Reflections on the interpersonal relation
nurse - patient in the field the clinical care
Eugenia Mejía Lopera1
Asistente en la Universidad de Antioquia, Medellín (Colombia)
Mailing Address: Calle
34A # 78 - 21 Apartamento 604, Medellín (Colombia)
Manuscript received by 14.11.2005
Index de Enfermería [Index Enferm] 2006; 54:
48-52 (original version in
Spanish, printed issue)
How to cite this document
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.
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.
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.
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.
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".
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.
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.
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
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.
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
The communication with the
patient in the ICU (Intensive Care Unit)
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.
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
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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