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 nursing’ but her ideas have influenced all fields of nursing. In 1948 Peplau completed her seminal work, ‘Interpersonal Relations in Nursing’. However, it wasn’t published until 1952 because at the 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 Peplau’s ideas, it is likely that she or he, will still have been influenced by them. 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.

Some may recognise many of her ideas as being similar to those developed in role theory, cognitive behavioural therapy, symbolic interactionism, or reflecting ‘common sense’. 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.

The nurse patient relationship is characterised by a number of overlapping phases with a number of therapeutic tasks or goals to be accomplished. During each phase the patient expresses needs which find expression and require intervention in unique ways.

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 other’s 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

The working phase incorporates the identification and exploitation sub-phases and the relationship may fluctuate back and forth as new problems are identified. 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 patient’s 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.

Nursing’s debt to Peplau

This brief and selective summary cannot do justice to Peplau’s 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 Peplau’s 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 Peplau’s 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 nursing’s 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). Peplau’s 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. Putnam’s 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.

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