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)

Barker, P. (1998). The future of the theory of interpersonal relations? A personal refection of Peplau’s theory. Journal of Psychiatric and Mental Health Nursing, 5, 213-220.

Beeber, L. S., & Bourbonniere, M. (1998). The concept of interpersonal growth in Peplau’s theory of nursing. Journal of Psychiatric and Mental Health Nursing, 5, 187-192.

Belcher, J. R., & Brittain-Fish, L. J., (2002). Interpersonal Relations in Nursing: Hildegard E. Peplau. In J. George (Ed.), Nursing theories: The base for professional nursing practice (5th ed.)(pp. 61-82). Upper Saddle River, NJ: Prentice Hall.

Callaway, B. J. (2002). Hildegard Peplau: Psychiatric nurse of the century. New York: Springer.

Chinn, P. L. (2008). Integrated theory and knowledge development in nursing (7th ed.). St. Louis, MO: Mosby.

Forchuk, C. (1993). Hildegarde E. Peplau: Interpersonal nursing theory – Notes on nursing theories (10). Newbury Park, CA: Sage.

Forchuk, C., & Reynolds, B. (1998). Guest editorial – interpersonal theory in nursing practice: the Peplau legacy. Journal of Psychiatric and Mental Health Nursing, 5, 165-166.

Jones, A. (1996). Education and debate. The value of Peplau’s theory for mental health nursing. British Journal of Nursing, 5(14), 877-881.

Lego, S. (1998). The application of Peplau’s theory to group psychotherapy. Journal of Psychiatric and Mental Health Nursing, 5(3), 193-196.

McNaughton, D. B. (2005). A naturalistic test of Peplau’s theory in home visiting. Public Health Nursing, 22(5), 429-438.

Meiers, S. J., & Sheran, K.,(2009). Chapter 10 Analysis of theory: Interpersonal relations. In S. Peterson & T. Bredow (Eds.), Middle range theories: Applications to nursing research (2nd Ed.)(pp. 378-380). Philadelphia, PA: Lippincott Williams & Wilkins.

O’Toole, A. W., & Welt, S. R. (Ed.). (1989). Interpersonal theory in nursing practice: Selected works of Hildegarde E. Peplau. New York: Springer.

Tomey, A. M., & Alligood, M. R. (2006). Nursing theorists and their work (6th ed.). St. Louis, MO: Mosby.

Peterson, S. J., (2009). Interpersonal Relations. In S. Peterson & T. Bredow (Eds.), Middle range theories: Applications to nursing research (2nd Ed.)(pp. 202-230). Philadelphia, PA: Lippincott Williams & Wilkins.