peplau's theory of interpersonal relations a case study

Peplau's Theory of Interpersonal Relations: A Case Study

Affiliations.

• 1 School of Nursing and Midwifery, The Aga Khan University, Karachi, SD, Pakistan.
• 2 Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
• PMID: 34538167
• DOI: 10.1177/08943184211031573

Theoretical frameworks offer guiding principles to guide nursing practice on well-defined nursing knowledge. Peplau's theory of interpersonal relationship empowers nurses in their work for regaining health and well-being for people. Understanding the theory and the connectedness that arises from this theory provides a structure for nurse-patient relations, even working through a language barrier as evidenced by the case scenario detailed in this article.

Keywords: Peplau’s theory of interpersonal relations; language barriers; nurse-patient relationship; nursing theory.

• Interpersonal Relations
• Nurse-Patient Relations*
• Nursing Theory*

Peplau’s Theory of Interpersonal Relations: A Case Study

Abstract: theoretical frameworks offer guiding principles to guide nursing practice on well-defined nursing knowledge. peplau’s theory of interpersonal relationship empowers nurses in their work for regaining health and well-being for people. understanding the theory and the connectedness that arises from this theory provides a structure for nurse-patient relations, even working through a language barrier as evidenced by the case scenario detailed in this article..

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References 2 publication s, the effect of professional nursing practice model training (mpkp) with the implementation of pillar iv nursing care delivery system (pillar iv ncds) at a hospital in kotamobagu, indonesia.

Background: Professional Nursing Practice Model Training (Model Praktik Keperawatan Profesional; MPKP) is one of the efforts to improve the quality of service in hospitals in nursing services to minimize errors or omissions that can occur. The training carried out is expected to be able to improve the implementation of pillar IV NCDS in hospitals. Aims: This study aimed to determine the effect of MPKP training with the application of pillar IV NCDS at the General Hospital of the Evangelical Masehi Church Bolaang Mongondow Monompia Kotamobagu. Methods: This research is a quantitative research type with a pre-experimental research design one group pre-test post-test design. This research was conducted in August 2022 as many as 52 nurse respondents working at the Monompia GMIBM Hospital Kotamobagu. Results: From the survey, it shows that the intervention will increase the number of nurses implementing the Pillar IV Nursing Care Delivery System (Pillar IV NCDs) including the assessment element (from 76.9% to 90.4%), nursing diagnosis (from 36.5% to 75.0%), planning (from 51.9% to 88.5%), action or measurement (from 84.6% and 92.3%), evaluation (from 46.2% to 90.4%), and nursing care notes (78.8% and 98.1%). There are differences in the implementation of pillar IV NCDS before and after being given MPKP training (p-value: <0.001). it is known that education level and the work experience of the nurses will significantly determine the success of the training, respectively with p value of <0.001 and 0.004. Conclusion: From the survey, we may note how the Professional Nursing Practice Model Training (MPKP) affecting the number of nursing implementing the Pillar IV NCDs. Data from the results can be used as recommendation to the hospitals’ human resources department in designing their program in order to increase the nurses’ competences.

Validación psicométrica de la «Escala de habilidades comunicacionales aplicada por paciente estandarizado» para la simulación clínica

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Advancing Nursing Practice Through Mentoring and Teaching-Learning

In the article that follows this introduction, there are insights into the importance of a theoretical framework for nursing practice. The authors detail the impact to nursing practice a theoretical framework provides by using a case study approach. The introductory thoughts in this article focus on inspiring mentoring models and teaching learning models within theoretically based nursing science and practice.

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• Hildegard Peplau: Interpersonal Relations Theory

Hildegard Peplau is a nurse theorist who created the Theory of Interpersonal Relations . Get to know Peplau’s theory and biography in this nursing theories study guide .

Table of Contents

Career and appointments of hildegard peplau, interpersonal relations theory, awards and honors, description, assumptions, society or environment, 1. orientation phase, 2. identification phase, 3. exploitation phase, 4. resolution phase, subconcepts of the interpersonal relations theory, four levels of anxiety, interpersonal theory and nursing process, recommended resources, external links, biography of hildegard e. peplau.

Hildegard Elizabeth Peplau (September 1, 1909 – March 17, 1999) was an American nurse who is the only one to serve the American Nurses Association (ANA) as Executive Director and later as President. She became the first published nursing theorist since Florence Nightingale .

Peplau was well-known for her Theory of Interpersonal Relations , which helped to revolutionize nurses’ scholarly work. Her achievements are valued by nurses worldwide and became known to many as the “Mother of Psychiatric Nursing” and the “Nurse of the Century.” 

Hildegard Peplau was born on September 1, 1909. She was raised in Reading, Pennsylvania, by her parents of German descent, Gustav and Otyllie Peplau. She was the second daughter, having two sisters and three brothers. Though illiterate, her father was persevering while her mother was a perfectionist and oppressive. With her young age, Peplau’s eagerness to grow beyond traditional women’s roles was precise. She considers nursing was one of few career choices for women during her time. In 1918, she witnessed the devastating flu epidemic that greatly influenced her understanding of the impact of illness and death on families.

When the autonomous, nursing-controlled, Nightingale era schools came to an end in the early 1900s, schools then were handled by hospitals, and the so-called formal “book learning ” was put down. Hospitals and physicians considered women in nursing as a source of free or inexpensive labor . Exploitation was widespread by nurse’s employers, physicians, and educational providers.

In 1931, she graduated from Pottstown, Pennsylvania School of Nursing. Peplau earned a Bachelor’s degree in interpersonal psychology in 1943 at Bennington College in Vermont. She studied psychological issues with Erich Fromm, Frieda Fromm-Reichmann, and Harry Stack Sullivan at Chestnut Lodge, a private psychiatric hospital in Maryland. Peplau held master’s and doctoral degrees from Teachers College, Columbia University, in 1947.

After graduating in Pennsylvania, Hildegard Peplau then worked as a staff nurse in her place and New York City. A summer position as a nurse for the New York University summer camp led to a recommendation for Peplau to become the school nurse at Bennington College in Vermont, where she earned a Bachelor’s degree in interpersonal psychology. Peplau’s lifelong work was largely focused on extending Sullivan’s interpersonal theory for use in nursing practice.

She served in the Army Nurse Corps and was assigned to the 312th Field Station Hospital from 1943-1945 in England, where the American School of Military Psychiatry was located. She met and worked with all the 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.

“Nursing has made great progress from being an occupation to becoming a professional in the 20th. Century. As the 21st. Century approaches, further progress will be reported and recorded in Cyberspace – The Internet being one conduit for that. Linking nurses and their information and knowledge across borders – around the world – will surely advance the profession of nursing much more rapidly in the next century.” – Hildegard Peplau

Peplau was certified in psychoanalysis by the William Alanson White Institute of New York City. In the early 1950s, she developed and taught the first classes for graduate psychiatric nursing students at Teachers College. Peplau was a member of the College of Nursing faculty at Rutgers University from 1954 until her retirement in 1974. She was a professor emeritus at the said university.

At Rutgers University, she created the first graduate-level program to prepare clinical specialists in psychiatric nursing. 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 to 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 supervised summer workshops for nurses throughout the United States, mostly in state psychiatric hospitals. In these seminars, she taught interpersonal concepts and interviewing techniques and 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, Peplau 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.

Peplau was devoted to nursing education at the full length of her career. After she retired from Rutgers, she served as a visiting professor at the University of Leuven in Belgium in 1975 and 1976. There she helped establish the first graduate nursing program in Europe.

She was the only nurse who served the ANA as executive director and later as president. She served two terms on the Board of the International Council of Nurses (ICN). And as a member of the New Jersey State Nurses Association, she actively contributed to the ANA by serving on various committees and task forces.

Her fifty-year career in nursing left an unforgettable mark on the field and the mentally challenged lives in the United States. During the peak of her career, she became the founder of modern psychiatric nursing, an innovative educator, advocate for the mentally ill, proponent of advanced education for nurses, Executive Director and then President of the ANA, and prolific author.

Like any other famous personalities, her life was often marked with controversy, which she faced with boldness, prowess, and conviction.

In 1952, Hildegard Peplau published her Theory of Interpersonal Relations influenced by Henry Stack Sullivan, Percival Symonds, Abraham Maslow, and Neal Elgar Miller.  Her theory is discussed further below.

Some of Hildegard Peplau’s works include: Interpersonal Relations In Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing , Interpersonal Theory in Nursing Practice: Selected Works of Hildegard E. Peplau , Basic principles of patient counseling: Extracts from two clinical nursing workshops in psychiatric hospitals, A Glance Back in Time: An article from Nursing Forum, On Semantics (psychiatric nursing): An article from Perspectives in Psychiatric Care, The Psychiatric Nurse–Accountable? To Whom? For What?: An article from Perspectives in Psychiatric Care and Psychotherapeutic Strategies: An article from Perspectives in Psychiatric Care.

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 co-authoring physician.

Peplau’s original book from 1952 has been translated into nine languages and in 1989 was reissued in Great Britain by Macmillan of London. In 1989, Springer published a volume of selected works of Peplau from previously unpublished papers. Her ideas have, indeed, stood the test of time. The archives of her work and life are housed at the Schlesinger Library at Harvard University.

Peplau was acknowledged with numerous awards and honors for her contributions to nursing and held 11 honorary degrees. She was awarded honorary doctoral degrees from universities including Alfred, Duke, Indiana, Ohio State, Rutgers, and the University of Ulster in Ireland.

She was named one of “50 Great Americans” in Who’s Who in 1995 by Marquis. She was also elected fellow of the American Academy of Nurse and Sigma Theta Tau, the national nursing honorary society.

In 1996, the American Academy of Nursing honored Peplau as a “Living Legend.” She received nursing’s highest honor, the “Christiane Reimann Prize,” at the ICN Quadrennial Congress in 1997. This award is given once every four years for outstanding national and international contributions to nursing and healthcare. And in 1998, the ANA inducted her into its Hall of Fame .

On March 17, 1999, Peplau died peacefully in her sleep at home in Sherman Oaks, California. She is survived by Dr. Leitia Anne Peplau and her husband, Dr. Steven Gordon, and their son, David Gordon of Sherman Oaks, CA; sister, Bertha Reppert (Byron), Mechanicsburg, PA; brother, John D. Forster (Dorothy), Reading, PA; niece, Dr. Carolynn Sears (Phillip) and children, Jessica and Jacob Sears, Pound Ridge, NY; niece Majorie Reppert, Jim Thorpe, PA; niece, Nancy Reppert, Mechanicsburg, PA; niece, Susanna Reppert (David Brill), Mechanicsburg, PA; niece, Karen Bently (William) and son, William, Sudbury, MA; and nephew, Carl Peplau, Hopewell Junction, NY.

The family requested that memorial contributions be made to the Peplau Research Fund through the American Nurses Foundation.

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 influenced by Henry Stack Sullivan, Percival Symonds, Abraham Maslow, and Neal Elgar Miller.

According to Peplau (1952/1988), nursing is therapeutic because it is a healing art, assisting an individual who is sick or in need of health care. Nursing can be viewed as an interpersonal process because it involves 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 due to the interaction. An individual learns when she or he selects stimuli in the environment and then reacts to these stimuli.

Hildegard Peplau’s Interpersonal Relations Theory

Hildegard Peplau’s Interpersonal Relations Theory emphasized the nurse-client relationship as the foundation of nursing practice. It emphasized the give-and-take of nurse-client relationships that 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 four components of the theory are person , which is a developing organism that tries to reduce anxiety caused by needs; environment , which consists of existing forces outside of the person and put in the context of culture; health , which is a word symbol that implies a forward movement of personality and nursing , which is a significant therapeutic interpersonal process that functions cooperatively with another human process that makes health possible for individuals in communities.

The nursing model identifies four sequential phases in the interpersonal relationship: orientation , identification , exploitation , and resolution .

It also includes seven nursing roles: Stranger role, Resource role, Teaching role, Counseling role, Surrogate role, Active leadership, and Technical expert role.

Hildegard E. Peplau’s 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 instrument” involving 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 due to the interaction. An individual learns when she or he selects stimuli in the environment and then reacts to these stimuli.

Hildegard Peplau’s Interpersonal Relations Theory’s assumptions are: (1) Nurse and the 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 client’s growth and avoid limiting their choices to those that nurses value.

Major Concepts of the Interpersonal Relations Theory

The theory explains nursing’s purpose 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.

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 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.”

Although Peplau does not directly address society/environment, she does encourage the nurse to consider the patient’s culture and mores when the patient adjusts to the hospital routine.

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 focuses on the client’s 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 :

The nurse’s orientation phase involves engaging the client in treatment, providing explanations and information, and answering questions.

• Problem defining phase
• It starts when the client meets the nurse as a stranger.
• Defining the problem and deciding the type of service needed
• Client seeks assistance, conveys needs, asks questions, shares preconceptions and expectations of past experiences.
• Nurse responds, explains roles to the client, identifies problems, and uses available resources and services.

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 .
• 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 based on the needs and interests of the patients.
• The individual feels like an integral part of the helping environment.
• They may make minor requests or attention-getting techniques.
• The principles of interview techniques must be used to explore, understand and adequately deal with the underlying problem.
• Patient may fluctuate on independence.
• Nurse must be aware of the various phases of communication.
• Nurse aids the patient in exploiting all avenues of help, and progress is made towards the final step.
• In the resolution phase, the client no longer needs professional services and gives up dependent behavior. The relationship ends.
• Termination of professional relationship
• The patient’s 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.
• The patient drifts away and breaks the nurse’s bond, and a healthier emotional balance is demonstrated, and both become mature individuals.

Peplau’s model has proved greatly used by 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 respond 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
• Health teacher
• Socializing agent
• Safety agent
• Manager of environment
• Administrator
• Recorder observer

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

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 the immediate task only); the person can learn a 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 .

Peplau’s Interpersonal Relations Theory and the Nursing Process are sequential and focus on the therapeutic relationship by using problem-solving techniques for the nurse and patient to collaborate on to meet the patient’s needs. Both use observation communication and recording as basic tools utilized by nursing.

Peplau conceptualized clear sets of nurse’s roles that every nurse can use with their practice. It implies that a nurse’s duty is not just to care, but the profession encompasses every activity that may affect the patient’s care.

The idea of a nurse-client interaction is limited to those individuals incapable of conversing, specifically those who are unconscious.

The concepts are highly applicable to the care of psychiatric patients considering Peplau’s background. But it is not limited to those sets of individuals. It can be applied to any person capable and has the will to communicate.

The phases of the therapeutic nurse-client are highly comparable to the nursing process , making it vastly applicable. Assessment coincides with the orientation phase; nursing diagnosis and planning with the identification phase, implementation as to the exploitation phase, and evaluation with the resolution phase.

Peplau’s 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 nurse-patient relationship’s natural progression, which leads to adaptability in any nurse-patient interaction, thus providing generalizability.

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 doesn’t have a felt need, such as with withdrawn patients.

Peplau’s theory has proved greatly used 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 nurse’s duty is not just to care, but the profession also incorporates every activity that may affect the client’s health.

However, the idea of nurse-client cooperation is found narrow with those individuals who are unfit and powerless in conversing, specifically those who are unconscious and paralyzed.

Studying Peplau’s Interpersonal Relations Theory of Nursing can be very substantial, especially to aspiring to be part of the profession. Knowing the seven nursing roles, future nurses can apply for different roles in different situations, which will guarantee their patients acquire the best care possible and ultimately speed along with treatment and recovery.

Recommended books and resources to learn more about nursing theory:

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

• Nursing Theorists and Their Work (10th Edition) by Alligood Nursing Theorists and Their Work, 10th Edition provides a clear, in-depth look at nursing theories of historical and international significance. Each chapter presents a key nursing theory or philosophy, showing how systematic theoretical evidence can enhance decision making, professionalism, and quality of care.
• Knowledge Development in Nursing: Theory and Process (11th Edition) Use the five patterns of knowing to help you develop sound clinical judgment. This edition reflects the latest thinking in nursing knowledge development and adds emphasis to real-world application. The content in this edition aligns with the new 2021 AACN Essentials for Nursing Education.
• Nursing Knowledge and Theory Innovation, Second Edition: Advancing the Science of Practice (2nd Edition) This text for graduate-level nursing students focuses on the science and philosophy of nursing knowledge development. It is distinguished by its focus on practical applications of theory for scholarly, evidence-based approaches. The second edition features important updates and a reorganization of information to better highlight the roles of theory and major philosophical perspectives.
• Nursing Theories and Nursing Practice (5th Edition) The only nursing research and theory book with primary works by the original theorists. Explore the historical and contemporary theories that are the foundation of nursing practice today. The 5th Edition, continues to meet the needs of today’s students with an expanded focus on the middle range theories and practice models.
• Strategies for Theory Construction in Nursing (6th Edition) The clearest, most useful introduction to theory development methods. Reflecting vast changes in nursing practice, it covers advances both in theory development and in strategies for concept, statement, and theory development. It also builds further connections between nursing theory and evidence-based practice.
• Middle Range Theory for Nursing (4th Edition) This nursing book’s ability to break down complex ideas is part of what made this book a three-time recipient of the AJN Book of the Year award. This edition includes five completely new chapters of content essential for nursing books. New exemplars linking middle range theory to advanced nursing practice make it even more useful and expand the content to make it better.
• Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice This book offers balanced coverage of both qualitative and quantitative research methodologies. This edition features new content on trending topics, including the Next-Generation NCLEX® Exam (NGN).
• Nursing Research (11th Edition) AJN award-winning authors Denise Polit and Cheryl Beck detail the latest methodologic innovations in nursing, medicine, and the social sciences. The updated 11th Edition adds two new chapters designed to help students ensure the accuracy and effectiveness of research methods. Extensively revised content throughout strengthens students’ ability to locate and rank clinical evidence.

Recommended site resources related to nursing theory:

• Nursing Theories and Theorists: The Definitive Guide for Nurses MUST READ! In this guide for nursing theories, we aim to help you understand what comprises a nursing theory and its importance, purpose, history, types or classifications, and give you an overview through summaries of selected nursing theories.

Other resources related to nursing theory:

• Betty Neuman: Neuman Systems Model
• Dorothea Orem: Self-Care Deficit Theory
• Dorothy Johnson: Behavioral System Model
• Faye Abdellah: 21 Nursing Problems Theory
• Florence Nightingale: Environmental Theory
• Ida Jean Orlando: Deliberative Nursing Process Theory
• Imogene King: Theory of Goal Attainment
• Jean Watson: Theory of Human Caring
• Lydia Hall: Care, Cure, Core Nursing Theory
• Madeleine Leininger: Transcultural Nursing Theory
• Martha Rogers: Science of Unitary Human Beings
• Myra Estrin Levine: The Conservation Model of Nursing
• Nola Pender: Health Promotion Model
• Sister Callista Roy: Adaptation Model of Nursing
• Virginia Henderson: Nursing Need Theory
• Hildegard Peplau (1909-1999) 1998 Inductee. (n.d.). . Retrieved July 1, 2014, from https://www.nursingworld.org/HildegardPeplau
• Sills, G. (n.d.). Hildegard Peplau.  Nursing Theorist Homepage . Retrieved January 3, 2014, from https://publish.uwo.ca/~cforchuk/peplau/obituary.html
• George B. Julia, Nursing Theories- The base for Professional Nursing Practice, 3rd ed. Norwalk, Appleton & Lange.
• Peplau, H. E. (1952). Interpersonal relations in nursing. In George, J. (Ed.).  Nursing theories: the base for professional nursing practice. Norwalk, Connecticut: Appleton & Lange.
• Peplau, H.E. (1988). The art and science of nursing: Similarities, differences, and relations. Nursing Science Quarterly, 1, 8-15. In George, J. (Ed.). Nursing theories: the base for professional nursing practice.  Norwalk, Connecticut: Appleton & Lange.
• Peplau Research Fund  – Supports research scholars in the ANF Nursing Research Grants Program.
• The Nurse Theorists – Hildegard Peplau Promo  – A video interview with Peplau
• Interpersonal Relations In Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing
• Interpersonal Theory in Nursing Practice: Selected Works of Hildegard E. Peplau

With contributions by Wayne, G., Ramirez, Q.

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Exploring the therapeutic relationship through the reflective practice of nurses in acute mental health units: A qualitative study

Diana tolosa‐merlos.

1 Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona Spain

Antonio R. Moreno‐Poyato

2 Department of Public Health, Mental Health and Maternal and Child Health Nursing, Nursing School, Universitat de Barcelona, L'Hospitalet de Llobregat Spain

3 IMIM (Hospital del Mar Medical Research Institute), Barcelona Spain

Francesca González‐Palau

4 Hospital Santa Maria, Salut/Gestió de Serveis Sanitaris, Lleida Spain

Alonso Pérez‐Toribio

5 Unitat de Salut Mental de l'Hospitalet, Gerència Territorial Metropolitana Sud, Institut Català de la Salut, L'Hospitalet de Llobregat Spain

Georgina Casanova‐Garrigós

6 Department and Faculty of Nursing, Universitat Rovira i Virgili, Tortosa Spain

Pilar Delgado‐Hito

7 Department of Fundamental Care and Medical‐Surgical Nursing, Nursing School, Universitat de Barcelona, L'Hospitalet de Llobregat Spain

8 GRIN‐IDIBELL (Nursing Research Group‐ Bellvitge Biomedical Research Institute), L'Hospitalet de Llobregat Spain

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Aims and objectives

To explore the therapeutic relationship through the reflective practice of nurses in acute mental health units.

In mental health units, the therapeutic relationship is especially relevant for increasing the effectiveness of nursing interventions. Reflective practice is considered an essential aspect for improving nursing care.

Action and observation stages of a participatory action research project.

Data were collected through reflective diaries designed for the guided description and reflection of practice interactions related to the therapeutic relationship and content analysis was applied. A total of 152 nurses from 18 acute mental health units participated. The COREQ guidelines were used.

The results were classified into three categories as follows: (i) Nursing attitude as a core of the therapeutic relationship. For the nurses, the attitudinal component was key in the therapeutic relationship. (ii) Nursing practices that are essential to the therapeutic relationship. Nurses identified practices such as creating a conducive environment, using an appropriate verbal approach, offering help and working together with the patient as essential for establishing a therapeutic relationship in practice. (iii) Contextual factors affecting the therapeutic relationship. The nurses considered the patient's condition, the care dynamics of the unit and its regulations, as well as the structure and environment of the unit, as contextual factors involved the establishment of an adequate therapeutic relationship in daily clinical practice.

Conclusions

This study has provided knowledge of the importance and role of the nurses' attitude in the context of the nurse–patient therapeutic relationship based on the reflections of nurses in mental health units regarding their own practice.

Relevance to clinical practice

These findings help nurses to increase awareness and develop improvement strategies based on their own knowledge and day‐to‐day difficulties. Moreover, managers can evaluate strategies that promote motivation and facilitate the involvement of nurses to improve the therapeutic relationship with patients.

What does this paper contribute to the wider global clinical community?

• An in‐depth analysis of nurses' reflections regarding the aspects that underlie the therapeutic relationship in their clinical practice enables the nurses themselves to become aware and to develop strategies for improvement based on their own knowledge.
• Understanding and confirming how the attitudinal component is a key element for nurses in the practice of the therapeutic relationship allows managers to evaluate strategies that promote motivation and facilitate the involvement of nurses to improve their practice with patients.
• The results point to the need for further studies aimed at identifying and implementing strategies that facilitate mental health nurses to incorporate and improve attitudinal skills related to establishing the nurse–patient therapeutic relationship in clinical practice.

1. INTRODUCTION

The nursing discipline is defined as a significant, therapeutic and interpersonal process that acts in conjunction with other human processes that make health possible for individuals (Peplau, 1988 ). The relationship established between nurse and patient is therapeutic, regardless of the setting in which care is provided (Stevenson & Taylor, 2020 ). However, in the mental health unit setting, the therapeutic relationship is especially relevant to increase the effectiveness of any nursing intervention (McAndrew et al., 2014 ). Reflective practice is considered an essential aspect of improving nursing care and generating knowledge (Vaughan, 2017 ). This paper aims to deepen the knowledge of the therapeutic relationship based on the reflections of nurses regarding their practice, in the context of current challenges within the mental health acute care setting.

1.1. Background

Based on Peplau's model of interpersonal relationships by ( 1988 ), which is the most widely held theory in the mental health nursing community, many authors have based their models on person‐centred mental health nursing (Barker & Buchanan‐Barker, 2010 ; O'Brien, 2001 ; Scanlon, 2006 ). All of them identify the therapeutic relationship as the foundation of nursing practice and the pillar upon which mental health nursing has been built (McAllister et al., 2019 ; Moreno‐Poyato et al., 2016 ). The proper establishment of the nurse–patient therapeutic relationship is especially relevant to increase the effectiveness of any nursing intervention in acute psychiatric units (McAndrew et al., 2014 ).

The therapeutic relationship could be defined as a human exchange (Peplau, 1988 ) that is based on effective communication that favours the possibility for a person to help another person to improve their health condition, with the objective that, through such communication, the person will be able to develop interpersonal and problem‐solving skills (Forchuk et al., 1998 ). To this end, concepts such as understanding, interest, availability, individuality, authenticity, warmth, respect and self‐knowledge are basic pillars for the nurse (Moreno‐Poyato et al., 2016 ). The literature points out that mental health nurses seem to be knowledgeable of the importance of the therapeutic relationship in inpatient units; however, the reality of clinical practice leads us to believe that theoretical knowledge is not enough to create a good bond with patients (Moreno‐Poyato et al., 2016 ). In addition, the literature points out that for nurses, the implementation of the therapeutic relationship in the current context of mental health units has suffered a strong impact related to neoliberal policies, with increased management and a risk‐centred approach (Kingston & Greenwood, 2020 ). Thus, today's environments are chaotic, and nurses are committed to therapeutic work, yet they struggle to balance it with the new demands of management (Kingston & Greenwood, 2020 ). In addition, barriers such as lack of time, communication problems (Harris & Panozzo, 2019a ), the physical structures of the units, the ratios or the cultures of care are external factors that limit the therapeutic relationship (Tolosa‐Merlos et al., 2021 ). If nurses are unable to become aware of how they respond to time pressure, frustration or unclear care policies, there is a risk that these barriers will become entrenched, new ones will be created and the patient will perceive their actions as lacking care, presence or involvement (Harris & Panozzo, 2019b ). Thus, although nurses recognise the importance of self‐awareness and knowing how to recognise how their actions can impact the therapeutic relationship and the care provided to patients, they are also aware of the need for self‐awareness (Thomson et al., 2019 ), institutions and, in general, care policies should encourage nurses to be aware of interpersonal influences, as well as the desirability of providing a safe and supportive clinical environment for these relationships (Stevenson & Taylor, 2020 ).

From the patients' point of view, in the complex environment of inpatient units, their interactions with staff are central components to their satisfaction regarding their experience with admission (Molin et al., 2021 ). When staff spend time, engage in daily activities, and recognise patients as individuals, patients seem to find it easier to be physically and emotionally closer to each other and to themselves (Eldal et al., 2019 ; Moreno‐Poyato et al., 2021 ). However, this therapeutic commitment is not always met in practice, and interventions to improve participation are few and far between and ineffective (McAllister et al., 2021 ).

Thanks to the therapeutic relationship, nurses are in a key position to lead the development of customised interventions (Molin et al., 2021 ). However, there is a significant gap in the literature regarding improving the quality of the therapeutic relationship in acute mental health units (Hartley et al., 2020 ). The nursing profession is characterised by its ability to reflect on practice to improve care and provide more person‐centred care, which is why there is a need to increase the use of evidence‐based practice (Vaughan, 2017 ). In fact, reflective practice allows practitioners to learn from their experiences (Bulman & Schutz, 2013 ; Schön, 1987 ). When nurses are given time to reflect through guided reflection questions they are able to gain valuable insight into practice (Bolg et al., 2020 ); therefore, reflective practice helps nurses integrate their emotional response and practical experience into a better understanding of the care they provide, incorporating knowledge and applying theory (Vaughan, 2017 ). Thus, although the nurse–patient therapeutic relationship has been extensively studied, no studies to date provide knowledge on the establishment of the therapeutic relationship and its implications based on the reflection on the nurses' own practice. Consequently, knowing the meaning of the therapeutic relationship together with the elements that facilitate and hinder its implementation in the complex practice of current acute mental health units can be a starting point for both nurses and managers to become aware of the needs and for the design of strategies for improvement, suited to the reality of clinical practice.

In this regard, the aim of this study was to explore the phenomenon of the therapeutic relationship through the reflective practice of nurses in acute mental health units.

2.1. Design

This study is part of a multicentre mixed methods study involving 18 acute mental health units in Catalonia (Spain) (MiRTCIME.CAT). The principal aim of the project is to improve the nurse–patient therapeutic relationship through the implementation of evidence. The project was carried out following a sequential and transformational design. Quantitative methods were used based on a single‐group quasi‐experimental design with baseline and follow‐up measurements in phases I and III of the project. In the second phase, qualitative methodology was used. In its qualitative component, participatory action research (PAR) was proposed, framed within the constructivist paradigm and following the model by Kemmis and Mctaggart ( 2008 ). A two‐cycle process consisting of four stages each was designed to carry out the PAR. Specifically, this work corresponds to the action and observation stages of the first cycle. These stages are basic in the PAR process of change and make it possible to generate relevant knowledge regarding habitual practice (Cusack et al., 2018 ). In fact, it allows nurses to understand their practices as the product of particular circumstances and thus to identify the crucial aspects on which it may be possible to transform the practices they are carrying out (Kemmis & Mctaggart, 2008 ). The study is reported in line with the Consolidated criteria for reporting qualitative research guidelines (COREQ: Tong et al., 2007 ) (File S1 ).

2.2. Participants

All the acute mental health units that were part of the Catalan Mental Health Network ( n  = 21) were informed of the study. The principal investigator presented the research project and its objectives to the management of each centre through informative sessions. Finally, 18 units agreed to participate. A nurse from each unit joined the research team and this researcher was in charge of coordinating the study at their centre and recruiting the nurses from each unit. All nurses employed in the participating units ( n  = 235) were invited to participate in the study. The inclusion criteria for the participating nurses were belonging to the permanent or interim staff and being assigned to the acute unit at the time the intervention began. The following nurses were excluded from the study: nurses who were training to obtain ‘the official qualification of mental health nurse’, staff nurses who were scheduled to be on leave or maternity leave during the intervention. Thus, a convenience sample of 195 nurses agreed to participate in PAR, of which, ultimately 152 nurses completed the action and observation stages of the first part of this study.

2.3. Data collection

During a previous meeting among the entire research team, a guide was agreed upon so that the nurses could self‐observe their clinical practice in relation to the establishment of the therapeutic relationship. The research team sent the self‐observation guide by email to each nurse, along with a reflective diary in which the nurses were asked to record the self‐observation data (File S2 ). The diary was to include the description and reflection of three types of common interactions in their usual clinical practice: (a) a standard situation of welcoming a patient for admission, (b) an interaction in which there was a pre‐agitational state that required verbal de‐escalation and (c) an interaction whereby the patient is approached individually, promoted by the nurse and in the absence of any demand on behalf of the patient. The structure of the diary, together with the instructions for completion, pursued two purposes. First, to enable nurses to reflect on their starting assumptions, to understand their practice, to understand themselves and their patients, and, finally, to understand their profession (Price, 2017 ). Second, to monitor the process of change planned for the PAR, according to the proposals of Kemmis and Mctaggart ( 2008 ). In this sense, for each interaction, the nurses had to record the description of the situation, the type of verbal and nonverbal language they had used, their reflected intervention, their emotions during the interaction and, finally, a reflection on the influence of the environment on the interaction. Once the nurses had completed the diary, they sent it to the research team by e‐mail. The data were collected between April and June 2018.

2.4. Ethical considerations

This study was approved by the Research Ethics Committees of all the participating hospitals. The nurses participated on a voluntary basis, and all participants signed an informed consent form. Nurses did not receive any compensation or incentive for participating in the study. To maintain the confidentiality and anonymity of the data obtained, each nurse received an alphanumeric code that was incorporated into their diary. The diaries were sent to a generic e‐mail of the project that was only accessible to the principal investigator of the project, subsequently, the data were stored on a computer used exclusively for this study.

2.5. Data analysis

The content analysis method was used to analyse the data (Crowe et al., 2015 ). The diaries reached the first author and were coded to preserve the anonymity and confidentiality of the participants. Under their responsibility, the entire coding and categorisation process was carried out in a consensual manner by a collaborative team that formed the backbone of the process of developing a rigorous coding system (Merriam, 2016 ). In the first stage of analysis, the text was fragmented into descriptive codes assigned exclusively according to their semantic content. In a second stage, these initial codes were grouped into more analytical subcategories, which classified the codes according to the meaning of the linguistic units and their combinations. This led to a third hierarchical stage in which, considering the semantic analysis of the previous subcategories, the codes were ranked inductively. The first and second steps were taken iteratively until a more specific understanding of the subcategories was achieved. These steps were carried out primarily by the first author and discussed and reflected upon continuously and critically within the research team. Throughout the process, the QRS NVivo 12 program was used as computer support.

2.6. Rigour

Reflexivity was continuous throughout the process. Most of the researchers were experts in mental health, with training in qualitative methodology and experience in previous similar studies. As this was a multicentre study and a very large research team, neutrality was ensured as team members adopted an open attitude towards sharing, reasoning and discussing the findings as they emerged. In addition, the team became aware of its initial onto‐epistemological positioning, which was reflected in the design of the self‐observation guide for this stage of the process. As the research progressed, team members repeatedly contrasted the experiences identified in the participants' diaries with their own opinions. They asked follow‐up questions for the generation of new knowledge without guiding the participants' responses, so that this initial positioning could not influence the subsequent analysis. Similarly, the credibility and confirmability of the data should be emphasised, given the triangulation of the researchers in the analysis process and the constant auditing of the results by the participants in subsequent groups. In relation to the transferability of the results, in the case of this study, where participation is so high and from so many centres, it ensures that the results are valid for all units.

3. FINDINGS

The diaries of 152 nurses working at 18 centres were collected and analysed. The nurses ranged in age from 22 to 62 years, with a mean age of 33.6 years (SD = 9.4). Over 70% of the nurses were female. Their experience in mental health was a mean of 7.6 years (SD = 7.5). Almost a quarter of them had the official title of mental health nurse specialist and over 25% of the nurses had a doctoral or master's degree. All facility shifts were equally represented in the sample, although 40% of the nurses had rotating shifts or served on an as‐needed basis (Table ​ (Table1 1 ).

Participants' sociodemographic and professional characteristics ( n  = 152)

Data are shown as absolute number (percentage).

Abbreviation: MH, mental health.

The nurses, by describing and reflecting on their interactions with patients, expressed what the therapeutic relationship was for them and how it was carried out in their usual clinical practice. In this sense, three main categories were identified that responded to how they gave meaning to what the therapeutic relationship represented in practice and what limitations they identified in it (Figure ​ (Figure1 1 ).

Nurses' reflections on the practice of the therapeutic relationship in acute mental health units

3.1. Nursing attitude as a core of the therapeutic relationship

After reflecting on their practice, the nurses stated that attitude was a key element in establishing a quality therapeutic relationship with patients in the units. In this regard, they identified different attitudinal components. In the first place, the nurses considered the attitude of openness to the relationship. This meant being open and available, offering time, letting the patient talk and being attentive to the person's needs.

Patients are confused when they are first admitted and need the staff to listen to them and spend time with them. I always try to use an empathetic approach and be honest from the very beginning. I think it is very important for the patient to know that they can count on me, I try to convey that I am available if they need me. (01DR101)

However, they also identified that, in order to maintain this attitude, they had to be aware of barriers such as the presence of prejudice, the unavailability of other team members, the belief that the therapeutic relationship is useless, or lying to the patient.

The first contact already gives me the feeling that there may be a personality background, a victimizing attitude, excessively correct at times, totally inadequate at others, in spite of which I stay on track and treat him with the utmost respect. (10DR101). Certain users only perform certain actions to push you to the limit. (13DR103)

Secondly, they referred to the communicative attitude as another basic element in the therapeutic relationship. In this case, the nurses considered that special attention should be paid to both their verbal and nonverbal language when interacting with patients. In this sense, they pointed out the need to establish a dialogue with the patient by means of clear and concrete messages, with an appropriate tone and without shouting, as well as showing interest in the conversation, listening attentively, without showing tiredness or boredom, and adapting their distance and physical contact to each situation.

I try to be aware of my gestures, I avoid being invasive, respecting the safety distance with the patient at all times. Regarding verbal language, I use neutral terms, a friendly and calm tone of voice. (04DR115). In a polite but firm manner, I explain to the patient his situation and the alternatives I can offer him instead of smoking. The language is clear and concise, responding directly to what he asks. Saying NO if necessary, as sometimes vague answers upset the patient even more. (04DR104)

In addition, they considered it extremely important that, as caregivers, they should adapt to the other person, that is individualise the care they provide in the context of the therapeutic relationship. This implies considering the patient's psychopathological and emotional state at any given moment, as well as the patient's age, language or culture. This often meant postponing interviews, adapting language, using sign language to communicate, agreeing on a special type of diet, or even relaxing the rules and letting the patient make a call outside the usual hours.

I try to be flexible and adapt things as much as I can to the patient and his or her characteristics. (03DR109). Sometimes the stigma in mental health appears from the self‐stigma and the treatment that the mental health professional gives to patients. Personality is lost by prioritizing the disorder, people talk about the schizophrenic, the depressive, the BPD… obviating the fact that there is a person behind it all, with a context and a manner of understanding and living their life. (05DR104)

Finally, the nurses emphasised the role of their own emotional experience of caregiving. This meant having self‐confidence, feeling they were able to help the patient and do their job well, feeling satisfied with their work and remaining calm, at ease, and relaxed with the patient during their interventions. Nurses also identified emotions that, conversely, had a negative effect on the therapeutic relationship, such as feeling fear, insecurity, tension, patient rejection, grief, helplessness and frustration when the interventions had not been resolved as expected.

To feel fulfilled in my daily work (18DR101). Calm and confident, well supported by the team. Satisfied to have successfully completed an admission. (16DR112). Then I felt helpless, as I could not find a way to reverse the situation. (12DR111)

3.2. Essential nursing actions for the therapeutic relationship

This category refers to the nurses' reflections on their actions in the context of the therapeutic relationship with patients. In their diaries, the nurses were describing and reflecting on different interventions and activities that were carried out in their usual practice and they detected certain actions that were common to all of them.

First, the nurses pointed out the importance of generating an appropriate environment to build a bond and facilitate the relationship with the patients. A calm, intimate, comfortable, unhurried environment without external stimuli or interruptions.

The room is quiet with the door closed and without any interaction from the environment…A pleasant and silent environment favors the therapeutic relationship between the professional and the patient. (04DR110)

In relation to the establishment of a good therapeutic bond, the nurses agreed that the welcome provided on admission was a fundamental intervention. This was viewed as one of the situations in which the therapeutic relationship took on a greater relevance, since this first contact was considered the key to the success of the subsequent relationship with the patient.

Without welcoming the patient when he or she enters the unit, a better quality of the patient/professional relationship cannot be achieved. (01DR113)

Secondly, the nurses felt that the verbal approach was also a relevant aspect of their practice in the context of the therapeutic relationship. For them, it was an essential step in order to be able to carry out any intervention, such as when welcoming a patient when they are admitted to the unit, the use of verbal de‐escalation techniques to ease the tension with very demanding and uncooperative patients or, on the contrary, to approach isolated patients who hardly interact with the environment, although the use of words is not always as effective as they would like it to be.

Verbal containment is one of the most relevant parts of our work. In a pre‐agitation situation, we may be able to transition a patient from pre‐agitation to calmness or from pre‐agitation to psychomotor agitation. (09DR108)

In this sense, the nurses described that the act of offering the patient their assistance was at the heart of the therapeutic relationship. They stated that this action was carried out in the context of being present, listening or through agreement with the patient by proposing alternatives to the demands and needs that they cannot meet.

As he speaks I give him my support with non‐verbal language. I take his hand and he hugs me. I offer my help. We agree that he will make an effort to eat some solid food at dinner and that I will give him a supplement (he has it prescribed if he needs it). (01DR101)

The nurses also acknowledged that interventions such as mechanical restraint were sometimes the only measure to reduce stimuli or were implemented because of patient aggressiveness, risk of escape or even medical indication. However, the nurses reflected that, although this intervention was performed relatively often, it could be seen as a failure and a deterioration in the therapeutic relationship.

(…) avoid as much as possible the adoption of measures that restrict the mobility of the people under our care, since we are aware that this produces a significant deterioration of the therapeutic relationship, adding to the patient's mistrust and suspicion (…) (07DR105)

Finally, the nurses pointed to therapeutic work as another fundamental aspect of the therapeutic relationship. This meant working with the patient on positive reinforcement and other aspects such as pharmacological adherence, identification of symptoms or awareness of the disease, explaining the objectives of admission and the importance of asking for help, respecting the patient's decisions and involving the person in their care and recovery.

The attitude is one of interest, I keep an eye on her so that she doesn't get distracted and can talk calmly. I ask her what she thinks we can do for her to explore her expectations with the admission. (07DR101)

3.3. Contextual factors affecting the therapeutic relationship

The nurses identified contextual factors that facilitated or, on the contrary, acted as barriers to the therapeutic relationship. Indeed, they described that the type of admission could already condition the therapeutic bond, with voluntary admission being a facilitator. The same is true of other factors such as knowing the patient from previous admissions, and whether the patient remembers having a good experience in those previous admissions. However, the nurses also considered elements that are intrinsic to the patient, such as language, culture or bad experiences of previous admissions, as factors limiting the establishment of the therapeutic relationship.

He is open to help and agrees to the admission (03DR110). I must admit that the fact that I know the user from previous admissions has helped the situation to unfold smoothly. (14DR106)

Similarly, the nurses identified barriers that hindered or prevented the establishment and maintenance of a good therapeutic relationship, related to both the environment and the physical structures of the units. In this sense, the structural barriers were related to the lack of adequate spaces to carry out interventions with patients with the intimacy that the nurses considered necessary. Other environmental factors were noted, such as environmental noise and tension, the unpredictability of some patients, the presence of the family or the multiple interruptions were elements that added to the difficulty of the therapeutic relationship.

That afternoon the environment allowed me to dedicate some time to the patient, since there were no emergencies, other admissions, or complicated situations in the unit that required nursing intervention, apart from the "scheduled" or "usual" activities such as the control of vital signs, medication, etc. (03DR105)

Finally, the nurses also expressed how the regulations and care dynamics of the units also conditioned the therapeutic relationship in daily clinical practice. Thus, unit regulations were recurrently brought up by the nurses as a major barrier, due to the numerous limitations and prohibitions.

I explain the rules of the unit: no cell phones, no smoking, no entering other rooms, no belts, no glass objects, etc. and the established schedules… (10DR104)

Nonetheless, the greatest source of difficulties was the care dynamics at the unit, ranging from lack of time, high workload, administrative tasks, staff rotations or the night shift.

Even so, there are barriers that hinder the therapeutic relationship. Sometimes, our language is influenced by the tension in the unit, the lack of time, excessive administrative tasks, etc.… (01DR101)

4. DISCUSSION

This study aimed to explore the phenomenon of the therapeutic relationship from the reflective practice of nurses in acute mental health units. The nurses highlighted that attitude was the core aspect of the therapeutic relationship after reflecting on their practice. Similarly, they also reflected on the actions that were customary in the habitual interventions carried out in the context of the therapeutic relationship, identifying the most common barriers encountered in practice. Finally, the nurses reflected on those aspects of the context of care that conditioned the therapeutic relationship in the clinical practice of acute mental health units.

These findings offer knowledge about relational competence, a competency of professional nursing that is highly relevant in mental health (D'Antonio et al., 2014 ). This competence is directly linked to participation in practice and incorporates not only knowledge and skills, but also attitudes and professionalism that involve applying evidence and learning to practice (Casey et al., 2017 ; Moreno‐Poyato, Casanova‐Garrigos, et al., 2021 ). Specifically, the attitudinal component highlighted in the results and its importance in the context of the nurse–patient therapeutic relationship has been described from a theoretical perspective by authors such as Peplau or Orlando (Forchuk, 1991 ), Travelbee ( 1971 ) and Watson (Turkel et al., 2018 ). Similarly, the empirical literature has collected multiple studies that study the importance of nurses' attitudes towards more general aspects of mental health, such as stigma (Young & Calloway, 2021 ), recovery (Gyamfi et al., 2020 ), coercion (Doedens et al., 2020 ; Laukkanen et al., 2019 ) or severe mental disorder (Economou et al., 2019 ). However, there is hardly any empirical evidence that explicitly shows the relevance and identifies the specific attitudinal skills of nurses in the context of the practice of the therapeutic relationship. Thus, it is likely that the fact that the nurses were able to reflect on their practice made them more aware of the importance of attitude in the context of the therapeutic relationship (Harris & Panozzo, 2019a ), as they were able to respond to the real challenge of establishing an adequate therapeutic relationship in their day‐to‐day work in the acute mental health units (Choperena et al., 2019 ). Moreover, the attitudinal capacity identified by the nurses encompassed aspects already empirically recognised in the context of the therapeutic relationship, such as availability, communication and individualisation (Delaney & Johnson, 2014 ; Harris & Panozzo, 2019b ; McAllister et al., 2019 ; Moreno‐Poyato et al., 2016 ). However, the nurses also highlighted other aspects that have been less empirically studied, such as the importance of self‐confidence and self‐assurance, both in a positive way in order to be able to establish an appropriate therapeutic relationship, (Roche et al., 2011 ; Van Sant and Patterson, 2013 ) as well as negatively, in the form of limitation (O'Connor & Glover, 2017 ; Van Sant and Patterson, ). These results confirm the relevance of Peplau and Orlando's theoretical approaches and the use of the nurse's awareness as a fundamental part of the nursing relationship (Forchuk, 1991 ; Thomson et al., 2019 ).

The results indicate that by reflecting on their practice, the nurses were able to identify those skills (practices) that are essential for the development of the therapeutic relationship and which were transversal to any intervention. The nurses emphasised the importance of generating an adequate environment for the relationship, considering the environment not only as an element of context typical of many acute care units, but also as an element that is essential for the development of the therapeutic relationship (Kingston & Greenwood, 2020 ), also considering that it was their responsibility to be able to build the space where the relationship could take place (McAllister et al., 2021 ; Raphael et al., 2021 ). As in other studies, nurses also identified skills such as verbal engagement, offering help or working with the patient as basic practices for the development of effective interventions in the context of the relationship with their patients (Harris & Panozzo, 2019a ; McAllister et al., 2019 ; Molin et al., 2018 ). Furthermore, in relation to specific interventions, reflection on practice allowed nurses to identify and become aware of nursing admission assessment and mechanical restraint as two common interventions in mental health units that were particularly influential in the therapeutic relationship with the patients. In this sense, for the nurses, welcoming the patient on admission was considered an essential intervention determining a large part of the success in building the therapeutic relationship with the patients (Forchuk et al., 1998 ; Peplau, 1997 ). However, the use of mechanical restraint compromised the therapeutic relationship and the patient's trust (Kinner et al., 2017 ), although they understood that, even if this measure was undesirable, at times it was necessary (Doedens et al., 2020 ).

In addition, the nurses reflected on the contextual factors that directly affected the therapeutic relationship with the patients. In this sense, the nurses paid attention to patient aspects such as voluntariness or involuntariness regarding admission (Moreno‐Poyato, El Abidi, et al., 2021 ) or being previously acquainted with each other from previous admissions and the experience of the relationship (Van Sant and Patterson, 2013 ). The nurses also emphasised the role of the environmental and structural conditions of the units (Staniszewska et al., 2019 ), as well as the regulations and the dynamics of care that were automatically generated in the intense day‐to‐day routine of the units (Adler, 2020 ; Kingston & Greenwood, 2020 ).

4.1. Strengths and limitations

This study has several strengths and limitations. First, it should be noted that this project faced major challenges from a methodological point of view as well as during its execution. Initially, a research group had to be formed with representation of the institutions to assess the feasibility of the project. Next, a balanced team of researchers, consisting of methodologists and clinicians had to be assembled to ensure that the different stages of the research project could be completed. The team had to be formed in several initial working sessions and, subsequently, there was a process of constant mentoring by the principal investigator to the rest of the team. In addition, a considerable volume of data had to be managed. For management and storage, a secure on‐line space was created, guarded and accessed only by the principal investigator of the project. All data were collected electronically to facilitate the circuit. In relation to the analysis, a team was set up under the responsibility of a researcher. This team had to work in a collaborative and consensual manner. Regarding more specific limitations, it should be mentioned that the nurses' reflections in the diaries could be subject to the Hawthorne effect and their responses may have been biased by social desirability. In this sense, the research team insisted on the importance of honesty in the nurses' responses and on the team's handling of the confidentiality of the data. Secondly, another limitation inherent to the use of diaries is related to memory bias and the stress associated with reflective practice. In relation to this, the team recommended specific instructions, both verbally and through the guide provided to the nurses, to prevent this from occurring. Furthermore, the representativeness of the participating nurses and the number of diaries obtained should be highlighted as strengths of the study. These facts enable the findings of this study to be transferred to similar contexts.

5. CONCLUSIONS

The present study contributes to the understanding of the phenomenon of the therapeutic nurse–patient relationship by reflecting on the actual practice of nurses in acute mental health units. The attitudinal component is at the heart of the therapeutic relationship, and, in this sense, it is fundamental for nurses to believe in themselves and their attitude to communicate, adapt and open up to the relationship with the patient. In addition, there are actions that are essential for nurses to establish a TR in practice such as creating a conducive environment, using an appropriate verbal approach, offering help and working together with the patient. Finally, nurses should consider the patient's conditions, the dynamics of care and regulations of the unit, as well as the structure and environment of the unit, as contextual factors to be able to establish an adequate TR with patients in daily clinical practice.

6. RELEVANCE TO CLINICAL PRACTICE

These findings have important implications. The study findings demonstrate that participatory methods stimulate nurses' reflection, motivation and critical thinking. By learning from the reflection of the nurses themselves about the aspects that underlie the therapeutic relationship in their clinical practice, this enables the nurses themselves to become aware and to develop strategies for improvement based on their own knowledge. Moreover, the individual reflection involved in these first stages of a participatory process provides the nurses with an intrinsic knowledge of how they approach the therapeutic relationship and shows that the attitudinal component is basic for them. In this sense, understanding and confirming how the attitudinal component is a key element for nurses in the practice of the therapeutic relationship allows managers to evaluate strategies that promote motivation and facilitate the involvement of nurses in improving their practice with patients. Moreover, these results point to the need to conduct mixed or qualitative studies aimed at exploring the aspects that facilitate the motivation, empowerment and attitudinal training of nurses in greater depth, rather than studies that only seek improvements in the theoretical knowledge of the therapeutic relationship.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

AUTHOR CONTRIBUTIONS

Study design: ARMP and PDH; Data collection: APT, FGP and GCG; Data analysis team: DTM; Final report draft: DTM, ARMP and PDH; Supervision the process of data collection and analysis and provide support and feedback during all study phases: ARMP; Contribution of the manuscript, and read and approved the final manuscript: All authors.

Supporting information

Acknowledgements.

We would like to acknowledge all the participants of MiRTCIME.CAT project.

Tolosa‐Merlos, D. , Moreno‐Poyato, A. R. , González‐Palau, F. , Pérez‐Toribio, A. , Casanova‐Garrigós, G. , & Delgado‐Hito, P. ; MiRTCIME.CAT Working Group (2023). Exploring the therapeutic relationship through the reflective practice of nurses in acute mental health units: A qualitative study . Journal of Clinical Nursing , 32 , 253–263. 10.1111/jocn.16223 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

College of Nurses of Barcelona (PR‐218/2017)

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Peplau's Theory of Interpersonal Relations

Peplau published her Theory of Interpersonal Relations in 1952, and in 1968, interpersonal techniques became the crux of  psychiatric nursing . The Theory of Interpersonal Relations is a middle-range descriptive classification theory. It was influenced by Henry Stack Sullivan, Percival Symonds, Abraham Maslow, and Neal Elger Miller.

The four components of the theory are: person, which is a developing organism that tries to reduce anxiety caused by needs; environment, which consists of existing forces outside of the person, and put in the context of culture; health, which is a word symbol that implies forward movement of personality and other other human processes toward creative, constructive, productive, personal, and community living.

The nursing model identifies four sequential phases in the interpersonal relationship: orientation, identification, exploitation, and resolution.

The orientation phase defines the problem. It starts when the nurse meets the patient, and the two are strangers. After defining the problem, the orientation phase identifies the type of service needed by the patient. The patient seeks assistance, tells the nurse what he or she needs, asks questions, and shares preconceptions and expectations based on past experiences. Essentially, the orientation phase is the nurse’s assessment of the patient’s health and situation.

The identification phase includes the selection of the appropriate assistance by a professional. In this phase, the patient begins to feel as if he or she belongs, and feels capable of dealing with the problem which decreases the feeling of helplessness and hopelessness. The identification phase is the development of a nursing care plan based on the patient’s situation and goals.

The exploitation phase uses professional assistance for problem-solving alternatives. The advantages of the professional services used are based on the needs and interests of the patients. In the exploitation phase, the patient feels like an integral part of the helping environment, and may make minor requests or use attention-getting techniques. When communicating with the patient, the nurse should use interview techniques to explore, understand, and adequately deal with the underlying problem. The nurse must also be aware of the various phases of communication since the patient’s independence is likely to fluctuate. The nurse should help the patient exploit all avenues of help as progress is made toward the final phase. This phase is the implementation of the nursing plan, taking actions toward meeting the goals set in the identification phase.

The final phase is the resolution phase. It is the termination of the professional relationship since the patient’s needs have been met through the collaboration of patient and nurse. They must sever their relationship and dissolve any ties between them. This can be difficult for both if psychological dependence still exists. The patient drifts away from the nurse and breaks the bond between them. A healthier emotional balance is achieved and both become mature individuals. This is the evaluation of the nursing process . The nurse and patient evaluate the situation based on the goals set and whether or not they were met.

The goal of psychodynamic nursing is to help understand one’s own behavior, help others identify felt difficulties, and apply principles of human relations to the problems that come up at all experience levels. Peplau explains that nursing is therapeutic because it is a healing art, assisting a patient who is sick or in need of health care. It is also an interpersonal process because of the interaction between two or more individuals who have a common goal. The nurse and patient work together so both become mature and knowledgeable in the care process.

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The nurse has a variety of roles in Hildegard Peplau’s nursing theory. The six main roles are: stranger, teacher, resource person, counselor, surrogate, and leader.

As a stranger, the nurse receives the patient in the same way the patient meets a stranger in other life situations. The nurse should create an environment that builds trust. As a teacher, the nurse imparts knowledge in reference to the needs or interests of the patient. In this way, the nurse is also a resource person, providing specific information needed by the patient that helps the patient understand a problem or situation. The nurse’s role as a counselor helps the patient understand and integrate the meaning of current life situations, as well as provide guidance and encouragement in order to make changes. As a surrogate, the nurse helps the patient clarify the domains of dependence, interdependence, and independence, and acts as an advocate for the patient. As a leader, the nurse helps the patient take on maximum responsibility for meeting his or her treatment goals. Additional roles of a nurse include technical expert, consultant, tutor, socializing and safety agent, environment manager, mediator, administrator, record observer, and researcher.

Some limitations of Peplau’s theory include the lack of emphasis on health promotion and maintenance; that intra-family dynamics, personal space considerations, and community social service resources are less considered; it can’t be used on a patient who is unable to express a need; and some areas are not specific enough to generate a hypothesis.

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Evidence and practice    

Open access empowering migrants during the resettlement process: applying peplau’s theory of interpersonal relations, irene nakasote ikafa lecturer in nursing, faculty of medicine and health, university of new england, new south wales, australia, colin adrian holmes adjunct professor, college of medicine and dentistry, james cook university, queensland, australia.

• To enhance your awareness of the issues that involuntary migrants commonly experience during the resettlement process

• To recognise the potential benefits of applying Peplau’s theory of interpersonal relations to support and empower involuntary migrants

• To understand the improvements to migrant support services that could be made

Background For many people, known as involuntary migrants, emigration is a last resort to escape armed conflict and persecution. Emigration may have positive outcomes for these people, but they may also experience several associated stressors that can have a negative effect on the resettlement process, particularly where there are significant lifestyle and cultural differences.

Aim To explore the issues affecting involuntary African migrants during their resettlement process in Western Australia and how Peplau’s theory of interpersonal relations could be used to inform how migrant support services could be improved to empower and support migrants.

Method An exploratory, qualitative research design was used. In-depth interviews were conducted with 30 involuntary migrants and five migrant support service providers. Thematic content analysis was used to identify themes from the data.

Findings Eight themes emerged from the data: reasons for migration; multiple losses; isolation and loneliness; employment issues; financial constraints; racial discrimination; migrants’ needs; and migrant support services.

Conclusion Migrant support services were often not easily accessible, culturally appropriate or sufficient for involuntary migrants. Peplau’s theory could be used to guide and empower migrants as they use support services and navigate the resettlement process.

Mental Health Practice . doi: 10.7748/mhp.2020.e1469

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software

[email protected]

None declared

Ikafa IN, Holmes CA (2020) Empowering migrants during the resettlement process: applying Peplau’s theory of interpersonal relations. Mental Health Practice. doi: 10.7748/mhp.2020.e1469

This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY 4.0) (see https://creativecommons.org/licenses/by/4.0/ ), which permits others to copy and redistribute in any medium or format, remix, transform and build on this work, even commercially, provided appropriate credit is given and any changes made indicated.

Published online: 21 July 2020

black and minority ethnic - culture - discrimination - diversity - ethnicity - mental health - multiculturalism - nurse-patient relations - patients - patient empowerment - professional - racism - transcultural care

Migrants include voluntary and involuntary migrants who have no intention of going back to their homeland ( Muggah 2003 , International Organization for Migration 2015 ). Voluntary migrants choose to move to another country, for example to seek employment and better life opportunities. In contrast, involuntary migrants – also known as refugees or forced migrants – are forced to leave their countries to escape civil wars, armed conflict, persecution or other disasters, and cannot return because of a well-founded fear of persecution ( Toole and Waldman 1993 ). They may have experienced sudden unrest in their country and been forced to leave immediately amid chaos and uncertainty about the future ( Crowley 2009 ).

Involuntary migrants may consider themselves fortunate when they arrive in their host country and are often relieved to be in a comparatively safe environment ( Ward 2000 , Irfaeya 2006 ). However, their resettlement can quickly become stressful as they experience issues finding their way around their new city or town and are unsure of how to accomplish daily activities such as using public transport, purchasing goods and using household utilities, as well as other unfamiliar community services for example public swimming pools. According to Pittaway et al (2009) , involuntary African migrants have lived in refugee camps for long periods, with many of their children born and raised in these camps; they can experience issues in adjusting to their new circumstances ( Abkhezr et al 2018 ).

This article reports on a study to explore the issues affecting involuntary African migrants during their resettlement process in Western Australia, undertaken in response to the increasing numbers migrating to Australia ( Australian Bureau of Statistics 2011 ). Peplau’s (1952a , 1952b) theory of interpersonal relations was used as the theoretical framework for the study, in view of involuntary migrants’ need for interpersonal support. Although this theory is specific to mental health practice, it can be applied to all areas of care, and could empower and assist migrants with the resettlement process in their host country.

Literature review

Involuntary African migrants may experience language barriers, social isolation, racial discrimination and unemployment, all of which can have a detrimental effect on their resettlement ( Pittaway et al 2009 , Abur 2018 ). Language issues are a crucial factor for migrants to Australia from non-English speaking countries, and Pittaway et al (2009) found that lack of proficiency in the English language negatively affects the ability of involuntary African migrants to obtain employment.

The experience of social isolation and loneliness is also common among all migrants to new countries because of separation from their extended family members, friends and the loss of social networks ( Ward 2000 , Murray 2010 ). Ogunsiji et al (2012) found that West African women in Australia experienced issues in developing social networks and obtaining employment; this led to feelings of loneliness and isolation, which negatively affected their mental health.

Subsequently, involuntary migrants are often profoundly affected by homesickness. Although this is not well understood, many studies have found it to be a common consequence of transcontinental migration ( Eisenbruch 1991 , Redwood-Campbell et al 2008 , Rosbrook and Schweitzer 2010 ). For involuntary migrants, even those escaping conflict and persecution, homesickness can become so distressing that the only acceptable resolution is to return to their country of origin, regardless of the cost or dangers involved.

To compound these issues, experiences of racial discrimination are common among non-white migrants in countries such as Australia where the established population is predominantly white. African migrants can be subjected to clear discrimination ( Guilfoyle and Harryba 2009 , Guilfoyle and Taylor 2010 , Salleh-Hoddin and Pedersen 2012 ). Fozdar and Torezani (2008) found that involuntary migrants in Australia experienced high levels of discrimination, while Shakespeare-Finch and Wickham (2010) found that six out of 12 Sudanese refugees in their study experienced racial discrimination and verbal abuse. These experiences resulted in feelings of exclusion, fear and regression. Participants also stated that racial discrimination made it highly challenging for them to find employment in Australia.

Involuntary migrants need to be empowered when they arrive in a host country such as Australia because they can experience challenging situations. Solomon (1976) described an American programme in which empowerment is offered as part of a problem-solving strategy for stigmatised people such as refugees. Cochran and Dean (1991) asserted that local communities can have a significant role in the empowerment of migrants, for example providing interpreting services and assisting in the validation and recognition of overseas qualifications ( Spinks 2009 ).

There is no specific research on the importance of empowerment in the resettlement of involuntary migrants; therefore, this study aimed to address this gap by evaluating support services and using Peplau’s theory as a framework to support and empower involuntary migrants during their resettlement process.

Peplau’s theory of interpersonal relations

In Hildegard Peplau’s (1952a , 1952b) theory of interpersonal relations, the therapeutic relationship between the nurse and the client is central to mental health practice. Peplau’s theory aims to facilitate problem-solving and coping skills in the context of this relationship, to provide effective care and work towards resolving the client’s mental health issues. The relationship comprises three phases: orientation, working and termination ( Box 1 ).

Box 1.

Phases of peplau’s theory of interpersonal relations, orientation phase.

• The client identifies a need and seeks professional assistance and support

• The mental health nurse meets the client as a stranger, they exchange views and the nurse clarifies their role in the process

• The nurse develops rapport and trust with the client, establishing a therapeutic relationship with them

• In this phase, it is crucial that the nurse demonstrates interest in the welfare of the client, while encouraging them to ask questions and voice their needs

• The nurse recognises that the client has the power to address their issues, which will emerge from the therapeutic relationship

Working phase

Identification subphase

• The client identifies the nurse as someone who can assist them with their issues

• The mental health nurse undertakes the roles of counsellor, advocate and teacher, and identifies the client’s needs or issues to be addressed, such as anxiety, social isolation, low self-esteem and confusion

• The nurse introduces the client to available healthcare services and resources

Exploitation subphase

The mental health nurse undertakes the resource and leader roles, working with the client to plan, implement and evaluate their care. The client uses the therapeutic relationship and the resources being offeredThe mental health nurse educates the client about their condition, assists them to develop their problem-solving and coping skills, and facilitates the client’s goal settingAs the client becomes increasingly independent, the power shifts from the nurse towards the client

Termination phase

• The client begins to feel that their situation has improved, and starts planning and pursuing their goals

• Effective communication and interaction with other clients, nurses and non-clinical staff are maintained, while the client establishes alternative sources of support

• The nurse can undertake the leader and resource roles, encouraging social and physical activities to enable the client to achieve a normal, productive and fulfilling life. Progress can be satisfying for the client and the nurse

• There is a mutually agreed termination of the therapeutic relationship between the nurse and the client

( Peplau 1952a , 1952b , 1992 , 1997 , Forchuk 1994 , Fawcett and Desanto-Madeya 2013 , Senn 2013 )

Peplau’s theory also includes six therapeutic relationship roles that mental health nurses can undertake: stranger, advocate, counsellor, teacher, leader and resource roles. Mental health nurses are required to use various therapeutic skills, including being present, authentic, respectful, using active listening skills and demonstrating empathy to clients ( Dziopa and Ahern 2009 , Delaney and Ferguson 2011 , Moreno-Poyato et al 2016 ). This theory provides a framework that mental health nurses working with involuntary migrants can use for interpersonal support.

To explore the issues affecting involuntary African migrants during their resettlement process in Western Australia and how Peplau’s theory of interpersonal relations could be used to inform how migrant support services could be improved to empower and support migrants.

The study used an exploratory, interpretive, qualitative research design, which forms part of the PhD of the lead author (INI) about the resettlement experiences of African migrants in Australia and the support services available to them.

Participants

The participants included ethnic African migrants from sub-Saharan African countries living in Western Australia. Convenience and purposive sampling methods were used to recruit participants.

People were invited to participate in the study if they met the following inclusion criteria:

• Ethnic African migrant.

• Aged 18 years or older.

• Permanent resident or an Australian citizen.

The exclusion criteria were:

• Non-ethnic African migrant.

• Young people under 18 years.

• Temporary visa holders.

The five migrant support service providers who participated in the study were managers or senior officers working in organisations funded by the government ( Box 2 ).

Box 2.

Migrant support service providers who participated in this study.

• Provider 1 – the president of the African Community Association of Western Australia, which provides assistance and information about support services to African community leaders, who then disseminate it to their communities

• Provider 2 – worked for the Ethnic Communities Council of Western Australia, which provides information and support to various ethnic groups in Western Australia

• Provider 3 – worked for a migrant resource centre that provides long-term settlement services to support the integration of involuntary migrants into communities

• Provider 4 – worked for the Association for Services to Torture and Trauma Survivors, which provides a free confidential counselling service for survivors of trauma and torture

• Provider 5 – worked for Centrecare Migrant Services, which provides long-term settlement services to involuntary migrants

Participants were recruited using several approaches. Flyers describing the study were distributed and displayed in public places around the Perth metropolitan area. Participants were also recruited from the social networks of the lead author. A total sample of 30 involuntary African migrants and five migrant support service providers was obtained. Of the involuntary migrant participants, 19 were female and 11 were male. Eight participants were aged 21-30 years, four participants were aged 31-40 years, 13 participants were aged 41-50 years, and five participants were aged 51-60 years. All the participants came from war-affected countries, including Burundi, Democratic Republic of the Congo, Liberia, Somalia, Sudan, Sierra Leone and Zimbabwe.

Data collection and analysis

The qualitative data were collected using in-depth, face-to-face interviews with African migrants about their experiences of the resettlement process and their perspectives on migrant support services. Migrant support service providers were also interviewed about their perspectives of migrants’ needs and support services. The interviews took approximately 45-60 minutes to complete. Interviews were audiotaped with the participants’ permission, then transcribed for analysis.

The data were analysed using thematic content analysis with open coding, with each transcript being read and reread to ascertain the meaning of its content. Similarities and differences in the data were identified and colour-coded, and words capturing similar ideas were captured to create broad categories, which were then reduced to develop the final themes for analysis.

Ethical considerations

Approval to conduct the study was granted by the Human Research Ethics Committee of Murdoch University, Perth Campus, Western Australia. Informed consent was obtained from all participants. The participants were assured of complete confidentiality and anonymity, and that any response would be identified only by a number or pseudonym that could not be traced to any specific person.

Eight themes emerged from the data analysis:

• Reasons for migration.

• Multiple losses.

• Isolation and loneliness.

• Employment issues.

• Financial constraints.

• Racial discrimination.

• Migrants’ needs.

• Migrant support services.

Reasons for migration

Eleven participants stated that they escaped from civil war and persecution from their homeland and had lived in refugee camps in neighbouring countries before they were finally resettled in Australia with a refugee status:

‘It’s actually civil war which made me come to Australia. There was no peace in my country; we were running away from rebels that were fighting with the government soldiers, so we had to run for our lives, got to a neighbouring country and stayed in the refugee camp until we had the opportunity to come here’ (participant 13).

Multiple losses

Participants experienced multiple losses, including the loss of their culture, food, family, friends and social networks:

‘Oh, heaps [of losses] – your family and the support network. It’s not there – it takes a lot to build that up’ (participant 11).

Isolation and loneliness

Some participants felt isolated and lonely, missing the social and extended family support to which they were accustomed:

‘I started to distinguish things and I found that [Australians] are very secluded; they don’t like to mingle if they don’t know you. Like, we have neighbours who we have lived next to our house for several years, but we hardly say “hi” – we just pass each other… We give them their space and they give us our space’ (participant 12).

Employment issues

A significant cause of stress and frustration identified by ten participants was related to finding employment:

‘I would say, not finding work in my field that I studied, like I did my university degree [in Australia] but I haven’t got a job in line with my career, which is so distressing and frustrating’ (participant 7).

‘Though we may have education back in our homeland, we come [to Australia and] we struggle to have our qualifications recognised and, if they are recognised, the next battle is to find a job in your profession’ (participant 8).

‘I am a little confused because I thought by now I would be well settled [with a job] and be comfortable’ (participant 23).

‘It’s not easy to get job opportunities. When you come and you are new – they always look at your experience in Australia, so it’s very hard to find a job’ (participant 24).

Financial constraints

Many male participants identified their main concern as being associated with financial constraints. They reported that it was easier to find minor jobs than professional jobs (those that require specialised knowledge and advanced education or training):

‘Of course there are financial difficulties because, when we Africans come to Western countries like Australia, we have a financial handicap because of unemployment. There are barriers of stereotyping whereby, people look at you and assume certain things about you that can even affect you in a harmful way mentally when you are looking for jobs’ (participant 6).

Racial discrimination

Many participants reported that racial discrimination was present in the employment market, workplaces and community. More than half of the involuntary migrants ( n =18/30) who were interviewed reported that they or their family members had experienced racial discrimination:

‘I think racism [is] unfortunately grounded in the history of this country, so it is something that people will find very difficult to escape from and it is going to be around for a long time. I’m not talking about the racism where people call you names or where you walk on the street and someone says “go [back to your] home”, but silent racism… Especially when you go to institutions, you get that silent treatment – turning heads and treating you like you don’t exist. You’re standing right there, but you don’t exist’ (participant 18).

‘I would say one thing that still sticks to my mind for me is racism here – it is there, but it is subtle and many times people do not want to talk about it. About a year ago somebody came to my property and grafted it, and it had racial slur’ (participant 29).

Migrants’ needs

The five migrant support service providers identified some common needs among African migrants. They reported that it is important for people coming from refugee camps to be shown how to use basic household utilities, taught how to use common community infrastructure and orientated to the Australian cultural and legal system:

‘I suppose needs that we see amongst people – refugees – is getting used to a new culture, using ATMs [automated teller machines] and public transport. I suppose another need is linking people with their community, so that they can visit on a regular basis, like in the Mirrabooka area, there are so many Sudanese people and they feel comfortable living there’ (provider 3).

‘Coming from refugee camps to come to a big city like Perth can be overwhelming due to cultural shock. They need to learn a new system [in Australia]’ (provider 4).

‘We pick them from the airport, show them how to use household utilities, and straight away they start asking, “When are we going to school? When are we learning English?”’ (provider 5).

The migrant support service providers reported that they mainly supported refugees:

‘The refugees need high level of support. A lot more of our energy goes into just putting a lot more structured education in place such as educating them how to use household utilities. Effectively, for the first six weeks we answer any questions. “I want to enrol my children in school”, [so] we work out what schools are available, how they get there – it’s the real practical support’ (provider 3).

Migrant support services

Perspectives of migrants.

All involuntary migrants reported that they received migrant support from the Integrated Humanitarian Settlement Strategy when they arrived in Australia and were provided with initial intensive settlement support. Participants also reported that they were able to access other migrant support services provided by the government such as Centrelink, Medicare and public housing:

‘I did [receive support], like Centrelink and at the moment, I’m living in a Homeswest house – government [public] housing’ (participant 13).

‘Yes, just like everyone who comes here on a refugee visa, we get support. We come as permanent residents and get support from Centrelink’ (participant 22).

‘I was able to get migrant support services because we were brought here by the United Nations High Commission for Refugees, so there was that support’ (participant 26).

Most participants suggested that support services should be broader and culturally appropriate for migrants.

Perspectives of migrant support service providers

The five migrant support service providers reported that migrant support services were not easily accessible by African migrants and they were insufficient to meet their needs:

‘We only give emergency relief assistance to new migrants. For example, we give phone vouchers. We also give them Coles vouchers to assist them with their initial settlement’ (provider 1).

‘To be honest, I look at it in the grand scheme of things. My main reason for saying this is that I don’t think there’s enough [support for migrants]. There’s enough people providing services, but they don’t provide broad enough services for everyone [such as] individualised English language tuition’ (provider 3).

‘We assist them with many basic skills such as showing them how to use public transport and how to use ATMs to access banks and we introduce them to the legal system in Australia. Refugees are given three weeks to learn about the system, this is not enough’ (provider 4).

‘I don’t think there’s enough support and there’s not enough coordination of what goes on to people. It may be there, but people don’t know because of communication barriers’ (provider 5).

The migrant support service providers recommended several improvements to support services that could be made, such as consulting with migrants, adapting services to meet their needs and coordinating long-term services.

In this study, all the participants had escaped armed conflict and persecution from their countries. They reported that they had experienced multiple losses, isolation and loneliness, and were missing the social and extended family support to which they were accustomed. Perlman and Peplau (1981) stated that loneliness is a negative feeling that follows when people feel that their interpersonal relationships with others are not sustaining their emotional needs. Therefore, migrant support services need to explore and address involuntary migrants’ relational and emotional needs.

Several male participants identified financial constraints were an issue because they had difficulty finding employment in Australia. In addition, many of the participants in this study had experienced employment issues, particularly finding professional jobs, which was a significant cause of frustration. Similarly, Pittaway et al (2009) established that unemployment among African migrants in Australia has been heightened by racial discrimination and lack of work experience. The Refugee Council of Australia (2011) also reported that employment services were not effective in supporting this group of migrants to find work.

Most of the participants reported that they or their family members experienced racial discrimination, and that this was present in the employment market, workplaces and community. These findings are consistent with those of other studies. For example, in the UK, Hack-Polay and Mendy (2018) established that, irrespective of their qualifications, migrants were often rejected from employment opportunities. In the US, Heger Boyle and Ali (2010) also concluded that racial discrimination affected involuntary migrants’ ability to obtain formal employment, while Murray’s (2010) study of Sudanese migrants in Australia found that one third of participants experienced discrimination. Another Australian study by Fozdar and Torezani (2008) also found that refugees experienced high levels of perceived discrimination.

Applying Peplau’s theory to the resettlement process

During the orientation phase of Peplau’s (1992) theory of interpersonal relations, the nurse meets the client as a stranger, establishes a therapeutic relationship with them, and identifies their immediate needs. The Integrated Humanitarian Settlement Strategy is the first settlement and healthcare service agency with whom all involuntary migrants in Australia have contact. The mental health nurses, doctors and other professionals who work for this agency provide initial assessment of involuntary migrants’ needs and intense settlement support on their arrival.

The migrant support service providers in this study reported that they collected refugees from the airport, undertook orientation, showed them how to use household utilities, assisted them with shopping and answered any questions. They also ensured that migrants had access to support services that met their immediate needs such as Centrelink, Medicare and healthcare services. Mental health nurses working for the Integrated Humanitarian Settlement Strategy can also recognise issues such as homesickness, isolation, loneliness, anxiety and stress and refer them for counselling. It is essential that all those working with this group of migrants exercise interpersonal skills and communicate clearly to identify and address migrants’ immediate needs, which may differ from one person to another.

The working phase of Peplau’s theory comprises identification and exploitation subphases. During the identification subphase, healthcare professionals such as mental health nurses working for the Integrated Humanitarian Settlement Strategy can identify and assess involuntary migrants’ signs of trauma, anxiety and refer them to services such as the Association for Services to Torture and Trauma Survivors for free confidential counselling. Mental health nurses can also ensure that new arrivals have access to healthcare resources, teach them coping strategies and problem-solving skills and support them to set goals for their future. During the exploitation phase, involuntary migrants can be encouraged to use community services, such as public libraries and public swimming pools. Appropriate uptake of community services and facilities can result in greater community integration of migrants and promote their mental health.

The migrant support service providers in this study reported that people coming from refugee camps needed to be shown how to use common community infrastructures. They acted as resource experts, teachers and advocates for migrants, and educated them how to use ATMs, public transport, public libraries and swimming pools. They also enrolled their children into schools and encouraged migrants to undertake apprenticeships or further their education at technical and further education institutions or universities to increase their chances of finding employment.

The migrant support service providers reported that they provided a high level of support to involuntary migrants. During the termination phase of Peplau’s (1952b , 1997) theory, involuntary migrants begin to feel settled and work towards achieving their goals. They become self-reliant, independent and able to obtain employment. Shakespeare-Finch and Wickham (2010) identified support strategies such as the establishment of wider migrant support networks that can assist and empower involuntary African migrants and facilitate their integration into their new country and community. Once they are well integrated, involuntary migrants can successfully compete for employment and cease to depend on support services provided by their community and government. Migrant support service providers and mental health nurses can reassess involuntary migrants and ensure they remain settled, then mutually agree to terminate the relationship.

Limitations

Participants may have self-selected by being able to read recruitment flyers because no participant required assistance with reading or an interpreter. In addition, the participants were recruited from one state in different areas of the Perth metropolitan region in Western Australia, which limits the generalisability of the study findings.

This study explored the issues that may affect involuntary African migrants during their resettlement process in Australia. The participants reported that they used support services, but that these were often not sufficiently broad or culturally appropriate. Migrant support service providers identified that involuntary migrants required a high level of support and that the available support services were inadequate and not easily accessible. They recommended several improvements that could be made to these migrant support services, such as consulting with migrants, adapting services to meet their needs and coordinating long-term services.

This study appears to be the first to use Peplau’s theory of interpersonal relations to identify how migrant support services might be improved to ensure they offer effective support for involuntary migrants. Peplau’s theory can be used by mental health nurses and migrant support service providers to guide and empower involuntary migrants as they use these services to navigate the resettlement process.

Implications for practice

• Mental health nurses could use Peplau’s theory of interpersonal relations as the basis for working with migrants to empower and support them during the resettlement process

• Mental health nurses need to continuously update their knowledge and be aware of the services and resources available for migrants and ensure all migrants can access these services if necessary

• Migrant support services can be improved by consulting with migrants, adapting services to meet their needs and coordinating long-term services

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Clinical Practice

p-ISSN: 2326-1463    e-ISSN: 2326-1471

2017;  6(2): 33-36

doi:10.5923/j.cp.20170602.03

Case Management of Substance Induced Psychosis Using Peplau’s Theory of Interpersonal Relations

Isaac Machuki Ogoncho , Philip Sanga, Dabo Galgalo Halake

Department of Nursing Sciences, University of Kabianga, Kericho, Kenya

Copyright © 2017 Scientific & Academic Publishing. All Rights Reserved.

Substance induced psychosis is a form of psychosis that develops from the use of alcohol or other drugs. The symptoms for this form of psychosis can resolve within days or weeks though tendencies of relapsing occur with persistent use of the drugs. The purpose of this article was to examine Peplau’s theory of interpersonal relations as a framework to assist nurses in understanding and managing patients with substance induced psychosis. The theory involves a therapeutic process that is collaboratively undertaken by both the nurse and the patient towards resolving an identified health problem. The nurse-patient relationship evolves through three phases of orientation, working and termination. The nurse may function as a stranger, leader, teacher, resource person, surrogate and counsellor in helping the patient adopt a healthier behaviour. The nurse-patient relationship allows the patient to freely express their emotions, feelings and thoughts about a given health problem. This enhances understanding of the health problem and guides nurses to helping the patients meet their individual needs. Nursing practice should focus on strengthening interpersonal relationships with patients to improve health outcomes.

Keywords: Substance abuse, Psychosis, Peplau’s theory, Interpersonal relations

Cite this paper: Isaac Machuki Ogoncho, Philip Sanga, Dabo Galgalo Halake, Case Management of Substance Induced Psychosis Using Peplau’s Theory of Interpersonal Relations, Clinical Practice , Vol. 6 No. 2, 2017, pp. 33-36. doi: 10.5923/j.cp.20170602.03.

Article Outline

1. introduction, 2. hildegard peplau’s theory of interpersonal relations, 3. case summary, 4. application of the theory in managing a patient with substance induced psychosis, 5. conclusions.

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Erin Nixon | Maria Åstrand

Erin Nixon, an executive and entrepreneur with strong experience in strategic management and operations, has been named assistant dean of admissions and financial aid at Stanford Graduate School of Business.

Quote I’ve experienced firsthand how [Stanford GSB] transforms the trajectory of its students. Attribution Erin Nixon

Nixon, who earned both her undergraduate and MBA degrees at Stanford, returns to Stanford GSB for a role that she says “at its heart, is about identifying and connecting with smart, highly motivated people who want to make a difference in the world. It is about bringing them together to create a strong, robust community, representing a wide variety of lived experiences, ambitions, and perspectives, united by common values.”

Over her 20-year career, Nixon has built and managed teams across multiple industries and international locations. After five years at Boston Consulting Group, she joined LinkedIn, where she was responsible for growing the global talent brand business, overseeing a team based in 18 countries around the world.

She then pivoted into the world of wine, opening an acclaimed wine bar and restaurant in Barcelona, Spain. In Barcelona, she has also worked as a strategy and operations leader and advisor for a few startups and small businesses, including a tech-enabled mental health provider and a digital marketing and brand agency for wine and spirits.

“We did a comprehensive, international search for someone who could do great work in a role that requires numerous skills — representing the GSB, managing a large professional team, and assessing talent and potential,” says Stanford GSB Senior Associate Dean for Academic Affairs Paul Oyer. “Erin has that rare combination of talents that will enable her to excel in all the aspects of this position. She is a great addition to the GSB’s leadership team.”

“I’m delighted to step into this role because I feel deeply aligned with the mission and goals of Stanford GSB,” Nixon says. “I’ve experienced firsthand how it transforms the trajectory of its students, unlocking leadership potential to drive meaningful impact in the world. Stanford is an incredibly inspiring place, and it’s a dream to be able to return to the Farm and serve the GSB community in this way.”

Nixon begins her new duties on July 1.

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