"HILDEGARD" E. PEPLAU PSYCHODYNAMIC NURSING

• BACKGROUND
  
  Hilda Peplau was born September 1, 1909, in reading Pennsylvania.
• As a child, she witnessed the devastating flu epidemic of 1918. This personal experience greatly influenced her understanding of the impact of illness and death on families.
• Peplau began her career in nursing in 1931 as a graduate of the Pottstown Hospital School of Nursing in Pennsylvania.
• She then worked as a staff nurse in Pennsylvania and new York City. A summer position as nurse for the New York University Summer camp led to a recommendation for degree in interpersonal psychology in 1943.
• From 1943-1945 Peplau served in the Army Nurse Corps and was assigned to the 312th Field Station Hospital in England where the American School of Military Psychiatry was located.
• Peplau held master's and doctoral degrees from Teachers College, Columbia University. She was also certified in psychoanalysis by the William Alanson White Institute of New York City. In the early 1950s, Peplau developed and taught the first classes for graduate psychiatric nursing students at Teachers College.
• Dr. Peplau was a member of the faculty of the College of Nursing at Rutgers University from 1954-1974.
• At Rutgers, Peplau created the first graduate level program for the preparation of clinical specialists in psychiatric nursing.
• Peplau vigorously advocated that nurses should become further educated so they could provide truly therapeutic care to patients rather than the custodial care that was prevalent in the mental hospital of that era.
• During the 1950's and 1960's, she conducted Summer workshop for nurses throughout the United States, mostly in state psychiatric hospitals. In these seminars, she taught interpersonal concepts and interviewing techniques, as well as individual, family and group therapy.
• Peplau was an advisor to the World Health Organization and a visiting professor at universities in Africa, Latin America, Europe and throughout the United Sates.
• After her retirement from Rutgers, she served a visiting professor at the University of Leuven in Belgian in 1975 and 1976. There she helped establish the first graduate nursing program in europe.
  
  MAJOR CONCEPTS AND DEFINITIONS
  
  PSYCHODYNAMIC NURSING Peplau defines psychodynamic nursing because her model evolves through this type of nursing. Psychodynamic nursing is being able to understand one’s own behavior to help others identify felt difficulties, and to apply principles of human relations to the problems that arise at all levels of experience.
  
  NURSE-PATIENT RELATIONSHIP
  
  Orientation Phase
  
  
• When the nurse and patient first meet is known as the orientation phase.
• This is a time when the patient and nurse come to know each other as people and each other’s expectations and roles are understood.
• The patient at this time needs to recognize and understand their difficulty and the need for help, be assisted to plan to use the professional services offered, and harness the energy derived from felt needs (Peplau, 1952, p 19).
• It may be expected that the patient will test limits in order to establish the integrity of the nurse.
• The tasks of this phase are to build trust, rapport, establish a therapeutic environment, assess the patients strengths and weakness and establish a mode of communication acceptable to both patient and nurse (Shives, 1994, p 91).
• When the patient can begin to identify problems the relationship progresses to the working phase.
• 
  
  
  Working Phase :
  
  Identification phase :
  
  
• Trust begins to develop and the patient begins to respond selectively to persons who seem to offer help.
• The patient begins to identify with the nurse and identify problems, which can be worked on.
• The meaning behind feelings and behavior of the nurse and patient are explored. Peplau (1952, p31) states that when a nurse permits patients to express what they feel, and still get all of the nursing that is needed, then patients can undergo illness as an experience that reorients feelings and strengthens positive forces in the personality.
• The tasks of this phase are to develop clarity about the patient's preconceptions and expectations of nurses and nursing, develop acceptance of each other, explore feelings, identify problems and respond to people who can offer help.
• In particular the nurse assists in the expression of needs and feelings, assists during stress, shows acceptance and provides information.
• The nurse and patient may make plans for the future but the implementation of the plan signifies the beginning of the exploitation phase of the working relationship.
  
  Exploitation phase
  
  
• The patient realistically exploits all of the services available to them on the basis of self interest and need (Peplau, 1952, p 37).
• The nurse assists the patient in their efforts to strike a balance between the needs for dependence and independence.
• The plan of action is implemented and evaluated. The patient may display a change in manner of communicating, as new skills in interpersonal relationships and problem solving are developed (Forchuk & Brown, 1989, p 32).
• The nurse continues to assess and assists in meeting new needs as they emerge.
  
  
  Resolution Phase
  
  
• The resolution phase involves the gradual freeing from identification with helping persons, and the generation and strengthening of ability to stand alone, eventually leading to the mutual termination of the relationship (Peplau, 1952, p 39).
• The patient abandons old needs and aspires to new goals.
• She or he continues to apply new problem solving skills and maintains changes in style of communication and interaction.
• Resolution includes planning for alternative sources of support, problem prevention, and the patient’s integration of the illness experience.

NURSING ROLES

1. Role of stranger

Peplau states that because the nurse and patient are strangers to each other, the patient should be treated with ordinary courtesy. In other words, the nurse should not prejudge the patient, but accept him as he is. During this nonpersonal phase, the nurse should treat the patient as emotionally able, unless evidence indicates otherwise.

2. Role of resource person

Nurse provides specific answers to questions, especially health information, and interprets to the patient the treatment or medical plan of care. These questions often arise within the context of a larger problem. The nurse determines what type of response is appropriate for constructive learning, either straightforward factual answers or providing counseling.

3. Teaching role

The teaching role is a combination of all roles and “always proceeds from what the patient knows and…..develops around his interest in wanting and ability to use…..information.

Peplau separates teaching into two categories :

Instructional : which consists largely of giving information and is the form explained in educational literature.

Experiential : which is using the experience of the learner as a basis from which learning products are developed.
Leadership role

The leadership role involves the democratic process. The nurse helps the patient meet the tasks at hand through a relationship of cooperation and active participation.

4. Surrogate role

The patient casts the nurse in the surrogate role. The nurse’s attitudes and behaviors create feeling tones in the patient that reactivate feelings generated in a prior relationship.

The nurse’s function is to assist the patient in recognizing similarities between herself and the person recalled by the patient.
She then helps the patient see the differences in her role and that of the recalled person.

In this phase, both patient and nurse define areas of dependence independence, and finally interdependence.

5. Counseling role

Peplau believes the counseling role has the greatest emphasis in psychiatric nursing.

Counseling functions in the nurse patient relationship by the way nurses respond to patient demands.

Peplau says the purpose of interpersonal techniques is to help the patient remember and understand fully what is happening to him in the present situation, so that the experience can be integrated rather than dissociated from other experiences in life.


MAJOR ASSUMPTIONS

Peplau identifies two explicit assumptions :

• The kind of person the nurse becomes makes a substantial difference in what each patient will learn as he receives nursing care.
• Fostering personality development toward maturity is a function of nursing and nursing education. Nursing uses principles and methods that guide the process toward resolution of interpersonal problems.
  
  Nursing
  Nursing described as a significant, therapeutic, interpersonal process.
  
  Person
  Peplau defines person in terms of man. Man is an organism that lives in an unstable equilibrium.
  Health
  Peplau defines health 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.
  
  Environment
  Peplau implicitly defines the environment in terms of existing forces outside the organism and in the context of culture, from which mores, customs, and beliefs are acquired.
  

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"THE TOP 10 QUALITIES OF A GOOD NURSE MANAGER"

By Sandra A. Thompson, RN., BSN., (Case Manager at John C. Lincoln Hospital-North Mountain, in Phoenix, AZ).
References : AMERICAN JOURNAL NURSING, AGUST 2004, VOL. 104, NO. 8.


1. The number-one quality a good nurse manage must have : respect staff as professionals

Nothing is worse than being treated like a child in the work-place. A manager who disrespects her staff, especially in front of others, loses staff respect in return. Nurse managers should refrain from micromanagement; nurses are professionals who can think for themselves. Restraining or limiting nurses because of a lack of trust is deadly to the relationship between staff and manager. Nursing autonomy is promoted at the professional level; it must be promoted at the managerial level as well.

2. Set standards and a clear professional example.

Nurses are expected to behave professionally, and the same holds true for managers. A nurse manager needs to be professional in her appearance, language, and behavior, just as a staff nurse must be. Coming to work disheveled or inappropriately dressed, using improper language, or failing to follow standards for attendance or behavior are a few examples of the do-what-I-say-and-not-what-I-do double standard. What goes for the nurse must go for the manager.

3. Be organized, yet creative and flexible.

Many workers have unusual organizational methods, but employees are effected when a nurse manager can't find an evaluation or forgets a deadline. The manager needs to be organized in a way that her staff can follow. She also needs to establish clear rules that she must be willing to adjust when necessary. For example, if a nurse's child has a school event that conflicts with the posted schedule, the manager must understand its importance and try to resolve the dilemma. Of course, the manager must also recognize when staff members abuse such flexibility and set limits accordingly.

4. Be an effective decision maker, as well as a conflict and crisis manager.

The nursing staff expects the manager to make intelligent decisions when conflicts and problems arise. For example, managers should expect employees to attempt to resolve conflicts among them-selves. But manager needs to realize that she might be asked to assist. No one likes confrontations, but nurse managers who shrink from problems will only create more discord among the staff. When a serious problem arises on the unit, the nurse manager is looked to for leadership and support. If the manager responds by disappearing, crying, or exploding, the staff has diminished resources for handling problems. Timeliness is another factor. If the nurse manager judges too quickly or delays decisions, the entire unit suffers. Nursing staff and administrators agree that the ability to make good decisions is essential for a successful nurse manager.

5. Motivate and empower staff

Change is a necessary part of business, even the business of health care. The nurse manager needs to find ways to motivate and involve staff. If a nurse manager displays a hopeless, cynical, or dispassionate attitude, so will the staff nurses. The effective nurse manager is involved with the nursing staff on all levels, welcomes their input, and works with them to ensure excellence, create autonomy, and increase job satisfaction and opportunities for advancement.

6. Have a good sense of humor

Nursing is one of the toughest and most stressful jobs around. Tension can become so overwhelming that laughing is the only alternative to crying. An affective manager understands this; we are all human, and sometimes appropriate humor can be the healthiest and most compassionate way to help staff and patients cope.

7. Be honest, fair, consistent, and reasonable

Lying is one of the quickest ways to break someone's trust, as is showing favoritism toward particular members of the staff. Deceit of any kind is devastating to the relationship between manager and staff. A good nurse manager knows that consistency matters-working for an unpredictable manager escalates tension and inhibits work. Being unreasonable in expectations and day-to-day dealings can also be harmful. A manager who wants to have an effective and cohesive team needs to be up front, realistic, and fair when it comes to interactions and expectations. Honest, sincere communication is always the best practice.

8. Be reliable resource and staff advocate

A nurse manager needs to have a solid clinical background, preferably in the specialty of the staff. Administrators often feel this is not necessary as long as the manager possesses strong managerial skills. From a staff nurse's perspective, however, respect is lost if the manager is out of touch with what the specialized nursing staff does. The manager also needs to support nursing staff. A manager who does not back up staff loses their respect. A manager who supports staff and is an advocate for them gains loyalty.


9. Be available and accessible to staff

Admittedly, meetings and other managerial responsibilities are important, but the nursing staff needs to know that the manager is available when needed. Acknowledging and incorporating staff suggestions, whenever possible, is also important to nurses.

10. Be a great communicator

Effective communication is one of the most important tools for a leader or manager. Information should be conveyed in a clear manner. Staff should be informed of expectations and upcoming changes (not reprimanded after they've unknowingly done it wrong), be given timely and accurate information and updates, be listened to, and receive positive feedback, one of the most frequent complaints from nurses is that their managers only talk to them when they are in trouble. The nursing professions has a reputation for "eating its young," and breaking this cycle can begin with positive interactions from the nurse manager.

While it's the responsibility of the nurse manager to develop these qualities, staff nurses have a role in fulfillment of the top-10 list as well. What can staff nurses do to support these qualities in their nurse managers?
First, seek educational and practice opportunities to develop these attributes personally.
Second , communicate honestly with the nurse manager about your professional needs. Let the manager know what it is you need to be successful in providing good nursing care.
Third, patiently allow for mistakes and misjudgments, just as you would like manager to do for you. Above all, show respect, support, and appreciation especially when the manager has exhibited or practiced one of the qualities of a great nurse manager.
It's logical that a good nurse manager will attract and retain nurses, and a bad one will drive them away. In light of the current nursing shortage, this issue becomes particularly important. What separates the good from the bad? Nurse managers who want to keep nurses will make it a priority to find out. Staff nurses who want good nurse managers will make it a priority to help them become so.

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"COMMUNICATION"

Communication is the evoking of shared or common meaning in another person.

Communication is the transmission of information, opinions, and intentions between and among individuals.


1. Model

The model has four basic elements :

a. The Communicator

The communicator is the person originating the massage.

b. The Receiver

The receiver is the person who receive the massage. The receiver must interpret and understand the massage.

c. Perceptual Screens

Perceptual screens are the windows through which we interact with people in the world. The communicator's and the receiver's perceptual screens influence the quality , accuracy, and clarity of the massage. The screen influence whether the massage sent and the massage received are the same or whether distortion occurs in the massage. Perceptual screens are composed of the personal factors each person brings to interpersonal communication, such as age, gender, values, beliefs, past experiences, cultural influences, and individual needs.

d. The Massage

The massage contains the thoughts and feeling that the communicator intends to evoke in the receiver. The massages has two primary components. The though or conceptual component of the massage is contained in the words, ideas, symbols, and concepts chosen to relay the massage. The feeling or emotional component of the massage (its affect) is contained in the intensity , force, demeanor, and sometimes the gestures of the communicator.

e. The Feedback Loop

The feedback loop may or may not be activated in the model. Feedback occurs when the receiver provides the communicator with a response to the massage.

f. The Language

The language of the massage is increasingly important because of the multinational nature of many organizations.

Communication Media

a. Face-to-face discussion
b. Telephone
c. Electronic mail
d. Individual letter
e. Personalized note or memo
f. Formal written report
g. Flyer or bulletin
h. Formal numeric report.


2. Reflecting Listening

Reflecting listening is the skill of carefully listening to another person and repeating back to the speaker the heard massage to correct any inaccuracies or misunderstandings. Reflecting listening enables the listener to understand the communicator's meaning, reduce perceptual distortions, and overcome interpersonal barriers that lead to communication failures. Reflecting listening ensures that the meanings of the sent and received massages are the same.


Reflective listening is a skill that you can practice and learn. Here are ten tips to help you become a better listener.

" Stop talking. You cannot listen if your mouth is moving.
" Put the speaker at ease. Break the ice to help the speaker relax. Smile
" Show the speaker you want to listen. Put away your work. Do not look at your watch. Maintain good eye contact.
" Remove distractions. Close your door. Do not answer the telephone
" Empathize with the speaker. Put yourself in the speaker's shoes.
" Be patient. Not everyone delivers massages at the same pace.
" Hold your temper. Do not fly off the handle.
" Go easy on criticism. Criticizing the speaker can stifle communication.
" Ask questions. Paraphrase and clarify the speaker's massage.
" Stop talking. By this stage, you are probably very tempted to start talking, but do not. Be sure the speaker has finished.

Four levels of verbal response by the receiver are part of active reflective listening :

a. Affirming Contact

The receiver affirms contact with the communicator by using simple statements such as " I see, "uh-huh, "Yes", I understand". The purpose of an affirmation response is to communicate attentiveness, not necessarily agreement.

b. Paraphrasing the Expressed

After an appropriate time, the receiver might paraphrase the expressed thoughts and feelings of the speaker. Paraphrasing is useful because it reflects back to the speaker the thoughts and feelings as the receiver heard them. This verbal response enables the receiver to build greater empathy, openness, and acceptance into the relationship while ensuring the accuracy of the communication process.

c. Clarifying the Implicit

Implicit thoughts and feelings are not clearly or fully expressed. The receiver may or may not assume that the implicit thoughts and feelings are within the awareness of the speaker.

d. Reflecting "Core" Feelings

1. Silence

Long, extended periods of silence may cause discomfort and be a sign or source of embarrassment, but silence can help both speaker and listener in reflective listening. From the speaker's perspective, silence may be useful in moments of thought or confusion about how to express difficult ideas or feelings.


2. Eye Contact

Eye contact is a nonverbal behavior that may help open up a relationship and improve communication between two people. The absence of any direct eye contact during an exchange tends to close communication.

3. One-Way versus Two-Way Communication

Reflecting listening encourages two-way communication. Two-way communication is an interactive form of communication in which there is an exchange of thoughts, feelings, or both and through which shared meaning often occurs. Problem solving and decision making are often examples of two-way communication.

One-way communication occurs when a person sends a massage to another person and no feedback, questions, or interaction follow. Giving instructions or giving directions are examples of one-way communication.


3. Five Keys To Effective Supervisory Communication

Interpersonal communication , especially between managers and employees, is a critical foundation for effective performance in organizations as well as health and well-being.

a. Expressive Speakers

Better supervisors express their thoughts, ideas, and feelings and speak up in meetings. They are comfortable expressing themselves. Supervisors who speak out let the people they work with know where they stand, what they believe, and how they feel.

b. Empathetic listeners

In addition to being expressive speakers, the better supervisors are willing, empathetic listeners. They use reflective listening skills; they are patient with, and responsive to, problems that employees, peers, and others bring to them about their work. They respond to and engage the concerns of other people. Empathetic listeners are able to hear the feelings and emotional dimensions of the massages people send them, as well as the content of the ideas and issues. Better supervisors are approachable and willing to listen to suggestions and complaints.
c. Persuasive Leaders (And Some Exceptions)

Better supervisors are persuasive leaders rather than directive, autocratic ones. All supervisors and managers must exercise power and influences in organizations if they are to ensure performance and achieve results. These better supervisors are distinguished by their use of persuasive communication when influencing others. Specifically, they encourage others to achieve results instead of telling others what to do.

The exceptions to this pattern of communications occur in emergency or high-risk situations, such as life-threatening traumas in medical emergency rooms or in oil rig firefighting. In these cases, the supervisor must be directive and assertives.

d. Sensitive to Feeling

Better supervisors are also sensitive to the feelings, self-image, and psychological defenses of their employees. Although the supervisor is capable of giving criticism and negative feedback to employees, he or she does it confidentially and constructively. Care is taken to avoid giving critical feedback or reprimanding employees in public. Those settings are reserved for the praise of employees accomplishments, honors, and achievements. In this manner, the better supervisors are sensitive to the self-esteem others.

e. Informative Managers

Finally, better supervisors keep those who work for them well informed and are skilled at appropriately and selectively disseminating information. This role involves receiving large volumes of information, through a wide range of written and verbal communication media, and the filtering through the information before distributing it appropriately.

4. Lines of Communication

Communication is described as a two-way process, yet in an organization, it is four-dimensional.
UPWARD
To Superior


HORIZONTAL OUTWARD
To Peer Members NURSES To Patient, Family, and Community
Of Health Team To Workers Family, and Friend's


DOWNWARD
To Subordinate

a. Downward Communication

The traditional line of communication is from superior to subordinate which may pass through various levels of management. Communication aims to impart what the personnel need to know, what they are to do and why they are to do these.

Downward communication includes policies, rules and regulations, memoranda, handbooks, interviews, job descriptions, and performance appraisal.

b. Upward Communication

Upward communication emanates from subordinates and goes upward. This is usually in the form of feedback to show the extent to which downward communication has been received, accepted, and implemented.

Upward communication does not flow as easily as downward communication. Subordinates may not have the ability to express their thoughts or may be too shy to express them. Supervisor and head nurse have a big role to play in ensuring the effectiveness of communication. Through tactful questioning or observation any misinterpretation can be detected to avoid difficulty in implementation.

c. Horizontal Communication

Horizontal communication or lateral communication flow between peers, personnel or departments on the same level. It is used most frequently in the form of endorsements, between shifts, nursing rounds, journal meetings and conferences, or referrals between departments or services.

Coordination of duties and cooperation among the various departments will be maximized if communication is open to ensure smooth work flow.

d. Outward Communication

Outward communication deals with information that flows from the caregivers to the patients, their families, relatives, visitors and the community.

The image of the organization to the public depends on the employee's understanding of its philosophy, vision, mission and objectives, and how these are communicated to the public. Clear explanation of policies, rules and regulations promote good public relations.

Outward communication also involves how employees value their work. This may be directly or indirectly communicated to their families. If they think highly of their jobs, their families become very supportive. It is common to hear, " My mom works in that hospital. That is our hospital."

Job satisfaction is related to open communication lines, positive communication between employees and their immediate supervisors, and personal feedback on job performance.

All personnel should have access to information when they need it most such as availability of supervisors, procedure manual, job descriptions, and work schedules. Such open access will enable them to do their jobs in the most effective and efficient manner. Communication should be clear and understandable.


BARRIERS TO COMMUNICATION

Barriers to communication are factors that block or significantly distort successful communication.

1. Physical Separation

The physical separation of people in the work environment poses a barrier to communication. Telephone and technology, such as electronic mail, often help bridge the physical gap. Although telephones and technology can be helpful, they are not as information rich as face-to-face communication.

Periodic face-to-face interaction help overcome physical separation problems, because the communication is much richer, largely because of nonverbal cues. The richer the communication, the less the potential for confusion or misunderstandings. Another way to overcome the barrier of physical separation is through regularly scheduled meetings for people who are organizationally interrelated.

2. Status Differences

Status differences related to power and the organizational hierarchy pose another barrier to communication among people at work, especially within manager-employee pairs. Because the employee is dependent on the manager as the primary link to the organization, the employee is more likely to distort upward communication than either horizontal or downward communication.

Make the supervisor more approachable and help reduce the risk of problems related to status differences. In addition, when employees feel secure, they are more likely to be straightforward in upward communication.

3. Gender Differences

Men and women have different conversational styles, which may pose a communication barrier between those of opposite sexes. For example, women prefer to converse face to face, whereas men are comfortable sitting side by side and concentrating on some focal point in front of them.
An important first step to overcoming the gender barrier to communication is developing an awareness of gender specific differences in conversational style. The differences can enrich organizational communication and empower professional relationships. A second step is to seek clarification of the person's meaning rather than freely interpreting meaning from one's own frame of reference.

4. Cultural Diversity

Cultural values and patterns of behavior can be vary confusing barriers to communication. Important international differences in work-related values exist between people in the United States, Germany and other nations. These value differences have implications for motivation, leadership, and teamwork in work organization. Habitual patterns of interaction within a culture often substitute for communication. Outsiders working in a culture foreign to them often find these habitual patterns confusing and a times bizarre. For example, the German culture places greater value on authority and hierarchical differences.

A first step to overcoming cultural diversity as a communication barrier is increasing awareness and sensitivity. In addition, companies can provide seminars for expatriate managers as part of their training for overseas assignments. A second step is developing or acquiring a guide, map, or beacon for understanding and interacting with members of other cultures.

5. Language

Language is a central element in communication. It may pose a barrier if its use obscures meaning and distorts intent. Although English is the international language of aviation.

Use simple, direct , declarative language. Speak in brief sentences and use terms or words you have heard from audience. As much as possible, speak in the language of the listener. Do not use jargon or technical language except with those who clearly understand it.


NONVERBAL COMMUNICATION

All elements of communication that do not involve words.

1. Proxemics

The study of an individual's perception and use of space, including territorial space, is called proxemics. Territorial space refers to bands of space extending outward from the body. These bands constitute comfort zones. In each comfort zone, different cultures prefer different types of interaction with others.
The first zone, intimate space, extends outward from the body to about 11/2 feet. In this zone, we interact with spouses, significant others, family members, and others with whom we have an intimate relationship. The next zone, the personal distance zone, extends from 11/2 feet outward to 4 feet. Friends typically interact within this distance. The third zone, the social distance zone, spans the distance from 4 feet to 12 feet. We prefer that business associates and acquaintances interact with us in this zone. The final zone is the public distance zone, extending 12 feet from the body outward. Most of us prefer that strangers stay at least 12 feet from us, and we become uncomfortable when they move closer.

2. Kinesics

Kinesics is the study of body movements, including posture. For example: nervousness may be exhibited through drumming fingers, pacing, or jingling coins in the pocket.

3. Facial and Eye Behavior

The face is a rich source of nonverbal communication. Facial expression and eye behavior are used to add cues for the receiver. The face often gives unintended clues to emotions the sender is trying to hide.

4. Paralanguage

Paralanguage consists of variations in speech, such as pitch, loudness, tempo, tone, duration, laughing and crying.

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