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Interpersonal relations in nursing
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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; O’Toole, 1989)
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 women’s roles
She wanted more out of life and knew nursing was one of few career choices for women in her day
(Callaway, 2002)
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 man’s world in both business and education
(Callaway, 2002)
The autonomous, nursing- controlled 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 nurse’s employers, physicians and educational providers
Nursing practice was controlled by medicine
(Chinn, 2008)
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
(O’Toole, 1989)
Hilda witnessed injustices in life, being determined to push past them for social justice
First exposure to Interpersonal Theory at Bennington Attended lectures by
Harold Stack Sullivan on Interpersonal Relations
Studied with Frieda Fromm-Reichman and Eric Fromm
She had vision to bring the Sullivanian theory to interactions with her patients – they needed: Humane treatment Dignity & respect Healing discussion
…in a time when there was none to
be found…
(Forchuk, 1993)
Teachers’ College: Director of Advanced Program in Psychiatric Nursing She created nursing
curriculum Included study of nurse-
patient interactions through “Process Recordings”
Peplau analyzed interactions of students with patients, taking her own experience into account
Reviewed them for recurring themes Using clinical data for theory
development – empirical evidence
(Forchuk, 1993; Gastmans, 1998)
Her book, or conceptual framework, was completed by 1948, entitled Interpersonal Relations in Nursing
(Forchuk, 1993)
Publishing her book took four additional years because it was groundbreaking for a nurse to contribute this scholarly work without a coauthoring physician
Peplau’s 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”
Peplau’s focus was the quality of nurse-patient interactions and nursing education
(O’Toole, 1989; Forchuk, 1993, p. 3)
BASIC ELEMENTS: the patient the nurse the interaction between them
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 health-promoting
HEALTH – Forward movement of personality and other ongoing human processes in the direction of creative, constructive, personal, and community living
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…”
NURSING ROLES - to assist client starting as stranger, then technical expert, resource person, surrogate, counselor, teacher and others
(Forchuk, 1993; Peterson, 2009)
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)
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
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
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
11) Each person will behave, during any crisis, in a way that has worked in relation to crisis in the past
(Forchuk, 1993)
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
(Belcher, 2002; Peterson, 2009)
EXPLOITATION PHASE Client’s trust of nurse reached full
potential Client making full use of nursing
services Solving immediate problems Identifying and orienting self to
[discharge] goals
RESOLUTION PHASE 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)
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
Within personalities, there are needs, frustrations, conflicts, and anxieties that are influential
Every human has basic needs and goals exerting tensions within the relationship
Nurse’s 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)
Psychological tasks of humans learning to live with others require attention
Developmental processes directly influence each person’s expressions of feelings, attitudes and beliefs
They bring about situations in which the nurse can assist the patient Counting on others Delaying satisfaction Identifying oneself Participating with others
(Peterson, 2009)
A wide range of concepts are identified by Peplau having an impact on the practice of the nurse and the evolving nurse-patient 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)
Nursing Process Methods
Observation “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
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)
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 shouldn’t speak the same way to patient as to family or friends. It should lead to therapeutic effects – promoting long-term well-being
Nurse’s 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
(O’Toole, 1989)
WITH THEORYWITHOUT THEORY New ostomy patient Nurse recognizes her own
anxieties of ostomy, as well as patient’s 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
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”
ADEQUACY: Contributes to the nursing
process Clearly consistent with
nursing’s values and mission
Limited in groups of people Fairly narrow set of
cultural assumptions (Meiers & Sheran, 2009)
I disagree that it’s 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
CLARITY: Clear and logical fashion Definitions are readily
understandable Though concepts are at a
high level of abstraction, they can be learned with practice
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 patient’s movement through the steps of the nursing process (Meiers & Sheran, 2009)
LEVEL OF DEVELOPMENT: Remains at the
descriptive level Focusing on phases of
relationships and interactional/inter- and intrapersonal phenomena
Not changed significantly since Peplau’s original writings were published over 50 years ago
DISCRIMINATION: 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
COMPLEXITY: 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 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
REALITY CONVERGENCE: 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 patient’s 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 Peplau’s theory”
I disagree - This theory is valuable as part of human development, maturity and individual healing in many contexts
PRAGMATIC UTILITY: Nurses’ critical thinking,
therapeutic-intervention/communication - beyond task oriented nursing
Requires self-scrutiny of motives and expectations by the nurse (maturity)(Belcher, 2002)
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) Utility based on individual use by
nurse to invest energy and vision into relationship understanding & healing
SCOPE: 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) 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 nurse-patient relationship and communication are discussed
SIGNIFICANCE/CONTAGIOUS/CONTEMPORARY USE:
Criterion for significance has been met for the nursing discipline
(Meiers & Sheran, 2009)
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
Translated into multiple languages
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)
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)
Most within National Healthcare System of Canada in recent years
Most research has been qualitative – not quantitative
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)
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
(Stockmann, 2005; Forchuk & Reynolds, 1998)
ROUTINE INTEGRATION into daily practice within any area of clinical nursing, with multi-faceted effects
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 self-gratifying, and more in tune to the needs of the patient (and support systems), as well as filtering into peer and professional relationships
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
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 Increased comprehension
of teaching in patients Patient and staff
increased sense of responsibility for selves
Empowerment of both patients & staff
Improved health outcomes
Success stories and patient comments could be shared in staff meetings and newsletters to reinforce the new staff behaviors
Role modeling by nursing & management would give the atmosphere of healing and caring – less stressful environment
Quantitative & qualitative research demonstrating positive health-care outcomes needs to take place (Jones, 1996)
Focus on quantitative research would verify the theory’s contemporary value, even with today’s 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
UPCOMINGNURSING RESEARCH
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, 2002)
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)
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 (O’Toole, 1989)
Fellow: American Academy of Nursing
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, nursing’s highest honor
(Callaway, 2002)
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)
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