This portfolio will explain Peplaus belief of interpersonal relationships in mental and psychiatric health being critical, the roles that the nurse assumes to provide an interpersonal involvement with a patient and the phases the nurse-client relationship progresses through in order to implement the interpersonal relationship. Peplaus theory of interpersonal relations has been used extensively through nursing history, it is used today as a basis for understanding, and providing care within, psychiatric nursing.
Hildegarde Peplau developed her theory for the purpose of assisting nurses to understand interpersonal relationship, to guide nursing practice and so the nurse can care for their patients in an understanding way. Peplau was the first theorist to describe interpersonal relations as the foundation of nursing practice (Townsend, 2009), her theory was described as the mother of mental health nursing (Arnold & Boggs, 2007). Peplau believes that interpersonal relationships are the key to mental health nursing, but more in particular developing specific interpersonal connections between a nurse and client (McQuiston & Webb, 1995).
The belief is that the nurse-client relationships should be built interpersonally through person-to-person communication (Craven & Hirnle, 2009). Peplau believed that the interpersonal relationship should be developed in a doing with the patient approach opposed to doing for the patient (Elder, Evans & Nizette, 2009). Peplaus nursing model uses the skill of interaction with the patient, as its main theme (Simpson, 1991). Peplau believes the development of skills needed to maintain and nurture the nurse-client relationship to be the most important factor in the process of care for mental health (Simpson, 1991).
Without this, the nurse could not truly be helpful or therapeutic. In the mental health context, a therapeutic relationship allows for a meaningful journey to recovery for the patient, through a shared experience between the nurse and client. Mental health care should not have a focus on medical treatment, but rather on the interpersonal model of nursing, which uses oneself as a therapeutic agent working together with the client (Feely, 1997). Peplau believed the development of trusting relationships to be the basis of successful outcomes (Simpson, 1991).
Peplau designed her model in the belief that the nurse will work in the company of the patient with a focus on the patients independent decision making and problem solving, promoting autonomy (Varcarolis & Halter, 2009). Peplau views nursing as a developmental educational instrument, with which the nurse would help individuals, families and communities achieve changes in wellbeing, illness and health care status to improved function (Craven & Hirnle, 2009). The nurse has a need to develop skills in the way of therapeutic and interpersonal communication to be successful in psychiatric nursing.
Communication is a key skill that underpins mental health nursing interventions (Elder, Evans & Nizette, 2009). Therapeutic skills such as listening, observing and talking as a participant, allows the nurse to actively engage with their clients. This communication can help increase the knowledge and awareness of health issues, problems and outcomes (Craven & Hirnle, 2009). Peplau believes therapeutic skills are essential to the nurse client relationship and allow the nurse to be aware of the clients behaviours and their own responses.
With this awareness, the nurse is able to help in providing assistance, information and encouragement to the patient as needed (Arnold & Boggs, 2007). Within the nurse-client relationship the client, their experiences, issues and problems are the main focus of communication (Craven & Hirnle, 2009). Peplau saw the interaction between nurse and client to be a pathway in developing an understanding of, and exploring, the patients needs, feelings, beliefs and attitudes (Simpson, 1991).
Therapeutic communication allows the client to express and work through these feelings, problems and concerns, developing coping skills related to their situation, treatment and care (Craven & Hirnle, 2009). Peplaus model helps the client and patient to grow, become better people, and have a self-understanding. For the nurse to help the patient to help themselves achieve this growth, the nurse must first understand herself. As Peplau says: Psychiatric patients are lacking the intellectual and nterpersonal competencies so necessary for the work involved in their search for self-understanding. It is the quality of the verbal participation of nurses in their interactions with patients-listening and posing investigative questions-that slowly but surely stimulates the development of the competencies in patients. (OToole & Welt, 1994, p. 275) Peplau proposed her model facilitates forward movement of personality (Feely, 1997, p. 115), for both the nurse and the patient.
The nurse-client relationship is client focused and goal directed but the nurse also has to assess how his or her role, communication skills, personal history and values may be affecting the interactions (Varcarolis & Halter, 2009). Communication with psychiatric patients can be a major problem, the nurse can relate to the client by self-disclosing appropriate experiences. This works to the clients benefit in that it may help the client feel understood and respected (OToole & Welt, 1994). For the nurse to be able to disclose personal experiences there is a need to have an understanding of self-awareness.
Peplau believed that for nurses to provide effective care, they would need to mature and develop as an individual themselves. This would mean that the patient has a greater opportunity to learn from the nurse about their illness, allowing a larger insight into themselves and their condition (Simpson, 1991). In nursing practice today a nurse can take on different roles to help the mental health patient develop an understanding of their condition. In Peplaus model the nurse assumes many different roles to provide care for the client (McQuiston & Webb, 1995).
Peplau believes the consideration of roles is essential in accommodating for the patients needs (Simpson, 1991). Using nursing roles effectively Peplau believes the nurse can encourage the patient to participate in their own care, care planning and solving problems (Alligood & Marriner-Tomey, 2010). The nursing approach that Peplau intended was as a participant observer, it was intended that the nurse actively engages with his/her clients whilst observing the clients behaviours and this can be achieved when assuming roles (Arnold & Boggs, 2007).
When speaking of the six roles she identified Peplau states that nurses had to provide nursing services that had favourable outcomes (FITNE, 1997). Peplaus ideas contain the following examples of roles: stranger, resource person, teacher, leader, surrogate for significant others, and counsellor (Arnold & Boggs, 2007). Mental health nursing involves therapeutic nurse-client relationships. Regardless of other roles the nurse assumed, the nurse and client always begin the relationship as strangers to each other (McQuiston & Webb, 1995).
The role of stranger can be revisited if the client makes progress and then stagnates, as the relationship will be brought right back to this first stage and the client and nurse will have to begin recognising what went wrong and start to understand each other again. The role of resource person can be undertaken by the nurse, for example, when providing information about support groups, and the role of teacher, for example, when educating the patient around symptoms of his/her illness. Peplau highlights the importance of the counsellor role in the process of psychiatric nursing (McQuiston & Webb, 1995).
The counselling role helps the client to understand the meaning of their current life circumstances, and provides guidance in the right direction to make changes (Arnold & Boggs, 2007). Having the knowledge that a relationship changes and moves through phases when nursing a mental health patient, can help the nurse understand the behaviours expected with the stage of the relationship. For example the anxiety the client may be feeling towards the situation related with that stage and having this understanding can help the nurse know how to interact with the patient.
The nurse-client relationship is believed, by Peplau, to develop through four overlapping phases which build on one another (Pubmed. gov, 1997). The phases are generally recognised as the orientation phase, the working phase which is subdivided into two aspects: identification and exploitation, and the resolution phase (Varcarolis & Halter, 2009). The nurse and patient pass through these phases during their interpersonal relationship and learn to work together to resolve difficulties focused on the patients care, the nurse assumes the different roles as discussed above throughout all phases (Arnold & Boggs, 2007).
The first meeting and development of a relationship is the orientation phase. Peplau maintained that the orientation phase sets the ground work for the rest of the relationship (Arnold & Boggs, 2007). This stage can be intimidating for the mental health patient and there will be a lot of tension and anxiety, especially heightened in psychiatric nursing. Peplau believes that the nurses response process, through learnt interpersonal skills, can help the patient to reduce and overcome these feelings (Barnum, 1998).
The patient uses this phase to make a comprehensive ssessment of what is happening to him and who around him he can trust and rely on (Simpson, 1991). This phase is where the nurse offers engagement and assesses ways of gathering data from the client, getting to know the situation and establishing a rapport with the client (Elders, Evans & Nizette, 2009). The orientation stage is where the nurse and client work together to define the problem, determine how the client views the problem and what strengths the patient has that can be used to resolve the problem (Arnold & Boggs, 2007).
The second phase, the working phase, in the nurse-client relationship has two parts, identification and exploitation. It is the stage of the relationship where the nurse and client together implement ideas, expectations and goals. They then work through these to develop resolution of the problem and learn how to manage problems. The quality of this phase is that the client will have a feeling of trust making it easier for the client to discuss deep issues (Arnold & Boggs, 2007).
Patients identify with nurses who are open and honest in their approach and who provide them with information (Simpson, 1991). The problem solving ability of the patient grows with this therapeutic approach and will be beneficial to the planning of care. The client will assume more of a partnership with the nurse for implementation of resolution (Simpson, 1991). The first part of the working phase is identification, the nurse and the client will develop goals directed at the resolution of the clients health care needs and the way they are going to achieve them.
This sub phase can be seen in relation to the planning part of the nursing process (Arnold & Boggs, 2007). During this first aspect of the working phase the client identifies problems that need to be addressed through the relationship (McQuiston & Webb, 1995). The second part of the working phase is exploitation, this aspect of the phase acts on the plans recognised in the identification sub phase and sees the patient utilising resources that are required to achieve resolution. Nurses help their clients seek out and use health care services.
They help the client develop personal strengths in order to resolve the issues, allowing the patient to be autonomic at the same time (Arnold & Boggs, 2007). The nurse does not solve the clients problem but provides the client with the opportunity to explore options and possibilities through assuming a teaching role or resource person role (McQuiston & Webb, 1995). The last phase of the nurse-client relationship is the phase of resolution, also viewed as the termination phase.
This part of the nurse-client relationship is where the nurse brings closure to the relationship helping the client to see the progress he or she has made. Peplau believes this final phase is where the nurse assists the client to review progress towards goals, makes referrals and brings a closure to the therapeutic relationship (Arnold & Boggs, 2007). Arnold and Boggs (2007) suggest that this phase corresponds with the evaluation phase of the nursing process. The resolution for a psychiatric client should involve a change in thoughts, feelings and behaviours (Elder, Evans & Nizette, 2009).
Simpson (1991) says that Peplau believed the resolution process to be a freeing process, where the patient begins to live a healthy life at home. In conclusion every interaction has a beginning, middle and an end. Peplaus model shows this through four phases of the interactive nurse-client relationship. Working through these phases helps the nurse have a better understanding of the relationship when nursing with a mental health client. Having a consideration of the six role examples nurses take on in the relationship is an important process in providing for the patients needs.
Having had this opportunity, to discuss the underlying knowledge of Peplaus theory, has greatly increased my understanding of the importance in creating a therapeutic interpersonal relationship in mental health nursing. Peplaus model is a great theoretical coaching framework that will guide my practice. It is necessary for understanding the nature of the problem-solving process within mental health nursing, and gaining knowledge of the pathway that will help the patient to the resolution of their problems.