Human-to-Human Relationship Model by Joyce Travelbee

“A nurse does not only seek to alleviate physical pain or render physical care – she ministers to the whole person. The existence of suffering, whether physical, mental or spiritual is the proper concern of the nurse.”

Introduction

As nurses, we have the responsibility towards our patients. This responsibility does not only focus on the physical defects, difficulties or illness they experience but as well as their total being whether it may be emotionally, psychologically and spiritually. In being able to provide quality health care to our patients, we must be able to have a good interaction and working relationship with them. We must be able to gain their trust, respect and establish rapport as well. As care providers, we must be able to assess the person as a whole not just by mainly focusing in each problem that they verbalize, share or complain.

The theory of Joyce Travelbee indeed has a very great contribution not only to those who are in the Psychiatric Nursing field but in the whole nursing practice. Not only should we be able to assist them towards wellness but also to be able to find meaning in the situation or experiences they had been through whether it may be good or bad. This theory does not only focus on the patient but as well as with the nurse practitioner, both having a unique personality.

Autobiography of the Theorist:

Joyce Travelbee, born in 1926, was a psychiatric nurse, educator and writer. In 1956, she completed her Bachelor of Science degree in Nursing Education at Louisiana State University and her Master of Science Degree in Nursing from Yale University in 1959. She started a doctoral program in Florida in 1973. Unfortunately, she was not able to finish the program because she died later that year. She passed away at the prime age of 47 after a brief sickness.

In 1952, Travelbee started to be an instructor focusing in Psychiatric Nursing at Depaul Hospital Affiliate School, New Orleans, while working on her baccalaureate degree. Besides that, she also taught Psychiatric Nursing at Charity Hospital School of Nursing in Louisiana State University, New York University and University of Mississippi. In 1970, she was named Project Director at Hotel Dieu School of Nursing in New Orleans. Travelbee was the director of Graduate Education at Louisiana State University School of Nursing until her death.

In 1963, Travelbee started to publish various articles in nursing journals. Her first book entitled Interpersonal Aspects of Nursing was published in 1966 and 1971. In 1969, she had her second book published entitled: Intervention in Psychiatrics Nursing: Process in One-to-One Relationship.

Description of the Theory:

Human-to-Human Relationship Model

Travelbee’s formulation of her theory was greatly influenced by her experiences in nursing education and practice in Catholic charity institutions. She concluded that the nursing care rendered to patients in these institutions lacked compassion. She thought that nursing care needed a “humanistic revolution”- a return to focus on the caring functions towards the ill person.

Travelbee’s mentor, Ida Jean Orlando, is one of her influences in her theory. Orlando’s model has similarities to the model that Travelbee proposes. The similarities between the two models are shown in Travelbee’s statement: “the nurse and patient interrelate with each other and by her description of the purpose of Nursing.” She stated that the purpose of nursing is to “assist an individual, family or community to prevent or cope with the experience of illness or suffering, and if necessary, to find meaning in these experiences.”

In her human-to-human relationship model, the nurse and the patient undergoes the following series of interactional phases:

1. Original Encounter

This is described as the first impression by the nurse of the sick person and vice-versa. The nurse and patient see each other in stereotyped or traditional roles.

2. Emerging Identities

This phase is described by the nurse and patient perceiving each other as unique individuals. At this time, the link of relationship begins to form.
3. Empathy

Travelbee proposed that two qualities that enhance the empathy process are similarities of experience and the desire to understand another person. This phase is described as the ability to share in the person’s experience. The result of the emphatic process is the ability to expect the behavior of the individual whom he or she empathized.

4. Sympathy

Sympathy happens when the nurse wants to lessen the cause of the patient’s suffering. It goes beyond empathy. “When one sympathizes, one is involved but not incapacitated by the involvement.” The nurse should use a disciplined intellectual approach together with therapeutic use of self to make helpful nursing actions.

5. Rapport

Rapport is described as nursing interventions that lessens the patient’s suffering. The nurse and the sick person are relating as human being to human being. The sick person shows trust and confidence in the nurse. “A nurse is able to establish rapport because she possesses the necessary knowledge and skills required to assist ill persons, and because she is able to perceive, respond to, and appreciate the uniqueness of the ill human being.”

Note that the above stated interactional phases are in consecutive order and developmentally achieved by the nurse and the patient as their relationship with one another goes deeper and more therapeutic.

Assumptions underlying the one-to-one Relationship:

1. Establishing, maintaining and terminating a one-to-one relationship are activities which fall within the province of nursing practice.

The goals in nursing differ distinctly from those in other health disciplines. Members of various health disciplines share the major overall goal of relationship therapy, namely, to assist the ill person toward social recovery. However, the specific methodology used to accomplish these goals varies. It needs to be emphasized that the one-to-one relationship lies within the province of nursing and that the nurse does not require the permission of the psychiatrist to practice nursing any more than the psychiatrist needs the permission of the nurse to practice psychiatry. This is not only to deny the importance of professional collaboration, it stresses that only nurses are prepared to decide the purposes, roles, activities and functions of nurses.

Members of other health professions are qualified neither by education nor experience to direct nursing activities. This point is emphasized because the “handmaiden-to-the-physician” viewpoint still guides some nurses in the practice of their professional activities. Nurses have many independent functions but only one dependent function, namely, the execution of legal medical orders. Aside fro this one dependent function, a physician cannot “order” nursing care any more than a nurse can “order” medical care. Only professional nurses can, and should, decide and guide the destiny of nursing.

2. A relationship is established only when each participant perceives athe other as a unique human being.

Strictly speaking, a nurse and a patient cannot establish a relationship. It is only when the roles of nurse and patient are transcended, and each perceives the other as a unique human being, that relationship is possible.
3. Only qualified psychiatric nurses are prepared to supervise nurses in the practice of psychiatric nursing.

The nurse who begins interacting with a psychiatric patient for the purpose of establishing a one-to-one relationship should have at her disposal a qualified psychiatric nurse supervisor. By supervisor we mean an individual who holds at least a master’s degree in the field of psychiatric-mental health nursing, she may be a clinical specialist in psychiatric nursing or a prepared psychiatrics nurse faculty member. The supervisor is a resource person with whom the nurse shares data relevant to the one-to-one relationship. The supervisor guides the nurse in clarifying data regarding the relationship and holds regularly scheduled conferences with the practitioner.


4. The major learning experience provided in the psychiatric nursing course in to provide students with the opportunity to establish, maintain and terminate one-to-one relationships.

It is believed that group work skills should be taught on the graduate level. Psychiatric nursing is upper-division nursing course, The concepts used to explain psychiatric nursing intervention are ambiguous and abstract. Time is required for students to understand and apply these concepts meaningfully in a nurse-patient situation. It is recommended that the psychiatric nursing course, on an undergraduate level, extend over a semester. The maturity level of students is also important in determining the extent to which they will be able to establish relatedness with mentally-ill individuals. It is recommended that psychiatric nursing be the last clinical nursing course offered in the program of study. (Behavioral concepts of course should be taught in all clinical nursing courses, not just in psychiatric nursing.)

Students enrolled in a baccalaureate program should, prior to the psychiatric nursing course, possess a basic understanding of major concepts from the natural, physical, biological, medical, behavioral, and nursing sciences. Content related to psychiatric nursing is taught concurrently with field experience. Students, through the group reconstruction process, are taught to apply theory to practice.


5. Nurses need to know how to use library facilities and how to search the literature for needed information.

It may seem somewhat simplistic and self-evident to state that nurses need to know how to use library facilities and how to search the literature for needed information and data. It cannot be assumed, however, that nurses or faculty members know how to use library resources to find reference materials.


6. The knowledge, understanding and abilities needed to plan, structure, give and evaluate care during the one-to-one relationship are necessary prerequisites for developing competency in group work.

Some nurses object to learning skills required to establish a one-to-one relationship on the basis that most nurses in psychiatric settings are required to work with large group of patients, not with individuals. They maintain it is more “realistic” for psychiatric nurses to be prepared to work with groups of patients. However, it is believed that group work is best taught on the graduate, not the graduate, level. It is further believed that the abilities developed in learning to establish, maintain and terminate the one-to-one relationship can be readily transferred and applied to group work. It is more difficult to transfer the knowledge and abilities needed for group work to the one-to-one relationship.

The Goals of the Nurse:

1. The nurse helps the ill person cope with present problems.

The nurse is concerned with “here-and-now” problems as perceived and defined by the ill person. She is not concerned with uncovering unconscious content or with tracking present problems back through the patient’s earliest formative years. This is not to deny that such information is useful (or interesting)-it does imply that the nurse’s primary aim is to help the patient conceptualize his present problem. Knowledge of the ill person’s past history as obtained from the chart, resource people and others is helpful insofar as what is learned guides the nurse in structuring nursing intervention; however, the nurse does not probe or request this information from the patient. If the patient reveals it, the nurse uses it’s knowledge to help her understand his present problem. It is well to remember that there may be a discrepancy between problems as perceived and defined by the patient and the patient’s problem as perceived and defined by nurses, psychiatrists and etc.


2. The nurse helps the ill person to conceptualize his problem.

As stated previously, one of the goals in the interactive process is to assist the ill person to identify or conceptualize problems as he perceives them. This is the primary focus of inquiry throughout the series of interactions. Problems identified by patients will and do change as relationship progresses.


3. The nurse assists the ill person to perceive his participation in an experience.

The nurse strives to assist the patient to see himself as an active participant in life and it’s events. The practitioner strives to assist the patient to gain (or regain) a sense of immediacy- of aliveness- and an appreciation of the uniqueness of his individuality. As the relationship progresses, it becomes easier for the patient to acknowledge that he is an active participant in life experiences and that what he thinks, feels, and does elicits a response from others. The patient begins to realize that he affects the behavior of those about him. The patient also learns that the individuals he encounters will react toward him on the basis of his behavior toward them. This knowledge is gained slowly and over a period of time as the patient begins to develop an appreciation of the cause-and-effect in behavior.

4. The nurse assists the ill person to face emerging problems realistically.

Problems, as initially conceptualized by the patient, frequently undergo a change. The initial presentation by the patient of a somewhat “superficial” problem gradually changes, and deeper problems begin to emerge as the relationship progresses and the patient is able to perceive his participation in life experiences.

5. The nurse assists the ill person to envisage alternatives.

Many ill individuals resort to stereotyped means of solving problems. The nurse assists the ill person to consider alternative means of solving problems in living. It may not occur to an ill person that choices are possible in relation to his particular problem or, if choices do exist, he cannot picture himself acting any differently than he has is the past. The ill person’s ability to envisage alternatives is a legitimate subject of inquiry.

6. The nurse assists the ill person to test new patterns of behavior.

Another general goal in interacting with ill persons is to assist them to test new patterns of behavior. A patient who has difficulty conversing with others is helped by talking with the nurse. The nurse then assists the patient to interact with another patient in the unit. A patient who has difficulty in approaching authority figures is helped by the nurse to approach the psychiatrist. Nurse and patient together develop the plan and the patient tests the new pattern of behavior. The extent to which the plan is successful is discussed during the nurse-patient interaction. The aim of testing new behavioral skills to help the patient to gain confidence in himself as a person who can plan, test, envisage alternatives and face the outcome of the testing. As the result of gaining this ability the patient gains a deeper appreciation of himself as an active participant in life experiences.

7. The nurse assists the ill person to communicate

Mentally ill individuals generally have difficulty in sharing their thoughts and feelings with others. A general goal in the nurse-patient relationship is to assist the patient to communicate logically and clearly with others and to become aware of what he communicates.

8. The nurse assists the ill person to socialize.

Mentally ill individuals generally have difficulty in socializing with others. The term socialize means more than the ability to talk with others. An individual who has the ability to socialize derives pleasure and enjoyment from interacting with others and is attentive to the needs of others. Socialization is a reciprocal process.

9. The nurse assists the ill person to find meaning in illness.

The nurse assists mentally ill individuals to find meaning in their suffering and distress. “Meaning is the reason given to particular life experiences by the individual undergoing the experience.” The term “meaning” is used in a restricted sense and refers only to those meanings which enable the ill individual not only to submit to illness, but to use it as an enabling life experience.


Metaparadigm in Nursing

1. Person

Person is defined as a human being. Both the nurse and patient are human beings. A human being is a unique, irreplaceable individual who is in the continuous process of becoming, evolving and changing.

2. Health

Travelbee stated that health is measured by subjective and objective health. “ A person’s subjective health status is an individually defined state of well-being in accord with self0appraisal of physical-emotional-spiritual status.” Objective health is “an absence of discernible disease, disability, or defect as measured by physical examination, laboratory tests, assessment by a spiritual director or psychological counselor.”

3. Environment

Environment was not clearly defined in Travelbee;s theory. She defined human conditions and life experiences encountered by all men as sufferings, hope, pain and illness. These conditions are associated to the environment.

4. Nursing

As defined by Travelbee, Nursing is “an interpersonal process whereby the professional nurse practitioner assists an individual, family or community to prevent or cope with the experience of illness and suffering and, if necessary, to find meaning in these experiences.”

She explained that nursing is an interpersonal process because it is an experience that occurs between the nurse and an individual or group of individuals.

Acceptance by the Nursing Community

1. Nursing Practice

The hospice is one good example in which Travelbee’s theory is applied. The hospice nurse attempts to build rapport or a working relationship with the patient, as well as with his significant others. She stated that understanding illness and suffering enables the patient not only to accept the sickness, but also to use it as self-actualizing life experience.

A sick person’s insight of worthlessness in his or her sickness leads to non-acceptance of his condition and the great possibility to lose hope.

A hospice nurse believes that the dying person must find meaning in his or her death before he or she can ever begin to accept the actuality of death, just as his or her loved one must find meaning in death before they can complete the grieving process.

2. Nursing Education

Travelbee’s concepts served as better assistance for nurses who help individuals understand the meaning of illness and suffering. Travelbee’s second book, Intervention in Psychiatric Nursing: Process in the One-to-One Relationship, has been used in different nursing programs. According to Travelbee’s model, courses in philosophy and religion would also be helpful in preparing nursing students to fulfill the purpose of nursing sufficiently.

3. Nursing Research

Numerous researches in research studies have cited some aspects of the one-to-one relationship projected by Travelbee. One study by O’Connor, Wicker and Germino, which is nearly related to some of Travelbee’s ideas, discovers how individuals who were recently diagnosed with cancer described their personal search for meaning. The results of this study make known that the search for meaning seems to be both a spiritual and psychosocial process. The researchers acknowledged nursing interventions that would support this process. No other theory of Travelbee that would create further development is available.