Introduction
Hildegard E. Peplau was an American nurse who developed the interpersonal relations theory of nursing. Her specialty was mental health nursing and her theory revolutionized nursing practice by emphasizing on the need for a partnership between the nurse and the patient instead of a situation where a patient receives health care services passively. Patient participation is the foundation of patient centered care which is one of the dimensions of quality in modern health care setting. Peplau’s interpersonal relations theory is a midrange nursing theory which bridges grand nursing theories to day-to-day nursing practice. This essay evaluates Peplau’s interpersonal relations theory with emphasis on the theoretical system, the scope of the theory, social significance and level of theory development.
Before Peplau developed her interpersonal relationship theory the only nursing theory that existed was Nightingale’s theory of nursing practice (Selanders, 2010). This is a gland nursing theory that defined the practice of nursing and emphasized on how the environment can be altered to improve care. Nightingale’s theory focuses on the patient’s physical needs with little coverage of psychological and emotional needs. Accordingly, nursing care should focus on putting the patient in the best conditions to promote comfort.
Theoretical System
Peplau’s interpersonal relations theory is a mid range theory that was developed to improve nursing practice by linking the grand theories that emphasize on the need for quality nursing services to practical steps that nurses can take to realize quality nursing services. The theory is developed on a conceptual framework of nurse-client relationship and the role of nursing. Peplau identified seven nursing roles which when linked with an effective nurse-client relationship leads to improved quality of care. When Peplau first developed the interpersonal relationship theory in 1940s, nursing practice was very different from today. Patients used to receive nursing care passively while nurses carried out the doctor’s orders without question or any contribution. Peplau realized that quality health care services can only be realized if both nurses and patients take a more active role. This would lead to the development of a shared experience where patients and nurses jointly contribute to health care services. In mental health nursing, nurse-patient relationship is a core requirement in nursing practice. Peplau (1997) defines nurse-client relationship as a deliberate engagement between nurses and their patients whose goal is to enhance the patient’s wellbeing. This relationship is built on the actions, feelings and thoughts of both the nurses and the patient.
An effective nurse-client relationship enhances nursing care and improves patient outcomes since the patient’s needs are considered fully when providing care. This is relevant to mental health nursing where nurses have to regularly listen at the client’s needs to know which interventions to take. Quality care is patient centric and the Peplau’s interpersonal relationship theory is an implementation of patient centered care.
Elements of an Effective Nurse-Client Relationship
The efficacy of Peplau’s interpersonal theory in improving nursing practice is based on the development of an effective nurse-client relationship. This relationship enables both the nurses and the patient to express their views freely (Norcross & Lambert, 2011). The elements that characterize an effective nurse-client relationship include the contract, boundaries, confidentiality and therapeutic nurse behavior. The contract is a mutual agreement between the nurse and the patient for collaboration in care provision. The contract is based on shared goals in which the nurse and the patient want to realize positive patient outcomes and wellbeing. For instance, in mental health a patient has to admit the need for health care and accept the services of the nurses. This will reduce instances of violence against health care providers and enhance care delivery. A contract based on realizing the shared goal of patient wellbeing enhances care and creates obligations.
Boundaries are the markers of each participant’s role and obligation. The interaction in a nurse-client relationship is based on the patient’s problems. The nurse has the responsibility of acting as the patients advocate and displaying professional behavior. The patient has a role of participating in care delivery and following the agreed nursing care delivery plan. Additionally, the patient has the responsibility of avoiding harm, in order to give health care services a chance. This is very significant in mental health nursing where the patients tend to have self harming behavior such as cutting themselves or even committing suicide. Confidentiality is an element of effective nurse-client relationship that is meant to plantain the patient’s self determination and privacy. This ensures that the patient and patient information is treated with dignity at all time and is not shared without the patients consent. Confidentiality makes it easy for the patient to share information with the nurse.
Therapeutic nurse behaviors are nursing-dependent behavior and practices that characterize professional nursing practice. Therapeutic nurse behaviors in psychiatric nursing enhance care delivery by emphasizing on the need for provision of physical care, conveying safety, protection and companionship (Hawamdeh & Fakhry, 2013). The most important therapeutic nursing behaviors that enhance the nurse-client relationship include empathy, cultural sensitivity, collaborative goal setting, ethical and safe practice, mutual respect and using best practices to enhance patient care.
The patients are party to the nurse-client relationship since they are the clients in need of health services. The client’s perspective of nurse-client relationship is characterized by patient expectations of care and the reality regarding the care received. Usually, the client’s primary expectations of care are to get relief from suffering and to have high patient wellbeing. Secondary expectations of nursing care include privacy and confidentiality. Patients view the nurse-client relationship as being effective when their needs and expectations are met (Morgan & Yoder, 2012). The relationship may be bright is bright when the patients feel their needs are catered for and nurses genuinely want to improve their wellbeing. The relationship is dark when the patients expectations are not met indicating low quality of care.
Development of the Nurse-Client Relationship
An effective nurse-client relationship results from a good development stage. The development stage of a good nurse-client relationship should formulate shared goals, anticipate potential barriers to the realization of the goals and identify ways to mitigate these barriers and enable the realization of the goals. Peplau, (1997) identified four stages; orientation phase, identification phase, exploitation phase, and resolution phase that are important in the development of effective nurse-client relationship.
During the orientation phase, the nurse and the patient gets acquainted. This happens when the patient is admitted and meets the nurses for the first time. The nurse’s role during orientation phase is to learn as much as possible about the patient and to develop trust (Dinç, & Gastmans, 2013). The orientation phase allows both the nurse and the patient to work through their preconceptions which enables them to develop mutual trust. Nurses can enhance the orientation phase by reassuring the patient of privacy, confidentiality and professional conduct throughout the process of care delivery. The identification phase follows the orientation phase and is the period during which the patient’s problems and needs are identified. This is is a critical phase for a nurse since not only must s/he identify the patient problems, needs and expectations but must also help the patient to realize his/her own interdependent. Realizing self interdependence helps the patient to participate actively in care delivery by creating a feeling of responsibility.
The exploitation phase is reached when the patient trusts the nurse fully. The patient is free to express him/herself and regularly uses nursing services to solve immediate problems. In psychiatric nursing the exploitation phase is characterized by patients that are free to speak to nurses about their problems, their views on the care being offered and their worries after they are discharged. This phase is most productive in terms of meeting patient needs and giving nurses opportunities to improve the quality of care offered. The patients in the exploitation phase are able to identify and orient their behavior to the discharge goals.
The final stage of developing an effective nurse-client relationship is the resolution phase. During this phase, the patient becomes less reliant on the nurse as increased independent is encouraged in line with the discharge goals. Increased self reliance on the patient’s side is as a result of development of self efficacy. When all the client’s needs have been met, the nurse-client relationship is mutually terminated.
Peplau’s Seven Nursing Roles
Peplau’s interpersonal relationship theory is a midrange nursing theory that links grand nursing theories to nursing practice on a day to day basis. To achieve this link, mid level theories is often action oriented. To qualify her midrange theory of interpersonal relationship, Paplau identified seven roles that nurses must do to enhance care delivery (D’Antonio et al., 2014). The roles demonstrate the dynamics of nursing practice which an effective nurse must adopt and embrace. The first role is that of a stranger who has to cultivate a patient’s trust. Nurses also act as resources in that they give information through patient education to help the patient understand the disease and treatment options. The resource role is integrated with the teaching role. The fourth role of nurses is counseling. In this capacity, nurses help the patients to understand and interpret the prevailing life circumstances and provide encouragement to the patients. Nurses also act as surrogates to help patients have a clear understanding of interdependence before they are fully independent. Nurses are active leaders who actively set goals, design interventions to meet these goals and evaluate the efficacy of these interventions. Nurse leadership helps them to gain autonomy and distinction from other health care professionals. The final role of nurses is acting as technical experts to provide quality care.
Scope of Peplau’s Interpersonal Relationship Theory
Peplau’s interpersonal relationship theory is a midrange nursing theory which is descriptive and links empirical grand nursing theories to nursing practice. The scope of Peplau’s interpersonal relationship theory is given by its definition of central concepts. From the theory, a person is a developing organism that suffers and gets anxious when their needs are not met. A person exists in the context of the environment which is characterized by culture. Nursing is a therapeutic interpersonal process in which a nurse helps people achieves health. The theory is further limited by its nature. Since it emphasizes on an interpersonal relationship to help meet the patient’s needs, the theory cannot be used on patients who cannot express their needs such as unconscious patients. Additionally, the theory does not integrate health promotion and health maintenance as important ways of achieving good health.
Level of Development
Peplau’s interpersonal relationship theory is a midrange nursing theory. It explains nursing concepts that are applicable on day-to-day nursing practice and can be tested. However, the scope of the theory is wide enough to make it relevant in many nursing fields. This wide scope of the theory makes it applicable to nursing practice. The theory was developed as a way of enhancing nurse autonomy and ensuring patients get holistic care. By recommending that care be provided in the context of an effective nurse-client relationship, Peplau anticipated some elements of modern quality care such as patient-centered care and culturally sensitive care. This prediction of measures of quality demonstrates the high level of development and the practical applicability of the theory in modern day nursing care settings. Although the theory is not developed enough to be applicable in health promotion and health maintenance which are the pillars of public health, the theory can nonetheless be applied in community health nursing.
Social Significance of Peplau’s Interpersonal Relationship Theory
The major social significance of Peplau’s interpersonal relationship theory is that it divides responsibility of delivering quality health care services between the nurses and the patients. Before the advent of Peplau’s interpersonal relationship theory, the patients received health care services passively with nurses being wholly responsible for providing care. The direct impact of this is that patients become equal partners in their health. Patient participation is critical for the management of chronic and lifestyle disease which are causing a large health burden. For instance, while a nurse provides medication to control blood pressure in patients suffering from hypertension, the patient has a responsibility of controlling risk factors such as high cholesterol and obesity which may complicate the condition and lead to poor outcomes. Involving patients in care delivery leads to immediate feedback on the quality and acceptability of care offered. Peplau’s interpersonal relationship theory can be extended to provide care to a community where the nurse builds a nurse-client relationship with the community. This has a positive social impact in that it leads to improved community health.
Conclusion
Peplau’s interpersonal relationship theory is a midrange nursing theory which whose goals are to define nursing practice and the process of care delivery. Midrange nursing theories serve to link empirical grand nursing theories to nursing practice on a day to day basis. Peplau’s theory was developed form a background of psychiatric nursing. From the theory, effective nursing practice is as a result of a functional nurse-client relationship. A nurse-client relationship is based on mutual trust and enables the patients to freely express their needs and participate in the interventions meant for meet these needs. Good health is achieved when the patient’s physical, psychological, and emotional needs are met. The theory identifies the roles of nursing which help to support care delivery. The theory anticipated concepts such as patient-centered care and culturally sensitive care making it applicable in modern nursing practice setting where patient-centered care and culturally sensitive care promote acceptability and quality of care. Despite its wide applicability in nursing practice, Peplau’s interpersonal relationship theory can only be implemented on patients who can understandably express their needs and are capable of developing a strong nurse-client relationship. This excludes some patients such as those who are unconscious or psychiatric patients who are withdrawn and do not communicate to the care providers.
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