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Process and Practice

One of the rules and functions of a nurse is that of being a leader, “who works together to accomplish a specific goal” (Kozier, et al. , 2004, p. 11), and that is, “to contribute to the stability, growth and effectiveness of the profession” (Lemire, 2005, p. 3). This paper presents Joyce Travelbee’s landmark work, The Human-to-Human Relationship” which accomplished a successful and significant change to the nurse education and for which she was accorded with international respect and distinction as one of the leaders in the nursing profession.

II. Travelbee’s “Human-to-Human Relationship:” The Health Care Scenario, The Response for Change and The Content A. The Health Care Scenario 1. Travelbee’s Health Care Exposure Joyce Travelbee, in her lifetime, (1926-1973) had shared her professional knowledge, skills, attributes and expertise in the field of nursing practice and had dedicated her life as a nurse educator and practitioner particularly in the specialization of psychiatric nursing.

As mentioned by Tomey (2002), she taught psychiatric nursing in various schools and hospitals such as Depaul Hospital Affiliate School, Charity Hospital School of Nursing, Louisiana State University, New York University, and University of Mississippi, Jackson (p. 418). Travelbee believed that the nursing care given to the patients in these institutions lacked compassion. Furthermore, she felt that nursing needed a “humanistic revolution” — a return to focus on the “caring” formation of a nurse (Tomey, 2002, p. 419). 2. The Kind of Nurse Education Preceding her Time

Nurse education prior to Travelbee’s time is more focused on the “disease entity approach” rather than on the “holistic care approach” (Tomey, 2002, p. 424). This makes no difference between medical practice and the nursing practice. Bosek and Savage (2007) noted that “medicine focuses more on the diagnosis, management, and treatment of disease and injuries” (p. 39). The human person, who is our client or patient, according to Parse (as cited in Dossey and Keegan, 2008) is “a summative paradigm who is viewed as a combination of component parts” (p. 119). B. The Response for Change

The issues earlier mentioned serve as core concepts and building blocks of Travelbee’s theory on “Human-to-Human Relationship” which by nature is an “interpersonal process” that can be best used as a nursing intervention in dealing with the suffering and illness of psychiatric patients. The development of this theory was influenced by Existentialism, a philosophical movement which emerged in the nursing education during the 60’s, and by her models who include the Existentialist philosopher, Victor Frankl and her predecessor, Ida Jean Orlando, who happened to be her mentor in the graduate school at Yale University. Existentialism

This philosophical movement which began to appear in the 1960’s had created “changes in nursing education…. From this perspective, greatest value is placed on the freedom of choice and the individual is the basis of reality” (Emerson, 2007, p. 22). The human person as subject is the authority and basis of all knowledge in Existentialist philosophy. During Travelbee’s lifetime, “holism” has become the resounding philosophy that exhorts to care for the whole person and not only his or her parts. Parse (as cited in Dossey and Keegan, 2008) says that, “the person as a unity is a holistic energy field that cannot be broken into parts” (p.

119). Travelbee declared that “a nurse does not only seek to alleviate physical pain or render physical care — she ministers the whole person. The existence of suffering, whether physical, mental or spiritual is the proper concern of the nurse” (Travelbee, 1971, p. 159). Moreover, the whole person is also a co-existing being. He or she is social or relational; most capable of creating, destroying and rebuilding personal and authentic relationships. It is elaborated in the works of two Existentialist philosophers, Martin Buber (1958) and Emmanuel Levinas (1991).

Martin Buber, a Jewish philosopher, as reported by Levinas and Hand (1989) outlined a “radical distinction between the ‘I-Thou’ and the ‘I-It’ — the former is a relation of reciprocity and mutuality between two subjects while the latter is a relation between a subject and a passive object” (p. 59). On the other hand, Emmanuel Levinas, viewed human relationships on the “revelation of the Other” (Fulford, et al. , 1996, 25). “Nursing writers, including Travelbee, have used Existential philosophy to focus on the subjective experiences of the nurse-patient relationship.

Travelbee (as cited by Fulford, et al. ) is primarily concerned with the nurse being with the patient in order to facilitate his or her search for meaning in the face of suffering (p. 25). Victor Frankl An Austrian, author of the landmark “Man’s Search for Meaning” and one of the last great psychotherapist of this century. In that later work, Frankl (as cited by Davenport, 2007) argues that the “will to meaning” is a “primary concern” of persons (p. 436). Life is not meaningful in itself; the individual must create and discover its meaning. Moreover, existential anxiety is normal.

Life cannot be lived, nor can death be faced without anxiety. “Suffering is an ineradicable part of life, even as fate and death. Without suffering and death, human life cannot be complete” (Frankl, 1962, p. 106). Therapy is a journey taken by the therapist and the client. This is what Frankl called as an existential therapy which involves “person-to-person therapeutic relationship” (Corey, 2008, p. 9). Frankl also advanced his theory on logotheraphy (healing through meaning), a “therapeutic approach that specifically aims to help clients discover purpose and orientation in their lives” (Cooper, 2003, p.

51). Ida Jean Orlando Orlando published her first book, “Dynamic Nurse –Patient Relationship: Function, Processes and Principles of Professional Nurse Practice,” in which she outlined her theory, “Nursing Process Discipline. ” It is empirical by nature in the sense that such theory is developed out of an actual research. According to Schmieding (2002), “Orlando recorded the content of 2000 nurse patient contacts and constructed her theory based on the analysis of the data” (p. 401). This theory remains one of the most effective practice theories available.

The theory constitutes three elements, namely, “the behavior of the patient, the reaction of the nurse and the nursing actions, which are designed for the patient’s benefits” (Schmieding, 2002, p. 402). Chinn and Jacobs (as cited in Heath, Potter and Perry, 1995) described the patient or the “client as a unique individual with a need that when met, diminishes distress, increases adequacy, or enhances well-being” (p. 5). Insofar as effective care is concerned, she linked it to the “nurse knowledge of patient and its nursing actions to the immediate needs that are validated by patient’s responses” (Johnson and Webber, 2004, p.

139). C. The Content The content of Travelbee’s theory, “Human-to-Human Relationship” shall be discussed under two classifications: The Four Main Paradigms and the Stages of Development. A. Four Main Paradigms There are four principal domains or meta-paradigm concepts of nursing, namely, person, environment, health and nurse (nursing). These concepts are the building blocks for all philosophies of nursing (Masters, 2005, p. 51). The understanding of the nursing theory can be fully grasped through the description of each of these concepts.

Travelbee described these domain concepts (as cited by Meleis, 2007, p. 369) as follows: 1. Human Being (Person) is a unique thinking, biologic, and social organism, and irreplaceable individual who is unlike any other person, who is influenced by heredity, environment, culture, and experiences. He is always in the process of becoming and capable of choosing (Travelbee, 1966, p. 26 & 34). 2. Nursing Client is a patient and is a human being who requests assistance from another human being who he believes in capable of helping and will help in solving his health problems.

3. Nursing is an interpersonal process of service vitally concerned with change and influence of others. An interpersonal process whereby the professional nurse practitioner assists an individual or family to find meaning in these experiences (Travelbee, 1966, pp. 5-6). 4. Goal of nursing is to assist an individual or family to prevent or cope with the experience of illness and suffering and if, necessary, to assist the individual or family to find meaning in these experiences (Travelbee, 1966, pp. 10-12, 20). B. Stages of Development

The nurse-patient (human-to-human) relationship is both existential and developmental. It is a continuous process of becoming and change, and it involves five stages or phases, namely, original encounter, emerging identities, empathy, sympathy, and rapport. Travelbee (as cited by Tomey, 2002, p. 423) describes each of these phases as follows: 1. Original Encounter. The original encounter is characterized by first impressions by the nurse of the ill person and by the ill person of the nurse. The nurse and patient perceive each other in stereotyped roles (Travelbee, 1971). 2. Emerging identities.

The emerging identities phase is characterized by the nurse and patient perceiving each other as unique individuals. The bond of relationship is beginning to form (Travelbee, 1971). 3. Empathy. The empathy phase is characterized by the ability to share in the other person’s experience. The result of the emphatic process is the ability to predict the behaviour of the individual with whom he or she has empathized. Travelbee believed that two qualities that enhanced the empathy process were similarities of experience and the desire to understand another person (Travelbee, 1971). 4. Sympathy.

Sympathy goes beyond empathy and occurs when the nurse desires to alleviate the cause of the patient’s illness or suffering. When one sympathizes, one is involved but not incapacitated by the involvement. The nurse is to create helpful nursing action as a result of reaching the phase of sympathy. This helpful nursing action requires a combination of the disciplined intellectual approach combined with the therapeutic use of self (Travelbee, 1971, p. 149). 5. Rapport. Rapport is characterized by nursing actions that alleviate a patient’s distress. The nurse and ill person are relating as human being to human being.

The ill person exhibits both 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 (Travelbee, 1971, p. 155). III. Conclusion Suffering and pain is a universal fact. It is adhered to even by the Eastern (Oriental) and Western philosophies. Whatever form of illness is suffering and the Existentialist philosopher, Karl Jaspers, calls it as “limit-situation” (Thornhill, 2002, p. 150) from health.

Illness in the light of Travelbee’s philosophy must be viewed not as fragment but from the entirety of the patient’s human personhood. There could be an end to this illness, pain or suffering and that must be the goal of every nurse practitioner. There is a seed of hope and some degree of expectation for relief. The therapy offered by Travelbee is not the “disease entity approach” but the humanistic and existential precepts of grasping the individuality, uniqueness, and difference of each patient. Moreover, it suggests that a positive nurse-patient relationship can bring about a favorable patient outcome.

Travelbee “believed that the nurse’s spiritual values and philosophical beliefs about suffering would determine the extent to which the nurse could help the ill people find meaning in these situations” (Boyd, 2007, 70). As to the theory’s practicability, it is applicable in all health care situations (i. e. psychiatry, geriatric, hospice) in which the developmental and existential “I-Thou” dimension of human existence is more than felt than being said. IV. References: Bosek, Marcia Sue DeWolf and Teresa A. Savage. (2007). The Ethical Component of Nursing Education. Philadelphia, PA: Lippincott, Williams and Wilkins.

Boyd, Mary Ann. (2007). Psychiatric Nursing. Philadelphia, PA: Lippincott, Williams and Wilkins. Cooper, Mick. (2003). Existential Therapies. Thousand Oaks, CA: SAGE Publications. Corey, Gerald (2008). Theory and Practice of Counselling and Psychotherapy. Florence, KY: Cengage Learning. Davenport, John J. (2007). Will as Commitment and Resolve: An Existential Account of Creativity, Love, Virtue, and Happiness. Bronx, NY: Fordham University Press. Dossey, Barbara Montgomery and Lynn Keegan. (2008). Holistic Nursing: A Handbook for Practice. Sudbury, MA: Jones and Bartlett Publishers. Emerson, Roberta J. (2007).

Nursing Education in the Clinical Setting. Philadelphia, PA: Elsevier Health Services. Frankl, Victor E. (1962). Man’s Search for Meaning. Boston, MA: Beacon Press. Fulford, K. W. M. , et al. (1996). Essential Practice in Patient-Centered Care. Malden, MA: Blackwell Publishing. Heath, Hazel B. M. , Patricia Ann Potter, and Anne Griffin Perry. (1995). Potter and Perry’s Foundation in Nursing Theory and Practice. St. Louis, MO: Elsevier Health Sciences. Johnson, Betty M. and Pamela Bayliss Webber. (2004). Introduction to Theory and Reasoning in Nursing. Philadelphia, PA: Lippincott, Williams and Wilkins.

Kozier, Barbara, et al. (2004). Fundamentals of Nursing: Concepts, Process, and Practice. New Jersey: Prentice Hall. Lemire, Judith A. (2005). Preparing Nurse Leaders: A Leadership Education Model. In Harriet R. Feldman and Martha J. Greenberg (eds). Educating Nurses for Leadership. New York, NY: Springer Publishing Company. Levinas, Emmanuel and Sean Hand. (1989). The Levinas Reader. Malden, MA: Blackwell Publishing. Masters, Kathleen. (2005). Role Development in Nursing Practice. Sudbury, MA: Jones and Bartlett Publishers. Meleis, Afaf Ibrahim. (2007). Theoretical Nursing: Development and Progress.

Philadelphia, PA: Lippincott, Williams and Wilkins. Schmieding, Norma Jean. (2002). Ida Jean Orlando: Nursing Process. In Ann Marinner Tomey and Martha Raile Alligood (eds). Singapore: Elsevier Health Sciences Asia. Thornhill, Christopher J. (2002). Karl Jaspers: Politics and Metaphysics. London: Routledge Tomey, Ann Marinner. (2002). Joyce Travelbee: Human-to-Human Relationship Model. In Ann Marinner Tomey and Martha Raile Alligood (eds). Singapore: Elsevier Health Sciences Asia. Travelbee, Joyce. (1971). Interpersonal Aspects of Nursing. Philadelphia, PA: F. A. Davis Co.

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