Transcript Hildegard Peplau Theory of Interpersonal Relationships

Kristyn Beaver
Darlene D’Arcangelo
Magdalena Stewart
Stephanie Teunessen

"The one concept of the Theory of Interpersonal
Relations is the nurse-patient relationship,
which is an interpersonal process made up of
four components-- two persons, the
professional expertise of the nurse, and the
client's problem or need for which expert
nursing services are sought--"
Kearney-Nunnery (2008)


Communication is key
to every NursePatient relationship.
Peplau provides clear
steps in her theory:


Orientation
Working
 Identification
 Exploitation


Evaluation
Resolution

Peplau’s theory can be
used in every aspect
of nursing:
Therapeutic
communication
 Research
 Problem solving
 Teaching
 Assessments

(Kearney, Nunnery 2008)
The 2 Persons
(Nurse & Pt)
The Nurse’s
Expertise
The Client’s
Need
(Kearney-Nunnery,2008)
Kristyn’s
Research
• Peplau Component: 2 Persons
Darlene’s
Research
• Peplau Component: Nurse’s Expertise
• Survivors of Sexual Violence by T.J.
Courey et.al., 2008
Magdalena’s
Research
Stephanie’s
Research
• A Naturalistic Test of Peplau’s Theory in
Home Visiting by D.B.McNaughton,2005
• Peplau Component: Education
•Using Peplau’s theory of Interpersonal Relations
to Guide The Education of Patients Undergoing
Urinary Diversion.
• Peplau Component: Client Need
• The Communication Experience of Nonvocal
Ventilated Patients by S. M. Carroll, 2007
Rationale of use of nursing theory (Relevance for
personal practice)


Nurses communicate every minute of every day, patients express
their needs to the nurse who is listening and engages the patient.
Peplau’s Clinical Methodology is a logical way to obtain
information from the patient.


Observe
*Communicate
*Record
*Analyze (Kearney, 2010)
This study was chosen as it was based on OB clients in the home
setting. These were at risk mother’s with threatened pregnancies.

Home visits for at risk pregnant mother’s. This study
was chosen as it used Peplaus’ interpersonal relations
as “it has been proven to be most helpful in home
visits; to aide in identifying problems, mutual problem
solving, clients’ use of health services and adopting of
health-promoting behaviors in home visiting
interventions “(McNaughton, 2005).




“This study was done to test the applicability of Peplau’s theory of
interpersonal relations in nursing in the context of home visiting”
(McNaughton, 2005).
Five nurse-client dyads were chosen: five clients and five public
health nurses.
“The method for conducting the research was with observing and
audiotaping the nurse-client interaction. The information was then
analyzed for changes beginning with the first prenatal home visit
and ending in the early postpartum period” (McNaughton, 2005
p. 430).
The author analyzed the transcripts of the meetings with the
mother’s. The information was studied for changes in patterns to
evaluate when each dyad entered into the different phases.



“A minimum of five visits were conducted. This number was based
on research indicating that change in clients’ health behavior or health
status is more likely to occur with at least four visits” (McNaughton,
2005 p. 431).
A researcher accompanied the nurses to the homes of these mother’s.
The researcher only observed and did not participate in any way in
the interaction. A Relationship form was filled out by the researcher
and nurse to evaluate each visit.
Analysis of these transcripts revealed when the client reached each
phase of Peplau’s theory:





Orientation: meeting as strangers
Identification: identifying problems/needs of the clients
Exploitation: where the client uses the nurse for education and for resources.
Resolution: when the patient is independent and applies new problem-solving skills,
develops new goals (McNaughton, 2005)
Conclusion of the study was that Peplau’s theory was indeed useful
in conducting research by giving clear steps, and that by utilizing the
theory, it called into question the benefit of only one or two home
visits for pregnant women at risk. The theory proved that women at
risk needed enough visits necessary; be it five or ten or more.
LIMITATIONS




This research study was very small, only
five couplets used.
The nurses were all white, middle-aged
women with many years of experience in
home visiting.
The clients were of varying ethnicity: four
mother’s were first time mothers, one was
expecting twins, one women was
expecting her second baby. One woman
was from Southeast Asia; One from
North Africa; three were born in the US;
one Caucasian, African American, Puerto
Rican. Four of the women were married.
The two immigrants were here without
their husbands.
If the nurses were of varying ethnicity as
well, then maybe all of the mother’s
would have been more receptive of the
nurses. Only one of the dyads reached the
resolution phase.
CREDIBILITY



Explained theory steps
clearly.
Explained research
steps clearly and how
they related to Peplau’s
theory.
Realized that only one
or two home visits were
not enough for mother’s
at risk.
PRACTICE IMPLICATIONS



Inferred that by learning better
communication skills nurses
could use their time with
patients more wisely.
Nurses have limited time with
each client, and much time is
spent on assessment, better
communication would aide
better time management.
Home visits using this model
were helpful to the mother’s at
risk in problem solving and
utilizing resources.
PERSONAL PRACTICE



Helped me to realize that how
my body language and tone of
voice are communicated with
my patients.
Listening and self-reflective
behavior are so important in
communication.
That by consistently using
these steps, I will not miss
hearing what my patient is
needing of me and then being
able to help them find
solutions best for them.
Nurse Expertise: Therapeutic
Communication
Survivors of sexual violence responded the key to a positive nurse- client
relationship is to:
“Engage in therapeutic communication and
help manage symptoms related to the
violence.” Courey, Martsolf, Draucker, and
Strickland (2008)
How did Peplau’s Theory:
“Frame the Research”?
Peplau’s theory is based on the nurse-client relationship of
helping to identify perceived difficulties
Advanced practice mental health nurses who analyzed the data:
“were struck by how the participants descriptions of their
encounters with the nurse were reminiscent of Peplau’s
description of the nurse-client relationship”. (Courey,
Martsolf, Draucker, and Strickland, 2008)
Survivors of sexual violence revealed the most important
interaction of the nurse was “the helping roles of counselor
and technical expert in exploring their experiences ”.
(Courey, Martsolf, Draucker, and Strickland, 2008) )
The Research Study Addresses the question:
How do survivors of sexual violence view their
interactions with nurses who provide for them?
Research: The Approach
-
60 survivors were interviewed, 30 men and 30 women.
Age range 18-62 years.
All discussed their experiences with sexual violence.
They were questioned regarding the overall experience
with those who provided care to them.
- What did survivors identify as supportive with their
encounter?
- What did the survivors identify as negative with their
encounter?
Research: The Findings
Positive Interactions
“Participants perceived health care
professionals helpful when they exhibited
interpersonal sensitivity especially in regards
to the participants experiences with violence”.
(Courey, Martsolf, Draucker, and Strickland,
2008).
Research: The Findings continued,
Positive Interactions
When survivors were asked what can promote
a therapeutic nurse-client relationship:
“The nurse must demonstrate active listening
skills, apply therapeutic communication
techniques, provide guidance, support in the
process of self discovery, and maintain
professional boundaries and self awareness”.
(Courey, Martsolf, Draucker, and Stricklannd
2008)
Research: The Findings continued,
Negative Interactions
Many survivors have reported a positive
interaction with the nurse, others often feel
anxious, skeptical, and reluctant to follow up.
Survivors also reported “Negative
experiences with professionals who treat
them harshly, do not listen to their stories of
abuse, and in some cases further victimizing
them”.(Courey, Martsolf, Draucker, and
Strickland, 2008) )
Limitations of Research Study:
There was not much investigation as to what made the encounters a positive
or negative experience.
“Experts suggest that the distrust some of the survivors
harbor is related to secondary victimization; defined as
victim blaming attitudes, behaviors and practices engaged
in by the nurse, which result in additional trauma
for rape survivors”. (Courey, Martsolf, Draucker, and
Strickland, 2008)
Implications for Practice
The Study:
Therapeutic Communication:
Personal Practice:
--Create an atmosphere of trust.
-Be engaged in communicating
with patient, active listening.
--Promote an environment of
respect and empathy.
-Treat the patient with respect, show
compassion and non judgemental
behavior towards the patient.
-Be sincere while communication
--Deliver information in a sensitive
manner.
-Allow the patient time to absorb
what is being communicated.
Peplau’s Theory Component: 2 Persons
The Research:
Using Peplau’s Theory of Interpersonal
Relations to Guide The Education of
Patients Undergoing Urinary
Diversion (Marchese, 2006).
Research Approach:
 The study involved patients who are diagnosed with bladder cancer
 Patients need to undergo urinary diversion
 Patients have significant pre and postoperative needs :
- physical needs include the management of the altered urinary system,
receiving adequate pain control, and understanding the role of
nutrition in recovery phase.
- daily exercise plan is necessary to maintain proper levels of activities
of daily living, prevent constipation, lessen the risk for pneumonia.
- lack of proper nutrition can delay the healing process and increase
risk for other surgical complications.
- social needs relate to concerns about finances, loss of income, medical
cost, inability to care for themselves.
Approach:
 All those needs may cause stress, anxiety, and depression. Knowledge
deficit about the diagnosis, surgical treatment options, pre-operative
testing procedures, and short and long term postoperative care create
an environment that may increase patients’ anger, grief, fear, and
anxiety.
 Peplau identifies a need for patients to also be a part of a community.
These patients need involvement with friends and family on a social
level beyond their assistance as caregivers. Rejoining their church
community, meeting friends, and participating in events may prevent
depression.
How does Peplau’s Theory “Frame the Research”?
 Peplau’s theory provides conceptual framework by which the nurse can
assess, plan, and intervene for optimal outcomes for the patient with
bladder cancer.
 The foundation of her theory explores the primacy of the nurse-patient
relationship.
 The nurse-patient relationship evolves through phases of orientation,
identification, exploitation, and resolution.
 According to Peplau nurses must recognize, accept, and encourage cues
that indicate the patient’s readiness for growth and movement.
Likewise they must identify and mobilize community resources to help
patients cope with sudden change in health status.
Framing the Research Cont…
- Patients diagnosed with bladder cancer may require a urinary
diversion to maximize their healthcare outcomes.
- These patients faced with sudden changes in their health status
develop complex, unmet needs that can be addressed by a planned
program of education.
- Peplau’s theory of interpersonal relations offers a framework for
patient teaching that emphasizes the importance of the nursepatient relationship
- This therapeutic relationship enables the nurse to provide the
patient with the information needed to understand the diagnosis,
cooperate in the treatment plan, facilitate postoperative recovery,
and return to a state of independence with quality of life.
Research Findings:
o Orientation:
 Assessment of prior knowledge and experience.
 Assessment of readiness to learn
 Presentation of educational materials
 Discussion of pre-operative procedures
 Different options for diversions; patient pathways.
o Identification:
 Demonstration of neo-bladder care: irrigation, tube
patency, care and cleaning of equipment, knowledge of
emergency situations.
Findings…
 Discussion of nutrition: prior eating habits, six small meals
daily, fluid requirement 2 quarts daily
 Development activity plan
o Exploitation
 Reaffirm patient’s knowledge and expertise,
 Promote independence
 Identify available community resources
 Role playing
 Present theoretical complex situations and have patient
problem solve.
Findings…
o Resolution
 Encourage participation in support group for continent
diversions
 Identify potential issues and discuss options:
- nocturnal incontinence
- sexual changes
- alterations in body image
- anxiety about cancer diagnosis
Findings…
 Suggested outcome measures for patients
undergoing a urinary diversion might include:
 The patient participates in a bladder cancer support groups
pre-operatively and postoperatively.
 The patient is able to engage in self-care activities to
support maintenance of the urinary diversion.
 The patient collaborates with the nurse to identify
resources to help him/her cope with post surgical
consequences.
Limitations/Credibility:
 The research is based on one study of a 60-year old male. The patient works full
time as an independent painting contractor, he is married and has two adult
sons.
- Limitation: It is a very narrow approach and does not give us a broad
spectrum of variety of patients in different ages, with different backgrounds and
support systems.
 During the initial meeting with urologic nurse the community resources were
identified. That included hiring associate who could work as subcontractor.
- Limitation: That is an ideal situation when the right community resources are
available, but that puts a lot of limitations on people who live in the area where
resources are not available or the type of services they need cannot be find. In
my practice I had a patient who owned landscaping company and when he
unexpectedly had to stay in a hospital for a surgery he could not find any help
with his business, including his two sons.
Limitations…
 The patient was married and had a support system at home that helped
him go through hospitalizations
- Limitation: Many older people don’t have available support system,
they are divorced or widowed; and children, if they have any, could be
living far away.
 The patient was an active and intelligent person who could easily
understand given education
- Limitation: Many patients that we have to deal with have limited
ability to accept new information especially about complex treatment.
Some elderly suffer from dementia or forgetfulness and educating these
patients could be a long process and may not always be successful.
Credibility:
 The study was very informative and descriptive
 It was written in a clear understandable form
 The study clearly connects the research findings with
Peplau’s interpersonal theory
It can be use as a guide when developing care plan
for patients similar to the one described in a study
 The finding can be applied to other areas of nursing
and other types of patients.
Implications for Practice:
 Study: Highly skilled and knowledgeable nurse plays critical role in
promoting the health
- Personal: It is crucial to have adequate knowledge about the area of
our practice, regardless of the type of nursing our input is a big part of
patient recovery. Whenever possible I take time to review the
medications or procedures that I will be teaching about.
 Study: effective communication is integral to the nurse-patient
relationship and necessary for the education to be successful.
- Personal: Developing good communication with the patient when we
first meet is a priority for me. If the patient doesn’t feel connected with
the nurse he/she will not be receptive to any teaching. I always assess the
patient and try to be flexible enough to meet his/her needs and readiness
for education
Implications…
 Study: It is important to involve the patient in establishing the
teaching goals, conduct frequent reviews of these goals, and evaluate
the efficacy of the teaching.
- Personal: Patients who are involved in their care have a sense of
independence and they respond to teaching better. I usually offer the
patient a choice for different teaching methods: video, brochure,
conversation or a combination of all. Instead of sitting and lecturing the
patient I give them option to decide on the form of our session.
The Research Study:
Silent, Slow Lifeworld: The
Communication Experience of
Nonvocal Ventilated Patients
(Carroll, 2007).
“…To me, anyone that can’t
talk, it’s a punishment, I
think. It’s terrible. Terrible.
[eyes well up with tears]…”
anonymous, pt quote from research
(Carrol, 2007).
 In
Peplau’s Theory: “Effective reciprocal
communication, involving clarification, is a
key part of interpersonal relations and
quality patient outcomes.” (Carroll,
2007,p.1166).
This research study addresses the question:
How do we achieve reciprocal
communication with patients that are
non-vocal (on a vent)?
19 Participants,
average age: 66
 Range of time spent on
ventilator : 1.5 wks to 9
years
 Setting: Rehab with
intent to wein from
ventilator
 Data: multiple methods
of collection used,
including interview,
questionnaires,
informal observations

1st question asked
during interview:
“What has the
experience of not
being able to speak
out loud been like for
you?”
 Interviewer tested
proficient in lipreading, patient
answers were repeated
for confirmation

 Regarding
the reciprocal nature of
communication: being voiceless not only
affected the participants’ expressions but
also their perceptions of how they were
treated by others.(Carroll, 2007,p.1168).
 Voicelessness
is a form of physical
restriction. Just as an arm can be used to
reach out and tap someone, a voice can be
used to call out for the same effect.(Carroll,
2007,p. 1169).
 Keeping
Communication as Natural as
possible- the participants preferred
mouthing words to any other means.
 The perception of a patient “giving up”
when not understood is not an experience
of futility, rather the participant decided his
or her message was “unimportant”.
 Patients that are given more time to express
themselves demonstrate increased
persistence and decreased futility.

(Carroll, 2007)
 “Uncertainty
is exacerbated when
communication impairments are present,
such as with this study’s participants,
because clarification and understanding
cannot be as readily sought. As a result,
interpersonal relationships are
impaired.”(Carroll, 2007, p.1175).
 Participants
found that having a
connection with the nurse facilitated
effective communication.(Carroll, 2007, p.
1175).
 Sample
of 19 participants was not ethnically
diverse, 18 were white, 1 was African
American.
 Only rehabilitation settings were used in
this study, which limited comparisons to
other settings where the model of nursing
care delivery might differ.
 The participants expected and hoped to
regain their voices, and this may have
shaped some of their understandings of
their experiences.
(Carroll, 2007)
THE STUDY:



Multiple, short interviews are
suggested to decrease patient
fatigue.
The interviewer being
proficient in lip-reading
allowed for the most natural
form of communication.
Conducting the study at
various levels of care (acute,
long term, etc) may discover
various perceptions of the
patients non-vocal
experience.
PERSONAL PRACTICE:



Spending quality time with the
patient is extremely important
with those that are unable to
communicate.
It is important to follow-up and
revisit the patient that can not
communicate regarding his or
her needs.
The patient that can not
communicate verbally may
feel physically restricted and
may not perceive his or her
non-physical needs as
important.
(Carroll, 2007)




Peplau’s Theory of Interpersonal Relationships provides
a structured framework to the various areas of research.
Following the various pathways in regards to the nurse
and patient relationship allows for clear direction for the
researcher.
Interacting therapeutically with survivors of sexual
violence requires the nurse to exhibit sensitivity, respect,
and remain non judgmental.
Applying Peplau’s theory to practice helps urologic
nurse evaluate and develop skills and teaching methods
to meet the needs of each patient.
Effective communication to the health care team is an
important need of the patient. When the communication
is restricted, it is important for the nurse to address this
need with priority.


Communication and Listening are the key
components to Peplau’s theory, along with self
reflection on the part of the nurse to know if
the nurse is not imposing her views on the
patient.
Home visits need to be the amount of visits
that serves the patients needs, however many
that is.




What are the steps in Peplau’s Methodology?
As a nurse providing care to sexual survivors
how could you implement Peplau’s theory?
What is the focus of patient education based on
Peplau’s model?
What implications are there for your nursing
practice in regards to patients that are unable
or have an altered ability to communicate and
the findings of the research? (Keep in mind: Patients
don’t have to be ventilated to be unable to communicate with
you verbally).






Carroll, S.M.(2007). Silent, Slow Lifeworld: The Commnication Experience
of Nonvocal Ventilated Patients. Quality of Health Research, 17, 11651177. doi: 10.1177/1049732307307334
Courey T J Martsolf D S Draucker C B Strickland K B 2008 Hildegard
Peplau's Theory and the Health Care Encounters of Survivors of
Sexual Violence.Courey, T. J., Martsolf, D. S., Draucker, C. B., &
Strickland, K. B. (2008). Hildegard Peplau's Theory and the Health
Care Encounters of Survivors of Sexual Violence. American Psychiatric
Nurses Association, 14(2), 136-143.
Kearney, R.N.(4th Ed.) (2008). Advancing your career. Philadelphia, PA.
F.A. Davis Company
Marchese,
McNaughton, D.B. (2005). A naturalistic test of Peplau’s theory in home
visiting. Public Health Nursing. 5 (22) pp. 429-438
doi:10.1111/j.0737.2005.220508.x
Music by Joe Probst; CD entitled Kickin’ Back, song; Kickin’ Back. (1996)

JLP&CO, South Bend, IN.