Travelbee’s Theory: Human-to-Human Rela- tionship Model-its suitability for palliative nur- sing care

Revista de Enfermagem Referência 2020, Série V, no2: e20010 DOI: 10.12707/RV20010 Travelbee’s Theory: Human-to-Human Relationship Model its suitability for palliative nursing care Teoria de Travelbee: Modelo de Relação Pessoa-a-Pessoa adequação à enfermagem em contexto de cuidados paliativos Teoría de Travelbee: Modelo de Relación de Persona a Persona un marco adecuado para los cuidados paliativos de enfermería


Introduction
In Travelbee's opinion (1963), "we must continually question the value of our achievement, continue learning, and actively seek to improve our ability . . . to gain increased understanding of our human condition" (p. 72). This theoretical article aims to encourage readers to reflect on and question their interventions, with a view to a sustained and reflective practice. Joyce Travelbee was born in 1926 and died in 1973 at the age of 47. She published predominantly in the mid-1960s, pioneered the role of a nurse as the explorer of perceived meanings of suffering, and discussed the significance of spirituality in nursing care (Meleis, 2012;Shelton, 2016;Travelbee, 1966). Travelbee developed the Human-to-Human Relationship Model presented in her book entitled Interpersonal Aspects of Nursing (1966Nursing ( , 1971. She discussed her theory with Viktor Frankl, whom she credits along with Rollo May for influencing her thinking (Meleis, 2012). Travelbee's theory extended the interpersonal relationship theories of Hildegard Peplau and Jean Orlando, and her distinctive synthesis of their ideas distinguished her work in terms of the therapeutic human relationship (Pokorny, 2014). Regarding schools of thought in nursing, Travelbee is considered an Interaction Theorist, along with other authors such as King, Orlando, Paterson and Zderad, Peplau, and Wiedenbach (Meleis, 2012). Travelbee's definitions of health, nursing, relationships, nursing problems, and nursing therapeutics are clearly conceptualized, with the integrity of the assumptions preserved throughout the definitions (Table 1). Travelbee's Human-to-Human Theory is a conceptual framework belonging to the totality paradigm (Shelton, 2016). Travelbee's theory is important in providing a framework to describe the human encounter between nurses and patients who are suffering from life-threatening illness or a long, debilitating disease (oncological or non-oncological), which is a common reality in palliative care (PC; Meleis, 2012;Shelton, 2016;Travelbee, 1971). This theory is applicable to and has been used in the PC movement, helping end-of-life patients and their families find meaning in suffering and fostering hope, even at end-of-life (Meleis, 2012;Parola, Coelho, Sandgren, Fernandes, & Apóstolo, 2018;Shelton, 2016;Travelbee, 1971). A study about caring in PC was recently carried out using this theoretical framework (Parola et al., 2018). Travelbee's theory has significantly influenced the hospice movement. According to Travelbee, nurses should find meaning in their experiences of caring for the patients, and the human-to-human relationship is the means through which the purpose of nursing if fulfilled (Pokorny, 2014;Travelbee, 1971). Travelbee believed that the purpose of nursing was to assist an individual and/or family to prevent or cope with the experience of illness and suffering and, if necessary, to find meaning in these experiences (Pokorny, 2014;Shelton, 2016;Travelbee, 1966Travelbee, , 1971). This belief is in line with the philosophy of PC, as well as with the definition of PC by the World Health Organization (2002), an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. (p. 84) The relationships established between nurses and patients are crucial therapeutic interventions. Professional relationships and interactions are purposeful, being a resource to patients experiencing crises or making transitions, with the intention to produce outcomes beneficial for patients, such as enhanced coping. The relationship between a nurse and an individual or family is a central concept in nursing practice (Pokorny, 2014;Travelbee, 1964Travelbee, , 1971). Travelbee mentioned that nursing needed a humanistic revolution and an improved focus on compassion (Pokorny, 2014;Travelbee, 1971). Table 1 Definition of domain concepts Nursing An interpersonal process and service vitally concerned with change and influence of others. An interpersonal process whereby the professional nurse practitioner assists 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.

Goal of nursing
To assist an individual or family to prevent or cope with the experience or illness and suffering and, if necessary, to assist the individual or family to find meaning in these experiences, with the ultimate goal being the presence of hope.

Health
World Health Organization (WHO) definition: Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political, economic, or social condition.

Environment
Not defined.

Human being
A unique thinking, biologic, and social organism, an irreplaceable individual who is unlike any other person, who is influenced by heredity, environment, culture, and experiences. Always in the process of becoming and capable of choosing. Understanding of a human being is through his perception of himself.
Revista de Enfermagem Referência 2020, Série V, nº2: e20010 DOI: 10.12707/RV20010 Nursing client A patient is a human being who requests assistance from another human being who he believes is capable of helping and will help in solving his health problems.

Nursing problem
Communication breakdown and distortion: 1. Failure to perceive patient as a human being 2. Failure to recognize levels of meaning in communication 3. Failure to listen, using value statements without reflection 4. Clichés and automatic responses 5. Failure to interrupt Nursing process Process to ascertain needs, validate inferences, decide who should meet needs, plan a course of action, and validate. Disciplined intellectual approach, a logical method of approaching nursing problems, using knowledge and understanding of concepts from all other sciences and nursing in caring for patients.

Nurse-patient relations
An experience between an individual in need of the services of a nurse, and a nurse for the purpose of meeting the needs of the individual.

Nursing therapeutics
Therapeutic use of self (nurse). Disciplined intellectual approach to patient problems. Everything the nurse does for and with the patient is designed to help the individual or family in coping with or bearing the stress of illness and suffering in the event the individual or family encounters these experiences. Help patients find meaning in their experiences.

Development
To discover meaning in suffering might be one of life's greatest quests. Travelbee provides the basis for such discovery (Shelton, 2016). Travelbee (1971) believed that "Every human being suffers because he is a human being, and suffering is an intrinsic aspect of the human condition" (p. 61). Through the phases of her theory, including rapport, empathy, and sympathy, one establishes ways to garner the meaning of suffering (Travelbee, 1963). Nursing is an interpersonal connection. The nurse is responsible for educating and providing strategies to help the patient avoid or alleviate the anguish of unmet needs, using ways to find meaning in these experiences (Pokorny, 2014;Shelton, 2016;Travelbee, 1971). Travelbee's framework teaches nurses to understand, or at least explore, the meaning of illness and suffering. It is through this existential identification that an individual can relate to another individual (Meleis, 2012;Shelton, 2016;Travelbee, 1971). Travelbee grounded her theoretical formulations on existentialist philosophy, from which she drew several of the theory's assumptions. She has efficiently and usefully synthesized assumptions and concepts of both developmental theory and existential philosophy by illustrating the complexity of humanity through significant milestones (Meleis, 2012;Pokorny, 2014). As mentioned by Meleis (2012), Travelbee's theory is a hierarchical one, developed around the concepts of nurse-patient relationship, suffering, and pain to explore the relationships among them. It is both a concatenated theory, isolating and conceptualizing the central theory concepts, and a hierarchical one, as it interprets the relationship among these variables. (p. 263) Travelbee's theory addresses one of the main concepts in nursing -interaction -but is restricted to interaction surrounding illness, one of the reasons why it is suitable for PC settings. It focuses on those components of illness that are considered of concern to nursing, that is, suffering and pain (Meleis, 2012;Travelbee, 1969). Studies using Travelbee's theory explored the nature of nursing activities perceived to offer support, comfort, and ease the suffering of a terminally ill patient and of significant others of terminally ill patients (Meleis, 2012;Parola et al., 2018). Travelbee expresses the importance for nurses to recognize their concept of what is human, for their relationship with another human being will be otherwise determined by that concept (Shelton, 2016). Travelbee (1971) defined human being as "a unique irreplaceable individual, a one-time being in this world, like yet unlike any person who has ever lived or ever will live" (p. 26). The nurse should promote patient-centered care, which recognizes the individuality of each human being. A person will respond to illness depending on culture, symptom burden, and whether there is a correlated significance to those symptoms (Meleis, 2012;Shelton, 2016;Travelbee, 1963). Depending on the impairment of functioning as well as the health professional's responses, a human connection that fosters understanding of the illness is developed (Travelbee, 1971).
Revista de Enfermagem Referência 2020, Série V, nº2: e20010 DOI: 10.12707/RV20010 As we know, every individual experiences suffering, as it is a part of being human. Travelbee (1971) emphasized that "It is probable that the more an individual cares for, and about others, the greater the possibilities of suffering" (p. 64). Communication is a requirement for good nursing and an essential part of this theory. Travelbee (1971) expresses striving to communicate "to know ill persons, to ascertain and meet nursing needs and to achieve the purpose of nursing" (p. 102). Human relationships become therapeutic as they pass through expected steps or stages (Meleis, 2012;Shelton, 2016). The four phenomena of interest are central to the discipline of nursing: person, health, environment, and nursing -nursing's metaparadigm. As previously mentioned, this theory is a conceptual framework belonging to the totality paradigm. Environment is not well defined in Travelbee's theory. Instead, Travelbee refers that the nurse should be observant of the patient in the place where the patient is present in order to determine that the patient is in need (Meleis, 2012;Shelton, 2016;Travelbee, 1971). Nursing is better defined. Foremost, the assumption of nursing is to create a human-to-human relationship. It is within the paradigm of nursing that the nurse/human helps the individual, family, or community to prevent or cope with illness and suffering. The nurse also assists with trying to find meaning in these experiences (Meleis, 2012;Pokorny, 2014;Travelbee, 1966). The concept of communication resonates through Travelbee's model. Recognizing the other human being is as significant as performing procedures. As highlighted, the nurse must establish a rapport, otherwise the nurse will not identify the patient's needs (Meleis, 2012;Travelbee, 1963Travelbee, , 1971. One could debate that in a PC setting, there would be no difference between caring for the person at end-of-life than treating illness in a primary care setting, except the triggers of suffering occur much more often. Travelbee's model is very suitable for this setting. Travelbee (1971) mentioned: "Nurses who know ill persons are more apt to be able to detect not only obvious changes in an individual's condition but are enabled to recognize the more subtle changes that may be occurring" (p. 98). The PC nurse should be able to anticipate an individual or relative's likelihood of suffering, and must clearly define the concept of suffering, hope, and the steps or phases required to establish a rapport (encounter, identity, empathy, sympathy), as well as understand that humans define or accept their suffering in a unique and multifaceted way (Coelho, Parola, Escobar-Bravo, & Apóstolo, 2016;Parola et al., 2018;Travelbee, 1971). The human-to-human relationship is, therefore, very important when the provision of nursing care occurs during the process of transition to the PC situation. As it is a transition, it is inherently associated with vulnerabilities and "the quality of nursing care given any patient is determined by the nurse's beliefs about illness, suffering, and death" (Travelbee, 1966, p. 55). As mentioned by Travelbee (1963Travelbee ( , 1964, both the nurse and the patient are human beings. A human being is a unique, irreplaceable individual, who is in the continuous process of becoming, evolving, and changing. For that reason, attention should be given to the patient's objective health (for example, monitoring of vital signs, laboratory tests), but also to his/her subjective health, that is, the state of well-being in accord with self-appraisal of physical-emotional-spiritual status. Based on this assumption, nurses will more easily understand, respect, and accept the patient as a unique person, building a closer trust relationship (Pokorny, 2014;Travelbee, 1963Travelbee, , 1971. It is a nursing intervention to help the patient to maintain hope and avoid hopelessness. In PC, this hope must be realistic and enlightening. Hope should be conveyed that the nurse will be by the patient's side until the end, providing the best care possible for a dignified end-oflife (Coelho et al., 2016). This relationship can only be established through an interaction process. Travelbee emphasized that nurses must be able to "assist patients to find meaning in the experience of illness, suffering and pain" (Travelbee, 1966, p. 165). By being able to connect with the patient and form a relationship that goes beyond providing medication and checking blood pressures, nurses can ensure a better, more productive, and meaningful experience for patients. Travelbee believed that nursing is accomplished through human-to-human relationships (Figure 1). These relationships begin with the original encounter (first impression by the nurse of the patient and vice-versa, and then progress through stages of emerging identities (the time when relationships begin, where nurse and patient perceive each other's uniqueness), developing feelings of empathy (the ability to share in the person's experience), and later feelings of sympathy (when the nurse wants to lessen the cause of patient's suffering; Pokorny, 2014;Travelbee, 1971 At this point, it seems relevant to clarify that empathy is the forerunner of sympathy. As an emotion comprehension of another person, it is important and desirable because it helps nurses to predict that person's behavior and to perceive accurately his thinking and feeling. However, it is essentially a neutral process; it does not really imply that a person takes action on the basis of the comprehension which has been gained. Sympathy, on the other hand, implies a desire, almost an urge, to assist the patient in order to relieve his/her distress; when one sympathizes, one is involved but not incapacitated by the involvement (Travelbee, 1964). According to Travelbee, sympathy is "a process wherein an individual is able to comprehend the distress of another, be moved or touched by another's distress, and desires to alleviate the cause. One 'shares' in the feelings of another and experiences compassion" (Travelbee, 1966, p. 146). The empathic nurse can perceive the distress of another person, recognize its source, and anticipate the behavior that will result from it. On the other hand, the sympathetic nurse feels the distress of another person, being touched and moved by it and actively wants to do something to alleviate it (Travelbee, 1964(Travelbee, , 1966. "There is a warmth, an urge to action, in sympathy that is not present in empathy" (Travelbee, 1964, p. 69). Some believe that being sympathetic means that nurses become so enmeshed in the patients' problems that they cannot meet their own needs because they are too busy meeting the other's needs. A nurse who is "too sympathetic" is usually seen as a nurse who cries when the patient cries and becomes depressed when the patient is depressed (Travelbee, 1964). However, quoting Travelbee (1964), This is not sympathy. The nurse in such a situation is not focusing on the patient, but on "herself " in the patient. She is not attempting to alleviate the patient's distress but is using the patient in order to relieve the tension of her own unmet needs. (p. 69) Sympathize is to give part of ourselves to the other, and, in the giving and sharing, become vulnerable. The act of sharing, and giving of ourselves in a deep personal way exposes nurses to the shocks of commitment and all that entails. It is probably an act of courage to allow ourselves to feel sympathy for another person because the feeling and expression of sympathy can cause pain (Travelbee, 1964(Travelbee, , 1971. This is particularly true in those circumstances when nurses are powerless to help the person with whom they feel sympathetic or when, despite the greatest efforts, nurses are unable to relieve his/her distress. By taking action to relieve distress, nurses reduce, in some measure, the tension of the urge to help. When nurses succeed, they feel personally enriched and fulfilled. However, when nurses fail, they may become frustrated, and the hurts of failure can cause nurses to take measures to protect themselves, to deny their feelings or crush them, lest they arise and catch them unprepared (Travelbee, 1964(Travelbee, , 1966. Nurses might not be willing to pay the price of failure, so they detach themselves from further feeling, "as a matter of fact, nurses are usually encouraged to empathize, but cautioned not to sympathize" (Travelbee, 1964, p. 68). Therefore, nurses are then not hurt by others or moved by their distress, but neither is their experience enriched by the contacts with others. To be sympathetic means that this human being who is capable of helping -the nurse -is concerned with this human being who is seeking to alleviate distress -the patient (Travelbee, 1963(Travelbee, , 1964. Nurses are not afraid to demonstrate interest or concern, but they are not engulfed to the point of inactivity. In simpler terms, sympathy means that the nurse cares (Travelbee, 1964(Travelbee, , 1966. Then, in and through caring, the nurse can provide what is called emotional support, helping another human being in a time of crisis (Travelbee, 1963(Travelbee, , 1964(Travelbee, , 1966. The sympathetic nurse is an authentic human being. Absent of sympathy, the nurse is a dehumanized abstraction communicating with other abstractions called patients and nursing thereby turns into a mechanical, dehumanized process (Travelbee, 1963(Travelbee, , 1964(Travelbee, , 1969. The nurse and the patient attain rapport in the final stage. Rapport is a way in which the nurse perceives and relates to the other human being/patient-family; it is composed of interrelated thoughts and feeling, interest in and concern for others, through a non-judgmental attitude, and respect for each person as a unique human being. According to Travelbee (1963), rapport is "empathy, compassion, and sympathy; a non-judgmental attitude, and respect for each individual as a unique human being" (p. 70). In PC settings, these aspects are very important given that the proximity of death is a unique moment for each person and family, and the sensitivity, empathy, and sympathy of the nursing team are crucial in the way PC care are delivered and experienced (Parola et al., 2018). There is evidence to support that empathetic care can improve patient-reported outcomes and increase patient satisfaction (Post et al., 2014;Sinclair et al., 2017). Thus, this theory should be addressed in every health profession. However, it is perhaps more essential in PC, where the relief of suffering, empathy, and sympathy in patients with progressive illness are clear goals of PC (Sinclair et al., 2017;World Health Organization, 2002). Rapport is essentially the catalyst which transforms a series of nurse-patient interactions into a meaningful nurse-patient relationship, a concern for others and an active and genuine interest in them. However, it takes more than interest; it is necessary a belief in the worth, dignity, uniqueness, and irreplaceability of each individual human being. It is important to refer that rapport doesn't "just happen"; it must be built day by day in the nurse's contacts and interactions with the patient, and it will change as changes occur in the interpersonal situation (Pokorny, 2014;Travelbee, 1963). Summarizing, Travelbee provides nursing with the principles for connecting to ill persons. She created a conceptual framework upon which to base therapeutic relationships with patients, families, and communities in suffering or having the potential for suffering (Meleis, 2012;Shelton, 2016).

Conclusion
Caring for the patient holistically, in a comprehensive way via communication and attention, can benefit the caring process. An active interest in the patients can build upon the human-to-human relationship. In summary, more important than the time spent with the patient is what nurses do with that time. This involvement requires insight and knowledge but it also requires the nurses to possess the openness and self-determination to expose themselves as human beings to other human beings, the patients. In addition, Travelbee was clear about the spirituality of both patients and nurses, referring that the spiritual values of an individual determine, to a large extent, his/her perception of the illness. The spiritual values of the nurse or his/her philosophical beliefs about illness and suffering determine the extent to which he or she will be able to support patient's discovery of meaning, or no meaning, in these conditions. Travelbee's theory encourages the nurse to take a step closer to the patients and their families. In the Human-to-Human Relationship Model, nursing is an interpersonal process whereby the nurse assists a patient/ family to prevent or cope with experience or illness and suffering and, if necessary, to find meaning in these experiences. Taking into consideration the nature of PC, nurses should perceive and recognize the uniqueness of every individual at end-of-life and, consequently, help them find meaning in suffering. The nurse has a chance to promote human-to-human connections. This should enable the attribution of meaning or at least a better understanding of humans' symptom burden and illness. However, in order to transfer Travelbee's Human-to-Human Relationship Model into clinical practice, nurses should be more aware of their own approach and stereotype expectations and have a truthful desire to understand the patients and their families and relieve their suffering, while promoting hope, even at end-of-life, as it is recommended by the philosophy of PC. How interpersonal relationships and decisions are made at end-of-life and death remains a challenge. However, Travelbee makes the case for its value for patients in PC. It all depends on what are the priorities in nursing practice: a superficial interaction or a nurse-patient relationship that is characterized by compassion and sympathy, which lie at the very heart of nursing. The contest is clear; the choice is ours.