The theory of interpersonal relationships by Peplau was developed many years ago and continues to influence nursing education, practice, and research today. The theory consists of three phases that are followed by the nurse with their patient. Peplau believed the nurse–patient relationship formed the foundation of nursing care.
She led the way in developing the practice and theory of mental health and psychiatric nursing. Her combination of theory and practice contributed to nursing knowledge within psychiatric mental health nursing and general nursing. Peplau’s theory was developed for psychiatric nursing practice but has been applied in many areas of nursing.
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Hildegard Peplau
Peplau was an American nurse born in 1909 and became the first published nursing theorist since Florence Nightingale. She developed the theory of interpersonal relations, which became very influential in nursing education.
Peplau did not want to follow traditional women’s roles and felt that nursing was one of the few career options at the time. As a young child, she saw the effects of the flu epidemic, which influenced her views on the impact of illness and death on the family.
Peplau graduated in 1931, earning a bachelor’s degree in interpersonal psychology, followed by a master’s, and a doctorate. She served in the Army Corps and worked with leading British and American psychiatry figures. Peplau dedicated much of her career to extending Sullivan’s interpersonal theory to be used in nursing practice.
She was certified in psychoanalysis and taught graduate psychiatric students while working at Rutgers University until she retired. Her fifty-year career in nursing was influential in both the profession and psychiatric care. When Peplau was a young nurse, she was told not to talk to patients; her main concern became patient ward conditions, particularly for psychiatric patients in asylums.
Her theory and techniques are still used in nursing practice today. Communication throughout the three phases of the theory of interpersonal relationships results in positive changes in patient behavior.
The theory of interpersonal relations
In 1952, Peplau published her theory of interpersonal relations. She believed nursing could be seen as an interpersonal procedure because of the interaction between at least two people with the same goal.
The theory focused on the nurse–patient connection as the bedrock of nursing. Peplau developed an interpersonal model that focused on the necessity of the nurse–patient partnership, without the client accepting treatment passively and the nurse following orders.
The theory has four components: person, environment, health, and nursing—the person tries to lessen anxious feelings, which are caused by needs; the environment involves the forces outside the person and relates to culture; health implies the person moving forward; and lastly, nursing is a meaningful therapeutic procedure.
The model initially outlined four phases in the relationship—orientation, identification, exploitation, and resolution—but was later revised by Peplau to include orientation, working, and termination.
The model identifies seven parts for nurses to play: resource, stranger, teacher, counselor, surrogate, technical expert, and active leader. At different stages, the nurse plays various roles to meet the patient’s needs. By playing these roles, the nurse builds an understanding of the patient’s needs, conflicts, frustrations, and anxieties; this leads to a relationship that enables the growth of both parties.
The goal is to have respect between the nurse and patient and for them to learn and grow while interacting—the nurse meets the patient as a stranger, just as the patient meets strangers in everyday life; then, the nurse creates an atmosphere of trust; as a teacher, the nurse educates the patient on health matters that are relevant to them; This also involves the nurse being a resource, providing information that the patient needs; as a counselor, the nurse helps the patient understand their current situation and provides encouragement and guidance to make changes; the surrogate nurse helps the patient clarify independence, dependence, and interdependence, and acts as an advocate for the patient, the nurse serves as a leader when taking responsibility for meeting treatment goals; and lastly, the nurse also serves as a technical expert.
Peplau prioritized the patient and transformed the role of the nurse practitioner. Peplau led the way in developing the practice and theory of mental health and psychiatric nursing. She proposed the nurse–patient relationship when patients were not involved in their care.
Peplau believed that the relationship between the nurse and the patient formed the foundation of nursing care, and this concept is now recognized in almost all nursing specialties. Communication is essential to the nurse–patient relationship.
Nurses can prioritize the patient and build strong relationships based on caring, ensuring patients receive the best treatment and that treatment plans recognize the patient’s goals.
Peplau helped combine theory and practice, contributing to nursing knowledge within psychiatric mental health nursing and general nursing. Her work continues to guide nursing education, practice, and research today. Peplau’s theory was initially developed for psychiatric nursing practice but has been applied in many areas, including emergency and rural settings.
Nurses must interact skillfully with patients in any environment. The nurse–patient relationship can create trust, goal setting, learning experiences, and therapeutic interventions. Nursing research and theory provide evidence and validity to nursing science.
Nursing theories provide the basis for evidence-based practice and research, increasing health promotion and prevention. Furthermore, evidence from research validates nursing practice and results in positive health outcomes.
The nurse uses the nurse–patient relationship to assess the patient’s emotional, spiritual, and psychological needs with personal strengths, an understanding of behavior, and effective communication skills. As a result, goals that benefit the patient are produced.
The patient trusts the nurse when they know their integrity and reliability. The nurse–patient relationship allows the nurse to feel empathy for the patient, which in return enable the nurse to understand the patient and communicate that understanding to the patient.
Peplau’s theory has three stages to the therapeutic nurse–patient relationship: orientation, working, and termination.
Orientation phase
During the brief orientation stage hospitalized patients know they need help and try and adapt to their new situation. The nurse meets the patients and finds information indicating their priorities and needs. The nurse must be an active listener, identify the problems, and determine the service needed.
Trust is established, and rapport is built between the nurse and the patient. Nurses assume their first role as that of a stranger. Nurses should demonstrate positive interest and respect towards the patient as they would to a stranger. The nurse needs to set boundaries and maintain them throughout each phase.
Nurses pass through this phase quickly and are expected to show courtesy and respect throughout all the phases. Some factors of the first phase are carried through the other two phases. This phase is essentially the nurse assessing the patient’s health and situation.
An example of the orientation phase within psychiatric nursing is when a nurse has their first encounter with a patient with schizophrenia. During this phase, the psychiatric nurse finds relevant information, creates a rapport, and develops trust while ensuring the patient understands their diagnosis.
The nurse considers the roles, purpose, and framework for assessing the patient’s needs. Establishing the right treatment plan and medication is essential when working with an adult with schizophrenia. Patients with schizophrenia benefit from individualized treatment plans that address their unique symptoms and personal priorities.
Adult patients are experts in themselves and can contribute to decision-making. These patients can be less likely to take medication than those with other serious mental illnesses. The nurse must communicate well about the patient’s treatment and medication(s).
During the orientation phase, the nurse can assess the patient’s knowledge of their condition and the likelihood of them taking medication. The psychiatric nurse can also consider culture, beliefs, values, past experiences, and expectations to better understand the patient and their views. The information gathered helps the nurse to provide appropriate and relevant care for the patient.
Working phase
Most of the work of the relationship happens here; this phase accounts for most of the time the nurse spends with the patient. Nurses use active listening and ask why the patient is seeking care to find out what is important to them. Nurses carry out assessments that contribute to the interdisciplinary plan of care.
This phase consists of the sub-phases of identification and exploitation. During the identification phase, the nurse may enact various roles. During this phase, patients understand more about the different functions of nurses and accept them as care providers, counselors, health educators, and resource persons.
Nurses use therapeutic communication techniques such as non-directive listening to support patients in developing awareness of their feelings towards their health. Nurses provide reflective and open-minded feedback to help patients build clarity of thought. During this phase, a nursing plan is developed and implemented.
Nurses implement interventions to meet short-term and long-term goals. During the working phase, the nurse uses knowledge and skill to solve the health problem. The patient sees the nurse as providing empathy and unconditional care and the power begins to move from the nurse to the patient as the patient becomes more independent.
During this phase, the psychiatric nurse working with a schizophrenic patient takes the issues and problems identified and creates a plan to address them. The patient tries to cope with their diagnosis and is involved in their care to encourage self-acceptance and set goals.
The patient can begin to feel more empowered and able to address their symptoms so that feelings of helplessness can be reduced. The nurse and the patient work together to implement the plans they have agreed to. Effective communication and joint decision-making can make patients more likely to consider a long-acting injectable antipsychotic (LAI).
Treatment should be discussed throughout the care journey. As the relationship strengthens, the patient can become more motivated, and the nurse can better understand the patient’s individual motivating factors. Patients may recognize the benefits of managing their symptoms and how this could improve their lives.
Termination phase
This is the final phase, and its success depends on how well the first two phases were navigated. The aim is for the patient’s needs to be met by collaboration between the patient, nurse, and healthcare team. The nurse can encourage the patient to reflect on their progress and review future goals.
Nurses educate patients about symptom management, recovery at home, and they make referrals for follow-up care and the continuation of support. The termination phase allows the patient to become more self-sufficient and have a healthier life.
This phase is a time for the patient to review what they have learned and make plans for the future. Having achieved symptom stability, the patient can decide on new goals, such as returning to school, getting a job, volunteering, or maintaining relationships with family and friends.
An essential part of treating patients with schizophrenia is for nurses to educate them on the importance of medical adherence. LAIs are professionally administered and ensure that the patient receives medication regularly. With symptoms under control, the patient can focus on their goals.
Theory and practice
Peplau’s theory has had a far-reaching effect on nursing practice. Although the theory was developed many years ago, it is still used in nursing today. Peplau introduced the idea that the nurse–patient relationship underpins nursing care. She combined practice and theory, contributing to psychiatric and general nursing practice.
The theory was initially developed for psychiatric nursing but has been applied to many nursing fields. Through the three phases of this theory, the nurse moves through each phase with the patient, building strong relationships and ensuring the patient receives the best care possible.