Peplau's Theoretical Model In Nursing Care

Nursing Care and Peplau's Theoretical Mode

Peplau's Theoretical Model,Peplau's Model and Nursing Care,Derivation or Origin of Model,Structure of interpersonal Relationship and Its Phases,Characteristics of Model,Peplau's Model and Nursing Theory,Significance of Model

Peplau's Theoretical Model

    Hildegard Peplau (1909-1999) formulated her theoretical ideas about the therapeutic process of nursing in the 1940s and published them in the now classic 1952 book, Interpersonal Relations in Nursing, after a lengthy dispute with publishers about the ability of a nurse to author a book. 

    At a time when nurses were “doers” for patients and “followers” of physicians' orders, Peplau's theoretical work and teachings helped catapult nursing from an occupation to a profession. 

    Peplau's ideas provided a foundation for nurses to understand health from a nursing theoretical perspective and to establish interpersonal relationships with patients as the significant context in which nurses facilitate patients' well-being.

Peplau's Model and Nursing Care

    Through Peplau's therapeutic relationship, the patient develops inner resources for healthy behaviors by actively participating with the nurse in a developmental process of change. 

    Peplau's interpersonal relationship is also a process through which nursing knowledge is developed and validated (Reed, 1996b). 

    Peplau (1992) purposefully linked her theory to practice and research, as evidenced in her basic assumption that “what goes on between people can be noticed, studied, explained, understood, and, if detrimental, changed” (p. 14).

Derivation or Origin of Model

    Peplau's theoretical model derives from the perspective of a critical philosophy that integrates both the science and practice of nursing in theory development. Peplau's theoretical model was based upon her study, observation, and analyzes of nurses and patients and was influenced by Harry Stack Sullivan and others' psychodynamic perspectives. 

    Peplau's (1952) classic descriptions of nursing express the nature and goals of the interpersonal process: 

    “Nursing is a human relationship between an individual who is sick or in need of health services, and a nurse especially educated to recognize and to respond to the need for help” (pp. 5-6), Nursing is an “educational instrument, a maturing force, that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal, and community living” (p. 16). 

    Peplau (1988) further described nursing as an “enabling, empowering, or transforming art” (p. 9). 

    Health, according to Peplau (1952), is a “word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal and community living” (p. 12). Illness forces a “stock taking by the sick person, which nurses can use to promote learning, growth and improved competencies for living” (Peplau, 1992, p. 13). 

    Health and illness are closely linked to successful management of anxiety, which ranges from pure euphoria to pure anxiety. An optimal level lies between these anxiety extremes, as determined by nurse and patient. 

    Through the therapeutic relationship, the nurse uses a complex set of strategies to assist the patient in using energy provided by anxiety to identify and grow from a problematic situation (O'Toole & Welt, 1989; Reed, 2005). The nurse patient relationship is fundamental to providing nursing care and derives from the human need for connectedness that is still essential in the 21st century (Peplau , 1997). 

    Through this interpersonal relationship, nurses assess and assist people to: 

(a) achieve healthy levels of intrapersonal anxiety.

(b) facilitate healthy pattern integrations interpersonally, with the overall goal of fostering well-being, health, and development. 

    This relationship also provides the context for the nurse to develop, apply, and evaluate theory-based knowledge for nursing care. Nurse interpersonal competencies, investigative skill, and theoretical knowledge as well as patient characteristics and needs are all important dimensions in the process and outcomes of the relationship (Peplau).

Structure of interpersonal Relationship and Its Phases

    The structure of the interpersonal relationship was originally described in terms of four phases: orientation, identification, exploitation, and resolution (Peplau, 1952). 

    Forchuk (1991), with the support of Peplau, clarified the structure as consisting of three main phases: orientation, working (which incorporated identification and exploitation), and termination. In a 1997 publication, Peplau endorsed this three phase view and explained that the phases were overlapping, each having unique characteristics. 

    Throughout these phases the nurse functions cooperatively with the patient in the nursing roles of stranger, resource person, counselor, leader, surrogate, and teacher. The nurse's range of focus includes the patient in relationship with the family, other health care providers, and community (Peplau, 1952, 1997).

    The orientation phase marks a first step in the personal growth of the patient and is initiated when the patient has a “felt need” and seeks professional assistance (Peplau, 1952, p. 18). 

    The nurse focuses on “knowing the patient as a person” and uncovering erroneous preconceptions, as well as gathering information about the patient's mental health problem (Peplau, 1997). The nurse and patient collaborate on a plan, with consideration of the patient's educational needs. 

    Throughout the process, the nurse recognizes that the power to accomplish the tasks at hand resides within the patient and is facilitated through the workings of therapeutic relationship.

    The focus of the working phase is on: 

(a) the patient's efforts to acquire and employ knowledge about the illness, available resources, and personal strengths

(b) the nurse's enactment of the roles of resource person, counselor, surrogate , and teacher in facilitating the patient's development towards well-being (Peplau, 1952, 1997). 

    The relationship is flexible enough for the patient to function dependently, independently, or interdependently with the nurse, based on the patient's developmental capacity, level of anxiety, self-awareness, and needs.

    Termination is the final phase in the process of the therapeutic interpersonal relationship. Patients move beyond the initial identification with the nurse and engage their own strengths to foster health outside the therapeutic relationship (Peplau, 1952, 1988). 

    In addition to addressing closure issues, the nurse and patient engage in planning for discharge and potential needs for transitional care (Peplau, 1997).

Characteristics of Model 

    Peplau's theoretical model can be categorized as a middle-range theory. It is narrower in scope than a conceptual model or grand theory and addresses a clearly defined number of measurable concepts (eg, therapeutic relationship, anxiety). 

    The theory has a specific focus on the characteristics and process of the therapeutic relationship as a nursing method to help manage anxiety and foster healthy development. As such, the model is directly applicable to research and practice.

Peplau's Model and Nursing Theory

    Peplau was explicit in promoting research-based theory, Research based on Peplau's theoretical model has addressed topics related to both nurse behaviors and patient health conditions. Nurse-focused topics include:

(a) the practices of psychiatric mental health nurses,

(b) family systems nursing, and

(c) the nature of the nurse-patient relationship in reference to roles and role changes over the trajectory of a mental illness, boundary issues in pediatric nursing, and concepts such as therapeutic intimacy. 

    Patient focused research has addressed health conditions including depression, psychosis, sexual abuse, Alzheimer's disease, and multiple sclerosis. 

    A particularly notable Peplau-based researcher is Forchuk (eg, Forchuk , 1994; Forchuk et al., 1998; Forchuck , Jewell, Tweedell , &Steinnagel , 2003) who, along with colleagues, has conducted a program of research into applications of the interpersonal relationship process in psychiatric mental-health nursing care.

Significance of Model

    Peplau's model is historically significant for practice in that it propelled psychiatric nursing from custodial-based care to interpersonal relationship theory-based care. Peplau is considered the founder of professional psychiatric mental-health nursing and was the first to initiate an area of advanced practice nursing. 

    Her theoretical ideas continue to be significant in contemporary nursing for their relevance in not only psychiatric mental-health nursing practice but practice anywhere a nurse-patient relationship exists. 

    Applications of the model are found in individual psychotherapy, reminiscence therapy, terminal illness care, and group and family therapy, Practices based upon Peplau's theory range from hospital to community home-based.

    Peplau's theory has provided an enduring educational foundation for teaching the nurse-patient relationship as a pivotal nursing process in all contexts of practice. 

    A common philosophy underlying all nursing curricula is a belief in the value of a therapeutic nurse patient relationship that promotes active participation of patients in their health care. 

    Peplau's theoretical work has also promoted a “paradigm of professionalization” and empowerment for educating nurses for the 21st century (Sills, 1998).

    Peplau's theoretical model continues to influence nursing research, practice, and education (O'Toole & Welt, 1989), although her original contributions have become knowledge in the public domain and are not always explicitly acknowledged. 

    Internationally, nurses are recognizing Peplau's legacy and the enduring relevance of his theory for nursing in the new millennium (eg, Barker[2000]). 

    The clinical significance of the therapeutic relationship is likely to increase as health problems shift to those related to stress related conditions, chronic illness, aging processes, and end of life, where medical surgical approaches alone have little success in promoting well being. 

    Peplau's interpersonal relationship theory is expected to withstand the current health care crisis and provide a cost-effective and satisfying resource for patient well being across a variety of nursing contexts.

    The reawakening of nursing by Peplau's ideas in the 1950s continues today through exploration, study, and use of the science based practice of interpersonal relations theory. 

    Beeber's (1998) research and theory development have extended Peplau's model in important ways, using aesthetic knowing to elaborate on the concept of interpersonal pattern and formalizing Peplau's (1997) idea of transitions in a practice theory of depression. 

    Metatheoretical writings of Peden (1998) and Reed (1996a), inspired by Peplau's practice based strategy of theory development, portend an emerging philosophy of nursing science that sanctions clinicians as well as traditional researchers as knowledge builders. 

    Through the creative scholarship of nurses, Peplau's theoretical model can continue to evolve and inspire development of nurse patient processes that meet contemporary health needs of society.