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hildegard pepalu nursing theory


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hildegard pepalu nursing theory

  1. 1. HILDGARD PEPALU'S THEORY Introduction Nurse patientrelationshipisboundbytrust.Trust isdevelopedbyagood rapportand interpersonal relationship.Andbydevelopingtrustthe efficiencyof care deliveryincreases.Thoughthere always existedaninterpersonalrelationshipbetweennurse andpatient,there wasnoclearstandon the levels and rolesof these relationhips. Thiswas the remarkable revelationof HildegardEPeplauwhofocusedonthe individualnurse and interactionprocess.DrPeplaupublishedherbookinterpersonalrelationsinnursinginthe year1952, in whichshe discussesthe phasesof interpersonal process,rolesfornursingandmethodsof studying nursingas a interpersonalprocess. Credential of the author  1909 born inthe 1st of SeptemberinPennsylvania  1931 graduatedas a registerednurse fromPottstowncollege of nursingPennsylvania  1943 B.A in interpersonalpsychologyBeuningtoncollege  1948 obtainedmastersdegree fromColumbia  1953 PhD.EdColumbiaUniversityNew York  1969 executivedirectorof ANA  1970-1972 Presidentof ANA  1972-1974 secondVice-President  Directorof NewJersystate nursesassociation  National nurse consultanttothe unitedstates  Chairedthe editorial boardof the journal of psycho-socialnursing  1974 retirement  1987 honoredasthe firstpsychosocial nurse Theoretical sources Peplauusedknowledgeborrowedfrombehavioral sciencesandwhatcan be termedthe psychological model. Harry Stack Sullivan,Percival Symonds,AbrahamMaslow andNeal ElgerMillerare some of the sources Peplauusedindevelopingherconceptual frame work,whodevisedthesetheoriesfromworksof Freud and Fromm.
  2. 2. values culture values culture Major concepts Psychodynamic nursing: Peplaudefinespsychodynamicnursingbecausehermodel evolvesthroughthistype of nursing. Psychodynamicnursingisbeingableto understandones’own behaviorto help others’ identify felt difficulties,andtoapplyprinciplesofhumanrelationsto the problemsthat arise at all levels of experience. Nurse patient relationship: Peplaudescribesfourphasesof nurse-patientrelationship;althoughseparatetheyoverlapandoccur overthe time of the relationship. Admission Duringintensive Treatmentperiod Convalescenceandrehabilitation Orientation  The individual has a felt need and seeks professional assistance. The nurse helps the patient recognize and understand his problem and determine his need for help. A mutual decision needstobe made regardingwhattype of professional assistance the patientandfamilyneeds.  The nurse needs to be aware of his personal reactions to the patients’. The patient’s culture religion race, educational background, experience and preconceived ideas and expectations all influencethe nursesreactionstothe patient.  The orientation phase is directly affected by the patients and nurses attitude about giving and receiving aid from a reciprocal person. Nursing is an interpersonal process, and both the patient and the nurse have an equallyimportantpartinthe therapeuticinteraction. Nurse Patient Discharge
  3. 3.  To summarize, the orientation begins with two strangers (patient and nurse) meeting, and by the end of the phase they collectively strive to identify the problem and are becoming more comfortable with one another, the helping environment and thus logically progress to the next phase. Identification  The patient meets and responds selectively to people who can meet his or her needs. Through out the identification phase, both the patient and nurse must clarify each others perception and expectationsduringthe interpersonal process.  In identification phase, the perception and expectations of patient and nurse are even more complex than in the orientation phase. The patient is now responding to the helper selectively. While working through the identification phase, the patient begins to have feeling of belonging and a capacity fordealingwithproblem.  These changes begin to reduce the feelings of helplessness, creating an optimistic attitude. And the patient is free to be explored and is ready to exploit the services provided and then moves on to the nextphase. Exploitation  Following identification, the patient moves into exploitation phase in which the patient takes advantage of all the resources available. The degree to which these services are used is based uponthe needsandinterestsof the patient.  During this phase the patient makes more demands than they did when they were seriously ill. They make many minor requests, or may use other attention getting techniques, depending on theirindividual needs.  The nurse may need to deal with the subconscious forces causing the patients action and may need to use interviewing techniques as tools to explore and understand and adequately deal with the underlying patients problems. So that the nurse patient rapport established to the point is not damaged, a therapeutic relationship must be maintained by the nurse that conveys an attitude acceptance concernandtrust.  The nurse must encourage the patient to recognize and explore feelings, thoughts emotions and behaviorsbyprovidinganonjudgmental atmosphere andatherapeuticemotional climate  In exploitation, the nurse use communication tools such as clarifying ,listening, accepting, teaching, and interpreting to offer services to the patient. The patient then takes advantage of the services offered based on his/her needs of interest. In this phase, the nurse aids the patient to use the servicestohelpsolve the problem,thusprogresstothe final stage.
  4. 4. Resolution  The patients needs have already been met by collaborative efforts between the patient and the nurse. The patient and the nurse now need to terminate the relationship and dissolve the links betweenthem.  Here all the phases of the relationship have been successfully accomplished. The needs have beenmetandresolutionandterminationare the endresult. Nursing roles: Peplaudescribessix differentnursingrolesthatemerge invariousphasesof nurse patientrelationship. Role of a stranger Peplau states that because the nurse and patient are strangers to each other, the patient should be treated with ordinary courtesy. In other words, the nurse should not prejudge the patient, but accept him as he is. During the non personal phase, the nurse should treat the patient as emotionally able, unlessevidencedotherwise.Thiscoincideswithidentificationphase. Role of a resource person The nurse provides specific answers to questions, especially health information and interprets the treatment to the patient. These questions often arise with in the context of a larger problem. The nurse determines what type of response is appropriate for constructive learning either straight forward factual answersor providingcounseling. Teaching role The teaching role is combination of all roles and always proceeds what the patient knows and develops around the areas of interest in wanting and ability to use information. Peplau separates teaching into twocategories: Instructural:largelygivinginformationandisfromexplainedineducationalliterature. Experimental: This is using the experience of the learner as a basis from which learning products are developed. The products of learning are generalizations and appraisals the patient makes about his experience The concept of learning used in the teaching role overlaps with the nurse counselor role, because the conceptof learningiscarriedoutthroughpsycho-therapeutictechniques. Counselorrole
  5. 5. Peplau believed that the counseling has the greatest impact in psychiatric nursing. Counseling function in the nurse patient relationship by the way nurses respond to the patients demands. Peplau says the purpose of interpersonal technique is to help the patient remember and understand fully what is happening to him in the present situation, so that the experience can be integrated rather than dissociatedfromotherexperiencesinlife. Leadershiprole The leadershiprole involvesthe democraticprocess.The nurse helpsthe patientmeetthe tasksathand througha relationship of cooperationandactive participation. Surrogate mother The patient casts the nurse in the role of surrogate. The nurse’s attitude and behavior creates feeling tones in the patient that reactivates feelings generalized in a prior relationship. The nurse function if to assistthe patientinrecognizingsimilaritiesbetweenherself andthe personrecalled. She then helps the patient to see differences in her role and that of the recalled person. In this phase, bothpatientandnurse define areasof dependence,independence andfinallyinterdependence. Basic considerations  Nursing: “A significant, therapeutic, interpersonal process and a human relationship between an individual who is sick or in need of health services and a nurse especially educated to recognize andtorespondto the needforhelp”  Person: Peplau defines person in terms of man. Man is an organism that lives in an unstable equilibrium  Environment: Peplau implicitly defines environment in terms of “ existing force outside the organism and in context of culture” from which mores, customs and beliefs are likely to lead to healthalwaysincluedthe interpersonal process.  Health: Peplau defines health as a word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive personal andcommunityliving.
  6. 6. Roles of the nurse Productive person in health ↓Anxiety Bound patient in illness Anxiety Theoretical assertions 1. Anxiety: Anxiety is an energy source inextricably related to human development from infancy to death and is required to biological and emotional growth. Anxiety is produced when communication with others thriven the biological and psychological security of the individual. The nurse through inter personal instruction with the patient, facilitates the patient’s ability to transform symptoms bound energy into problem solving energy. The resulting reduction in anxietymovesthe patienttowardshealth. 2. Communications: Clear supportive communication is the key element in the development of a person. Communication with others helps one to attend and clarify one’s perception of reality and to achieve a sense of understanding with one another. This involves an awareness of verbal and non verbal communication and the symbolic meaning behind these communications. It is one of the nurses responsibilities to assess these factors and to influence the patient communicationinmannerthatcontributestohealthymodesof thought. 3. Interpersonal process: The interpersonal process is based upon a participatory relationship between the nurse and the patientin which the nurse governs the purpose and the process, and the patient controls the content; it describes the method by which the nurse facilitates useful transformationsof the patientsenergyoranxiety.  A—nurse affectshealthoutcomesthroughcommunicationwiththe patient.  B—resultingreductioninanxietymovesthe patienttowardshealth  C—nurse maintainsneutralemotional positionandresistsbeinginfluencedbythe patient  D—nurse has a role in healthpromotionandreductionof anxiety. D B A C Energy transformation
  7. 7. Application of the model Nursing process  Peplau states that “during the period of orientation the patient clarifies his first, whole impressionof the problem”,whichresemblesthe assessmentphase.  The problems identified are the nursing diagnoses and the set goals are the planning phase. This happensduringthe identificationphase of the nursingprocess.  These goals gives rise to the plan and direct it into appropriate helping resources with a meaning for the action done. The patient finally reaps benefit from the services offered to him by using the knowledge of the nurse and the skills of the nurse. This is the implementation phase and it coincideswith Peplaus’exploitationphase.  Although evaluation is not discussed by Peplau, the patient is assessed for the readiness of the patienttoproceedandterminate the relationshipresultinginthe resolutionphase. Nursing education  Peplau contributed significantly to moving the nursing profession to graduate education. Her model has been used extensively in educating both undergraduates as well as graduate nursing studentsabouta majorcomponentof nursingactivities—the interpersonalrelationship.  She has provided theoretically based knowledge for nursing specialization in psychiatric settings where inone-to-one relationshipisthe primarymethodologyinnursing. Nursing practice  Peplau model provides clear direction to nursing practice through the six roles and four phases of the interpersonal process. Nursing practioner uses these to clarify nursing focus in health care as well as to facilitate collaboration with other health care professionals and the patient, particularlywhenthe focusismental health.  Peplauemphasizes on the effective communication between the nurse and the patient. Through various communication skills the nurse can convey interest and concern to the patient; clarify and validate assumptions about the patient; help the formulation meaning of identified problems and generally guide the patient in transforming anxiety based energy to solve problems. Nursing research  Peplau postulated several topics of research today. Her model provides a theoretical frame work for research about anxiety and mental health as a whole. The theory can be used for qualitative and quantitative researchdesigns.  Her interpersonal models’ operational concepts can be used in explaining the effectiveness of the nursingprocessinproductive patientbehavior.
  8. 8. Critique Simplicity Its simple because  Interpersonal relationsbetweenpatientsandnurse iseasilyunderstood  The keyconceptsare defined  There isa sequential descriptionof the interpersonal problems.  Rolesof the nurse are clearlyindicated.  Ideasare takenfromspecificandappliedtogeneral.  Peplauisconsistentwithestablishedtheoriesandprinciples. Generality  Qualityof generalityisnotmetforthe reasonthat the theorycan not be appliedinall patients.  Peplau has a narrow perception of environment and does not explain the environmental influenceonthe personbutfocusesmore onthe psychological taskswithinthe person.  In applying theory to clinical practice, there exist limitations in working with unconscious patient as the major concept in the theory is interaction. And so the theory cannot be applied in senile, unconsciousandnewborn. Empirical precision Peplautheorycanbe termedempiricallyprecisebecause of the following:  Theoryisbasedon reality.  The relationshipbetween the theoryandempiricaldataallowsforvaluationandverification.  Peplauoperationallydefinesthe fourphasesof the interpersonal process,the nurse withregard to herrolesand the patientwithregardto hisstate of dependence.Withfurtherresearchthe dependence will increase. Derivable consequences  The evaluative criteriaof the derivableconsequenceshave beenmet.  Peplau’sthoughtandideashave touchedmanynurses.  Her workcan be consideredpioneeringinnursing,filedandherworkhas providedsignificant contributiontonursingknowledge base. Further development As nursing broadens its scope, there appears to be a need for further development of Peplau ‘s theory for use with healthy people, group and community. Further development is also indicated for clients who are unable to use their communication skills effectively. Increased use of theory is needed for furtherrefinementof the theoryandtobuilda nursing’sknowledgebase. The constructs of focal attention, dissociation forbidding gestures and personification deserve additional study.
  9. 9. Case study: Ms y has been brought in by the relatives as she tried to commit suicide. She is a very aggressive and sensitive she is angry and possessive the relatives told that she is from an Indian Christian family. She hates hospital setting as she reveals that she hates nurses because they cause a lot of pain. She has never spoken to a nurse openly before fearing their competency nor has she ventilated to anybody as she just takes every body for granted. She thinks that she is possessed. With the interpersonal model Ms Y enters the orientation phase. INFLUENCES OF ORIENTATION PHASE PATIENT: VALUES: aggressive sensitive, possesive angry. CULTURE AND RACE:IndianChristian PASTEXPERIENCES:the nursesare painrpoducingpeople.the nurse was impolite withheraslike everybody else.neverspoke withanurse about behavior.neverventilatedto anybody. BELIEF AND PRECONSIEVEDIDEAS: She thinksshe ispossed,nursesare for justgivingmedication EXPECTATIONS:wantsthe sprittobe expelled.expectsdrugstoreduce symptoms. NURSE VALUES:calm,patient,empathetic CULTURE AND RACE:indianchristan PASTEXPERIENCE:well experienced withsimilarpatients,anxiousabout the approch towardsthe patient. BELIEF AND PRECONSIEVEDIDEAS: the patientismentalyunstable,might harm physicaly,mighttalkquickly. mightnot be interestedtotalkto anurse. EXPECTATIONunderstandthe problemof the patinetventilation fromthe patinetenhancingself disclosure.
  10. 10. The nurse meets the patient; enquires the identifying data; assess the mental status and activity of the patient; asks the patient to ventilate her feelings; enquires about the injury; assess of presence of any other illness, substance abuse; enquires the attitude in the work place and family. The data received is recorded and analyzed The analyzed data is prioritized and is clarified with the client. His needs and expectations are noted. Problems are stated and identified in the form of nursing diagnoses; violence self directed related to manic episode. The expected outcomes are listed: expected outcomes: verbalize the ability to describe and recognize early symptoms of escalating anxiety, demonstrates actions and absence of verbal intension to harm self. Interventions taken: instruct the client to seek out staff when experiencing feelings of agitation, hostility, or suspiciousness. Engage the client in gross motor activity such as walking or running. Engage in brief frequent contacts through out the day. Maintain a progress record . as the violence is controlled, inform regarding the termination and discharge Once the patient has achieved adequate criteria , stopped activities and verbalism to harm self. The patient is reassured and informed about the termination time and schedule and follow up. Hence the patient’s family or guardian is contacted and preparation for discharge begins. The patient is instructed about the follow up and discharged and the relationship terminates. Orientation/ assessment. Nursesrole :stranger. Identification/nursing diagnosisandplanning stage.Resource person, teacher,leader, surrogate,counselor. Exploitation/ implementation: Resource person, teacher,leader, surrogate, counselor. Resolution/ evaluation: role: of the nurse Resource person,teacher, leader,surrogate, counselor.