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Peplau's Theory of Interpersonal Relations: Application in Emergency and Rural

Nursing

Article  in  Nursing Science Quarterly · January 2013

DOI: 10.1177/0894318412466744 · Source: PubMed

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466744
2466744Nursing Science QuarterlySenn
2013
NSQXXX10.1177/089431841

Practice Applications
Nursing Science Quarterly
26(1) 31­–35

Peplau’s Theory of Interpersonal Relations: © The Author(s) 2013

Reprints and permission:
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Application in Emergency and Rural Nursing DOI: 10.1177/0894318412466744
http://nsq.sagepub.com

Joanne F. Senn, RN; BSN1

Abstract
The author in this column highlights aspects of Peplau’s theory of interpersonal relations and its use both in emergency
nursing and rural nursing. Long and Weinert identified the concepts of rural nursing. Some differences between Peplau’s
theory and rural nursing can be identified through definitions of theory and conceptual models. Despite these differences,
there are some common themes between both theories that are described and compared.

Keywords
emergency nursing, nurse-patient relationship, nursing theory, rural nursing, Peplau

Nurse scholars agree that nurses utilize some form of nursing
theory, or conceptual model in daily practice and they pro-
pose that nursing theory is vital to nursing existence. Meleis
(1985) defined theory as "an articulated and communicated
conceptualization of invented or discovered reality (central
phenomenon and relationships) in or pertaining to nursing
for the purpose of describing, explaining, predicting or pre-
scribing nursing care"(p. 29). Through theory analysis,
nurses gain power through knowledge and understanding
of the phenomena that characterize the nursing situation
(Melnyk, 1989).
Fawcett (2010) stated that conceptual models of nursing
and nursing theories are a starting point for nursing practice
instead of other points of view, such as the medical model.
She believed nurses need to adopt the conceptual-theoretic-
empirical system to acquire knowledge in nursing to guide
nursing practice.
In terms of advocating evidenced-based nursing prac-
tice, it is essential that nursing theories are developed,
tested, and disseminated for practical use. Polit and Beck
(2012) described conceptual models as ideas assembled in
terms of their relevance to a common theme. Conceptual
models are more broad and abstract than theories. Fawcett
(2010) delineated nursing theory and nursing conceptual
model in the different contexts for which each is used.
One example of a nursing theory is the middle-range
theory. Middle-range theories focus on a portion of reality
or human experience, involving a selected number of con-
cepts. Mariner-Tomey and Alligood (2006) added that
nursing theory provides autonomy by reinforcing nursing
practice, education and research. Nursing research
findings from rigorous studies provide a robust basis for
nursing decisions and actions and help guide nursing
practice.
Quantitative as well as qualitative research is the founda-
tion of evidence-based nursing practice. Qualitative research
cannot be disregarded since this research includes human
experiences such as love, happiness, hope, and despair. It
seems logical to utilize middle-range theories for testing
nursing theory in order to differentiate nurse’s contributions
to the health and well-being of human beings from contribu-
tions by other disciplines. Conceptual models may lead to
middles-range theory development, which can generate
empirical research findings to validate nursing actions and
practice. Nursing theory leads to the further development of
nursing knowledge through its research potential. Most theo-
ries described in the literature relate to the metaparadigm of
nursing (Fawcett, 2010).
In practice, thoughtful, effective, communication, and
interpersonal skills can produce positive health outcomes
whether it is in an emergency department or a public health
setting. According to Fawcett (2010), nurses assess and inter-
vene in the context of the metaparadigm to produce the
desired outcome. The nurse-patient relationship fosters trust
and understanding between nurse and patient. Through this
relationship, goals for the patient are set and can be achieved.
Peplau’s Theory of Interpersonal Relations
Peplau (1952) developed the theory of interpersonal rela-
tions. She was a staff nurse, researcher, and educator.
Peplau urged nurses to use nursing situations as a source of
1
University of Alabama
Contributing Editor:
Paula M. Karnick, RN, PhD, Associate Professor, Lewis University, 5023 N.
Busse, Chicago, Illinois, 60656
Email: pmkarnick@aol.com

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32 Nursing Science Quarterly 26(1)
observation from which concepts could be derived that
were unique to nursing (Peden, 2001). Her primary con-
cerns were the conditions in patient wards, particularly
psychiatric patients in asylums during the 1940s and
1950s.
Ironically, as Peplau worked as a young nurse in hospi-
tals, she was told she should not talk to the patients. She
referred to an earlier version of her theory as talking to
patients, which would be transformed as a therapeutic
interpersonal relation theory that would not only be used in
treating psychiatric patients but all patients. This includes
areas of clinical practice, research, nursing administration,
and nursing education. Today, Peplau’s theory is widely
taught as a component of the psychiatric nursing curricu-
lum in nursing programs.
Peplau’s (1952) theory evolved through educational
endeavors and desire to achieve better outcomes for patients.
Her techniques and theory are still practiced today. Peden
(2001) said that, “Peplau’s work introduced a woman ahead
of her time, and today her theory keeps in pace with post-
modern nursing influences that have reinforced nurses’
awareness of the knowledge-rich context of practice, at the
level of the patient” (pp. 62-63).
Peplau’s theory can be classified as a middle-range the-
ory. She defined nursing as the therapeutic relationship
between both individuals; therefore, it necessitated that the
nurse interact with the patient purposefully. Peplau believed
that: “through the devise of the therapeutic nurse-patient
relationship, the nurse could be most beneficial to human
beings” (Fawcett, 2010, p. 529). Peplau admitted that her
theory focused on psychological and interpersonal phenom-
ena and did not include most aspects of the physiological
phenomenon (Fawcett, 2010). Peplau’s (1952) theory is not
applicable to patients with severely altered mental states or
for infants and young children. Despite this, the nurse can
collect pertinent data and facilitate a plan of care by estab-
lishing relationships with parents of infants and children
and through the relationships with the families of mentally-
compromised patients.
Peplau’s theory is abstract with a one-dimensional
concept, unlike some other nursing theories. The dimension
of nursing here is achieved through the nurse-patient rela-
tionship. The theorist emphasized that the terms relations
and relationships should not be used as one in the same.
This implies that the study of what goes on between two
people or their relations can be quite elusive. The nurse-
patient relationship can be expressed as a process with over-
lapping phases. The three identifiable phases in this process
are: a) the orientation phase, b) the working phase, and c)
the termination phase.
According to Peplau (1952), her process of communica-
tion was a means to promote favorable changes in patient
behaviors. Her model defined health in a broad sense, as the
forward movement of the personality and human processes
(Fawcett, 2010). In each of these phases the nurse-patient
relationship has certain nurse and patient behaviors and
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purpose. The nurse uses the nurse-patient relationship to
assess the patient’s psychological, emotional, and spiritual
needs with learned communication skills, personal strengths,
and an understanding of human behavior. The result is to
produce desirable goals that benefit the patient. In any patient
setting, trust occurs when the patient is confident in the
nurse’s conveyance of integrity and reliability. It is through
the nurse-patient relationship that the nurse can express
empathy toward the patient. From this perspective empathy
is the ability to perceive the meaning and feelings of the
patient and to communicate that understanding to the patient.
The initial phase of Peplau’s theory is orientation. During
this time the patient has health-seeking behaviors. The nurse
is identified as someone who is qualified to help the patient.
This period sets the stage for a more trusting relationship. In
the orientation phase the nurse collects data, makes initial
assessments of the patient’s needs, potential, interests, and
the patient’s inclination to experience fear or anxiety
(Fawcett, 2010). It is important for the nurse to establish
boundaries and maintain these during all phases of the pro-
cess. Phase two of Peplau’s theory is the working phase,
which is appropriately named because most of the work of
the relationship occurs here. This phase has two sub phases;
identification and exploitation. As the patient makes prog-
ress toward positive health outcomes, the focus is on the
patient’s reactions and the work that the patient needs to
accomplish. During the identification stage, the nurse may
assume various roles. For example, the nurse may be the
care provider, the surrogate parent, the educator or the coun-
selor (Fawcett, 2010). It is here where the nurse uses profes-
sional knowledge, education, and skill to solve a particular
health problem. This is an important period where the
patient identifies the nurse as consistently helping, provid-
ing unconditional care, and providing empathy. Initially in
the nurse-patient relationship, the nurse may act as a surro-
gate parent if the patient is in a developmental stage of infancy
or adolescence. During the working phase power shifts away
from the nurse to the patient as the patient becomes more
independent with personal care. During this time, the nurse
starts activating the discharge plan and acts primarily as an
educator and leader. The final phase of the theory is the termi-
nation phase. This phase allows the nurse and patient to dis-
engage from the nurse-patient relationship altogether. During
this time, the nurse summarizes the discharge plan and helps
the patient organize actions to progress toward new socially
interdependent relationships. According to Peplau, the termi-
nation of the nurse-patient relationship enhances the patient’s
ability to become more self-reliant in leading a productive
healthier life (Fawcett, 2010).
Implications of Peplau’s Theory in
Emergency Nursing
Emergency nursing requires skillful and tactful communica-
tion between nurses and patients. The interactions between
nurses and patients in the emergency setting may be brief,
Senn 33
but should have meaning for the patients. Emergency nurses
are cross-trained in many aspects of nursing that include,
traumatic injuries, psychiatric illnesses, substance abuse,
cardiopulmonary emergencies, pediatrics, and obstetrics.
Hines and Fraze (2011) found that one out of eight emer-
gency department visits were related to mental illness and/or
substance abuse. It is essential for the emergency nurse to
communicate proactively with the patients and their families
utilizing empathy, assertiveness, and active listening.
Emergency nurses can use the components of Peplau’s
(1952) theory particularly when applying the principles of
the phases in the nurse-patient relationship. The process
used by the triage nurse in an emergency department is simi-
lar to the process described in the initial orientation phase of
the theory. During the initial meeting the stage is set during
the interaction between the nurse and the patient. The type
and quality of interaction either facilitates or hinders further
communication. For instance, referring to a patient as
a frequent flyer may have extremely negative effects on the
outcome. The triage nurse has now set the entire tone for the
experience and the patient may have a negative perception
that leads to mistrust.
Sometimes patients will describe their emergency room
experience solely based on the interaction with the triage
nurse. In general, triage nurses should have good interper-
sonal skills along with sound clinical knowledge. When
patients arrive in an emergency department with a problem
or perceived problem, they may be apprehensive. The nurse
should use a non-judgmental, calm approach with an under-
standing of cultural diversity. In the event that the patient
cannot pinpoint the immediate problem, the nurse needs to
use skills to extract the information through an effective and
timely interview process.
An Emergency Department Case Study
and Use of Peplau’s Nursing Theory
A 32 year-old woman runs into the emergency department
screaming, “I can’t breathe!” She has tears streaming down
her face and has a strong odor of alcohol on her breath. Her
respiratory rate is 26 per minute and her pulse oximetry
reading is 99%. The nurse introduces herself to the patient.
Here is where orientation occurs as the patient displays
health-seeking behavior, and the emergency triage nurse is
identified as someone qualified to intervene and help. She
watches her non-verbal cues and body language and deals
with the patient with empathy. This behavior facilitates ini-
tial trust in the nurse-patient relationship. While the nurse
completes the initial vital signs, she notices an odor of alco-
hol on the patient’s breath and she realizes that the patient is
hyperventilating due to anxiety. At this time, the nurse needs
to explore her own feelings and beliefs when dealing with
the patient, whether negative or neutral. According to
Fawcett (2010), the importance of this comes from the
philosophical claim that in each interpersonal relationship,
the behaviors tend to be organized around how each person
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thinks of self. In this case, the nurse realizes through her
interview process that this patient has a history of panic
attacks and she has recently been dismissed from her job. In
this sub phase of identification, the patient may feel helpless
and the nurse provides reassurance. The nurse actively lis-
tens to the patient as the patient explores similar previous
episodes and reveals methods in which she dealt with past
experiences. When the nurse allows the patient to express
feelings, the patient’s experience may strengthen positive
forces in personality (Fawcett, 2010).
Peplau was responsible for developing a protocol for use
in nursing practice for patients experiencing severe anxiety.
The anxiety protocol identifies a specific criterion that was
derived from her theory. The nurse observes for anxiety-
related behaviors such as crying, yelling or hyperventilating
as displayed by the patient. Consequently, the nurse should
focus efforts on maintaining the patient’s awareness of the
anxiety and connect it to the anxiety-relieving behaviors
(Fawcett, 2010). The emergency nurse continues to interact
with the patient in the working phase through counseling and
clarifying information. The patient realizes through the
nurse-patient relationship and self-examination that she is
having a panic attack. She also recalls she has medicine pre-
scribed in the event of reoccurrences. The patient discloses
that the reason she was fired from her job was that she was
intoxicated and did not show up for work. She assumes
responsibility for this and makes an outpatient appointment
for the substance abuse program that she had attended in the
past. She remembers how this was helpful for her. The
patient also makes an appointment with her therapist on her
own before she is discharged from the emergency depart-
ment. The exploitation phase is seen here when the patient
takes responsibility and acts on her own without the nurse.
Finally, the nurse and patient review the discharge plan
including: feelings that led to panic attacks, medications, and
follow-up appointments. They reviewed signs and symptoms
requiring return to the emergency department. This is the
phase of in the nurse-patient relationship where termination
occurs and the relationship ends.
In the emergency department setting, the nurse uses the
phases of the nurse-patient relationship in briefer periods
since the average emergency room visit is usually less than
four hours. Nurses are generally excellent multi-taskers in
that they can talk to patients therapeutically, while perform-
ing tasks such as starting an intravenous line, or changing a
dressing. In this case, the nurse used the nurse-patient-rela-
tionship with skill and empathy, and she developed a mutual
trust facilitating the patient’s independence with positive
health behaviors. Peplau’s theory is appropriately used in the
context of emergency nursing practice.
Rural Nursing
Rural nursing is now taught in some community health nurs-
ing curriculums and graduate nursing programs. Long and
Weinert (1989) were the first nurse scholars to recognize
34 Nursing Science Quarterly 26(1)
rural nursing and highlighted that the needs of rural dwellers
were not adequately met through existing models and a
unique approach was needed to emphasize the needs of rural
patients. In 1989, the researchers gave a broad definition of
rural nursing "as the provision of nursing to persons living
in sparsely populated areas" (Winters & Lee, 2010, p. 41). It
is important to update the term rural in terms of the nursing
populations served. Rural populations in the United States
are areas that are not urbanized and usually consist of country
towns or smaller cities. The United States Census Bureau
(2010) defined geographical areas that have sparse popula-
tion densities where much of the land is used for agriculture.
In recent years, urban clusters have been included in the
definition of rural. These are subdivisions within a rural area,
which is defined as an area with 2,500 to 5,000 persons. The
purpose of expanding the definition was for the purposes of
economic development and access to resources (United
States Census Bureau, 2010). The Office of Rural Health
Policy (2012) identified over 16% of the individuals in the
United States are characteristic of rural populations. The
definition of rural can vary depending on which government
agency is defining it. Low income and isolated rural popula-
tions in large metropolitan areas can be considered rural
populations when it relates to access to healthcare. In the
United States, rural is also defined by each individual state
and its properties of land and residents. Individuals residing
in remote Alaska have quite different characteristics than
individuals residing in remote Appalachia in North Carolina.
The initial studies on rural nursing were from qualitative
and quantitative data based on rural individuals’ health per-
ceptions and needs (Long & Weinert, 1989). The participants
in the qualitative study were individuals working as farmers,
ranchers, and loggers in rural Montana. Rural nursing was
initially defined by a set of relational statements about how
people in rural areas define health and how they access
healthcare. Winters and Lee (2010) admit that continued
research is needed to provide a more solid foundation for
rural nursing.
Rural nursing is multidimensional, unlike Peplau’s one-
dimensional theory of interaction. Winters and Lee (2010)
described concepts of rural nursing practice. The first dimen-
sion of rural nursing is health, which is defined by the patient
and as the ability to work and maintain activities of daily
living. Nurses, who practice in rural settings, need to
approach nurse-patient interactions with rural concepts in
mind. The rural nurse needs to understand the rural dweller’s
belief systems in order to promote positive interactions that
lead to healthy outcomes. Health to a farmer probably may
mean that he can continue plowing the farm for the crop due
tomorrow. A trip to the emergency department for an illness
or injury would be delayed if he could perform his activities.
A second concept in rural nursing is isolation and distance.
Rural people are often isolated from clinics, doctors’ offices,
hospitals, and even pharmacies. A third concept of rural
nursing is self-reliance and use of informal healthcare.
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People living in rural areas are known for their hardiness.
They will take care of something themselves before asking
for outside help. They may use folk remedies passed down
from generations, the local pharmacist, friends, paramedics,
other family members or church members to aid in their care.
They consider medical personnel, as outsiders, and they do
not welcome them into their world with ease. This is impor-
tant for the nurse to remember when providing care to rural
populations.
Initial trust and barrier removal needs to occur to obtain
access to rural patients. A study by Sivamalai (2008) included
special issues working with rural clients such as anonymity,
isolation from support services; knowledge of the commu-
nity; and the requirement to care for relatives and friends.
Patients expected frontline rural nurses to be both generalists
and specialists and have a broad knowledge of most health
concerns. Rural patients said that it was highly important for
nurses to listen to their point of view and understand what
they are experiencing.
Comparison of Peplau’s Theory and
Rural Nursing
Peplau’s (1952) theory and rural nursing can both be useful,
particularly in the process of the nurse-patient relationship
and to provide foundations for further nursing research.
According to Koloroutis (2010), the nurse-patient relation-
ship is the foundation for excellent care delivery. Nurse
accountability for a therapeutic relationship with a patient is
essential in achieving quality outcomes. These perspectives
are different, but have the common themes of empathy,
nurse-patient relationships, listening, and advancing health-
promoting behavior. Peplau’s (1952) theory can be used in
nursing specialties as the nurse patient relationship is the
main dimension. Her theory has been widely tested and
evidenced-based practice has evolved through qualitative
and quantitative research based on her theory. The concepts
of rural nursing are based on statements about rural indi-
viduals’ beliefs, the environment in which they live, and
their social systems. The metaparadigm of nursing seems to
be lacking definitions in the literature of rural nursing.
One main difference between rural nursing and Peplau’s
(1952) theory is that rural nursing needs to be developed
much further with evidence for it to be accepted and dissemi-
nated in nursing practice. Winters and Lee (2010) relayed
that a revision of rural nursing. Another difference in rural
nursing and Peplau’s theory is that rural nursing is limited to
certain rural populations, and cannot be generally applied in
many other types of nursing. Nurses can certainly apply
some rural nursing concepts when caring for rural dwellers.
Conclusion
It is critical that nurses have the ability to skillfully inter-
act with patients in any setting. This fosters trust, mutual
 Senn 35
goal-setting, therapeutic interventions, and improved
learning experiences for the patient and the nurse. More
often than not, nurses use a combination of nursing theo-
ries and conceptual frameworks in daily nursing practice.
Theories such as Peplau’s (1952) and concepts from rural
nursing continue to evolve to guide nursing practice in
the future. The information acquired through the devel-
opment of nursing theory and research, provides
increased validity and substance to the unique science of
nursing. It is important for nurses to utilize nursing the-
ory and conceptual models in the context of their appro-
priate settings and populations. In evidence-based
practice, nursing theories provide strong building blocks
to produce research specific to nursing interventions,
which is essential to increase health promotion and
health prevention behaviors for patients. The evidence
produced through research helps to validate nursing
activities that can be directly responsible for positive
health outcomes.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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