nursing

1. HILDGARD PEPALU'S THEORY
Introduction
Nurse patientrelationshipisboundbytrust.Trust isdevelopedbyagood rapportand interpersonal
relationship.Andbydevelopingtrustthe efficiencyof care deliveryincreases.Thoughthere always
existedaninterpersonalrelationshipbetweennurse andpatient,there wasnoclearstandon the levels
and rolesof these relationhips.
Thiswas the remarkable revelationof HildegardEPeplauwhofocusedonthe individualnurse and
interactionprocess.DrPeplaupublishedherbookinterpersonalrelationsinnursinginthe year1952, in
whichshe discussesthe phasesof interpersonal process,rolesfornursingandmethodsof studying
nursingas a interpersonalprocess.
Credential of the author
 1909 born inthe 1st
of SeptemberinPennsylvania
 1931 graduatedas a registerednurse fromPottstowncollege of nursingPennsylvania
 1943 B.A in interpersonalpsychologyBeuningtoncollege
 1948 obtainedmastersdegree fromColumbia
 1953 PhD.EdColumbiaUniversityNew York
 1969 executivedirectorof ANA
 1970-1972 Presidentof ANA
 1972-1974 secondVice-President
 Directorof NewJersystate nursesassociation
 National nurse consultanttothe unitedstates
 Chairedthe editorial boardof the journal of psycho-socialnursing
 1974 retirement
 1987 honoredasthe firstpsychosocial nurse
Theoretical sources
Peplauusedknowledgeborrowedfrombehavioral sciencesandwhatcan be termedthe psychological
model.
Harry Stack Sullivan,Percival Symonds,AbrahamMaslow andNeal ElgerMillerare some of the sources
Peplauusedindevelopingherconceptual frame work,whodevisedthesetheoriesfromworksof Freud
and Fromm.

2. values
culture
values
culture
Major concepts
Psychodynamic nursing:
Peplaudefinespsychodynamicnursingbecausehermodel evolvesthroughthistype of nursing.
Psychodynamicnursingisbeingableto understandones’own behaviorto help others’ identify
felt difficulties,andtoapplyprinciplesofhumanrelationsto the problemsthat arise at all levels of
experience.
Nurse patient relationship:
Peplaudescribesfourphasesof nurse-patientrelationship;althoughseparatetheyoverlapandoccur
overthe time of the relationship.
Admission
Duringintensive Treatmentperiod
Convalescenceandrehabilitation
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
needstobe made regardingwhattype of professional assistance the patientandfamilyneeds.
 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
influencethe nursesreactionstothe 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 equallyimportantpartinthe therapeuticinteraction.
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
expectationsduringthe 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 fordealingwithproblem.
 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 nextphase.
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
uponthe needsandinterestsof 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
theirindividual 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 concernandtrust.
 The nurse must encourage the patient to recognize and explore feelings, thoughts emotions and
behaviorsbyprovidinganonjudgmental atmosphere andatherapeuticemotional 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 servicestohelpsolve the problem,thusprogresstothe 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
betweenthem.
 Here all the phases of the relationship have been successfully accomplished. The needs have
beenmetandresolutionandterminationare the endresult.
Nursing roles:
Peplaudescribessix differentnursingrolesthatemerge invariousphasesof nurse patientrelationship.
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,
unlessevidencedotherwise.Thiscoincideswithidentificationphase.
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
answersor providingcounseling.
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
twocategories:
Instructural:largelygivinginformationandisfromexplainedineducationalliterature.
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
conceptof learningiscarriedoutthroughpsycho-therapeutictechniques.
Counselorrole

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
dissociatedfromotherexperiencesinlife.
Leadershiprole
The leadershiprole involvesthe democraticprocess.The nurse helpsthe patientmeetthe tasksathand
througha relationship of cooperationandactive 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
assistthe patientinrecognizingsimilaritiesbetweenherself andthe personrecalled.
She then helps the patient to see differences in her role and that of the recalled person. In this phase,
bothpatientandnurse define areasof dependence,independence andfinallyinterdependence.
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 andtorespondto the needforhelp”
 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
healthalwaysincluedthe 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 andcommunityliving.

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
anxietymovesthe patienttowardshealth.
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
communicationinmannerthatcontributestohealthymodesof thought.
3. Interpersonal process: The interpersonal process is based upon a participatory relationship
between the nurse and the patientin 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
transformationsof the patientsenergyoranxiety.
 A—nurse affectshealthoutcomesthroughcommunicationwiththe patient.
 B—resultingreductioninanxietymovesthe patienttowardshealth
 C—nurse maintainsneutralemotional positionandresistsbeinginfluencedbythe patient
 D—nurse has a role in healthpromotionandreductionof 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
impressionof the problem”,whichresemblesthe assessmentphase.
 The problems identified are the nursing diagnoses and the set goals are the planning phase. This
happensduringthe identificationphase of the nursingprocess.
 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
coincideswith Peplaus’exploitationphase.
 Although evaluation is not discussed by Peplau, the patient is assessed for the readiness of the
patienttoproceedandterminate the relationshipresultinginthe resolutionphase.
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
studentsabouta majorcomponentof nursingactivities—the interpersonalrelationship.
 She has provided theoretically based knowledge for nursing specialization in psychiatric settings
where inone-to-one relationshipisthe primarymethodologyinnursing.
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,
particularlywhenthe focusismental health.
 Peplauemphasizes 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 researchdesigns.
 Her interpersonal models’ operational concepts can be used in explaining the effectiveness of
the nursingprocessinproductive patientbehavior.

8. Critique
Simplicity
Its simple because
 Interpersonal relationsbetweenpatientsandnurse iseasilyunderstood
 The keyconceptsare defined
 There isa sequential descriptionof the interpersonal problems.
 Rolesof the nurse are clearlyindicated.
 Ideasare takenfromspecificandappliedtogeneral.
 Peplauisconsistentwithestablishedtheoriesandprinciples.
Generality
 Qualityof generalityisnotmetforthe reasonthat the theorycan not be appliedinall patients.
 Peplau has a narrow perception of environment and does not explain the environmental
influenceonthe personbutfocusesmore onthe psychological taskswithinthe 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,
unconsciousandnewborn.
Empirical precision
Peplautheorycanbe termedempiricallyprecisebecause of the following:
 Theoryisbasedon reality.
 The relationshipbetween the theoryandempiricaldataallowsforvaluationandverification.
 Peplauoperationallydefinesthe fourphasesof the interpersonal process,the nurse withregard
to herrolesand the patientwithregardto hisstate of dependence.Withfurtherresearchthe
dependence will increase.
Derivable consequences
 The evaluative criteriaof the derivableconsequenceshave beenmet.
 Peplau’sthoughtandideashave touchedmanynurses.
 Her workcan be consideredpioneeringinnursing,filedandherworkhas providedsignificant
contributiontonursingknowledge 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
furtherrefinementof the theoryandtobuilda nursing’sknowledgebase.
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:IndianChristian
PASTEXPERIENCES:the nursesare
painrpoducingpeople.the nurse was
impolite withheraslike everybody
else.neverspoke withanurse about
behavior.neverventilatedto
anybody.
BELIEF AND PRECONSIEVEDIDEAS:
She thinksshe ispossed,nursesare
for justgivingmedication
EXPECTATIONS:wantsthe sprittobe
expelled.expectsdrugstoreduce
symptoms.
NURSE
VALUES:calm,patient,empathetic
CULTURE AND RACE:indianchristan
PASTEXPERIENCE:well experienced
withsimilarpatients,anxiousabout
the approch towardsthe patient.
BELIEF AND PRECONSIEVEDIDEAS:
the patientismentalyunstable,might
harm physicaly,mighttalkquickly.
mightnot be interestedtotalkto
anurse.
EXPECTATIONunderstandthe
problemof the patinetventilation
fromthe patinetenhancingself
disclosure.

10. The nurse meets the patient; enquires the
identifying data; assess the mental status
and activity of the patient; asks the
patient to ventilate her feelings; enquires
about the injury; assess of presence of any
other illness, substance abuse; enquires
the attitude in the work place and family.
The data received is recorded and
analyzed
The analyzed data is prioritized and is clarified
with the client. His needs and expectations are
noted. Problems are stated and identified in the
form of nursing diagnoses; violence self directed
related to manic episode. The expected outcomes
are listed: expected outcomes: verbalize the
ability to describe and recognize early symptoms
of escalating anxiety, demonstrates actions and
absence of verbal intension to harm self.
Interventions taken: instruct the client to seek out
staff when experiencing feelings of agitation,
hostility, or suspiciousness. Engage the client in
gross motor activity such as walking or running.
Engage in brief frequent contacts through out the
day. Maintain a progress record . as the violence
is controlled, inform regarding the termination
and discharge
Once the patient has achieved adequate criteria ,
stopped activities and verbalism to harm self. The
patient is reassured and informed about the
termination time and schedule and follow up.
Hence the patient’s family or guardian is
contacted and preparation for discharge begins.
The patient is instructed about the follow up and
discharged and the relationship terminates.
Orientation/ assessment.
Nursesrole :stranger.
Identification/nursing
diagnosisandplanning
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.