1. Peplau's Theoretical Model 459
and labeled the variables differently in order change. Peplau's interpersonal relationship is
to specify relationships. The HPM may also also a process through which nursing knowl-
be inappropriate when nurses are interacting edge is developed and validated (Reed,
with clients who are cognitively impaired or 1996b). Peplau (1992) purposefully linked
unable to communicate. Examples would in- her theory to practice and research, as evi-
clude infants or individuals with severe neu- denced in her basic assumption that "what
rological deficits. Overall, the predictive goes on between people can be noticed, stud-
power of the model will always be limited by ied, explained, understood, and, if detrimen-
the inherent uniqueness and variation of each tal, changed" (p. 14).
human's behavior. Peplau's theoretical model derives from
Strengths of the HPM include its use of the perspective of a critical philosophy that
concepts that are logical and basic, its gener- integrates both the science and practice of
alizability, and its usefulness in research and nursing in theory development. Peplau's the-
clinical practice. Fender's model also ad- oretical model was based upon her study,
dresses the barriers to action that are im- observation, and analyses of nurses and pa-
portant areas to focus nursing intervention. tients and was influenced by Harry Stack Sul-
Lastly, Fender has taken a truly holistic ap- livan and others' psychodynamic perspec-
proach, considering sociocultural, psycho- tives. Peplau's (1952) classic descriptions of
logical, and biological variables. The content nursing express the nature and goals of the
of the HPM model is consistent with contem- interpersonal process: "Nursing is a human
porary beliefs that health promotion is a na- relationship between an individual who is
tional and international priority and a cost- sick or in need of health services, and a nurse
effective alternative to sick care. especially educated to recognize and to re-
spond to the need for help" (pp. 5-6). Nurs-
CARYN A. SHEEHAN ing is an "educative instrument, a maturing
force, that aims to promote forward move-
ment of personality in the direction of cre-
Peplau's Theoretical Model ative, constructive, productive, personal, and
community living" (p. 16). Peplau (1988) fur-
Hildegard Peplau (1909-1999) formulated ther described nursing as an "enabling, em-
her theoretical ideas about the therapeutic powering, or transforming art" (p. 9).
process of nursing in the 1940s and published Health, according to Peplau (1952), is a
them in the now-classic 1952 book, Interper- "word symbol that implies forward move-
sonal Relations in Nursing, after a lengthy ment of personality and other ongoing hu-
dispute with publishers about the ability of man processes in the direction of creative,
a nurse to author a book. At a time when constructive, productive, personal and com-
nurses were "doers" for patients and "follow- munity living" (p. 12). Illness forces a "stock-
ers" of physicians' orders, Peplau's theoreti- taking by the sick person, which nurses can
cal work and teachings helped catapult nurs- use to promote learning, growth and im-
ing from an occupation to a profession. Pep- proved competencies for living" (Peplau,
lau's ideas provided a foundation for nurses 1992, p. 13). Health and illness are closely
to understand health from a nursing theoreti- linked to successful management of anxiety,
cal perspective and to establish interpersonal which ranges from pure euphoria to pure
relationships with patients as the significant anxiety. An optimal level lies between these
context in which nurses facilitate patients' anxiety extremes, as determined by nurse
well-being. and patient.
Through Peplau's therapeutic relation- Through the therapeutic relationship, the
ship, the patient develops inner resources for nurse uses a complex set of strategies to assist
healthy behaviors by actively participating the patient in using energy provided by the
with the nurse in a developmental process of anxiety to identify and grow from a problem-

2. 460 ENCYCLOPEDIA OF NURSING RESEARCH
atic situation (O'Toole & Welt, 1989; Reed, that the power to accomplish the tasks at
2005). The nurse-patient relationship is fun- hand resides within the patient and is facili-
damental to providing nursing care and de- tated through the workings of therapeutic re-
rives from the human need for connectedness lationship.
that is still essential in the 21st century (Pep- The focus of the working phase is on: (a)
lau, 1997). Through this interpersonal rela- the patient's efforts to acquire and employ
tionship, nurses assess and assist people to: knowledge about the illness, available re-
(a) achieve healthy levels of anxiety intraper- sources, and personal strengths, and (b) the
sonally and (b) facilitate healthy pattern inte- nurse's enactment of the roles of resource
grations interpersonally, with the overall goal person, counselor, surrogate, and teacher in
of fostering well-being, health, and develop- facilitating the patient's development toward
ment. This relationship also provides the con- well-being (Peplau, 1952, 1997). The rela-
text for the nurse to develop, apply, and eval- tionship is flexible enough for the patient to
uate theory-based knowledge for nursing function dependently, independently, or in-
care. Nurse interpersonal competencies, in- terdependently with the nurse, based on the
vestigative skill, and theoretical knowledge patient's developmental capacity, level of
as well as patient characteristics and needs anxiety, self-awareness, and needs.
are all important dimensions in the process Termination is the final phase in the pro-
and outcomes of the relationship (Peplau). cess of the therapeutic interpersonal relation-
The structure of the interpersonal relation- ship. Patients move beyond the initial identifi-
ship was originally described in terms of four cation with the nurse and engage their own
phases: orientation, identification, exploita- strengths to foster health outside the thera-
tion, and resolution (Peplau, 1952). Forchuk peutic relationship (Peplau, 1952, 1988). In
(1991), with the support of Peplau, clarified addition to addressing closure issues, the
the structure as consisting of three main nurse and patient engage in planning for dis-
phases: orientation, working (which incorpo- charge and potential needs for transitional
rated identification and exploitation), and care (Peplau, 1997).
termination. In a 1997 publication, Peplau Peplau's theoretical model can be catego-
endorsed this three-phase view and explained rized as a middle-range theory. It is narrower
that the phases were overlapping, each having in scope than a conceptual model or grand
unique characteristics. Throughout these theory and addresses a clearly defined num-
phases the nurse functions cooperatively with ber of measurable concepts (e.g., therapeutic
the patient in the nursing roles of stranger, relationship, anxiety). The theory has a spe-
resource person, counselor, leader, surrogate, cific focus on the characteristics and process
and teacher. The nurse's range of focus in- of the therapeutic relationship as a nursing
cludes the patient in relationship with the method to help manage anxiety and foster
family, other health care providers, and com- healthy development. As such, the model is
munity (Peplau, 1952, 1997). directly applicable to research and practice.
The orientation phase marks a first step Peplau was explicit in promoting research-
in the personal growth of the patient and is based theory. Research based on Peplau's the-
initiated when the patient has a "felt need" oretical model has addressed topics related
and seeks professional assistance (Peplau, to both nurse behaviors and patient health
1952, p. 18). The nurse focuses on "knowing conditions. Nurse-focused topics include: (a)
the patient as a person" and uncovering erro- the practices of psychiatric mental-health
neous preconceptions, as well as gathering nurses, (b) family systems nursing, and (c)
information about the patient's mental health the nature of the nurse-patient relationship
problem (Peplau, 1997). The nurse and pa- in reference to roles and role changes over
tient collaborate on a plan, with consider- the trajectory of a mental illness, boundary
ation of the patient's educative needs. issues in pediatric nursing, and concepts such
Throughout the process, the nurse recognizes as therapeutic intimacy. Patient-focused re-

3. Pet Therapy 461
search has addressed health conditions in- [2000]). The clinical significance of the thera-
cluding depression, psychosis, sexual abuse, peutic relationship is likely to increase as
Alzheimer's disease, and multiple sclerosis. A health problems shift to those related to
particularly notable Peplau-based researcher stress-related conditions, chronic illness,
is Forchuk (e.g., Forchuk, 1994; Forchuk et aging processes, and end of life, where medi-
al., 1998; Forchuck, Jewell, Tweedell, & cal-surgical approaches alone have little suc-
Steinnagel, 2003) who, along with col- cess in promoting well-being. Peplau's inter-
leagues, has conducted a program of research personal relationship theory is expected to
into applications of the interpersonal rela- withstand the current health care crisis and
tionship process in psychiatric mental-health provide a cost-effective and satisfying re-
nursing care. source for patient well-being across a variety
Peplau's model is historically significant of nursing contexts.
for practice in that it propelled psychiatric The reawakening of nursing by Peplau's
nursing from custodial-based care to inter- ideas in the 1950s continues today through
personal relationship theory-based care. Pep- exploration, study, and use of the science-
lau is considered the founder of professional based practice of interpersonal relations the-
psychiatric mental-health nursing and was ory. Beeber's (1998) research and theory de-
the first to initiate an area of advanced prac- velopment have extended Peplau's model in
tice nursing. Her theoretical ideas continue important ways, using aesthetic knowing to
to be significant in contemporary nursing for elaborate on the concept of interpersonal pat-
their relevance in not only psychiatric mental- tern and formalizing Peplau's (1997) idea of
health nursing practice but practice anywhere transitions in a practice theory of depression.
a nurse-patient relationship exists. Applica- Metatheoretical writings of Peden (1998) and
tions of the model are found in individual Reed (1996a), inspired by Peplau's practice-
psychotherapy, reminiscence therapy, termi- based strategy of theory development, por-
nal illness care, and group and family ther- tend an emerging philosophy of nursing sci-
apy. Practices based upon Peplau's theory ence that sanctions clinicians as well as tradi-
range from hospital to community and tional researchers as knowledge-builders.
home-based. Through the creative scholarship of nurses,
Peplau's theory has provided an enduring Peplau's theoretical model can continue to
educational foundation for teaching the evolve and inspire development of nurse-pa-
nurse-patient relationship as a pivotal nurs- tient processes that meet contemporary
ing process in all contexts of practice. A com- health needs of society.
mon philosophy underlying all nursing cur-
ricula is a belief in the value of a therapeutic PAMELA G. REED
nurse-patient relationship that promotes ac- NELMA B. SHEARER
tive participation of patients in their health
care. Peplau's theoretical work has also pro-
moted a "paradigm of professionalization" Pet Therapy
and empowerment for educating nurses for
the 21st century (Sills, 1998). Pet therapy (use of a companion animal to
Peplau's theoretical model continues to in- benefit the health of humans) has become
fluence nursing research, practice, and educa- a very popular intervention for a variety of
tion (O'Toole & Welt, 1989), although her clients, and many nurses as well as pet owners
original contributions have become knowl- have become involved in its delivery. While
edge in the public domain and are not always at the intuitive level pet therapy appears to
explicitly acknowledged. Internationally, be beneficial, there are relatively few scientific
nurses are recognizing Peplau's legacy and studies to support its effectiveness. This
the enduring relevance of her theory for nurs- growing body of research on pet therapy has
ing in the new millennium (e.g., Barker largely been generated by multidisciplinary

4. Contributors xxvii
Joanne W. Rains, DNS, Mary Anne Rizzolo, EdD, Norma Martinez Rogers,
RN RN, FAAN PhD, RN
Dean and Associate Director for Professional Assistant Professor
Professor Development University of Texas Health
Indiana University East National League for Science Center
Division of Nursing Nursing School of Nursing
Richmond, IN New York, NY San Antonio, TX
Collaborative Research Research on Interactive Minority Women
Video Offenders
Barbara Rakel, MA, RN
Advanced Practice Nurse Carol A. Romano, MS,
Beverly L. Roberts, RN,
Supervisor RN, FAAN
PhD, FAAN, FGSA Director, Nursing
University of Iowa
Arline H. and Curtis F. Information Systems and
Hospitals and Clinics
Garvin Professor of Quality Assurance
Iowa City, IA
Nursing Warren Grant Magnuson
Ethnography Frances Payne Bolton Clinical Center
Pamela G. Reed, PhD, RN, School of Nursing National Institutes of
FAAN Case Western Reserve Health
Professor University Bethesda, MD
University of Arizona Cleveland, OH Data Stewardship
College of Nursing Falls; Functional Health
Tucson, AZ Eileen Virginia Romeo,
Karen R. Robinson, PhD MSN, RN
Peplau's Theoretical
Non Clinical Lecturer in Doctoral Student
Model; Spirituality
Gastroenterology Case Western Reserve
Barbara Resnick, PhD, Institute of Infection, University
CRNP, FAAN, FAANP Immunity and Frances Payne Bolton
Associate Professor Inflammation School of Nursing
University of Maryland University Hospital Cleveland, OH
School of Nursing Queens Medical Center Or em's Self-Care Deficit
Baltimore, MD Nottingham, United Nursing Theory
Continuing Care Kingdom Marlene M. Rosenkoetter,
Retirement Communities Current Procedural PhD, RN, FAAN
Virginia Richardson, DNS, Terminology-Coded Professor
RN, CPNP Services; Denial in Medical College of Georgia
Assistant Dean for Student Coronary Heart Disease School of Nursing
Affairs Atlanta, GA
Associate Professor Bonnie Rogers, PhD, Retirement
Indiana University COHN-S, LNCC, FAAN
Associate Professor and Virginia K. Saba, EdD,
School of Nursing
Director, Occupational RN, FAAN, FACMI
Indianapolis, IN
Safety and Health Distinguished Scholar,
Pediatric Primary Care Adjunct
Education and Research
Susan K. Riesch, DNSc, Georgetown University
Center
RN, FAAN School of Nursing and
University of North
Professor, School of Health Studies
Carolina at Chapel Hill
Nursing Washington, DC
School of Public Health
University of Wisconsin- Chapel Hill, NC Home Health Care
Madison Classification System;
Nursing Occupational Home Health Systems;
School of Nursing
Injury and Stress Nursing Informatics;
Madison, WI
Nursing Centers Nursing Information
Systems

5. xxviii CONTRIBUTORS
AH Salman, MD, RN Judith Kennedy Schwarz, Shyang-Yun Pamela K.
PhD Candidate PhD, RN Shiao, PhD, RN, FAAN
Case Western Reserve Consultant, Ethics and Associate Professor
University End-of-Life Care University of Texas
Frances Payne Bolton New York, NY Health Sciences Center
School of Nursing Advance Directives School of Nursing
Cleveland, OH Houston, TX
Depression and Joan L. Shaver, PhD, RN,
Endotracheal Suctioning
Cardiovascular Diseases; FAAN in Newborns: NICU
Hypertension Professor and Dean
Preterm Infant Care
University of Illinois at
Helen A. Schaag, RN, Chicago Elaine K. Shimono, MA,
MSN, MA College of Nursing RN
Project Director, CPAP Chicago, IL Clinical Director
Research Study Sleep Psychiatry Care Center
University of Kansas Mount Sinai Medical
School of Nursing Nelma B. Shearer, PhD,
Center
Kansas City, KS RN
New York, NY
Caregiver; Home Care Assistant Professor
College of Nursing (Martha E.) Rogers
Technologies
Arizona State University Science of Unitary
Karen L. Schumacher, PhD, Tempe, AZ Persons
RN Peplau's Theoretical
Assistant Professor Mary Cipriano Silva, PhD,
Model RN, FAAN
University of Pennsylvania
School of Nursing Caryn A. Sheehan, MSN, Professor Emeritus
Philadelphia, PA RN George Mason University
Transitions and Health Assistant Professor College of Nursing and
St. Anselm College Health Science
Elizabeth A. Schlenk, PhD, Department of Nursing Fairfax, VA
RN Manchester, NH Clinical Professor
Assistant Professor Fender's Health School of Public Health
University of Pittsburgh Promotion Model and Health Sciences
School of Nursing University of
Pittsburgh, PA Mary Shelkey, PhD, RN, Massachusetts
Patient Contracting ARNP Amherst, MA
Assistant Professor Ethics of Research;
Donald F. Schwarz, MD, Seattle University Philosophy of Nursing
MPH, MBA College of Nursing
Deputy Physician-in-Chief Seattle, WA Carol E. Smith, PhD, RN
Chief, Craig-Dalsimer Alzheimer's Disease Professor
Division of Adolescent University of Kansas
Medicine Deborah Shelton, PhD, School of Nursing
University of Pennsylvania RN, CNA, BC Kansas City, KS
Schools of Medicine and Associate Professor of
Nursing Nursing Caregiver; Home Care
Philadelphia, PA University of Connecticut Technologies; Quality of
School of Nursing Life
Adolescence; Adolescent
Pregnancy and Storrs, CT
Parenting; Infant Injury Child Delinquents

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