Hildegard Peplau's Interpersonal Relations Theory

HILDEGARD PEPLAU

Interpersonal Relations Theory

“The kind of person that the nurse becomes makes a substantial difference in what each patient will learn as he or she receives nursing care”

Getting to know the Theorist

Often regarded by many as the “Psychiatric Nurse of the Century”, Hildegard Peplau was born on September 1, 1909 at Reading, Pennsylvania. At a very young age, she decided that, unlike her friends, she would not leave school, go to work and band over her wages to her father. She was raised at a time when women were taught to believe they had to choose between marriage and work. She worked very hard for her studies and successfully graduated from Pottstown, Pennsylvania Hospital School of Nursing in 1931 and later worked as an operating room supervisor at Pottstown Hospital. In 1943, she received a Bachelor of Arts in Interpersonal Psychology from Bennington College, Vermont, a Master of Arts in Psychiatric Nursing from Teacher’s College, Columbia, New York, in 1947, and a Doctor of Education in Curriculum Development from Columbia in 1953.

From the beginning of her career in the late 1930s, Peplau worked tirelessly to advance nursing education and practice. Her efforts and excellent leadership skills saved the American Nurses Association from the point of bankruptcy and moved the nursing profession towards scientific recognition and respectability.

She became a member of the Army Nurse Corps and worked in a neuropsychiatric hospital in London, United Kingdom during World War II. She also worked at Bellevue and Chesnut Lodge Psychiatric Facilities and worked with renowned psychiatrists Freida Fromm-Riechman and Harry Stack Sullivan.

Hildegard Peplau had been considered as one of the renowned nursing leaders of her time that her writings and research are repeatedly featured at the American Journal of Nursing from 1951 to 1960.

Her first book, “Interpersonal Relations in Nursing” published in 1952, was one of the first books that stated the need to emphasize importance of the nurse-patient relationship in providing health care. Hildegard Peplau holds numerous awards like The Christiane Reimann Prize at International Council of Nurses Quadrennial Congress and a fellowship at the American Academy of Nursing.

On March 7, 1999, Hildegard Peplau died peacefully at her home in Sherman Oaks, California after a brief illness at the age of 89. Hildegard Peplau’s 50-year career in nursing left a remarkable stamp on the profession, and on the lives of the mentally ill around the world.

Metaparadigm in Nursing

Person

            Peplau defines person as a man who is an organism that lives in an unstable balance of a given system.

Health

            Peplau considers “health” as a word that symbolizes movement of the personality and other ongoing human processes that directs the person towards creative, constructive, productive and community living. Peplau also gave importance on the belief that for one’s health to be achieved and maintained, his needs must be met. These needs are physiological demands and interpersonal conditions.

Environment

            Peplau defines Environment as forces outside the organism and in the context of the socially-approved way of living, from which vital human social processes are derived such as norms, customs and beliefs. However, these given conditions that lead to health always include the interpersonal process.

Nursing

Peplau described Nursing as a significant, therapeutic interpersonal process. It functions cooperatively with human processes that present health as a possible goal for individuals. When nurses, together with the health care team offer health services, they project health holistically taking while considering the socioeconomic, spiritual, emotional and physical aspect of every person. When interacting with patients or clients in every setting available, the nurses uses the interpersonal model as a way to explore and to identify the needs of the person seeking professional help.

Interpersonal Relations Theory

Peplau described the nurse-patient relationship as a four-phase phenomenon. One can view them as separate entities, but they could overlap with each other over the course of the nurse-patient interaction. Each phase is unique and has distinguished contributions on the outcome of the nurse-patient interaction.

In Psychiatric Nursing, or the nursing of the mentally ill, the concepts introduced by Peplau were so important in the practice of this discipline that nursing leaders formulated a therapy out

of it.

                                                                                         Phases of Nurse-Patient Relationship

1. Orientation	The initial interaction between the nurse and the patient wherein the latter has a felt need and expresses the desire for professional assistance. The nurse assists the patient in recognizing and understanding the “patient” experience.
2. Identification	The patient and the nurse explore the experience and the needs of the patient which leads to a feeling of relatedness. Its is very important in the relationship that the nurse assists the patient in the reorienting his feelings and sustaining a constant positive environment.
3. Exploitation	in this phase, the patient derives the full value of the relationship as he moves on from a dependent role to an independent role to an independent one. New goals are projected by the nurse, but the power is shifted to the patient as these goals would be achieved through personal or self-effort.
4. Resolution	In its final stages, the patient earns independence over his care as he gradually puts aside old goals and formulates new ones. Even through the patient and the nurse end the relationship, it is very apparent that the experience leaves a lasting impression on patient since illness and assuming a dependent role is a unique human experience.

                                                                                                                                                    

            The Interpersonal Therapeutic Process is based on the theory proposed by Peplau and particularly useful in helping psychiatric patients become receptive for therapy. Often referred by Peplau as “Psychological Mothering”, it includes the following steps:

*The patient is accepted unconditionally as a participant in a relationship that satisfies his needs;

*There is recognition of and response to the patient’s readiness for growth, as his initiative; and

*Power in the relationships shifts to the patient as the patient is able to delay gratification and to invest in goal achievement (Stuart and Larala,2005)

Nursing Roles

          In the course of the nurse-patient relationship, the nurse assumes several roles which empower and equip her in meeting the needs of the patient. These roles are appropriately being used by the nurse in different nursing situations and phases of Interpersonal Relationship. These roles could overlap one over the other and could be observed as soon as the situation comes up.

Role of the Stranger

        In their initial contact, the nurse and the patient are strangers to one another. As the nurse attempts to know the patients better, she must treat him with outmost courtesy, which includes acceptance of the patient as a person and due respect over his individuality. This role coincides with the Identification Phase.

Role of the Resource Person

         As the patient assumes a dependent role, the nurse provides specific answers to his queries which include health information, advices, and simple explanation of the healthcare team’s course of care. It is the responsibility of the nurse to appropriately change her responses to the patient’s level of understanding.

Teaching Role

          As the interaction progresses, the nurse assumes a teaching role as she gives much importance for self-care an in helping him understand the therapeutic plan. In assuming this role, the nurse must determine how the patient understands the subject at hand. She must develop her discussion around the interest of the patient and his ability of using the information provided.

Leadership Role

          Although dependent to the healthcare team over his care, the patient is still considered vital in deciding as to what course his plan of care would take. The nurse as a leader must act in behalf of the patient’s best interest and the same time enable him to make decisions over his own care. This is achieved through cooperation and active participation.

Surrogate Role

          The patient’s dependency for his care give the nurse a surrogate (temporary care giver) role. This creates an atmosphere wherein feelings previously felt, such as feeling towards her mother. Some other relationships are reactivated and nurtured. Although the patient recognizes that the nurse has similarities with the person whom he recalls in previous relationships, the nurse must assist the patient to make sure that her surrogate role is different and only temporary.

Counseling Role

          Peplau believes that the counseling role has the greatest important and emphasis in nursing. This role strengthens the nurse-patient relationship as the nurse becomes a listening friend, an understanding family member, and someone who gives sound and emphatic advises. The very core of the interpersonal technique is from the patient to remember and to understand the experience and how could it be integrated into his daily life.

Acceptance by the Nursing Community

Practice

          Some of Peplau’s ideas were not widely accepted at the time they were introduced. Such as the concepts of learning through experiences between the patients and the students. At that time, her research and emphasis on the give-and -take of nurse-client relationships was seen by many as new and revolutionary. However, as the concepts that form her Interpersonal Relations Model were applied and tested, many nursing experts now recall Peplau as the one who brought a new perspective, a new approach and theoretical foundation for nursing practice. Her ideas paved way for integrating other scientific disciplines into nursing especially in formulating the paradigm of psychiatric nursing in its early days.

          As it became apparent that nursing practice in its true value could only be accomplished through starting and strengthening the nurse-patient relationship, many clinicians now believed that it’s in the interest of the profession and of the patient to utilize her interpersonal model extensively.

          Some researchers also used her model in their studies. They found out those nurses who promote trust by remaining available at all times being constant in their approach, facilitates the movement of influence from the nurse to the patient.

          In psychiatric Nursing, Peplau’s Interpersonal Model is used in counseling women undergoing depression. Because of the maintained and strengthened nurse-patient relationship, women were able to describe patterns that resulted from their negative thinking and independently found strategies to manage them.

Education

        Hidegard  Peplau’s book, Interpersonal Relations in Nursing(1951) is being used s a manual of instruction to help[ graduate nurses and nursing students alike in creating a significant nurse-patient relationship in any setting they are into. Critiques of her model were published in numerous academic circles. Some specializing in psychiatric nursing. Most comments of her works were published two decades or more after they were initially published.

          Her theoretical ideas, particularly her views of nursing and nursing process, the psychodynamic theory, and her views of nursing and nursing process, the psychodynamic theory and her prescribed methods, have been an essential part of the collective culture of the nursing profession.

Research

          At the arrival of the Interpersonal Model, nursing researchers follow the major assumption that the patient problems were within the person phenomena and were dealt inside the nurse-patient interaction studies. When her model was slowly integrated research has shifted to perspective within the social system as newer studies indicate that broader sets of relationship could also affect a person in many ways. Peplau influenced upcoming leaders especially those in the graduate school in the field of Psychiatric Nursing. The role of the nurse as a stranger changed one’s view on anxiety as an important definition of stress and its real effect on learning. Other psychiatric nurses developed a behavior scale using Peplau’s conceptual framework and her assumptions in regards with the therapeutic behavior of nursing experts were able to identify ways to reduce anxiety and therefore, stress, in patients.

ANALYSIS

Simplicity

                The major focus of Peplau’s theory, interpersonal relations, is easily understood. The theory’s basic assumptions and key concepts were clearly given, explained, broken down and outlined. In turn, she also demonstrated how this model could be used as a process when she introduced the Four Phases of Nurse-Patient Relationship. The different roles of the nurse added further understanding on how nurses could effectively use the Interpersonal Model by identifying which role is appropriate at a given phase or situation in perfect harmony with the nursing process.

                Peplau’s logic was taken from specific observations and applies them in general also called as Inductive Reasoning. She also studied theories from other disciplines and effectively applied them in the nursing profession. Her theories and principles were consistent with those of well-known psychiatrists such as Harry Stack Sullivan, Sigmund Freud, and Abraham Maslow.

                Hildegard Peplau closely observed relationships of the interpersonal process, nurse, patient and psychobiological experiences. She was able to discover patterns that enabled the nurse and the patient to achieve the full measure of their relationship. Peplau’s theory could be described as the meeting of quality with simplicity.

Generality                                                                                             

                Peplau believed that all nurses, regardless of their area or clinical setting, could effectively utilize her model. However, the theory can be used only to situations that communication can occur between the nurse and the patient. The use of the model is limited or impossible in working with senile, comatose or newborn patients. In these given situations, the nurse-patient relationship is often one-sided. Knowing this, the nurse and the patient cannot work together to develop goals and become more knowledgeable. For the nurse to function as an educative, therapeutic and maturing force, understanding the meaning of the experience to the patient is very important. This evaluative standard is not met.

Empirical Precision

                Peplau provides a theory based on reality. Her theory could be tested and observed using pure observation. The relationship between the theoretical area and empirical data could be validated and verified. Peplau functionally categorizes the four phases of the interpersonal process, with the nurse’s role taken into consideration together with the patient’s level of dependence. We may consider Peplau’s theory to be precise but with continued research and development, the degree of precision could be more increased.

Derivable Consequence

                In historical perspective, Peplau is one of the first theorists after Florence Nightingale to present a theory in nursing. Her works are highly regarded as pioneering, and more so, widening the perception of nursing as a noble profession.

                Peplau’s works, thoughts, and ideas have greatly touched the lives of many patients and nurses, from students to practitioners. Although her work has been published five decades ago, it never ceases in providing the direction for nursing practice, education and research. Peplau’s work has provided a significant contribution to the profession.

APPLICATION OF PEPLAU’S THEORY

Assessment

                In utilizing the interpersonal model, the nurse in the role of a stranger, moves in to explore the patient’s feelings with care accompanied with respect and courtesy. As she and the patient discuss feelings and concerns, she has the opportunity to collect accurate data which will give her a deep and thorough understanding of the patient’s condition.

Diagnosis

                Fatigue related to perceived overwhelming role and emotional demands.

                Risk for Impaired Parent-Infant Attachment related to disappointment with the infant (gender) and life event stressor with new baby and other responsibilities secondary to economic difficulties

Implementation

1. Assess further causative or contributing factors related to the feelings expressed by the patient.
2. Allow the patient to express her feelings regarding the effects of emotional fatigue she’s experiencing.
3. Help the patient identify these factors and let her strategize how to minimize or reduce them.
4. Assist the patient to identify strengths abilities and interests.
5. Provide significant others the opportunities to discuss feelings in private.
6. Initiate health teaching and referrals.

Evaluation

                Upon entering the Resolution Phase, the nurse and patient would evaluate if the goals of the relationship were met and the patient must be encouraged to formulate her own goals. It would be very important for the nurse to facilitate the expression of the patient’s feelings towards ending and relationship and how she perceives the independence over her care after the nurse-patient relationship.

Evaluation outcome expected in the clinical vignette is for the patient to accept the realities of the present event and gain independence in nurturing and taking good care of the newborn with her support system.

BY: 

Lantano, Marc

Binongcal, Kimberly

Mallare, Debra

REFERENCE: Balita, Carl E.,Octaviano, Eufemia F. (2008). Sampaloc, Manila: Ultimate Learning Series