2.  Hildegard E. Peplau, first
published nursing
theorist in a century,
since Nightingale
 Created the nursing
middle-range theory of
Interpersonal Relations
 Helped revolutionize the
scholarly work of nurses
 Contributor to mental
health laws/reform
(Tomey & Alligood, 2006; O’Toole, 1989)

3.  Hildegard E. Peplau -- born September
1, 1909 in Reading, PA to immigrant
parents of German decent
 Illiterate, work-a-holic father
 Oppressive, perfectionist mother
 Raised in a paternalistic family
and a paternalistic society
 Though higher education was never
discussed at home, Hilda was strong-
willed, with motivation and vision to
grow beyond traditional women’s roles
 She wanted more out of life and knew
nursing was one of few career choices
for women in her day
(Callaway, 2002)

4.  WW I ended in 1918,
along with the great flu
epidemic the same year
 Industry expansion &
bullish stock market
 Women first vote 1920
 Roaring 20s &
Prohibition
 It was a man’s world in
both business and
education
(Callaway, 2002)

5.  The autonomous, nursing-
controlled Nightingale era
schools came to an end –
schools controlled by hospitals
now and formal book learning
was discouraged
 Hospitals and physicians saw
women in nursing as a source of
free or inexpensive labor
 Exploitation was not uncommon
of nurse’s employers,
physicians and educational
providers
 Nursing practice was controlled
by medicine
(Chinn, 2008)

6.  Peplau pushed forward beating
the odds:
 Graduate Pottstown, PA Hospital School of
Nursing in 1931
 BA Psychology: Bennington College, VT
1943
 World War II: Army Nurse Corps -- worked
in a neuropsychiatric hospital in London,
England
 MA Psychiatric Nursing: 1947; Ed.D.
Nursing Education: 1953, both graduate
degrees from Teachers’ College, Columbia
University
 Certification in Psychoanalysis for
Teachers: William Alanson White Institute,
New York City, 1954
(O’Toole, 1989)

7.  Hilda witnessed injustices
in life, being determined
to push past them for
social justice
 First exposure to
Interpersonal Theory at
Bennington
 Attended lectures by
Harold Stack Sullivan on
Interpersonal Relations
 Studied with Frieda Fromm-
Reichman and Eric Fromm
 She had vision to bring the
Sullivanian theory to
interactions with her
patients – they needed:
 Humane treatment
 Dignity & respect
 Healing discussion
…in a time when
there was none to
be found…
(Forchuk, 1993)

8.  Teachers’ College: Director of
Advanced Program in Psychiatric
Nursing
 She created nursing curriculum
 Included study of nurse-patient
interactions through “Process
Recordings”
 Peplau analyzed interactions of
students with patients, taking her
own experience into account
 Reviewed them for recurring themes
 Using clinical data for theory
development – empirical evidence
(Forchuk, 1993; Gastmans, 1998)
 Her book, or conceptual
framework, was completed by
1948, entitled Interpersonal
Relations in Nursing
(Forchuk, 1993)

9.  Publishing her book took four
additional years because it was
groundbreaking for a nurse to
contribute this scholarly work without
a coauthoring physician
 Peplau’s original intent was not theory
development per se
 She wanted “only to convey to the
nursing profession ideas [she] thought
were important to improve practice”
 Peplau’s focus was the quality of
nurse-patient interactions and nursing
education
(O’Toole, 1989; Forchuk, 1993, p. 3)

10.  BASIC ELEMENTS:
 the patient
 the nurse
 the interaction between them
 DEFINITIONS:
 CLIENT/PATIENT – person,
couple, group, community,
deserving of humane care with
dignity, privacy, ethics
 ENVIRONMENT - Physiological,
psychological and social fluidity
that may be illness-maintaining
or health-promoting
 HEALTH – Forward movement
of personality and other ongoing
human processes in the
direction of creative,
constructive, personal, and
community living
 INTERPERSONAL – Phenomena
that occur between persons
 NURSE – The medium of the art of
nursing; a maturing force. “The
unique blend of ideals, values,
integrity, and commitment to the
well-being of others…”
 NURSING ROLES - to assist client
starting as stranger, then technical
expert, resource person, surrogate,
counselor, teacher and others
(Forchuk, 1993; Peterson, 2009)

11.  Two original assumptions:
1) The kind of nurse each person
becomes makes a substantial
difference in what each client
will learn as she or he is nursed
throughout his or her
experience with illness
2) Fostering personality
development in the direction of
maturity is a function of nursing
and nursing education; it
requires the use of principles
and methods that permit and
guide the process of grappling
with everyday interpersonal
problems or difficulties
 Later Peplau added:
3) Nursing can take as its unique
focus the reactions of clients to
the circumstances of their
illnesses or health problems
4) Since illness provides opportunity
for learning and growth, nursing
can assist clients to gain
intellectual and interpersonal
competencies, beyond those that
they have at the point of illness,
by gearing the nursing practices
to evolving such competencies
through nurse-client interactions
(Forchuk, 1993)

12. 5) Psychodynamic nursing crosses all
specialty areas of nursing. It is not
synonymous with psychiatric nursing
since every nurse-client
relationship is an interpersonal
situation in which recurring
difficulties of everyday life arise
6) Difficulties in interpersonal relations
recur in varying intensities
throughout the life of everyone
7) The need to harness energy that
derives from tension and anxiety
connected to felt needs to positive
means for defining, understanding
and meeting productively the
problem at hand is a universal need
8) All human behavior is purposeful and
goal-seeking in terms of feelings of
satisfaction and/or security
9) The interaction of nurse and client is
fruitful when a method of
communication that identifies and uses
common meanings is at work in the
situation
10) The meaning of behavior to the client is
the only relevant basis on which nurses
can determine needs to be met
11) Each person will behave, during any
crisis, in a way that has worked in
relation to crisis in the past
(Forchuk, 1993)

13.  ORIENTATION PHASE
 Get acquainted phase of the nurse-
patient relationship
 Preconceptions are worked through
 Parameters are established and met
 Early levels of trust are developed
 Roles begin to be understood
 IDENTIFICATION PHASE
 The client begins to identify
problems to be worked on within
relationship
 The goal of the nurse: help the
patient to recognize his/her own
interdependent/participation role
and promote responsibility for self
(Belcher, 2002; Peterson, 2009)

14.  EXPLOITATION PHASE
 Client’s trust of nurse reached full
potential
 Client making full use of nursing
services
 Solving immediate problems
 Identifying and orienting self to
[discharge] goals
 RESOLUTION PHASE
 Final phase of nurse-patient
relationship
 Sense of security is found as patient
has less reliance and identification
upon nurse helper
 Client has increased self-reliance to
deal with his/her problem
(Belcher, 2002; Peterson, 2009)

15.  ROLES of NURSE: Interlocking functions
a nurse undertakes to assist a client
 Stranger (Orientation phase)
 Technical Expert & Authority Figure
 Surrogate for significant others
 Resource Person
 Change-Agent
 Researcher
 Counselor
 Arbitrator
 Teacher
 & More
 Specific roles variable within each
nurse-client situation, being limited only
by the imagination and skill of the nurse

16.  Within personalities, there are
needs, frustrations, conflicts, and
anxieties that are influential
 Every human has basic needs and
goals exerting tensions within the
relationship
 Nurse’s own self-understanding
helps nurse to respond to these
tensions and coping mechanisms
 Nurse guides patient towards
healing; tension and anxiety are
converted into purposeful action
as the result of the therapeutic
relationship
(Peterson, 2009)

17.  Psychological tasks of
humans learning to live with
others require attention
 Developmental processes
directly influence each
person’s expressions of
feelings, attitudes and beliefs
 They bring about situations in
which the nurse can assist the
patient
 Counting on others
 Delaying satisfaction
 Identifying oneself
 Participating with others
(Peterson, 2009)
 A wide range of concepts are
identified by Peplau having an
impact on the practice of the
nurse and the evolving nurse-
patient relationship
 Intrapersonal factors,
interpersonal factors and
specific clinical phenomena are
assessed
 Problems and goals can be
identified, then strategies
implemented for healing and
personal growth to take place
(Forchuk, 1993)

18.  Nursing Process Methods
 Observation
 “Observation and
understanding of what is
observed are essential
operations for making
judgments and designing
experiences with patients
that aid them in the
solution of their
problems”
 Communication
 Process Recording –
Analyze & Evaluate
 Nurse self-scrutiny is required,
along with observing and
analyzing his/her own behavior
 Communication: verbal and
nonverbal requires nurse to
recognize and understand
meanings
 Process recordings – used as
tools in the educational
development of nurse to gain
insights and learning skills
associated with healing in the
context of the relationship
(Peterson, 2009, p. 218)

20.  Nurse gains competencies of higher
understanding of self, concepts, roles
and processes to help patient toward
growth and healing
 Peplau warns: danger of ‘social talk’
with patients – Nurses shouldn’t
speak the same way to patient as to
family or friends. It should lead to
therapeutic effects – promoting long-
term well-being
 Nurse’s own emotional needs should
not get in the way of tending to the
needs of the patient
 Interpersonal Relations theory assists
the nurse to
 Observe more intelligently
 Intervene more sensitively
(O’Toole,
1989)

21. WITH THEORYWITHOUT THEORY
 New ostomy patient
 Nurse recognizes her own
anxieties of ostomy, as well as
patient’s anxiety (avoidance of
care and involvement)
 Nurse assists patient to explore
feelings through therapeutics
 Nurse openly prompts patient
to talk about concerns during
care of the appliance
 Encourages patient to look at,
touch, & care for appliance
progressively throughout care
 New ostomy patient
 Nurse senses tentions and tries
to help by lightening the mood
through distraction toward
other events – pt smiles
 Nurse continues to help the
patient by caring for the
appliance for the patient
 Inadequate coping is reinforced
 Another day went by with nurse
promoting increased patient
dependency by staff “helping”

22.  ADEQUACY:
 Contributes to the nursing
process
 Clearly consistent with
nursing’s values and mission
 Limited in groups of people
 Fairly narrow set of cultural
assumptions
(Meiers & Sheran, 2009)
 I disagree that it’s limited in
groups - Lego demonstrates it
has potential for group work
(Lego, 1998)
 It can be used in any specialty
area of nursing with patient
contact
 It is holistic in nature
 CLARITY:
 Clear and logical fashion
 Definitions are readily
understandable
 Though concepts are at a high
level of abstraction, they can be
learned with practice

23.  CONSISTENCY:
 Concepts and ideas are
parsimonious
 Worldview is
phenomenological in
nature and remains
consistent throughout
the theory
(Meiers & Sheran, 2009)
 LOGICAL
DEVELOPMENT:
 Logically inductively and
deductively based
 Many psychological
theorists’ works
integrated into
development
 Nursing role promotes the
patient’s movement
through the steps of the
nursing process
(Meiers & Sheran, 2009)

24.  LEVEL OF
DEVELOPMENT:
 Remains at the descriptive
level
 Focusing on phases of
relationships and
interactional/inter- and
intrapersonal phenomena
 Not changed significantly
since Peplau’s original
writings were published over
50 years ago
 DISCRIMINATION:
 Peplau is clear about making
distinctions between the
nursing and the medical
profession
 But theory can be used by all
helping professions in
practically all areas of the
relationship arena
(Meiers & Sheran, 2009)
 The patients who have
overwhelming physiological
needs (or unconscious) are not
good candidates for this theory
application (Belcher, 2002)
 Use with family members would
be appropriate

25.  COMPLEXITY:
 Theory has breadth, life and fluidity
 The basic core of the theory is
simple, but certain aspects of the
psychology in communication make
it more complex
(Meiers & Sheran, 2009)
 The concepts are at a fairly high
level of abstraction
 Both inductive and deductive
reasoning ability are part of this
theory
 Both quantitative and qualitative
research can take place
 REALITY CONVERGENCE:
 The basic tenants reality based,
particularly in nursing situations
requiring healing nurse-patient
communication
 Real life Application: Nurses should be
treating patients in a holistic fashion, no
matter the context - It should be utilized
more than it is, for the patient’s sake
 It requires time & practice to master –
start with the basics: a continual
process improvement
 Considering the economy & managed
care, Jones reports (1996) “…the need
to provide cost-effective quantifiable
care may negate the value of Peplau’s
theory”
 I disagree - This theory is valuable as
part of human development, maturity
and individual healing in many contexts

26.  PRAGMATIC UTILITY:
 Nurses’ critical thinking,
therapeutic-
intervention/communication -
beyond task oriented nursing
 Requires self-scrutiny of motives and
expectations by the nurse (maturity)
(Belcher, 2002)
 Requires understanding of inductive
reasoning skills
 It is the basis of higher levels of
caring
 Directly affects interventions dealing
with communication
 The interactions with the patient
spawn deeper thinking in both the
patient and the nurse towards
positive healthcare outcomes
(Meiers & Sheran, 2009)
 Utility based on individual use by
nurse to invest energy and vision into
relationship understanding & healing
 SCOPE:
 Used in practice domains where
interpersonal or intrapersonal
difficulties are taking place – [all (?)]
 Uses are broad; not confined to only
psychiatric nursing, but other areas of
nursing as well
(Meiers & Sheran, 2009)
 Limited in realm of
physiological/medical issues – but
helpful to patients with concerns or
“issues” –most pts have these to
some degree
 Very useful in settings of nursing
education where focus on nurse-
patient relationship and
communication are discussed

27.  SIGNIFICANCE/CONTAGIOU
S/CONTEMPORARY USE:
 Criterion for significance has been met
for the nursing discipline
(Meiers & Sheran, 2009)
 Continued references to the theory in
contemporary research and literature
attests to continued utility
 Many elements of the theory have
become public domain and integrated
into nursing practice without Peplau
being credited
 Theory has stood the test of time,
though only moderate and variable
use for formal research has occurred
(Belcher, 2002; Meiers & Sheran, 2009)
 Used internationally in Australia and
New Zealand, Belgium, Canada, the
UK, Ireland and the United States
 Translated into multiple languages
 Use of the theory by psychiatric nurses
and advanced practice nurses is not
uncommon
 Documented as useful in many other
areas of nursing: health education,
palliative care, oncology, AIDS care,
quality of life and many others
(Belcher, 2002)

28.  Used widely around the world
– nursing education
 Often integrated into policies
without credit to Peplau –
Public Domain
 Patient health education,
palliative care, oncology, AIDS
care, quality of life, private
practice, nurse practitioners,
home care & of course,
psychiatric nursing
 Nurse counseling of
individuals and groups
(Belcher, 2002; Lego, 1998; McNaughton, 2005;
Beeber, 2001)

29.  Most within National Healthcare
System of Canada in recent years
 Most research has been
qualitative – not quantitative
 Home care, Public Health,
Depression, Education of Patients,
Nature of Nurse-patient relations,
Role expectations, Preferred
Nursing care of ventilated patients
(Peterson, 2009)
 Yet worldwide influences on the
development of psychiatric
nursing practice have been
substantial
 For any theory, the acid test is
utility in practice
(Stockmann, 2005; Forchuk & Reynolds, 1998)
 U.S. focus has been on cost
containment, causing delivery to
be fragmented and restricted -
minimal research efforts
 Research has been fairly
inconsistent and scattered
abroad
(Stockmann, 2005; Forchuk & Reynolds, 1998)

30.  ROUTINE INTEGRATION
into daily practice within any area
of clinical nursing, with multi-
faceted effects
 Nurses in private counseling
practice would increase
 Theory requires the mature nurse to
look deeply at own behavior,
attitudes, motives, & actions during
daily practice & in relationships –
self-scrutiny
(Belcher, 2002)
 Invites the nurse to be less self-
gratifying, and more in tune to the
needs of the patient (and support
systems), as well as filtering into
peer and professional relationships
 RESULTS: All interactions
within practice would be more
mature and healing in a context of
caring, potentially improving peer
relations as well
 Near elimination of disrespect
between staff members with
improved focus on the welfare of
the patient – better focused care
plans

31.  Patients would perceive
being better understood
 Would comprehend
instruction with less anxiety
 Would give higher scores in
levels of satisfaction regarding
their nursing care
 Re-admissions would
decrease
 Increased comprehension of
teaching in patients
 Patient and staff increased
sense of responsibility for
selves
 Empowerment of both
patients & staff
 Improved health outcomes
 Success stories and patient
comments could be shared in
staff meetings and newsletters to
reinforce the new staff behaviors
 Role modeling by nursing &
management would give the
atmosphere of healing and caring
– less stressful environment

32.  Quantitative & qualitative research
demonstrating positive health-care
outcomes needs to take place (Jones, 1996)
 Focus on quantitative research would
verify the theory’s contemporary value,
even with today’s financial constraints
 It might require a blended effort of
Psychology and Nursing scholars
 Specifically, quantitative studies needed
to support the efficacy of the theory in
relation to patient outcomes
 Improved mental and physical health status
 Positive patient education results
 Favorable patient satisfaction
UPCOMING
NURSING
RESEARCH

33.  During her military service, Hilda
mothered Letitia Anne Peplau or
“Tish,” born January 30, 1945
 Hilda remained unmarried in a
time when it was clearly socially
unacceptable, keeping it a secret
from all but her immediate family
 She had her brother, Walter,
legally adopt Tish, so that Hilda
could continue to pursue her
scholarly endeavors while legally
raising her “niece”
 Hilda was not going to let social
prejudices stop her from making
further progress in her chosen
career of nursing…
 She continued and transformed
nursing from a “Science of doing”
to a “Science of knowing”
 Peplau played a role in landmark
legislation that established the
National Institute of Mental Health
in 1946
 An ambassador for graduate
education in nursing - teacher,
mentor, advisor, and sponsor – she
inspired generations of students
 Though often disappointed by her
profession, her career was
always rewarding -- She had
powerful vision to move nursing
forward as a profession of respect
(Callaway, 2002)

35.  Even in retirement, Hilda was
tenacious for nursing education
and continued to write for
publications and lecture
internationally
 Many accomplishments did not
“seem” noticed by the nursing
profession to Hildegard until
after her retirement
 Hilda contributed joyously as
the nursing profession moved
forward with developing higher
education programs
 ANA created the Hildegard
Peplau Award for contributions
to the advancement of nursing
through research, and inducted
Hilda into the ANA Hall of Fame
(Callaway, 2002)

36.  Developed the first graduate nursing
program devoted exclusively to the
preparation of clinical specialists in
psychiatric nursing
 Executive Director of the American
Nurses’ Association: 1969-70,
President from 1970-72, and Second
V.P. from 1972-74
 Third Vice-President and board
member for the International Council
of Nurses: 1973-81
 She served as World Health
Organization (WHO) consultant and
visiting professor at the University of
Leuvan in Belgium for two periods,
1975 and 1976 to 1977 (O’Toole,
1989)
 Fellow: American Academy of
Nursing
 After retirement she earned nine
Honorary Doctorates from Rutgers
University (Professor Emerita),
Columbia University, Duke University,
and others
(Callaway, 2002; Forchuk, 1993)
 Pronounced a “Living Legend” By the
American Academy of Nursing
 Labeled “Mother of Psychiatric
Nursing” and “Psychiatric Nurse of the
Century”
 Received Christiane Reimann Prize,
nursing’s highest honor
(Callaway, 2002)

37.  Hilda passed away, age 89,
March 17, 1999 leaving a
legacy of dignified and healing
relations with patients, as well
as healthy roots for nursing
education and scholarly
pursuits
 She made many contributions
to nursing and society during a
critical time in world history
 Hildegard carried a light and
will be remembered as the
“Mother of Psychiatric
Nursing”
(Callaway, 2002)

38.  Barker, P. (1998). The future of the theory of interpersonal relations? A personal refection of
Peplau’s theory. Journal of Psychiatric and Mental Health Nursing, 5, 213-220.
 Beeber, L. S., & Bourbonniere, M. (1998). The concept of interpersonal growth in Peplau’s
theory of nursing. Journal of Psychiatric and Mental Health Nursing, 5, 187-192.
 Belcher, J. R., & Brittain-Fish, L. J., (2002). Interpersonal Relations in Nursing: Hildegard E.
Peplau. In J. George (Ed.), Nursing theories: The base for professional nursing practice (5th
ed.)
(pp. 61-82). Upper Saddle River, NJ: Prentice Hall.
 Callaway, B. J. (2002). Hildegard Peplau: Psychiatric nurse of the century. New York: Springer.
 Chinn, P. L. (2008). Integrated theory and knowledge development in nursing (7th
ed.). St.
Louis, MO: Mosby.
 Forchuk, C. (1993). Hildegarde E. Peplau: Interpersonal nursing theory – Notes on nursing
theories (10). Newbury Park, CA: Sage.
 Forchuk, C., & Reynolds, B. (1998). Guest editorial – interpersonal theory in nursing practice:
the Peplau legacy. Journal of Psychiatric and Mental Health Nursing, 5, 165-166.

39.  Jones, A. (1996). Education and debate. The value of Peplau’s theory for mental health
nursing. British Journal of Nursing, 5(14), 877-881.
 Lego, S. (1998). The application of Peplau’s theory to group psychotherapy. Journal of
Psychiatric and Mental Health Nursing, 5(3), 193-196.
 McNaughton, D. B. (2005). A naturalistic test of Peplau’s theory in home visiting. Public Health
Nursing, 22(5), 429-438.
 Meiers, S. J., & Sheran, K.,(2009). Chapter 10 Analysis of theory: Interpersonal relations. In S.
Peterson & T. Bredow (Eds.), Middle range theories: Applications to nursing research (2nd
Ed.)
(pp. 378-380). Philadelphia, PA: Lippincott Williams & Wilkins.
 O’Toole, A. W., & Welt, S. R. (Ed.). (1989). Interpersonal theory in nursing practice: Selected
works of Hildegarde E. Peplau. New York: Springer.
 Tomey, A. M., & Alligood, M. R. (2006). Nursing theorists and their work (6th
ed.). St. Louis, MO:
Mosby.
 Peterson, S. J., (2009). Interpersonal Relations. In S. Peterson & T. Bredow (Eds.), Middle range
theories: Applications to nursing research (2nd
Ed.)(pp. 202-230). Philadelphia, PA: Lippincott
Williams & Wilkins.