REFLECTIVE PAPER

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REFLECTIVE PAPERJOYCE TRAVELBEE NURSING THEORIST"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." Joyce TravelbeeRead the following excerpt of the nurse theorist, Joyce Travelbee. Review and answer the questions which follow the excerpt. Include the questions in your typed report and email your assignment to your instructor by the date shown on your course calendar.

Definition of the One-to-One RelationshipThe one-to-one relationship is a goal to be achieved. It is the end result of a series of planned purposeful interactions between two human beings, a nurse and a patient. It is also a series of learning experiences for both participants during which they develop increased interpersonal competencies.

Discussion of the One-to-One RelationshipA relationship does not just happen it is deliberately and consciously planned for by the nurse. A relationship is more than just talking with an ill person for a specified period each day, or having a series of interactions with a patient. The number of interactions added together do not necessarily constitute a relationship. One of the characteristics of a relationship is that both learn as a result of, or because of, the interactive process. If changes do not occur in either or both participants, then it is assumed that a relationship has not been established.As a result of the relationship the ill person grows in his ability to face reality, to discover practical solutions to problems, to become less estranged from the community, and to derive pleasure from communicating and socializing with his fellow human beings.The nurse grows as a human being as a result of the encounter with the emotionally ill person. The practitioner learns new ways of assisting the ill person to move toward meaningful participation in the human community. She learns more about self and, over a period of time, develops the ability to audit and change her behavior. The nurse grows in ability to face and confront reality situations and to cope with expectations of self and others. Sometimes this involves facing unrealistic goals she may have established. It is never easy to compare what one wishes to accomplish with what one has accomplished and to live with the hiatus between the two.The nurse becomes increasingly aware of her strengths and - what is harder to assimilate and use constructively - her limitations. It is hard to admit that one is human and fallible, lacks knowledge and wisdom, and makes mistakes in judgment. It is also hard to accept the fact that, while all patients can be helped, not all patients will recover; social recovery may be an unrealistic goal for some patients. But who among us possess the wisdom to know beyond a shadow of a doubt that a patient will not recover? Too many factors are involved to know this with any degree of certainty. The nurse therefore strives to assist all patients. Few patients show dramatic changes and improvement. The nurse learns that change takes place slowly over a period of time and that the relationship develops in uneven stages. In the beginning progression is evident; this is followed by a period of retrogression and then a period of stagnation before a period of progression occurs again. In the period of stagnation there is no discernible movement in the relationship and the nurse learns to appreciate the necessity of waiting. There is a tempo to all human relationships. This tempo, once comprehended, enables the nurse to wait for the next stage without becoming discouraged.As a result of establishing a relationship, the nurse learns how little she knows, how much there is to learn, and how wide the gulf is between the two. The nurse learns to respect and appreciate the uniqueness of the individual patient. She realizes in a concrete way that a patient is not a label or an illness; each is a human being in his own righta human being who does not easily fit into a diagnostic mold. This appreciation and insight are not easily gained. They are earned by the nurse who possesses courage and perseverance, and who has a profound understanding of the human condition.This relationship is purposeful and goal directed. It is helpful to have a frame of reference with general guidelines to assist the nurse in structuring and maintaining a relationship. The following section explores the nine goals of the nurse in Travelbees one-to-one relationship with a discussion of each goal.The Goals of the Nurse1. The nurse helps the ill person to 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 tracing present problems back through the patients earliest formative years. This is not to deny that such information is useful (or interesting)---it does imply that the nurses primary aim is to help the patient conceptualize his present problem. Knowledge of the ill persons 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, then the nurse uses this knowledge to help her understand his present problem. It is well to remember that there may be a discrepancy between problem(s) as perceived and defined by the patient and the patients problems as perceived and defined by nurses, psychiatrists, etc.2. The nurse helps the ill person to conceptualize his problem.As previously stated, one of the goals in the interactive process is to assist the ill person to identify or conceptualize problem(s) 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 the relationship progresses.The practitioner elicits information from the patient and helps him to conceptualize problem(s). Various communication techniques, including planned inquiry, are used. The nurse listens carefully to the patient or may ask direct questions. Many types of problems may be conceptualized by patients; these may range from the very vague to the very specific. Some patients will deny the existence of problems requiring psychiatric or nursing intervention. However the patient defines his problem, whether the nurse believes the patient or thinks the problem is unrealistic is unimportant at this point. It is important that the nurse elicit a complete account of the problem(s) as the patient perceives them. A patient may maintain he is in the hospital because the doctor wants to find out why he is having trouble sleeping. This is the patients conception of the problem and the logical starting point for discussion in the nurse-patient interaction.After the patient has identified the problem the nurse begins to collect data regarding it. She does not necessarily limit inquiry to the problem as defined by the patient; however, it is recommended that clarification of the problem as defined by the patient be given precedence in the interaction. Actually, anything having relevance to the problem is a subject of legitimate inquiry.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 its events. For example, a patient has insomnia. Obviously this behavior is caused by something. The patient is helped to focus on his behavior. What is his explanation for the insomnia? When did the insomnia begin? What does the patient think caused him to develop insomnia? What helps him to sleep? What hinders him? What can the patient do to help himself? The emphasis is on helping the ill person to realize that he is an active agent, i.e. that something he does, thinks, or feels will play a part in producing or alleviating the problem.The practitioner strives to assist the patient to gain (or regain) a sense of immediacyof alivenessand an appreciation of the uniqueness of his individuality. The nurses message is that the ill person is an active, not passive, participant in life experiences. With the help and support received in the relationship hopefully the patient will begin toPerceive this, although it is probably one of the most difficult goals to accomplish in working with patients. It is not easy for the hypothetically normal individual to identify and acknowledge his participation in an experience, and it is even more difficult for a mentally ill person to do so.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 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. For example, the patient whose initial problem was insomnia may now define his problem as a fear of sleeping lest he lose control of himself or as a fear of recurrent nightmares. A patient whose initial problem was crying spells may now be able to disclose her sense of loss, anger and depression following the death of her husband. This process takes place over a period of time as the patient begins to trust the nurse and gains the support needed to reveal himself.5. The nurse assists the ill person to envisage alternatives.Many ill individuals resort to stereotyped means of solving problems, i.e., their thinking tends to be of a dichotomized either or variety. 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 in the past. The ill persons ability to envisage alternatives is a legitimate subject of inquiry. The nurse may elicit this by asking: What can you do to solve this problem? Is there anything else you can do? The nurse does not make choices for the patient. She does assist the patient to understand that there is usually more than one solution to a problem.

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 on 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 is 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.The nurse needs to appreciate how very difficult it may be for a patient to test a new mode of behavior. For example, a patient wished to test whether she could approach a stranger. The stranger she selected was another patient on the unit. She planned to approach the patient and say: Good morning, how are you? The patient was successful but later stated that she trembled and shook as she approached the strange lady. Afterwards she was very pleased and had gained confidence in herself as a result of having been able to engage in this relatively simple activity. The activity was, of course, not simple to the patient; it was a trial about which she experienced a veritable agony of anxiety. Success does not always occur. The inability to test new behavior may be quite discouraging to a patient, as may the failure to carry through a plan to test a new pattern. In such situations nurse and patient explore what occurred and identify any factors which may have hindered the patient.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.The goal of socializing has been construed by some nurses to mean that the nurse is to get patients involved in group activities such as playing cards or engaging in games. Some patients are helped to socialize by engaging in game-type activities, but this is by no means true of all patients. It is quite possible for a patient to engage mechanically in game-like activities without socializing or being interested in the activity or in the people with whom he is in enforced contact. Judgment is necessary to select the type and kind of socialization experience best suited for a particular patient. Judgment is also required, on the part of the nurse, to decide the appropriate time to initiate such activity.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. It is the why of Nietsches often quoted comment: He who has a why to live for, can bear almost any how. (Frankl, Viktor: Mans Search for Meaning: An Introduction to Logotherapy. Washington Square Press, New York, 1963.) 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 a enabling life experience.The goal of finding meaning in illness is based on two assumptions: (1) Every ill person seeks a reason, or meaning, for enduring his illness, and (2) illness and suffering can be self-actualizing experiences provided the ill individual perceives some meaning in his suffering. It is believed that illness can and should be a learning experience, i.e. an experience that can help the person grow and develop as a human being as a result of his suffering.The mentally ill and the physically ill both attempt to find reasons for their suffering and distress. Individuals in both groups may blame themselves or others for causing the illness. They may blame God, bad luck, fate, relatives, friends, acquaintances or co-workers for causing, or contributing to the development of, their illness. Some mentally ill persons, through lack of insight, may not blame others because they do not believe they are ill.Most patients seek, and find, a blame object. The search for a blame object is probably a necessary initial phase in the patients attempt to find meaning in illness or to discover possible reasons why he is suffering. The blame phase can become a formidable barrier. One of the first obstacles the nurse encounters in helping the mentally ill person find meaning in illness is this blame barrier. The nurse must assist the patient to surmount or rise above it.It is not only patients who remain fixated at a blame levelnurses and other health workers may also have this problem. Because of certain theories regarding the etiology of the major functional mental illness it is quite possible for the nurse to blame the patients relativesusually the motherfor causing the patients illness and to absolve the patient from any responsibility for his behavior. Whether the parents were or were not the cause of the patients illness is not so important as the effect this belief has on the nurses attitude. Nurses and other health workers can and do convey to the patient the message that he is not responsible for his behavior. An unfortunate consequence of this attitude is that the patient is led to believe he is an irresponsible individual who cannot change his behavior of affect his future destiny.Under the best of circumstances it is difficult to perceive meaning in illness and suffering. It is impossible if the individual cannot rise above the blame level and if this behavior is reinforced by those whose task it is to help and comfort.The blame barrier can, through relatedness with a helping person, be surmounted. How does the nurse assist the patient to use mental illness as a meaningful learning experience? The emotionally ill person requires a why to live for in order to somehow endure the how. The why to live for varies with each patient. The nurse, through relating with the patient, helps him to search for and find a why which has meaning for him. The nurse cannot give meaning to an ill person but she can assist him to find a basis for meaning. It is probable that meaning can be found only to the extent a patient is able to perceive his participation in life experience and to accept his human condition. The ability to accept the human condition implies that the individual does not exempt himself from sufferingwhether this suffering be primarily mental, physical, or spiritual in origin.The nurse strives to understand the patients attitude toward suffering and his manner of dealing with it. Mentally ill persons are generally handicapped by the ineffective means that they use to cope with life problems. The nurse attempts to identify these ineffective methods and to assist the ill person to develop methods which are more effective.Nine goals of the nurse in the one-to-one relationship have been discussed. Many factors will affect the nurses ability to achieve these goals. Some of theses are: The nurses knowledge and ability to use it, the degree or kind of pathological behavior exhibited by the patient, the character structure of both nurse and patient, and such variables as the sex, age, color, ethnic background, religious views and social class of both nurse and patient.

Common problems encountered in establishing and maintaining a nurse-patient relationship are discussed in detail in the classic works of Joyce Travelbee: Process in the One-to-One Relationship and Interpersonal Aspects of Nursing, F.A. Davis Company, Philadelphia, 1966.

Joyce Travelbee(1926-1973) developed the Human-to-Human Relationship Model presented in her book Interpersonal Aspects of Nursing(1966, 1971).Travelbee, J. (1971).Interpersonal aspects of nursing (2nd ed.).Philadelphia: F.A. Davis.

Answer the following questions based on your personal understanding of Joyce Travelbees work: (include the questions in your typed report.)1. Discuss the one to one nurse/patient relationship according to Joyce Travelbee.

2. Who benefits from this relationship and how?

3. Describe the stages of the one to one relationship according to Travelbee.

4. List and briefly describe the nine goals of the one to one relationship. Offer your own example of each of the 9 goals.

5. Explain the blame barrier. What is your role as a nurse in dealing with this important issue?

6. Personally reflect on the thoughts and feelings you have had regarding Psychiatric Mental Health Nursing and how Travelbees theory affects your ideas.

In Travelbees Human to Human Relationship Model, she proposes the following: The therapeutic use of self is the ability to use ones personality consciously and in full awareness in an attempt to establish relatedness. Joyce Travelbee, 1966