Journal Reading (Peplau and the Psychodynamic Nursing)
Remembering Hildegard Peplau
By Richard Lakeman
On the 17th of March 1999, HildegardPeplau died at the age of 89, ending a
nursing career, which spanned over fifty years. Peplau is often recognised as
the mother of psychiatric nursingbut her ideas have influenced all fields of
nursing. In 1948 Peplau completed her seminal work, Interpersonal Relations
in Nursing. However, it wasnt published until 1952 because atthe time it
was too revolutionary for a nurse to publish a book without a medical
practitioner as a co-author. This work which has been published in nine
languages, has perhaps done more to facilitate the development of
nursing from an occupation to a profession than any other. Sills (1998, p.171)
described Peplau as a woman of uncommon intellect, socialized outside
the traditional 1940s model of nursing in the United States, who developed a
paradigm of professionalism. that has permeated every aspect of her long
and distinguished career.
Even if a nurse has never read any of the hundreds of articles or books,
which cite and develop Peplaus ideas, it is likely that she or he, will still have
been influenced by the. Peplau suggested that nurses can and do make a
difference to people in the context of interpersonal relationships, which have
a discernible pattern, predictable phases and during which the nurse
assumes roles such as counsellor, leader or teacher.
A number of studies suggest that Peplau's theory remains a common frame
of reference for most psychiatric nurses (Hirschmann, 1989). Some selected
ideas from the works of Peplau (1952, p16) described nursing as "a
significant, therapeutic, interpersonal process. It functions co-operatively
with other 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 in the direction of
creative, constructive, productive, personal and community living". Lack of
growth, for whatever reason, implies impaired health in the individual and
basic human needs must be met if a healthy state is to be achieved and
maintained (Stuart & Sundeen, 1987, p 46).
A number of assumptions are implicit in Peplau's original and latter writings
(Forchuk, 1991). For example, the relationship of nurse and patient is
influential in the outcome for the patient; People may assume a number of
roles and have the capacity for empathy in relationships (Torres, 1986, p
171); People tend to behave in ways which have worked in the past when
faced with a crisis (Forchuk, 1991); Anxiety and tension arise from unmet or
conflicting needs, and the energy which arises may be harnessed into
positive means for defining, understanding and meeting the problem at
hand.
Orientation Phase
The phase of the relationship, when the nurse and patient first meet is
known as the orientation phase. This is a time when the patient and nurse
come to know each other as people and each others expectations and roles
are understood. The patient at this time needs to recognise 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
(Peplau, 1952, p 19). It may be expected that the patient will test limits in
order to establish the integrity of the nurse. 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 (Shives, 1994, p 91). When the patient can begin
to identify problems the relationship progresses to the working phase.
Working Phase
During the identification phase trust begins to develop and the patient
begins to respond selectively to persons who seem to offer help. The patient
begins to identify with the nurse and identify problems, which can be worked
on. The meaning behind feelings and behaviour of the nurse and patient are
explored. Peplau (1952, p31) 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. 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. In particular the
nurse assists in the expression of needs and feelings, assists during stress,
shows acceptance and provides information. 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. During the
exploitation phase the patient realistically exploits all of the services
available to them on the basis of self interest and need (Peplau, 1952, p 37).
The nurse assists the patient in their efforts to strike a balance between the
needs for dependence and independence. 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 (Forchuk & Brown, 1989, p 32). The nurse continues to
assess and assists in meeting new needs as they emerge.
Resolution Phase
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
(Peplau, 1952, p 39). The patient abandons old needs and aspires to new
goals. She or he continues to apply new problem solving skills and maintains
changes in style of communication and interaction. Resolution includes
planning for alternative sources of support, problem prevention, and the
patients integration of the illness experience.
Roles of the Nurse
The nurse may assume different roles within the relationship. The first role
assumed by both the nurse and patient is stranger. This role requires respect
and positive interest on the part of the nurse. The nurse may function as a
resource person, providing specific answers to questions usually formulated
with relation to a larger problem. As teacher the nurse assists the patient as
a learner to grow and learn from experience. As leader the nurse may assist
the patient as follower in a democratically implemented nursing process
(Stuart & Sundeen, 1987, p 46). The nurse may be cast into surrogate roles
by patients based on their significant past relationships. Considerable
importance is also assigned to the role of the nurse as counsellor which is
viewed as helping the patient integrate the facts and feelings associated
with an episode of illness into his or her total life experience. Nurses may
assume many other roles but in the context of the interpersonal relationship
all aim to assist the patient to meet the goals of therapy, need satisfaction
and growth (Stuart & Sundeen, 1987, p45).
Communication
Peplau (1952) expanded on a number of concepts drawn from
developmental, psychoanalytical and behavioural theory in order to assist
the nurse in understanding behaviour. Peplau (1952, p 290) defined
communication as an interpersonal process involving the selection of
symbols or concepts that go some way towards developing a common
understanding. Anxiety is present in all individuals to some degree and is
cognitively triggered by real or imagined, internal or external threats to an
individuals security (Forchuk, 1991). The ability to empathise with the
patient, and self-understanding are necessary requisites of the nurse as
therapist. Stuart and Sundeen (1987) describe Peplau's concepts as
belonging to a school of thought called the interpersonal view of behavioural
deviations which hold that behaviour evolves within the context of
interpersonal relations. A common belief within this theory is that by
experiencing a healthy relationship with the therapist, the patient can learn
to have more satisfying interpersonal relationships in general. Closeness
within the relationship is seen as necessary as it builds trust, empathy,
enhances self-esteem and fosters growth towards healthy behaviour. The
process of therapy involves re-educating the patient in more successful ways
of relating.
Nursings debt to Peplau
This brief and selective summary cannot do justice to Peplaus ideas, which
have been developed, expanded and put into practice over the last fifty
years. It is my hope that more people will continue to access Peplaus
original work, which will highlight that she was primarily a pragmatist rather
than an academic theorist. It captures the essence of what nursing is and
can become, lending it a timeless quality. Peplau developed knowledge with
practical import on learning, anxiety, hallucinations, interpersonal concepts,
individual, family and group therapy. She articulated a framework for
partnership and recovery, which continue to have significance for
contemporary practice.
Peplau developed and taught in the first graduate programme in psychiatric
nursing in the United States, assisted in the development of the first
graduate programme in Europe and was instrumental in developing the role
of nurse specialist. She was an advisor to the World Health Organisation, a
member of the International Council of Nurses, a fellow of
the Academy of Sigma Theta Tau, and has been awarded some of nursing
highest honours. Few students struggling to complete academic studies
would be failed to be impressed by Peplaus credentials, which include no
less than seven doctoral degrees!
Peplau (1987) viewed psychiatric nursing as a viable, complimentary and
necessary alternative to psychiatric-medical treatments. She encouraged
nurses to be proud of the development of nursing and challenged us to
remember that Somewhere, somehow, at some time in the past,
courageous nurses determined these skills, learned them, fought for the
right to use them, refined them, and taught them to other nurses. All nurses
have an obligation to remember that part of nursings past, and to keep their
own skills in pace with new opportunities for nursing into the next century.
(Peplau, 1989, p.32), Peplau was one such courageous woman who has left
us a legacy of practical knowledge to enable the survival and continued
development of nursing. We are forever in her debt.
References
Forchuk, C. & Brown, B. (1989). Establishing a nurse-client
relationship. Journal of
Psychosocial Nursing, 27(2), p 30-34.
Forchuk, C. (1991). Peplaus theory: Concepts and their relations.Nursing
Science
Quarterly, 4(2), p 54-60.
Hirschmann, M. (1989). Psychiatric and mental health nurses beliefs about
therapeutic
paradox. Journal of Child Psychiatric Nursing, 2(1), p 7-13.
Marriner-Tomey, A. (1994). Nursing Theorists and Their Work (3rd Ed). St
Louis, USA:
Mosby.
Peplau, H.E. (1952). Interpersonal Relations in Nursing. New York: G.P.
Putnams Sons.
Peplau, H. E. (1987). Psychiatric skills: Tomorrow's world. Nursing Times,
83(4), 29-32.
Shives, L.R. (1994). Basic Concepts of Psychiatric-Mental Health Nursing (3rd
Ed).
Philadelphia: J.B. Lippincott Company.
Sills, G. M. (1998). Peplau and professionalism: the emergence of the
paradigm of
professionalization. Journal of Psychiatric and mental Health Nursing,
5(4), 167-171.
Stuart, G.W. & Sundeen, S.J. (1987). Principles and Practice of Psychiatric
Nursing (3rd
Ed). St. Louis, USA: C.V. Mosby Co.
Torres, G. (1986). Theoretical Foundations of Nursing. USA: Appleton-
Century-Crofts.
