Joyce Travelbee’s Human-to-Human Relationship Model: Why is this a Lost Art among Nursing Students & New-Graduate Registered Nurses? Jessica Tucciarone, RN, BSN, TCRN
Doctor of Nursing Practice Student, Hofstra University Introduction/Background
Theoretical Framework/Conceptual Model -
Joyce Travelbee defines nursing as an “interpersonal process whereby the professional nurse assists an individual, family, or community to prevent or cope with experience or illness and suffering, and if necessary, to find meaning in these experiences” (PMHNP Resources, 2020). She defines both the patient and the nurse as human beings with relatively equal physiological needs. She highlights, however, that the true difference between the patient and the nurse is that the patient relies on the nurse for health maintenance interventions and education (Current Nursing, 2020).
This researcher will evaluate the internal barriers of nursing students near the end of their curriculum and new-graduate Registered Nurses with less than six months of nursing experience using a qualitative approach. This type of interview will be rooted in phenomenology because it seeks to understand what internal barriers exist in the study population based on their lived experiences which will be defined as their BSN curriculums, and if applicable, their minimal experience as new-graduate Registered Nurses. This researcher will take a Husserlian approach by utilizing a structured interview and bracketing herself from the study participants. It is important to remain neutral to the nursing students’ and novice nurses’ responses to the interview because the researcher is an intermediately experienced Registered Nurse and may have conflicting opinions to the study participants.
Utilizing these definitions, Travelbee developed the Human-toHuman Relationship Model which considers both the nurse and the patient as human beings who experience suffering and illness simply because they are human. She emphasizes, however, that it is up to the nurse to utilize empathy and sympathy to develop a trusting rapport with her patient in order to successfully fulfill the purpose of the nursing profession (Current Nursing, 2020 & Shelton, 2016). Therefore, Travelbee implies that nurse will not be able to adequately fulfill her role in providing holistic patient care unless she develops a humanistic relationship with all her patients.
Theoretical Assumptions The Human-to-Human Relationship Model assumes that nursing is fulfilled only by developing human-to-human relationships. This model is divided into five consecutive and interactional phases for successfully creating these empathetic relationships (Current Nursing, 2020). The ultimate goal of developing these relationships is to lessen the patient’s suffering and to improve patient education and outcomes related to both acute and chronic illness: 1. Original encounter phase. During the nurse and the patient’s initial encounter, it is essential that they “break the bond of categorization” in order to view each other as equal human beings rather than simply a nurse and a patient (PMHNP Resources, 2020). This phase assumes the patient relies on another human being, specifically the nurse, only for assistance with maintaining both subjective and objective health (PMHNP Resources, 2020). 2. Phase of emerging identities. This phase assumes that both the nurse and the patient separate their own past experiences from their role in this relationship (PMHNP Resources, 2020). This type of bracketing aids to prevent biases that may be introduced by one’s own experiences from interfering with developing an objective, non-judgmental relationship. 3. Empathy phase. The nurse and the patient must empathize with each other by sharing each other’s psychological state of mind without directly sharing their feelings (PMHNP Resources, 2020). 4. Sympathy phase. Once empathy has been achieved, the nurse and patient may start to sympathize with one another by introducing their personal feelings. The overall goal of the nurse in this phase is to decrease the patient’s suffering (PMHNP Resources, 2020). It is important to maintain professionalism, however, when bringing sympathy into the human-to-human relationship. 5. Phase of rapport. This phase is characterized by nursing interventions that serve to lessen the patient’s suffering. By this phase, the patient trusts and feels confident that the nurse can meet his needs without feeling like the nurse is superior to the (PMHNP Resources, 2020). This phase assumes that the nurse adequately developed a humanistic relationship with the patient rooted in equality and will be able to maintain it throughout the duration of this relationship.
The Husserlian-style structured interview will consist of open-ended questions that seeks to learn more about the study participants’ perceptions across multiple aspects of their nursing experience. The primary researcher will first ask the study participants to identify and describe Joyce Travelbee’s Human-to-Human Relationship Model and how this relates to their nursing care. Then, the interviewer will ask the participants to define “holistic, empathetic patient care” in their own words and to determine if they perceive themselves as nurses who are able to provide such care. Next, there will be some questions asking how their current or alma matter BSN programs on Long Island, New York prepared them to provide this care to patients. The interviewer will ask for specific examples of what types of relevant education their BSN programs provided in this such as standardized patient scenarios, case-based learning, or lecture-based learning and if the study population felt these learning activities improved their knowledge of and ability to provide humanistic patient care. Specifically for the novice Registered Nurses with less than six months of experience, the primary researcher will ask if their experience in their current jobs at Northwell Health influenced their ability to provide this care either positively or negatively. The interviewer will ask these participants if there are any empathy-based programs taught during their new-graduate Registered Nurse orientation and will evaluate these programs using similar questions to the portion evaluating the BSN programs. Finally, the primary researcher will ask the participants to identify their strengths and potential barriers in their ability to provide empathetic patient care rooted in Travelbee’s model. The researcher will obtain relevant demographics for her study population including age, sex, town of residence, cumulative grade point average in their BSN program, and number of months of experience if the participant is a new-graduate Registered Nurse. The primary researcher will obtain permissions from both the BSN programs and Northwell Health hospitals on Long Island to interview their students and novice Registered Nurses. The researcher will guarantee anonymity to her participants and ensure that their responses will not affect their academic standing in their BSN programs or employment standing in their jobs. The interview will be written by the primary researcher but evaluated by three Doctor of Nursing Practice-prepared professors at Hofstra University to establish credibility. The primary researcher will carefully analyze the information obtained in these interviews to determine if the study population feels their BSN programs adequately prepared them in not only defining but applying Travelbee’s nursing theory to their practice in clinical rotations and in their first Registered Nurse jobs.
Literature Review: Abdoli & Safavi presented nursing students with simulated patient situations: two of which presented patients in physical distress while two of which presented patients in emotional or spiritual distress. 100% of the students accurately responded to verbal and nonverbal cues from the patient scenarios rooted in physical illness and medical diagnoses. However, many of the students were unable to adequately perceive the patients’ mental stressors in the simulations rooted in emotional suffering (Abdoli & Safavi, 2010). Therefore, nursing students tended to respond more effectively and automatically to patients’ physical problems but generally became uncomfortable in responding to patients’ emotional and spiritual stressors which hinders their ability to develop human-to-human relationships. Nursing these students had uncomfortable and ineffective initial encounters with the simulated patients experiencing emotional suffering; therefore, they were unsuccessful in creating an empathetic relationship with the simulated patients (Abdoli & Safavi, 2010). The current body of knowledge identifies the failure of traditional lecture-based BSN curriculums in teaching nursing students how to apply Travelbee’s theory to nursing practice upon graduation. Literature highlights the significance of allowing students to practice empathetic communication in BSN programs because empathy scores tend to decline as nursing students progress through academic years. However, empathy scores improved after specific education and training (Lee et al., 2018). Using a quasi-experimental design, these researchers enrolled BSN students in experiential learning programs that encourage experiencing, reflecting, thinking, and acting in response to situations that would challenge the nursing students’ ability to be empathetic toward patients. The students were rated by nursing professors and standardized patients during an Objective Structure Clinical Examination. Patient-centered, empathetic nursing care scores for the experimental group were significantly higher for the simulation-based experimental group than from the traditional lecture-based control group (p <0.01) (Lee et al., 2018). Shapiro et al. identified another potential barrier for medical students to be empathetic toward patients: the lack of humanities- and literature-based courses incorporated in medical education. They conducted a qualitative-quantitative pilot study where they administered a voluntary patient-centered care literature course to first-year medical students. The researchers sought to determine if this course would improve their empathy toward patients and found that empathy toward prose and literature statistically improved after participating in the class (p < 0.01). Additionally, students had a deeper understanding of patient experiences and a more humanistic approach to patient care as evidenced by their participation in the post-intervention qualitative interview (Shapiro, et al., 2004).
Application of Theory in Future Research and Practice: Although this is a theory commonly taught in BSN curriculums, the current body of literature suggests there is a disconnect between these curriculums and preparedness of new-graduate Registered Nurses in developing empathetic relationships with their patients (Abdoli & Safavi, 2010): 1. Abdoli & Safavi & Shapiro et al. identified barriers in healthcare education that may be related to the inability to nursing students to apply Travelbee’s Human-to-Human Theory into nursing practice, but this is not enough to graduate Registered Nurses with the confidence to create empathetic relationships with their patients starting with the initial encounter. 2. Freitas et al. suggest that experienced nurses integrate Orlando’s Nursing Process with Travelbee’s theory provide comprehensive patient-centered care, but there is no research focused on the abilities of novice Registered Nurses to integrate these theories in practice.
Discussion/Conclusion: These data will highlight strengths and identify gaps in the current BSN curriculums for schools on Long Island as well as identify internal barriers that nursing students and new-graduate Registered Nurses have regarding applying Travelbee’s theory to their nursing practice. The BSN programs may use these data to implement standardized patient scenarios rooted in providing empathetic care to patients, so nursing students may practice these skills during their studies. This may help nursing students to overcome their internal barriers and graduate Registered Nurses with adequate practice guided by Travelbee’s Human-to-Human Relationship Model. Nursing professors and students may learn how to collaborate in developing a plan to overcome these specific barriers to promote confidence in developing a therapeutic relationship with their patients, so they may treat not only the patients’ physical needs but also their emotional and spiritual needs.
References
Abdoli, S., & Safavi, S. S. (2010). Nursing students' immediate responses to distressed clients based on Orlando's theory. Iranian journal of nursing and midwifery research, 15(4), 178-184. Current Nursing. (2020, March). Nursing theories. Human-To-Human Relationship Model - Joyce Travelbee. https://www.currentnursing.com/nursing_theory/Joyce_Travelbee.html. Freitas, R. J. M. de, Moura, N. A. de, Feitosa, R. M. M., Guedes, M. V. C., Freitas, M. D. de, Silva, L. de F. da, & Monteiro, A. R. M. (2018). NURSING PROCESS BASED ON THE JOYCE TRAVELBEE MODEL. Journal of Nursing, 12(12), 3287–3294. Lee, K.-C., Yu, C.-C., Hsieh, P.-L., Li, C.-ching, & Chao, Y.-F. C. (2018). Situated teaching improves empathy learning of the students in a BSN program: A quasi-experimental study. Nurse Education Today, 64, 138–143. https://doi.org/10.1016/j.nedt.2018.02.013 PMHNP Resources. (2020, February 9). Joyce Travelbee Interpersonal Theory of Nursing. PSYCH-MENTAL HEALTH NP. https://pmhealthnp.com/joyce travelbee-interpersonal-theory-of-nursing/. Shapiro, J., Morrison, E., &amp; Boker, J. (2004). Teaching Empathy to First Year Medical Students: Evaluation of an Elective Literature and Medicine Course Education for Health: Change in Learning &amp; Practice, 17(1), 73–84. https://doi.org/10.1080/13576280310001656196 Shelton, G. (2016). Appraising Travelbee's Human-to-Human Relationship Model. J Adv Pract Oncol, 7(6), 657-661. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29588870
Acknowledgement I would like to thank Dr. Renee McLeod, my professor from the Adult-Gerontology Acute Care Doctor of Nursing Practice Program at Hofstra University for guiding me in my NUR205 independent study and for helping me develop my research.