Microsoft Word - webber corrected proof (1).docx Corresponding Author: Katie M Webber, RN, Doctoral Student University of Calgary Email: katherine.webber@ucalgary.ca Journal of Applied Hermeneutics ISSN: 1927-4416 September 13, 2020 ãThe Author(s) 2020 Relational Complexity in Pediatric Oncology: A Hermeneutic Research Inquiry Katie M. Webber Abstract In this paper, I explore the fit of philosophical hermeneutics with understanding relational complexity in pediatric oncology nursing. I begin by introducing the applicability of philosophi- cal hermeneutics to the practice of nursing and nursing research. I then contextualize pediatric oncology and offer my address of the topic of relational complexity in nurse-parent relationships within pediatric oncology contexts. In the second part of the paper, I draw connections between Gadamer’s philosophical hermeneutics and relational complexity by considering the significance of one’s relation to the other, conversation and self-disclosure, and the interpretation of friend- ship in nurse-parent relationships. I conclude the paper by briefly returning to how my research, guided by philosophical hermeneutics, might contribute to nursing practice. Keywords Nursing, nurse-parent relationships, relational complexity, philosophical hermeneutics, Gadamer, friendship In October 2019, I had the pleasure of accompanying my supervisor, Dr. Nancy Moules, to the North American Society for Philosophical Hermeneutics conference in Oregon. There, she presented a paper, “Hermeneutic Practice: What Gadamer has to Teach Nursing,” a paper soon to be published as a chapter in Ted George’s upcoming book The Gadamerian Mind. In this paper, Dr. Moules eloquently summarized over twenty-five years of her life’s work and contributions to understanding the applicability and fit of hermeneutics within practice disciplines, in particular, nursing. As Dr. Moules suggested, this fit of philosophical hermeneutics and the practice of nursing is the substantive claim that nursing is an interpretive practice. Although the practice of nursing involves a significant focus on technical knowledge (e.g., administering chemotherapy, Webber Journal of Applied Hermeneutics 2020 Article 7 2 performing a bone marrow transplant), what I believe is the strength of nursing practice is an ability, as Gadamer (1960/2004, p. 20) suggested, to “grasp the ‘circumstances’ in their infinite variety,” or phronesis. Illuminating this further, McCaffrey and Moules (2016) suggested that, One of Gadamer’s concepts that speaks most naturally to nurses is his retrieval of phronesis, or practical wisdom. Nursing done well demonstrates the exercise of judgment in the moment, drawing upon knowledge of various kinds, and applying it judiciously and helpfully according to the contours of the unique instance. (p. 4) As Dr. Moules (2019) also suggested, the fit of Gadamer’s philosophical hermeneutics with nursing is evidenced by how nurses “recognize the importance of history – how a disease devel- oped, what symptoms came first, and when – and they know how to ‘read’ this history into its current context of particularities” (p. 2). This contextual history-reading involves engaging with the patient about their perspective of their history, and thus, nursing is also an inherently rela- tional practice (Moules, 2019), concerned with how nurses can relate themselves helpfully to their patients (Peplau, 1952, p. ix). From a Gadamerian perspective, this relating helpfully is often facilitated through language and through seeking to understand what the other has to say (Moules, 2019). As Risser (2002) suggested, “Gadamer’s project of philosophical hermeneutics entails a trans- formation of hermeneutics beyond the framework of methodology … for the sake of the broader experience of understanding and interpretation that is found in experience itself” (p. 167). In their book, Conducting Hermeneutic Research, Moules et al. (2015) applied Gadamerian herme- neutic philosophy to the process of conducting research in practice disciplines. Rather than a strict methodological approach for researchers in practice disciplines to follow, Moules et al. have offered a “way to proceed” (p. 8) in research “beyond the framework of methodology” (Risser, 2002, p. 167) that is attentive to particulars, asks questions of that which lies beneath the surface (Moules et al., 2015), and rigorously examines a topic in a way that challenges us to “live in the world differently” (Moules et al., 2015, p. 191). In nursing research today, there is a great investment in proving experiences through the collec- tion of aggregate data, which is then regarded as fact. However, as Gadamer (2007) reminded us, Thus, what is established by statistics seems to be a language of facts, but which ques- tions these facts answer and which facts would begin to speak if other questions are asked are hermeneutic questions. Only a hermeneutical inquiry would legitimate the meaning of these facts and thus the consequences that follow them. (p. 84) As a nurse working with children and their families who experience cancer, it is quite clear that a strict statistically driven, methodologically focused approach to understanding their individual experiences cannot simply be limited to responses on a yes/no/maybe survey. Understanding experience involves a willingness to engage in complexity and tension, through dialogue and conversations with those who are best able to speak to the experience (Moules et al., 2015), in this case, nurses and parents who experience relational complexity in pediatric oncology. It is for these reasons that I have found Gadamer’s philosophical hermeneutics applicable, if not trans- formative, to my inquiry into the topic of relational complexity in pediatric oncology nursing. Webber Journal of Applied Hermeneutics 2020 Article 7 3 Contextualizing Pediatric Oncology Nursing For children, and their families, the experience of being diagnosed with cancer is well- understood as a stressful and life-altering experience (Björk et al., 2005; Coyne et al., 2016). In pediatric oncology care contexts, family-centered care is a priority, and so both the child and their family are considered to be the patient. As the most accessible healthcare provider and due to pediatric patients requiring active or continuing care from diagnosis and then throughout the remainder of their childhood, pediatric oncology nurses often develop close and meaningful relationships with patients and their families (Boyce et al., 2018; Brimble et al., 2019; Slobogian et al., 2017). Slobogian et al. (2017) suggested that “oncology nurses become educators, caregiv- ers, hand holders, and trusted confidants through the most traumatic and triumphant experiences. Patients often feel like their nurses are like family” (p. 394). While pediatric oncology nurses are not biological family members, it is clear that there is a possibility for familial familiarity in nurses’ relationships with children and their families who are experiencing cancer. Accordingly, there is an inherent complexity about these relationships, due to their extended length, the intensity of treatments, and the emotional nature of cancer (Hopia & Heino-Tolonen, 2019). A definition of complex that the Merriam-Webster (n.d.) dictionary suggests is “a group of obviously related units of which the degree and nature of the relationship is imperfectly known.” Pediatric oncology nurses and children with cancer and their families are obviously related to one another, and while there is something that is known about these relationships, there is a degree of imperfection and ambiguity that is worthy of exploration and understanding. In philo- sophical hermeneutics, the commitment to understanding experience in a way that, as Gadamer (1996) suggested, acknowledges the need to “build a bridge over the existing divide between the theoretician who knows the general rule and the person involved in practice who wishes to deal with the unique situation of [the] patient who is need of care” (p. 94) is a compelling reason to explore the applicability of philosophical hermeneutics to understanding the inherently complex relational work of pediatric oncology nursing. According to Gadamer (1960/2004), “understand- ing begins … when something addresses us” (p. 310), which I now offer as a portal into the topic of relational complexity within nurse-parent relationships in pediatric oncology. Address of the Topic A particular moment in my nursing career has continued to shape my perspective about the complex relationships between nurses and the parents of children diagnosed with cancer. I had been assigned to care for a palliative patient, who I had worked with countless times over the years of her treatment. On one of her final days, I spent much of my shift in her room with her and her family, orientating them to a new, but emotionally challenging reality, one defined by finality. Due to her disease progression, she was severely nauseated, and despite our best at- tempts with antiemetics and supportive care to control her nausea, she had vomited, mostly all over her mother. While her mother held her young daughter in her arms, cleaned her, and settled her, I leaned down to wipe the vomit off of her mother’s shoes. In trying to make light of the situation, I looked up at her mother, who was also a nurse, smiled, and in jest said, “I am being such a good… ”. As I started to say “nurse,” she interrupted me. In the exact moment I said “nurse,” she said “friend.” Webber Journal of Applied Hermeneutics 2020 Article 7 4 Days later, this patient died, and the demands of working in pediatric oncology coupled with the need to maintain professional boundaries, which limited any opportunity for follow up, meant that I did not have the opportunity to truly reflect upon the gravity of my experience. It was not until several years later, sitting in my supervisor’s office, that the memory of this experience resurfaced. At this point in my graduate studies, I was wrestling to settle on a topic of interest that might be worthy of a thesis project. I listed off several tangible ideas, mostly related to quality improvement and educational initiatives. Somehow, though, towards the end of the conversation, and perhaps out of desperation to connect with a topic that really mattered to me, some iteration of, “but what really brought me to graduate school was …”. Awkwardly, and with eyes rimmed with tears, I shared this experience with my supervisor. Her response was emphatic, “This is what you must study.” It was in this moment that I knew that I had come home to my topic. The ethically complex landscape of professional boundaries and nurse-parent relationships in pediatric oncology is, at best, challenging to navigate, and inherently wrought with tension. However, despite being uncomfortable and perhaps even stressful at times, tension may also offer opportunity for understanding. Its Latin root word, tendere, indicates, “to be stretched” (Merriam-Webster, n.d.). When something is stretched it becomes thinner, more malleable, and more vulnerable, revealing gaps in understanding that are not always available to us in strength. Rather than seeking to resolve the tension between the art of navigating complex relationships and the science of regulated professional boundaries, the aim of my research is to increase understanding for the sake of its applicability to practice – to better support the relational needs of parents of children with cancer and the nurses who care for them. Drawing Connections between Gadamer’s Philosophical Hermeneutics and Relational Complexity in Pediatric Oncology I-Thou, One-Other One’s relational engagement with, and understanding of, the other is a significant concern in hermeneutic philosophy and is helpful in framing the topic of relational complexity within nurse- parent relationships in pediatric oncology. As a novice nurse researcher interested in relational complexity, my own understanding about one’s relation to the other has, and continues to be, informed by several philosophers, in particular, Hans-Georg Gadamer. Gadamer (1960/2004) suggested that: In human relations the important thing is, as we have seen, to experience the Thou as tru- ly Thou – i.e. not to overlook his [sic] claim but to let him really say something to us. Here is where openness belongs…Without such openness to one another there is no genuine human bond. Belonging together always also means being able to listen to one another…Openness to the other, then, involves recognizing that I myself must accept some things that are against me, even though no one else forces me to do so. (p. 369) Gadamer articulated the importance of listening, the significance of not overlooking the other, and the value of openness, even when it might be against our own selves. In nurse-parent rela- Webber Journal of Applied Hermeneutics 2020 Article 7 5 tionships, particularly in contexts where the relationship develops and can become more complex over time, the challenge of continuing to listen to what the other has to say is no small task, particularly when conflict about care might arise. Nurses can overlook parents’ perspectives, even unintentionally, and I would suggest that parents can also overlook nurses’ perspectives. While Gadamer’s conceptualization of the other was not written about nurse-parent relationships, there is an opportunity for his philosophy to influence how nurses’ and parents and listen to each other, even when their perspectives might differ. According to Risser (2002), “Gadamer’s hermeneutics is concerned with the opening of shared life in which one is able to hear the voice of the other” (p. 167). Being able to hear the voice of the other is significant in nursing practice. We see in nursing, especially in pediatric oncology nursing, an emphasis on providing care that is focused or centered on the needs of the patient and their family, rather than the needs of the healthcare provider or institution. The principles of family-centered care, according to Kuo et al. (2012) involve open and objective exchanging of information; respecting and honoring diversity and difference; collaboration and partnership; care planning that is negotiable; and contextual care that acknowledges the patient’s family and community. However, despite these well-intentioned principles of care that are focused on the family, care that is authentically family-centered continues to be difficult to realize in everyday clinical practice (Kuo et al., 2012). Optimally, nurses and parents collaboratively partner to provide care to the sick child (Kuo et al., 2012). However, a frequent criticism of family centered care is that it fails to acknowledge several inequities inherent in situations that involve the provision of care (Kuo et al., 2012; McNeil, 2012), leaving nurses and parents feeling frustrated with inadequate healthcare systems. Theories about why family centered care has been challeng- ing to implement include misunderstanding about role responsibilities of parents and nurses, structural challenges related to resource management, and diverse cultural perspectives (Coyne & Cowley, 2007; Shields, 2010). Admittedly, while I would agree that the issues related to implementing care that is family-centered are complex and layered, what is a worthy reminder in everyday nursing practice is the significance of working to remain open to the other, and as Gadamer (1996) suggested, giving “due recognition to the fact that what is involved is always a relationship between two human beings” (p. 171). While there is an undeniable asymmetry of nurse as care provider and parent as care receiver, there remains a mutual humanness between both the nurse and the parent, which is often at risk of being forgotten, due to competing, and often imposed, demands of the healthcare system. This mutual humanness is often understood and expressed through language, or more specifically, through conversation. Gadamer (1972/2007) suggested that the art of conversation, a capacity to hear the other, is at risk of disappearing, which may also point to why family centered care can be difficult to actualize in clinical practice. Conversation and Self-Disclosure In pediatric oncology settings, opportunities for conversations to occur between parents of children with cancer and nurses occur twenty-four hours a day, seven days a week. Countless times a day, nurses enter in to and out of hospital rooms, completing necessary medical tasks, but also, over time and as relationships develop, sometimes just to play a quick game with a patient or to debrief difficult news with a parent. This is often where the work of phronesis becomes alive in pediatric oncology nursing care, as “contextualized knowledge” (Moules et al., 2015, p. Webber Journal of Applied Hermeneutics 2020 Article 7 6 50) that is informed by the particularities and intricacies of the complex circumstances of cancer. While the conversations are not always productive, there remains a real possibility for meaning- ful conversations between parents and nurses to occur where, as Gadamer suggested (1972/2007) “one is open, and finds the other open, enough that the threads of the conversation can run back and forth” (p. 352). It is in these conversations that the pronounced titles of nurse as nurse and parent as parent become less of the focus, and laughter and tears are held in common, rather than expressed on behalf of one towards the other. As Gadamer (1972/2007) offered, “something is a conversation for us if it leaves something behind in us” (p. 355). Upon reflection and with experience, nurses and parents may feel that something has been left behind in them, a lasting influence of their conversations, and the necessary building blocks of their relationships. Due to the nature of cancer treatment, which does not offer breaks for birthdays, vacations, or anything else, conversations between nurses and parents may involve planning a surprise birthday through the window of a hospital room for a severely immunocompromised child or, unfortunately, processing with a parent how they might be able to tell their child that they are going to die. It is for these reasons, and many more, why the conversations between parents and nurses in pediatric oncology sometimes extend beyond shift change. While conversations of equal reciprocity are not the goal, in the nursing profession there remains an overwhelming apprehension about the degree to which self-disclosure might be able to contribute therapeutically to helping relationships (Baca, 2011; College and Association of Registered Nurses of Alberta, 2020; Manfrin-Ledit, 2015). Quite fairly, excessive self-disclosure can be disruptive, if not harmful, to the therapeutic nature of helping relationships (Baca, 2011; Manfrin-Ledet, 2015; Morse et al., 2008). However from a patient perspective, self-disclosure can also provide a “reprieve from being the centre of attention” (Audet & Everall, 2010, p. 333), offering some balance to the inherently asymmetrical nature of provider-receiver relationships, more readily establishing trust, reducing feelings of judgment (Audet & Everall, 2010), and challenging “the one-sided clinical gaze” (Frayling, 2010) that patients can sometimes perceive from their healthcare providers. To illustrate how nurses and parents engage conversationally, and the application that Gadameri- an philosophical hermeneutics might offer to deepening understanding about the conversations that nurses have with parents, I will offer an example. An interaction might begin with a nurse explaining a medical skill that the parent must learn to do before they can be discharged home with their child – a pedagogical conversation (Gadamer 1972/2007). According to Gadamer, the challenge of a pedagogical conversation is that it can be difficult for the teacher, in this case the nurse, to maintain a capacity for conversation. Gadamer wrote “the incapacity for conversation above all rests on the side of the teacher, and in particular, in so far as the teacher is the principle purveyor of knowledge, on the monological structure of modern science and theoretical educa- tion” (p. 356). However, according to Gadamer, there is still the possibility of engaging authenti- cally in conversation in “individualized conversational situations in which the true function of conversation is preserved” (p. 356). Gadamer further distinguished between three types, one of which is the curative form of conversation. Although in his discussion about curative conversa- tions, Gadamer referred specifically to psychoanalytic conversations between a patient and a doctor, I suggest that there is still something applicable to this example of a nurse teaching a Webber Journal of Applied Hermeneutics 2020 Article 7 7 medical skill to a parent. According to Gadamer, a successful curative conversation is “truly a joint enterprise aimed at understanding, and not simply the application of knowledge on the part of the doctor [or in this case, the nurse]” (p. 357). Rather than simply applying their knowledge about how to correctly perform the task, a pediatric oncology nurse might notice a parent’s trepidation and underlying anxiety and take the time to acknowledge and respond to the stress of the situation, rather than the need to discharge the family within a predetermined, system- imposed timeframe. In other words, the nurse is paying attention to the “fecundity of the individ- ual case” (Gadamer, 1960/2004, p. 36), deepening understanding about this particular parent’s experience of having to be now play the role of both parent and nurse in their own home. Per- haps this parent is mourning a lost sense of normalcy for their child, who now has a medical device implanted into their body for years to come, or, perhaps there is something else that needs to be uncovered. There is always a significant potential for the incapacity for conversation to occur, particularly if the nurse reduces the significance of the experience by not noticing or misunderstanding the parent’s anxiety, or worse yet, choosing to ignore it. However, in the event that the nurse choses a posture of openness, seeks understanding through conversation, and engages more relationally, perhaps even disclosing something about their own experience of anxiety to the parent, there is a genuine possibility that such a conversation may be successful in deepening (Gadamer, 1972/2007, 1996) both the nurse’s and parent’s understanding of themselves and the other. Put another way, despite the pressure to focus on technical skills and pre-determined care delivery, a posture of openness towards the other allows for an opportunity for the conversation to become, as Gadamer might say (1960/2004) less conducted and more genuine. As Gadamer (1972/2007) offered, Conversation has a transformative power. Where a conversation is successful, something remains for us and something remains in us that has transformed us. Thus a conversation is a close neighbor of friendship. Only in conversation…can friends find each other and develop that kind of community in which everyone remains the same for the other be- cause they find the other in themselves and find themselves in the other. (p. 355) When a nurse finds something of themself in a parent and when a parent finds something of themself in a nurse, through meaningful conversations that complexify and deepen their relation- ships, it then becomes an interpretive experience, for nurses and parents, of or like friendship. Interpreting Friendship in Relationally Complex Nurse-Parent Relationships While it is generally undisputed that nurses and parents can develop close, meaningful relation- ships due to the particular contextual features of pediatric oncology, there is significant tension about what this closeness should be called. Admittedly, despite my own experience of having a patient’s mother call me a “friend,” I too am uncertain about what language to use that works to describe the closeness, meaningfulness, and complexity of nurse-parent relationships. Nurse scholars have worked to conceptualize these relationships, describing them as experiences of befriending (Balaam, 2014; Bignold et al., 1995; Fegran & Helseth, 2009), friendliness (Gardner, 2010; Geanellos, 2002), or as resembling friendships (Bignold et al., 1995). However, using the term friendship, as a descriptor of nurse-parent relationships, is uncommon and generally dis- Webber Journal of Applied Hermeneutics 2020 Article 7 8 couraged due to its reciprocal nature (Bignold et al., 1995; Brous, 2016; Caroline, 1993; Fegran & Helseth, 2009; Hartlage, 2012). It is important, then, to understand the nuances of language used to describe nurse-parent relationships. As Geanellos (2002) clarified about nursing relation- ships, “friendship is qualitatively different than friendliness and results in a deeper knowing and stronger bond” (p. 242), which is also reflected in Gadamer’s (1985/1999, 1999/2009) work on the phenomenon of friendship. Gadamer’s (1985/1999) interest in the phenomenon of friendship began early in his career, with his inaugural lecture at Marburg in 1928 entitled, “The Role of Friendship in Philosophical Ethics.” It was not until much later that Gadamer returned more extensively to friendship in two essays, “Friendship and Self-Knowledge: Reflections on the Role of Friendship in Greek Ethics” (1985/1999) and “Friendship and Solidarity” (1999/2009). In both essays, Gadamer (1985/1999) argued for Greek thought to be re-considered, “…in opposition to the modern philosophy domi- nated by the primacy of self-consciousness” (p. 131). As Vessey (2005) suggested, “Gadamer regularly return[ed] to the Greeks to arrive at insights into solutions to contemporary philosophi- cal questions that avoid some of the errors of modern thinkers” (p. 63). In considering the application of friendship in our modern linguistic use, Gadamer was concerned that “the word ‘friendship’ is used with colorless frequency” (Gadamer, 1999/2009, p. 4). Gadamer’s efforts to re-cover friendship can be helpful in understanding the complexities of distinguishing between friendship and “mere friendliness” (Gadamer, 1985/1999, p. 134) in nurse-parent relationships. According to Gadamer (1985/1999), the distinction between ‘kinds’ of friendship is not strict or exact, so true friendship al- ways exists within all limited kinds of friendship. What is under discussion … [is] the true essence, which in other kinds of friendship is only partly realized, yet realized in such a way that it is still meaningful to inquire into what they have in common. (p. 133) This is helpful in the understanding the experience of friendship in nurse-parent relationships, as it leaves space for the possibility that nurses and parents may experience a form or kind of friendship with one another that bears both similarities and differences to that of true friendship. As Gadamer (1999/2009) suggested, “[a]ll life friendships probably will always have something of the unattainable, which would be the real, true, final, and complete, the Good” (p. 10). Gada- mer (1999/2009) also suggested that friendship becomes known through living it, not because its standards have been achieved. This perhaps speaks to the difficulty of aggregately defining nurse-parent relationships as friend-like, like-friends, friendships, characterized by friendliness, and so forth. From Gadamer’s (1985/1999) perspective, the distinction between friendship and “mere friendliness” (p. 134) is nuanced, but clear. He says, that merely being well disposed to someone … or having good will toward someone is not friendship … it would be mere friendliness so long as the two people were not really openly bound to each other. The common condition of all ‘friendship’ is more than that: the true bond that – in various degrees – signifies a ‘life together’. (p. 134) The question remains, then, do nurses and parents in pediatric oncology experience friendship, or perhaps more clearly, live a “life together” (Gadamer, 1985/1999, p. 134)? It is possible to Webber Journal of Applied Hermeneutics 2020 Article 7 9 consider this, as children and their parents often spend weeks or even months living in the hospital to receive intense treatments for their cancer. When they are well enough to be dis- charged, nurses continue to visit children and their families in their homes. Accordingly, these relationships develop, and just as patients and their parents move from home to hospital and back again, the relationships that develop with nurses can move between professional and more personal and back again. However, it is also significant to note that parents do not have the choice about whether or not their child has cancer and, therefore, do not get to choose whether or not they want to share their lives with nurses who provide care to their child. If the purpose of describing the phenomenon of friendship in pediatric oncology nursing was to best represent the most relationships, I would suggest that friendliness would both allow for the acknowledgement that reciprocity can exist in these relationships, while still not assuming that parents and nurses are “openly bound to each other” (Gadamer, 1985/1999, p. 134). However, in considering how to approach my research on the topic of relational complexity in pediatric oncology, I am concerned that asking questions about the nature of friendliness in nurse-parent relationships may not get to the heart of their experiences. Furthermore, what, then, do I do with being called “friend,” by a parent - a grieving mother of a dying child? It becomes increasingly necessary to attend to language in conversation as well as to acknowledge the particularities of the individual cases of experience (Gadamer, 1960/2004). In the moment when that mother called me “friend,” the boundaries between nurse and parent became more blurred in the best sense, and in a varied degree that Gadamer suggested, we did share some life together; friendship was a good that arose and was shared between us (Walhof, 2006). Furthermore, as Geanellos (2002) challenged, “should the way nurses and clients consider their relationships be discounted because it conflicts with professional understandings?” (p. 242). While I have not arrived yet at what to call the meaningfulness of the relationships experienced between nurses and parents in pediatric oncology, I am grateful for Gadamer’s significant efforts to restore the meaningfulness of friendship in our modern world and his careful exploration of the nuances of language. Despite the ambiguity that remains about the nature of meaningful relationships in nurse-parent relationships in pediatric oncology settings, I have been encouraged by Gadamer (1960/2004), who offered that “hermeneutic work is based on a polarity of famili- arity and strangeness; but … the true locus of hermeneutics is this in-between” (p. 306). In this way, hermeneutic work is not easy work, but it is worthy work in the sense of finding “language that works” (Moules et al., 2015, p. 202). It is my sincere hope that despite the challenges of articulating relational complexity, there is something yet to be uncovered about complexity in nurse-parent relationships that will change the way nursing is practiced in pediatric oncology settings. Returning to the Research and its Application to Practice As a nurse coming from practice and entering into research with very little education in philoso- phy, foraying into German philosophy has felt immensely challenging, and there is much left to learn. However, hermeneutic philosophy has also brought some comfort; by providing language and understanding, as at its core, it is deeply rooted in practical application (Moules et al., 2015). For example, the first time I read Gadamer’s (1960/2004) discussion of phronesis, or his remind- Webber Journal of Applied Hermeneutics 2020 Article 7 10 er that “in the vast technical structure of our civilization we are all patients” (Gadamer, 1996, p. 81), I felt as though I was coming home to something about nursing that I had not had the language to express before. While this holds personal significance for me, in understanding the work that I do as a pediatric oncology nurse, I believe it also points to the significance of the application of philosophical hermeneutics to nursing research, which for me centers around relational complexity in nurse-parent relationships. Accordingly, I would like to close by articu- lating how this research, guided by philosophical hermeneutics, might contribute in a significant way to nursing practice. In my proposed research, I will conduct interviews with nurses and parents, who can best speak to the topic (Moules, 2002; Moules et al., 2015) of relational complexity. “Hermeneutic research is not validated by numbers, but by the completeness of examining the topic under study and the fullness and depth to which the interpretation extends understanding” (Moules, 2002, p. 14). As with all good research, the aim is to “produce knowledge that discernably matters to someone for something” (Sandelowski, 2004, p. 1367). The impetus to suggest strategies in which the knowledge gained from the research can be translated to practice has become quite prevalent in nursing, as, of course, it is necessary to consider how research might tangibly inform practice (Moules et al., 2015). In hermeneutics, the aim of interpretation is to make sense of something, to understand it (Zimmerman, 2015). This understanding is honored through application, and, in the case of hermeneutic nursing research, in its phronetic applicability to practice. There is the potential for this research, guided by philosophical hermeneutics, to be usefully applied to practice in a variety of ways. This research may have symbolic utility (Sandelowski, 2004), for example, by persuasively demonstrating the need to improve psychosocial support for nurses and parents in pediatric oncology contexts. There is also the potential for this research to be have instrumental utility (Sandelowski, 2004), for example, through the inclusion of nurse and parent perspectives into policy development about professional boundaries. Perhaps, though, the greatest possibility for the applicability of this research is the least concrete form of research utilization – conceptual utilization, which “entails no observable action at all but, rather, a change in the way users think about problems, persons, or events” (Sandelowski, 2004, p. 1371). Conclusion The complexities of pediatric oncology nursing practice, to engage in meaningful relationships with parents of children diagnosed with cancer, is a topic that is, arguably, taken for granted. While we know that nurses and parents engage relationally with one another, what is often misunderstood are the inherent complexities of engaging meaningfully in relationships, while also maintaining institutionally determined boundaries that limit expressions of reciprocal self- disclosure. The significance of this research does not lie, necessarily, in the agreement of all the participants that relationships are complex. Rather, the significance of the research lies in how the understanding gained from this research, “will make a difference in the matters of human consequences of living well in conditions where suffering exists” (Moules et al., 2015, p. 200). Hermeneutics offers a philosophical framework that best allows for the room needed to hold space for the tensions, complexities, and meaningfulness that nurses and parents experience while caring for children with cancer. Webber Journal of Applied Hermeneutics 2020 Article 7 11 References Audet, C.T., & Everall, R.D. (2010). Therapist self-disclosure and the therapeutic relationship: A phenomenological study from the client perspective. British Journal of Guidance & Counselling, 38(3), 327-342. https://doi.org/10.1080/03069885.2010.482450 Baca, M. (2011). Professional boundaries and dual relationships in clinical practice. Journal for Nurse Practitioners, 7(3), 195-200. https://doi.org/10.1016/j.nurpra.2010.10.003 Balaam, M-C. (2014). 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