An INTERPERSONAL RELATIONSHIP (often referred to as an IPR) is the connection that exists between two or more individuals. Observation, assessment, communication, and evaluation skills serve as the foundation for an interpersonal relationship. Development of any interpersonal relationship requires the individual to have a basic understanding of self and what that individual brings to the relationship. The second most important skill is that of communication, including both verbal and nonverbal communication.

The relationship that nurses have with their patients is considered the cornerstone of all other components of nursing. Regardless of the patient’s health status—ranging from well individuals living in the community to patients who are critically or terminally ill—establishing a nurse−patient relationship is one of the nurse’s primary goals. It is this relationship that is reflected and integrated into the plan of care for any patient of any age, culture, or socioeconomic background.

The interpersonal relationship in nursing is often considered to be the one-to-one relationship between the nurse and patient. However, the nurse also needs to develop interpersonal relationships with the patient’s family and key individuals in the patient’s environment.

Interpersonal relationships form the basis of nursing interventions for psychiatric-mental health nursing. To do this, nurses must learn how to build the relationship and develop the skills for enhancing the interaction among the nurse, patient, family, and other important individuals in the patient’s life.

This chapter provides an introduction to interpersonal relationships, which serves as the foundation for the rest of the book. Several interpersonal models have been developed in nursing. Two prominent nursing theories that specifically address the interpersonal relationship as the core concept are described. These are the theories of Hildegard Peplau and Joyce Travelbee.

HILDEGARD E. PEPLAU

Hildegard E. Peplau is considered the founder of psychiatric-mental health nursing theory and professional practice. She has been referred to as the “mother” of psychiatric nursing and, in an authorized biography by Callaway (2002), as the psychiatric nurse of the century. She is well known within the national and global nursing communities, not only for her contributions to psychiatric nursing but also for her activism throughout nursing. During her professional career, she served as president of the American Nurses Association (ANA) and subsequently, as the ANA executive director. She also served as a board member of the International Council of Nurses (ICN). In 1997, she received the highest award from this organization, the Christine Reimann Prize.

Peplau was always a staunch supporter of professional education for nurses and of specialization for post-basic preparation. She was responsible for developing the first master’s degree clinical nurse specialist psychiatric-mental health nursing program at the Rutgers University School of Nursing in New Jersey.

Biographical Background

Hildegard E. Peplau was born September 1, 1909, in Reading, Pennsylvania; she died in 1999 at the age of 89 years (Figure 2-1). She was the second in a family of five children. Her parents had immigrated to the United States from Poland before any of the children were born. Throughout her school years, Peplau excelled; she decided on a career in nursing to advance her education and to provide a means for making her own way in the world. She graduated from the Pottstown Hospital School of Nursing in 1931 and from the Bennington College in 1942 with a bachelor of arts degree with a major in interpersonal psychology.

Figure 2-1 Hildegard E. Peplau.

While studying at Bennington, Peplau was exposed to the work of Harry Stack Sullivan. Sullivan’s theory described personality as behavior in relation to others. He identified a person’s need for satisfaction and security with the development of anxiety if these needs are not met. Sullivan’s work greatly influenced Peplau who also emphasized basic needs and anxiety.

Peplau served in the Army Nurse Corps as a first lieutenant in World War II. Following her service, she received a master’s degree from Columbia University in 1947 and a doctorate in education in 1953.

Peplau was a dedicated nurse and scholar and quickly rose to the top of her profession. She directed the graduate program in psychiatric nursing at Columbia Teachers College from 1948 to 1953. It was during this time that she wrote the seminal text: Interpersonal Relationships in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing. Although the book was completed in 1948, it was not published until 1952 (Peplau, 1952). Her book was considered most unusual in nursing because it was one of the first nursing books written by a nurse without a physician as coauthor. In fact, the 3-year delay in publication was because the book was considered too revolutionary for a nurse to publish (O’Toole & Welt, 1989).

Peplau’s Theory of Interpersonal Relationships

Peplau viewed nursing as an interpersonal process between two or more persons directed toward a therapeutic goal. Therapeutic goal attainment is achieved by the nurse’s deliberate actions that occur along a sequence of phases.

The environment also plays a key role in human development (Peplau, 1992). The environment included factors such as culture, adult presence, economic status, and prenatal environment, as well as the interactions between the patient and the others, that is, family, parents, or nurse.

Anxiety is another key component of Peplau’s theory. (See Chapter 13 for a more in-depth discussion of anxiety.) Drawing on the work by Sullivan and his interpersonal theory, she identified different levels of anxiety and their effects on an individual. Peplau emphasized the need for nurses to recognize anxiety and intervene accordingly to improve the individual’s state.

Peplau believed that the interpersonal competencies of nurses are essential to assisting patients to regain health and well-being. These interpersonal competencies are based on the nurse’s ability to understand his or her own behavior. Peplau stressed the need for nurses to be able to feel within themselves the feelings that others are communicating verbally or nonverbally. Most commonly, these feelings are anxiety or panic. Nurses then integrate this understanding and self-awareness to assist others in identifying their problems. (See Chapter 3 for more information on developing self-awareness.)

Phases of the Interpersonal Process

Initially, Peplau described four phases in the interpersonal process: the orientation phase, identification phase, exploitation phase, and resolution phase (Peplau, 1952, 1991). Later, these four stages were condensed into three stages: orientation phase, working phase, and termination phase (Peplau, 1988, 1997). The four-stage model is described in Figure 2-2.

Orientation

The first phase of Peplau’s interpersonal process is the ORIENTATION PHASE. This phase includes the initial contact the nurse has with the patient. During this phase, the patient seeks assistance. The nurse identifies himself or herself and the purpose and nature of the relationship. It is in this orientation phase that the nurse also communicates the temporal dimension of the relationship to the patient; that is, he or she informs the patient about the time frame available for the therapeutic interaction.

Peplau emphasizes that the patient is the focus of the communication. Personal information about the nurse is not needed. The patient conveys his or her needs, asks questions, and shares information. The nurse observes the patient and makes assessments of the patient’s status and needs during this phase of the relationship. Acting as a participant observer, the nurse uses his or her knowledge about influencing factors and takes into account the patient’s previous experiences, values, beliefs, culture, and expectations. The nurse also is cognizant of his or her own previous personal experiences, values, beliefs, culture, preconceived ideas, and expectations; assesses his or her own self; and determines how these may influence the nurse–patient relationship. This knowledge of self is an important factor in the relationship.

Figure 2-2 Peplau’s model of interpersonal relationships. Peplau initially identified four phases of the interpersonal process as orientation, identification, exploitation, and resolution. Note that the exploitation phase is the largest because the majority of work occurs at this time. In follow-up research, Peplau combined the phases of identification and exploitation, calling it the “working phase.” As conceptualized by J. Jones.

At the beginning of the orientation phase, the nurse and the patient meet as strangers, but as the relationship is developed, the problem is identified. The nurse explains routines, roles, and expectations to elicit the full participation of the patient. Subsequently, the patient begins to develop a sense of belonging and the ability to deal with the present difficulties. The patient and the nurse are ready to move to the next phase of the relationship.

Identification

In the IDENTIFICATION PHASE, the patient recognizes the health care needs for which the nurse can provide assistance. The patient views the nurse as a skilled provider of care capable of helping the patient to meet these needs and accepts the nurse’s help. The nurse, in turn, senses that the patient has identified the needs and has cast the nurse in the role of the care provider. Additionally, the nurse identifies personal knowledge, attributes, and skills that he or she can bring to the relationship when providing nursing care. Together, the patient and nurse develop mutual goals and begin working together to address the patient’s needs. Expression and exploration of the patient’s feelings are key during this time.

Exploitation

During the EXPLOITATION PHASE, the bulk of the work in the nurse–patient relationship is accomplished with the patient taking full advantage of the nursing services offered. This phase encompasses all of the therapeutic activities that are initiated to reach the identified goal. Throughout this phase, the nurse and the patient must continue to clarify expectations and goals and to define the work to be done based on identification of patient needs. Evidence-Based Practice 2-1 highlights a research study that applies Peplau’s theory to women with depression.

Open communication is essential during this time and requires a trusting relationship between nurse and patient. Without this trust, the work essential to meeting the therapeutic goals cannot be completed.

The relationship between the nurse and the patient during this phase is intense as the patient begins to take responsibility for his or her own health goals. This shift in responsibility from the nurse to the patient characterizes this phase. However, this transition to greater responsibility may be the most difficult point in the nurse–patient relationship. The exploitation phase requires that the nurse begins to foster independence in the nurse–patient relationship and starts the process of “letting go” in preparation for the next phase. Health care providers, including nurses, sometimes have difficulty in relationships when their clients are not dependent on them. This may indicate a boundary issue. (For more information on health boundary management in therapeutic relationships, see Chapter 4.) Although the patient may initially be dependent on the nurse, as the exploitation phase progresses the patient develops independence.

Resolution

The RESOLUTION PHASE of the relationship occurs when the patient’s needs have been met through the collaborative work of nurse and patient. The nurse’s evaluation of the patient’s readiness to move through termination of the relationship is crucial to resolution. During a successful termination, the patient moves away from the nurse and understands that he or she can manage independently. The patient assumes the power to meet his or her needs and set new goals. However, if the relationship is terminated prematurely, the patient may relapse and thus require a rebuilding of the therapeutic relationship.

 

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