Hildegard Peplau: Interpersonal Relations Theory

Peplau put the nurse-patient relationship at the center of nursing and gave it structure: defined phases, defined roles, and a working account of anxiety. If you have ever moved a patient from stranger to partner over the course of care, you were using her model. It is the backbone of psychiatric nursing.

Biography of Hildegard E. Peplau

Hildegard Elizabeth Peplau (September 1, 1909 – March 17, 1999) was an American nurse, the only person to serve the American Nurses Association (ANA) as both Executive Director and later President. She was the first published nursing theorist since Florence Nightingale, known for the Theory of Interpersonal Relations and to many as the "Mother of Psychiatric Nursing" and the "Nurse of the Century."

Early Life

Peplau was born September 1, 1909, and raised in Reading, Pennsylvania, by parents of German descent, Gustav and Otyllie Peplau. She was the second daughter, with two sisters and three brothers. Her father was illiterate but persevering; her mother was a perfectionist and oppressive. From early on, Peplau wanted to grow beyond the traditional roles open to women, and nursing was one of the few careers available to her. In 1918 she witnessed the devastating flu epidemic, which shaped her understanding of how illness and death hit families.

Education

When the autonomous, nursing-controlled Nightingale-era schools ended in the early 1900s, hospitals took over and downplayed "book learning," treating women in nursing as a source of cheap or free labor open to exploitation by employers, physicians, and educators. In 1931 Peplau graduated from the Pottstown, Pennsylvania School of Nursing. She earned a bachelor's degree in interpersonal psychology in 1943 at Bennington College in Vermont and studied psychological issues with Erich Fromm, Frieda Fromm-Reichmann, and Harry Stack Sullivan at Chestnut Lodge, a private psychiatric hospital in Maryland. She held master's and doctoral degrees from Teachers College, Columbia University, in 1947.

Career and Appointments

After graduating in Pennsylvania, Peplau worked as a staff nurse there and in New York City. A summer position with a New York University camp led to a recommendation that made her school nurse at Bennington College, where she earned her bachelor's degree. Her lifelong work centered on extending Sullivan's interpersonal theory into nursing practice.

She served in the Army Nurse Corps with the 312th Field Station Hospital from 1943 to 1945 in England, home of the American School of Military Psychiatry, where she met and worked with the leading figures in British and American psychiatry. After the war she helped reshape the U.S. mental health system through the National Mental Health Act of 1946.

Peplau was certified in psychoanalysis by the William Alanson White Institute of New York City. In the early 1950s she developed and taught the first graduate psychiatric nursing classes at Teachers College. She was on the College of Nursing faculty at Rutgers University from 1954 until her retirement in 1974 and was professor emeritus there. At Rutgers she created the first graduate-level program to prepare clinical specialists in psychiatric nursing. A prolific writer and a sought-after speaker, she argued hard that nurses needed more education to provide truly therapeutic care rather than the custodial care common in mental hospitals of the era.

Through the 1950s and 1960s she ran summer workshops for nurses across the United States, mostly in state psychiatric hospitals, teaching interpersonal concepts, interviewing technique, and individual, family, and group therapy. She advised the World Health Organization and was a visiting professor in Africa, Latin America, Belgium, and across the United States. A strong advocate for graduate education and research, she consulted to the U.S. Surgeon General, the U.S. Air Force, and the National Institute of Mental Health, and sat on many government policy-making groups.

After retiring from Rutgers, she was a visiting professor at the University of Leuven in Belgium in 1975 and 1976, helping establish the first graduate nursing program in Europe. She was the only nurse to serve the ANA as executive director and later president, served two terms on the Board of the International Council of Nurses (ICN), and contributed to the ANA through committees and task forces as a member of the New Jersey State Nurses Association.

Her 50-year career left a lasting mark on the field and on the lives of the mentally ill in the United States. At its peak she was the founder of modern psychiatric nursing, an innovative educator, an advocate for the mentally ill, a proponent of advanced education for nurses, Executive Director and then President of the ANA, and a prolific author.

Interpersonal Relations Theory

In 1952, Peplau published her Theory of Interpersonal Relations, influenced by Harry Stack Sullivan, Percival Symonds, Abraham Maslow, and Neal Elgar Miller.

Works

Peplau's works include Interpersonal Relations in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing; Interpersonal Theory in Nursing Practice: Selected Works of Hildegard E. Peplau; Basic Principles of Patient Counseling; A Glance Back in Time (Nursing Forum); On Semantics (Perspectives in Psychiatric Care); The Psychiatric Nurse: Accountable? To Whom? For What? (Perspectives in Psychiatric Care); and Psychotherapeutic Strategies (Perspectives in Psychiatric Care).

Her book Interpersonal Relations in Nursing was completed in 1948, but publication took four more years because it was groundbreaking for a nurse to write scholarly work without a co-authoring physician. The 1952 book has been translated into nine languages and was reissued in Great Britain by Macmillan of London in 1989, the same year Springer published a volume of her selected works from previously unpublished papers. The archives of her work and life are housed at the Schlesinger Library at Harvard University.

Awards and Honors

Peplau held 11 honorary degrees, including doctorates from Alfred, Duke, Indiana, Ohio State, Rutgers, and the University of Ulster in Ireland. Marquis named her one of "50 Great Americans" in Who's Who in 1995, and she was elected a fellow of the American Academy of Nursing and of Sigma Theta Tau. In 1996 the American Academy of Nursing named her a "Living Legend." She received nursing's highest honor, the "Christiane Reimann Prize," at the ICN Quadrennial Congress in 1997, given once every four years for outstanding national and international contributions. In 1998 the ANA inducted her into its Hall of Fame.

Death

Peplau died peacefully in her sleep at home in Sherman Oaks, California, on March 17, 1999.

Hildegard Peplau's Interpersonal Relations Theory

Peplau's theory makes the nurse-client relationship the foundation of practice. The give-and-take of that relationship was revolutionary at the time. She built an interpersonal model around a partnership between nurse and client, the opposite of a client passively receiving treatment while the nurse passively carries out orders.

According to Peplau (1952/1988), nursing is therapeutic because it is a healing art that helps a person who is sick or in need of health care. It is an interpersonal process: an interaction between two or more people with a common goal. That common goal drives the therapeutic process, in which nurse and patient respect each other as individuals and both learn and grow from the interaction. A person learns by selecting stimuli in the environment and reacting to them.

The four components of the theory are person, a developing organism that tries to reduce the anxiety caused by needs; environment, the forces outside the person, set in the context of culture; health, a word symbol implying forward movement of the personality; and nursing, a significant therapeutic interpersonal process that works cooperatively with other human processes to make health possible.

The model identifies four sequential phases in the relationship: orientation, identification, exploitation, and resolution. It also defines seven nursing roles: stranger, resource, teaching, counseling, surrogate, leadership, and technical expert.

Description

Peplau defined nursing as "an interpersonal process of therapeutic interactions between an individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help." It is a "maturing force and an educative instrument" involving interaction between two or more people with a common goal, one that drives the therapeutic process in which nurse and patient respect each other and both learn and grow.

Assumptions

Peplau's assumptions: nurse and patient can interact; both mature as a result of the therapeutic interaction; communication and interviewing skills remain fundamental nursing tools; and nurses must understand themselves clearly in order to promote the client's growth and avoid limiting the client's choices to those the nurse values.

Major Concepts

Nursing's purpose is to help others identify their felt difficulties and to apply the principles of human relations to problems that arise at every level of experience.

Man

Peplau defines man as an organism that "strives in its own way to reduce tension generated by needs." The client is an individual with a felt need.

Health

Health is "a word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living."

Society or Environment

Peplau does not address society or environment directly, but she urges the nurse to consider the patient's culture and mores as the patient adjusts to hospital routine.

Nursing

Nursing is a "significant, therapeutic, interpersonal process," a "human relationship between an individual who is sick, or in need of health services, and a nurse specially educated to recognize and to respond to the need for help."

Therapeutic Nurse-Client Relationship

A professional, planned relationship focused on the client's needs, feelings, problems, and ideas. It runs through a sequential pattern of steps toward a common goal.

1. Orientation Phase

The nurse engages the client in treatment, provides explanation and information, and answers questions. This is the problem-defining phase: it starts when the client meets the nurse as a stranger, the problem is defined, and the type of service needed is decided. The client seeks assistance, conveys needs, asks questions, and brings preconceptions and expectations from past experience; the nurse responds, explains roles, identifies problems, and uses available resources and services.

2. Identification Phase

The client begins to work interdependently with the nurse, express feelings, and feel stronger. Appropriate professional assistance is selected. The patient develops a sense of belonging and a capacity to deal with the problem, which cuts the feelings of helplessness and hopelessness.

3. Exploitation Phase

The client makes full use of the services offered, using professional assistance to work through problem-solving alternatives. Services are used according to the patient's needs and interests, and the individual feels like an integral part of the helping environment. The patient may make minor requests or use attention-getting behavior, and may fluctuate between dependence and independence. The nurse uses interview technique to explore and address the underlying problem, stays aware of the phases of communication, and helps the patient use every avenue of help while moving toward the final step.

4. Resolution Phase

The client no longer needs professional services, gives up dependent behavior, and the relationship ends. The patient's needs have been met by the collaborative work of patient and nurse. Termination can be hard for both when psychological dependence persists. As the patient drifts away and breaks the bond, a healthier emotional balance shows, and both emerge as mature individuals.

Subconcepts: Nursing Roles

Peplau's model has been widely used by later theorists and clinicians to build more sophisticated therapeutic interventions. The roles of the nurse in the therapeutic relationship are:

Stranger: offering the client the same acceptance and courtesy the nurse would give any stranger.

Resource person: providing specific answers to questions within a larger context.

Teacher: helping the client learn, formally or informally.

Leader: offering direction to the client or group.

Surrogate: standing in as a substitute, such as a parent or sibling.

Counselor: promoting experiences that lead toward health, such as the expression of feelings.

Technical expert: providing physical care and operating equipment.

Peplau held that the nurse takes on many other roles she left "to the intelligence and imagination of the readers" (Peplau, 1952), among them consultant, health teacher, tutor, socializing agent, safety agent, manager of environment, mediator, administrator, recorder observer, and researcher.

Four Levels of Anxiety

Peplau defined anxiety as the initial response to a psychic threat, described in four levels.

Mild anxiety is a positive state of heightened awareness and sharpened senses; the person can take in all available stimuli (the perceptual field) and learn new behaviors and solve problems.

Moderate anxiety narrows the perceptual field to the immediate task; the person can learn or solve problems only with assistance and can be redirected by another person.

Severe anxiety brings dread and terror. The person cannot be redirected to a task, focuses only on scattered details, and has physiologic symptoms of tachycardia, diaphoresis, and chest pain.

Panic anxiety can bring loss of rational thought, delusions, hallucinations, and complete physical immobility and muteness. The person may bolt and run aimlessly, often risking injury.

Interpersonal Theory and the Nursing Process

Peplau's theory and the nursing process are sequential and both center on the therapeutic relationship, using problem-solving so nurse and patient collaborate to meet the patient's needs. Both rely on observation, communication, and recording as basic tools.

Analysis

Peplau laid out clear nurse roles usable in any practice, making the point that the nurse's duty is not just to care but spans every activity that touches the patient's care. The model fits psychiatric patients well, given Peplau's background, but it applies to anyone able and willing to communicate; its main limit is the patient who cannot converse, such as the unconscious. The phases map closely onto the nursing process: assessment to orientation, nursing diagnosis and planning to identification, implementation to exploitation, and evaluation to resolution.

Strengths

The theory helped later theorists and clinicians build more therapeutic interventions, and its roles capture the dynamic character of clinical nursing. Its phases give a simple, natural progression to the nurse-patient relationship, which makes it adaptable and generalizable to any nurse-patient interaction.

Weaknesses

Peplau emphasized the relationship over health promotion and maintenance, which got less attention. The theory also cannot be used with a patient who has no felt need, such as a withdrawn patient.

Conclusion

Peplau's theory has been heavily used by later theorists and clinicians, including the seven nursing roles that capture the dynamic character of clinical nursing. The nurse's duty is not only to care but to account for every activity that affects the client's health. The model is narrow for those who cannot converse, particularly the unconscious or paralyzed. Studied closely, it gives future nurses a set of roles to apply across situations, which helps patients get the best care and speeds treatment and recovery.