hildegard pepalu nursing theory

nursing

1. HILDGARD PEPALU'S THEORY
Introduction

Nurse patient relationship is bound by trust. Trust is developed by a good rapport and interpersonal
relationship. And by developing trust the efficiency of care delivery increases. Though there always
existed an interpersonal relationship between nurse and patient, there was no clear stand on the levels
and roles of these relationhips.
This was the remarkable revelation of Hildegard E Peplau who focused on the individual nurse and
interaction process. Dr Peplau published her book interpersonal relations in nursing in the year 1952, in
which she discusses the phases of interpersonal process, roles for nursing and methods of studying
nursing as a interpersonal process.
Credential of the author
 1909 born in the 1
st
of September in Pennsylvania
 1931 graduated as a registered nurse from Pottstown college of nursing Pennsylvania
 1943 B.A in interpersonal psychology Beunington college
 1948 obtained masters degree from Columbia
 1953 PhD.Ed Columbia University New York
 1969 executive director of ANA
 1970-1972 President of ANA
 1972-1974 second Vice-President
 Director of New Jersy state nurses association
 National nurse consultant to the united states
 Chaired the editorial board of the journal of psycho-social nursing
 1974 retirement
 1987 honored as the first psychosocial nurse

Theoretical sources
Peplau used knowledge borrowed from behavioral sciences and what can be termed the psychological
model.
Harry Stack Sullivan, Percival Symonds, Abraham Maslow and Neal Elger Miller are some of the sources
Peplau used in developing her conceptual frame work, who devised these theories from works of Freud
and Fromm.

2. values
culture
race
values
culture
race
Major concepts
Psychodynamic nursing:
Peplau defines psychodynamic nursing because her model evolves through this type of nursing.
Psychodynamic nursing is being able to understand ones’ own behavior to help others’ identify
felt difficulties, and to apply principles of human relations to the problems that arise at all levels of
experience.
Nurse patient relationship:
Peplau describes four phases of nurse-patient relationship; although separate they overlap and occur
over the time of the relationship.

Admission
During intensive Treatment period

Convalescence and rehabilitation


Orientation
 The individual has a felt need and seeks professional assistance. The nurse helps the patient
recognize and understand his problem and determine his need for help. A mutual decision
needs to be made regarding what type of professional assistance the patient and family needs.
 The nurse needs to be aware of his personal reactions to the patients’. The patient’s culture
religion race, educational background, experience and preconceived ideas and expectations all
influence the nurses reactions to the patient.
 The orientation phase is directly affected by the patients and nurses attitude about giving and
receiving aid from a reciprocal person. Nursing is an interpersonal process, and both the patient
and the nurse have an equally important part in the therapeutic interaction.



Nurse Patient
Discharge

3.  To summarize, the orientation begins with two strangers (patient and nurse) meeting, and by
the end of the phase they collectively strive to identify the problem and are becoming more
comfortable with one another, the helping environment and thus logically progress to the next
phase.


Identification
 The patient meets and responds selectively to people who can meet his or her needs. Through
out the identification phase, both the patient and nurse must clarify each others perception and
expectations during the interpersonal process.
 In identification phase, the perception and expectations of patient and nurse are even more
complex than in the orientation phase. The patient is now responding to the helper selectively.
While working through the identification phase, the patient begins to have feeling of belonging
and a capacity for dealing with problem.
 These changes begin to reduce the feelings of helplessness, creating an optimistic attitude. And
the patient is free to be explored and is ready to exploit the services provided and then moves
on to the next phase.

Exploitation
 Following identification, the patient moves into exploitation phase in which the patient takes
advantage of all the resources available. The degree to which these services are used is based
upon the needs and interests of the patient.
 During this phase the patient makes more demands than they did when they were seriously ill.
They make many minor requests, or may use other attention getting techniques, depending on
their individual needs.
 The nurse may need to deal with the subconscious forces causing the patients action and may
need to use interviewing techniques as tools to explore and understand and adequately deal
with the underlying patients problems. So that the nurse patient rapport established to the
point is not damaged, a therapeutic relationship must be maintained by the nurse that conveys
an attitude acceptance concern and trust.
 The nurse must encourage the patient to recognize and explore feelings, thoughts emotions and
behaviors by providing a nonjudgmental atmosphere and a therapeutic emotional climate
 In exploitation, the nurse use 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/her needs of interest. In this phase, the nurse aids the patient
to use the services to help solve the problem, thus progress to the final stage.

4. Resolution
 The patients needs have already been met by collaborative efforts between the patient and the
nurse. The patient and the nurse now need to terminate the relationship and dissolve the links
between them.
 Here all the phases of the relationship have been successfully accomplished. The needs have
been met and resolution and termination are the end result.



Nursing roles:
Peplau describes six different nursing roles that emerge in various phases of nurse patient relationship.
Role of a stranger
Peplau states that because the nurse and patient are strangers to each other, the patient should be
treated with ordinary courtesy. In other words, the nurse should not prejudge the patient, but accept
him as he is. During the non personal phase, the nurse should treat the patient as emotionally able,
unless evidenced otherwise. This coincides with identification phase.

Role of a resource person
The nurse provides specific answers to questions, especially health information and interprets the
treatment to the patient. These questions often arise with in the context of a larger problem. The nurse
determines what type of response is appropriate for constructive learning either straight forward factual
answers or providing counseling.
Teaching role
The teaching role is combination of all roles and always proceeds what the patient knows and develops
around the areas of interest in wanting and ability to use information. Peplau separates teaching into
two categories:
Instructural: largely giving information and is from explained in educational literature.
Experimental: This is using the experience of the learner as a basis from which learning products
are developed. The products of learning are generalizations and appraisals the patient makes about his
experience
The concept of learning used in the teaching role overlaps with the nurse counselor role, because the
concept of learning is carried out through psycho-therapeutic techniques.
Counselor role

5. Peplau believed that the counseling has the greatest impact in psychiatric nursing. Counseling function
in the nurse patient relationship by the way nurses respond to the patients demands. Peplau says the
purpose of interpersonal technique is to help the patient remember and understand fully what is
happening to him in the present situation, so that the experience can be integrated rather than
dissociated from other experiences in life.
Leadership role
The leadership role involves the democratic process. The nurse helps the patient meet the tasks at hand
through a relationship of cooperation and active participation.
Surrogate mother
The patient casts the nurse in the role of surrogate. The nurse’s attitude and behavior creates feeling
tones in the patient that reactivates feelings generalized in a prior relationship. The nurse function if to
assist the patient in recognizing similarities between herself and the person recalled.
She then helps the patient to see differences in her role and that of the recalled person. In this phase,
both patient and nurse define areas of dependence, independence and finally interdependence.

Basic considerations
 Nursing:
“A significant, therapeutic, interpersonal process and 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”
 Person: Peplau defines person in terms of man. Man is an organism that lives in an unstable
equilibrium
 Environment: Peplau implicitly defines environment in terms of “ existing force outside the
organism and in context of culture” from which mores, customs and beliefs are likely to lead to
health always in clued the interpersonal process.
 Health: Peplau defines health as 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.

6. Roles of the
nurse
Productive
person in
health
↓Anxiety
Bound
patient in
illness
Anxiety
Theoretical assertions
1. Anxiety: Anxiety is an energy source inextricably related to human development from infancy to
death and is required to biological and emotional growth. Anxiety is produced when
communication with others thriven the biological and psychological security of the individual.
The nurse through inter personal instruction with the patient, facilitates the patient’s ability to
transform symptoms bound energy into problem solving energy. The resulting reduction in
anxiety moves the patient towards health.
2. Communications: Clear supportive communication is the key element in the development of a
person. Communication with others helps one to attend and clarify one’s perception of reality
and to achieve a sense of understanding with one another. This involves an awareness of verbal
and non verbal communication and the symbolic meaning behind these communications. It is
one of the nurses responsibilities to assess these factors and to influence the patient
communication in manner that contributes to healthy modes of thought.
3. Interpersonal process: The interpersonal process is based upon a participatory relationship
between the nurse and the patient in which the nurse governs the purpose and the process, and
the patient controls the content; it describes the method by which the nurse facilitates useful
transformations of the patients energy or anxiety.













 A—nurse affects health outcomes through communication with the patient.
 B—resulting reduction in anxiety moves the patient towards health
 C—nurse maintains neutral emotional position and resists being influenced by the patient
 D—nurse has a role in health promotion and reduction of anxiety.
D
B
A
C
Energy
transformation

7. Application of the model

Nursing process
 Peplau states that “during the period of orientation the patient clarifies his first, whole
impression of the problem”, which resembles the assessment phase.
 The problems identified are the nursing diagnoses and the set goals are the planning phase. This
happens during the identification phase of the nursing process.
 These goals gives rise to the plan and direct it into appropriate helping resources with a meaning
for the action done. The patient finally reaps benefit from the services offered to him by using
the knowledge of the nurse and the skills of the nurse. This is the implementation phase and it
coincides with Peplaus’ exploitation phase.
 Although evaluation is not discussed by Peplau, the patient is assessed for the readiness of the
patient to proceed and terminate the relationship resulting in the resolution phase.
Nursing education
 Peplau contributed significantly to moving the nursing profession to graduate education. Her
model has been used extensively in educating both undergraduates as well as graduate nursing
students about a major component of nursing activities—the interpersonal relationship.
 She has provided theoretically based knowledge for nursing specialization in psychiatric settings
where in one-to-one relationship is the primary methodology in nursing.
Nursing practice
 Peplau model provides clear direction to nursing practice through the six roles and four phases
of the interpersonal process. Nursing practioner uses these to clarify nursing focus in health care
as well as to facilitate collaboration with other health care professionals and the patient,
particularly when the focus is mental health.
 Peplau emphasizes on the effective communication between the nurse and the patient. Through
various communication skills the nurse can convey interest and concern to the patient; clarify
and validate assumptions about the patient; help the formulation meaning of identified
problems and generally guide the patient in transforming anxiety based energy to solve
problems.
Nursing research
 Peplau postulated several topics of research today. Her model provides a theoretical frame work
for research about anxiety and mental health as a whole. The theory can be used for qualitative
and quantitative research designs.
 Her interpersonal models’ operational concepts can be used in explaining the effectiveness of
the nursing process in productive patient behavior.

8. Critique
Simplicity
Its simple because
 Interpersonal relations between patient sand nurse is easily understood
 The key concepts are defined
 There is a sequential description of the interpersonal problems.
 Roles of the nurse are clearly indicated.
 Ideas are taken from specific and applied to general.
 Peplau is consistent with established theories and principles.
Generality
 Quality of generality is not met for the reason that the theory can not be applied in all patients.
 Peplau has a narrow perception of environment and does not explain the environmental
influence on the person but focuses more on the psychological tasks with in the person.
 In applying theory to clinical practice, there exist limitations in working with unconscious patient
as the major concept in the theory is interaction. And so the theory cannot be applied in senile,
unconscious and new born.
Empirical precision
Peplau theory can be termed empirically precise because of the following:
 Theory is based on reality.
 The relationship between the theory and empirical data allows for valuation and verification.
 Peplau operationally defines the four phases of the interpersonal process, the nurse with regard
to her roles and the patient with regard to his state of dependence. With further research the
dependence will increase.
Derivable consequences
 The evaluative criteria of the derivable consequences have been met.
 Peplau’s thought and ideas have touched many nurses.
 Her work can be considered pioneering in nursing, filed and her work has provided significant
contribution to nursing knowledge base.
Further development
As nursing broadens its scope, there appears to be a need for further development of Peplau ‘s theory
for use with healthy people, group and community. Further development is also indicated for clients
who are unable to use their communication skills effectively. Increased use of theory is needed for
further refinement of the theory and to build a nursing’s knowledge base.
The constructs of focal attention, dissociation forbidding gestures and personification deserve additional
study.

9. Case study: Ms y has been brought in by the relatives as she tried to commit suicide. She is a very aggressive and
sensitive she is angry and possessive the relatives told that she is from an Indian Christian family. She hates
hospital setting as she reveals that she hates nurses because they cause a lot of pain. She has never spoken to a
nurse openly before fearing their competency nor has she ventilated to anybody as she just takes every body for
granted. She thinks that she is possessed. With the interpersonal model Ms Y enters the orientation phase.


INFLUENCES OF ORIENTATION PHASE
PATIENT:
VALUES: aggressive sensitive,
possesive angry.
CULTURE AND RACE: Indian Christian
PAST EXPERIENCES: the nurses are
pain rpoducing people. the nurse was
impolite with her as like every body
else. never spoke with a nurse about
behavior. never ventilated to
anybody.
BELIEF AND PRECONSIEVED IDEAS:
She thinks she is possed, nurses are
for just giving medication
EXPECTATIONS:wants the sprit to be
expelled. expects drugs to reduce
symptoms.
NURSE
VALUES:calm, patient, empathetic
CULTURE AND RACE:indian christan
PAST EXPERIENCE:well experienced
with similar patients, anxious about
the approch towards the patient.
BELIEF AND PRECONSIEVED IDEAS:
the patient is mentaly unstable, might
harm physicaly, might talk quickly.
might not be interested to talk to
anurse.
EXPECTATIONunderstand the
problem of the patinet ventilation
from the patinet enhancing self
disclosure.

10. Thenursemeetsthepatient;enquiresthe
identifyingdata;assessthementalstatus
andactivityofthepatient;asksthe
patienttoventilateherfeelings;enquires
abouttheinjury;assessofpresenceofany
otherillness,substanceabuse;enquires
theattitudeintheworkplaceandfamily.
Thedatareceivedisrecordedand
analyzed
Theanalyzeddataisprioritizedandisclarified
withtheclient.Hisneedsandexpectationsare
noted.Problemsarestatedandidentifiedinthe
formofnursingdiagnoses;violenceselfdirected
relatedtomanicepisode.Theexpectedoutcomes
arelisted:expectedoutcomes:verbalizethe
abilitytodescribeandrecognizeearlysymptoms
ofescalatinganxiety,demonstratesactionsand
absenceofverbalintensiontoharmself.
Interventionstaken:instructtheclienttoseekout
staffwhenexperiencingfeelingsofagitation,
hostility,orsuspiciousness.Engagetheclientin
grossmotoractivitysuchaswalkingorrunning.
Engageinbrieffrequentcontactsthroughoutthe
day.Maintainaprogressrecord.astheviolence
iscontrolled,informregardingthetermination
anddischarge
Oncethepatienthasachievedadequatecriteria,
stoppedactivitiesandverbalismtoharmself.The
patientisreassuredandinformedaboutthe
terminationtimeandscheduleandfollowup.
Hencethepatient’sfamilyorguardianis
contactedandpreparationfordischargebegins.
Thepatientisinstructedaboutthefollowupand
dischargedandtherelationshipterminates.

















Orientation/ assessment.
Nurses role : stranger.
Identification/ nursing
diagnosis and planning
stage. Resource person,
teacher, leader,
surrogate, counselor.


Exploitation/
implementation :
Resource person,
teacher, leader,
surrogate,
counselor.

Resolution/
evaluation: role: of
the nurse Resource
person, teacher,
leader, surrogate,
counselor.