Hildegard Peplau first published her theory on psychodynamic nursing in 1952, which focuses on the therapeutic relationship that develops over time between client and nurse. Peplau saw the nurse's first goal as understanding her own behavior in an interpersonal process that often views "nursing care" as any activity that may affect the patient’s well-being. While these highly conceptual ideas saw resistance early on, their successful application with psychiatric patients gradually earned them legitimacy over time, particularly in the world of mental health nursing.

Major Concepts

Peplau defined patient care as "a human relationship between an individual who is sick... and a nurse specially educated to recognize and to respond to the need for help." The nurse's primary aim, says Peplau, should be to help the sick individual identify their perceived difficulties, and then employ human relations principles to resolve them. The healing process happens through a series of four phases, and is predicated on the notion that nurse and patient share a common goal that will make both parties more knowledgeable and mature in the end. This naturally requires meaningful interaction between patient and nurse, and therefore has proved ineffective on unconscious, incoherent or heavily withdrawn patients.

Six Distinct Roles

Peplau believed that a nurse must simultaneously serve six major and distinct roles. The first is that of a stranger, offering acceptance and trust as he would to anyone he just met. Second is a teacher who can impart knowledge, while the third is a resource person who can provide specific answers to questions. The fourth role is a surrogate -- someone who can stand in for a key figure in the patient's life, like a sibling or parent. Fifth is a counselor who can advance ideas leading to health and wellness, while sixth is a leader who can provide direction in the healing process. Peplau also saw her assuming ancillary roles, such as a safety agent, mediator, administrator, researcher, observer and technical expert.

Four Phases of the Nurse-Patient Relationship

Peplau identified four sequential phases that are elemental to a therapeutic nurse-patient relationship. The first is orientation, where the client meets the nurse as a stranger and seeks assistance. The nurse responds by answering questions and providing information about the treatment process. The second is identification, where the nurse begins providing professional assistance to the client. During this phase, the client opens up and in turn starts feeling stronger; the perception of helplessness fades. The third phase is exploitation, where the patient makes full use of the nurse's many roles and becomes integral in his own recovery. The last phase is resolution, when the patient is no longer dependent on the nurse; at this point, both parties terminate the relationship.

Four Levels of Anxiety

Peplau identified several levels of anxiety in persons who might seek a therapeutic relationship with a nurse. Mild anxiety creates a state of heightened senses and an acute awareness that is helpful in resolving issues and learning more positive behavior. Moderate anxiety decreases the patient's perceptual field so that problem-solving and behavior modification become possible only with outside assistance. Severe anxiety involves feelings of extreme fear or dread that eliminates the patient's ability to focus on any task. This type of anxiety may also manifest itself physically through excessive perspiration, chest pains and a faster heartbeat. Panic anxiety is completely debilitating and may involve hallucinations, delusions, physical immobility and irrational thought.