Interpersonal theory in nursing practice

Interpersonal theory in nursing practice:

·              Nursing is no longer a vocation, but a profession. Since the time of Florence Nightingale, it has formed a definite part of hospital organization. woman now enters the profession—one who does not consider nursing as a good vocation alone, or look upon it from the viewpoint of the idealism of its service; but one who also views it in its broader perspective, thinking of its ,educative and social service. The nurse is an educator and a social worker whether she is, conscious of it or not. Dr. Haven Emerson goes so far as to say:

"I have often felt that there is among the nursing group the largest potential power forthe correction of social ills that exists within the country, because nobody else knows what is the horror, the fear, that 'hangs over people from unemployment, as the nurse does. Nobody sees what it means to be politically "hounded the way the nurse does of the home which is subject to political catastrophe. The nurse knows well what it means for a family breadwinner to suffer a reduction of wages. The nurse is the eyes and conscience of the community in seeing and judging those matters which adversely affect the health and life, the survival of babies and children and parents in the home."

In the hospital the nurse contacts all departments. An interrelationship exists between her and the medical staff, the adjunct departments, and the administration. Often she is the only, confidante of the patient. She must keep a correct record of her observations, of symptoms, or of any physical or mental changes of the patient. She must co‐operate with the administration in reporting the seriously ill. No hospital today is considered efficient which does not have a well‐qualified, well‐disciplined nursing staff. Good nursing service is one of its greatest assets.

·       Peplau's theory of interpersonal relations:

Hildegard E. Peplau, one of the world's leading nurses and known too many as the "Nurse of the Century”. Dr. Peplau is the only nurse to serve the American Nurses Association (ANA) as Executive Director and later as President. She was also elected to serve two terms on the board of the International Council of Nurses (ICN). Peplau is universally regarded as the mother of psychiatric nursing. Her theoretical and clinical work led to the development of the distinct specialty field of psychiatric nursing. Peplau's seminal book, Interpersonal Relations in nursing (1952), was completed in 1948. Publication was delayed for 4 years because at that time it was  considered too revolutionary for a nurse to publish a book without a physician co‐author. Peplau's book has been widely credited with transforming nursing from a group of skilled workers to a fully fledged profession. Since the publication of Peplau's work, interpersonal process has been universally integrated into nursing education and nursing practices worldwide. It has been argued that Dr. Peplau's life and work produced the greatest changes in nursing practice since Florence Nightingale. (Anita Werner O'Toole, et.al, 1989)

Peplau's theory of interpersonal relations provides a useful framework for investigating clinical phenomena and guiding nurses' actions. While the case data are encouraging, it is suggested that there is a need to test the clinical effectiveness of Peplau's concepts by utilizing experimental research designs. Hildegard Peplau interpersonal theory incorporates communication and relationship concepts from Harry Stack Sullivans’s Interpersonal Theory. (Joyce, 2005)

Through this interpersonal relationship, nurses assess and assist people to: (a) achieve healthy levels of anxiety interpersonally and (b) facilitate healthy pattern integrations interpersonally, with the overall goal of fostering well‐being, health, and development. This relationship also provides the context for the nurse to develop, apply, and evaluate theory‐based knowledge for nursing care. Nurse interpersonal competencies, investigative skill, and the theoretical knowledge as well as patient characteristics and needs are well important dimensions in the process and outcomes of the relationship.

The structure of the interpersonal relationship was originally described in four phases. Her theory focuses primary on the nurse‐client relationship in which problem‐solving skills are developed. Four phases occur during this interactive process: orientation, identification, exploitation andresolution.  Forchuk (1991), with the support of Peplau, clarified the structure as consisting ofthree main phases: orientation, working (which incorporated identification and exploitation), and termination. In a 1997 publication, Peplau endorsed this three phase view and explained that the phases were overlapping, each having unique characteristics. Throughout theses phases the nurse functions cooperatively with the patient in the nursing roles of:

·     Counseling Role ‐ working with the patient on currentproblems.

·     Leadership Role ‐ working with the patientdemocratically.

·     Surrogate Role ‐ figuratively standing in for a person inthe patient's life.

·     Stranger ‐ accepting the patient objectively.

·     Resource Person ‐ interpreting the medical plan to thepatient.

·     Teaching Role ‐ offering information and helping thepatient learn.

Forchuk’s structurural classification of interpersonal relationship:

o     The orientation phase marks a first step in the personal growth of the patient and is initiated when the patient has felt need and seeks professional assistance. The nurse focuses on knowing the patient as a person and uncovering erroneous preconceptions, as well as gathering information about the patient’s mental health problem. The nurse and patient collaborate on a plan, with consideration of the patient’s educative needs. Throughout the process, the nurse recognizes that the power to accomplish the tasks at hand resides within the patient and is facilitated through the workings of the therapeutic relationship. (Peplau, H.E, 1952)

o     The focus of the working phase is on: (a) the patient’s efforts to acquire and employ knowledge about the illness, available resources, and personal strengths, and (b) the nurse’s enactment of the roles of resource person, counselor, surrogate and teacher in facilitating the patient’s development toward well‐being. The relationship is flexible enough for the patient to function dependently, independently, or interdependently with the nurse, based on the patient’s developmental capacity, level of anxiety, self‐awareness, and needs.

o     Termination is the final phase in the process of the therapeutic interpersonal relationship. Patients move beyond the initial identification with the nurse and engage their own strengths to foster health outside the therapeutic relationship. In addition to addressing closure issues, the nurse and patient engage in planning for discharge and potential needs for transitional care. (Joyce J. Fitzpatrick, Meredith Wallace, 2005)

Peplau’s theoretical model can be categorized as a middle‐range theory. It is narrower in scope than conceptual model or grand theory and addresses a clearly defined number of measurable concepts (e.g., therapeutic relationship, anxiety). The theory has specific focus on the characteristics and process of the therapeutic relationship as a nursing method to help manage anxiety and foster healthy development. As such, the model is directly applicable to research and practice.

This theory is also historically significant for, it propelled psychiatric nursing from custodial based care to interpersonal relationship theory based care. Peplau is considered the founder of professional psychiatric mental health nursing and was the first to initiate an area of advanced practice nursing. Her theoretical ideas continue to be significant in contemporary nursing for their relevance in not only psychiatric mental health nursing practice but practice anywhere a nurse patient relationship exits. Applications of the theory are found in individual psychotherapy, reminiscence therapy, terminal illness care, and group and family therapy. Practices based upon Peplau’s theory range from hospital to community and home based. (Peplau, H.E, 1952)

Peplau’s theory has provided an enduring educational foundation for teaching the nurse patient relationships as a pivotal nursing process in all contexts of practice. A common philosophy underlying all nursing curricular is a belief in the value of a therapeutic nurse patient relationship that promotes active participation of patients in their health care. Peplau’s theoretical work has also promoted a paradigm of professionalization and empowerment for educating nurse for the 21st century.

The reawakening of nursing by Peplau’s ideas in the 1950s continues today through exploration, study, and use of the science based practice of interpersonal relations theory. Analysis of this theory reveals that it is effective in long term care, home health and psychiatric setting where time allows for the development of a nurse client relationship and hopefully a resolution to promote health. However the theory’s effectiveness is limited in short term, acute care nursing setting, where hospitalizations last for only few hours or for few days. It is also ineffective when the client is considered to be group of individuals, a family, or a community.