble from some physical or emotional scar of war?

So many questions flooded over me as I now studied not only his hands but his brown and weathered face in profile. He smiled occasionally, but it never seemed to correlate with anything. I found myself deeply engrossed in this gentleman and really curious about his back-story. I wanted to hear some of his life experiences and understand his relationships with those about whom he cared.

Common decency, however, and respect for both him and his daughter prevented me from intruding more visibly. Later, in the airport, I saw them again, this time walking together quite slowly, hand-in-hand and seemingly lost in their own connection. Even slightly bent at the waist, he still towered over her as she clung tightly to his much larger hand. I thought from a distance it just might have looked as it did when she was seven.


A Brief Overview of the Therapeutic Practices

Wondering is a state of mind characterized by curiosity, openness, and acceptance—a joyful not-knowing and an intentional elimination of our own agenda. Wondering is supported by the actions of

  • becoming empty,
  • using wide eyes (ongoing assessment rather than resting on early conclusions),
  • listening and watching with curiosity, and
  • purposefully eliminating all barriers to the above.

Wondering happens when we have a devotion to the principle that the patient always has something to teach us, without which we cannot really do our jobs.

Followingis a series of intentional acts of devotion to being lead and taught by the patient and family. Following is supported by the actions of

  • listening to, respecting, and acting on what we learn from our patients about who they are and what they want and need,
  • paying attention not only to the patient’s words, but also to voice tone, body language, facial expression, and gaze (including eye contact or lack thereof), and
  • continually adjusting our next caregiving act to align with what we are learning from the patient.

When we practice following, the patient experiences him- or herself not on a production line, but in the hands of people who are interested in learning how to provide specific care for each individual patient according to his or her needs and desires.

Holding is a conscious decision to lift up, affirm, and dignify that which the patient or family member has taught us, resulting in intense focus on the patient or family member, while treasuring both the information and the person. It means creating a “safe haven” for healing; one in which the person feels accepted and held with dignity and respect. Holding is supported by the actions of

  • keeping confidences as needed and appropriate,
  • remembering in specific acts of care, that which has been learned about the patient, the family, the culture, and the history,
  • speaking of and writing about the patient and family—at change of shift report, in the hall, in notes—with dignity and an eagerness to transmit treasured information, and
  • being a steady and nonjudgmental presence even in the face of strong emotional responses.

Each of the therapeutic practices, when practiced within a container of presence and attunement with the patient and family, creates the therapeutic relationship. Where we find presence, attunement, wondering, following and holding, we find authentic human connection. Where clinicians connect authentically with patients and their families, we have therapeutic relationships.

We are honored that you are participating in this vital work!