Hildegard Peplau Theory of Interpersonal Relationships

1. Hildegard PeplauTheory of Interpersonal Relationships Kristyn Beaver Darlene D’Arcangelo Magdalena Stewart Stephanie Teunessen

2. Peplau’s Theory : One Concept • "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)

3. Why Peplau’s Theory?Relevance for Personal Practice: • Communication is key to every Nurse-Patient 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)

4. The Components of Peplau’s Theory (Kearney-Nunnery,2008)

5. Research Studies Selected:We have chosen to share the findings of research articles that pertain to each of the 4 components of Peplau’s Theory.

6. Our Research on Peplau’s 4 Components:

7. A Naturalistic Test of Peplau’s Theory in Home Visiting by D.B. McNaughton, 2005 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.

8. Research Studies Selected • 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).

9. Research Findings for Home Visits • “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.

10. Research Findings continued… • “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.

11. Critique of the Research Limitations Credibility • 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. • 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.

12. Implications for Practice Practice implications Personal Practice • 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. • 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.

13. 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)

14. How did Peplau’sTheory: “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) )

15. 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?

16. 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).

17. 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)

18. 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) )

19. 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)

20. Implications for Practice The Study: Therapeutic Communication: Personal Practice: -Be engaged in communicating with patient, active listening. -Treat the patient with respect, show compassion and non judgemental behavior towards the patient. -Be sincere while communication -Allow the patient time to absorb what is being communicated. • --Create an atmosphere of trust. • --Promote an environment of • respect and empathy. • --Deliver information in a sensitive • manner.

21. Peplau’s Theory Component: 2 Persons Using Peplau’s Theory of Interpersonal Relations to Guide The Education of Patients Undergoing Urinary Diversion (Marchese, 2006). The Research:

22. ResearchApproach: • 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.

23. 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.

24. 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.

25. 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 nurse-patient 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.

26. Research Findings: • 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. • Identification: • Demonstration of neo-bladder care: irrigation, tube patency, care and cleaning of equipment, knowledge of emergency situations.

27. Findings… • Discussion of nutrition: prior eating habits, six small meals daily, fluid requirement 2 quarts daily • Development activity plan • Exploitation • Reaffirm patient’s knowledge and expertise, • Promote independence • Identify available community resources • Role playing • Present theoretical complex situations and have patient problem solve.

28. Findings… • 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

29. 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.

30. 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.

31. 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.

32. 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 theoryIt 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.

33. 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

34. 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.

35. Peplau’s TheoryComponent: Patient Need The Research Study: Silent, Slow Lifeworld: The Communication Experience of Nonvocal Ventilated Patients (Carroll, 2007).

36. Patient Needs: Communication “…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).

37. How did Peplau’s Theory “Frame the Research”? 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)?

38. Research: THE APPROACH • 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 lip-reading, patient answers were repeated for confirmation

39. Research: THE FINDINGS 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).

40. Research: FINDINGS cont. 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)

41. More Findings: “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).

42. Limitations of Research Study: (Carroll, 2007) 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.

43. Implications For Practice: The Study: Personal practice: • 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. • 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)

44. critical reflection & Discussion

45. Critical Reflection: • 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.

46. Critical Reflections continued • 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.

47. Discussion Questions: • 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).

48. References: • Carroll, S.M.(2007). Silent, Slow Lifeworld: The Commnication Experience of Nonvocal Ventilated Patients. Quality of Health Research, 17, 1165- 1177. 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.