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This nursing critique paper examines the work of Hildegard Peplau a

ntroduction

This paper is an analysis and critique of a published nursing philosophy and theory by the nurse theorist Madeleine Leininger, called Culture Care theory. The analysis is based on Leininger’s publications about her theory starting in the mid-1950’s with her major contribution stemming from her second book, Transcultural Nursing: Concepts, Theories, Research, and Practice in 1978. The model used to analyze the Culture Care theory is the Chinn and Kramer model. This model was developed by Peggy Chinn and Maenoa Kramer in 1983. The model utilizes a two-step process to evaluate theories called theory description and critical reflection. Theory description consists of purpose, concepts, definitions, relationships, structure, and assumptions. Critical reflection analyzes the purpose of the theory utilizing a series of questions. (McEwen & Willis, 2010, p. 95) This model will be used to critique one of the oldest theories in nursing.

Purpose

Transcultural Nursing Theory highlights and is a guide for nurses. The theory highlights those culturally based care factors which may have a direct influence on each individual’s health, well-being, illness, or approach to death. The purpose and goal of the transcultural nursing theory is to provide culturally congruent, safe, and meaningful care to clients of diverse or similar cultures. (Leininger, 2002, p. 190) Leininger has established a theory that studies cultures to understand their differences and similarities. Cultural competence is important within the nursing profession due to differences in each individual’s perception of illness and wellness. The Culture Care Theory establishes an alliance between culture and health care. The alliance is crucial in the establishment of higher level of health awareness and increased well-being for each individual or community. An individual’s health beliefs and practices are directly linked to his/her culture. In determining interventions and appropriate care for an individual or community, the Cultural Care theory, targets cultural beliefs and practices. The theory continues with the belief that nurses need to consider that not all cultures are similar, and there are variations within each culture. The theory consistently focuses on how the individual or community should be treated differently and separately, and personal uniqueness should always be considered. This belief stems from Leininger’s personal belief in “God’s creative and caring ways.” (Leininger, 2002, p. 190)

Concepts & Definitions

Transcultural theory uses the concepts of culture, race, and ethnicity to understand human behavior. When providing culturally competent care nurses should understand the meaning of these terms. Leininger also focuses on a few other concepts such as cultural competence, cultural awareness, and acculturation. Leininger’s theory focuses on numerous concepts, but these were selected based on the importance of nurses integrating the most basic concepts of transcultural nursing into their well-established knowledge base. “Culture influences all spheres of human life. It defines health, illness, and the search for relief from disease or distress. With increased mobilization of people across geographical and national borders, multicultural trends are emerging in many countries.” (Ayonrinde, 2003, p. 233) Culture is defined as a set of beliefs, values, and assumptions about life that are widely held among a group of people and that are transmitted across generations. (Leininger & McFarland, 2002, p. 47) Burchum (2002) defines culture as a learned world view…”shared by a population or group and transmitted socially that influences values, beliefs, customs, and behaviors, and is reflected in the language, dress, food, materials, and social institutions of a group” (Burchum, 2002, p. 7)

All cultures are not alike, and all individuals within a culture are not alike. The culture care theory focuses on each person as a separate entity and unique individual regardless of race or ethnicity. Individuals may be of the same race, but of different cultures. Race is defined as a social classification that relies on physical markers such as skin color to identify group membership. (Leininger & McFarland, 2002, p. 75) Many nurses overlook cultural differences of individuals due to their similar racial characteristics. Race is considered one of the identifying characteristics of a culture. This identifying characteristic represents and falls under the umbrella of the term ethnicity. Ethnicity is defined as a cultural membership that is based on individuals sharing similar cultural patterns that, over time, create a common history that is resistant to change. (Leininger & McFarland, 2002, p. 75)

Cultural competence is an important factor in nursing. Culturally competent care is provided not only to individuals of varying racial or ethnic minority groups, but also to groups that vary by age, religion, socioeconomic status or sexual orientation. Cultural competence is defined as a combination of culturally congruent behaviors, practice attitudes, and policies that allow nurses to work effectively in cross cultural situations. (Leininger & McFarland, 2002, p. 78) Religious and cultural knowledge is important in the healthcare profession. It is also important that nurses identify their own belief systems, and assess how these personal beliefs will affect their patient care. Self-evaluation is imperative in providing non-judgmental and non-biased patient care. The awareness of your own beliefs is called, cultural awareness, and is defined as self-awareness of one’s own cultural background, biases, and differences. (Burchum, 2002) Not only must nurses be aware of their own beliefs, but also must be willing to learn and understand an individual’s beliefs. The process of learning a new culture is acculturation. Adapting to a new culture requires changes in each nurse’s practices.

Relationships & Structure

The relationship and structure between the concepts in the culture care theory is presented in Leininger’s sunrise model. (Figure 1) This model is viewed as a rising sun and should be utilized as an available tool for nurses when conducting cultural assessments. This model interconnects Leininger’s concepts and forms a structure that is usable in practice. The model provides a systematic way to identify the beliefs, values, meanings, and behaviors of people. The dimensions of the model include technological, religious, philosophic, kinship, social, values and lifeway, political, legal, economic, and educational factors. These factors influence the environment and language, which affects the overall health of the individual. Individuals who may not feel understood may refuse or delay care or may withhold vital information. The factors within the sunrise model, environment and language, affects the overall health system. The overall health system is comprised of the folk and professional health system. The folk health system consists of the traditional beliefs, while the professional health system consists of our learned knowledge such as organized school and evidenced-based practice. The combination of these systems creates the nursing profession which allows us to meet the cultural, spiritual, and physical needs of each individual. These factors help nurses understand the client and recognize what is unique about the client. This model helps each nurse avoid stereotyping an individual into a culture based on the minimal factors of race or ethnicity. (Leininger, 2002, p. 191)

The last dimension of the model help nurses establish culturally congruent care through the utilization of three concepts: culture care preservation/maintenance, culture care accommodation/negotiation, or culture care repatterning/restructuring. Cultural preservation means that the nurse supports and facilitates cultural interventions. (Burchum, 2002) Cultural interventions may include the use of acupuncture or acupressure for relief before utilizing standard practices/interventions. Cultural accommodation requires the nurse to support and facilitate cultural practices, such as the burial of placentas, as long as these practices are found not to be harmful to individuals or the surrounding community. (Burchum, 2002) Cultural repatterning requires the nurse to work one-on-one with an individual or community in an effort to restructure, change, or modify their cultural practice. (Burchum, 2002) Cultural repatterning is instructed to only be used when the practice is found to be harmful to an individual or community. All of these factors and concepts guide the nurse towards their ultimate goal of providing culturally competent care. These factors and goals allow the nurse to fulfill the individual’s need of having holistic and comprehensive culturally based care.

Assumptions

There are a number of theoretical premises for the cultural care theory. Leininger (2002) highlighted five important assumptions. The first is “Care is the essence of nursing and a distinct, dominant, central, and unifying focus.” (Leininger, 2002, p. 192) Nurses provide care with sensitivity and compassion. Cultural care theory requires nurses to provide that same care, but based on the cultural uniqueness of each individual. Secondly, “Culturally based care (caring) is essential for well-being health, growth, survival, and in facing handicaps or death.” (Leininger, 2002, p. 192) Non-culturally competent care has been linked to increased health care cost and decreased compliance by individuals. Individuals tend to be non-compliant if their culture needs are not met or have been dismissed. The third assumption is “Culturally based care is the most comprehensive, holistic, and particularistic means to know, explain, interpret, and predict beneficial congruent care practices.” (Leininger, 2002, p. 192) Culturally competent nursing care is designed for a specific client, reflects the individual’s beliefs and values, and is provided with sensitivity. The fourth is “Culturally based caring is essential to curing and healing, as there can be no curing without caring, although caring can occur without curing.” (Leininger, 2002, p. 192) Therefore, there is an increased need to recognize the impact of culture on health care and to learn about the culture of the individuals to whom your provide care. The last assumption is “Culture care concepts, meanings, expressions, patterns, processes, and structural forms vary transculturally, with diversities (differences) and some universalities (commonalities).” (Leininger, 2002, p. 192) Nurses should be aware of cultural beliefs, cultural behaviors, and cultural differences and should avoid the temptation of premature generalizations. Following these assumptions of the cultural care theory nurses will be less judgmental and more accepting of cultures. This form of practice will promote holistic care for all cultures.

Critical Reflection

Culture Care Theory has played a significant role in nursing practice. The theory highlights numerous concepts, in which, Leininger clearly defines and consistently utilizes in numerous publishing’s. The concepts in Leininger’s theory are the gold standard for transcultural nursing. Leiningers concepts are referred to in the majority of literature referring to transcultural nursing. The theory is complex with a number of concepts and interrelationships which form the rising sun model (mentioned above). The complexity is important as it develops a meaningful and comprehensive view of cultural and holistic based care. Leininger’s theory has a high level of generality due to its ability to be applied broadly and to all cultures, ethnicities, and races. The key to Leininger’s theory is communication. The theory crosses languages and minimizes language barriers by providing a road map of how to eliminate language barriers, through the use of interpreters. The theory consistently approaches culturally based care by requiring the nurse to use cultural knowledge as well as specific skills when deciding nursing interventions and practices. It continues to be consistent in requiring the same approach for all nurses when providing cultural based care. A cultural assessment is the consistent method noted in the Culture Care theory. It is described as a tool to be used by nurses when attempting to provide culturally competent care. The cultural assessment provides an understanding of an individual’s health perception, which guides culturally appropriate interventions.

Conclusion

Culture care theory is widely accessible as it is the major and most significant contributor to transcultural nursing. (Ayonrinde, 2003) Cultural care theory played and will continue to play a significant role in nursing practice, research and education. The goal of Healthy People 2020 is to eliminate health disparities among different populations based upon numerous factors. Nurses are the key in moving forward with eliminating these disparities. Today’s environment is multicultural and the emphasis on providing culturally competent care has increased. The Culture Care theory is well established and “it has been the most significant breakthrough in nursing and the health fields in the 20th century and will be in greater demand in the 21st century.” (Leininger, 2002, p. 190) Nurses are the leaders in providing culturally competent care and the Culture Care theory is the foundation. By the year 2050 it is estimated that minorities will comprise 46 percent of the population. (Betancourt, Green, Carrillo, & Park, 2005, p. 500) Leininger has established a strong foundation and because of her work, nurses will be at the forefront of culturally based care. Nurses are armed and ready, with Leiningers tools and guidance, ready to meet the future demands for culturally competent nursing care.

a nursing theorist and nurse practitioner. Because Peplau’s figure in the nursing profession has had such a revolutionary impact, we will examine her early life then later her career as a nurse as well as how these experiences impacted her work a nursing theorist and the nursing profession. Peplau’s theory will be examined with the following critique: meaning and thought process of theory, origins of the theory, usefulness of the theory in practice, testability of the theory utilizing a scientific model, and an overall thorough and well researched presentation and evaluation of the theory. Furthermore, utilizing the components mentioned above we will examine an area in nursing practice that this theory could be applied and the relationship between this theory and nursing practice.

Keywords: Hildegard Peplau, nursing theory, interpersonal process theory, nurse-client relationship

Peplau’s Interpersonal Theory

On March 17th, 1999, Hildegard Peplau died at the age of 89, ending a nursing career that spanned over 50 years of excellence. Peplau is often recognized as the “mother of psychiatric nursing” but her work and ideas have influenced the nursing profession profoundly. Known to many as the “nurse of the century,” Peplau was a nursing theorist and one of the world’s leading nurses, dynamically changing nursing practice from a career to a profession, inspiring all nurses to attain greater education develop and cultivate their profession, and developing nursing theories that revolutionized nursing practice.

In 1948, Peplau completed her exemplary work, “Interpersonal Relations in Nursing.” However, it was not published until 1952 because at the time the work was “too revolutionary for a nurse to publish a book without a physician as co-author,” (Lakeman). During her time, nursing schools are controlled by hospitals while nursing practice was controlled by medicine (Chinn, & Kramer, 2004). Peplau began her theory development in “response to the need in the late 1940’s to develop advance psychiatric nursing for graduate programs in psychiatric nursing, (Forchuk, 1993). At that time, the available nursing literature in psychiatric nursing was not adequate for graduate level, university-based psychiatric nursing education programs (Forchuk, 1993). She stated that her original intent was not theory development but “to convey to the nursing profession ideas she thought were important to improve practice,” (Forchuk, 1993). Peplau’s theory work was grounded in the interpersonal theory and the clinical experiences of herself and students. Peplau stated “concepts emerged from practice-my own and supervisory review of graduate student nurses beginning in 1948-from actual nurse-patient-relationship date (McQuiston, & Webb, 1995). Peplau was strongly influenced by the interpersonal development model of Harry Stack Sullivan and incorporated his theory of personality development and the self system in her work. She was also influenced by George Hubert Mead’s early work of symbolic interactionists, Rollo May’s work on anxiety, and Miller and Dollard’s understanding of learning (McQuiston, & Webb, 1995).

Peplau’s Interpersonal theory focuses on the interpersonal processes and therapeutic relationship between the nurse and the client (McQuiston, & Webb, 1995). Peplaus’s theory operates on two major assumptions which states, “the kind of nurse each person becomes makes a substantial difference in what each client will learn as she or he is nursed throughout her or his experience with illness” (Peplau, 1952) and “fostering personality development in the direction of maturity is a function of nursing and nursing education; it requires the use of principles and methods that permit and guide the process of grappling with everyday interpersonal problems or difficulties,” (Peplau, 1952). The main concepts of nursing include nursing, person, environment, and health. Peplau defined each of these concepts: nursing as “a educative instrument, a maturing force, that aims to promote forward movement of the personality in the direction of creativity, constructive, productive, personal and community living”; person as “a human being that lives in a unstable environment with physiological, psychological and social fluidity”; health as “a word symbol that implies forward movement of personality and other on-going human processes in the direction of creative, constructive, personal, and community living”; environment as a physiological, psychological and social fluidity that may be illness-maintaining or health promoting; and interpersonal relationships as “any processes occurring between two or more person,” (McQuiston, & Webb, 1995). Peplau’s major concepts overlap into the development of sub-concepts. The sub concepts of major concepts are patient or client-person and nurse-person. Patient or client-person “refers to sick and well individuals, groups, families, and communities for whom nurses provide direct nursing services” while nurse person refers to “the unique blend of ideals, values, integrity, and commitment to the well-being of others,” (McQuiston, & Webb, 1995) For the purpose of this paper, I am only going to elaborate on the major concept of interpersonal relationship and its sub-concepts.

Through interpersonal relationship, nurses assist patients to achieve healthy levels of anxiety interpersonally and facilitate healthy pattern integrations interpersonally while fostering the patient’s well-being, health, and development. Peplau’s interpersonal relationship originally includes four phases: orientation, working, and resolution. However, in 1997, Peplau merged the phases to three main phases. These phases are orientation, and resolution (George, 1995). Each of these phases are seen as being interlocking and requiring overlapping roles and functions as the nurse and the client learn to work together to resolve difficulties in relation to health problems (McQuiston, & Webb, 1995). Throughout these phases, the nurse functions with the patient in the nursing roles of counseling role (working with the patient on current problems); leadership role (working with the patient democratically), surrogate role (figuratively standing in for a person in the patient’s life); stranger (accepting the patient objectively); resource person (interpreting the medical plan to the patient); and teaching role (offering information and helping the patient learn) (Wilkenson).

During the orientation phase of the relationship, the client and nurse come together as strangers meeting for the first time and get to know each other as well as identifying the main problem. In this phase, the task is “to build trust, rapport, establish a therapeutic environment, assess the patient’s strengths and weakness and establish a mode of communication acceptable to both patient and nurse” (Lakeman). Once the patient identifies the problems, they move on to the working phase.

Working phase has two sub-phases: identification and exploitation. In the identification phase, the nurse and patient interaction focuses solely to “develop clarity about 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,” (Lakeman). After the nurse and patient adhere to a care plan, they can move on to exploitation phase. During the phase of exploitation, the plan of action is implemented and evaluated. The client takes full advantage of all available services that is available to promote optimal health and well-being. An important aspect of this phase is to have client become more independent by taking control of the situation by using services that are made available to him/her. Within this phase, clients begin to develop responsibility and become more independent. Peplau stated that “exploiting what a situation offers gives rise to new differentiation’s of the problem and to the development and improvement of skill in interpersonal relations” (Peplau, 1952). Once the problem is solve, the relationship moves to the resolution stage. Peplau states “the stage of resolution implies the gradual freeing from identification with helping persons and the generation and strengthening of ability to stand more or less alone” (Peplau, 1952). Resolution includes “planning for alternative sources of support, problem prevention, and the patient’s integration of illness experience,” (Lakeman).

Peplau’s theory is historically significant for practice as it propelled psychiatric nursing from custodial based care to interpersonal relationship theory based care. Her theoretical ideas continue to be significant in nursing as it is relevant not only in psychiatric mental health nursing but also in domains where interpersonal or intrapersonal difficulties are taking place (McQuiston, & Webb, 1995). In fact, two recent Canadian surveys found that in tertiary care psychiatric hospital, two thirds of the nursing staff used Peplau’s theory as a basis for their practice while American survey of mental health nurses in private practice found that approximately half were guided by Peplau’s theory (McQuiston, & Webb, 1995). In addition, Peplau’s theory does direct nursing actions that lead to favorable outcomes. Her interpersonal process directly improves communication, interviewing skills, and assessment of all health care practitioners. The most significant aspect of her theory is “the focus on the patient and adjusting nursing interventions based on the patient’s needs,” (George, 1995). A good application of this theory is to a 55 year old male with a history of cocaine-abuse who presents to the hospital with chest pains. During the orientation phase, nurse and client through therapeutic and effective communication identifies the problem of the patient, which is chest pain. In the identification phase, the nurse acts as a counselor and advocate and educate patient on substance abuse. In the exploitation phase, the nurse acts as a teacher, counselor, resource person and mediator by utilizing available service and implementing plan. The resolution phase is when patient expresses relief of chest pain and patient has plan for health maintenance.

Peplau’s model is categorized as a middle-range theory. Its scope is narrower than conceptual model or grand theory and clearly addresses defined number of measurable concepts (Smith, & Liehr, 2008). The theory also has “specific focus on the characteristics and process of the therapeutic relationship as a nursing method to help manage anxiety and foster healthy development.” (Smith, & Liehr, 2008). Thus, the theory can be directly applicable to research and practice. Peplau’s theory has generated testable hypotheses by using various methods including descriptive, content analysis, experimental, and instrument development studies (George, 1995). Some research that was generated by Peplau’s theory are: Burd (1963) developed and tested a nursing intervention framework for working with anxious patients using Peplau’s work on anxiety and Forchuk and Brown (1989) created an instrument to assess the Peplau’s nurse-client relationships (George, 1995).

Peplau’s theory provides a logical systematic view of nursing situations. The four progressive phases in the nurse-patient relationship are clear and logical. Key concepts are clearly defined, consistent and clearly understood. The phases provide simplicity regarding the natural progressing of the nurse patient relationship. The theory has multi-use and can be applied to any nurse-patient relationship except comatose, senile, and infant patients and is easily accessible to practitioners to guide and improve their practice.

Peplau’s Interpersonal Relations was designed to describe the client’s experience within a hospital setting (George, 1995). The model provided a new way of examining the relationship between the nurse and the client. The strength of the model is its focus on the nurse-client relationship. The focus on this relationship to the exclusion of all other relationships allows for the nurse and the client to work together as partners in problem solving (Forchuk, 1993). The model supports and encourages empowerment of the patient by assisting and supporting the client to become accountable for their well being. In addition, the focus on the partnership of the nurse and the client and the emphasis on meeting the identified needs of the client, make the model ideal for short-term crisis intervention (George, 1995). The model also focuses on health promotion and wellness, not just the treatment of the ill. Most importantly, Peplau stresses that both patient and nurse can mature from the therapeutic interaction as they both meet in a creative relationship where there is a continuing sense of mutuality and togetherness. However, the model exhibits several weaknesses. Since the focus of the model is on the nurse-client relationship, the client would be required to develop this relationship with every nurse he/she comes in contact with, which would be numerous. This could make a client’s stay in a facility care very stressful as each nurse would come with their own unique personality, views and perspectives. It would require a high degree of adaptation on the part of the client (Young, 1998). Furthermore, the model is only adaptable to nursing settings where there can be communication between nurse and patient (McQuiston, & Webb, 1995). This does not include comatose, senile, or newborn patient where the nurse-patient relationship is usually one sided. In these cases, the nurse and patient cannot work together to become more knowledgeable, develop goals, and mature. The strength of the model, the relationship between the nurse and the client is also a weakness of the model.

I would definitely use Peplau’s Interpersonal Theory in my advanced practice setting. As I mentioned earlier, Peplau’s theory is clear, easily understandable and very accessible. It would promote and improve communication with patients, resulting in patient’s adherence to prescribed treatment with less anxiety and higher satisfaction regarding their nursing care. Most importantly, this would decrease readmissions to the hospital as patient will have increase comprehension of their disease process and treatment, empowerment of both staff and patient and improved health outcomes.