THEORETICAL                   Reflections on the interpersonal relation nurse - patient in the field the clinical care María Eugenia Mejía Lopera1 1Profesora Asistente en la Universidad de Antioquia, Medellín (Colombia) Mailing Address: Calle 34A # 78 - 21 Apartamento 604, Medellín (Colombia) Manuscript received by 14.11.2005 Manuscript accepted by 8.02.2006 Index de Enfermería [Index Enferm] 2006; 54: 48-52 (original version in Spanish, printed issue)               How to cite this document     Mejía Lopera ME. Reflections on the interpersonal relation nurse - patient in the field the clinical care. Index de Enfermería [Index Enferm] (digital version) 2006 54. In </index-enfermeria/54/e6137.php> Consulted     Abstract The aim of this article displays the nursing like a human relation between a patient and a nurse, by means of which it is possible to recognize and to respond to the necessity of aid and to the problem of the patient. The reflection is based on the thought of Hildegard Peplau, who constructed a model of nursing care about the interpersonal relations with the patients, which the nurse can approach the meaning that patients assign to the disease, to the behaviors and the feelings, in order to incorporate them to the care and to help them to lead their potentialities towards useful forms to bear its illness. At the professional practice, the author of this article has observed the form in which the unconsciousness, the obligatory sedation or the endotraqueal intuba-tions, take to many patients hospitalized in the intensive cares units, to have interferences in the communication with the surroundings; this aspects suppresses the symbols to interpret the atmosphere and to act consequently. The theoretical proposal like the professional experience, they allow to conclude that if the patients do not have an effective interrelation with the surroundings and the nurses, it is required that the nurses value them integrally to propose sustained alternatives of care in solid scientific knowledge, abilities practical and stop degree of human sensitivity to reach the interpretation of the condition of the patient and for helping it to satisfy its basic necessities with well-being.       Introduction      "The professions dedicated to giving of services are distinguished for a social, explicit objective and recognized by the society. It is expected from the Doctor to make diagnostic and treatments; from the journalist to inform and east to the public opinion. The nurse, however, it's perceived and described in different ways, not only for the common people, but for the same professionals"1. To the nurse is looked as an angelical being that it distributes gifts to their step, as the doctor's assistant or as that person that among other things, he/she takes a bath to the patients. However, to execute the care, their object of knowledge and reason of being, requires of a scientific, technological and humanistic formation that allows them, in their interaction with the patients, to carry out actions that demand the participation from both. The nursing is a human relationship among a sick person and a nurse that has a specialized formation, to recognize and to respond to the necessity of help; from this relationship frequently arises, the clarification of the patient's problem.      When thinking of the interpersonal relationships in nursing, I remember a reading that I did a couple of years ago and from which I don't keep the physical evidence. It told how a nurse, in spite of the obstacles that were presented for the care of a patient, didn't require of sophisticated technology neither of sublime knowledge, to achieve that starting from the interaction generated from the patient's entrance, a relationship was begun that would last for a lot of time and that it would help the patient in the trajectory toward the independence. The title attracted my attention: "While... the walls listened". This reading has always been present in my interaction with the patients that are unconscious for some reason.      The article related the experience of a nursing student that was alone in a night shift, because it unit didn't have patients; toward the dawn an unconscious patient entered as consequence of a traffic accident; the patient only reacted to deep pain; when looking for some company, she took the patient as her listener. She gave him a warm welcome, explained what had happened to him not only during that day but the following ones, everything that would have had to be done in order to achieve his well-being. With sentences like "it is possible that you cannot help me... ", she always kept him in mind in the planning and execution of his care.      One night, her assistant was going to help her changing the position of the patient; she that always called him for his name said: "Mark, we will turn you to your right side; I'm sorry, my hands are very cold". The assistant looked curious: "Are you speaking to him?, To the walls? ". She answered that maybe she was. After multiple complications in his clinical state and several months of hospitalization, the patient recovered and he returned to his house.      When the student graduated, she went to visit her friends of the hospital and being in the nursing position, a man arrived in seat of wheels greeting the whole personnel very friendly. One of her friends presented him saying: "He is Mark, one of our miracles". She introduces to mark telling him that she was present when he did arrive to the hospital but that maybe he won't remember her; however he responded to her: "Yes, I remember your voice. It was the only way to know that I was alive and not dead. You were the first one that told me about the hell that I was living. I was afraid of dying, but then I listened to your voice and I knew that I would live again".      Now that I begin to discover the theories formulated by thinkers of the nursing that weren't being explained before, I found how my professional practice has always been based in the interaction nurse - patient, nurse - family, nurse - team of health. And I evoke, the first encounter, which has always been decisive in this relationship that remains sometimes, until after the patients get recovered.      Hildegard Peplau, outlines that in this period, the patient clarifies the first global impression of the problem and participates in this phase asking questions, trying to discover what he/she needs to know to feel secure and watching the form in that the professionals respond to him/her. She built a model that offers the nurses the possibility to come closer to the meanings that the patients assign to the illness, to the behaviours and the feelings, so that they can incorporate them to the actions of care and to help them to direct their potentialities toward forms that they can use to carry their pain2.      The North American nurse's theorist Joyce Travelbee it's based in her accumulated experiences in the field of the nursing more than in the evidence of a certain investigation study3. According to her, "the relationship nurse - patient is the means through which the purpose of the nursing is achieved that is to say, to attend the individual or family to prevent or to confront the illness experience and suffering, and to help the patient to find meaning in these experiences.      The nurse should be very receptive to detect the necessities of the patient and especially to understand which the help that the patient requires is. The form in which the nurse feels the patients help, supposes difference in the result of the attendance, from the point of view of expansion of the personality. The patients adapt to the situation or they learn something, as a result of the experience of the illness and of the nursing. However, it is necessary to frequently ask, what happens to those patients that arrive unconscious to the hospital as consequence of cerebral lesions or of any nature. The reading that I made, illustrates this relationship that I will try to analyze centred in the postulates made by Hildegard Peplau and by the light of the paradigms and the ways of knowledge in nursing. The communication with the patient in the ICU (Intensive Care Unit)      During the vigil, we maintain constant interaction with our fellows. This is a vital aspect in which we are confined for all of our lives. Because the nursing work is to offer a social and human service, the interpersonal relationships are inherent to it. The effective communications it's essential for the interaction, because through it we get in touch with the person and the world that surround us, we can make choices, get and give information, and modify objectives. The encounter between a nurse and a patient in any environment of the care, supposes the interrelation of two human beings that above all are people; the communication among them settles down by means of diverse codes and one of them is the language.  However, many patients hospitalized in the ICU, cannot use the language for communicating with the environment, among other reasons for unconscious states, obligatory sedation or endotraqueal intubations. If the individual interprets the environment by means of the symbols and their meanings and acts in consequence, it is of supposing that this function can be depressed or abolished in the patients with alteration of the conscience. The ICU patients presents threat of death, loss of the autonomy, separation of the family and of the environment, they don't understand the language neither the monitoring, loses the role, the dignity, the oral expression and the activity.      For all the above mentioned, the situations of the patients health in critical state, challenges the whole personnel that participates of their care to be recursive in the communication with them, which makes imperative that the workers of the health, search for codes that allow them to interact with the patient. The care at the ICU is clinic and individual, that's why it determines the permanent interaction between the nurses and a patient. Paradigmatic visions of the care      These patients doesn't have effective relations with the environment and the nurses; because of this it's required that the nurses propose caring alternatives by means of a solid scientific knowledge, practical abilities and with a high degree of human sensibility to be able to understand the patient condition. The nursing will never be able to have a single vision of the paradigm on the care because, on one hand, it has the inheritance philosophical positivist of the science that it studies the nature and the phenomena like something out of the context and demonstrable, and on the other hand, of a philosophy "postpositivist" that emphasizes the perception, studying the thought, it admits the value of the subjective and of the context4.      The interpersonal relationships express the social fact that all the individuals and community have. Monti and Tingen, in a titled article "multiple Paradigms of the nursing science", they play two important aspects of the Interpretive Paradigm where they explain the relationships between the nurses and the patients. First, Many of the first scientists of the nursing were formed in the disciplines of the social sciences, and that exposed them to alternative ways of seeing the world; it is worthwhile to remember that at the moment the teaching of the nursing, is not unaware to the postulates of these disciplines. The other one is the interpretive approach as an appropriate way with the language and the nursing beliefs; while the pattern medical scientific talks about the reductionism, objectivity, manipulation, prediction and control, the interpersonal relationships in nursing are based in the holism, the individualism and the autonomy.      Having present that the interpersonal relationships reflect to the nursing like an eminent social discipline, I find interesting to present a comparative among the empiric and interpretive paradigms proposed by Monti and Tingen5. In the empiric paradigm, the behaviours can be reduced to parts, the organism is passive and the movement is caused by external forces, the investigation problems are positivists in the search of causal relationships among phenomena, the nursing paradigm is particular and deterministic, the reality is independent of the context and you can verify via the senses, the human beings are machines in those that the sum on their parts are closed systems and the purpose of the sciences is to guided to the verification and justification, the test of the theory and the identification of the causes. In the interpretive paradigm, the nursing paradigm is transformative, the reality it is based in the experience and it can never be determined because multiple realities exist, the knowledge is derived of the experiences loaded with value, knowledge and perception, the individual vision is holistic, irreducible and dependent of the context, the investigation problems look for the meanings via qualitative methods and the purpose is the discovery of meanings, the theory generation and the knowledge of the reality. Theorics abstractions      The relationship caregiver - caretaker is based on the requirements of the patient. The developments of the nursing, like an eminently social science, have arisen exactly from the personal interactions among nurses and patients; each one of the theoretical ones of the nursing has transcended this relationship for diverse interests; let us see some postulates.      For Virginia Henderson6, this relationship arises in the measure that the nurse is able to identify and to satisfy the human being 14 necessities. The nurse is a substitute or help in the satisfaction of those necessities, while the patient gets ready to do it by himself. Their objective is to give the independence back to the patient as soon as possible.      For Ernestine Widdenbach, the interpersonal relationships among patient and nurse are possible when the nurse interprets the necessity of the patient's help and is of highly importance the biology and sociology knowledge. The person should maintain it physiologic and emotional balance since the body and the mind are inseparable; it requires help to get their independence.      Madeleine Leininger in her theory of the diversity and universality of the cultural cares, presents her conviction that people of different cultures can offer information and guide the professionals to receive the cares that they want or need from others7. The culture determines the patterns and lifestyles that influence in the decisions of people, to help the nurse to discover and to document the patient's world. Peplau's sequence      Although each nurse's theory proposes approaches to the patient from the different areas of the human being and that in the daily practice each nurse does it with her experience, I consider that the theoretical proposal of Hildegard E. Peplau suggests clear postulates to guide this relationship.      Peplau's main interest is to delineate the psychological tasks that are developed in interpersonal situations, particularly the relationship nurse - patient. The reach of the nursing depends on the nurse capacity to recognize the difficulties that outline the relationships with people and on the ability to solve them, in such a way that they can develop new abilities to face new problems; at this point, she considers that the patient is mature and the patient is able to understand his/her situation.      Peplau describes and analyzes four phases in the relationship nurse - patient: In the orientation phase, the patient looks for help as consequence of it illness and in the interaction with the nurse, it can find alternatives for the adaptation. In the identification phase, the patient believes to know what the situation is offering and responds selectively to those who offer help. In the phase of exploitation, attempts in diverse ways to take advantage from the relationship and to exploit the goods and services at it disposal. For the resolution phase, as soon as they old necessities are satisfied, the patient postpones them gradually.      It also proposes six roles in the interpersonal relationships: strange, person resource, educational, leader, substitute and adviser. Each one of them accomplishes their function so that in the psychobiological patient's experiences, the unsatisfied necessities, the frustrations or obstacles can be intervened in front of the goals, the conflicts related with the difficult decisions and the anxiety that it expresses an inexplicable uneasiness.      In nursing knowledge, Benoliel in 19878 exposes that "to know can be interpreted as being conscious in a particular and individual way, of the complexities of a given situation and to collect experienced internal resources previously to give them meaning". In this concept, the author and Peplau outline the same thing; the available elements to face a given situation, come from previous experiences even if they are not form the same nature of the current one. It is the nurse's duty, as being social participant in the resolution of the patients' problems, to help them to identify in the interaction person - person the tools that they have available to face the difficulty that they are going through.      Carper in 1978, identified four patterns of knowledge derived from the analysis and the structure of the nursing knowledge9. The four patterns are distinguished according with the logical type of their meaning and they have been designated as: 1. Empiric, the nursing science; 2. aesthetic, the nursing art; 3. of personal knowledge and 4. Ethical, the moral knowledge of nursing. Personal knowledge      Keeping in mind that the topic of this article are the interpersonal relationships nurse - patient, I want to refer shortly to the pattern of personal knowledge; however, I cannot leave aside the pattern of aesthetic knowledge because by means of it, the nurse understands the patient's situation, more than what the nurse sees and to this she gives an understanding. The pattern of personal knowledge refers to the knowledge, to the confrontation and the personal upgrade, like basic rules in the interactions and confrontations with the human beings.  The symbolic dimension of the personal knowledge is to experience opening to the life and the being. The being cannot describe or express from a different way to be itself. What others perceive is the personality or the person's existence10.      The previous appreciation is very important in the nurse's relationship with the patient that has interferences for the communication. The nursing knowledge should drive the care toward the solution of problems; but for it, the nurse requires ability in the identification of these, dexterity that is demonstrated in being able to go but there of the clinical history, of the medications, of the monitors and of the tubes that surround the patient; is to be able to discover in a look, in an expression or in a movement, the patient's transcendent expression that takes care.      Maybe if we only stopped to look with attention to the patient, if deliberately we planned the sensorial contact, we could discover that still in their unconscious state or of isolation, it maintains it individuality and that we are not allowed to label it for the routines of a care systematized for all the patients of the ICU.      Until today, I haven't had the opportunity to check with any patient that has been unconscious, the impact of considering it individuality, but I have felt the satisfaction of being in peace with the nursing. This is a scientific discipline laid on the foundation in the service to the other, but this only isn't enough; the service requires so many morphophisiologyc and phisiopathologyc knowledges, as social and humanistic that allow to the patient, in its interaction with the nurse, the development of potentialities and in this relationship the accumulate of necessary experiences for future encounters with other patients.      The interpersonal relationships in nursing shouldn't longer be considered "inside the series of innate gifts"11. The relationship with the patient is the axis of the cares and it demands the formation based scientifically as the wisdom of the expert professional that dominates the science and the art of the care. References 1. Castrillón MC. La dimensión social de la práctica de la enfermería. Medellín: Universidad de Antio-quia - Yuluka; 1997. 2. Peplau HE. Relaciones interpersonales en enfermería: Un marco de referencia conceptual para la enfermería psicodinámica. España: Salvat Editores; 1990, p.64. 3. Travelbee J. Interpersonal aspects of nursing. Philadelphia: FA Davis Company; 1966, p.121. 4. Sánchez B. Análisis del paradigma de enferme-ría. El Arte y la Ciencia del Cuidado. Bogotá: Universidad Nacional de Colombia; 2002. p.95 5. Monti EJ, Tingen MS. Multiple Paradigms of Nursing Science. Adv Nurs Scie 1999; 21 (4): 64-80. 6. 6. McKee NJ, Danko M, Heidenreiter TJ, Hunt NE, Marich JE, Marriner Tomey A, McCreary CA, Stuart M. El arte de la ayuda de la Enfermería clínica. En: Marriner Tomey A, Raile Alligood M. Modelos y teorías en enfermería. Madrid: Harcourt Brace; 1999. p.86-98. 7. Welch AZ, Alexander Sr JE, Beagle CJ, Butler P, Dougherty DA, Andrews Robards KD, Solotkin KC, Velotta C. Cuidados culturales. La teoría de la diversidad y la universalidad. En: Marriner Tomey A, Raile Alligood M. Modelos y teorías en enfer-mería. Madrid: Harcourt Brace; 1999. p.439-462. 8. Benoliel JQ. Response to "Toward holistic inquirí in Nursing: A proposal for síntesis in pat-terns and methods. Citado por: Durán de Villalobos MM. En: Enfermería. Desarrollo Teórico e Investigativo. Bogotá: Facultad de Enfermería Universidad Nacional de Colombia; 2001, p. 26. 9. Carper B. Fundamental patterns of knowing in Nursing. Citado por: Durán de Villalobos MM. En: Enfermería. Desarrollo Teórico e Investigativo. Bogotá: Facultad de Enfermería Universidad Na-cional de Colombia; 2001, p. 26-27. 10. Durán de Villalobos MM. Enfermería. Desarro-llo Teórico e Investigativo. Bogotá: Facultad de Enfermería Universidad Nacional de Colombia; 2001, p. 31. 11. Mordacq C. Pourquoi des Infirmières? Paris: Le Centurión; 1972. 62. Citado por: Collière MF. En: Promover la Vida. De la práctica de las mujeres cuidadoras a los cuidados de enfermería. 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