Peplaus Theoretical Model 459and labeled the variables differently in order change. Peplaus interpersonal relationship isto specify relationships. The HPM may also also a process through which nursing knowl-be inappropriate when nurses are interacting edge is developed and validated (Reed,with clients who are cognitively impaired or 1996b). Peplau (1992) purposefully linkedunable to communicate. Examples would in- her theory to practice and research, as evi-clude infants or individuals with severe neu- denced in her basic assumption that "whatrological deficits. Overall, the predictive goes on between people can be noticed, stud-power of the model will always be limited by ied, explained, understood, and, if detrimen-the inherent uniqueness and variation of each tal, changed" (p. 14).humans behavior. Peplaus theoretical model derives from Strengths of the HPM include its use of the perspective of a critical philosophy thatconcepts that are logical and basic, its gener- integrates both the science and practice ofalizability, and its usefulness in research and nursing in theory development. Peplaus the-clinical practice. Fenders model also ad- oretical model was based upon her study,dresses the barriers to action that are im- observation, and analyses of nurses and pa-portant areas to focus nursing intervention. tients and was influenced by Harry Stack Sul-Lastly, Fender has taken a truly holistic ap- livan and others psychodynamic perspec-proach, considering sociocultural, psycho- tives. Peplaus (1952) classic descriptions oflogical, and biological variables. The content nursing express the nature and goals of theof the HPM model is consistent with contem- interpersonal process: "Nursing is a humanporary beliefs that health promotion is a na- relationship between an individual who istional and international priority and a cost- sick or in need of health services, and a nurseeffective alternative to sick care. especially educated to recognize and to re- spond to the need for help" (pp. 5-6). Nurs- CARYN A. SHEEHAN ing is an "educative instrument, a maturing force, that aims to promote forward move- ment of personality in the direction of cre-Peplaus Theoretical Model ative, constructive, productive, personal, and community living" (p. 16). Peplau (1988) fur-Hildegard Peplau (1909-1999) formulated ther described nursing as an "enabling, em-her theoretical ideas about the therapeutic powering, or transforming art" (p. 9).process of nursing in the 1940s and published Health, according to Peplau (1952), is athem in the now-classic 1952 book, Interper- "word symbol that implies forward move-sonal Relations in Nursing, after a lengthy ment of personality and other ongoing hu-dispute with publishers about the ability of man processes in the direction of creative,a nurse to author a book. At a time when constructive, productive, personal and com-nurses were "doers" for patients and "follow- munity living" (p. 12). Illness forces a "stock-ers" of physicians orders, Peplaus theoreti- taking by the sick person, which nurses cancal work and teachings helped catapult nurs- use to promote learning, growth and im-ing from an occupation to a profession. Pep- proved competencies for living" (Peplau,laus ideas provided a foundation for nurses 1992, p. 13). Health and illness are closelyto understand health from a nursing theoreti- linked to successful management of anxiety,cal perspective and to establish interpersonal which ranges from pure euphoria to purerelationships with patients as the significant anxiety. An optimal level lies between thesecontext in which nurses facilitate patients anxiety extremes, as determined by nursewell-being. and patient. Through Peplaus therapeutic relation- Through the therapeutic relationship, theship, the patient develops inner resources for nurse uses a complex set of strategies to assisthealthy behaviors by actively participating the patient in using energy provided by thewith the nurse in a developmental process of anxiety to identify and grow from a problem-
460 ENCYCLOPEDIA OF NURSING RESEARCHatic situation (OToole & Welt, 1989; Reed, that the power to accomplish the tasks at2005). The nurse-patient relationship is fun- hand resides within the patient and is facili-damental to providing nursing care and de- tated through the workings of therapeutic re-rives from the human need for connectedness lationship.that is still essential in the 21st century (Pep- The focus of the working phase is on: (a)lau, 1997). Through this interpersonal rela- the patients efforts to acquire and employtionship, nurses assess and assist people to: knowledge about the illness, available re-(a) achieve healthy levels of anxiety intraper- sources, and personal strengths, and (b) thesonally and (b) facilitate healthy pattern inte- nurses enactment of the roles of resourcegrations interpersonally, with the overall goal person, counselor, surrogate, and teacher inof fostering well-being, health, and develop- facilitating the patients development towardment. This relationship also provides the con- well-being (Peplau, 1952, 1997). The rela-text for the nurse to develop, apply, and eval- tionship is flexible enough for the patient touate theory-based knowledge for nursing function dependently, independently, or in-care. Nurse interpersonal competencies, in- terdependently with the nurse, based on thevestigative skill, and theoretical knowledge patients developmental capacity, level ofas well as patient characteristics and needs anxiety, self-awareness, and needs.are all important dimensions in the process Termination is the final phase in the pro-and outcomes of the relationship (Peplau). cess of the therapeutic interpersonal relation- The structure of the interpersonal relation- ship. Patients move beyond the initial identifi-ship was originally described in terms of four cation with the nurse and engage their ownphases: orientation, identification, exploita- strengths to foster health outside the thera-tion, and resolution (Peplau, 1952). Forchuk peutic relationship (Peplau, 1952, 1988). In(1991), with the support of Peplau, clarified addition to addressing closure issues, thethe structure as consisting of three main nurse and patient engage in planning for dis-phases: orientation, working (which incorpo- charge and potential needs for transitionalrated identification and exploitation), and care (Peplau, 1997).termination. In a 1997 publication, Peplau Peplaus theoretical model can be catego-endorsed this three-phase view and explained rized as a middle-range theory. It is narrowerthat the phases were overlapping, each having in scope than a conceptual model or grandunique characteristics. Throughout these theory and addresses a clearly defined num-phases the nurse functions cooperatively with ber of measurable concepts (e.g., therapeuticthe patient in the nursing roles of stranger, relationship, anxiety). The theory has a spe-resource person, counselor, leader, surrogate, cific focus on the characteristics and processand teacher. The nurses range of focus in- of the therapeutic relationship as a nursingcludes the patient in relationship with the method to help manage anxiety and fosterfamily, other health care providers, and com- healthy development. As such, the model ismunity (Peplau, 1952, 1997). directly applicable to research and practice. The orientation phase marks a first step Peplau was explicit in promoting research- in the personal growth of the patient and is based theory. Research based on Peplaus the- initiated when the patient has a "felt need" oretical model has addressed topics related and seeks professional assistance (Peplau, to both nurse behaviors and patient health 1952, p. 18). The nurse focuses on "knowing conditions. Nurse-focused topics include: (a) the patient as a person" and uncovering erro- the practices of psychiatric mental-health neous preconceptions, as well as gathering nurses, (b) family systems nursing, and (c) information about the patients mental health the nature of the nurse-patient relationship problem (Peplau, 1997). The nurse and pa- in reference to roles and role changes over tient collaborate on a plan, with consider- the trajectory of a mental illness, boundary ation of the patients educative needs. issues in pediatric nursing, and concepts such Throughout the process, the nurse recognizes as therapeutic intimacy. Patient-focused re-
Pet Therapy 461search has addressed health conditions in- ). The clinical significance of the thera-cluding depression, psychosis, sexual abuse, peutic relationship is likely to increase asAlzheimers disease, and multiple sclerosis. A health problems shift to those related toparticularly notable Peplau-based researcher stress-related conditions, chronic illness,is Forchuk (e.g., Forchuk, 1994; Forchuk et aging processes, and end of life, where medi-al., 1998; Forchuck, Jewell, Tweedell, & cal-surgical approaches alone have little suc-Steinnagel, 2003) who, along with col- cess in promoting well-being. Peplaus inter-leagues, has conducted a program of research personal relationship theory is expected tointo applications of the interpersonal rela- withstand the current health care crisis andtionship process in psychiatric mental-health provide a cost-effective and satisfying re-nursing care. source for patient well-being across a variety Peplaus model is historically significant of nursing contexts.for practice in that it propelled psychiatric The reawakening of nursing by Peplausnursing from custodial-based care to inter- ideas in the 1950s continues today throughpersonal relationship theory-based care. Pep- exploration, study, and use of the science-lau is considered the founder of professional based practice of interpersonal relations the-psychiatric mental-health nursing and was ory. Beebers (1998) research and theory de-the first to initiate an area of advanced prac- velopment have extended Peplaus model intice nursing. Her theoretical ideas continue important ways, using aesthetic knowing toto be significant in contemporary nursing for elaborate on the concept of interpersonal pat-their relevance in not only psychiatric mental- tern and formalizing Peplaus (1997) idea ofhealth nursing practice but practice anywhere transitions in a practice theory of depression.a nurse-patient relationship exists. Applica- Metatheoretical writings of Peden (1998) andtions of the model are found in individual Reed (1996a), inspired by Peplaus practice-psychotherapy, reminiscence therapy, termi- based strategy of theory development, por-nal illness care, and group and family ther- tend an emerging philosophy of nursing sci-apy. Practices based upon Peplaus theory ence that sanctions clinicians as well as tradi-range from hospital to community and tional researchers as knowledge-builders.home-based. Through the creative scholarship of nurses, Peplaus theory has provided an enduring Peplaus theoretical model can continue toeducational foundation for teaching the evolve and inspire development of nurse-pa-nurse-patient relationship as a pivotal nurs- tient processes that meet contemporarying process in all contexts of practice. A com- health needs of society.mon philosophy underlying all nursing cur-ricula is a belief in the value of a therapeutic PAMELA G. REEDnurse-patient relationship that promotes ac- NELMA B. SHEARERtive participation of patients in their healthcare. Peplaus theoretical work has also pro-moted a "paradigm of professionalization" Pet Therapyand empowerment for educating nurses forthe 21st century (Sills, 1998). Pet therapy (use of a companion animal to Peplaus theoretical model continues to in- benefit the health of humans) has becomefluence nursing research, practice, and educa- a very popular intervention for a variety oftion (OToole & Welt, 1989), although her clients, and many nurses as well as pet ownersoriginal contributions have become knowl- have become involved in its delivery. Whileedge in the public domain and are not always at the intuitive level pet therapy appears toexplicitly acknowledged. Internationally, be beneficial, there are relatively few scientificnurses are recognizing Peplaus legacy and studies to support its effectiveness. Thisthe enduring relevance of her theory for nurs- growing body of research on pet therapy hasing in the new millennium (e.g., Barker largely been generated by multidisciplinary
Contributors xxviiJoanne W. Rains, DNS, Mary Anne Rizzolo, EdD, Norma Martinez Rogers, RN RN, FAAN PhD, RNDean and Associate Director for Professional Assistant Professor Professor Development University of Texas HealthIndiana University East National League for Science CenterDivision of Nursing Nursing School of NursingRichmond, IN New York, NY San Antonio, TX Collaborative Research Research on Interactive Minority Women Video OffendersBarbara Rakel, MA, RNAdvanced Practice Nurse Carol A. Romano, MS, Beverly L. Roberts, RN, Supervisor RN, FAAN PhD, FAAN, FGSA Director, NursingUniversity of Iowa Arline H. and Curtis F. Information Systems andHospitals and Clinics Garvin Professor of Quality AssuranceIowa City, IA Nursing Warren Grant Magnuson Ethnography Frances Payne Bolton Clinical CenterPamela G. Reed, PhD, RN, School of Nursing National Institutes of FAAN Case Western Reserve HealthProfessor University Bethesda, MDUniversity of Arizona Cleveland, OH Data StewardshipCollege of Nursing Falls; Functional HealthTucson, AZ Eileen Virginia Romeo, Karen R. Robinson, PhD MSN, RN Peplaus Theoretical Non Clinical Lecturer in Doctoral Student Model; Spirituality Gastroenterology Case Western ReserveBarbara Resnick, PhD, Institute of Infection, University CRNP, FAAN, FAANP Immunity and Frances Payne BoltonAssociate Professor Inflammation School of NursingUniversity of Maryland University Hospital Cleveland, OHSchool of Nursing Queens Medical Center Or ems Self-Care DeficitBaltimore, MD Nottingham, United Nursing Theory Continuing Care Kingdom Marlene M. Rosenkoetter, Retirement Communities Current Procedural PhD, RN, FAANVirginia Richardson, DNS, Terminology-Coded Professor RN, CPNP Services; Denial in Medical College of GeorgiaAssistant Dean for Student Coronary Heart Disease School of Nursing Affairs Atlanta, GAAssociate Professor Bonnie Rogers, PhD, RetirementIndiana University COHN-S, LNCC, FAAN Associate Professor and Virginia K. Saba, EdD,School of Nursing Director, Occupational RN, FAAN, FACMIIndianapolis, IN Safety and Health Distinguished Scholar, Pediatric Primary Care Adjunct Education and ResearchSusan K. Riesch, DNSc, Georgetown University Center RN, FAAN School of Nursing and University of NorthProfessor, School of Health Studies Carolina at Chapel Hill Nursing Washington, DC School of Public HealthUniversity of Wisconsin- Chapel Hill, NC Home Health Care Madison Classification System; Nursing Occupational Home Health Systems;School of Nursing Injury and Stress Nursing Informatics;Madison, WI Nursing Centers Nursing Information Systems
xxviii CONTRIBUTORSAH Salman, MD, RN Judith Kennedy Schwarz, Shyang-Yun Pamela K.PhD Candidate PhD, RN Shiao, PhD, RN, FAANCase Western Reserve Consultant, Ethics and Associate Professor University End-of-Life Care University of TexasFrances Payne Bolton New York, NY Health Sciences Center School of Nursing Advance Directives School of NursingCleveland, OH Houston, TX Depression and Joan L. Shaver, PhD, RN, Endotracheal Suctioning Cardiovascular Diseases; FAAN in Newborns: NICU Hypertension Professor and Dean Preterm Infant Care University of Illinois atHelen A. Schaag, RN, Chicago Elaine K. Shimono, MA, MSN, MA College of Nursing RNProject Director, CPAP Chicago, IL Clinical Director Research Study Sleep Psychiatry Care CenterUniversity of Kansas Mount Sinai MedicalSchool of Nursing Nelma B. Shearer, PhD, CenterKansas City, KS RN New York, NY Caregiver; Home Care Assistant Professor College of Nursing (Martha E.) Rogers Technologies Arizona State University Science of UnitaryKaren L. Schumacher, PhD, Tempe, AZ Persons RN Peplaus TheoreticalAssistant Professor Mary Cipriano Silva, PhD, Model RN, FAANUniversity of PennsylvaniaSchool of Nursing Caryn A. Sheehan, MSN, Professor EmeritusPhiladelphia, PA RN George Mason University Transitions and Health Assistant Professor College of Nursing and St. Anselm College Health ScienceElizabeth A. Schlenk, PhD, Department of Nursing Fairfax, VA RN Manchester, NH Clinical ProfessorAssistant Professor Fenders Health School of Public HealthUniversity of Pittsburgh Promotion Model and Health SciencesSchool of Nursing University ofPittsburgh, PA Mary Shelkey, PhD, RN, Massachusetts Patient Contracting ARNP Amherst, MA Assistant Professor Ethics of Research;Donald F. Schwarz, MD, Seattle University Philosophy of Nursing MPH, MBA College of NursingDeputy Physician-in-Chief Seattle, WA Carol E. Smith, PhD, RNChief, Craig-Dalsimer Alzheimers Disease Professor Division of Adolescent University of Kansas Medicine Deborah Shelton, PhD, School of NursingUniversity of Pennsylvania RN, CNA, BC Kansas City, KSSchools of Medicine and Associate Professor of Nursing Nursing Caregiver; Home CarePhiladelphia, PA University of Connecticut Technologies; Quality of School of Nursing Life Adolescence; Adolescent Pregnancy and Storrs, CT Parenting; Infant Injury Child Delinquents
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