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Nursing Science Quarterly Volume 22 Number 1 January 2009 34-40 © 2009 Sage Publications A Comparison
Nursing Science Quarterly
Volume 22 Number 1
January 2009 34-40
© 2009 Sage Publications
A Comparison of Two Nursing Theories
in Practice
10.1177/0894318408329339
http://nsq.sagepub.com
hosted at
http://online.sagepub.com

Peplau and Parse

Cindy T. McCarthy, RN; BN

Master’s of Nursing Student, University of New Brunswick

Catherine Aquino-Russell, RN; PhD

Associate Professor, University of New Brunswick

This column illuminates nursing practice through two unique theoretical perspectives: Peplau’s theory of interpersonal rela- tions and Parse’s theory of humanbecoming. Processes of each practice method will be explicated as each is related to a practice scenario. The key differences between Peplau’s and Parse’s practice methodologies are identified. Nursing is a unique, evolving, everchanging profession for which theory can be used as a guide for practice. This column demonstrates two of these unique theories. Whether through health promotion or quality of life from the person’s perspective, theory pro- vides meaning in nursing practice and in everyday life.

Keywords: nursing practice methodology; Parse’s humanbecoming theory; Peplau’s interpersonal relations

N ursing theory can be viewed as the metaphor of Rudolph guiding Santa’s sleigh through a blinding

snow storm. Nursing theory illuminates meaning through clarifying nurses’ values, beliefs, and thoughts about human beings, their health, and life in general; theory guides the way for nursing practice. Different nursing the- ories provide opportunities for different approaches to care, thereby allowing nurses to be creative in their practice methods. The authors here discuss the practice methodolo- gies (including assumptions, principles, and key concepts) of Peplau’s (1997) theory of interpersonal relations and Parse’s (1998) humanbecoming theory. These two theories will be compared through their application to a practice scenario. The goal of this paper is to illuminate meaning in practice for two of the many different nursing theories, and to stimulate the reader to consider the many possibilities for engaging in practice guided by a nursing theory. A nurse has come a long way from what the American Nurses Association described in 1940 as being “the morally virtu- ous woman who tries to reduce the suffering of those in need by faithfully obeying the doctor’s instructions” (as cited in Gastmans, 1998, p. 1313).

Peplau’s Interpersonal Relations in Practice

To comprehend Peplau’s theory is to look at nursing of the past, and value the contributions that Peplau has

made for the nursing of today. One of Peplau’s greatest contributions to the science of nursing was her value for integrating theory into nursing practice. Peplau believed that the nature and objectives presented in nursing prac- tice determined the scientific questions to be posed for research and therefore the development of nursing as a unique, autonomous profession (Gastmans, 1998). The importance of human relationships cannot be understated. The central phenomenon of Peplau’s theory is the nurse-client relationship; the majority of nurses’ work transpires during interactions with clients (Peplau, 1997). Peplau’s theory has provided a framework to guide nurses’ practice. Initially the framework was used within psychiatric nursing, but can now be applied to all areas (Peden, 2006). Prior to the work of Peplau, clients were considered objects and were to be observed, rather than subjects to participate with and engage with in relation- ships (Peden, 2006). The aim of nursing according to Peplau is to “promote forward movement of personality in the direction of creative, constructive, productive, per- sonal, and community living” (Gastmans, 1998, p. 1313).

Characteristics of Interpersonal Relations

Peplau (1997) identified characteristics encompassing caring relationships in her theory. The first is the com- municative characteristic of the nurse-client relationship. Conversation is invited by the nurse; clients express thoughts and feelings through words, that place the client

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in a dependent relationship with the nurse. The language or speech provided by the nurse leads to therapeutic effects and client well-being (Gastmans, 1998). Self- awareness and self-reflection, on the part of the nurse, are as critical to the relationship as is the assessment of the client’s situation (Forchuk, 1994). Peplau’s (1997) theory provides a practice framework that is interac- tional; both the client and the nurse reflect on beliefs, thoughts, and feelings (Yamashita, 1997). The second characteristic relates to the nature of the therapeutic relationship. This relationship exists in a pro- fessional manner. The goal for the nurse is to support the client’s overall health and well-being (Gastmans, 1998). There exists a hint of vagueness when considering the nurse-client relationship. On one hand nurses experience clients as people who are separate from themselves, while at the same time nurses may be strongly connected or attached to clients. Because of the connecting and separat- ing nature of the relationship, nurses must respect clients as independent, autonomous individuals (Gastmans, 1998). The above experiences have been defined as “proximity and distance, unity and separation, equality and difference—in short, the rejection of any aspiration to complete trans- parency—means that nurses respect their patients as having a unique value in themselves” (Gastmans, 1998, p. 1317). In essence, the nurse’s ability to offer presence that is caring will directly influence client outcomes. The third characteristic is that as the nurses enter the nurse-client relationship, they seek to learn who the per- son is. For instance, nurses may ask, “What are the client’s desires and needs?” or “What may contribute to improvement in this person’s situation?” With the knowl- edge obtained, nurses seek available possibilities or resources to meet the needs. When considering knowl- edge, Peplau reiterated the importance of knowledge that is intuitive and of a non verbal nature (Gastmans, 1998). A fourth characteristic of the nurse-client relationship is that regardless of the professional nature of the relation- ship, expertise and distance on the part of nurses, there remains an opportunity for human connection or contact (Gastmans, 1998). The meaning intended here is that nurses are professionally involved with clients; however, nurses are also involved in personal relationships with indi- viduals. This relationship is inevitable and occurs among all human beings. The skills of greatest importance within the nurse-client relationship are empathy, judgment, and an ability to seek the means that will offer the desired results for each individual client (Gastmans, 1998). “The quality of nursing [care] must always be seen in light of the rela- tionship between a unique nurse and a unique patient” (Gastmans, 1998, p. 1317).

Phases of Interpersonal Relations

The relationship between the nurse and client is a process which can be tracked through phases, and has a starting and ending point (Yamashita, 1997). There are three phases of Peplau’s (1997) theory of interpersonal relations. The first is the orientation phase. This phase is characterized initially as a unidirectional process. The nurses introduce themselves and state the objectives of the interaction and the time available for the clients. Nurses gather pertinent information from clients, such as a pertinent history. At this critical phase, the focus of the nurse is the client. The focus flows through active listen- ing and posing questions to prompt the client’s descrip- tions and personal stories (Peplau, 1997). During the orientation phase, nurses must be cautious of sharing personal experiences. The consequences of sharing personal stories with clients, during orientation, are that the client becomes the sounding board for the nurse and the nurse’s needs will be the focus rather than the needs of the client. The ability of the nurse to transi- tion from social to professional relationships can be chal- lenging and uncomfortable (Peplau, 1997). The next phase of the relationship is the working phase. The client moves into this phase once issues to work on have been identified (Yamashita, 1997). This phase is further divided into identification and exploitative phases. The iden- tification phase involves the nurse in an affirming role, to be there to assist the client in meeting needs. The nurse may also play a consultant role, by assisting the client to think through issues to reach personal solutions (Price, 1998). The focus is on the reactions of the client to illness and to gain an understanding of self (Peplau, 1997). One major challenge for the nurse, within the identification phase, is negotiating a level of commitment to offer to the client. Often support is desired for a longer term than is available (Price, 1998). During the exploitative phase, a plan is set forth, pri- orities to work on are identified, and teaching is pro- vided. The nurse moves among many roles during this phase. An understanding of the different roles, such as teaching, interviewing, and counseling, is imperative so that the nurse has an awareness of when movement from one role to another occurs (Peplau, 1997). The final phase is that of termination. During this phase, there is a summarizing of accomplishments and closure. The discussion of termination is initiated in the working phase, which prepares the client for the eventual end of the therapeutic relationship. The summary of the relationship is provided (Peplau, 1997). By this phase, clients are able to identify supports outside of the nurse-client relationship that they can draw upon in times of need (Price, 1998).

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As human beings, we require relationships. At their finest, “relationships confirm self-worth, provide a sense of connectedness with others, and support self-esteem. Relationships constitute the social fabric of life” (Peplau, 1997, p. 166). A great deal of the knowledge for the prac- tice of nursing extends from that of the social sciences, the humanities, and biology (Peplau, 1997).

Parse’s Humanbecoming Practice Methodology

Humanbecoming is living a human life. Through liv- ing, one is becoming. The humanbecoming school of thought pertains to what is involved in living a human life (Edwards, 2000). The humanbecoming practice method- ology involves three processes: illuminating meaning, synchronizing rhythms, and mobilizing transcendence (Parse, 1998). These processes are founded on the assumptions, postulates, principles, and concepts of the humanbecoming theory that reflect three major themes:

meaning, rhythmicity, and transcendence (Parse, 1998).

The Humanbecoming Ontology

The first assumption is “humanbecoming is freely choosing personal meaning with situation, living value pri- orities” (Parse, 2008, p. 370). Choosing meaning is making

decisions for which one is responsible (Edwards, 2000) and that are of value to the person. Meaning is not static but ever-changing (Parse, 1998). The first principle is “struc- turing meaning is the imaging and valuing of languaging” (Parse, 2008, p. 370). Humanbecoming is ongoing creation

(Parse, 1998). It is a “seamless symphony of becoming

. the was, is, and will-be all-at-once” (Parse, 1996, p. 182).

. .

Within this first principle, there are concepts. One is lan- guaging. Parse (1998) identified this concept as speaking– being silent and moving–being still. Another concept is imaging. Imaging reflects the explicit–tacit knowing (Parse, 1998). Explicit knowing is defined as critical reflec- tion whereas tacit knowing is acritical (Parse, 1998). Valuing is another concept within the first principle. Valuing is the choices one makes (Parse, 1998). As individ- uals constantly interpret their situations (uncover the mean-

ing) they are also creating them. Meaning is the first theme

within the humanbecoming theory. “Meaning

. . .

is not sta-

tic but ever-changing, and thus portends the unknown, the yet-to-be truths for the moment” (Parse, 1998, p. 29). The practice method process of illuminating meaning is “explicating what was, is, and will be. Explicating is making clear what is appearing now through languag- ing” (Parse, 1998, p. 69). The nurse lives this practice

method process in true presence with the person (or fam- ily), by asking for example: What is important to you now? The second assumption of the humanbecoming theory is “Humanbecoming is configuring rhythmical patterns of relating with humanuniverse” (Parse, 2008, p. 370). In this assumption, the human is open in terms of connect- edness with the universe. Humanuniverse is cocreated (Parse, 2007). The second principle is “configuring rhyth- mical patterns of relating is the revealing-concealing and enabling-limiting of connecting-separating” (Parse, 2008, p. 370). Parse defined paradox as “an intricate rhythm expressed as a pattern preference. Paradoxes are not opposites to be reconciled or dilemmas to be overcome but, rather, lived rhythms (Parse 2007, p. 309). Within the second principle there are three paradoxes. There is revealing–concealing. Whenever one reveals one is at the same time concealing (Parse, 2007). The next paradox is enabling–limiting. When choosing one possible, one is restricting another (Parse, 1992). The third paradox is connecting–separating. This is explicated with the para- dox, attending–distancing (Parse, 2008). Parse (1992) offered a meaningful analogy that illuminates the rhyth- mical movement when she wrote “dwelling with the rhythm is like treading water, while one appears to remain in the same place, different waves arise to create subtle movement and often gigantic leaps” (p. 40). Rhythmicity (the second theme of the humanbecom- ing theory) is the “cadent, paradoxical patterning of the human-universe mutual process” (Parse, 1998, p. 29). It is lived with the practice process of synchronizing rhythms, which “is dwelling with the pitch, yaw, and roll of the human-universe process. Dwelling with is immers- ing with the flow of connecting-separating” (Parse, 1998, p. 70). In living this in practice, the nurse “stays with persons as they describe the ups and downs, strug- gles, moments of joy [or sorrow] and the unevenness of day-to-day living in the now moment” (p. 70), not trying to calm uneven rhythms, but going with the rhythms set by the person or family, moving with the flow. The third assumption of the humanbecoming theory is “humanbecoming is cotranscending illimitably with emerging possibles” (Parse, 2008, p.370). Humans move with “creation of new ventures, as struggling and leaping beyond shifts the view of the now, expanding horizons, and bringing to light other possibles” (Parse, 1998, p. 30). The third principle is “cotranscending with possi- bles is the powering and originating of transforming” (Parse, 2008, p. 370). One reviews and ponders various pathways. Giving consideration to the options, persons choose the most viable option for them, thus moving on, with their hopes and dreams (Parse, 1998). The concepts

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in this principle are powering, originating, and trans- forming. Powering refers to the pushing–resisting rhythm. This pushing–resisting rhythm can also bring about conflict. Conflict is not viewed negatively, it is seen as an opportunity to reflect and move in another direction. “Originating is inventing new ways of conforming- not conforming in the certainty-uncertainty of living” (Parse, 1998, p. 49). The paradox of living conformity– nonconformity surfaces as persons seek to be like others, yet not to be like others, while the paradox of certainty– uncertainty surfaces as individuals make choices amidst the ambiguity of the unknown. Transforming is the chang- ing of change, seeing the familiar in a new light (Parse, 1998). One is continually gaining new experiences. Transcendence is the third theme of the humanbecoming. The third process in the humanbecoming practice method is mobilizing transcendence. The nurse lives true presence with persons, dwelling with them as they dis- cover the possibles of their circumstances. Persons iden- tify their own options (Jonas, Mitchell, & Rasmusson, 1991). This is transcendence. The central focus of humanbecoming is quality of life from the person’s perspective (Parse, 1998). Nurses live the humanbecoming practice method in true presence with others. True presence is “reflecting the belief that each person knows the way somewhere within self” (Parse, 1992, p. 40). A nurse can be in true presence in three ways: first, through face to face discussion, whereby the nurse engages in conversations about what is important, listens to the person’s interpretation of drawings, or experiences music together, to mention a few; second, through silent immersion, which is presence without words; finally, through lingering presence, where one can experience glimpses of a moment be it past, present, or the not-yet-lived (Parse, 1997).

Practice Scenario

The following scenario is presented for the purposes of demonstrating both Peplau’s and Parse’s theories as lived in practice. A 15-year-old young man, who for con- fidentiality purposes will be referred to as Brad, arrived at the emergency room (ER) by ambulance. He was unconscious and bleeding from the mouth and nose, and had what was thought to be cerebral spinal fluid seeping from his right ear. The young man was taken immedi- ately to the trauma room and the lifesaving tasks began. Brad’s condition was critical; he had a massive head injury from an accident involving a motor vehicle. Brad’s parents arrived, as well as his extended family members. There were grandparents, aunts, uncles, and a

10-year-old cousin with whom Brad was out riding when the accident occurred. Brad’s family was in distress, they wanted to see Brad. The family had many questions and looked to the nurse for answers. They wanted to know what was happening to Brad, they wanted to know if he would be all right. The nurse guided by Peplau’s theory of inter- personal relations is discussed first, followed by a view of the practice situation through the lens of the humanbecom- ing theory.

Application of Peplau’s Interpersonal Relations Theory

Brad’s family was seeking professional assistance by asking questions about his condition. The nurse guided by Peplau’s theory began by developing a relationship with Brad’s family, identifying herself as one of the nurses working in the ER. The nurse began discussions with Brad’s family, familiarizing herself with each family member’s role to determine who Brad’s parents were, and who were the grandparents, and other extended family members. During the orientation phase of the nurse-fam- ily relationship the nurse actively listened to Brad’s family members and asked details of what had happened to Brad from the family’s perspective. The nurse learned, during the discussions with Brad’s parents that Brad had been rid- ing his four-wheeler that afternoon and was not wearing his helmet. They had warned him and insisted that he wear his helmet; however, he did not listen. Brad’s parents stated that they were to blame for their son’s condition as they had bought him the four-wheeler for his birthday. Through conversations with Brad’s family members, the nurse was able to calm the family members and redirect their stress and anxiety through discussions. The Peplau nurse used the discussion about anxiety to move the rela- tionship forward; trust was obtained between the nurse and family and a working relationship was established (Comley, 1994). The family members were experiencing great anxiety (fear of the unknown) and asking what would help them to move away from the anxiety, while at the same time suggesting various options. Brad’s family members were ready to move forward (beyond the hysterics) and they demanded to see Brad. They were prepared to learn what they could do to help him, yet the nurse wondered how they could move past the guilt of the situation. The family discovered their focus through guidance from the nurse. The nurse informed the family member that Brad would most likely need to be transferred to another healthcare facility, due to the head injuries that he had suffered. These needs could be stabilized, but he would require a higher level of care than could be provided at the current facility. The Peplau

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nurse worked toward the learning required for addressing these problems with the family (Peplau, 1997). The Peplau nurse, at this time, occupied several roles as the nurse physically caring for Brad, the nurse counseling Brad’s family, and the nurse providing teaching and information to Brad’s family. The nurse provided the facts of Brad’s condition to the family members in such a way as to build upon their current knowledge (Peplau). The nurse assisted the family members to find strengths within themselves. Brad’s family members discovered how important the support from each other was and would continue to be. While the Peplau nurse is enhancing learning through working with the anxiety of Brad’s family members and of self, the nurse is able to self-reflect on her participation in the relationship, and increase understanding of her per- sonal and professional strengths and weaknesses. Brad required a transfer to a different setting. The nurse- family relationship, according to Peplau (1997), is limited by time. In preparation for the termination phase, the nurse informed the family that Brad would eventually be leaving this facility. The nurse then summarized the information provided by the family (they wanted to be together, to sup- port one another, and to be there for one another, now and always) and made other suggestions for learning to address the anxiety of the situation and the future.

Nurse Living the Art of Humanbecoming

The nurse that was guided by humanbecoming theory viewed the situation and acknowledged that she could only be in one place at one time. She saw that Brad’s med- ical care needs were being cared for by others and also saw that the family members were in extreme crisis and alone. She made a decision to spend time in true presence with Brad’s family, while other healthcare professionals worked on life-saving tasks for Brad’s mangled body. “True presence is a powerful interhuman connection expe- rienced at all realms of the universe. It is being with the rhythms of the sounds and silences, the visions and blind- nesses of the whole-in-motion” (Parse, 1997, p. 34). The Parse nurse engaged in illuminating meaning with Brad’s family members through languaging. The nurse asked:

What is it like for you right now? Brad’s family members wanted information, and to be in control of what was hap- pening to them and to Brad. The nurse guided by the val- ues of humanbecoming witnessed the meaning that was cocreated with the thoughts and ideas of Brad’s family. The family members expressed guilt, anger, and hope. Through being with, and bearing witness to the values and priorities presented by Brad’s family, the nurse stayed with them with loving presence in the absence of judg- ment (Bournes & Naef, 2006). Face to face discussions

provided explanations of the events that were transpiring, while at the same time, discussions moved the family members beyond the moment. Brad’s family, through true presence with the nurse, was able to transform and envi- sion the possibles (Bournes & Naef). They identified their hopes for Brad and their dreams for his future. In synchronizing rhythms, the nurse spent time with the family, dwelling with the family’s rhythm, moment to moment, the ups, the downs, the pain, the sorrow. The nurse lived true presence through silent immersion with Brad’s family as well. The helplessness they felt about what was happening to their little boy, their only child, became explicit. There was much to be gained from one another as the nurse witnessed the family members’ unfolding meaning. The nurse asked Brad’s family to reflect on their memories by asking, “What was life like with Brad?” Brad’s family members recounted the events of this tragic day over and over, recalling many happy and sad moments (Parse, 1994). The moments of the day came together with the moments that have not yet been lived, those of tomorrow (Parse, 1997). Through humanbecom- ing nursing practice the meaning of the situation surfaced. It is this meaning that is transforming. The nurse guided by the humanbecoming theory offered true presence not only with Brad’s parents, grand- parents, aunts, and uncles, but also with Brad’s 10-year- old cousin. The nurse provided him with drawing materials and invited him to draw. He drew a picture of Brad and him walking along the river. The nurse asked Brad’s cousin to talk about his picture and what the picture meant to him. The young boy talked of how they had done everything together. He spoke of how Brad was more like his brother, his best friend, and how he felt the accident was his fault because he had asked Brad to go four-wheeling that day. The boy cried while the nurse placed her hand on his shoulder. This boy’s meaning surfaced as the nurse lived in that moment, together with Brad’s cousin, being open to what arose (Karnick, 2005). In this way personal meaning was illuminated through art. As the Parse nurse lived true presence with Brad’s fam- ily, there was a special bond created, a nurse-family bond. This bond transcended beyond the present situation to synchronize with the rhythms of the young man’s family, to dwell with the struggles as they were pushed from the guilt of his accident amid the fury of the situation, meet- ing resistance as they attempted to reach serenity, realizing that no one was to blame for the horrible accident. The pushing–resisting rhythms, of guilt–blamelessness and fury–serenity, brought about conflict. The conflict pro- vided the family with the opportunity to ponder possibles with Brad: sharing moments, holidays, birthdays, and the day he was born. As the nurse lived true presence with

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Brad’s family, she did not seek to change the way the fam- ily members were feeling. Rather, the nurse moved with the family members as they experienced both the high and low moments of Brad’s changing condition. In living the practice process of illuminating meaning, the nurse asked Brad’s family, “What is important to you now?” Meaning unfolded as Brad’s mother shared that what was most important to her at this moment was that her son not suffer. She knew that he would probably not sur- vive this accident and just wanted him to die peacefully. The nurse dwelled with the rhythms as the family member lived the rhythmical and paradoxical pattern of health. Brad’s mother stated in the moment that she did not want her son to die, yet she was planning for his peaceful death. The nurse did not try to change this, but went with the flow, moment to moment. They spoke of the nature and extent of Brad’s injures and how they could not have changed the outcome of today’s unfolding. This meaning signified that Brad’s family members, somewhere within, knew the way. In mobilizing transcendence, the Parse nurse in true pres- ence spent time with the family in the process of trans- forming—a shift from what is familiar to what has been illuminated. She asked them: What will it be like for you tomorrow? They spoke of their tomorrows possibly with- out Brad. There were tears, hugs, and silences. The nurse went with the rhythms and witnessed the family’s grief. This continuous understanding will lead the way (Parse, 1992). The processes of the humanbecoming practice method did not happen in a linear fashion, they happened all-at-once, nurse with person(s).

Comparison of Peplau’s and Parse’s Theories

One of the major differences between the practice of Peplau’s interpersonal relations theory and that of Parse’s humanbecoming theory is the goal for nursing. According to Peplau’s theory, the goal of nursing is to promote health through the forward movement of personality (Martin, Forchuk, Santopinto, & Butcher, 1992). The goal of nursing, according to Parse’s (1998, 2007) theory, is quality of life from the person’s (family’s) perspective. Peplau’s theory is concerned with the nurse-client rela- tionship; whereas Parse values humanbecoming in nurse with person. These are two very different foci; one is on the relationship and the other on human beings living health (Venes, 2005). In essence, the relationship between the nurse and client is a minute portion of the human experience as a whole. Yet, given the time period that Peplau wrote her theory she was heading in a mag- nificent direction, well beyond her time, beginning with her thoughts about human relationships and how they

affect an individual’s health, the discipline of nursing, and ultimately the art and science of nursing. Peplau (1997) asserted that as nurses assist clients through the many roles they play and through the phases of the nurse-client relationship, nurses are gaining “invaluable data for advancement of the nursing profession” (p. 164). As nurses, we constantly evaluate our verbal and nonverbal communications with clients for personal growth on a professional level. Yet, from another view, Parse (1998) asserted that through true presence, meaning is illuminated and both the nurse and the person are becoming as they synchronize rhythms and mobilize transcendence.

Conclusion

The practice of nursing, as guided by both Peplau’s the- ory of interpersonal relations and Parse’s humanbecoming theory, demonstrates the value and uniqueness of the art and science of nursing; how nursing is everchanging and evolving as both a discipline and as a practice profession. By comparing the two theorists’ perspectives through a practice application, the uniqueness is brought to the fore- front, as both Parse and Peplau view the achievement of an individual’s health through very different lenses and place value on different priorities. Nursing is so much more than the here and now; it is being with the person, taking time to listen, not only to the person and family, but also to one’s self. Nursing theory is the light that guides a nurse’s way, just as Rudolph’s light guided Santa through the dark and stormy, snowy nights.

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