HILDEGARD PEPLAU

Theory of Interpersonal Relations

Prepared by Rey D. Pinalba, RN, MN

1
Hildegard Peplau

• “ Nursing is as interpersonal process

because it involves interaction
between two or more individuals with
a common goal. Nursing is
therapeutic in that it is a healing art
assisting an individual who is sick or in
need of health care”

2
 • Peplau's theory focuses on the interpersonal process and
therapeutic relationship that develops between the nurse
Hildegard Peplau and client.
• The client is an individual with felt need.
• Nursing's goal is to educate the client and family and to
help clients reach mature personality development (Chinn
and Kramer, 2004).
• The nurse strives to develop a nurse-client relationship in
which the nurse serves as a resource person, counselor, and
surrogate. Psychodynamic nursing involves:
• Understanding of one's behavior
• Helping other identify felt difficulties
• Applying principles of human relations to the problems that
arise at all levels of experience.
• The attainment of goal is achieved through the use of a
series of steps following a series of pattern in the
interpersonal relationship namely:
• 1. Orientation Phase
• 2. Working Phase
• A. Identification
• B. Exploitation
• 3. Termination Phase (Resolution Phase)

3
History and Background
• Hildegard Peplau was born in Reading, Pennsylvania in 1909.

• Graduated from a diploma program in Pottstown, Pennsylvania in 1931.

• • Earned Bachelor of Arts in Interpersonal Psychology from Bennington College in 1943.

• Finished Master of Arts in Psychiatric Nursing from Colombia University, New York in 1947.

• Achieved EdD in curriculum development in 1953.

• Has been Professor emeritus from Rutgers University. Started first post baccalaureate program in nursing.

• Published Interpersonal Relations in Nursing in 1952. In 1968. introduced interpersonal techniques – the crux of psychiatric
nursing.

• Worked as executive director and president of ANA. (American Nurse's Association)

• Worked with WHO, NIHM (National Institute of Mental Health) and nurse corps.

• She died in March 17, 1999 at the age of 90 years.

4
Theory of Interpersonal Relations
• Hildegard E. Peplau has been described as the mother of
psychiatric nursing because her theoretical and clinical work
led to the development of the distinct specialty field of
psychiatric nursing.
• she stressed the importance of nurses’ ability to understand
their own behavior to help others identify perceived
difficulties.
• Has 3 sequential phases in the Interpersonal nurse-patient
relationship:

5
phases of the nurse-patient relationship
• Orientation

• Identification

• Exploitation

• Resolution

6
• Orientation Phase

• Problem defining phase.

• Starts when client meets nurse as stranger.

• Defining problem and deciding type of service needed.

• Client seeks assistance, conveys needs, asks questions, shares

preconceptions and expectations of past experiences.

• Nurse responds, explains roles to client, helps to identify problems

and to use available resources and services.

• During the orientation phase, the individual has a felt need and seeks
professional assistance. The nurse helps the individual to recognize and
understand his/her problem and determine the need for help.

7 7
• Working Phase

A. Identification Phase

• Selection of appropriate professional assistance.

• Patient begins to have a feeling of belonging and a capability

of dealing with the problem which decreases the feeling of
helplessness and hopelessness.

• The patient identifies with those who can help him/her. The nurse
permits exploration ,-Of feelings to and the patient in
undergoing illness as an experience that reorients feeling and
strengthens positive forces in the personality and provides
needed satisfaction.

8 8
B. Exploitation Phase

• Use of professional assistance for problem solving alternatives.

• Advantages of services are used and based on the needs and interests of the patients.

• Individual feels as an integral part of the helping environment.

• The individual may make minor requests or attention getting techniques.

• The principles of interview techniques must be used in order to explore, understand and adequately deal with the
underlying problem.

• Patient may fluctuate on independence.

• During this phase, the patient attempts to derive full value from what he/she is offered through the relationship.
The nurse can project new goals to be achieved through personal effort and power shifts from the nurse to the
patient as the patient delays gratification to achieve the newly formed goals.

• Nurses must be aware about the various phases of communication.

• Nurses aid the patient in exploiting all avenues of help and progress is made towards the final step.

9 9
• Resolution Phase

• Termination of professional relationship.

• The patient's needs have already been met by the collaborative effort
of patient and nurse.

• Now they need to terminate their therapeutic relationship and dissolve

the links between them.

• Sometimes may be difficult for both as psychological dependence

persists.

• Patient drifts away and breaks bond with nurse and healthier emotional
behavior is demonstrated and both become mature individuals.

• The patient gradually puts aside old goals and adopts new goals. This is
a process in which the patient frees himself from identification with the
nurse.

10 10
In capsule:
• Orientation: Nurse and patient come together as strangers; meeting
initiated by patient who expresses a "felt need", work together to
recognize, clarify, and define facts related to the need.

• Identification: Patient participates in goal setting; has feeling of

belongingness and selectively responds to those who can meet his/her
needs.

• Exploitation: Patient actively seeks and draws knowledge and expertise

of those who can help.

• Termination (Resolution): Occurs after other phases are completed

successfully. This leads to termination of the relationship.

11 11
six nursing roles:
• Stranger

• resource person

• Teacher

• Leader

• Surrogate

• counselor

12
Peplau advocates that the roles of the nurse in the nurse-patient
interpersonal relationship are as follows:

• Stranger receives the client in the same way one meets a stranger in other life
situations. Provides an accepting climate that builds trust.

• Teacher who imparts knowledge in reference to a need or interest.

• Resource Person: one who provides a specific needed information that
aids in the understand ing of a problem or new situation.

• Counselor: helps to understand and integrate the meaning of current life

circumstances; provides guidance and encouragement to make changes.

• Surrogate: helps to clarify domains of dependence, interdependence and

independence and acts on client's behalf as an advocate.

• Leader: helps client assume maxi mum responsibility for meeting treatment
goals in a mutually satisfying way.

13
• Interpersonal Theory and Nursing Process

• Both are sequential and focus on therapeutic relationship.

• Both use problem solving techniques for the nurse and patient to collaborate on with the end purpose
of meeting the patients needs.

• Both use observation, communication, and recording as basic tools utilized by nursing.
Assessment Orientation
Data collection and analysis (continuous) Non-continuous data collection
May not be a felt need Felt need
Define nedds
Nursing Diagnosis Identification
Planning Interdependent goal setting
Mutually set goals

Implementation Exploitation
Plans initiated toward achievement of mutually set goals Patient actively seeking and drawing help
May be accomplished by patient, nurse of family Patient initiated

Evaluation Resolution
Based on mutually expected behaviors Occurs after other phases are completed successfully
May lead to termination and initiation of new Leads to termination
plans 14 14
15
• Concepts
• Person. A developi ng organism that tries to reduce anxiety caused by needs.

• Environment. Existing forces outside the organism and in the context of

culture.

• Health. A word symbol that implies forward movement of personality and

other ongoing human processes in the direction of creative, constructive,
productive, personal and community living.

• Nursing. A significant therapeutic interpersonal process. It functions

cooperatively with other human processes that make health possible for
individuals in communities.

• According to Peplau (1952/1988), nursing is therapeutic because it is a

healing art, assisting an individual who is sick or in need of health care.

16 16
•END

17
Ida Jean Orlando
“Theory of
Deliberative
Nursing Process”
By: Rey D. Pinalba RN, MN
• "A deliberate nursing process has elements of
continuous reflection as the nurse tries to
understand the meaning to the patient of the
behavior she observes and what he needs from
her in order to be helped. Responses
comprising this process are stimulated by the
nurse's unfolding awareness of the particulars
of the individual situation.” (Orlando, 1961,
p.67)

• “What do I see?”
• “What do I think?"
• “What do I feel?”
• "How do I act?”
• The role of the nurse is to find out and meet the
patient’s immediate need for help.
• The patient's presenting behavior may be a plea
for help, however, the help needed be what it
appears to be.
• Nurses need to use their perception, thoughts
about the perception, or the feeling endangered
from their thoughts to explore with patients the
meaning of their behavior. This process helps the
nurse find out the nature of the distress and
what help the patient needs.
 • Ida Jean Orlando, a first-generation Irish American was born in 1926.
• She received her Nursing Diploma from St. John's University, NY and her MA in Mental Health
Nursing from Columbia University, New York.
• Orlando was an Associate Professor at Yale School of Nursing where she was Director of the
Graduate Program in Mental Health Psychiatric Nursing.
• While at Yale she was project investigator of a National Institute of Mental Health grant
• entitled: Integration of Mental Health Concepts in a Basic Nursing Curriculum,
• It was from this research the she developed her theory which was published in her 1961
• book: "The Dynamic Nurse-Patient Relationship."

History and • She furthered the development of her theory when at McLean Hospital in Belmont, MA as
Director of a Research Project: Two systems of Nursing in a Psychiatric Hospital.

Background • The results of the research are contained in her 1972 book titled: The Discipline and Teaching of
Nursing Processes.
• Orlando held various positions in the Boston area, was a board member of Harvard Community
Health Plan, and served as both a national and International consultant.
• She is a frequent lecturer and conducts numerous seminars on the nursing process.
• Orlando's theory was developed in the late 1950's from observations she recorded between a
nurse and patient.
• Despite her efforts, she was only able to categorize the records as “good” or “bad” nursing.
• It then dawned on her that both the formulations for "good" and "bad" nursing contained in the
records. From these observations she formulated the deliberative nursing process.
• Overview of Orlando's Nursing Process Theory .
The major dimensions of Orlando's Nursing Process Theory are as follows:
• 1. Professional nursing function: organizing principle.
• 2. The patient's presenting behavior: Problematic situation
• 3. Immediate reaction: internal response.
• 4. Deliberative nursing process: reflective inquiry.
• 5. Improvement: resolution.
• 1. Professional Nursing Function - Organizing Principle
• • The nurse's unique function is "finding out and meeting the patient's immediate needs
• for help" (Orlando, 1972. p.20)
• "Nursing... is responsive to individuals who suffer or anticipate a sense of helplessness; it is focused on the process of care in an immediate
experience, it is concerned with providing direct assistance to individuals in whatever setting they are found for the purpose of avoiding. relieving,
diminishing, or cutting the individual's sense of helplessness" (Orlando, 1972. p.20).
• The patient's sense of helplessness, stress, or need originates from physical limitations, adverse reaction to the setting, and experiences that prevent
a patient from communicating his or her needs.
• "Need is situationally defined as a requirement of the patient which if supplied relieves or diminishes his immediate distress or improving his
immediate sense of adequacy or well-being” (p.5).
• It is the nurse's responsibility to meet the patient's immediate needs for help either by supplying it directly or by calling in the services of others.
• The central core of the nurse's practice is to understand what is happening between the
• patient and the nurse that provides a framework for the help the nurse gives the patient (Orlando, 1961).
• Nursing thought: “Does the patient have an immediate need for help or not?"
• "First, the nurse must take the initiative in helping the patient express the specific meaning of his behavior in order to ascertain his distress."
• Second, she must help the patient explore the distress in order to ascertain the help he requires for his immediate) need (for help) to be met”
(Orlando, 1961, p.26).
• The nurse's focus of inquiry is always on the patient's immediate experience.
• If the patient is in need and the need is fulfilled, the nursing function has been fulfilled.
• “The product of the meeting the patient's immediate need for help is... 'improvement in the immediate verbal and nonverbal behavior of the patient.
This observable change allows the nurse to believe or disbelieve that her activity relieved, prevented, or diminished the patient's sense of
helplessness” (Orlando, 1961, p.26)
• 2. The Patient's Presenting Behavior – Problematic Situation
• To find out the immediate need for help, the nurse must first
recognize the situation as problematic.
• “The presenting behavior of the patient, regardless of the form in
which it appears, may be a plea for help” (Orlando, 1961, [.40).
• Both the patient and the nurse participate in the exploratory process
to identify the problem as well as the solution.
• The nurse-patient situation is a dynamic whole; each is affected by
the behavior of the other. The interaction is unique for each situation.
• The patient's behavior stimulates the nurse's immediate reaction and
becomes the starting point of the investigation.
• 3. Immediate Reaction - Internal Response
• The problematic situation in the form of the patient's presenting behavior (e.g. requests, comments, complaints,
questions, moaning, crying, wheezing, clenching fist, pallor, reddened face, difficulty of breathing, increased blood
pressure), triggers an automatic immediate reaction in the nurse that is both cognitive and affective.
• The reaction comprises the nurse's perceptions, thoughts about the perceptions, and the feelings evoked from the
thoughts; they cannot be controlled. These items occur in an automatic, almost instantaneous sequence.
• In any person's process of action, four distinct items occur sequentially:
• 1. The person perceives with any one of his five sense organs an object or objects;
• 2. The perceptions stimulate automatic thought;
• 3. Each thought stimulates an automatic feeling; and
• 4. Then, the person acts (Orlando 1972, p.5).
• The interactions of these items is called the nursing process. The first three items cannot be observed; only the
action can. The action is what the person says verbally or conveys nonverbally.
• The nurse's immediate reaction is unique for each situation. What the nurse perceives, thinks, or feels reflects his
or her individuality. The automatic thoughts come from the nurse's interpretation or meaning attached to the
perception. It may or may not be correct from the patient's point of view (Orlando, 1961).
• Regardless of the extent of nurse's accuracy, the perception that evoked the thoughts are communications from
the patient and represent the raw data for the nurse to use in investigating or exploring the patient's behavior.
(Orlando, 1961). B e
• 4. Deliberative Nursing Process – Reflective Inquiry
• The deliberative nursing process views the nurse-patient situation as a
dynamic whole.
• The nurse's behavior affects the patient, and the nurse is affected by the
patient's behavior. Understanding the patient's behavior is a complex
process in which observations and thoughts are used in a serial responsive
way to get the "facts of the case."
• To be successful, the nurse's focus must be on the patient rather than on as
assumption that he/she knows what the patient's problems are and on
arbitrary decisions about what action to take
• The use of Orlando's (1961) deliberative process requires that there is a
shared communicating process between the nurse and the patient to
determine the following:
• 1. The meaning of the patient's behavior
• 2. The help required by the patient
• 3. Whether the patient was helped by the nurse's action.
• Orlando (1972) describes the components of a person's action process. In a person-to-person encounter, each experiences an
immediate reaction. This contains the following:
• ✓ The person's perception of the other person's behavior
• ✓ The thought about this perception
• ✓ The feeling associated with the thought Unless the content of a person's reaction is openly disclosed, it remains a secret from
the other person.
• If a nurse makes a statement to the patient and does not disclose what perception thoughts, or feelings led to his or her action,
the patient remains unaware of it because it was not expressed. This action process often functions in secret (Orlando, 1972).
• Guidelines that specify a person's use of the content or his/her reaction in a deliberative way are as follows:
• a. “In a situation a person verbally states to the other person any or all of the items of his or her immediate reaction;
• b. The stated item must be expressed as self-designated; and
• c. The person asks the other person to verify or correct the item verbally expressed" (Schmieding 1993, p.24).
• The deliberate nursing process describes as follow: “Whatever the nurse perceives about the patient with any one of the five
sense organs and thinks and feels about the perception must, at least in part be verbally expressed as self-designated to the
patient and then asked about" (Schmieding 1993, p.25).
• According to Orlando (1961), “The nurse does not assume that any aspect of her reaction to the patient is correct, helpful, or
appropriate until she checks the validity of it in exploration with the patient(p.56).
• The nurse will find it more efficient to find out what the patient's immediate need for help is by first exploring and understanding
the meaning of his/her perception. The patient is more likely to agree with the correctness of the perception and often explains its
meaning to the nurse.
• The longer it takes to find out the patient's immediate need for help, the more distressed the patient becomes (Orlando, 1961).
• The nurse uses thoughts to try to understand the nature of the patient's distress. When using thoughts, the nurse
must give the perception from which the thought was derived and ask the patient whether it is valid or not.
• Feelings come from the thought about the perception. The nurse must state the perception that evoked the
thought from which the feeling was derived.
• Nurse: “I m concerned that you keep asking for the bedpan. But I don't think you really need it. Am I right or not?"
• Patient: “Yes, but I'm afraid I might have chest pain again and then I wouldn't be able to call for the nurse." If
nurses do not resolve their feelings with patients, these same feelings occur each time they are in contact with the
patients.
• Furthermore, unexpressed feelings may show in the nurse's verbal or nonverbal behavior.
• • Regardless of what aspect of his/her reaction the nurse uses, the patient is affected by the action. Therefore the
nurse initiates a process of exploration to ascertain how the patient is affected by what she says or does. Only this
way can she be clearly aware of how and whether her actions are helping the patient” (Orlando, 1961, p.67).
• When nurses explain their immediate actions to the patients in a deliberative way, they are more likely to meet
the patient's immediate needs for help because when they use it, patients are more likely to use it also.
• This approach minimizes the nurse's opportunity to make private interpretations about patients and maximizes the
chance to correct or verify his or her private interpretation of the patient's action. Therefore both nurses and
patients have a better understanding of how each experience the immediate situation (Orlando, 1972). If this is not
done, patients remain distressed because the communication between them is unclear since the nurse stated an
automatic, response to the patient (Orlando, 1961).
• Orlando (1961) noted that automatic personal responses contribute to situation conflicts. Thus it is important to
understand them so that problems associated with their use can be avoided.
• Basing her ideas on Orlando (1972, Schmieding (1993) emphasizes the following reasons that
automatic personal responses are not helpful:
• 1. When the nurse withholds his or her immediate reaction, the patient cannot verify or correct
it. The withholding of the nurse's perception, thoughts or feelings allows the patient to make
assumptions about the nurse's verbal and nonverbal behavior.
• 2. If the nurse’s response is not stated as self designated, the patient is allowed to make
assumptions about the origin of what is heard (the use of “we” does not clearly provide the
origin)
• 3. If the nurse's response is not in the form of a question, the other verifies what she or he heard.
As a result neither person in the contact knows the immediate reaction of the other; therefore
each is left with an unverified understanding of the other's action (p. 28).
• Actions based on the nurse's conclusion, without the patient's participation, are often not helpful.
Therefore, the nurse decides for reasons other than the meaning of the patient's behavior. Thus if
action are carried out automatically, even though they could be correct. they are ineffective in
helping the patient because the patient was not involved (Orlando. 1961).
• A nurse's past experience are not sufficient as the basis for understanding the patient's
immediate behavior.
• Therefore, in each nurse-patient experience, a deliberative process of inquiry is required to
prevent the use of automatic responses and arbitrary actions. When this occurs, the patient's
immediate behavior improves.
• 5. Improvement -Resolution
• When a situation becomes clear, it loses its problematic character and a new equilibrium is established.
• • When the patient's immediate need for help have been determined and met, there is improvement
(Orlando, 1961).
• If the patient's behavior has not changed, the function of nursing has not been met and the nurse
continues with the inquiry process until there is improvement. (Orlando, 1961).
• This change is observable both in patient's verbal and nonverbal behavior.
• This allows the nurse to conclude that the patient's sense of helplessness has been relieved,
prevented, or diminished (Orlando, 1972).
• If the patient's behavior has not changed, the function of nursing has not been met and the nurse
continues with the inquiry process until there is Improvement.
• According to Orlando, li ik oot the nurse's activity that is evaluated but rather its result namely whether
the nurse's action helped the patient communicate his or her need for help and whether that need was
met.
• In each contact the nurse repeats a process of learning how to help the individual patient.
• The nurse's own individuality and that of the patient requires that she go through this each time she is
called upon to render service to those who need her.
 ASSUMPTIONS
• When the patients cannot cope with their needs without help, they become
distressed with feelings of helplessness.
• Nursing, in its professional character, does add to the distress of the patient.
• Patients are unique and individual in their responses.
• Nursing offers mothering and nursing analogous to an adult mothering and
nurturing of a child.
• Nursing deals with people, environment, and health. Patient needs help in
communicating needs, they are uncomfortable and ambivalent about
dependency needs.
• Human beings are able to be secretive or explicit about their needs, perceptions,
thoughts and feelings. The nurse-patient situation is dynamic, actions and
reactions are influenced by both nurse and patient.
 ASSUMPTIONS
• When the patients cannot cope with their needs without help, they become distressed with
feelings of helplessness.
• Nursing, in its professional character, does add to the distress of the patient.
• Patients are unique and individual in their responses.
• Nursing offers mothering and nursing analogous to an adult mothering and nurturing of a child.
• Nursing deals with people, environment, and health. Patient needs help in communicating needs,
they are uncomfortable and ambivalent about dependency needs.
• Human beings are able to be secretive or explicit about their needs, perceptions, thoughts and
feelings. The nurse-patient situation is dynamic, actions and reactions are influenced by both
nurse and patient.
• Human beings attach meanings to situations and actions that are not apparent to others.
• Patient's entry into nursing care is through medicine,
• The patient cannot state the nature and meaning of the distress for his need without the nurse's
help or without her first having established a helpful relationship with him.
• Any observation shared and observed with the patient is immediately useful in ascertaining and
meeting his need or finding out that he is not in need at that time.
• Nurses are concerned with a need that patients cannot meet on their own.
•END
 Joyce Travelbee

“Human-Human
Relationship Model of
Nursing”

By: Rey D. Pinalba RN MN

• “Suffering ranges from a feeling of unease to extreme torture, and varies in intensity,
duration, and depth. The role of nursing is to help the patient find meaning in the
experience of suffering, as well as help the patient maintain hope.”
• “Human-to-human relationship id the means through which the purpose of nursing is
fulfilled.”
• “Interpersonal process is a therapeutic human-to-human relationship formed during
illness and experience of suffering.”
 History and Background
• Joyce Travelbee was born in 1926 and is known for her work as a nursing theorist.
• In 1956, Travelbee earned her Bachelor of Science in Nursing degree from Louisiana State
University. She was given a Master of Science in Nursing degree in 1959 from Yale
University. Her career dealt predominantly with psychiatric nursing and education. She
worked as a psychiatric nursing instructor at the DePaul Hospital Affiliate School in New
Orleans, Louisiana, and worked later in the Charity Hospital School of Nursing in Louisiana
State University, New York University, and the University of Mississippi.
• Some of Joyce Travelbee's works include:
• Travelbee's Intervention in Psychiatric Nursing: A One-To-One Relationship
• Interpersonal Aspects of Nursing
• Intervention in Psychiatric Nursing: Process in the One-To-One Relationship
• Joyce Travelbee died in 1973 at the age of 47.
Overview
• Nursing: It's Definition
• Nursing is an Interpersonal Process...
• Nursing is an interpersonal process because it is always concerned with people
either directly or indirectly. The "people" nurses are concerned with include ill and
healthy individuals, their families, visitors, personnel and members of the allied
discipline.
• Nursing is also a "process", and by that we mean it is an "experience" or a
happening, or series of happenings between a nurse, an individual, or group of
individuals in need of the assistance a nurse can offer. Nursing, viewed as a
process stresses the dynamic character inherent in every nursing situation.
Nursing situation, being experiences in time and space, are dynamic and fluid,
and are ever in the process of evolving or becoming.
• Change is taking place in every nursing situation. There is continuous movement, activity, or change
occurring as a result of the interaction, the nurse influencing the recipient and in turn being
influenced by the recipient.
• To identify and be able to bring about change in a purposeful, enlightened, thoughtful manner in a
nursing activity.
• The nurse is vitally concerned with change and, in a sense, it may be said that she invariably wants
to change or influence others.
• Assists an Individual, Family, or Community...
• A nurse always assists others. Who is assisted? The individual or family in need of the services of
the nurse. This assisting function is held jointly by nurses and members of the other health
disciplines.
• To prevent Illness and Suffering…
• Nurses are always concerned with illness and with health since both theses concepts are pivotal
ones in nursing practice.
• Concept: Health
• Travelbee proposed two different criteria of health: the subjective and objective aspect of
health.
• Subjective health is defined individually, i.e., in accord with each person's appraisal of his
physical-emotional-spiritual status as perceived by him. Thus subjective health is highly
individualistic. The appraisal of subjective health status implies that a person is as healthy as
he perceives himself to be at any given time.
• Using an objective criterion, health would be defined as an absence of discernible, disease,
disability, or defect as measured by physical examination, laboratory tests, assessment by a
spiritual director or psychological counselor.
• The process of nursing, i.e., everything the nurse does for and with the recipient 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.
 Definition of a Human-to-Human
Relationship
• A human-to-human relationship in nursing refers to an experience or
series of experiences between the human being who is the nurse and an ill
person, or an individual in need of the services of the nurse.
• The major characteristics of this experience (or experiences) is that the
nursing needs of the individual, family, or community are met.
• These needs are met by a nurse who possesses and uses a disciplined
intellectual approach to problems combined with the therapeutic use of
self.
• A human-to-human relationship is purposefully established and maintained
by the professional nurse practitioner.
• Concept: The Human Being
• A human being is a unique, irreplaceable individual - a one-time-being in this world, like
yet unlike any person who has ever lived or ever will live.
• A biological organism affected, influenced, and changed by heredity, environment, the
culture, and all of the experiences he encounters, confronts, or runs away from.
• A being possessing the innate ability to transcend the material aspect of his nature - a
limited yet unlimited individual.
• A creature of contradictions continually confronted by choices and conflict. Confronted by
choices and the burden of choosing and deciding.
• A human being is a thinking organism capable of rational, logical thinking, yet at times
displaying irrational, illogical, “either-or", "black-white" dichotomized thinking.
• A being capable of maturity yet always maintaining a soft core of immaturity.
• A human being is an individual possessing the ability to know others yet her completely being able to
understand another human being, Able to communicate his individuality to others, yet always possessing
a core of incommunicability that cannot be put into words.
• A human being is a social being capable of relatedness with others – able to know, to like to love, and to
respond to and appreciate the utter uniqueness of others. At the same time capable of alienating,
disliking, mistrusting, and hating others.
• A human being strives to transcend the self, to rise above the limitations of his human condition or,
instead of transcending, to escape, or try to forget the core of the incommunicable loneliness, longing,
aloneness, restlessness and dissatisfaction that are embedded and embodied in self.
• A human being is an individual who knows that one day he will die. He knows he will die but, for the most
part his knowledge remains abstract and theoretical. The human being affirms and denies, acknowledges
and rejects, believes and disbelieves that life's culminating experience will happen to him.
• The human being is always in the process of becoming, evolving or changing. A distinguished feature of
man is his capacity to recall the past and to anticipate the future while living in the present.
 The Uniqueness of the Human Being
• A major premise of Travelbee's work is that there is an utter uniqueness to every individual. Each
person is different in his own unique way. This difference can be accounted for, not only on the
basis of heredity and environment, but seems to be especially due to the particular life experiences
each person encounters, his perception of these experiences and the manner in which he reacts to
these experiences. Two individuals may encounter the same experience, but each will react to this
experience in his own unique way.
• A guiding supposition to use in relationships with others is to assume and act on the assumption
that human beings are more different than they are alike.
 The Communalities of Human Experience
• As there are profound differences between human beings so are there likenesses. These likenesses are
not concerned with similarities between individuals but have to do with common life experiences every
human being, if he lives long enough, will encounter. An understanding of the meaning of these common
life experiences is essential if the professional nurse is to meet the nursing needs of people.
• Each human being is like every human being in that all are of the family of mankind, although the
differences between groups of people and individuals may be vast and profound, such as differing
cultures, life experiences and language differences. Still there is one common denominator, bond, or link
connecting each to the other.
• There is a language that can be understood by every person despite cultural, language or other barriers,
and that is our capacity to comprehend the common life experiences of others.
• The commonalities of human experiences are based on the assumptions that every human being
undergoes certain experiences during the process of living and reacts to these experiences in a way that
can be comprehended or understood by another.
• What are these common life experiences? It is assumed that each individual encounters similar
experiences during the process of living. All persons at some time in their life will be conformed by
illness and pain (mental, physical or spiritual suffering), and eventually they will encounter death,
Each person will to some extent, experience anxiety, loneliness, guilt and perhaps depression or
despair. Each person will lose a loved one by death, separation or through the withdrawal of love
once freely given. Hence, all will, at one time or another. grieve over the loss of a loved one. And
there are probably few individuals who have not, at one time or another asked, "Who am I? Why am
I here?", "Where am I going?"; and all too common." Why did this have to happen to me?"
• Lest these commortalion soum morbid and depressing, it must also be stressed that although all
individuals will undergo these experiences and will search meaning in them, so true that most
people at one time or another, and in varying degrees, will experience such feelings as joy,
happiness, contentment, wonder, love, and compassion, and they will also feel the impact of dislike,
hatred, lust, anger, envy, jealousy, and similar emotions.
• Love, tenderness and compassion are readily comprehended and understood by individuals of all
cultures and backgrounds. The language of love is universal and needs no interpreter.
• The process of Human reduction:
• Refers to the diminishing capacity to perceive ill persons as human beings accompanied by
increasing proclivity to perceive ill persons as an “illness”, or as a “task” to be performed, instead of
as human beings.
• Effect on the Human Being When Perceived as “Patient”
• The most common emotional response an individual feels when subjected to the frustration of
dehumanization is anger. The anger may not be directed towards any particular person: however
the individual may experience feelings of irritability, tension, and restlessness or may develop
transient somatic symptoms. Instead of anger, an individual may experience sadness, depression,
hopelessness, and apathy.
CONCEPT: Suffering
• ✓ The Nature of Suffering
• Every human being suffers because he is a human being, and suffering is an intrinsic aspect of the
human condition. At one time or another and in varying degrees, every human being encounters
distressing difficulties which are. for the most part, unavoidable and unforeseeable. In order to experience
suffering, an individual must perceive a situation as distressing and he must have a conscious awareness
of the distress.
• ✓ Definition of Suffering
• Suffering is a feeling of displeasure which ranges from simple transitory mental, physical, or spiritual
discomfort to extreme anguish, and to those phases beyond anguish, namely, the malignant phase of
despairful “Not Caring”, and the terminal phase of apathetic indifference.
• a. The Malignant Phase: Despairful “Not Caring"
• Despairful “not caring” is experienced when the individual has suffered mentally, physically, or spiritually
too intensely, over too long a period of time, without assistance and without surcease of suffering.
• Such a person is usually dominated by angry feelings of hopelessness which are bitterly that he does not
care and the vehemence of his protesting is an indication of how deeply he truly cares – how very much
he has suffered and how needful he is, It is not necessary for an individual to have a terminal illness in
order to experience despairful "not-curing".
• b. The Terminal Phase: Apathetic Indifference
• Apathetic indifference occurs when the individual progresses beyond the stage of despairful "not-
caring“. Such an individual does not complain, neither does he bitterly express the angry feelings of
hopelessness so typical during the phase of despair.
• ✓ Causes of Suffering
• Suffering is experienced when the individual encounters various types of distressing difficulties. A
distressing difficulty may include any of the following experiences which can happen to oneself or to
a loved one: illness, physical pain, mental pain, losses of all kinds - i.e., of a loved one through
death, divorce, desertion or separation, of a love object such as a beloved pet or material
possessions; of position, status or prestige; of one's integrity - and various types of real or imagined
injuries to pride and self-esteem.
• An individual may also suffer because he feels cut off from others - that he remains on life's
periphery and uninvolved, uncommitted, uncared for and uncaring.
• Reactions to Suffering and Illness
• There are many ways of reacting to suffering and illness. All reactions to suffering in illness are
highly individualistic. However, it is probable that most individuals attempt to arrive at a reason or
cause of illness and suffering. They want to know what has caused this illness to occur to
themselves (or to loved ones). The second most prevalent question is why has this happened to
themselves (or to loved ones). It is probable that most reactions to suffering and illness can be
classified into two broad categories: the “Why me?" reaction; and the "acceptance reaction" or the
"why not me” type of reaction.
• The source of "why me" reaction is probably nonacceptance of the experience of illness and
suffering. One manifestation of the “why me" reaction is the tendency to want to hold someone, or
something, responsible for what has happened.
• Blaming
• An individual may blame himself or his loved one for causing or being exposed to illness
• Bafflement
• The person may wonder why this illness or suffering happened to him. He may wonder why he was singled out or
"picked out“. The perennial question is: "Why did this have to happen to me?”
• Such individuals display a hurt perplexity and bafflement combined with a feeling of having been unjustly or unfairly
treated. The individual frequently cannot even direct his anger towards a "blame object at this point. There is only a
permeating. all-pervasive feeling of being ill-treated, and the person finds little or no meaning in such "unjust" and
unwarranted suffering". These feelings soon solidify into a depressive episode or a self- pitying attitude
• Depression
• Varying degrees of sadness, discouragement and depression are frequently engendered by illness. Depression is
defined as anger turned inward toward the self. Any loss of self-esteem, status, prestige, body function, or body part
may induce depression In a sense, the ill person may be said to go through a process of grieving the loss of bodily
function or a body part.
• To be helpless and dependent on others for care can produce deep feelings of worthlessness in some individuals.
• The ill person's world becomes increasingly restricted and loneliness becomes almost unbearable. To be bedridden and
in pain and to have no hope of recovery is difficult enough to bear - how much more difficult it is when the ill person
realizes that his friends and relatives have lost interest in him.
• Longing
• There are times when an ill person may feel a deep, surging, almost overwhelming desire to be well
again. The desire to feel strong, to participate in activities denied one may almost inundate the
individual with strong feelings of inexpressible longing and yearning. Longing can be a deeply
painful experience especially when such feelings are accompanied by the inescapable knowledge
that no matter how much one wishes, years, or hopes, nothing will be changed.
• Self-pity
• Self-pity is engendered and a general "I-feel-sorry-for-myself attitude is displayed. Such self-pity is
probably anger turned inward toward the self. To feel sorry for oneself is an intense suffering. The
individual is imprisoned within himself and enveloped in a laden, heavy feelings of self-pity.
• The "Acceptance Reaction"
• The acceptance reaction is the least common of all responses to suffering and illness. An individual
who displays acceptance as a reaction to illness and suffering is able to receive these conditions
without protest (i.e., in the sense that an injustice is being done), and in some rare instances, is able
to make an affirmative response to these conditions. By an affirmative response is meant the
individual is able to view his illness or suffering as channel through which good may be derived, and
in so viewing his illness in this manner experiences a type of resignation that is akin to deep
serenity.
Concept: Hope
• Hope is a mental state characterized by the desire to gain an end or accomplish a goal combined
with some degree of expectation that what is desired or sought is attainable. According to Lynch,
"hope... is a sense of the possible". The hoping person believes that if he obtains the object of his
desires, life will be changed in some way, i.e., will be more comfortable, meaningful. or enjoyable.
• Hope probably emanates from the knowledge that help form available in times of need and distress.
• Differentiation and Characteristics of Hope:
• a. Hope is strongly related to dependence on others.
• Help or the cooperation of others is required in order to survive. The ill and suffering human being
depends on others and hopes for their assistance even though he may not wish to ask for help.
• b. Hope is future-oriented.
• The individual who hopes desires a change in his present life situation. He is, in effect, dissatisfied
and finds little comfort in living in the now of the present moment.
• Hope is related to choice.
• The hoping individual believes he has some choices available to hlm. When a person hopes he perceives
some alternatives of avenues to escape in the situation. Having some choice in a different situation,
being free to choose one alternative over another, probably more than any other factor, is a major source
of the Human being's sense of freedom and autonomy. The freedom to choose and to decide for oneself
can endanger in an individual the feeling of being in control at least to some extent, of his on destiny.
• Hope is related to wishing.
• In this text, the term wishing" is defined as the act of desiring to possess something or condition,
accomplish a task or undergo an experience. Wishing is a component of hoping but it is differentiated
from hope only on the basis of probability of attaining the object of one's wish. The wish is related to
“magic hope". The individual who utilizes "magic hope” realizes that the possibility of his obtaining the
object of his wish is very slight. To wish then, is to desire the improbable or impossible and to have
knowledge of the low degree of probability of ever gaining the object of one's wishes.
• Hope is closely related to trust and perseverance.
• By trust is meant the assured belief that other individuals are capable of assisting in times of distress and will probably
do so. The individual may must however he may be incapable of requesting assistance. The situation can be a
devastating one for an ill person who realizes that no one will help and that he must proceed alone.
• Perseverance is the ability to keep trying to continue to work towards solving one’s problems, ameliorate one’s distress,
or change one’s status or condition.
• Hope is related to courage.
• The hopeful person possesses courage, Courage is the ability to realize one's inadequacies and fears and yet to
persevere towards one's goals, even though there may be little or no certainty that the individual will be able to attain
the object of his hope.
• Courage is not an automatic process. An individual does not become courageous simply because he wishes to be.
Courage is a quality which must be produced with each individual experience - by confronting each problem and
difficulty as it occurs in one’s life and doing one’s best to cope with such a situation.
• Hopelessness
• The hopeless individual is devoid of hope.
• The Nurse's Role
• It is the task of the professional nurse practitioner to assist the ill person to maintain hope and avoid
hopelessness. Conversely, it is also the professional nurse's task to assist the individual
experiencing hopelessness to regain hope. Generally, the professional practitioner assists
individuals to maintain hope and avoid hopelessness first by being available and willing to help, for
example, by being available and willing to listen to the ill person's anxieties and fears.
• It is the role of the professional nurse practitioner to render the needed assistance without being
asked. If the nurse is not certain what it is the individual requires she then asks the ill person.
• To be ill and to suffer may be to experience any or all of the following: pages 423-428.
Concept: Communication
• Communication takes place during every encounter the nurse has with the recipients of her care. It
occurs when the nurse and ill person converse with each other, as well as when each is silent. The
ill individual communicates something to the nurse by his appearance, behavior, posture, facial
expression, mannerisms and gestures, as does the nurse to the ill individual. Both the nurse and
the ill person communicate whether or not they are aware that it is happening.
• A major belief of this work is that it is the task of the professional nurse practitioner to plan,
direct, and guide purposefully the interaction with the ill person in such a way as to fulfill the
purpose of nursing.
• The nurse must also be able to
• (1) understand the meaning of the ill person's communication and
• (2) use this information in order to plan nursing intervention.
• Communication Techniques
• Communication techniques are methods used to accomplish the specific as well as me overall goals of
nursing intervention. As such, the communication techniques include not only the use of verbal
interchange with ill persons but also all non-verbal means used by the nurse to influence the recipient of
her care. Techniques are valuable and useful in facilitating communication when used in a judicious
manner.
• Communication techniques are a means to an end, the end being the achievement of the purpose of
nursing.
• A guiding principle in selection and use of communication techniques is as follows: The nurse should use
any communication technique whereby she is enabled to explore and understand the meaning of the ill
person's communication.
• Certain prerequisites are necessary before using communication techniques purposefully and effectively.
• These prerequisites imply possession by the nurse of the knowledge underlying the skills and the ability
to use this knowledge in order to achieve the purpose of nursing,
• THE TECHNIQUES
• 1. Open-Ended Comments or Questions
• 2. Reflecting Technique
• is probably the best known, least understood, and most popular communication technique. There are two
general categories of reflecting techniques: one is to reflect (or repeat) certain words or phrases spoken
by the other person in order to facilitate communication. This is known as reflecting content. When
reflecting content the nurse repeats the individual's statement in the form of a question.
• An example of reflecting content is as follows:
• Mr. Cruz "I want to go home."
• Nurse, "You want to go home?"
• Mr. Cruz "Yes. I'm so worried about my children and my wife."
COMMUNICATION BREAKDOWN
• In order for communication to take place there must be a sender and a recipient, and the message must be understood
by all concerned. Communication breakdown (or failure to communicate) occurs when a message is not received, or
when a message is misinterpreted or misunderstood.
• Communication breakdown can also occur when one participant in the interaction receives and correctly interprets the
message, but for some reason does not wish the other person to know that the message has been understood.
• MAJOR CAUSES OF COMMUNICATION BREAKDOWN AND DISTORTION
• 1. Failure to Perceive the ill Person as a Human Being
• Meaningful communication cannot occur in interactions when a participant fails to perceive the other as a unique
human being. Failure to perceive the ill person as a human being is usually due to the nurse's stereotypes and
preconceptions about ill persons.
• Some conceptions and stereotypes are as follows:
• 1. All males are cooperative when ill.
• 2. All females are demanding when ill.
• 3. All (Black, Italian, Jewish, Indian, Catholic, etc.) individuals behave in certain ways when ill.
• A nurse also fails to perceive the ill person as a human being if she treats him as if he were someone else (i.e., the
nurse's relative or someone from the nurse's past).
• 2. Failure to Recognize Levels of Meaning in Communication
• Communication breakdown may be caused by failure to recognize that messages transmitted during the
communication process may have meanings other than the apparent “obvious” literal meaning.
Communication is also blocked when nurses accept statements made by ill persons at "face value," with
no reflection or thought; or when nurses answer questions too quickly without exploring the ill person's
meaning and intention.
• 3. Failure to Listen
• Communication is blocked when one participant in an interaction fails to receive (listen to. or hear) a
transmitted message. Failure to listen is a major cause of communication breakdown. Listening is an
active process requiring the expenditure of energy as well as the ability to focus one's entire attention on
the other individual. The nurse may not be willing to expend the necessary energy; she may be tired,
preoccupied, bored or disinterested. She may fail to listen because of the manner in which the ill person
speaks, i.e., if he mumbles, speaks in a low monotonous voice, or displays other speech habits which
tend to encourage not-listening.
• 4. Using Value Statements without Reflection
• A nurse uses value statements when she responds to an ill person's comments by using such
statements as "isn't that fortunate" or "fine” or “wonderful,” etc., before discovering how the ill
person feels about the situation in question.
• 5. Cliches and Automatic Responses
• The use of clichés and automatic responses hinders and blocks communication. A cliche is a tríte
tired, meaningless, hackneyed phrase or question. Cliches are used automatically without reflection
or thought on the part of the nurse.
• Cliches include “pat answers" and "stock replies." Unless the nurse strives to become consciously
aware of how she communicates she will probably revert to the use of cliches, which are employed
to avoid thinking and also to maintain distance between the nurse and the ill human being.
• 6. Accusing, Blaming and Teasing
• Another effective means of blocking communication is to accuse, blame or tease ill persons. Some
nurses blame ill persons and verbally accuse them of causing their own illness or injury.
• The ill person may be accused, taunted, teased or in some way made to feel stupid, careless or
inadequate. An individual who knows he caused his illness or injury is not helped by a nurse who
accuses him of having brought his condition on himself.
• 7. Failure to Interrupt
• Another major cause of communication breakdown and distortion seems to stem from the nurse's
belief that it is impolite to interrupt ill persons while they are speaking. For example, an ill person
may talk for some period of time, may bring forth numerous and diverse ideas that require
exploration. The nurse may not clearly understand what the individual means. Unless the nurse
interrupts the individual's conversation, it is not likely that she will be able to remember, much less
explore with the person, the meaning of his comments.
Human- to-Human Relationship
• A major assumption of this work is that it is the task of the professional nurse practitioner to
establish a human-to-human relationship.
• Another major assumption is that a human-to-human relationship is established after nurse and
recipient of her care have progressed through four preceding interlocking phases.
• These phases are: (1) the original encounter, (2) emerging identities, (3) empathy, and (4)
sympathy. All of these phases culminate in rapport and the establishment of the human-to human
relationship.
• A human-to-human relationship is primarily an experience of series of experiences between a
nurse and the recipient (s) of her care. The major characteristic of theseexperiences is that
the nursing needs of the individual (or family) are met. The human. human relationship is
purposefully established and maintained by the professional nurse practitioner. It is a mutually
significant experience. It is a reciprocal process.
• Phases Leading To The Establishment of a Human-to-Human Relationship
• (1) Phase of the Original Encounter (2) Phase of Emerging Identities (3) Phase of Empathy (4) Phase of
Sympathy (5) Phase of Rapport
• 1. Phase of Original Encounter
• When a nurse encounters a person for the first time, she observes and develops inferences and value
judgments about the individual, as the person usually does about the nurse.
• Observation is the first and most important step in the nursing process.
• Observation and development of inferences which follow are important, since they serve as a basis for
decisions made.
• 2. Phase of Emerging Identities
• The phase of the emerging identities is characterized by the ability to appreciate the uniqueness of
another person, as well as the ability to establish a bond with other individual. It is getting beyond and
outside of self to some extent in order to perceive another, yet using self as the instrument to accomplish
this purpose.
• 3. Phase of Empathy
• Empathy is an experience which takes place between two or more individuals. It is basically the ability to
enter into, or share in and comprehend the momentary psychological state of another individual
• It is a process wherein an individual is able to see beyond outward behavior, and sense accurately
another's inner experience at a given point in time.
• To empathize is to intellectually understand another on the basis of similarity, to gain some understanding
of the mental world of another; but it is not relatedness.
• 4. Phase of Sympathy
• The ability to sympathize emerges and results from the empathic process. It is step beyond empathy in
that in sympathy there is a basic urge or desire to alleviate distress. This desire to alleviate distress,
absent in empathy, is a distinguishing characteristic of sympathy.
• ln nursing, sympathy implies genuine concern about the misfortune or dintre another, combined with a
desire to aid the afflicted individual.
• Comparison Between Empathy and Sympathy
• Empathy is a process wherein an individual is able to comprehend the psychological state of another.
• Sympathy, implies a desire to aid the other individual in order to relieve his distress.
• Both empathy and sympathy require a perceptual openness to experience, and uns mental freedom to
make use of one's personal background of experience in order understand and appreciate the
experiences of others.
• Phase of Rapport
• The establishment of a human-to-human relationship, and the experience that is rapport, is the terminus
of all nursing endeavor. Rapport is that which is experienced when nurse and ill person have progressed
through the four interlocking phases preceding rapport and the establishment of a human-to-human
relationship namely, (1) the original encounter, (2) emerging identities, (3) empathy, and finally (4)
sympathy.
• Rapport is a process, a happening, an experience, or series of experiences undergone simultaneously by
the nurse and the recipient of her care.
•END
 Lydia Hall
“Care, Core and Cure Theory
of Nursing”
By: Rey D. Pinalba RN MN








































 Faye Glenn Abdellah
“Twenty-One Nursing
Problems”
History and Background
Overview of Abdellah's “ Patient-Centered Approaches to
Nursing Model”
The Twenty-one Nursing Problems
Nursing Problems
PROBLEM SOLVING