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A Comparison of the
Peplau Interpersonal Relations Model
Neuman Health Care Systems Models
Applied to a Clinical Situation
This paper is not for copy, in whole or in part, or for distribution without my express permission. Where permission has been given, please ensure that reference citations to selected passages are given proper recognition.
Conceptual frameworks of nursing models have provided the professional nurse a foundation for the development of individual practice. This paper will examine the Peplau Interpersonal Relations Model and the Neuman Health Care Systems Model. After an overview of the two models, a comparison of the models will be presented. Both models then will be applied to a specific client situation to determine the impact that either model would have on my individual psychiatric nursing practice. In the next section, an overview of Peplau's Interpersonal Relations Model will be presented, followed by Neumans's Health Care Systems Model.
PEPLAU'S INTERPERSONAL RELATIONS MODEL
This section will deal with the delineation of Peplau's interpersonal relations model as it relates to the metaparadigm of the discipline of nursing. These concepts are the view of the person, health, nursing and the environment.
Peplau's model describes the individual as a system comprising the components of the physiological, psychological and social spheres. The model views the individual as being an unstable system where equilibrium is a desirable state, but occurs only through death. This is supported by Peplau's statement that "man is an organism that lives in an unstable equilibrium (i.e., physiological, psychological, and social fluidity) and life is the process of striving in the direction of stable equilibrium, i.e., a fixed pattern that is never reached except in death" (1992, p. 82).
Peplau didn't include an exact definition of health within her model. Peplau viewed health as "a word symbol that implied forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living"(1992, p.12). Further, she described what she saw as being two necessary and interacting conditions for an individual to experience health. These conditions included the physiological demands of the human organism, and interpersonal needs, which are personal and social and meet the personality needs of the individual, which allows for expression of these capacities in a productive and useful manner.
Although Peplau's model was first published in 1952, her thoughts on nursing were quite progressive for the period and have relevance to nursing practice today. Peplau stated that "the goals of nursing are currently in transition; it's major concerns fifty years ago had to do with getting sick people well; today, nursing is more concerned with ways for helping people to stay well" (1992, p.6). As nurses become more interested and focused on health promotion as opposed to providing care for only those that are ill, this statement holds particular relevance.
The model views nursing in two ways. Firstly, nursing is educative. Secondly, nursing is therapeutic. With these two functions combined, they allow nurses and clients to develop skills for problem solving. This process of education and therapeutic interaction occurs only within the relationship of the nurse and the client.
Within the concept of the environment, Peplau's Interpersonal Relations Model sharply differs from other models pertaining to nursing. The model views the environment as being and occurring in the context of the nurse client relationship. The interpersonal focus of the model on this relationship is unique as it examines not only the client, but also the self-reflection of the nurse in the context of the ongoing relationship between the nurse and the client. This is supported by the assertion of Forchuk that "the focus is the interpersonal process and relationships, not the constituent parts (or individuals)". (1993, p.7).
This interpersonal relationship between the nurse and the client as described by Peplau (1992, pp. 17-42) has four clearly discernible phases. These phases are orientation, identification, exploitation and resolution. 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.
During the orientation phase of the relationship, the client and nurse come together as strangers meeting for the first time. During this phase, the development of trust and empowerment of the client are primary considerations. An essential component during orientation as described by Peplau is "The patient needs to recognize and understand his difficulty and the extent of need for help" (1992, p. 22). This is best achieved by encouraging the client to participate in identifying the problem and allowing the client to be an active participant in what is of concern to them. Peplau stated that "such orientation is essential to full participation and to full integration of the illness event into the stream of life experiences of the patient" (1992, p. 24). The client, by asking for and receiving help, will feel more at ease expressing their needs knowing that the nurse will take care of those needs. Once orientation has been accomplished, the relationship is ready to enter the next phase.
During the identification phase of the relationship, the client in partnership with the nurse, identify problems that require working on within the relationship. At this stage, the client will selectively respond to a nurse that seems to offer the kind of help needed by the client. Once the client has identified the nurse as a person willing and able to provide the necessary help, the main problem and other related sub-problems can then be worked on, in the context of the nurse client relationship. Throughout the identification phase, both the nurse and the client must clarify each other's perceptions and expectations. The perceptions and expectations of the nurse and the client will affect the ability of both to identify problems and the necessary solutions. When clarity of perceptions and expectations is achieved, the client will learn how to make use of the nurse client relationship. In turn, the nurse, will make full use of their professional education to assist the client in achieving full use of the relationship. Once identification has occurred, the relationship enters the next phase.
During the phase of exploitation, the client takes full advantage of all available services. The degree to which these services are used is based upon the needs and the interest of the client. During this time, the client begins to feel like an integral part of the helping environment and starts to take control of the situation by using the help available from the services offered. Within this phase, clients begin to develop responsibility and become more independent. From this sense of self-determination, clients develop an inner strength that allows them to face new challenges. This is best described by Peplau who 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" (1992, pp. 41-42). It's important to note that although the nurse client relationship may predominately be more in one phase, all phases can be seen in every interaction between the nurse and the client. As the relationship passes through all of the aforementioned phases and the needs of the client have been met, the relationship passes to closure or the phase of resolution.
Resolution occurs when all of the needs of the client are met. 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" (1992, p. 40).
NEUMAN'S HEALTH CARE SYSTEMS MODEL
This section will delineate the Neuman Health Care Systems Model as it relates to the metaparadigm of the discipline of nursing. These concepts are the view of the person, health, nursing and the environment.
The Neuman model is represented schematically by viewing the person as containing a basic core, surrounded by lines of resistance, encapsulated by a normal line of defense and finally surrounded by a flexible line of defense. This schematic representation is illustrated by concentric rings, which surround the basic core structure of the person.
Neuman's model describes the person as being an open and dynamic system that is constantly interacting with both the internal and external environments. The person or as described by Neuman, the client system, is made of an inner core. Neuman describes this inner core as consisting of "basic survival factors common to the species, such as variables contained within it, innate or genetic features, and strengths and weaknesses of the system parts" (1995, p. 26). Within all client systems, whether the client system is considered one or many, five variables exist. These variables or components consist of the physiological, psychological, sociocultural, developmental and the spiritual. The model views the client system as being in dynamic equilibrium.
Surrounding this basic inner core structure as represented schematically, are the lines of resistance. These lines of resistance as described by Neuman is "the usual wellness state" (1995, p. 26). The usual wellness state contains certain baseline features and characteristics. These are the basic and innate characteristics of the client and would include such things as coping abilities, cognitive abilities and genetic constitution. George views the lines of resistance as "providing protection to the basic structure and become activated when the normal line of defense is invaded by environmental stressor" (1995, p. 285).
The normal line of defense as described by Neuman "represents what the client has become, the state to which the client has evolved over time, or the usual wellness level" (1995, p. 30). Neuman further states "the normal defense line is a standard against which deviancy from the usual wellness state can be determined" (1995, p. 30). Factors which may influence the normal line of defense include system variables, coping patterns, life-style factors, developmental factors as well as cultural considerations (1995, p.30). The normal line of defense is considered to by dynamic. This is due to it's ability to become and remain stable as the client system deals with stressors throughout the life continuum while protecting the basic structure of the client while maintaining integrity of the overall system.
The flexible lines of defense surround the normal line of defense. As Neuman reports "it ideally prevents stressor invasions of the client system, keeping the system free from stressor reactions, or symptomatology." (1995, p. 27). This flexible line of defense is dynamic in nature and acts in an accordion like fashion. This accordion like action as described by Neuman states that "as it expands away from the normal defense line, greater protection is provided; as it draws closer, less protection is available" (1995, p. 27). Any single or multiple stressors have the ability to reduce the effectiveness of this flexible line of defense. This line of defense when ineffective in response to a stressor results in the client exhibiting symptoms of instability or illness.
The Neuman model views health as being on a continuum ranging from wellness to illness. Neuman states "Health for the client is equated with optimal system stability, that is, the best possible wellness state at any given time" (1995, p. 32). Further, Neuman "views health as a manifestation of living energy available to preserve and enhance system integrity" (1995, p. 32). The view that health and illness can be represented on a continuum supports Neuman's assertion that the client system is open and in constant interaction with the internal and external environments. This is supported by Neuman when stating that the health and illness continuum "implies that energy flow is continuous between the client system and the environment" (1995, p. 33). Variances in health or wellness is caused by the invasion of stressors through the normal line of defense.
The model views nursing as being primarily concerned with maintaining the client system stable. This is achieved through assessment of the actual and potential effects of environmental stressors on the client system. Secondly, system stability is maintained by assisting clients with any adjustments required to achieve optimal levels of health or wellness. This belief that nursing assists in achieving and maintaining client system stability is achieved through various levels of prevention. Neuman delineates these levels of prevention into the categories of primary prevention as intervention, secondary prevention as intervention and tertiary prevention as intervention.
Primary prevention as intervention is used for primary prevention of illness as the basis for wellness. Primary prevention is used to protect the client systems normal line of defense by strengthening the flexible line of defense. This is achieved by prevention of system stress and through the reduction of risk factors. Primary prevention is best described as health promotion.
Secondary prevention as intervention is used when there has been penetration of the client's normal line of defense. In this mode, prevention is geared towards health attainment. This is achieved through the treatment of symptoms in an effort to obtain client stability and to conserve energy of the client system. An important aspect of secondary prevention is that the client system may achieve progress beyond the baseline normal line of defense. The client system during this stage of intervention may also stabilize at a level which is lower prior to the onset of the illness or the client system may return to it's pre-illness level of stability.
Tertiary prevention as intervention is used for maintenance of system stability. This level of prevention is concerned with maintaining and supporting existing strengths and conserving energy within the client system. The major concern is preventing further regression.
All three levels of prevention can be viewed as being circular. Each level of intervention leads backs toward the goal of primary prevention or health promotion. These levels of prevention provide direction for nursing action.
The environment as described by Neuman is defined as "all internal and external factors or influences surrounding the identified client or client system" (1995, p. 30). As with the models view of the person, health and nursing, the environment is seen as being dynamic in nature. Neuman holds the view that "the client may influence or be influenced by environmental forces wither positively or negatively at any given point in time" (1995, p. 30). Environmental stressors are viewed as potentially being both positive or negative. This dynamic interaction between the client system and the environment will produce outcomes, which will be either corrective or regulative for the overall client system. The environment is classified as being either internal, external or created. Each environment will be dealt with separately.
The internal environment as described by Neuman "consists of all forces or interactive influences internal to or contained solely within the boundaries of the defined client/client system" (1995, p. 31).
The external environment according to Neuman "consists of all forces or interactive influences external to or existing outside the defined client/client system" (1995, p. 31). The external environment contain the interpersonal and the extrapersonal as subcomponents.
The created environment is a representation of the client's mobilization of the system variables. Those variables being the physiological, psychological, sociocultural, developmental and the spiritual. This created environment as stated by Neuman "supersedes or goes beyond the internal and external environments, encompassing both" (1995, p. 31). The created environment encompasses the intrapersonal, interpersonal and extrapersonal environments.
Having provided an overview of the two models, the next section will compare and contrast the differences and the similarities of the two models.
COMPARISON OF THE PEPLAU AND NEUMAN MODELS
In this section, Peplau's Interpersonal Relations Model and the Neuman Healthcare Systems model will be compared and contrasted. The basis for this comparison will be the metaparadigm of nursing. This includes the view of the person, health, nursing and the environment.
Both the Peplau and the Neuman models view the individual as a system comprising the physiological, psychological and social spheres.
The Neuman models expands the view of the person with the belief that the client system is an open system and includes a developmental and spiritual component. Peplau's model doesn't make a statement as to whether the system is open and doesn't include a developmental and spiritual component to the view of the person.
The basic premise of Peplau's view of the person is that as a system, the individual is unstable although equilibrium is a desirable state. This view of equilibrium as a desirable state as put forward by Peplau includes the belief that achieving such a state occurs only through death.
Neuman's basic view of the client or client system is that a steady state or equilibrium is the normal state of the client system. Neuman considers this steady state as being dynamic, not static. This goes to the premise that the person as a system is open and is in constant interaction with the environment.
The Peplau model doesn't include any exact definition of health. Health is seen as forward movement of the individual's personality and other ongoing human processes. This view included the belief that two interacting conditions were necessary for health attainment. Those conditions included the physiological demands of the individual and interpersonal needs. Peplau didn't provide elaboration on what exactly interpersonal needs where. The interpersonal needs are broken down to what is described as being personal and social which meet the personality needs of the individual. Again, Peplau didn't expand on what personality is. With these conditions present, the individual can use expression of those capacities in a productive and useful manner.
The Neuman model views health as being on a continuum ranging from health to illness with health being desirable to achieve system stability. Any variance in the usual steady state or wellness is seen as an invasion or penetration of stressors through the normal line of defence. This variance is believed to bring about the manifestation of illness. As the normal line of defence would include the physiological and interpersonal needs of the client, there is some similarity to the Peplau model. The Neuman model expands this view further to include the other variables, which are seen as being related to the wellness of the individual. Those variables would include the psychological, social, developmental and spiritual components of the client. These variables are better explained and defined within the Neuman model. Neuman also considers health as being dynamic with constant input and interaction from these variables and from the environment.
The Peplau model believes that nursing is maturing, educative and therapeutic. Peplau within her model saw health promotion as being a primary function of nursing. The model holds the view that the process of education and therapeutic interaction occurs only within the context of the nurse client relationship. This view of nursing is consistent with Peplau's belief that forward movement of the personality and other processes are the basis of health and wellness. As the nurse acts as a maturing, educative and therapeutic force with the individual, growth of the individual will occur. Within the Interpersonal Relations model, reference is made those outside of the client. Specifically, to the family. There is little elaboration on these outside influences with respect to the client. Rather it's an acknowledgement of the presence of others within the sphere of the client. These other relationships are seen as having little impact on the overall health of the function and therefore serve little purpose for nursing with respect to the health of the individual.
The Neuman model is strongly based in the belief of health promotion. It proposes three levels of intervention as prevention. The levels of prevention are termed as being primary, secondary and tertiary. These levels of prevention as intervention can easily be seen as being educative and therapeutic for the client. These levels of prevention lead to stability of the client system, which Neuman believes is the basis of health. As the Neuman system is an open and dynamic system, multiple factors are given consideration when examining the health of the individual. There is provision made for the assessment of factors such as family and significant others in determining health outcomes for the client system. The levels of prevention seek to enhance and strengthen the client's line of defence, which can be viewed as being educative and therapeutic. All levels of prevention seek to achieve a state of stability and wellness. The preventative levels are circular in nature and lead back to the original goal of primary prevention, which is educative, and promotion of health.
It's within the area of the environment that the two models differ sharply.
Peplau's Interpersonal Relations Model view of the environment is narrow and focused. The model considers the environment to be the relationship and interaction between the nurse and the client. This view is exclusive. The relationship of the nurse and the client requires self-reflection on the part of both. Peplau described four discernable phases of the nurse client relationship, which constitute the environment. The phases are described as being the phase of orientation, identification, exploitation and resolution. It's within the context of this relationship that the needs of the client are expressed and met. This meeting of needs occurs between the nurse and the client in the context of an understanding. As the nurse and the client pass through the four phases, the client increasingly becomes more independent and in charge of their needs and their health which eventually brings the relationship to closure or resolution. The four phases of the relationship are considered to be interlocking and overlapping. Consequently, the nurse and the client can pass through a variety of phases within the relationship during any interaction between them. This interlocking and overlapping of phases makes the relationship a dynamic one.
The Neuman Healthcare Systems Model takes a sharply different view of the environment. As with the Interpersonal Relations Model, The Healthcare Systems Model views the client as being fully interactive within the environment. The environment is categorized as being either internal, external (which can be either interpersonal or extrapersonal) or the created. The Neuman model holds the view that the client may influence or be influenced by the environment. This is also the position of the Peplau model. Where Neuman views this interaction as being either corrective or regulative of the client system, the Peplau model considers this interaction of the client within the environment to have a forward moving or growth enhancing effect. With respect to Neuman's idea of the created environment, Peplau has no such statement or provision within the Interpersonal Relations model.
The client is a 37-year-old Caucasian male, unmarried, with a long and well-documented history of Schizophrenia. The exact onset of his illness is unknown and undocumented but dates back to his youth. The client has had numerous hospitalizations to a variety of centres, all within the lower mainland area, specifically R.C.H., R.V.H., St. Paul's and V.G.H. He has also had several admissions to the C.R.E.S.S.T. program in the New Westminster area.
The client is the third child of five, born and raised in the lower mainland. He has two older brothers, one younger brother and a younger sister. Both older brothers as reported by the client have been diagnosed as being Schizophrenic. His younger brother and sister are both bipolar; again, the client reports this. He denies that either parent has a mental illness.
Since the age of 17, the client has lived independently with his older brother in a rented house. He has always maintained close contact with the local mental health centre and has always been medication complaint. This compliance is well documented in all records related to the clients stay while in facility care. For many years, the client has been maintained outside of facility care. Within the last year, he has had two admissions to R.C.H. and four admissions to C.R.E.S.S.T. His admission stays average approximately 10 - 21 days.
Five months ago, the client filed charges of sexual misconduct against his father. The client reports that molestation with physical abuse began at the age of 8 and continued until he was 17 years old and left home to live with his brother. He reports that his recent frequent requirements of facility care are directly related to difficulty he has been having as a result of filing charges against his father.
On each admission to C.R.E.S.S.T., the client presents with a disheveled appearance and poor hygiene and grooming. His motor movement is accelerated as manifested by constant pacing, inability to sit for any period of time as well as difficulty sleeping. His affect is flat and his mood is predominately downcast and sad. There are no bouts of tearfulness and the client denies suicidal and homicidal ideation. He is pleasant upon approach and is easily engaged in conversation. His thought processes are grossly disturbed. He reports auditory and visual hallucinations. In his reporting of the hallucinations he is non-specific, stating only, that he hears a male voice that is unfamiliar to him. He reports ideas of reference and reports receiving messages from the television and the radio which tell him that he is a bad person. He is fully oriented in all spheres. He is relevant and coherent. There is congruence between his affective expression and his thought processes.
Recently, the clients father passed away. Upon hearing of his father's passing, the client began experiencing auditory hallucinations. His primary therapist at the mental health centre was concerned that the client could easily decompensate given his current presentation of acute symptoms as well as the stress of having his father passing away.
Upon admission to C.R.E.S.S.T. the client admitted to having profound feelings of guilt surrounding his father's death. He reported feeling somewhat responsible for his father's death. He attributed his feelings of responsibility to his pressing charges of sexual misconduct against his father. His overall appearance and presentation was consistent with his previous admission to the C.R.E.S.S.T. facility.
APPLICATION OF THE MODELS TO THE CLIENT SITUATION
PEPLAU'S INTERPERSONAL RELATIONS MODEL
The focus of this model when applied to this client situation would involve determining the current phase of the nurse-client relationship. The first phase of Peplau's model is orientation.
As the client has previously been cared for at C.R.E.S.S.T., he is familiar with the layout of the facility as well as the general rules and regulations of the facility with respect to admission. Again, due to the client's familiarity with the facility, and the ease at which he engages in conversation with the nursing staff, orientation in this situation was quickly established. This led us to the next phase of our relationship. The phase of identification.
In the second phase of the relationship, identification, The client and I were quickly able to identify problems that required attention. These problems included the clients feelings of guilt surrounding the death of his father as well as his experiencing auditory hallucinations. We also identified the client as experiencing mixed emotions about his fathers passing. Specifically, the sadness and relief that he was feeling about the passing of his father. We also identified the client as requiring some form of additional support given that he had been relatively stable for many years, yet required several admissions to hospital and C.R.E.S.S.T. within the past year. This identification having occurred led us to enter the next phase of our relationship. That phase being exploitation.
Within the phase of exploitation, John quickly began making use of the available resources and services at his disposal. As we had developed a trusting relationship with mutual respect for one another, the client made use of one to one interactions with me to discuss his thoughts and feelings. During the interactions where he expressed his feelings of mixed emotions, he was assured of the normalcy of those feelings and thoughts. Given that he had been sexually and physically abused by his father, it's only natural that the client would experience feelings of relief about his fathers passing. Again, the feelings of sadness he was experiencing is well within the range of normalcy given that this was his father. This acknowledgement and assurance that his feelings were normal and to be expected provided comfort and relief for the client. He expressed that he was unsure how he should be feeling and was greatly relieved to hear that such feelings could be expected. With each interaction, the client became more visibly comfortable. His restlessness began to dissipate and within four days, his normal sleeping pattern had returned. No medication changes had occurred during this time and no prn medications were given or asked for by the client. One the fifth day of his admission he reported that he was no longer experiencing auditory hallucinations and stated that he was feeling much better.
As the client had been hospitalized twice and had four admissions to C.R.E.S.S.T. within a one year period, the client was provided with information on services which could be accessed to assist him further should the need arise. These services would be community based as opposed to facility based to maximize his independence. These services included information related to crisis lines, after hours-emergency support and grief counseling. The client followed through on accessing these services by making an appointment to meet with a community based grief counselor. He also made an appointment for intake to a service providing counseling for survivors of sexual abuse. With the client making full use of the available services, our relationship then entered the final phase, resolution.
During the phase of resolution, the client became less dependent on me for one to one interactions and no longer sought further assistance in arranging continuing supports in the community. Although Peplau's model considers resolution to occur only after a freeing from helping persons and the development of the ability to stand alone, this freeing was achieved from facility care. It could be argued that resolution in this situation didn't in fact occur, as the client would continue to have identification with helping persons.
Having applied the Interpersonal Relations Model to this client situation, the next section will deal with the application of this situation to the Neuman Health Care Systems Model.
NEUMAN'S HEALTH CARE SYSTEMS MODEL
The focus of this model when applied to this client situation would be the strengthening of the flexible line of defense and the assessment of the clients reaction to known or possible stressors. Within this model, stressors are categorized as being interpersonal, intrapersonal, extrapersonal and created. Another aspect of consideration is which level of prevention as intervention would be applicable to this situation. For the purpose of this paper, the client system will be (the client).
As the flexible line of defense requires strengthening, it would be useful to first examine the stressors being experienced by the client.
An intrapersonal stressor for the client would be his Schizophrenia. This would include his complaints of auditory and visual hallucinations with ideas of reference. Another intrapersonal stressor for the client would be the limited effect that his current medication regime is having on his acute symptoms, which included him having difficulty sleeping. Both interpersonal and extrapersonal stressors exacerbate these intrapersonal stressors. The interpersonal stressors are the strained relationship with his father, the charges he brought forward against his father for sexual and physical abuse, the recent passing of his father and the feelings of guilt the client was experiencing surrounding the death of his father and a perceived strain in the relationship he has with the older brother that he lives with. The client reported this. The clients expression of fear that his relationship with his brother could suffer as a result of the fathers passing was based on the clients assumption that his brother may hold him partly responsible for the death. The client attributed these stressors to the exacerbation of acute psychiatric symptoms. Although the client reported experiencing fear that his relationship with his brother could suffer due to the disclosure of abuse and the death of his father, there was no indication that this had occurred. During the clients stay at C.R.E.S.S.T. his brother visited on several occasions, which the client reported as having gone well. This perception of the client was part of the created environment. The extrapersonal stressor was identified as inadequate community resources. Resources, which could be utilized to maintain the client outside of facility care. Once the stressors had been identified, a determination of the level of prevention required to strengthen the flexible line of defense could be made.
In this clients situation, the identified stressors had penetrated the line of defense. Therefore, the goal is to prevent further regression. This is a tertiary level of intervention. As tertiary prevention is concerned with maintaining and supporting existing strengths of the client, this was achieved through one to one conversations with the client. These one to one conversations served to support the existing strengths of the client. A specific intervention was reinforcing the solidity of the relationship he had with his brother. It was pointed out to the client that he described their visits as going well. Further, he reported that since bringing forward the charges against his father, the relationship with his brother hadn't changed. This served to affirm the support of his brother and alleviated the clients concerns regarding their relationship. During our one to one conversations, the client was allowed to express his mixed feelings of relief and sadness about his father's passing and the associated guilt he was experiencing. To strengthen his coping abilities, the situation was normalized. Given the situation of the client, his feelings and thoughts were normal and to be expected and reinforcement of this normalcy provided relief for the client. From this level of intervention, within four days the client was no longer experiencing auditory or visual hallucinations and his sleeping pattern had returned to his pre-illness level. The alleviated of his psychiatric symptoms was achieved without alteration to his established medication regime. Having achieved a level of functioning to that of pre-illness led me to pursue a primary level of intervention.
The primary level of intervention is aimed at health promotion. One of the identified stressors was inadequate community resources. The client attends the areas mental health centre on a regular basis. However, these appointments with the mental health centre occur only once a month. The client was provided with information related to crisis lines, after hours-emergency support and grief counseling. The client made connection with these resources by making intake appointments. Having made these connections to community resources served to strengthen the flexible line of defense, which will assist in fighting off further invasion of the normal line of defense.
Having applied the Neuman Health Care System Model to this client situation completes this section. A conclusion will now be presented outlining the strengths and the weakness of both the Peplau Interpersonal Relations Model and the Neuman Health Care Systems Model.
Peplau's Interpersonal Relations Model when first published in 1952 was designed to describe the client's experience within a hospital setting. The model provided a new way of examining the relationship between the nurse and the client.
The strength of the model is it's 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. The model encourages and supports empowerment of the client by encouraging the client to accept responsibility for the direction of their well being. 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. The model while focusing on getting sick people well is also interested in health promotion and wellness, not just treatment of the ill.
The model has several weaknesses. As the focus of the model is on the nurse-client relationship and the level of trust and self reflection which is required, the client would be required to develop this relationship with every nurse they come in contact with. As the provision of healthcare is twenty-four hours a day, the client would be required to develop a relationship with numerous nurses. This could make a client's stay in 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. The strength of the model, the relationship between the nurse and the client is also a weakness of the model. While it makes provision for the physiological and social aspects of the client, these areas of the model are not well developed and defined. The model also provides for no provision of an environment outside of the context of the nurse-client relationship. In essence, this narrow focus and lack of development makes Peplau's work more of a theory of nursing as opposed to a model of nursing.
Neuman's Health Care Systems Model is complete and comprehensive. The strength of the model is it's view of the client being an open system and dynamic in all aspects. The consideration of stressors coming from a variety of sources, whether internal, externally, or from a created environment is particularly useful in assessing and understanding the complex health issues of the client. The levels of prevention allow interventions to be geared towards the client's current situation, with the focus on health attainment and health promotion. A major strength of this model is in it's ability to be applied to one or to many client systems. George notes that "The major strength of the Neuman Systems Model is it's flexibility for use in all areas of nursing - administration, education, and practice" (1995, p. 297).
The Neuman model has several weaknesses. As the model is comprehensive, it could easily be used by disciplines other than nursing. While on the surface this may present as being beneficial from a consistency point of view, it could lead to duplication of health assessment information if the model was used by a variety of disciplines. Use of the model by a variety of disciplines could lead to a lack of differentiation between nursing and the other disciplines. The model requires further clarification of some terms. Specifically, it needs to better define the terms interpersonal and extrapersonal. A more concise explanation of the lines of defense and the lines of resistance would also be useful.
Both models have useful application for psychiatric nursing. The focus of the Peplau model on the nurse-client relationship provides a foundation for interactions between the nurse and the client. However, the Neuman Health Care Systems Model, being more comprehensive, provides a better foundation for the assessment and intervention of illness and the promotion of health.
Forchuk, C. (1993). Hildegarde E. Peplau Interpersonal Nursing Theory.
Newbury Park, California: Sage
George, J.B. (1995). Nursing Theories The Base for Professional Nursing Practice (4th. ed).
Norwalk, Connecticut: Appleton & Lange
Neuman, B. (1995). The Neuman Systems Model (3rd. ed.)
Stamford, Connecticut: Appleton and Lange
Peplau, H.E. (1992). Interpersonal Relations in Nursing
New York: Springer
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