INTERPERSONAL

RELATIONS
Hildegard E. Peplau
A Middle-Range Nursing Theory Analysis

By

Ann M. Sparks, RN-BSN

OVERVIEW OF THE NURSE SCHOLAR

Hildegard E. Peplau, first published nursing theorist in a century, since Nightingale Created the nursing middle-range theory of Interpersonal Relations Helped revolutionize the scholarly work of nurses Contributor to mental health laws/reform
(Tomey & Alligood, 2006; OToole, 1989)

BACKGROUND BIRTH AND CHILDHOOD

Hildegard E. Peplau -- born September 1, 1909 in Reading, PA to immigrant parents of German decent

Illiterate, work-a-holic father Oppressive, perfectionist mother

Raised in a paternalistic family and a paternalistic society Though higher education was never discussed at home, Hilda was strong-willed, with motivation and vision to grow beyond traditional womens roles She wanted more out of life and knew nursing was one of few career choices for women in her day
(Callaway, 2002)

HISTORICAL EVENTS OF HILDA'S YOUTH

WW I ended in 1918, along with the great flu epidemic the same year Industry expansion & bullish stock market Women first vote 1920 Roaring 20s & Prohibition It was a mans world in both business and education
(Callaway, 2002)

NURSING EDUCATION OF PEPLAU'S TIME

The autonomous, nursingcontrolled Nightingale era schools came to an end schools controlled by hospitals now and formal book learning was discouraged
Hospitals and physicians saw women in nursing as a source of free or inexpensive labor Exploitation was not uncommon of nurses employers, physicians and educational providers Nursing practice was controlled by medicine
(Chinn, 2008)

NURSING EDUCATION & MILITARY SERVICE

Peplau pushed forward beating the odds:

Graduate Pottstown, PA Hospital School of Nursing in 1931 BA Psychology: Bennington College, VT 1943 World War II: Army Nurse Corps -worked in a neuropsychiatric hospital in London, England MA Psychiatric Nursing: 1947; Ed.D. Nursing Education: 1953, both graduate degrees from Teachers College, Columbia University Certification in Psychoanalysis for Teachers: William Alanson White Institute, New York City, 1954
(OToole,

1989)

FOUNDATION OF PEPLAUS FRAMEWORK

Hilda witnessed injustices in life, being determined to push past them for social justice First exposure to Interpersonal Theory at Bennington

She had vision to bring the Sullivanian theory to interactions with her patients they needed:

Humane treatment Dignity & respect Healing discussion

Attended lectures by Harold Stack Sullivan on Interpersonal Relations Studied with Frieda Fromm-Reichman and Eric Fromm

in a time when there was none to be found

(Forchuk, 1993)

PEPLAUS FRAMEWORK FOUNDATIONS

Teachers College: Director of Advanced Program in Psychiatric Nursing She created nursing curriculum Included study of nursepatient interactions through Process Recordings Peplau analyzed interactions of students with patients, taking her own experience into account

Her book, or conceptual framework, was completed by 1948, entitled Interpersonal Relations in Nursing
(Forchuk,

1993)

Reviewed them for recurring themes Using clinical data for theory development empirical evidence
(Forchuk, 1993; Gastmans, 1998)

GOALS OF THE THEORY

Publishing her book took four additional years because it was groundbreaking for a nurse to contribute this scholarly work without a coauthoring physician Peplaus original intent was not theory development per se She wanted only to convey to the nursing profession ideas [she] thought were important to improve practice Peplaus focus was the quality of nurse-patient interactions and nursing education
(OToole, 1989; Forchuk, 1993, p. 3)

INTERPERSONAL RELATIONS THEORY

BASIC ELEMENTS:

the patient the nurse the interaction between them

INTERPERSONAL Phenomena that occur between persons NURSE The medium of the art of nursing; a maturing force. The unique blend of ideals, values, integrity, and commitment to the well-being of others

DEFINITIONS:

CLIENT/PATIENT person, couple, group, community, deserving of humane care with dignity, privacy, ethics ENVIRONMENT Physiological, psychological and social fluidity that may be illness-maintaining or healthpromoting HEALTH Forward movement of personality and other ongoing human processes in the direction of creative, constructive, personal, and community living

NURSING ROLES - to assist client starting as stranger, then technical expert, resource person, surrogate, counselor, teacher and others
(Forchuk, 1993; Peterson, 2009)

GUIDING ASSUMPTIONS OF THE THEORY

Two original assumptions:

1) The kind of nurse each person becomes makes a substantial difference in what each client will learn as she or he is nursed throughout his or her experience with illness
2) Fostering personality development in the direction of maturity is a function of nursing and nursing education; it requires the use of principles and methods that permit and guide the process of grappling with everyday interpersonal problems or difficulties

Later Peplau added:

3) Nursing can take as its unique focus the reactions of clients to the circumstances of their illnesses or health problems
4) Since illness provides opportunity for learning and growth, nursing can assist clients to gain intellectual and interpersonal competencies, beyond those that they have at the point of illness, by gearing the nursing practices to evolving such competencies through nurse-client interactions
(Forchuk, 1993)

ADDITIONAL ASSUMPTIONS BY FORCHUK

5) Psychodynamic nursing crosses all specialty areas of nursing. It is not synonymous with psychiatric nursing since every nurse-client relationship is an interpersonal situation in which recurring difficulties of everyday life arise 8) All human behavior is purposeful and goal-seeking in terms of feelings of satisfaction and/or security 9) The interaction of nurse and client is fruitful when a method of communication that identifies and uses common meanings is at work in the situation 10) The meaning of behavior to the client is the only relevant basis on which nurses can determine needs to be met

6) Difficulties in interpersonal relations recur in varying intensities throughout the life of everyone
7) The need to harness energy that derives from tension and anxiety connected to felt needs to positive means for defining, understanding and meeting productively the problem at hand is a universal need

11) Each person will behave, during any crisis, in a way that has worked in relation to crisis in the past
(Forchuk, 1993)

RELATIONSHIPS HAVE FOUR PHASES

ORIENTATION PHASE

Get acquainted phase of the nurse-patient relationship Preconceptions are worked through Parameters are established and met Early levels of trust are developed Roles begin to be understood

IDENTIFICATION PHASE

The client begins to identify problems to be worked on within relationship The goal of the nurse: help the patient to recognize his/her own interdependent/participation role and promote responsibility for self

RELATIONSHIP PHASES (CONTD)

EXPLOITATION PHASE

Clients trust of nurse reached full potential Client making full use of nursing services Solving immediate problems Identifying and orienting self to [discharge] goals Final phase of nurse-patient relationship Sense of security is found as patient has less reliance and identification upon nurse helper Client has increased self-reliance to deal with his/her problem
(Belcher, 2002; Peterson, 2009)

RESOLUTION PHASE

THE NURSE ASSISTS THROUGH ROLES

ROLES of NURSE: Interlocking functions a nurse undertakes to assist a client Stranger (Orientation phase) Technical Expert & Authority Figure Surrogate for significant others Resource Person Change-Agent Researcher Counselor Arbitrator Teacher & More Specific roles variable within each nurse-client situation, being limited only by the imagination and skill of the nurse

Historically, psychiatric nurses acted as surrogate parent, promoting dependency & custodial care Peplau believed this unhealthy, preventing healing & growth Instead, focus is on improving patients autonomy & maturity
(Forchuk, 1993)

______________

INFLUENCED PSYCHOBIOLOGICAL EXPERIENCES

Within personalities, there are needs, frustrations, conflicts, and anxieties that are influential Every human has basic needs and goals exerting tensions within the relationship

Nurses own self-understanding helps nurse to respond to these tensions and coping mechanisms Nurse guides patient towards healing; tension and anxiety are converted into purposeful action as the result of the therapeutic relationship
(Peterson, 2009)

CERTAIN PSYCHOLOGICAL TASKS

Psychological tasks of humans learning to live with others require attention Developmental processes directly influence each persons expressions of feelings, attitudes and beliefs They bring about situations in which the nurse can assist the patient

A wide range of concepts are identified by Peplau having an impact on the practice of the nurse and the evolving nursepatient relationship Intrapersonal factors, interpersonal factors and specific clinical phenomena are assessed Problems and goals can be identified, then strategies implemented for healing and personal growth to take place
(Forchuk, 1993)

Counting on others Delaying satisfaction Identifying oneself Participating with others

(Peterson, 2009)

UNDERSTANDING INTERPERSONAL PROCESSES

Nursing Process Methods

Observation

Nurse self-scrutiny is required, along with observing and analyzing his/her own behavior Communication: verbal and nonverbal requires nurse to recognize and understand meanings Process recordings used as tools in the educational development of nurse to gain insights and learning skills associated with healing in the context of the relationship
(Peterson, 2009, p. 218)

Observation and understanding of what is observed are essential operations for making judgments and designing experiences with patients that aid them in the solution of their problems

Communication Process Recording Analyze & Evaluate

VISUAL MODEL OF MAJOR CONCEPTS

THEORY INSIGHTS - PROFESSIONALISM

Nurse gains competencies of higher understanding of self, concepts, roles and processes to help patient toward growth and healing Peplau warns: danger of social talk with patients Nurses shouldnt speak the same way to patient as to family or friends. It should lead to therapeutic effects promoting long-term well-being Nurses own emotional needs should not get in the way of tending to the needs of the patient Interpersonal Relations theory assists the nurse to

Observe more intelligently Intervene more sensitively

(OToole, 1989)

Check your emotional baggage at the door of patient care

WITHOUT THEORY

WITH THEORY

New ostomy patient Nurse senses tentions and tries to help by lightening the mood through distraction toward other events pt smiles Nurse continues to help the patient by caring for the appliance for the patient Inadequate coping is reinforced Another day went by with nurse promoting increased patient dependency by staff helping

New ostomy patient Nurse recognizes her own anxieties of ostomy, as well as patients anxiety (avoidance of care and involvement) Nurse assists patient to explore feelings through therapeutics Nurse openly prompts patient to talk about concerns during care of the appliance Encourages patient to look at, touch, & care for appliance progressively throughout care

COMPARISON ON A MED-SURG UNIT

EVALUATION OF THEORY

ADEQUACY:

CLARITY:

Contributes to the nursing process Clearly consistent with nursings values and mission Limited in groups of people Fairly narrow set of cultural assumptions
(Meiers & Sheran, 2009)

Clear and logical fashion Definitions are readily understandable Though concepts are at a high level of abstraction, they can be learned with practice

I disagree that its limited in groups - Lego demonstrates it has potential for group work
(Lego, 1998)

It can be used in any specialty area of nursing with patient contact It is holistic in nature

EVALUATION OF THEORY

CONSISTENCY:

Concepts and ideas are parsimonious Worldview is phenomenological in nature and remains consistent throughout the theory
(Meiers & Sheran, 2009)

LOGICAL DEVELOPMENT:

Logically inductively and deductively based Many psychological theorists works integrated into development Nursing role promotes the patients movement through the steps of the nursing process
(Meiers & Sheran, 2009)

EVALUATION OF THEORY

LEVEL OF DEVELOPMENT:

DISCRIMINATION:

Remains at the descriptive level Focusing on phases of relationships and interactional/inter- and intrapersonal phenomena Not changed significantly since Peplaus original writings were published over 50 years ago

Peplau is clear about making distinctions between the nursing and the medical profession But theory can be used by all helping professions in practically all areas of the relationship arena
(Meiers & Sheran, 2009)

The patients who have overwhelming physiological needs (or unconscious) are not good candidates for this theory application (Belcher,
2002)

Use with family members would be appropriate

EVALUATION OF THEORY

COMPLEXITY:

REALITY CONVERGENCE:

Theory has breadth, life and fluidity The basic core of the theory is simple, but certain aspects of the psychology in communication make it more complex
(Meiers & Sheran, 2009)

The basic tenants reality based, particularly in nursing situations requiring healing nurse-patient communication Real life Application: Nurses should be treating patients in a holistic fashion, no matter the context - It should be utilized more than it is, for the patients sake It requires time & practice to master start with the basics: a continual process improvement Considering the economy & managed care, Jones reports (1996) the need to provide cost-effective quantifiable care may negate the value of Peplaus theory I disagree - This theory is valuable as part of human development, maturity and individual healing in many contexts

The concepts are at a fairly high level of abstraction

Both inductive and deductive reasoning ability are part of this theory Both quantitative and qualitative research can take place

EVALUATION OF THEORY

PRAGMATIC UTILITY:

SCOPE:

Nurses critical thinking, therapeuticintervention/communication beyond task oriented nursing Requires self-scrutiny of motives and expectations by the nurse (maturity)
(Belcher, 2002)

Used in practice domains where interpersonal or intrapersonal difficulties are taking place [all (?)] Uses are broad; not confined to only psychiatric nursing, but other areas of nursing as well
(Meiers & Sheran, 2009)

Requires understanding of inductive reasoning skills It is the basis of higher levels of caring Directly affects interventions dealing with communication The interactions with the patient spawn deeper thinking in both the patient and the nurse towards positive healthcare outcomes
(Meiers & Sheran, 2009)

Limited in realm of physiological/medical issues but helpful to patients with concerns or issues most pts have these to some degree Very useful in settings of nursing education where focus on nursepatient relationship and communication are discussed

Utility based on individual use by nurse to invest energy and vision into relationship understanding &

EVALUATION OF THEORY

SIGNIFICANCE/CONTAGIOU S/CONTEMPORARY USE:

Translated into multiple languages

Criterion for significance has been met for the nursing discipline
(Meiers & Sheran, 2009)

Use of the theory by psychiatric nurses and advanced practice nurses is not uncommon
Documented as useful in many other areas of nursing: health education, palliative care, oncology, AIDS care, quality of life and many others
(Belcher, 2002)

Continued references to the theory in contemporary research and literature attests to continued utility Many elements of the theory have become public domain and integrated into nursing practice without Peplau being credited Theory has stood the test of time, though only moderate and variable use for formal research has occurred
(Belcher, 2002; Meiers & Sheran, 2009)

Used internationally in Australia and New Zealand, Belgium, Canada, the UK, Ireland and the United States

PREVIOUS APPLICATION TO PRACTICE

Used widely around the world nursing education Often integrated into policies without credit to Peplau Public Domain

Patient health education, palliative care, oncology, AIDS care, quality of life, private practice, nurse practitioners, home care & of course, psychiatric nursing
Nurse counseling of individuals and groups
(Belcher, 2002; Lego, 1998; McNaughton, 2005; Beeber, 2001)

PREVIOUS APPLICATION TO RESEARCH

U.S. focus has been on cost containment, causing delivery to be fragmented and restricted - minimal research efforts Research has been fairly inconsistent and scattered abroad

Most within National Healthcare System of Canada in recent years Most research has been qualitative not quantitative

(Stockmann, 2005; Forchuk & Reynolds, 1998)

Home care, Public Health, Depression, Education of Patients, Nature of Nurse-patient relations, Role expectations, Preferred Nursing care of ventilated patients

(Peterson, 2009)

Yet worldwide influences on the development of psychiatric nursing practice have been substantial For any theory, the acid test is utility in practice
(Stockmann, 2005; Forchuk & Reynolds, 1998)

RECOMMENDED FOR NURSING PRACTICE

ROUTINE INTEGRATION

into daily practice within any area of clinical nursing, with multi-faceted effects

RESULTS:

All interactions within practice would be more mature and healing in a context of caring, potentially improving peer relations as well Near elimination of disrespect between staff members with improved focus on the welfare of the patient better focused care plans

Nurses in private counseling practice would increase Theory requires the mature nurse to look deeply at own behavior, attitudes, motives, & actions during daily practice & in relationships self-scrutiny
(Belcher, 2002)

Invites the nurse to be less selfgratifying, and more in tune to the needs of the patient (and support systems), as well as filtering into peer and professional relationships

RECOMMENDED FOR NURSING PRACTICE

Patients would perceive being better understood

Would comprehend instruction with less anxiety Would give higher scores in levels of satisfaction regarding their nursing care

Re-admissions would decrease

Success stories and patient

comments could be shared in staff meetings and newsletters to reinforce the new staff behaviors

Increased comprehension of teaching in patients Patient and staff increased sense of responsibility for selves Empowerment of both patients & staff Improved health outcomes

Role modeling by nursing &

management would give the atmosphere of healing and caring less stressful environment

RECOMMENDED FUTURE RESEARCH

UPCOMING NURSING RESEARC H

Quantitative & qualitative research demonstrating positive health-care outcomes needs to take place (Jones, 1996) Focus on quantitative research would verify the theorys contemporary value, even with todays financial constraints

It might require a blended effort of Psychology and Nursing scholars

Specifically, quantitative studies needed to support the efficacy of the theory in relation to patient outcomes

Improved mental and physical health status Positive patient education results Favorable patient satisfaction

LIFE OF SIGNIFICANCE DURING CAREER

During her military service, Hilda mothered Letitia Anne Peplau or Tish, born January 30, 1945 Hilda remained unmarried in a time when it was clearly socially unacceptable, keeping it a secret from all but her immediate family She had her brother, Walter, legally adopt Tish, so that Hilda could continue to pursue her scholarly endeavors while legally raising her niece Hilda was not going to let social prejudices stop her from making further progress in her chosen career of nursing

She continued and transformed nursing from a Science of doing to a Science of knowing Peplau played a role in landmark legislation that established the National Institute of Mental Health in 1946 An ambassador for graduate education in nursing - teacher, mentor, advisor, and sponsor she inspired generations of students Though often disappointed by her profession, her career was always rewarding -- She had powerful vision to move nursing forward as a profession of respect
(Callaway,

HILDAS PASSIONS: NURSING AND TISH

LIFE OF SIGNIFICANCE IN RETIREMENT

Even in retirement, Hilda was tenacious for nursing education and continued to write for publications and lecture internationally Many accomplishments did not seem noticed by the nursing profession to Hildegard until after her retirement Hilda contributed joyously as the nursing profession moved forward with developing higher education programs

ANA created the Hildegard Peplau Award for contributions to the advancement of nursing through research, and inducted Hilda into the ANA Hall of Fame
(Callaway, 2002)

CONTRIBUTIONS, POSITIONS & AWARDS

Developed the first graduate nursing program devoted exclusively to the preparation of clinical specialists in psychiatric nursing Executive Director of the American Nurses Association: 1969-70, President from 1970-72, and Second V.P. from 1972-74 Third Vice-President and board member for the International Council of Nurses: 1973-81 She served as World Health Organization (WHO) consultant and visiting professor at the University of Leuvan in Belgium for two periods, 1975 and 1976 to 1977
(OToole, 1989)

After retirement she earned nine Honorary Doctorates from Rutgers University (Professor Emerita), Columbia University, Duke University, and others
(Callaway, 2002; Forchuk, 1993)

Pronounced a Living Legend By the American Academy of Nursing

Labeled Mother of Psychiatric Nursing and Psychiatric Nurse of the Century

Received Christiane Reimann Prize, nursings highest honor
(Callaway, 2002)

Fellow: American Academy of Nursing

INTERPERSONAL RELATIONS LEGACY

Hilda passed away, age 89, March 17, 1999 leaving a legacy of dignified and healing relations with patients, as well as healthy roots for nursing education and scholarly pursuits She made many contributions to nursing and society during a critical time in world history

Hildegard carried a light and will be remembered as the Mother of Psychiatric Nursing
(Callaway, 2002)

REFERENCES

Barker, P. (1998). The future of the theory of interpersonal relations? A personal refection of Peplaus theory. Journal of Psychiatric and Mental Health Nursing, 5, 213-220.

Beeber, L. S., & Bourbonniere, M. (1998). The concept of interpersonal growth in Peplaus theory of nursing. Journal of Psychiatric and Mental Health Nursing, 5, 187-192.
Belcher, J. R., & Brittain-Fish, L. J., (2002). Interpersonal Relations in Nursing: Hildegard E. Peplau. In J. George (Ed.), Nursing theories: The base for professional nursing practice (5th ed.)(pp. 61-82). Upper Saddle River, NJ: Prentice Hall. Callaway, B. J. (2002). Hildegard Peplau: Psychiatric nurse of the century. New York: Springer. Chinn, P. L. (2008). Integrated theory and knowledge development in nursing (7th ed.). St. Louis, MO: Mosby.

Forchuk, C. (1993). Hildegarde E. Peplau: Interpersonal nursing theory Notes on nursing theories (10). Newbury Park, CA: Sage.
Forchuk, C., & Reynolds, B. (1998). Guest editorial interpersonal theory in nursing practice: the Peplau legacy. Journal of Psychiatric and Mental Health Nursing, 5, 165-166.

REFERENCES

Jones, A. (1996). Education and debate. The value of Peplaus theory for mental health nursing. British Journal of Nursing, 5(14), 877-881.

Lego, S. (1998). The application of Peplaus theory to group psychotherapy. Journal of Psychiatric and Mental Health Nursing, 5(3), 193-196.
McNaughton, D. B. (2005). A naturalistic test of Peplaus theory in home visiting. Public Health Nursing, 22(5), 429-438. Meiers, S. J., & Sheran, K.,(2009). Chapter 10 Analysis of theory: Interpersonal relations. In S. Peterson & T. Bredow (Eds.), Middle range theories: Applications to nursing research (2nd Ed.)(pp. 378-380). Philadelphia, PA: Lippincott Williams & Wilkins. OToole, A. W., & Welt, S. R. (Ed.). (1989). Interpersonal theory in nursing practice: Selected works of Hildegarde E. Peplau. New York: Springer. Tomey, A. M., & Alligood, M. R. (2006). Nursing theorists and their work (6th ed.). St. Louis, MO: Mosby.

Peterson, S. J., (2009). Interpersonal Relations. In S. Peterson & T. Bredow (Eds.), Middle range theories: Applications to nursing research (2nd Ed.)(pp. 202-230). Philadelphia, PA: Lippincott Williams & Wilkins.