Peplau's Psychodynamic Nursing

Psychodynamic Nursing

Theoretical Sources

- borrowed from behavioral science—psychological model

Use of Empirical Evidence

Maslow – people are motivated to attain self-actualization

Miller – personality theory, adjustment mechanisms, psychotherapy and principles of social learning

Pavlov’s – stimulus-response model influenced the principles of Miller’s social learning

Sullivan – the pioneer of modern psychiatry and includes cultural and social determiners to Freud’s interpersonal relationship model

MAJOR CONCEPTS AND DEFINITIONS

Psychodynamic nursing describe the dynamic relationship between a nurse and a patient.

Psychodynamic nursing is being able to understand one’s own behavior to help others identify felt difficulties, and to apply principles of human relations to the problems that arise at all levels of experience.

Peplau challenged psychiatric nursing to thrive in the new millennium in four central areas:

- the nurse-patient relationship

- engagement in evidence-based practice

- competence in information technology

- leadership in shifting the health care paradigm to community-based delivery.

NURSE-PATIENT RELATIONSHIP

(Interpersonal Relations Theory)

She described four phases of this relationship:

1. Orientation - in which the person and the nurse mutually identify the person's problem
2. Identification - in which the person identifies with the nurse, thereby accepting help
3. Exploitation - in which the person makes use of the nurse's help
4. Resolution - in which the person accepts new goals and frees herself or himself from the relationship.

Orientation Phase

1. When the nurse and patient first meet is known as the orientation phase.

2. 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.

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 patient’s 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.

Identification Phase

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.

Exploitation Phase

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.

Resolution Phase

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 patient’s integration of the illness experience.

Psychological Mothering:

1. The patient is accepted unconditionally to satisfy his needs.
2. There is recognition of and in response to the patient’s readiness for growth and his initiative.
3. Power in the relationships shifts to the patient as the patient is able to delay gratification and to invest in goal achievement.

NURSING ROLES

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.

Peplau separates teaching into two categories : Instructional—which consists largely of giving information and is the form explained in educational literature. Experiential— which is using the experience of the learner as a basis from which learning products are developed.

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 client’s 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.

MAJOR ASSUMPTIONS

Peplau identifies two explicit assumptions :

1. The kind of person the nurse becomes makes a substantial difference in what each patient will learn as he receives nursing care.

2. Fostering personality development toward maturity is a function of nursing and nursing education. Nursing uses principles and methods that guide the process toward resolution of interpersonal problems.

NURSING METAPARADIGM

Nursing

Nursing described as a significant, therapeutic, interpersonal process.

Person

Peplau defines person in terms of man. Man is an organism that lives in an unstable equilibrium.

Health

Peplau defines health as a word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living.

Environment

Peplau implicitly defines the environment in terms of existing forces outside the organism and in the context of culture, from which mores, customs, and beliefs are acquired.

Theoretical Assertions

Interpersonal Relations in Nursing

• Patient-nurse relationship
• Awareness of feelings
• Use of experiential learning method

Logical Form

- inductive approach

- empirical generalizations

- observes empirical events and generalizes from specific to all similar events

Application and Importance of the Theory

PRACTICE:

1. Integration of scientific disciplines in formulating paradigm of psychiatric nursing.
2. Strengthen nurse-patient relationship.
3. The start of psychiatric nursing.
4. Used for counseling women undergoing depression.

EDUCATION:

1. Interpersonal Relations in Nursing—used as a manual of instruction to nursing students.
2. Foundation of psychiatric nursing education.

RESEARCH:

1. Different studies on the nursing phenomena.
2. Improvement of the social system.
3. Stress management program.
4. Formation of behavior scale.
5. Therapeutic behavior of the nurses.

Analysis of the Theory

SIMPLICITY

1. The major theory that is interpersonal relations is easily understood.
2. Assumptions and key concepts were clearly given, explained, broken down and outlined.
3. Demonstrated clearly and identified properly the four phases of nurse-patient relationship and interpersonal model.
4. Applied effectively in the nursing profession.
5. It is consistent and semantic.

GENERALITY

1. Applicable to all nurses in any setting.
2. Used only in the situations that communication can occur.
3. It is impossible in working with senile, comatose or newborn patients. (one-sided relationship)

EMPIRICAL PRECISION

1. Based on reality.
2. Could be tested and observed using pure observation.
3. Theoretical area and empirical data are validated and verified.

DERIVABLE CONSEQUENCES

1. Widens the perception of nursing profession.
2. Broaden the scope of nursing practice.
3. Touched the lives of many.

References
Octaviano, E.F. & Balita, C.E. (2008). Theoretical Foundations of Nursing: The Philippine
Perspective, 77–86. Philippines: Ultimate Learning Series.
Tomey, A.M. & Alligood, M.R. (2002). Nursing Theorists and Their Work. 5th ed. Missouri:
Mosby, 379–388.