1.

Brief History

Hildegard Peplau was born September 1, 1909, in Reading, PA, the second daughter of immigrants Gustav and Ottylie Peplau, and one of six children. As a child, she witnessed the devastating flu epidemic of 1918, a personal experience that greatly influenced her understanding of the impact of illness and death on families. Peplau began her career in nursing in 1931 as a graduate of the Pottstown, PA, School of Nursing. She then worked as a staff nurse in Pennsylvania and New York City. A summer position as nurse for the New York University summer camp led to a recommendation for Peplau to become the school nurse at Bennington College in Vermont. There she earned a bachelors degree in interpersonal psychology in 1943. At Bennington and through field experiences at Chestnut Lodge, a private psychiatric facility, she studied psychological issues with Erich Fromm, Frieda Fromm Reichmann, and Harry Stack Sullivan. Peplaus life-long work was largely focused on extending Sullivans interpersonal theory for use in nursing practice. From 1943 to 1945 she served in the Army Nurse Corps and was assigned to the 312th Field Station Hospital in England, where the American School of Military Psychiatry was located. Here she met and worked with all the leading figures in British and American psychiatry. After the war, Peplau was at the table with many of these same men as they worked to reshape the mental health system in the United States through the passage of the National Mental Health Act of 1946. Peplau held masters and doctoral degrees from Teachers College, Columbia University. She was also certified in psychoanalysis at the William Alanson White Institute of New York City. In the early 1950s, Peplau developed and taught the first classes for graduate psychiatric nursing students at Teachers College. Dr. Peplau was a member of the faculty of the College of Nursing at Rutgers University from 1954 to 1974. At Rutgers, Peplau created the first graduate level program for the preparation of clinical specialists in psychiatric nursing. She was a prolific writer and was equally well known for her presentations, speeches, and clinical training workshops. Peplau vigorously advocated that nurses should become further educated so they could provide truly therapeutic care to patients rather than the custodial care that was prevalent in the mental hospitals of that era. During the 1950s and 1960s, she conducted summer workshops for nurses throughout the United States, mostly in state psychiatric hospitals. In these seminars,

she taught interpersonal concepts and interviewing techniques, as well as individual, family, and group therapy. Peplau was an advisor to the World Health Organization and was a visiting professor at universities in Africa, Latin America, Belgium, and throughout the United States. A strong advocate for graduate education and research in nursing, she served as a consultant to the U.S. Surgeon General, the U.S. Air Force, and the National Institutes of Mental Health. She participated in many government policy-making groups. After her retirement from Rutgers, she served as a visiting professor at the University of Leuven in Belgium in 1975 and 1976. There she helped establish the first graduate nursing program in Europe. Hildegard E. Peplau, 89, died on March 17,1999 at her home in Sherman Oaks, CA. after a brief illness. 2. Theory Analysis A. How the Theory Came about With Peplau's eagerness and drive to learn about life, and the many processes it presents, she created a theoretical framework in the psychiatric nursing field that can be applied to nursing as a whole. Peplau is known for her many contributions to nursing, but one that sticks out above the rest is her theory of Interpersonal Relations in Nursing. It was published in 1952. She believed that "nursing is based on the interpersonal process and the nurse-patient relationship" This means that nursing care revolves around not just the patient, but around the nurse, the patient, and the therapeutic relationship they create together. This relationship should produce certain goals that are "twofold: first is the survival of the patient; second is the patient's understanding of his or her health problems and learning from these problems as he or she develops new behavior pattern". This means that not only does the patient learn how to better themselves, but the nurse learns about their patient through personal interactions and through thorough assessments of their health and health history. This theory has and will continue to greatly affect how nurses work in today's health-care system and also student nurses learning how to complete thorough care plans and how to establish a therapeutic relationship. The interpersonal theory of Hildegard Peplau has many different facets that relate to the Austin Peay School of Nursing Philosophy. The Austin Peay School of Nursing states that the aim of the Austin Peay Nursing Program is centered on the four paradigms of nursing: the person, the nurse, the environment, and health. Peplau's theory is based upon "recognizing the importance of nursing rather than continuing to define and delineate nursing" .Thus, Peplau's theory of interpersonal relationships is very similar to that of the philosophy students follow and can be applied to many different aspects throughout the nursing career.

B. Major Concepts Hildegard Peplau identified factors influencing the blending of the nurse-patient relationship

These Factors are: 1. Values-belief or ideas shared by the members of a culture about what is good or desirable and what is not. 2. Culture-is what makes people unique from others. Culture is based on peoples religion, belief and nationality. 3. Race- A category of people who share certain inherited physical characteristics such as skin color, facial features, and stature. 4. Preconceived ideas-an opinion formed beforehand without adequate evidence. 5. Beliefs-strong feeling that something is true or real. 6. Past experiences-a series of events participated in or lived through 7. Expectations- the fact or state of expecting or looking forward to an event that is about to happen Hildegard Peplau identified four sequential phases internal relationships. These phases are: Orientation, Identification, Exploitation and resolution. According to her, theses phases may overlap, interrelate, and vary in duration as the process evolved toward a solution. Peplau also assumed different nursing roles during various phases. The Peplau's Seven Nursing Roles illustrate the dynamic character roles typical to clinical nursing. 1. Stranger Role: Receives the client the same way one meets a stranger in other life situations; provides an accepting climate that builds trust. Accepting the patient objectively. 2. Resource Person Role: Answers questions, interprets clinical treatment data, gives information. Interpreting the medical plan to the patient. 3. Teaching Role: Gives instructions and provides training; involves analysis and synthesis of the learner's experience. Offering information and helping the patient to learn. 4. Counseling Role: Helps client understand and integrate the meaning of current life circumstances; provides guidance and encouragement to make changes. Working with the patient on current problems. 5. Surrogate Role: Helps client clarify domains of dependence, interdependence, and independence and acts on clients behalf as advocate. Figuratively standing in for a person in the patient's life. 6. Active Leadership Role: Helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way. Working with the patient democratically. 7. Technical expert role: Provides physical care by displaying clinical skills; Operates equipment Phases of interpersonal relationship A. Orientation Phase-during the admission

1. When the nurse and patient first meet is known as the orientation phase wherein client meets nurses as strangers. 2. This is a time when the patient and nurse come to know each other as people and each others expectations and roles are understood. 3. The patient at this time needs to recognize and understand their difficulty and the need for help, be assisted to plan to use the professional services offered, and harness the energy derived from felt needs. 4. It may be expected that the patient will test limits in order to establish the integrity of the nurse. 5. The tasks of this phase are to build trust, rapport, establish a therapeutic environment, assess the patients strengths and weakness and establish a mode of communication acceptable to both patient and nurse. 6. When the patient can begin to identify problems the relationship progresses to the working phase. B. Identification Phaseduring the intensive treatment period 1. Trust begins to develop and the patient begins to respond selectively to persons who seem to offer help. 2. The patient begins to identify with the nurse and identify problems, which can be worked on. 3. The meaning behind feelings and behavior of the nurse and patient are explored. Peplau states that when a nurse permits patients to express what they feel, and still get all of the nursing that is needed, then patients can undergo illness as an experience that reorients feelings and strengthens positive forces in the personality. 4. The tasks of this phase are to develop clarity about the patient's preconceptions and expectations of nurses and nursing, develop acceptance of each other, explore feelings, identify problems and respond to people who can offer help. 5. In particular the nurse assists in the expression of needs and feelings, assists during stress, shows acceptance and provides information. 6. The nurse and patient may make plans for the future but the implementation of the plan signifies the beginning of the exploitation phase of the working relationship. C. Exploitation Phase-during convalescence and rehabilitation 1. The patient realistically exploits all of the services available to them on the basis of self interest and need.

2. The nurse assists the patient in their efforts to strike a balance between the needs for dependence and independence. 3. The plan of action is implemented and evaluated. The patient may display a change in manner of communicating, as new skills in interpersonal relationships and problem solving are developed. 4. The nurse continues to assess and assists in meeting new needs as they emerge. D. Resolution Phase-during discharge 1. The resolution phase involves the gradual freeing from identification with helping persons, and the generation and strengthening of ability to stand alone, eventually leading to the mutual termination of the relationship. 2. The patient abandons old needs and aspires to new goals. 3. She or he continues to apply new problem solving skills and maintains changes in style of communication and interaction. 4. Resolution includes planning for alternative sources of support, problem prevention, and the patients integration of the illness experience. Nursing Process Versus Peplaus theory Assessment

Orientation

Data collection and analysis [continuous] May not be a felt need

Non continuous data collection Felt need Define needs

Nursing diagnosis Planning

Identification

Interdependent goal setting

Mutually set goals Exploitation

Implementation

Plans initiated towards achievement of mutually set goals May be accomplished by patient , nurse or family

Patient actively seeking and drawing help Patient initiated

Evaluation

Resolution

Based on mutually expected behaviors May led to termination and initiation of new plans

Occurs after other phases are completed successfully Leads to termination

Metaparadigm Person An organism striving to reduce tension generated by needs Environment The interpersonal process is always included, and psychodynamic milieu receives attention, with emphasis on the clients culture and mores. Health Ongoing human process that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living. Nursing Interpersonal therapeutic process that functions cooperatively with others human processes that make health possible for individuals in communities. Nursing is an educative instrument, a maturing force that aims to promote forward movement of personality. C. PARADIGM OF HILDEGARD PEPLAUs INTERPRSONAL RELATION IN NURSING

NURSE

NURSE
Values Culture Race Preconceived ideas Belief Past Experiences Expectation Nurse-patient Relationship Orientation Identification Exploitation Resolution

PATIENT
Values Culture Race Preconceived ideas Belief Past Experiences

Expectation According to Peplau, the nurse and the patient approach their course of action coming from different backgrounds and individual uniqueness. Both the nurse and the patient have learned these unique perceptions from different environments, mores, customs, and belief of the

individuals given culture. Each person comes with these factors that influence perceptions, and it is these differences in perception that are very important in the interpersonal process. 3. Critique of the Theory a. Yes, it is still applicable since most of the nursing care we provides involve nurse-patient relationship. Peplaus theory is significant in terms of the different phases of the nurse-patient interaction and the different roles of the nurse plays an important function in giving nursing care to patient. It thus, becomes important for nurses to understand the principle behind each of these concepts so that clinical nursing will be more meaningful for the nurse. Eventually, this will translate to better patient outcomes like improved health, prevention of disease and or enhancement of care faculties. b. Peplaus theory plays an important role to the patients health wherein both nurse and patient is involve in the nursing care. For example if a terminally ill patient want to know some sensitive information about his/her condition; the nurse can then be assume a surrogate/advocate role wherein nurse assume patients behalf by telling the doctors about the concern of the patient so that he/she will provide the needed information. c. Peplaus theory may lead to favorable outcome since it was widely use in most of clinical setting. It is important to follow carefully the 4 phases of interpersonal relationship beginning from orientation phase wherein patients rapport is important so that there would be a mutual relationship all throughout the phases until the last phase which is the resolution phase wherein termination of mutual relationship occurs so that favorable outcome will be met which is patient self reliance to deals in his/her problem. 4. Theory Application A. Case study about Throat Cancer Barney, a 89 years old male patient born on March 15, 1923 at Mexico, Pampanga. He is the 2nd youngest siblings in the Family and he is the only sibling alive. He is married but separated. He has 4 children. Barney is currently resides at Mexico Pampanga. Barney was admitted at SHMC on October 21, 2012 with a chief complaint of constipation and throat pain. He was diagnosed of Throat cancer t/c ileus Constipation. Currently he was still admitted because of continuous radiation treatment for cancer. History of Past illness Barney doesnt have any previous serious illness. He usually had a fever, cough and cold treated by over the counter drugs. Barney verbalized that his cancer was diagnosed this year. He found out that his left neck area becomes swollen and there was presence of pain. Barney undergoes series of test; from the result he was then diagnosed of having a cancer. History of Present illness 3 days prior to admission he has an abdominal pain, poor appetite, generalized weakness, and throat pain. From the symptoms experience he seek immediate medical advice

and chose to go to emergency room of SHMC. The Initial diagnosis of Barney is Throat cancer t/c Ileus constipation. The attending physician ordered for a continuous radiation therapy for the treatment of cancer. Esomeprazole, buscopan, Lactulose and Maalox for abdominal pain and constipation. Intravenous fluid and peripheral parenteral nutrition of Nutriflex lipid for generalized weakness and poor appetite. Nursing Diagnosis Acute pain Imbalance nutrition less than body requirement related to poor appetite Activity intolerance related to generalized weakness Impaired bed mobility related to generalized weakness

B. Relationship of the case study to Peplaus Theory To determine the relationship of the actual case study to peplaus theory of interpersonal relationship in Nursing, the identified four sequential phases should be followed which includes Orientation, Identification, Exploitation and resolution. In this theory application the researcher portrayed as a nurse to Barney. Orientation Barney was admitted last October 21, 2012 at SHMC. The nurse met him and his relatives on the day of admission. It is normal to feel awkward at first time since it was the first time to meet one another. The nurse and patient plays as a stranger. The nurse tries to established rapport by creating a comfortable environment and initiation of therapeutic conversation for Barney. From then the nurse build a mutual trust. The nurse, along with the patient mutually clarified and defined the problems by asking question about his condition. The nurse answered him in a simple way for him to understand. In this phase, the nurse and patients culture, religion, race, preconceived ideas, belief and expectation was influenced by the nurse-patient relationship. Since the patient is in the older age they have unique viewpoints to the concepts with that of the nurse. At the end of orientation phase, the nurse and patient will continue to develop a mutual relationship with another. Identification From the continuous interaction with one another, the nurse and patient were able to establish therapeutic relationship. Furthermore from the therapeutic conversation the nurse will help the patient to verbalize feeling for his condition so that he will have a positive attitude wherein this will help to deepen their relationship. Also in this phase, both the patient and nurse clarify preconception and expectation which are more complex with those in the initial phase. The patient begins to have feelings of belongingness and ability to handle problems. The nurse creates a hopeful and positive environment which helps the patient to ease feeling of despair.

Exploitation In this phase, the patient takes advantage of all services available from the nurse since they develop a mutual relationship. In line with the actual case, Barney become more meticulous with the services provided and asking more demands. The nurse made use of therapeutic communication and they made a collaboratively works with each other so that they will surpass all the challenges and works toward meeting the goals which is patients health. Clinical Application of Peplau's Theory of Interpersonal Relations Peplau identified roles of nursing such as counselor, resource, teacher, technical expert, surrogate, and leader (Chitty & Black, 2007, p. 341). She also defined four phases of the nursing relationship: orientation, identification, exploitation, and resolution ("Theory of Interpersonal Relations," 2010). The author's purpose is to relate these roles and phases with the nursing process: assessment, diagnosing, planning, implementation, and evaluation. Assessment is the gathering of information (Chitty & Black, 2007, p. 195). This step of the nursing process corresponds to Peplau's orientation phase ("Theory of Interpersonal Relations," 2010). In assessment it is important for a nurse to take the leader role so the direction of the assessment is well organized and the nurse gets the needed information. The nurse must also be a counselor and employ the skills of listening and helping the patient through coping with illness. Assessment is the starting point for the rest of the nursing process; if the assessment is wrong the rest of the process is compromised. Therefore the nurse must also be a technical expert in assessment because it is a learned skill. The data collected in assessment is then grouped and problems and associated causes can be identified (Chitty & Black, 2007, p. 197). The identification phase of Peplau's theory is associated with this phase ("Theory of Interpersonal Relations," 2010). In this phase of the nursing process a nurse would take the role of resource. The nurse holds the knowledge to identify problems and begin to formulate ideas about how to relieve them. The nurse may also begin to play Peplau's surrogate role in this phase if a patient need is not being met by the nurse's agency. Planning involves setting goals and outcomes (Chitty & Black, 2007, p. 200). The planning phase of nursing is also related to Peplau's identification phase ("Theory of Interpersonal Relations," 2010). In Peplau's theory it is very important for the nurse and patient to communicate and work together in identifying goals and outcomes ("Theory of Interpersonal Relations," 2010). Peplau proposes that by working together the nurse and the patient grow and learn from the process ("Theory of Interpersonal Relations," 2010). The nurse would be a counselor and teacher at this step. The nurse would need to be sure the patient understood desired outcomes and did not have any further questions. Any anxiety or other emotions related to patient goals would also need to be addressed. Implementation involves putting the plan into action (Chitty & Black, 2007, p. 204). Peplau's phase of exploitation is comparable to this step ("Theory of Interpersonal Relations," 2010). In

this phase a nurse would be a surrogate for the patient by obtaining the resources needed for optimal health. The nurse would be a teacher explaining interventions to the patient and how to complete some of these interventions on their own. Nurse's would counsel patients on behavior changes and help the patient through feelings about these changes. The role of technical expert would be important in this phase because a nurse would need particular skills to perform specific interventions. Evaluation involves a nurse determining if a goal has been met (Chitty & Black, 2007, p. 204). Peplau's resolution phase mirror's this step ("Theory of Interpersonal Relations," 2010). At this point in the helping relationship a nurse would take on the role of teacher. The nurse would teach a patient how to continue improvement, the importance of compliance, or other behavior changes needed to promote health. A nurse would act as a resource helping a patient obtain resources that may be hindering a patient's progress towards a goal. The role of counselor may become important if this step is also associated with termination of services. The nurse would need to address the patient's feelings about the end of the working relationship.

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