Hildegard Peplau

Hildegard Peplau
PhD, RN, FAAN

(1909 - 1999

Hildegard Peplau was born in Reading, Pennsylvania on September 1st, 1909. After graduating
from the Pottstown, Pennsylvania Hospital School of Nursing in 1931 she worked as an
operating room supervisor at Pottstown Hospital. She later received a B.A. in interpersonal
psychology from Bennington College, Vermont, in 1943, an M.A. in psychiatric nursing from
Teachers College, Columbia, New York, in 1947, and an Ed.D in curriculum development from
Columbia in 1953.

During World War II, Hildegard Peplau was a member of the Army Nurse Corps and worked in
a neuropsychiatric hospital in London, England. She also did work at Bellevue and Chestnut
Lodge Psychiatric Facilities and was in contact with renowned psychiatrists Freida Fromm-
Riechman and Harry Stack Sullivan. Hildegard Peplau holds numorous awards and positions.

)
Hildegard E. Peplau, PhD, RN, FAAN, known as the "mother of psychiatric nursing," died at the age of 89
on March 17, 1999. The only nurse to serve the ANA as executive director and later as president, she
served two terms on the Board of the International Council of Nurses (ICN). In 1997, she received
nursing's highest honor, the Christiane Reimann Prize, at the ICN Quadrennial Congress. In 1996, the
American Academy of Nursing honored Peplau as a "Living Legend," and, in 1998, the ANA inducted her
into its Hall of Fame. (Extract from the "Peplau leaves legacy of achievement" article below - Nursing
World May 1999)
Hildegard Peplau's fifty-year career in nursing left an indelible stamp on the profession of nursing, and on
the lives of the mentally ill in the United States. She wore many hats - founder of modern psychiatric
nursing, innovative educator, advocate for the mentally ill, proponent of advanced education for nurses,
Executive Director and then President of the American Nurses Association, and prolific author. Her life
was often marked with controversy, which she faced with courage and determination.
 Interpersonal relations model - Peplau's seminal book, Interpersonal Relations in Nursing, was
completed in 1948, but not published for four years because it was then considered too
revolutionary for a nurse to publish a book without a physician co-author. (Information from
Nursingtheory.net)
 Peplau leaves legacy of achievement: - Nursing World May 1999 (A Tribute)
 Hildegard Peplau Nursing Theorist Homepage. - University of Western Ontario School of Nursing.

Peplau's Interpersonal Relations Model

Peplau published her model in 1952, entitled Interpersonal Relations in Nursing. She
formulated this model by expanding on the works of Freud, Fromm, Malsow, Sullivan, and
Miller. The model describes the individual as a system, which comprises of physiological,
psychological and social components.
The model views nursing in two ways. Firstly, nursing is educative. Secondly, nursing is
therapeutic. Combined, these two fuctions allow nurses and clients to develop critical
thinking skills.
The model still holds relevant for nurses today. For the profession of nursing has
incorporated the concepts found within the model. Currently, students in nursing programs
are being taught health promotion and disease prevention, in addition to caring for acute,
chronic and palliative clients.

General Information:
 Based her model on psychodynamic nursing, which applies prinicples of human
experience, that she defines as using an understanding of one's own behavior to help other
identify their difficulties.
Phases of nurse-pateint relationship reflects occurences in personal interactions.
Phases are examined separately but overlap and occur over time.
Phases are divided into orientation, identification, exploitation, and resolution.
Nurse assumes different roles in each phase, such as a teacher, resource, counselor, leader,
technical expert, and surrogate. (Coffin, 1998)

Major Concepts Defined in Peplau's Model

Person ~ Striving towards equilibrium in an unstable environment; a self-system in

physiological, psychological, and social fluidity
Health ~ Forward movement of the personality
Illness ~ Symptoms from axiety-bound energy
Environment ~ Fluid context of the nurse-client relationship
Nursing ~ Therapeutic interpersonal process carried out through the relationship
between the person and the nurse

Four Phases in Peplau's Interpersonal Relations Model

 Orientation Phase:
~ Client had a felt need and seeks professional assistance.
~ Nurse and client meet, become increasingly more comfortable with one another while
defining the problem together.
~ Nurse and client work together to understand their reactions to one another (influening
factors such as culture).

Identification Phase:
~ Client selectively determines who will offer the help required.
~ Client's involvement may differ according to individual (one may be more interdependent
while another is dependent).
~ Development of the nurse-client relationship.
~ Client may begin to feel a sense of belonging and increase in self-confidence.
~ Sense of helplessness and hopelessness replaced by an increasing optimistic attitude.

Exploitation Phase:
~ Nurse assists the client to access and utilize available resources, while maintaining a
theraputic relationship.
~ Client benefits from what is offered to them through the nurse-client relationship.
~ Client becomes more activily involved and may gain control over some aspects of the
situation.

Resolution Phase:
~ Client's needs have been met through collaboration with the nurse.
~ Resolution is achieved when client no longer identifies with the nurse nad dissolves the
relationship.

Peplau’s Phases in Nursing

Orientation

In the initial phase of orientation, to nurse and patient meet as two strangers. The patient and/or the
family have a “felt need”; therefore, professional assistance is sought. However, this need may not be
readily identified or understood by the individuals who are involved. For example, a 16 year old girl may
call the community mental health center because she feels very down. It is in this phase that the nurse
needs to assist the patient and family to realize what is happening to the patient.

It is of the utmost importance that the nurse work collaboratively with a patient and family in analyzing
the situation, so that they together can be recognized, clarify, and defined existing problem. In the
previous example the nurse, in the counselor’s role, helps the teenage girl who feels very down to
realize that this feelings stem from an argument with her mother over last evening’s date. As the nurse
listens, a pattern evolves: the grill argues with her mother and then feels depressed. As these feelings
are discussed, the girl recognizes that the arguing is the precipitating factor leading to the depression.
Thus, the nurse and the patient have defined the problem. Later, the girl and her parents agree to
discuss the issue with the nurse. Therefore, by mutually clarifying and defining the problem in the
orientation phase, the patient can direct the accumulated energy from her anxiety about unmet needs
and begin working with the presenting problem. Nurse-patient rapport is established and continues to
be strengthened while concerns are being identified.

While the patient and family are talking to the nurse, a mutual decision needs to be made regarding
what type of professional assistance the patient and family need. The nurse, as a resource person, may
work with them. As an alternative, the nurse might, with a mutual agreement of all parties involved, the
for the family to another source such as a psychologist, social worker, or psychiatrist. In the orientation
phase, the nurse, patient, and family decide what types of services are needed.

The orientation phase is directly affected by the patient’s and nurse’s attitudes about getting a receiving
aid from a reciprocal person. And is beginning phase, the nurse needs to be aware of her or his personal
reactions to the patient. For example, the nurse may react differently to the 40 year old man with
abdominal pain who enters the emergency room quietly in contrast to the 40 year old man with
abdominal pain who enters the emergency room boisterously after a few alcoholic drinks. The nurse’s,
as well as patient’s, culture, religion, race, educational background, experiences, and preconceived ideas
and expectations all influence the nurse’s reaction to the patient. In addition, the same factors
influence the patient’s reaction to the nurse. For example, the patient may have stereotype the nurse
as being able to perform only technical skills such as giving medications are taking blood pressures, and
therefore may not perceive the nurse as a resource person who can help define the problem. Nursing is
an interpersonal process, and both the patient and the nurse have an equally important part in the
therapeutic interaction.

The nurse, the patient, and the family work together to recognize, clarify, and define the existing
problem. This in turn decrees is the tension and anxiety associated with a felt need and the fear of the
unknown. Decreasing tension and anxiety prevents future problems that might arise as a result of
repression or not resolving significant events. Stressful situations are identified through therapeutic
interaction. It is imperative that the patient recognized and begin to work through feelings connected
with events before an illness.

In summary, in the beginning of the orientation face, the nurse and the patient meet as strangers. At
the end of the orientation phase, they are concurrently striving to identify the problem and are
becoming more comfortable with one another. In addition, the patient becomes more comfortable in
the helping environment. The nurse and the patient are now ready to a logical the progress to the next
phase, identification.

Identification

In the next phase, identification, the patient response selectively to the people who can meet his or her
needs. Each patient responds differently in this phase. For example, the patient might actively seek out
the nurse or stoically wait until the nurse approaches. The responds to the nurse is threefold: (1)
participate with and be interdependent with the nurse, (2) be autonomous and independent from the
nurse, or (3) B passive and dependent on the nurse. An example is that of a 70 year old man who wants
to plan his new 1600 calorie diabetic diet. If the relationship is interdependent, the nurse in patient
collaborate on the meal planning. Should the relationship be independent, the patient plans the diet
himself with minimal of input from the nurse. In a dependent relationship, the nurse does the meal
planning for the patient.

Throughout the identification phase, both the patient and nurse must clarify each other’s perceptions
and expectations. Past experiences of both the patient and the nurse will influence their expectations
during this interpersonal process. As mentioned in the orientation face, the initial attitudes of the
patient and nurse are important in building a working relationship for identifying the problem and
choosing appropriate assistance.

In the identification phase, the perception and expectations of the patient and nurse are even more
complex than in the orientation face. The patient is now responding to the helper selectively. This
requires a more intense therapeutic relationship.

To illustrate, a patient who has had a mastectomy may mention to the nurse her inability to understand
the arm exercise that have been explained to her as being an important regimen following surgery. The
nurse observes that affect that arm is edematous or swollen. While the nurse is exploring possible
reasons for the edema, the patient admits she is not doing her arm exercise. The patient states that a
friend told her that exercising after surgery the delays healing. To facilitate the patient’s understanding
and subsequent assumption of the exercise, the nurse can identify it professional people, such as the
physical therapist, the nurse, and the Physician, where will clarify the patient’s misconceptions.
Generally, it is best if the nurse objectively discuss each professionals roll with a patient so that she will
be aware of the advantages and disadvantages of consulting with each professional. However, in this
case, the patient states that she does not care to discuss the exercise with the nurse or physical
therapist because she perceives her physician to do be the only one who has the appropriate
information. Thus, previous perceptions of nursing and physical therapy can influence the patient’s
current position on the selection of the professional person.

While working through the identification phase, the patient begins to have feelings of belonging and the
capacity for dealing with the problem. These changes begin to decrease feelings of helplessness and
hopelessness, creating and optimistic attitude from which inner strength ensues.

Exploitation

Following identification, the patient moves into the expectation phase, in which the patient takes
advantage of all services available. The degree to which these services are used is based upon the needs
and the interest of the patient. The individual begins to feel as though he or she is an integral part of
the helping environment and begins to take control of the situation the extract in help from the services
offered. In the previous example of the woman with the and edematous arm, the patient, who is now in
the exploitation phase, begins to understand the information regarding the arm exercise. She reads
pamphlets and watches video tapes describing the exercise; she discuss concerns with the nurse; and
she may inquire about joining an exercise group through the physical therapy department.
During this phase some patients may make more demands than they did when they were seriously ill.
They may make many minor request or may use other attention getting techniques, depending on their
individual needs. These actions may often be difficult, if not impossible, for the Health Care Provider to
completely understand. The nurse may need to deal with the subconscious forces causing the patient’s
actions, and may need to use interviewing techniques as tools to explore, understand, and adequately
deal with underlying patient problems. So that the nurse-patient rapport established to this point is not
damaged, a therapeutic relationship must be maintained by the nurse that conveys an attitude of
acceptance, concern, and trust. The nurse must encourage the patient to recognize and explorer
feelings, thoughts, emotions, and behaviors by providing a nonjudgmental atmosphere and a
therapeutic emotional climate.

Some patients may take an active interest in, and become involved in, self care. Such patients become
self sufficient and demonstrate initiative by establishing appropriate behavior for a goal attainment.
Through self determination, patients progressively develop responsibility for self, belief in potentiality,
and adjustment toward self reliance and independents. These patients realistically began to establish
their own goals toward improved health status. They strive to achieve a direction in their lives that
promotes the feeling of well-being. Patients who develop self care become productive, the trust and
depend on their own capabilities, and they also become responsible for their own actions. As a result of
the self determination, they develop sources of inner strength that allow them to face new challenges.

While in impaired health, most patients fluctuate between dependence on others and independent
functioning at an optimal health level. This point is illustrated by using the previous example of the
woman who had an edematous arm after surgery. On some days she wants to actively exercise on
schedule. Other days she states she is too tired to exercise a tall. When the patient does not exercise,
the nurse needs to intervene by reminding the patient of her scheduled exercises.

This type of inconsistent behavior can be compared to the adjustment reaction of the adolescent in a
dependency-independency conflict. The patient may temporarily be in a dependent role while having
the simultaneous need for independence. Various triggers create the onset of the psychological
disequilibrium. The patient vacillates unpredictably between the two behaviors and appears confused
and anxious, protesting dependence while fearing independence. In caring for patients who fluctuate
between dependence and independence, the nurse must approach the specific behavior that is
presented rather than trying to handle the composite problem of inconsistency. The nurse should
provide an atmosphere of acceptance and support, one in which the person can become more self
aware and begin to use his or her strengths to minimize weaknesses.

In exploitation, the nurse uses communication tools such as clarifying, listening, accepting, teaching, and
interpreting to offer services to the patient. The patient then takes advantage of the services offered
based on his or her needs and interest. Throughout this phase, the patient works collaboratively with a
nurse to meet challenges and work toward maximum health. Thus, in the exploitation phase, the nurse
aids the patient in using services to help solve the problem. Progress is made toward the final step – the
resolution phase.
Resolution

The last phase in Peplau’s interpersonal process is resolution. The patient’s needs have already been
met by the collaborative efforts between the patient and nurse. The patient and nurse now need to
terminate their therapeutic relationship and dissolve the link between them.

Sometimes the nurse and patient have difficulty dissolving these links. Dependency needs in
therapeutic relationship often continues psychologically after the physiological needs have been met.
The patient may feel that it is just not time yet to end the relationship. For example, a new mother has
a desire to learn infant care. During the first home visit, the community health nurse and the new
mother set their goals of having the mother properly demonstrate various facets of infant care by the
fourth visit. After instruction and demonstration by the community health nurse on the first to visit, the
mother demonstrates correctly all facets of infant care by the fourth visit. Their goal is met. The
relationship is ended because the mother’s problem was sold. However, one week after the resolution,
the mother telephones the community health nurse five times with minor questions on infant care. The
mother has not dissolve the dependency link with the community health nurse.

The final resolution may also be difficult for the nurse. In the previous example, the mother maybe
willing to terminate the relationship; however, the community health nurse may continue to visit the
home to watch the baby develop. The nurse may be unable to free her or himself from the bond in their
relationship. In resolution, as in the other phases, anxiety and tension increase in the patient and the
nurse if there is unsuccessful completion of the phase.

During successful resolution, the patient drifts away from identifying with the helping person, the nurse.
The patient then becomes independent from the nurse as the nurse becomes independent from the
patient. As a result of this process, both the patient and nurse become stronger maturing individuals.
The patient’s needs are met, and movement can be made toward new goals. Resolution occurs only
with the successful completion of the previous phases.

Peplau’s Theory and Nursing’s Metaparadigm

Nursing’s metaparadigm includes the four concepts of human beings, health, society or environment,
and nursing. Peplau defines man as an organism that strives in its own way to reduce tension generated
by needs. Health is defined as a word symbol that implies forward movement of personality and other
ongoing human process in the direction of creative, constructive, productive, personal, and community
living.

Although Peplau was not directly address society or environment, she does encourage the nurse to
consider the patient’s culture and mores when the patient adjust the hospital routine. Currently, when
a nurse, considers the patient’s environment, the nurse examines many more factors, such as cultural
background and home and work environment, rather than considering only a patient’s adjustment to
the hospital. Peplau has a narrow perception of the environment, which is a major limitation of her
theory. The theory does not examine the broad range of environmental influences on the person but
focuses more on the psychological task within the person, a view that was timely in 1949 when the book
was written. In examining their story colt trends with psychiatric nursing, the view is categorized as
being within the person, as later contrasted the view of within the relationship and within the social
system, both of which consider a broader range of environmental influences on the person.

Peplau considers nursing to be a significant, therapeutic, interpersonal process. She defines it as a

human relationship between an individual who is sick, or in need of Health Services, and the nurse
especially educated to recognize and to respond to the needs for help. The nurse to assist the patient in
this interpersonal process. Major concepts within these process are nurse, patient, therapeutic
relationship, goals, human needs, anxiety, tension, and frustration.

Relationship between Peplau’s Phases and the Nursing Process

Peplau’s continuum of the four phases of orientation, identification, exploitation, and resolution can be
compared to the nursing process. The nursing process is defined as a deliberate, intellectual activity
whereby the practice of nursing is approached in an orderly, systematic manner.

There are similarities between the nursing process and Peplau’s interpersonal phases. Both Peplau’s
phases and the nursing process are sequential and focus on therapeutic interactions. Both is stressed
that the nurse and the patient should use problem solving techniques collaboratively, with the end
purpose of meeting the patient’s needs. Both emphasize assisting the patient to define general
complaints more specifically so that is specific patient needs can be identified. Both use observation,
communication, and recording as a basic tools for nursing practice.

The nursing process and Peplau’s interpersonal of phases are also different. When considering
differences, it must be take into account the Peplau’s book Interpersonal Relations in Nursing was first
published in 1952. Professional nursing today has more defined goals and more is specialty areas of
practice. Nursing as moved away from the role of physician’s helper and toward consumer advocacy.
The American Nurses’ Association, in 1973 Standards of Nursing Practice, states: “Nursing diagnosis are
derived from health status data”. Peplau, however, wrote that physician’s primary function was
“recognizing the full import of the nuclear problem and the kind of professional assistance that is
needed”, which results, for the physician, in “the task of evaluating and diagnosing the emergent
problem”. Peplau’s view opposes the current viewpoint of independent functioning by nurses.

Nursing functions, according to Peplau, include clarification on of the information on the Physician gives
the patient as well as collection of data about the patient that may point out other problem areas. In
contrast, given today’s expanded roles in nursing, independent nurse practitioners may or may not refer
the patient to the physician, depending on the patient’s needs. Through expanded roles, nursing is
becoming more accountable and responsible, giving professional nursing greater legal independence
than previously. The nursing process provides a mode for evaluating the quality of nursing care. Such a
violation is the core of legal accountability.

Peplau identified needs, frustration, conflict, and anxiety as important concepts in nursing situations.
Furthermore, she states that this concepts must be addressed for patients and nurse growth to occur.
Today’s nurse evaluates many concepts such as intrafamily dynamics, socioeconomic forces like financial
resources, personal space considerations, and community social service resources for each patient.
These concepts provide a broader perspective for viewing the patient in his or her environment than do
Peplau’s concepts of needs, frustration, conflict, and anxiety. Today, even if an alley, group, are a
community may be collectively defined as the patient in the nursing process.

Peplau’s orientation phase parallels the beginning of the assessment phase in that the nurse and patient
come together as strangers. This meeting is initiated the the patient, who expresses a need, although
the need is not always understood. Co jointly, the nurse and patient begin to work through recognizing,
clarifying, and gathering facts important that is made. This step is presently referred to as data
collection in the assessment phase of the nursing process.

In the nursing process the patients need is not necessarily a felt need. For example, the nurse may be
currently working in the community by assessing people who perceive themselves to be healthy. A
school nurse screen hearing for schoolchildren. If a hearing deficit is found, a referral is initiated by the
nurse. Children do not usually seek out the nurse for this deficit. In this situation, the need must be
identified for the child and for the parents to persuade them to seek assistance for the hearing deficit.
For example, the nurse sends home and note about the hearing deficit so that the parents and child
become aware of the problem. The nurse may also have to follow up the note by telephone call or
home visit. The nurse is actively helping the child and family to identify a need.

Orientation and assessment are not synonymous and must not be confused. Collecting data is
continuous throughout Peplau’s phases. In the nursing process, the initial collection of data is the
nursing assessment, and further collection of data becomes an integral part of the reassessment.

In the nursing process, the nursing diagnosis involves once the health problems our deficits are
identified. The nursing diagnosis is a summary statement of the data collected and analyzed. Peplau
writes that during the period of orientation the patient clarifies his first, whole impression of his
problem; whereas in the nursing process, the nurse’s judgment forms the diagnoses from the data
collected.

Mutually set goals evolved from the nursing diagnosis. These goals give direction to the plan and
indicate the appropriate helping resources. When the nurse and patient discuss helping resources, the
patient can selectively identify with a resource person. According to Peplau, the patient is then viewed
as being in the identification phase.

When collaborating on mutual goals, the nurse and patient may have conflicts based on preconceptions
and expectations of each person, as described earlier in Peplau’s identification phase. The nurse and
patient must resolve any discrepancies before mutual goals can be set. Goal setting should be an
interdependent activity between the patient and nurse.

The next phase in the nursing process is the planning phase. In the planning phase, the nurse must
specially formulate how the patient is going to achieve the mutually set goals. The nurse to actively
seeks patient input so that the patient feels like an integral part of the plan. When the patient feels
involved in the plan, compliance is more likely to occur. In the planning phase, the nurse considers the
patient’s own skills for handling his or her problems. Peplau stresses that the nurse wants to develop a
therapeutic relationship so that the patient’s anxiety will be constructively channeled into seeking
resources, so that feelings of hopelessness will decrease. Planning can still be considered to be within
Peplau’s identification phase.

The patient also begins to have a feeling of belonging within the therapeutic relationship because both
patient and nurse must have mutual respect, communication, and interest. This feeling of belonging
must be analyzed and should assist the patient to develop a healthier personality rather than imitative
behavior. Peplau states, “Some patients identify tool readily with nurses, expecting that all of their
wants we’ll be taken care of and nothing will be expected of them”. In Peplau’s identification phase,
patient selectively responds to people who can meet his or her personal needs. Therefore, the
identification phase is initiated by the patient. In the implementation phase, as in Peplau’s exploitation,
the patient is finally reaping benefits from the therapeutic relationship by drawing on the nurse’s
knowledge and expertise. In both the implementation and exploitation phases, the individualized plans
have already been formed, based on the patient’s interest and needs. Similarly, in both phases the
plans are geared toward completion of desired goals. However, there’s a difference between
exploitation and implementation. In explained a shun, the patient is the one who actively seeks varying
types of services to obtain the maximum benefits available, whereas in implementation there is a
prescribed plan or procedure, holistic in nature, use to achieve predetermined goals or objectives based
on nursing assessment. Thus, explained a shun is oriented to the patient. In contrast, implementation
can be accomplished with a patient are by other persons, including health professionals in the patient’s
family.

In Peplau’s resolution phase, all other phases have been successfully accomplished, the needs have been
met, and resolution and termination are the end result. Although Peplau does not discuss evaluation, it
is referred to as an inherent factor in determining the readiness of the patient to proceed through the
resolution phase.

In the nursing process, evaluation is a separate step, and mutually established expected end behaviors
are used as evaluation tools. Time limits on attaining the goals are set for evaluation purposes,
although, these limits may change with reassessment. In evaluation, if the situation is clear-cut, the
problem moves toward termination. If the problem is unresolved, goals and objectives are not met; if
nursing care is ineffective, reassessment must be done. New goals, planning, implementation, and
evaluation are then established.