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Book Review-Relationship-Based Care: A Model for Transforming Practice

Healthcare isn’t sausage-making. In sausage-making, “what’s in there” doesn’t matter. It’s simply that it tastes good. In fact, most people don’t want to know about the sausage-making process. However, in healthcare, we’re talking about people, and the process matters. That’s the heart of Relationship-Based Care: A Model for Transforming Practice – an understanding that the process of delivering care is important and the best way to do that is by recognizing the importance of relationships.

Three Directions

In the healthcare system, there are three primary kinds of relationships that a provider can have. First, there’s the obvious relationship to the patient – and their family. The second relationship is with the colleagues. Healthcare is a “team sport.” No provider can work alone. Finally, there’s the relationship to one’s self.

It may seem that a relationship to self is an odd thing to add; however, the truth is that the lack of self-care and self-awareness on the part of providers leads to burnout – and poorer outcomes for the patient. (See for more on burnout causes and resolutions.) The truth is that the relationship to self is the relationship from which the other relationships initiate.

Connecting to the Mission

Every day, care providers face new patients. They present with the same kinds of conditions and the same acuity as the day before and the day before that. There are variations to be sure, but the patients keep coming. It seems like the provider isn’t having an impact. The same patient comes back with the same problem, because they didn’t heed the provider’s advice.

It can be frustrating and demoralizing to realize that you can’t save everyone – that you can’t help everyone. As each day becomes more and more of a grind, it’s possible to lose your way – and wonder why you’re pushing yourself if you’re not seeing any results. That’s when it’s important to reconnect with the mission of the organization and to our personal mission.

Simon Sinek in Start with Why explains that connecting to why we’re doing something has a powerful effect on our productivity and our ability to continue in the face of adversity. In some cases, we know why we’re doing something – our personal and organizational missions – but we’re lost, because we don’t feel like we’re accomplishing the mission. Instead, we feel as if we’re engulfed in chaos, and we’re just trying to survive.

Put Out the Fire

The Healing Power of Relationships

We think we’ve got the world figured out. We believe that our technology and techniques save lives – and to some extent, that’s true. Our technology does save lives, but there’s more to it than that. Aristotle knew that there was more than one way to know the truth. There’s the science – episteme – but there’s also the art – techne. The truth is that our technology and techniques are only part of the solution. (See Theory U for more about different kinds of knowing.)

In Being Mortal, Atul Gawande recounts research that assisted living facilities with patients who were given something to care for – a plant or an animal – lived longer than those who didn’t have something to care for. Our connection to other living things is a powerful tool for health.

Florence Nightingale knew this. She believed that the role of the nurse was to help patients attain the best possible condition, so nature could act, and self-healing could occur. The icon of nursing didn’t believe it was the nurse’s role to heal but rather to create the conditions for healing to occur, and those conditions seem to be found in caring, compassionate relationships.

Transforming an Environment of Care

Jayne Felgen developed a model, I2E2, for transforming the environment of care. The model is four concepts:

  • Inspiration – How do you connect people with the things that inspire them – in other words, their mission?
  • Infrastructure – The set of practices, systems, and processes that make the inspirational vision achievable.
  • Education – The promotion of competence, confidence, and personal commitment through providing the knowledge and skills necessary to do the job.
  • Evidence – Gut feel isn’t enough. In today’s healthcare world, it’s necessary to know for sure that the work being done is making a real difference.

The model encourages the tools that we know lead to change, including creating the initial pull to drive the change forward, supporting the individual both at a systemic and educational level to help them understand they can be successful, and providing continuing support in the form of demonstratable results. (See Diffusion of Innovations for more about motivating people to change.)

The Five Cs (Conditions)

In every organization, there are barriers to change. In fact, organizations, by their very nature, are resistant to change. The network of policies and procedures are designed to form a network that provides strength around unnecessary change. However, there are conditions that make it more likely that change can occur. They are:

  • Clarity – When people know what’s happening at a deep level – both to them and to the organization at large – they can move forward with less fear. (See The Fearless Organization about the role of fear in organizations and Trust=>Vulnerability=>Intimacy, Revisited for more on the role of safety.)
  • Competency – The more people feel competent, the more willing they are to step forward into the change. (See The Psychology of Hope for how waypower impacts a person’s ability to maintain hope.)
  • Confidence – The feeling that someone knows what is being asked of them and has the skills to execute on that leads to confidence – or courage – to move forward. (See Find Your Courage for more.)
  • Collaboration – Collaboration is the ability to work together towards a common goal. That’s essential if you want to transform an organization, because in all but the smallest of organizations, there are multiple people involved whom you need to work with. (See Collaborative Intelligence for a very detailed investigation in how to make collaboration work.)
  • Commitment – Being “bought in” to a goal is critical to its success. Commitment carries the change beyond just doing it if it’s easy, and instead moves it to the world of grit, where there’s a burning desire inside the person who is willing to face adversity to accomplish the goal. (See Grit for more.)

Though the 5 Cs aren’t a rich model for organizational change, it does provide a good framework for some of the basics.

Person not Diagnosis

Diabetes in room 3. Stroke in room 4. Breathing trouble in room 5. It’s a quick way of communicating, but it’s not a respectful way. In healthcare, we’ve got HIPAA to consider, but we can’t use that as a shield for our thoughts and words. Everyone has a story. Everyone is a real person – and they’re much more than a diagnosis.

When we dehumanize people, as referring to them by their diagnosis tends to do, we make it easier to unconsciously treat them poorly. Stanley Milgram demonstrated that, given light environmental controls and encouragement, most people are willing to administer what they believe are life-threatening shocks to others – if they’re not in the same room. (See The Lucifer Effect and Moral Disengagement for more on Milgram’s experiments and the topic of dehumanization in general.) Though we don’t want to admit it, the more we fail to think and communicate about patients as real people with real fears, hopes, and aspirations, the easier we make it to discount them – and that’s the opposite of being in a relationship with them.

Leadership as Being in a Relationship

Joseph Rost laid out in Leadership for the Twenty-First Century how he believed all leadership is done in relationships – non-coercive relationships – and how everyone is a leader. Rather than believing there are two classes of people (separating people into us vs. them), Rost believed that all of us are in relationships with others and are capable of leading. The common thread is that the relationship is accomplished for a meaningful, mutual purpose. In healthcare, the well-being of the patient is a meaningful, mutual purpose.

Sometimes in leading recovery, the patient will lead, and other times, the nurse will lead. Sometimes, in healthcare organizations, the manager will be leading, and other times the nurse will be leading. Leading is, according to Rost, centrally focused on the ability to be in a relationship.

Most nurses recognize that their relationship with their patients, the ability to be with them at their times of such great vulnerability and need, is a sacred and privileged trust. This puts them in the position to lead the patient to better health – as non-coercively as possible.

Organizational Models

Relationship-Based Care spends a great deal of time investigating structural models of organization and approaches to how to deliver the best care. From the historically highly authoritative to the more collaborative approaches, the walk-through shows the progression from a very power-based approach to one that is more collaborative and focused on mutual relationships.

The concerns are addressed about how organizations can maintain consistency of delivery when the delivery is done in a more collaborative and relationship-driven way. The fact of the matter is providing professionals with more autonomy provides for better outcomes – when that autonomy works inside of a well-defined framework.

I’m reminded of Chris Lowney’s work, Heroic Leadership, and how the Jesuits learned which things couldn’t be adapted to fit a culture they were working with – and which could. This clarity about the things that were and weren’t negotiable made it possible to operate effectively in very different environments.


Relationship-Based Care recommends reflection – and that’s important both at an individual level and at a level of process improvement. When we do institutional reflection like after-action reviews (see Lost Knowledge), more commonly seen as root cause analysis, systemic cause analysis, or morbidity and mortality meetings, we create the opportunity to learn from our mistakes and not repeat them.

Perhaps it’s worth some reflection to see if you are providing the best Relationship-Based Care.

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