From Therapeutic Relationships to Transitional Care

A Theoretical and Practical Roadmap

Cheryl Forchuk, Cheryl Forchuk

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000344417
• Edition: 1
• Topic: Médecine
• Subtopic: Soins infirmiers

This text provides a foundational understanding of therapeutic relationships and the transitional discharge model (TDM), a person-centered, evidence-based model that supports a smooth transition from hospital to community for people with mental illness

Starting with background into the ground-breaking work of Dr. Hildegard Peplau, the mother of modern psychiatric nursing, and moving towards a transdisciplinary transitional discharge perspective, chapters introduce students and practitioners to theoretical, historical, and current perspectives on therapeutic relationships as they relate to transitional care. These perspectives foreground empirical research and practical applications that can be implemented in hospital and community settings. The Appendix features an essential "TDM toolkit" with forms, learning topics, and checklists developed by programs that implement TDM.

Essential reading for those studying psychiatric nursing, this book combines theory, research, and best practices into a "roadmap" for students across nursing and psychiatric disciplines to coordinate these systems without having to implement radical changes to practice.

Part I

Theoretical Perspectives

The theoretical perspectives are rooted in the ground-breaking research of Dr. Hildegard Peplau, the mother of modern psychiatric nursing. I was introduced to Dr. Peplau’s work as an undergraduate, but it was not until I completed my master’s degree and began my work as a clinical nurse specialist (CNS) that I truly began to understand its significance. I was the sole CNS for a large tertiary care facility that had ten inpatient programs and ten community programs when I started in 1980 at Hamilton Psychiatric Hospital, Ontario, Canada. Given this breadth, I primarily worked on a consultation basis with complex situations where the usual care provided by expert nurses and other staff was simply not working. I was brought in as a fresh set of eyes and ears to meet with the client, care team, and, usually, family to make suggestions and follow up as needed. I would generally have at least two new consultations a week, with follow-up lasting for a month to a year, depending on the situation.

After the first year, I did an analysis of the first 100 consultations and found that close to 80% of consultations were related to the therapeutic relationship (interestingly, about 10% of issues were related to a diversity of sexuality issues, including abuse and identity; the remaining 10% were complex clinical issues, such as an unusual combination of comorbidities or a rare condition). I felt perplexed by the large number of concerns relating to such a basic nursing concept as the therapeutic relationship, especially among highly skilled nurses. This inquiry drew me back to Dr. Peplau’s work.

I re-read the original work by Dr. Peplau and reviewed the series of 20 audiotapes she had produced, as well as a videotaped simulated interview she created. These resources were very helpful in assisting with the issues I was encountering in practice. In early 1983, we invited Dr. Peplau to our hospital for three days. Although she was well into her 70s by that point, she was fully booked until April 1984.

We had a full agenda for Dr. Peplau’s visit, with lots of time for dialogue. At the end of the visit she said that she was very impressed with the caliber of nursing care, said, “write me,” and then gave me her home address. I was eight months pregnant with my second child and shortly after the visit took maternity leave. I honestly was a bit intimidated by the idea of simply writing to the mother of modern psychiatric nursing, so I didn’t write. At Christmas (I was still on maternity leave), I received a call from the hospital that I had a Christmas card from Dr. Peplau and was asked if someone lived nearby to drop it off. The card essentially said, “Merry Christmas – you didn’t write,” and urged me to write back. So, I wrote back and maintained a regular correspondence that lasted until her death in 1990 (I have two very fat binders of all her letters). We were able to meet a few times over those years, as well as have phone calls, and she connected me with many other nursing scholars.

One of the first things she did in her letters was suggest I needed to get a PhD in nursing. I thought I had an iron-clad excuse: I had two children under the age of three, and there was no PhD program in nursing in Canada at that time. She basically said – “Stop making excuses. Kids are easier to manage when younger and you will never get PhD programs in nursing in Canada until enough of you get one outside of the country.” So, after some well-intended badgering, I eventually started my PhD at Wayne State in Detroit in 1987, graduating in 1992.

Chapter 1 in this book gives an overview of Peplau’s theory. You will see the references to personal communication in this book that reflect our conversations about having her theory look more like a theory, which needed to include a picture. The diagram illustrating her theory in that chapter went back and forth many times between us until she was happy that it was an accurate picture. I was very happy when she later told me that she had it translated into Japanese for presentations in Japan about her theory! Some of this material originally was in a small booklet published by Sage as a series on nursing theorists in 1993 [Forchuk, C. (1993). Hildegard E. Peplau: Interpersonal nursing theory. SAGE Publications]. The copyright reverted to me after it went out of print. It has been revised and updated as a chapter in this book.

Chapter 2 in this book is a republication of a paper of the main findings from my PhD thesis, which tested Peplau’s theory [Forchuk, C. (1994). The orientation phase of the nurse-client relationship: Testing Peplau’s theory. Journal of Advanced Nursing, 20(3), 532–537. https://doi.org/10.1111/j.1365-2648.1994.tb02392.x ]. This work flowed from the hypotheses of the theory as described in the first chapter. The idea that both the nurse and client are important partners in the relationship was validated. Central concepts in the theory can predict the development of the therapeutic relationship.

1 Overview of Peplau’s Theory

Cheryl Forchuk

Hildegard Peplau is a nursing pioneer and the mother of modern psychiatric-mental health nursing practice (see Table 1.1). Peplau stated that she began her theory development in response to

the need in the late 1940s to develop “advanced psychiatric nursing” for graduate programs in psychiatric nursing. The available nursing literature in psychiatric nursing at that time was not in any way adequate for graduate level, university-based psychiatric nursing education programs.

(personal correspondence, December 23, 1990)

Table 1.1 Biographical Sketch of a Nurse Theorist: Hildegard E. Peplau

Born	September 1, 1909
Position	Professor Emerita, Rutgers University
Registered Nurse	Pottstown, Pennsylvania Hospital School of Nursing
B.A.	Interpersonal psychology, Bennington College, Vermont
M.A.	Teaching and supervision of psychiatric nursing Teacher’s College, Columbia University
Ed.D.	Teacher’s College, Columbia University, New York, New York
Fellow	American Academy of Nursing
Other	Honorary Doctorates from University of Indianapolis, Rutgers University, Columbia University, Duke University, Boston College and Alfred University; and numerous other honors.
Died	March 17, 1999 in Sherman Oaks, California. She was in her 90th year.

Forchuk, C. (1993). Hildegard E. Peplau: Interpersonal nursing theory. SAGE Publications.

Her original intent was not theory development, but “only to convey to the nursing profession ideas [she] thought were important to improve practice” (personal correspondence, July 1989).

Peplau’s (1952) first book, Interpersonal Relations in Nursing, was published in 1952 and reissued in 1988 and 1991. This book outlined her conceptual framework for psychodynamic nursing. Peplau’s conceptual framework signified the end of a long drought in the development of nursing theory as it was the first published nursing theory development since Nightingale.

Origins of the Theory

Dr. Peplau first studied interpersonal relations theory in the 1930-1940s at Bennington College (personal correspondence, December 23, 1990). This interpersonal focus underpinned her later theory development.

Peplau was strongly influenced by the interpersonal development model of Harry Stack Sullivan (1952) and incorporated his theory of personality development and the self-system in her work. Peplau, like Sullivan, was also influenced by the early work of symbolic interactionists such as George Hubert Mead (1934). Examples of the influence of symbolic interactionism can be seen in the focus on social influences on personal development and with the idea that communication involves the use of symbols. Other influences include Rallo May’s (1950) work on anxiety and the understanding of learning developed by Miller and Dollard (1941).

Peplau’s 1952 work was grounded in 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 data” (personal correspondence, August 1989).

Since 1952, Peplau was a prolific writer. She published a second book in 1964, dictated a series of 20 audiotapes to teach and communicate her theory, and published more than 80 chapters and articles. Her work has endured over the years and is widely used in clinical practice. Sills (1978) reviewed several prominent nursing journals and found that references to Peplau’s work had not only been sustained, but actually increased over the years.

In the late 1980s, two Canadian surveys (Martin & Kirkpatrick, 1987, 1989) found that in a tertiary care psychiatric hospital, approximately two-thirds of the nursing staff used Peplau’s theory as a basis for their practice. Similarly, an American survey (Hirschmann, 1989) of mental health nurses in private practice found that approximately half were guided by Peplau’s theory. With less emphasis on nursing theory in recent years, more recent surveys were not found; however, chapters in current psychiatric-mental health nursing texts sti...