Abstract
Peplau’s theory of interpersonal communication is one of the most influential works in nursing practice and can be traced to many modern theories and healthcare policies. Being initially devised for application in psychiatric nursing practice, it has since found implementation in many fields of healthcare, including nursing practice, education, administration, and research thanks to its scalability, flexibility, and comprehensibility. Despite several limitations, it has a potential for reshaping APRN practice in general and is expected to improve outcomes in specific aspects such as medication prescription, preparation, and administration.
Introduction of Theorist and Theory
Hildegard Peplau was born in Reading, Pennsylvania in 1909, in the family of German descent (Snowden, Donnell, & Duffy, 2014). By the time she was able to pursue a nursing career, the nursing profession was primarily restricted to simple supportive tasks and did not emphasize communication. In 1931, Peplau graduated in the Pottstown Pennsylvania School of Nursing. From then on, her primary interest was in the psychology of interpersonal communication. In 1943 she earned a bachelor’s degree in interpersonal psychology at Bennington College followed by a master’s and a doctoral degree from Columbia University in New York in 1947 (Snowden et al., 2014). Roughly in this period she first looked to extend the nursing practice to the communication domain. The main idea behind her early work was that nurses could be of greater help to patients if their tasks go beyond simple cleaning and laundry duties. Another notable contribution to the shaping of her theory was her involvement in the transformation of the American mental health system following the introduction of the National Mental Health Act of 1946.
Her seminal work, Interpersonal relations in nursing, which laid out the foundations of her theory, was published in 1952. Importantly, despite bearing a resemblance to the conceptual framework, it is referred to as a theory since it is testable (Peterson & Bredow, 2013). It is also important to note that while it has a wide scope of application, it is recognized as a middle-range theory by most scholars and was initially defined as such by Peplau herself, describing it as “a partial theory for the practice of nursing as an interpersonal concept” (Peterson & Bredow, 2013, p. 139).
Support Theory
Peplau’s theory is based on several psychological and social concepts, most prominently those by Neal Elger Miller and Abraham Maslow. The one which plays a central role and is used as support theory is Harry Stack Sullivan’s interpersonal theory of personality. Its notions form a basis for Peplau’s work since the latter relies heavily on the interaction with peers. Sullivan’s basic premise is that human personality develops based on the interaction with the surrounding individuals. In other words, personality requires a social environment to be shaped.
Peplau utilizes this principle to shift the attention of nursing practitioners from mechanistic and utilitarian tasks to communication as a central tool for improving patient’s health. The core thesis of nursing as an interpersonal process built around the interaction between two or more individuals is also based on the social nature of human relations. Finally, while not explicitly stated in Peplau’s works, her interpersonal theory is defined by many scholars as psychodynamic as it requires the reflective analysis and understanding of behavior for successful implementation (Peterson & Bredow, 2013). The concept of behavior as a means for achieving the desired needs and avoiding anxiety is also borrowed from Sullivan’s theory.
Components of the Nursing theory
Major Concepts and Metaparadigm Definitions
Despite its complexity, Peplau’s theory relies on four concepts that are perceived as universal in the metaparadigm of nursing.
Nursing
As was already mentioned above, the main focus of Peplau’s theory is on the relations between a nurse and a patient. Thus, nursing can be defined as a therapeutic interaction between someone who experiences health problems and needs help (patient) and someone who possesses relevant knowledge and has access to resources that can assist the patient in reaching this goal (nurse). In the broad sense, nursing is on par with other common social processes and must acknowledge and cooperate with them to raise the chances of achieving good health (D’Antonio, Beeber, Sills, & Naegle, 2014). It can clearly be seen that technical and resource-supplying procedures are not prioritized by this definition – instead, they are assigned a secondary role.
Persons
Two persons are central to the theory – a nurse and a client, i.e. a patient. A nurse is defined as a person with definable expertise, e.g. the ability to identify the problems of patients, allocate relevant skills for solving them, and demonstrate the capacity to form with the patient the kind of relationship which would be the most beneficial for reaching the desired outcome. The nurse must also possess values and commitment consistent with achieving patient’s well-being. A patient is a person who is entitled to universal human rights such as privacy, confidentiality, respect, and ethical care and is in need of health care. Additionally, the patient may or may not actively participate in a relationship with the nurse.
Health
In Peplau’s theory, health is a process of moving towards the state of productive and constructive living. She identifies two main aspects of health – biological, which is determined by physiological principles of human functioning, and social, which is defines emotional and psychological well-being of individuals.
Environment
This concept is mostly restricted to therapeutic environment and is broken down into two categories. The structured environment, such as a hospital or a ward, is traditionally associated with technicalities of healthcare. The unstructured component, i.e. an interconnected system which includes patients, staff, and visitors, is often poorly managed or overlooked but conveys significant importance for the patient outcomes. A properly maintained environment results in an atmosphere which facilitates recovery.
Philosophical Underpinnings
Due to the relative complexity and diversity of the interpersonal relations theory, it is not possible to conclusively assign it to a specific philosophical foundation. Nevertheless, it aligns well with the existential phenomenology (Butts, Bandhauer, & Rich, 2013). According to this view, nursing acquires an interpretive character since the task of observing the patient requires involvement with the existential situations of the latter. The identification of patients’ problems can be viewed as meaning-seeking activities resulting from nurse-patient relationship aimed at achieving a mutually satisfying result.
Goals of Nursing
As can be seen from the definitions, the main goal of nursing is the creation of the environment which promotes the attainment of positive health by the patient. This is achieved primarily by establishing appropriate communication channels and assuring the participation of the patient in achieving the desired results. Other important components of the environment formation, and, by extension, minor nursing goals, are mutual education and constant development directed at achieving personal and community well-being.
Theory and Nursing Process
Peplau suggests breaking down the process into four phases. It is important to understand that the chronological order of the phases is not necessarily exact, as most of the time the phases are overlapping and integrating into each other.
Phase of orientation
After identifying the patient’s problem, the nurse is expected to deliver the informational resources relevant for its solution (resource person), encourage the patient to communicate the issues associated with the problem (counselor), help the patient reenact prior relations to locate and address existing issues (surrogate), and provide the specific technical and clinical information which is most likely unavailable to the patient at this phase (technical expert). Notably, the latter is positioned at the end of the list because it is mostly a secondary role.
Phase of identification
At this phase, the patients often make a choice of further behavior model. Ideally, they decide to interact with the nurse in active pursuit of attainment of positive outcome. Two major difficulties at this stage are reluctance to facilitate a collaboration because of the previous negative experience and the false interpretation of participation which leads to excessive dependence. At this stage, the nurse largely plays the role of a leader.
Phase of exploitation
This phase includes most of the clinical and nursing interventions. Depending on the chosen role, the patient may display varying level of involvement. Nevertheless, one of the nurse’s goals at this phase must be towards decreasing the patient’s dependence and promoting empowerment.
Phase of resolution
This phase is initiated once all of the predetermined initial goals (i.e. the problem which triggered the visit) are fulfilled. By this time patient should determine a new set of goals aimed at maintenance and improvement rather than addressing a specific issue. During the resolution, the patient should become proficient enough to stop feeling dependent on the nurse, so the relation is terminated as unnecessary. Both sides of the relation are expected to enrich their knowledge and resource base as a result of this relation.
Aside from the primary roles of surrogate, leader, resource person, and counselor, Peplau isolates the role of a stranger, which sees limited use during the orientation phase, and teacher, which can be observed throughout the process and is gradually substituted with one of a leader.
Current Applications of Theory in Nursing
Despite being initially devised for application in psychiatric nursing practice, Peplau’s theory has since found implementation in many fields of healthcare, including administration and research.
Practice
Nursing practice remains an area where the influence of Peplau’s theory is featured most prominently. If, for example, a patient is restricted to bed because of the pelvic traction, the nurse starts with informing him of the reasons for restriction (resource person). She then describes possible benefits of self-care and provides the patient with the information on the exercises which would contribute to improvement (teacher). The identification phase can be facilitated by providing additional information on prevention of complications and explaining the role of patient initiative. During the exploitation phase, the nurse provides the necessary activities, such as massage of upper and lower extremities, and oversees the activities executed by the patient, such as breathing exercises and passive exercises aimed at maintaining muscle tone and strength. When the patient is able to move on his own, the resolution phase commences, during which he should be able to understand the importance of basic recovery exercises and utilize them in future with little to no help from a medical professional.
Education
While the theory is not applicable to education in its entirety, its inherent principles are useful for organizing the education of patients. Specifically, when explaining the procedure of a certain exercise, the nurse must detail the reasons behind its usefulness and, hopefully, dispel common misconceptions which are known to result in adverse results (the roles of a teacher and resource person). At the same time, the educational programs must contain sufficient material to convince the patients in the benefits of active participation (leader role). Finally, the educational sessions must facilitate trust and incorporate the possibility for patients to come forward with their concerns and seek consultation from nurses (counselor role).
Administration
A similar principle can be utilized in administrative practices. The priority of communication in managerial nursing practices is expected to boost loyalty and commitment of the staff. Similarly, articulating the benefits of suggested administrative intervention is known to improve cooperation of employees and raise satisfaction rate (Brunetto, Farr-Wharton, & Shacklock, 2012). It is important to note that such approach is not directly implied by the original theory and should thus be exercised with caution.
Research
Among the less evident applications of Peplau’s theory is its use to maximize participation in research by increasing retention rates. Currently, the retention and recruitment of participants are among the biggest concerns in clinical research field. While the introduction of incentives is expected to increase the number of participants, a growing body of evidence shows that relations between the personnel and participants of the study plays a crucial role in successful sampling (Penckofer, Byrn, Mumby, & Ferrans, 2011). An article by Penckofer et al. (2011) offers a framework for utilizing Peplau’s theory to improve participation by establishing better communication and facilitate understanding. While this is a tempting concept, such approach requires additional adjustment. The suggested framework is thus recommended for discussion.
Applicability to APRN
As was noted above, nursing practice presents the best opportunities for applying Peplau’s theory. In particular, the scalability of the theory allows using its principles in many areas of APRN practices, such as medication prescription, preparation, and administration. According to the current understanding, a sufficient share of medication errors can be prevented by participation of patients in healthcare process and providing them with relevant knowledge (Keers, Williams, Cooke, & Ashcroft, 2013).
Both aspects are central to the discussed theory, making it appropriate for implementation. It is important to acknowledge that Peplau’s is not a practice theory and, therefore, does not include tools for predicting and measuring outcomes. Nevertheless, the growing body of research confirms the relation between the educational events along with patient-empowering environment and a decrease in preventable medication errors (Keers et al., 2013). Thus, it is possible to assume that strengthening the presence of teacher and leader roles while minimizing that of technical expert will likely result in better patient outcomes. Such approach would also require greater emphasis on identification phase.
Critique of the Theory
The theory in question is consistent, testable, and displays scientific integrity. Admittedly, it is fairly complex but can be presented in comprehendible terms to improve understanding. Admittedly, such simplification sometimes leads to misinterpretation and, on some occasions, incorrect usage (such as reaching false attainment followed by overdependence on a nurse), and several notions usually require in-depth explanation, such as the role of surrogate (often reported as obscure) (Peterson & Bredow, 2013). After overcoming such minor barriers, the theory is applicable to the majority of healthcare fields and is scalable to the degree where it can be used as a grand theory or a practice one. The limitations of the theory include the absence of assessment tools and weak emphasis on evidence-based practice, both of which can be averted by minor modifications. Overall, the theory remains among the most influential works in nursing practice and is traceable in most modern theories, guidelines, and healthcare policies.
References
Brunetto, Y., Farr-Wharton, R., & Shacklock, K. (2012). Communication, training, well-being, and commitment across nurse generations. Nursing Outlook, 60(1), 7-15.
Butts, J. B., Bandhauer, D., & Rich, K. L. (2013). Philosophies and theories for advanced nursing practice. Burlington, MA: Jones & Bartlett Publishers.
D’Antonio, P., Beeber, L., Sills, G., & Naegle, M. (2014). The future in the past: Hildegard Peplau and interpersonal relations in nursing. Nursing Inquiry, 21(4), 311-317.
Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Safety, 36(11), 1045-1067.
Penckofer, S., Byrn, M., Mumby, P., & Ferrans, C. E. (2011). Improving subject recruitment, retention, and participation in research through Peplau’s theory of interpersonal relations. Nursing Science Quarterly, 24(2), 146-151.
Peterson, S. J., & Bredow, T. S. (2013). Middle range theories: Application to nursing research. New York, NY: Lippincott Williams & Wilkins.
Snowden, A., Donnell, A., & Duffy, T. (2014). Pioneering theories in nursing. London, England: Andrews UK Limited.