The Nursing Associate's Handbook of Clinical Skills. Группа авторов
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Hildegard Peplau devised a model for therapeutic relationships and interactions. In this model, Peplau focused on psychology and communication and produced a four‐stage model which is illustrated in Figure 5.1.
The first stage of Peplau’s model is the orientation phase. This, in healthcare, is when the practitioner and patient first meet. At this point, the patient has needs, and the healthcare professional is the person to address these needs. This is the stage where the felt need is expressed by the patient. It is here where questions are asked and information is given in order to understand each other and the situation, where boundaries are identified, and at this stage, trust starts to develop.
The second stage is the identification phase. This is where the patient and the healthcare professional work together to formulate goals and to implement the care. This is largely led by the healthcare professional, and in this phase, the healthcare professional may take on many roles including that of a care giver, an emotional supporter and educator amongst others.
The third stage is the exploitation phase; the patient is becoming more independent and more confident. They are starting to look after themselves and can start to look at being discharged from care. They have learnt from the healthcare professional and are no longer as dependent on them.
The final stage is the resolution phase. This is where the relationship ends because the patient is discharged home and is no longer in need of the therapeutic relationship. The interaction ends, and the relationship is terminated.
A direct correlation between Peplau’s model and the nursing process has been identified in literature over time as illustrated in Box 5.1. The major difference between the two is that Peplau’s model is linear, whereas the nursing process is cyclical. The key similarity is the mutual respect required for this relationship to work and the implemented care to be successful.
Figure 5.1 Peplau’s model of interpersonal relations.
Source: Based on Peplau (1952).
Box 5.1 Peplau’s Model Compared with the Nursing Process
| PEPLAU’S MODEL | THE NURSING PROCESS |
| Orientation Information gathering | Assessment Information gathering |
| Felt need expressed Patient identifies their needs. | Nursing diagnosis The nurse and the patient identify the current issues. |
| Identification Care required is identified by the patient and is implemented largely by the healthcare professional with involvement from the patient. | Care planning (implementation) The nurse (with the patient) plans how the care will be administered by the team. |
| Exploitation The patient becomes more independent and requires less input from the healthcare team. | Implementation The negotiated care is performed with the patient. |
| Resolution The patient is discharged, and the therapeutic relationship comes to an end. | Evaluation The nurse and patient assess the care given to determine what changes are required, if any. This may be the end of the relationship, or further needs are identified, and the cycle starts again. |
The Importance of Active Listening
In order to build that therapeutic relationship, the healthcare professional must communicate with the patient and, furthermore, communicate effectively. A key aspect of communication includes listening. Of course, everyone would claim to listen to people, but in a therapeutic relationship, the healthcare professional must listen actively. This is different from listening passively to someone speak; the technique of engaging in active listening requires much effort and skill. Haley et al. (2017) identify that the skill of active listening demonstrates a higher level of empathy than demonstrated through passive listening; active listening can help the healthcare worker to become more empathetic.
Communication is an essential element of healthcare, and Alsawy et al. (2019) found that meaningful conversations can reduce feeling of isolation and depression. They also found that when the patients felt their healthcare professionals were actively listening to them, the communication interaction was more enjoyable and meaningful for them. True active listening requires practice and reflection, and Nemec et al. (2017) state that besides training to learn the skills, a therapeutic interaction requires both physical and mental preparation.
Red Flag
How to Listen Actively
There are two specific elements of communication that a healthcare professional needs to be aware of in order to demonstrate that they are hearing the person they are listening to. They are verbal and non‐verbal communication. Webb & Mille (2011) describe these as attending verbally, vocally and non‐verbally. These will be explained, in turn, starting with non‐verbal communication, also referred to as non‐verbal attending.
Firstly, it is important to physically demonstrate that there is time for this interaction (Sally & Dallas 2010). This can be achieved by closing the door, drawing curtains and providing privacy. It is also important to ensure there are no interruptions during the interaction. Sitting with the patient, as opposed to standing over them, also shows that there is time for this interaction.
Avoiding physical barriers is very important. It is tempting to take notes to ensure nothing is forgotten, but this is an immediate barrier to effective communication (Ali 2018). Therapeutic communication should be a conversation, so taking notes is not appropriate and may make the patient feel uncomfortable. Taking notes can create pauses and breaks, and should this happen, then natural communication is stilted. The use of furniture can also be an issue. If a table is in between the healthcare professional and the patient, then there is a physical barrier which may hinder the interaction, so this should be avoided. How the healthcare professional physically presents themselves is also important, as this is another element of non‐verbal communication.
Take Note
One way to remember how to optimise communication through body posture is the pneumonic SOLER (Egan 2010). Table 5.1 provides an explanation of the mnemonic SOLER.
It is important to note that silence is a very important part of communication, and not everyone will be comfortable with that. Silence allows