Hildegard Peplau

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Hildegard E. Peplau (September 1, 1909 March 17, 1999)[1] was an American nurse and the first
published nursing theorist since Florence Nightingale and created the middle-range nursing theory of
interpersonal relations, which helped to revolutionize the scholarly work of nurses. As a primary
contributor to mental health law reform, she led the way towards humane treatment of patients with
behavior and personality disorders.[2][3]
Contents
[hide]

1Biography
o

1.1Early life

1.2Career

2Theoretical work

3Peplau's model
o

3.1Peplau's Six Nursing Roles

3.2Peplau's Developmental Stages of the Nurse-Client Relationship

3.2.1Orientation Phase

3.2.2Identification Phase

3.2.3Exploitation Phase / Working Phase

3.2.4Resolution Phase/Termination Phase

4See also

5References

6External links

Biography[edit]
Early life[edit]
Hilda was born in Reading, Pennsylvania to immigrant parents of German descent, Gustav and
Otyllie Peplau. She was the second daughter born of six children. Gustav was an illiterate, hardworking father and Otyllie was an oppressive, perfectionist mother. Though higher education was
never discussed at home, Hilda was strong-willed, with motivation and vision to grow beyond
traditional womens roles. She wanted more out of life and knew nursing was one of few career
choices for women in her day.[4] As a child, she was watcher of people's behaviours. She witnessed

the devastating flu epidemic of 1918, a personal experience that greatly influenced her
understanding of the impact of illness and death on families.[5] At this time she witnessed people
jumping from windows in delirium because of the flu epidemic.[6]
In the early 1900s, the autonomous, nursing-controlled, Nightingale era schools came to an end
schools became controlled by hospitals, 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 by nurses employers, physicians and educational providers. Nursing practice was
controlled by medicine.[7]

Career[edit]
Peplau began her career in nursing in 1931 as a graduate of the Pottstown Hospital School of
Nursing in Pottstown, PA. She then worked as a staff nurse in Pennsylvania and New York City. A
summer position as nurse for the New York University summer camp led to a recommendation for
Peplau to become the school nurse at Bennington College in Vermont. There she earned a
bachelors degree in interpersonal psychology in 1943. At Bennington and through field experiences
at Chestnut Lodge, a private psychiatric facility, she studied psychological issues with Erich
Fromm, Frieda Fromm-Reichmann, and Harry Stack Sullivan. Peplaus lifelong work was largely
focused on extending Sullivans interpersonal theory for use in nursing practice. [8]
From 1943 to 1945 she served in the Army Nurse Corps and was assigned to the 312th Field Station
Hospital in England, where the American School of Military Psychiatry was located. Here she met
and worked with leading figures in British and American psychiatry. After the war, Peplau was at the
table with many of these same men as they worked to reshape the mental health system in the
United States through the passage of the National Mental Health Act of 1946.[9]
Peplau held masters and doctoral degrees from Teachers College, Columbia University. She was
also certified in psychoanalysis at the William Alanson White Institute of New York City. In the early
1950s, Peplau developed and taught the first classes for graduate psychiatric nursing students at
Teachers College. Dr. Peplau was a member of the faculty of the College of Nursing at Rutgers
University from 1954 to 1974. At Rutgers, Peplau created the first graduate level program for the
preparation of clinical specialists inpsychiatric nursing.[10]
She was a prolific writer and was equally well known for her presentations, speeches, and clinical
training workshops. Peplau vigorously advocated that nurses should become further educated so
they could provide truly therapeutic care to patients rather than the custodial care that was prevalent
in the mental hospitals of that era. During the 1950s and 1960s, she conducted summer workshops
for nurses throughout the United States, mostly in state psychiatric hospitals. In these seminars, she
taught interpersonal concepts and interviewing techniques, as well as individual, family, and group
therapy.
Peplau was an advisor to the World Health Organization and was a visiting professor at universities
in Africa, Latin America, Belgium, and throughout the United States. A strong advocate for graduate
education and research in nursing, she served as a consultant to the U.S. Surgeon General, the
U.S. Air Force, and the National Institute of Mental Health. She participated in many government
policy-making groups. She served as president of the American Nurses Association from 1970 to
1972 and a second vice president from 1972 to 1974. [11] After her retirement from Rutgers, she
served as a visiting professor at the University of Leuven in Belgium in 1975 and 1976.[12]
She died peacefully in her sleep at home in Sherman Oaks, California.[13]

Theoretical work[edit]
In her interpersonal relationship theory, Dr. Peplau emphasized the nurse-client relationship as the
foundation of nursing practice. Her book on her conceptual framework,Interpersonal Relations in
Nursing, was completed in 1948. Publication took four additional years because it was

groundbreaking for a nurse to contribute this scholarly work without a coauthoring physician.At the
time, her research and emphasis on the give-and-take of nurse-client relationships was seen by
many as revolutionary. Peplau went on to form an interpersonal model emphasizing the need for a
partnership between nurse and client as opposed to the client passively receiving treatment (and the
nurse passively acting out doctor's orders).The essence of Peplau's theories is the creation of
a shared experience. Nurses, she thought, could facilitate this through observation, description,
formulation, interpretation, validation, and intervention.For example, as the nurse listens to her client
she develops a general impression of the client's situation. The nurse then validates her inferences
by checking with the client for accuracy. The result may be experiential learning, improved coping
strategies, and personal growth for both parties.

Peplau's model[edit]
Peplau's Six Nursing Roles[edit]
Peplau describes the six nursing roles that lead into the different phases:
1. Stranger role: Peplau states that when the nurse and patient first meet, they are considered
to be strangers to one another. Therefore, the patient should be treated with much respect,
courtesy and equally as anybody else. The nurse should not prejudge the patient or give
assumptions on the patient but take the patient as they are. The nurse should treat the
patient as emotionally stable, unless evidence states otherwise.
2. Resource role: The nurse provides answers to questions primarily on health information.
The resource person is also in charge of relaying information to the patient about the
treatment and plan of care. Usually the questions are arisen from larger problems therefore,
the nurse would determine what type of response is appropriate for constructive learning
whether giving straightforward answers or providing information on counselling.
3. Teaching role: The teaching role is a role that is a combination of all roles. Peplau
determined that there are two categories that the teaching role consists of: Instructional and
experimental. The instructional consists of giving a wide variety of information that is given
to the patients and experimental is using the experience of the learner as a starting point to
later form products of learning which the patient makes about their experiences.
4. Counseling role: Peplau believes that counselling has the biggest emphasis in psychiatric
nursing. The councilor role helps the patient understand and remember what is going on and
what is happening to them in current life situations. Also, to provide guidance and
encouragement to make changes.
5. Surrogate role: The patient is responsible for putting the nurse in the surrogate role. The
nurses behaviors and attitudes create a feeling tone for the patient that trigger feelings that
were generated in a previous relationship. The nurse helps the patient recognize the
similarities and differences between the nurse and the past relationship.
6. Leadership role: Helps the patient assume maximum responsibility for meeting treatment
goals in a mutually satisfying way. The nurse helps the patient meet these goals through
cooperation and active participation with the nurse. [14]

Peplau's Developmental Stages of the Nurse-Client Relationship [edit]

Orientation Phase[edit]

The orientation phase is initiated by the nurse. This is the phase during which the nurse and the
patient become acquainted, and set the tone for their relationship, which will ultimately be patient
centered. During this stage, it is important that a professional relationship is established, as opposed
to a social relationship. This includes clarifying that the patient is the center of the relationship, and
that all interactions are, and will be centered around helping the patient. This phase is usually
progressed through during a highly impressionable phase in the nurse-client relationship, because
the orientation phase occurs shortly after admission to a hospital, when the client is becoming
accustomed to a new environment and new people. The nurse begins to know the patient as a
unique individual, and the patient should sense that the nurse is genuinely interested in them. Trust
begins to develop, and the client begins to understand their role, the nurse's role, and the
parameters and boundaries of their relationship.
Identification Phase[edit]
The client begins to identify problems to be worked on within relationship. The goal of the nurse is to
help the patient to recognize his/her own interdependent/participation role and promote responsibility
for self.
Exploitation Phase / Working Phase[edit]
During the Working Phase, the nurse and the patient work to achieve the patient's full potential, and
meet their goals for the relationship. A sign that the transition from the orientation phase to the
working phase has been made, is if the patient can approach the nurse as a resource, instead of
feeling a social obligation to the nurse (Peplau, 1997). The client fully trusts the nurse, and makes
full use of the nurse's services and professional abilities. The nurse and the patient work towards
discharge and termination goals.
Resolution Phase/Termination Phase[edit]
The termination phase of the nurse client relationship occurs after the current goals for the client
have been met. The nurse and the client summarize and end their relationship. One of the key
aspects of a nurse-client relationship, as opposed to a social relationship, is that it is temporary, and
often of short duration (Peplau, 1997). In a more long term relationship, termination can commonly
occur when a patient is discharged from a hospital setting, or a patient dies. In more short term
relationships, such as a clinic visit, an emergency room visit, or a health bus vaccination visit, the
termination occurs when the patient leaves, and the relationship is usually less complex. However, in
most situations, the relationship should terminate once the client has established increased self
reliance to deal with their own problems.

Introduction

Theorist -Hildegard. E. Peplau

Born in Reading, Pennsylvania [1909], USA

Diploma program in Pottstown, Pennsylvania in 1931.

BA in interpersonal psychology - Bennington College in 1943.

MA in psychiatric nursing from Colombia University New York in 1947.

EdD in curriculum development in 1953.

Professor emeritus from Rutgers university

Started first post baccalaureate program in nursing

Published Interpersonal Relations in Nursing in 1952

1968 :interpersonal techniques-the crux of psychiatric nursing

Worked as executive director and president of ANA.

Worked with W.H.O, NIMH and Nurse Corps.

Died in 1999.

Theory of interpersonal relations is a middle range descriptive classification theory.

The theory was influenced by Harry Stack Sullivan's theory of inter personal relations (1953).

The theorist was also influenced by Percival Symonds, Abraham Maslow's and Neal Elger Miller.

Peplau's theory is also refered as psychodynamic nursing, which is the understanding of ones own behavior.

Major Concepts

The theory explains the purpose of nursing is to help others identify their felt difficulties.

Nurses should apply principles of human relations to the problems that arise at all levels of experience.

Peplau's theory explains the phases of interpersonal process, roles in nursing situations and methods for studying
nursing as an interpersonal process.

Nursing is therapeutic in that it is a healing art, assisting an individual who is sick or in need of health care.

Nursing is an interpersonal process because it involves interaction between two or more individuals with a
common goal.

The attainment of goal is achieved through the use of a series of steps following a series of pattern.

The nurse and patient work together so both become mature and knowledgeable in the process.

Definitions

Person: A developing organism that tries to reduce anxiety caused by needs.

Environment: Existing forces outside the organism and in the context of culture

Health: A word symbol that implies forward movement of personality and other ongoing human processes in the
direction of creative, constructive, productive, personal andcommunity living.

Nursing: A significant therapeutic interpersonal process. It functions cooperatively with other human process that
make health possible for individuals in communities.

Roles of nurse

Stranger: receives the client in the same way one meets a stranger in other life situations provides an accepting
climate that builds trust.

Teacher: who imparts knowledge in reference to a need or interest

Resource Person : one who provides a specific needed information that aids in the understanding of a problem or
new situation

Counselors : helps to understand and integrate the meaning of current life circumstances ,provides guidance and
encouragement to make changes

Surrogate: helps to clarify domains of dependence interdependence and independence and acts on clients behalf
as an advocate.

Leader : helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way

Additional Roles include:

1. Technical expert
2. Consultant
3. Health teacher
4. Tutor
5. Socializing agent
6. Safety agent
7. Manager of environment
8. Mediator
9. Administrator
10. Recorder observer
11. Researcher
Phases of interpersonal relationship
Identified four sequential phases in the interpersonal relationship:
1.
2.
3.
4.

Orientation
Identification
Exploitation
Resolution

Orientation phase

Problem defining phase

Starts when client meets nurse as stranger

Defining problem and deciding type of service needed

Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and expectations of past
experiences

Nurse responds, explains roles to client, helps to identify problems and to use available resources and services

Factors influencing orientation phase

Identification phase

Selection of appropriate professional assistance

Patient begins to have a feeling of belonging and a capability of dealing with the problem which decreases the
feeling of helplessness and hopelessness

Exploitation phase

Use of professional assistance for problem solving alternatives

Advantages of services are used is based on the needs and interests of the patients

Individual feels as an integral part of the helping environment

They may make minor requests or attention getting techniques

The principles of interview techniques must be used in order to explore, understand and adequately deal with the
underlying problem

Patient may fluctuates on independence

Nurse must be aware about the various phases of communication

Nurse aids the patient in exploiting all avenues of help and progress is made towards the final step

Resolution phase

Termination of professional relationship

The patients needs have already been met by the collaborative effect of patient and nurse

Now they need to terminate their therapeutic relationship and dissolve the links between them.

Sometimes may be difficult for both as psychological dependence persists

Patient drifts away and breaks bond with nurse and healthier emotional balance is demonstrated and both
becomes mature individuals

Interpersonal theory and nursing process

Both are sequential and focus on therapeutic relationship

Both use problem solving techniques for the nurse and patient to collaborate on, with the end purpose of meeting
the patients needs

Both use observation communication and recording as basic tools utilized by nursing

Assessment

Orientation

Data collection and analysis [continuous]

Non continuous data collection

May not be a felt need

Felt need

Define needs

Nursing diagnosis
Planning

Mutually set goals

Implementation

Identification

Interdependent goal setting

Exploitation

Plans initiated towards achievement of mutually set

goals

May be accomplished by patient , nurse or family

Patient actively seeking and drawing help

Patient initiated

Evaluation

Resolution

Based on mutually expected behaviors

Occurs after other phases are completed

successfully

May led to termination and initiation of new plans

Leads to termination a

Peplaus work and characteristics of a theory

Interrelation of concepts
o

Four phases interrelate the different components of each phase.

Applicability
o

The nurse patient interaction can apply to the concepts of human being, health, environment and nursing.

Theories must be logical in nature o

This theory provides a logical systematic way of viewing nursing situations

Key concepts such as anxiety, tension, goals, and frustration are indicated with explicit relationships
among them and progressive phases

Generalizability
o

Theories can be the bases for hypothesis that can be tested

o

Peplau's theory has generated testable hypotheses.

Theories can be utilized by practitioners to guide and improve their practice.

o

This theory provides simplicity in regard to the natural progression of the NP relationship.

Peplaus anxiety continuum is still used in anxiety patients

Theories must be consistent with other validated theories, laws, and principles but will leave open unanswered
questions that need to be investigated.
o

Peplau's theory is consistent with various theories

Limitations

Personal space considerations and community social service resources are considered less.

Health promotion and maintenance were less emphasized

Cannot be used in a patient who doesnt have a felt need eg. With drawn patients, unconscious patients

Some areas are not specific enough to generate hypothesis

Research Based on Peplaus Theory

Hays .D. (1961). Phases and steps of experimental teaching to patients of a concept of anxiety: Findings revealed
that when taught by the experimental method, the patients were able to apply the concept of anxiety after the
group was terminated.

Burd .S.F. Develop and test a nursing intervention framework for working with anxious patients: Students
developed competency in beginning interpersonal relationship.

References
1.

Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW, N

2.

George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton &
Lange.

3.

Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.

4.

Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

5.

Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

6.

Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing Concepts Process & Practice 3rd ed. London
Mosby Year Book.

7.

Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse
therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15

8.

Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225

9.

Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd edition, Thomson, NY, 2002.

The need for a partnership between nurse and client is very substantial in
nursing practice. This definitely helps nurses and healthcare providers
develop more therapeutic interventions in the clinical setting. Through
these, Hildegard E. Peplau developed her Interpersonal Relations
Theory in 1952, mainly influence by Henry Stack Sullivan, Percival
Symonds, Abraham Maslow, and Neal Elgar Miller.

Description
Peplaus theory 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 instrumentinvolving an
interaction between two or more individuals with a common goal.
In nursing, this common goal provides the incentive for the therapeutic
process in which the nurse and patient respect each other as individuals,
both of them learning and growing as a result of the interaction. An
individual learns when she or he selects stimuli in the environment and then
reacts to these stimuli.

Assumptions

The assumptions of Peplaus Interpersonal Relations Theory are: (1) Nurse

and patient can interact. (2) Peplau emphasized that both the patient and
nurse mature as the result of the therapeutic interaction. (3) Communication
and interviewing skills remain fundamental nursing tools. And lastly, (4)
Peplau believed that nurses must clearly understand themselves to promote
their clients growth and to avoid limiting clients choices to those that
nurses value.

Major Concepts
The theory explains the purpose of nursing is to help others identify their felt
difficulties and that nurses should apply principles of human relations to the
problems that arise at all levels 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 defined as 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
Although Peplau does not directly address society/environment, she does
encourage the nurse to consider the patients culture and mores when the
patient adjusts to hospital routine.

Nursing
Hildegard Peplau considers nursing to be a significant, therapeutic,
interpersonal process. She defines it as 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 and planned relationship between client and nurse that
focuses on the clients needs, feelings, problems, and ideas. It involves
interaction between two or more individuals with a common goal. The
attainment of this goal, or any goal, is achieved through a series of steps
following a sequential pattern.
Four Phases of the therapeutic nurse-patient relationship:

Orientation Phase
The orientation phase is directed by the nurse and involves engaging the
client in treatment, providing explanations and information, and answering
questions.

Problem defining phase

Starts when client meets nurse as stranger
Defining problem and deciding type of service needed
Client seeks assistance ,conveys needs ,asks questions, shares

preconceptions and expectations of past experiences

Nurse responds, explains roles to client, helps to identify problems
and to use available resources and services

Identification Phase
The identification phase begins when the client works interdependently with
the nurse, expresses feelings, and begins to feel stronger.

Selection of appropriate professional assistance

Patient begins to have a feeling of belonging and a capability of
dealing with the problem which decreases the feeling of
helplessness and hopelessness

Exploitation Phase
In the exploitation phase, the client makes full use of the services offered.

In the exploitation phase, the client makes full use of the services

offered.
Use of professional assistance for problem solving alternatives

Advantages of services are used is based on the needs and interests

of the patients
Individual feels as an integral part of the helping environment
They may make minor requests or attention getting techniques
The principles of interview techniques must be used in order to

explore, understand and adequately deal with the underlying

problem
Patient may fluctuates on independence
Nurse must be aware about the various phases of communication
Nurse aids the patient in exploiting all avenues of help and progress
is made towards the final step

Resolution Phase
In the resolution phase, the client no longer needs professional services and
gives up dependent behavior. The relationship ends.

In the resolution phase, the client no longer needs professional

services and gives up dependent behavior. The relationship ends.

Termination of professional relationship
The patients needs have already been met by the collaborative

effect of patient and nurse

Now they need to terminate their therapeutic relationship and

dissolve the links between them.

Sometimes may be difficult for both as psychological dependence

persists
Patient drifts away and breaks bond with nurse and healthier
emotional balance is demonstrated and both becomes mature
individuals

Subconcepts
Peplaus model has proved of great use to later nurse theorists and clinicians
in developing more sophisticated and therapeutic nursing interventions.

The following are the roles of the Nurse in the Therapeutic relationship
identified by Peplau:
Stranger: offering the client the same acceptance and courtesy that the
nurse would to any stranger
Resource person: providing specific answers to questions within a larger
context
Teacher: helping the client to learn formally or informally
Leader: offering direction to the client or group
Surrogate: serving as a substitute for another such as a parent or a sibling
Counselor: promoting experiences leading to health for the client such as
expression of feelings
Technical Expert: providing physical care for the patient and operates
equipment
Peplau also believed that the nurse could take on many other roles but these
were not defined in detail. However, they were left to the intelligence and
imagination of the readers. (Peplau, 1952)
Additional roles include:

Technical expert
Consultant
Health teacher
Tutor
Socializing agent
Safety agent
Manager of environment

Mediator
Administrator
Recorder observer
Researcher

Anxiety was defined as the initial response to a psychic threat. There are
four levels of anxiety described below.

Four Levels of Anxiety

Mild anxiety is a positive state of heightened awareness and sharpened
senses, allowing the person to learn new behaviors and solve problems. The
person can take in all available stimuli (perceptual field).
Moderate anxiety involves a decreased perceptual field (focus on
immediate task only); the person can learn new behavior or solve problems
only with assistance. Another person can redirect the person to the task.
Severe anxiety involves feelings of dread and terror. The person cannot be
redirected to a task; he or she focuses only on scattered details and has
physiologic symptoms of tachycardia, diaphoresis, and chest pain.
Panic anxiety can involve loss of rational thought, delusions, hallucinations,
and complete physical immobility and muteness. The person may bolt and
run aimlessly, often exposing himself or herself to injury.

Interpersonal Theory and Nursing Process

Both Peplaus Interpersonal Relations Theory and the Nursing Process are
sequential and focus on therapeutic relationship by using problem solving
techniques for the nurse and patient to collaborate on, with the end purpose
of meeting the patients needs. Both use observation communication and
recording as basic tools utilized by nursing.
Assessment

Orientation

Continuous data collection and analysis

May not be a felt need

Nursing Diagnosis & Planning

Mutually set goals

Implementation
Plans initiated towards achievement of

Non-

continuous
data collection
Felt need
Definite needs

Identification
Interdependen
t goal setting
Exploitation
Patient

mutually set goals

May be accomplished by patient, nurse, or
significant other.

actively
seeking and
drawing help
Patient
initiated

Evaluation
Based on mutually expected behaviors
May led to termination and initiation of
new plans

Resolution
Occurs after

other phases
are completed
successfully
Leads to
termination

Strengths
Peplaus theory helped later nursing theorists and clinicians develop more
therapeutic interventions regarding the roles that show the dynamic
character typical in clinical nursing.
Its phases provide simplicity regarding the natural progression of the nursepatient relationship, which leads to adaptability in any nurse-patient
interaction, thus providing generalizability.

Weaknesses
Though Peplau stressed the nurse-client relationship as the foundation of
nursing practice, health promotion and maintenance were less emphasized.
Also, the theory cannot be used in a patient who doesnt have a felt need
such as with withdrawn patients.

Conclusion
Peplaus theory has proved of great use to later nurse theorists and clinicians
in developing more sophisticated and therapeutic nursing interventions
including the seven nursing roles, which show the dynamic character roles
typical in clinical nursing. It entails that a nurses duty is not just to care but
the profession also incorporates every activity that may affect the clients
health.
However, the idea of a nurse-client cooperation is found narrow with those
individuals who are unfit and powerless in conversing, specifically those who
are unconscious and paralyzed.
Studying Peplaus Interpersonal Relations Theory of Nursing can be very
substantial especially to those who are aspiring to be part of the profession.
Having the knowledge of the seven roles of nursing, future nurses can apply
different roles in different situations, which will guarantee their patients to
acquire the best care possible, and will ultimately speed along treatment and
recovery.