The nurse patient relationship is a key concept in peplaus theory. If switching from a theoretical to practical application is to be effective, the clinicians must establish outcome measures that incorporate the unique needs of the patient(Marchese, 2006). The outcome measures guide the practitioners in the assessment of the patient individual needs, and determine the care required. Peplau stresses that successful intervention only occur, if the patient is valued and accepted by the nurse. Acceptance is attained by seeking active patient participation in the development of the goals for the intervention.
Peplau (1992) theory of interpersonal relations provides a conceptual framework by which the nurse can assess, plan, and intervene for optimal outcomes for the patient. The foundation of her theory explores the primacy of the nurse patient relationship (Forchuck, 1991; Peplau, 1997).
According to peplau (1992), the nurse is a complex individual, who is the sum of all past experiences, rigorous nursing training, and unique personality traits. Also, the patient is a complex individual, has unique personality and knowledgeable within his or her own frame of reference (Peplau, 1992). The nurse patient relationship is initiated with a change in a health status of the patient, and the availability of a nurse with the ability to provide specific skills (Peplau, 1992).
The nurse patient relationship evolves through the phases of orientation, identification, exploitation, and resolution. The nurse must adapt to several roles so that the needs of the patient are met within each different phase (Forchuck, 1991; Peplau, 1997). Nursing roles include stranger, teacher, leader, surrogate, counselor, and resource person (Peplau, 1997).
Patient diagnosed with bladder cancer may require urinary diversion to maximize their health care outcomes. These patients, faced with sudden change in their health status, develop complex unmet need that can be addressed by planned program of education. Peplau's theory of interpersonal relations offers a framework for patient teaching that emphasizes the importance of the nurse-patient relationship. This therapeutic relationship enable the nurse to provide the patient with the information needed to understand the diagnosis, cooperating in treatment plan, facilitate postoperative recovery, and return to a state of independence with quality of life.
A 60-years old male is diagnosed with muscle-invasive bladder cancer. He has seen by his urologist after two episodes of hematuria. Patient had no recently body weight, shortness of breathing. He undergoes cystoscopy and bladder biopsy that revealed muscle-invasive bladder cancer. Past history including tobacco use of 30 cigarette per day for 30 years. Before one year ago patient stop smoking post severe upper respiratory tract infection. No other health problem when obtained history from patient. All blood test were within normal and chest x-ray, abdomen pelvic CT scan also normal related to age. The consulting urologist discussed option for continent diversion, and explanation that his chances for long term, disease free recovery were excellent. The patient referring to the registered nurse for additional teaching. The first meeting with the nurse, the patient was very agitated and anxious, announcing he didn't have time for this teaching session and could not plan any surgery at this time due to the concern of his business. His immediate concern centered on his ability pay his pills, support his family, and maintain his business. Compounding theses concerns were fear, anxiety, grief, and knowledge deficit regarding the cancer diagnosis and the need to undergo surgery to remove his bladder. His wife was present and equally anxious and tearful. When the patient concerns were validated and discussed, potential community resources to help them through this difficult time were identified. These included hiring associates who could work as subcontractors, identifying his wife as temporary bookkeeper, and involving the social worker to mobilize the other available community resources. The initial teaching session was concluded with minimal information being given to the patient about the surgery, but the steps taken to help him plan for his surgery contributed to a significant change in his behavior and willingness to consider future option. Flexibility in addressing the patient's primary concern rather than implementing the planned teaching session fostered the therapeutic nurse-patient relationship. Until next meeting to the patient, the nurse gives him written material to review. At the second session, readiness to learn was assessed. The first, the patient was asked to explain what he understood about the proposed surgery. Also, he was asked if he read the materials given to him at last interview. The patient was given the opportunity to ask questions. Body language, eye contact, and focused attention span all indicated the patient was expressing his willingness to learn. Based on patient description of the surgery, information about anatomical changes, pre and post operative care, and expected recovery time were discussed. Visual aids used to enhance the teaching session. After deciding the operation date and time, the patient seen by same nurse to review the education material and re-affirm his choice of surgical intervention. Then the patient was marked for a new stoma site in order the neobladder was unable to be performed. After doing the surgery the patient and his wife were taught to irrigate the neobladder, using normal saline (NS) 0.9 in 30 CC increments to remove mucus and blood clots. They were taught how to clean the irrigation equipment and where to purchase additional supplies as necessary. The teaching strategies stressed the importance of maintain the patency of the drainage tube. These lessons involve verbal, written, and hand on demonstration and return demonstration. Short term goals included maintained of integrity of urinary diversion, return to normal activity, improve nutritional status and focusing on psychosocial aspect of recovery. After eight days from operation, patient was discharged, he demonstrates care of the urinary drainage tube and incision. He also has given supplies for home use. Also, the patient verbalized the importance of adequate protein in his diet and the need for six small meals daily. His family members were recruited to assist him in daily walks, and provide needed social contact.
Phases of the interpersonal process in peplau's theory.
Phases of interpersonal
Teaching activities for the patient undergoing urinary diversion
Patient recognition of need for help.
Resources provided on limited basis as acceptable by patient. Initiation of nurse-patient relationship.
1- Assessment of prior knowledge and experience.
2- Assessment of readiness to learn.
3- Presentation of education materials.
4- Involvement of patient in developing mutual teaching goals.
5- Discussion of pre-operative procedures.
6- Different option for diversions; patient pathways.
Patient identifies problems to be worked on.
The patient has some working knowledge of the health care needs.
Trust level with nurse is in early stages and the patient will selectively begin to assimilate knowledge and accept interaction with nurse.
Imitative behavior begins and gradually switches to a creative constructive response.
1- Demonstration / return demonstration of neo bladder care, bladder irrigation, maintaining tube patency, care and cleaning of equipment, knowledge of emergency situation.
2- discussion on nutrition
A- Reassessment of prior eating habits; reduce empty calories. B- Six small meals daily with attention to five food groups. C- fluid requirement 2 quarts daily.
3- development of activity plan
a- rationales for exercise
b- Intensity and duration.
Comfort and trust level established.
Patient takes advantage of service offered by nurse and benefits from relationship with nurse.
Some vacillation between dependence on nurse and self-direction.
Focus on incorporating learned experiences into future health status and quality of life (QOL).
1- Reaffirm patient's knowledge and experience.
2- Promote independence.
3- Identify available community resources.
4- Role playing.
5- Present theoretical complex situations and have patient problem solve.
Prior goals have been met and new goals are formed.
Patient experiences a sense of security because needs have been met in a timely manner.
Increase in self-reliance and decrease reliance and identification with urologic nurse.
1- Encourage participation in support group for continent diversions.
2- Identify QOL issues and discuss options.
a- nocturnal incontinence.
b- Sexual changes.
c- Alteration in body image.
d- Anxiety about cancer diagnosis.
In conclusion, a highly skilled nurse with good observation and communication skills plays a critical role in promoting the health of patients undergoing urinary diversion. The scope of patient need required a nurse competent to assume the changing role in the four phases of the interpersonal process described by peplau (1992; 1997). Peplau's theory emphasize that effective communication is integral to the nurse-patient relationship and necessary for education efforts to be successful. To that end, it is important to involve the patient in establishing the teaching goals and evaluate the efficacy of teaching methods used. Applying this theory to practice help the nurse to evaluate and develop skills and teaching methods to meet the needs of each patient.