Communication between nurses and patients is a process that starts with their first contact and extends to the therapeutic relationship. The communication established between the nurse and the patient, unlike standard communication, focuses on helping and problem solving. Therapeutic communication skills are a precondition for this communication to be effective [1]. The nursing process, which is a scientific practice method of nursing; dialogue is realized through interpersonal environment and certain verbal communication skills, in other words therapeutic communication [2,3]. Therapeutic communication is evaluated as a technique in which many basic elements such as the here and now of the relationship between the patient and the nurse and empathy, sincerity, giving information, respect, understanding, summarizing, feedback, encouragement and clarification are used for the benefit of the patient [4]. In other words, therapeutic communication is an approach that facilitates the patient's self-expression and emotions, contributes to the mutual understanding of individuals and provides accurate explanation and understanding in realizing the desired health goals [5]. Therefore, therapeutic communication in all areas of nursing constitutes the essence of psychosocial care practices regardless of the patient's illness. Many of the patients who have been hospitalized or need nursing care due to any physical illness may have difficulty in coping with the stressful situations brought about by the disease phenomenon and may struggle with some psychosocial problems. Therapeutic communication methods are used effectively in the solution of these mental problems, which also form the basis of consultation-liaison psychiatry. Therapeutic communication practices are the main method of nursing care process, especially in psychiatric nursing. Nurses can understand the patient correctly, determine their needs and achieve positive results; empathy ability, ability to handle emotions are closely related to interpersonal communication [3]. According to many nurse theorists such as Travelbee, nursing; defined as the communication established between the patient and the nurse.

Travelbee and the Human-Human Relationship Theory

Joyce Travalbee, one of the pioneers of psychiatric nursing, published her book "Interpersonal Aspects of Nursing" in 1966 and 1971 and revealed the "Human-Human Relationship Theory". Travelbee was influenced by Viktor Frankl, the founder of existential psychotherapy, while developing his theory.

In her Travelbee theory, she expanded on Hildegard Peplau and Jean Orlando's interpersonal relationship theories and made a unique synthesis of their ideas, revealing some differences in terms of therapeutic human relations [6]. Travelbee's theory; discusses communication skills, communication facilitating techniques and communication barriers [7]. Travelbee's theory of interpersonal communication, which is based on "human-to-human relationship", considers humans as beings participating in a relationship [8-10]. Travelbee states that the basis of nursing practices is based on “human-to-human relationship”. She states that when communication with the patient deepens in nursing practices and does not reach the level of human-to-human relationship, the effect of communication in the care relationship will be limited [7-10].

In the "human-to-human Relationship" theory, nurses and patients were defined as humans. The relationship established between the nurse and the patient consists of participation based on recognizing and appreciating the humanity of each. At the stages where existing roles are exceeded, a therapeutic adjustment relationship can be reached. In theory, all the thoughts, feelings and attitudes of the nurse and the patient about each other are perceived, transmitted and shared. Experiences here enable the patient and nurse to find meaning in suffering or illness. Finding meaning from the illness increases the acceptance and adjustment of the burden of the illness or the psychosocial problems related to the illness. Finding meaning provides healing by revealing feelings of hope. Travelbee believed that this is the essence of nursing [7-10].

The nurse should use patient-centered care that recognizes the individuality of each person. Each person responds to illness depending on culture, symptom burden and whether the symptoms are of any relevance to them. Nurses and patients go through various stages to achieve the goal of nurse-patient relationships. Each stage has specific tasks and by mastering each task, a healthy development of the relationship is ensured. These stages are defined as:

• First Encounter Stage: The nurse and the patient perceive each other in stereotypical and apparent roles at the first meeting. With these roles, they may have prejudices about each other based on some old experiences [7-11]

• Stage of Emergence of Identities: At this stage, the patient and nurse reveal their identities by using verbal communication (taking anamnesis, asking questions, asking for information) and non-verbal communication types (body image, facial expressions, gestures, movements). They get to know each other as two people, leaving their roles as nurses and patients. [7-9,12]

• Empathy Stage: The patient and nurse can understand each other's feelings, thoughts and, accordingly, their reactions and behaviors. Empathy is a very important concept that is necessary for establishing healthy relationships in every field. The more developed a nurse's empathy skills, the more effective it will be for her to be able to understand the individual and give holistic care [7,8,13]

• Sympathy Stage: There are critical studies on the concept and use of sympathy in the literature and it is generally seen as unprofessional for nurses to establish a sympathetic relationship with their patients. Travelbee explains sympathy by talking about the misuse of sympathy, not sympathy

Sympathy is an emotion that elicits helping people and is often confused with compassion and identification. The nurse, who is identified with the patient, is so intertwined with the patient's problems that by directing her attention not to the patient but to herself in the patient's identity, she may become sad and cry with the patient. In this way, the nurse comforts herself by experiencing her feelings openly, sees herself as a continuation of the patient and cannot help her. Identification brings the feeling of pity in the continuation of this relationship. Experiencing pity does not help to understand and evaluate the sick individual and it also causes the nurse to see himself as superior, thus not creating both empathy and sympathy. In the sense of sympathy, there is warmth, sincerity and direction in works done for the benefit of the patient. The nurse who experiences the feeling of sympathy is a professional who takes action with the desire to help others by perceiving their pain [7-10].

• Friendly Relationship (Rapport) Stage: All stages, all these experiences, thoughts, feelings and attitudes that both the nurse and the patient have and can do, result in harmony, which is defined as perceiving, sharing and therapeutic communication. When Healthy Relationships are established, nurses can help patients accept the illness and find meaning in the illness [7-10]

According to Travelbe, the methods of finding meaning are:

Roundabout (İndirect) Methods

• Simile method (similar story)

• Implicit problem approach (using indefinite pronouns)

• Personal experience approach (shared experience)

The Direct Method İnvolving Joking Questioning and Explanation

• Use of open-ended comments or questions

• Use of mirroring technique

• Use of perception sharing

• Conscious use of clichés [7-10]

The theory provides opportunities for nurses to confront their problems and/or develop new behavioral patterns by offering new possibilities and awareness while helping nurses to solve the patient's "here and now" problems. The theory that Travelbee put forward as a result of his experiences with psychiatric patients has a wide range of use [7-10].

Use of Theory in Nursing

Nursing consists of a system where theories are the basis for systematic practice and practices prove and support theory [14,15]. One of the most important tools used to reflect nursing knowledge and theories into practice; It is the nursing process used to determine the needs of the healthy/sick individual and to provide individual-specific care [15]. The use of the nursing process together with a nursing model is important in solving the problems of the healthy/sick individual, as well as in the development of nursing science. The main purpose of professional nursing science is to produce scientific knowledge that can be used by nursing practices and to enable the scientific content produced to be used in the field [14].

The purpose of using the theories in field applications is to analyze the effects of applications made to increase the health levels of individuals in the clinical field, to provide systematic care, to develop applications and to contribute to the nursing literature by transforming them into scientific knowledge [15,16]. Although it has been seen that theory-based practices are used more frequently in the field of nursing in recent years, it is stated that it still has not reached the desired level [17,18]. According to Mc Kenna et al. [9], nurses think that theory and models cannot be applied to practice because they are theoretically weighted, that there is not enough education in schools about how to transfer them in practice, that evidence-based practices are not actively used in nursing and for this reason, they do not want to use theory and models in their practices [9]. In a study examining the use of theories in postgraduate theses in Turkey 2020; It was determined that the studies mostly (74.4%) consisted of doctoral thesis studies and the health belief model (25.0%) and adaptation model (22.5%) were the leading models used [19]. It is seen that the human-human relationship theory of Travelbee, one of the important theorists in the field of nursing, is not used in nursing theses, but only in a thesis study in the field of midwifery [20].

The purpose of this review is to analyze the limited number of application studies using the human-human relationship theory of Travelbee, which is not frequently used in the literature and to raise awareness for use in future studies.

Related studies were reached by searching the Google scholar, Medline, Cochrane, Sciencedirect and Pubmed databases with the keywords "Travelbee", "Therapeutic communication", "Nursing", "Empathy". There was no time limit for screening the studies. Due to the limited number of studies, studies written in mother tongue other than English were also included. This study was produced from the doctoral thesis as a preliminary study of the responsible author.

Studies Using Travelbee's Human-Human Relationship Theory

According to Travelbee, the nursing process; It covers all the actions, thoughts and care processes of the nurse with the patient and their family. In this process, therapeutic communication techniques such as active listening, reflection, sharing observations, clarifying, empathy, sympathy, approval, sharing hope, focusing, humor, touching, giving information, silence and asking questions are actively used [7].

Using Joyce Travelbee's Interpersonal Relationship Theory, Oliveira et al., [21], evaluated the interpersonal relationship process of a newborn lying in a newborn unit with his mother. Data collection was carried out through person-to-person interaction and a six-question tool was applied that revealed the possibilities of mutual assistance in the face of the child's health problems. By interacting with the mother, an attempt was made to alleviate suffering, doubts and fears. As a result, the mother's adaptation to the disease and the clinic was realized. It has been seen that Travelbee's theoretical approach is relevant and serves as a guide for nurses to practice more ethical and humane care [21]. Travelbee's theory encourages the nurse to get one step closer to patients and their families. In the Person-to-People Relationship Model, nursing is an interpersonal process in which the nurse assists a patient/family to prevent or cope with illness and suffering and, if necessary, to find meaning in these experiences. This process includes compliance at the final stage. Adaptation is the nurse's perception of the other person/patient-family, being able to share related thoughts and feelings without judgment and relating to them as a unique person [21].

In a study by Navarro et al., [22], in Chile, the effect of human-to-human relationship theory on the satisfaction level of patients and their relatives who have difficulties in communication, especially those with high education and young people and their relatives were examined. In this study carried out in the context of the hospital, they examined the effect of the theory-based communication method on user satisfaction in the dimensions of proactivity, professional attitude, verbal communication, non-verbal communication and emotional support and showed that the level of satisfaction increased considerably in many dimensions. Joyce Travelbee's theory, which revealed the qualitative aspects of care quality such as nurse-patient communication, contributed to in-hospital quality management and helped to reveal the importance of nursing professionals to develop their own practices and their values ​​in care management by taking time to communicate with people [22].

Bezerra et al., [23], conducted a qualitative study using Travelbee's theory for therapeutic relationships to be established with schoolchildren in hospital children's wards. In this study, it was observed that the theory helped to establish therapeutic communication with the child and to implement the pediatric care plan and an empathetic communication developed between the nurse and the child [23].

Turan and Vural [24], used Joyce Travelbee's human-to-human relationship model in the nursing care of a woman diagnosed with endometrial cancer. The friendly relationship emphasized in the theory increased the self-confidence of the patient and provided the desire and motivation for recovery. It is thought that this model is especially suitable and important for individuals diagnosed with cancer and will constitute a good guide in care for nurses [24].

Freitas et al., [25], created a nursing care plan for the diagnosis of low self-esteem, sleep disorder and depression in a 34-year-old patient who experienced long-term pain due to lumbar disc herniation. In the implementation of this plan, they benefited from Travelbee's human-human relationship model. At the same time, massage, acupuncture, rehabilitation, etc. related to pain management. used in additional methods. As a result, in the applied nursing interventions, the patient's pain decreased, the sleep process was regulated, low self-esteem and depression regressed and the patient was able to adapt to the disease. The mental balance, which has been disturbed due to the intense stress caused by illness and suffering, has been rearranged. Thus, the recovery process of the patient was accelerated [25].

In a thesis study conducted by Çalim [20], the effect of communication training given according to Travelbee Theory on the interpersonal communication skills of midwives and birth satisfaction of mothers was examined. As a result of the study, it was observed that there was a statistically significant difference (p<0.05) between the pre- and post-training Empathy Skills Scale mean scores of the midwives and the observation scores of their Communication Skills Behaviors. There was a statistically significant difference between the mean scores of the Mother Satisfaction Scale in Normal Delivery of women who had normal delivery before and after midwives' communication training (p<0.05). According to Travelbee Theory, communication training given to midwives improved their empathy and communication skills; the satisfaction of women they care for at birth has increased [20].

Damar and Türkmen [26], set out with the idea of ​​how Travelbee's human-to-human relationship model can be used in communication with young children hospitalized in pediatric wards or intensive care units. steps have been applied. In the study, the human-human relationship model created by Joyce Travelbee [26].

Parola et al., [6], revealed that Travelbee's theory is applicable in palliative care, helping end-of-life patients and their families find meaning in suffering and hope even at the end of life [6].

In a study by Karakut and Bucak [27], Joyce Travelbee's human-to-human relationship model was used in a patient with diabetes who was diagnosed with covid 19 after angio. It was observed that the patient was tense, unhappy and uneasy in the first days and as a result of the friendly relationship used by the nurse in communication with the patient, the patient had more energetic and more positive approaches and the healing process accelerated. Helping the patient maintain hope and avoid despair is a nursing intervention. By connecting with the patient, establishing a relationship that goes beyond giving medication and controlling blood pressure, nurses can provide a better, more productive and meaningful experience for patients [27].

Another concept that Travelbee emphasizes is the therapeutic use of the self. This “use” includes the ability to look within, to understand oneself, to understand and be aware of the dynamics of human behavior, to interpret one's own behavior and that of others. Being aware, understanding the patient and interpreting the patient's situation also depend on the nurse's ability to empathize. The best way to gain empathy is to experience the patient's experiences [21,28]. In a study conducted by Taylan et al., [28], in order to experience what patients with stoma experience and to raise awareness among nurses, they put a stoma bag filled with up to 1/3 of water to 35 nurses and asked them to work for 6 hours in this case. In this study, nurses stated that they often felt anxiety and fear, restricted their movements while working and were ashamed to inform their surroundings about stoma. At the end of the application, it was determined that most of the nurses stated that their awareness about the difficulties experienced by individuals with stoma increased [28]. With this and similar studies, what the sick individual experiences or can experience in physical diseases can be experienced.

As seen in the study examples, the theory has been shown as an effective method in establishing therapeutic communication with the patient, empathy, understanding the patient, finding meaning in pain, communicating with terminal patients, patients with difficulties in communication and their relatives and communication with pediatric patients. Therefore, Travelbe's theory can be used in all areas of nursing to communicate with patients and to provide them with psychosocial care. Especially CLP (Consultation Liaison Psychiatry) nurses can evaluate and use the therapeutic communication power of the theory in the care of patients with mental problems due to the burden of disease. Theory; It can contribute to the understanding of the psychiatric problems of terminal patients and their families and to the process of finding meaning and adaptation to life of both the nurse and the patient and their relatives. Especially in psychiatric nursing practices, it is often not possible to understand individuals with impaired mental health, to empathize with them and to experience their experiences. The theory can strengthen the empathetic approach of psychiatric nurses towards their patients with the existing communication steps in this regard. Thus, the quality of care can be increased and there can be a benefit in preventing stigma.

When we look at the studies related to the theory, it is seen that randomized controlled experimental studies that serve to create evidence are very insufficient. Studies are more in the form of case reports.

The use of theory in the field of nursing is extremely important in the development of nursing science and nursing practice. Nurses can combine theoretical and clinical knowledge and put them into practice by understanding the essence of the theories in line with their own experiences. In this context, although years have passed, Travelbee's human-to-human relationship theory maintains its feature as a practical therapeutic communication model that can be applied in every field of nursing. Despite this feature, it has not been used in graduate thesis studies. In addition, the number of studies using the theory is quite limited and it has often been used in short case studies. Contributing to the literature by supporting the theory with experimental and quantitative studies can be an important gain. Nurses who want to contribute to the field of communication and empathy, which are considered the basis of nursing, especially in psychiatric nursing, can be recommended to use this theory. More studies and evidence are needed in this area.

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