MAKALAH

KRITIKAL REVIEW JURNAL SAINS

“Hildegard Peplau”

Tugas Kelompok 6
Mata Kuliah Sains Keperawatan

DISUSUN OLEH:

METTY ASTUTI 1421312002

SUNARTI SWASTIKARINI 1421312028
RIKA NOVARIZA 1421312042
ANDIKA CAESAR 1421312057

MAGISTER KEPERAWATAN
FAKULTAS ILMU KEPERAWATAN
UNIVERSITAS ANDALAS
 2014
KATA PENGANTAR

Syukur Alhamdulillah kelompok ucapkan Kehadiran Allah SWT, yang telah memberikan
rahmat, hidayah, serta karunia-Nya sehingga kelompok dapat menyelesaikan tugas Sain
Keperawatan tentang Kritikal Jurnal teori “Hildegard Peplau” dengan baik. Shalawat dan
salam kelompok mohonkan kepada Allah SWT semoga disampaikan kepada Nabi
Muhammad SAW yang telah memberikan contoh dan suri tauladan bagi manusia untuk
keselamatan di dunia dan di akhirat.
Dalam penulisan Makalah ini kelompok telah berusaha semaksimal mungkin dengan
mencurahkan segenap kemampuan, waktu, dan tenaga untuk menyelesaikannya. Namun
demikian kelompok menyadari Makalah ini masih jauh dari kesempurnaan, hal ini
disebabkan oleh keterbatasan kemampuan dan pengalaman kelompok. Untuk itu diharapkan
adanya saran dan kritikan yang bersifat membangun dari pembaca demi kesempurnaan
Makalah ini.
Makalahini diajukan dalam rangka memenuhi syarat dalam perkuliahan Sains
Keperawatan. Dalam menyelesaikan Makalah ini kelompok banyak mendapatkan masukan,
bantuan, dukungan, bimbingan dan arahan dari berbagai pihak, untuk itu dengan segala
kerendahan hati dan penuh penghargaan kelompok mengucapkan terima kasih.
Akhir kata semoga makalah ini lebih sempurna, dapat diterima dan bermanfaat bagi
kita semua.

Padang, September 2014

Kelompok 6
 BAB I
PENDAHULUAN
A. Latar Belakang

Sains keperawatan merupakan ilmu yang terus berkembang sesuai dengan

perkembangan respon manusia terhadap lingkungannya. Perkembangan sains
keperawatan didasari oleh falsafah, filosofi dan paradigma keperawatan sebagai
kerangka ilmu untuk meningkatkan pelayanan keperawatan secara holistik. Sains
keperawatan memiliki falsafah berupa keyakinan dan kerangka berpikir secara
sistematis dan ilmiah yang mendasari suatu gambaran yang berdasarkan pada realitas
dan logika sehingga menjadi panduan perawat untuk memberikan pelayanan asuhan
keperawatan secara profesional. Ilmu keperawatan juga memiliki paradigma
keperawatan sebagai kerangka ilmu untuk berfokus pada pelaksanaan praktek
pelayanan keperawatan yang terdiri dari manusia, lingkungan, sehat, dan
keperawatan.
Teori adalah sekelompok konsep yang membentuk sebuah pola yang nyata atau
suatu pernyataan yang menjelaskan suatu proses, peristiwa atau kejadian yang
didasari fakta-fakta yang telah di observasi tetapi kurang absolute atau bukti secara
langsung. Teori keperawatan adalah usaha-usaha untuk menguraikan atau
menjelaskan fenomena mengenai keperawatan. Teori keperawatan digunakan sebagai
dasar dalam menyusun suatu model konsep dalam keperawatan yang digunakan
dalam menentukan model praktek keperawatan.
Teori selain dipergunakan dalam menyusun sebuah model, juga memiliki
karakteristik, diantaranya teori mampu mengidentifikasi dan menjabarkan konsep
khusus yang berhubungan dengan hal-hal nyata yang ada di alam, teori berdasarkan
alasan-alasan yang sesuai dengan kenyataan yang ada, teori harus bersifat konsisten
sebagai dasar-dasar dalam mengembangkan suatu model konsep, teori mampu
menunjang terhadap aplikasi, teori harus sederhana dan sifatnya umum sehingga
dapat digunakan pada kondisi apapun dalam praktik, serta teori dapat dipergunakan
dalam pedoman praktik.
Untuk menjalankan tugas keperawatan, banyak teori keperawatan yang
digunakan, salah satunya adalah Hildegard E. Peplau. Model konsep dan teori
keperawatan yang dijelaskan oleh Peplau menjelaskan tentang kemampuan dalam
memahami diri sendiri dan orang lain yang menggunakan dasar hubungan antar
manusia yang mencakup 4 komponen sentral yaitu klien, perawat, masalah kecemasan
yang terjadi akibat sakit (sumberkesulitan) dan proses interpersonal.
Pelayanan keperawatan profesional merupakan area yang dapat memunculkan
berbagai perkembangan ilmu dan teori keperawatan. Hasil dari pemberian pelayanan
 keperawatan profesional dengan pendekatan sains keperawatan dapat menjadi solusi
dari fenomena keperawatan sehingga dapat meningkatkan kualitas perawatan sebagai
bagian dari pelayanan kesehatan. Oleh sebab itu, pengembangan sains keperawatan
memiliki hubungan interaktif antara pendidikan, pelayanan/praktik, dan riset
keperawatan sebagai ilmu terapan yang memiliki otonomi profesional.
Melalui makalah ini, kelompok tertarik untuk membahas tentang pengembangan
sains keperawatan dari Filosofi, falsafah dan paradigma dengan hubungannya antara
keperawatan dalam pengembangan sain keperawatan.

B. Tujuan
1. Tujuan umum
Mampu memahami dan menganalisa jurnal sesuai konsep teori Hildegard E.
Peplau.
2. Tujuan khusus
a. Mampu memahami model konsep teori Hildegard E. Peplau.
b. Mampu menganalisa jurnal sesuai teori Hildegard E. Peplau.

C. Manfaat
Manfaat dari penyusunan makalah ini diharapkan mahasiswa mampu mengetahui,
menganalisis, dan menerapkan pengembangan sains keperawatan di pendidikan,
pelayanan, dan riset keperawatan sebagai bagian dari pelayanan keperawatan
profesional.

BAB II

TINJAUAN TEORITIS

A. Teori

Teori adalah kumpulan konsep-konsep, definisi-definisi dari suatu fenomena yang

dihubungkan atau dikaitkan sehingga dihasilkan sesuatu hal yang mudah dipahami, bisa
berupa pernyataan kata-kata, penjelasan, penggambaran, perkiraan terhadap suatu
fenomena. Keberadaan teori sangat bermanfaat dalam pengembangan ilmu pengetahuan,
khususnya perencanaan proses penelitian. Teori selain dipergunakan dalam menyusun
sebuah model, juga memiliki karakteristik, diantaranya teori mampu mengidentifikasi
dan menjabarkan konsep khusus yang berhubungan dengan hal-hal nyata yang ada di
alam, teori berdasarkan alasan-alasan yang sesuai dengan kenyataan yang ada, teori
harus bersifat konsisten sebagai dasar-dasar dalam mengembangkan suatu model konsep,
teori mampu menunjang terhadap aplikasi, teori harus sederhana dan sifatnya umum
sehingga dapat digunakan pada kondisi apapun dalam praktik, serta teori dapat
dipergunakan dalam pedoman praktik.

Teori-teori diklasifikasikan berdasarkan pada beberapa komponen, yaitu: (1)

bahwa konsep diidentifikasi dan didefinisikan, (2) bahwa klarifikasi asumsi-asumsi
mendasari suatu kebenaran yang mana dan darimana alasan teori-teori dihasilkan, (3)
darimana konteks tempat teori, dan (4) telah teridentifikasi hubungan antara dan diantara
konsep-konsep (Chin & Kramer,1999; Higgins & Moore,2003).

Teori-teori dibedakan berdasarkan tujuan, sumber, tingkat kepentingan, level dan

cakupan. Perbedaan – perbedaan tersebut digunakan untuk mengklasifikasikan. Dasar
tujuan dari teori adalah deskripsi, penjelasan, prediksi dan atau control. Sumber – sumber
dalam teori keperawatan meliputi perkembangan ilmu keperawatan itu sendiri dan dari
disiplin ilmu lain yang digunakan dalam keperawatan. Dengan demikian ada terminologi
yang digunakan untuk mencirikan antara dua sumber tersebut yaitu teori keperawatan
dan teori dalam keperawatan.

Ada beberapa pendapat dalam mengklasifikasikan tingkatan teori keperawatan.

Teori secara luas (the broad-scope theories) disebut sebagai macro, holistic, molar,
general, situasional dan grand. Teori yang lebih sempit (narrow-scope theories) disebut
middle range, circumscribed atau situational/factor. Teori yang paling sempit (theories
narrowest) disebut micro, molecular, atomistic, narrow-range, phenomena, prescriptive,
factor, situation-specific atau practice (Babbie, 1995; George, 1995; Parker, 2001;
Rinehart,1978). Penyebutan secara umum tingkatan teori menyebut Meta-theory, Grand
theory, middle range theory, micro theory atau practice theory.

Berikut ini akan dijelaskan tingkatan berfikir secara teoritis dalam keperawatan.
Masing – masing tingkatan teori akan dijelaskan berdasarkan penjelasan abstrak dan
cakupan, kemampuan secara umum, tipe dan peran (kegunaan) dari teori;
a. Meta-theory

Meta-theory adalah tingkatan yang paling abstrak dari semua level teori. Isu dari
teori ini berhubungan dengan mengarahkan pada pencarian jawaban dari sebuah
pertanyaan ilmiah (Higgins& Moore, 2004). Meta-theory berhubungan dengan isu –
isu ilmiah dan di kenal dengan filsafat ilmu, yang menfokuskan pada penggujian dari
sebuah ilmu, prosesnya dan produk. Teori ini menghasilkan dasar dari ilmu
pengetahuan.

Teori ini mempunyai manfaat bagi ilmuwan dan praktisi keperawatan. Teori ini
juga digunakan untuk menjawab pertanyaann yang tidak dapat dijawab oleh ilmu
pengetahuan. Contohnya, pada kasus-kasus menjelang ajal dan kematian, studi ilmiah
akan mencari jawaban tentang perubahan – perubahan fisiologi yang terjadi pada
kematian. Akan tetapi, studi ilmiah diperlukan untuk menjawab pertanyaan,”Apakah
kematian itu adalah sebuah proses atau sebuah hasil ?”. Sebagai teori yang paling
kuat/kokoh diantara semua level teori, Meta-theory dalam ilmu keperawatan berfungsi
mengungkapkan sebagian dari isu-isu yang ditujukan melalui proses :

1) Klarifikasi hubungan antara ilmu keperawatan dan praktek.

2) Mendefinisikan, mengembangkan, dan menguji teori.

3) Menciptakan dasar ilmu dari keperawatan, dan

4) Memeriksa dan menginterpretasikan pandangan dasar filosofi dan

hubungannya dengan keperawatan.

b. Grand theory

Teori keperawatan grand theory adalah paradigma umum tentang ilmu

keperawatan ( Higgins & Moore,2004). Teori ini bersifat formal, merupakan system
teori yang bersifat abstrak dari kerangka disiplin keilmuan. Konsep dan propositions
(asumsi-asumsi)nya melebihi kondisi yang spesifik dan populasi pasien.

Grand theory memerlukan spesifikasi lebih lanjut dalam banyak kasus, serta
pemisahan pernyataan-pernyataan teoritisnya supaya bisa diuji dan dibuktikan secara
teoritis. Para ahli grand theory menyatakan rumusan-rumusan teoritis mereka pada
 tingkat abstraksi yang sangat umum, dan sering dijumpai kesulitan-kesulitan
mengaitkan rumusan-rumusan itu dengan realitas. Sifat abstraknya ini mengakibatkan,
grand theory terkadang sulit dipahami oleh siswa baru perawat dan orang yang awam.

Menurut Higgins & Moore (2004), grand theory mempunyai kontribusi yang
signifikan dalam keperawatan, antara lain yaitu:

1) Memberikan batasan – batasan sehingga keperawatan dapat mempunyai identitas

dalam keberadaannya.

2) Selain itu, grand theory juga mempunyai kontribusi untuk memberikan perspektif
sejarah keperawatan, keadaan waktu itu,

3) Memberikan gambaran bagaimana para pencipta mengembangkan teori, juga

filosofi mereka mendasari ilmu keperawatan, pendidikan mereka serta prespektif
terhadap praktek keperawatan.

Contoh dari ilmuwan yang menemukan grand theory adalah Florence Nightingale,
dan temuannya merupakan grand theory pertama yang tertulis dalam perkembangan
ilmu keperawatan.

c. Middle range theory

Menurut Higgins & Moore (2004) sejarah perkembangan dari middle theory
termasuk baru dalam ilmu keperawatan. Sama halnya dengan grand theory, middle-
range theory menjelaskan mengenai dunia empiris dalam keperawatan, tetapi hal itu
lebih spesifik dan sedikit formal dibanding grand teory yang lebih abstrak. Middle
range theory membutuhkan diskusi tentang “what it is” dan “what comes before and
after in its range”.

Middle range theory memiliki kriteria, lingkup, tingkat abstraksi, dan kestabilan
penerimaan secara luas. Dalam lingkup dan tingkatan abstrak, middle range theory
cukup spesifik untuk memberikan petunjuk riset dan praktek, cukup umum pada
campuran populasi klinik dan mencakup fenomena yang sama. Sebagai petunjuk riset
dan praktek, middle range theory lebih banyak digunakan dari pada grand theory,
middle grand theory dapat diuji dalam pemikiran empiris.
 d. Micro theory (practice theory)

Micro range theory merupakan tingkatan teori yang tidak formal dan bersifat
sementara dibandingkan tingkatan teori lainnya. dan sangat terbatas dalam hal waktu
dan lingkup aplikasinya (Higgins & Moore 2004). Meskipun biasanya menggunakan
pendekatan penilaian, para ilmuan dan praktisi selalu memberikan gambaran,
mengorganisir dan melakukan test terhadap ide-ide mereka. Micro range theory
memiliki dua tingkatan, yaitu higher level dan lower level.

Micro range theory pada higher level sangat dekat hubungannya dengan middle
range theory, tetapi terdiri dari satu atau dua konsep-konsep utama dan frekuensi
aplikasinya dibatasi dengan sebuah kejadian. Contohnya teori yang ada hubungannya
dengan perawatan luka dekubitus atau perawatan kateter.

Micro range theory pada lower level didefinisikan sebagai satu set hipotesa kerja
atau proposisi. Para ilmuan dan praktisi menggunakan proposisi kerja secara sementara,
menjelaskan atau melakukan test hipotesa kerja yang ada kaitannya dengan kesehatan
sebagai hasil interaksi antara manusia dan lingkungan.

B. Analisis penerapan teori pada jurnal sampai saat ini

Hildegrad Peplau menerbitkan bukunya hubungan antar-pribadi (interpersonal) dalam
keperawatan, sehubungan dengan bukunya “teori parsial untuk praktek keperawatan”
Peplau membahas mengenai tahap-tahap proses hubungan antar-pribadi, peran dalam
kerja keperawatan, dan metode-metode dalam mempelajari keperawatan sebagai satu
proses interpersonal.

Menurut Peplau, keperawatan adalah terapeutik yaitu satu seni menyembuhkan,

menolong individu yang sakit atau membutuhkan pelayanan kesehatan. Keperawatan
dapat dipandang sebagai satu proses interpersonal karena melibatkan interaksi antara dua
atau lebih individu dengan tujuan yang sama. Dalam keperawatan tujuan bersama ini
akan mendorong kearah proses terapeutik dimana perawat dan pasien saling
menghormati satu dengan yang lain sebagai individu, kedua-duanya mereka belajar dan
berkembang sebagai hasil dari interaksi. Belajar menempatkan diri saat individu
mendapat stimulus dalam lingkungan dan berkembang penuh sebagai reaksi kepada
stimulus tersebut.

Untuk mencapai tujuan ini atau tujuan-tujuan yang lain di capai melalui penggunaan
serangkaian langkah-langkah dan pola yang pasti. Saat hubungan perawat dan pasien
berkembang pada pola terapeutik ini, ada cara yang fleksibel dimana fungsi perawat
dalam berpraktek – dengan membuat penilaian – dengan keahlian yang didapatkan
melalui ilmu pengetahuan, dengan menggunakan kemampuan teknis dan peran asumsi.

Ketika perawat dan pasien mengidentifikasi satu masalah pertama kalinya dan mulai
focus pada tindakan yang tepat, pendekatan yang dilakukan melalui perbedaan latar-
belakang dan keunikan individu. Setiap individu dapat pandang sebagai satu struktur
yang unik bio-psyko-spri-sos yang satu dengan yang lain tidak bertentangan.

Setiap individu telah belajar dari lingkungan, adat-istiadat, kebiasaan, dan

kepercayaan yang berbeda yang membentuk budaya individu tersebut. Setiap orang
datangdari (pemikiran) sudut pandang yang berbeda sehingga mempengaruhi persepsi
dan perbedaan persepsi ini sangat penting dalam proses interpersonal. Sebagai tambahan
bagi perawat dari latar belakang pendidikan, yang mengerti tentang teori perkembangan,
konsep adaptasi kehidupan, respon konflik, juga wawasan yang luas tentang peran
keperawatan professional dalam proses hubungan interpersonal.
Sebagai perawatdanpasien yang berhubungan terus harus mengerti peran masing-masing
dan factor sekitar yang meningkatkan masalah hingga keduanya saling berbagi atau
berkolaborasi dalam mencapai tujuan bersama.

Perawat dan klien bekerja sama dan hasilnya akan saling mengenal dan akan matang
secara proses. Peplau memandang keperawatan sebagai “ kekuatan yang matang dan
instrument yang mendidik”. Dia percaya bahwa keperawatan adalah hasil pengalaman
belajar mengenai diri sendiri dan orang lain yang terlibat dalam hubungan interpersonal.
Konsep ini didukung oleh Genevieve Burton (1950) penulis lain tentang
keperawatan mengatakan : “ tingkah laku orang lain harus dimengerti agar dapat
mengerti diri sendiri secara jelas”. Orang-orang yang tersentuh dengan diri sendiri akan
lebih sadar terhadap berbagai ragam jenis reaksi bujukan individu yang lain.

Sebagai perawat ialah mengarahkan pasien untuk penyelesaian masalah yang dihadapi
setiap hari, sehingga metode dan prinsip-prinsip yang digunakan dalam berpraktek
secara professional akan meningkat secara efektif. Setiap permasalahan akan
mempengaruhi kepribadian perawat dan meningkatkan professionalisme. Inilah cirri diri
perawat yang memiliki perubahan langsung dalam terapeutik, hubungan interpersonal.

Peplau mengidentifikasi empat tahapan hubungan interpersonal yang saling berkaitan

yaitu: (1) orientasi, (2) identifikasi, (3) eksplorasi, (4) resolusi (pemecahan
masalah). Setiap tahap saling melengkapi dan berhubungan sebagai satu proses untuk
penyelesaian masalah.

Beberapa penelitian telah dilakukan terkait dengan konsep Hildegard E. Peplau.

Judul : Peplau's Theoretical Model

Penulisan : Reed, Pamela G; Shearer, Nelma B.
York: Springer Publishing Company, 2006.

Analisis : Jurnal ini membahas tentang perkembangan teori Peplau. Hildegard

Peplau merumuskan ide-ide teoritis nya tentang proses terapi
keperawatan pada 1940-an dan diterbitkan dalam buku pada tahun
1952 tentang Hubungan Interpersonal dalam Keperawatan.
Hubungan interpersonal yang Peplau juga merupakan proses dimana
pengetahuan keperawatan dapat dikembangkan dan divalidasi (Reed,
1996b). Peplau (1988) Keperawatan adalah hubungan manusia antara
individu yang sakit atau membutuhkan pelayanan kesehatan, dan
perawat terutama dididik untuk mengenali dan merespon kebutuhan
bantuan. Dan Peplau (1952) Kesehatan merupakan simbol kata yang
menyiratkan gerak maju kepribadian dan proses manusia lainnya
yang sedang berlangsung ke arah kreatif, konstruktif, produktif, hidup
pribadi dan komunitas. Hubungan perawat-pasien sangat penting
untuk memberikan asuhan keperawatan dan bersumber dari
kebutuhan manusia akan keterhubungan yang masih penting dalam
abad ke-21 (Peplau, 1997). Struktur hubungan interpersonal yang
awalnya digambarkan dalam empat fase: orientasi, identifikasi,
eksploitasi, dan resolusi (Peplau, 1952). Forchuk (1991), dengan
dukungan dari Peplau, menjelaskan struktur sebagai terdiri dari tiga
tahap utama: orientasi, bekerja (yang dimasukkan identifikasi dan
eksploitasi), dan terminasi. Dalam publikasi tahun 1997, Peplau
mendukung ini tampilan tiga fasa dan menjelaskan bahwa fase yang
tumpang tindih, masing-masing memiliki karakteristik yang unik.
Model teoritis Peplau dapat dikategorikan sebagai middle range
theory. Hal ini sempit dalam lingkup dari model konseptual atau
grand theory dan alamat sejumlah jelas konsep terukur (misalnya,
hubungan terapeutik, kecemasan). Teori ini memiliki fokus khusus
 pada karakteristik dan proses hubungan terapeutik sebagai metode
keperawatan untuk membantu mengelola kecemasan dan mendorong
perkembangan yang sehat. Dengan demikian, model ini langsung
berlaku untuk penelitian dan praktek. Model Peplau adalah historis
signifikan untuk praktek dalam hal itu mendorong keperawatan
psikiatri dari perawatan kustodian berbasis antarpribadi hubungan
berbasis teori perawatan. Peplau dianggap sebagai pendiri profesional
psikiatri keperawatan kesehatan mental dan adalah yang pertama
untuk memulai suatu daerah praktik keperawatan canggih. Aplikasi
model ditemukan dalam psikoterapi individu, perawatan penyakit
terminal, dan kelompok dan terapi keluarga. Praktek berdasarkan
Peplau teori berkisar dari rumah sakit kepada masyarakat dan
keluarga. Pekerjaan teoritis Peplau juga telah mempromosikan
"paradigma profesionalisasi" dan pemberdayaan untuk mendidik
perawat untuk abad ke-21 (Sills, 1998). Secara internasional, perawat
mengakui warisan Peplau dan relevansi abadi teorinya untuk
keperawatan di milenium baru (misalnya, Barker 2000). Kebangkitan
keperawatan oleh ide-ide Peplau di tahun 1950-an berlanjut hari ini
melalui eksplorasi, studi, dan penggunaan praktek sciencebased teori
hubungan interpersonal. Beeber (1998) penelitian dan pengembangan
teori telah diperpanjang Model Peplau dalam cara yang penting,
menggunakan estetika mengetahui untuk menguraikan konsep pola
interpersonal dan meresmikan Peplau (1997) gagasan transisi dalam
teori praktek depresi. Tulisan metateoretis dari Peden (1998) dan
Reed (1996a), terinspirasi oleh strategi practicebased Peplau
pembangunan teori, meramalkan filosofi muncul ilmu keperawatan
bahwa sanksi dokter serta peneliti tradisional pengetahuan-
pembangun.

Judul : Examining peplau's pattern integrations in long-term care

Penulis : Schafer, Penny; Middleton, Joan. Rehabilitation Nursing 26.5
(Sep/Oct 2011): 192-7.
Analisis : Jurnal ini memperlihatkan bagimana terjadi perkembangan dari teori
peplau yang sebelumnya peplau terdiri dari Peplau mengidentifikasi
empat fase hubungan terapeutik: (a) orientasi, (b) identifikasi, (c)
eksploitasi, dan (d) resolusi. Tugas utama dari fase orientasi adalah
untuk mengidentifikasi masalah dan kebutuhan yang memotivasi
pasien untuk mencari bantuan. Selama fase identifikasi, perawat dan
pasien terus mengklarifikasi masalah dan pasien menilai kemampuan
perawat untuk membantu. Pasien mengidentifikasi dengan perawat
berdasarkan kebutuhan mereka untuk bantuan dan kemampuan
perawat untuk membantu. Tahap eksploitasi terjadi ketika pasien, atas
dasar kepentingan pribadi atau kebutuhan, membuat penuh
penggunaan layanan yang tersedia. Fase resolusi ditandai dengan
persepsi pasien kebutuhan baru sebagai kebutuhan asli terpenuhi.
Meskipun potensi perawat untuk berkembang secara profesional
melekat dalam hubungan terapeutik perawat-pasien, itu adalah
kebutuhan pasien yang tetap merupakan bagian terpenting hubungan
itu. Ketika kebutuhan dasar pasien terpenuhi, kebutuhan yang lebih
kompleks lainnya muncul. Sayangnya, ketika kebutuhan perawat
tidak diakui, mereka menjadi prioritas utama atau nya dan
mengharuskan fokus perawat tentang cara-cara di mana pasien adalah
memenuhi kebutuhan ini bukan pada kebutuhan pasien (Peplau,
1952). Perawat, kurang menyadari apa yang sebenarnya terjadi, tidak
cukup siap untuk menggunakan hubungan interpersonal untuk
meningkatkan pertumbuhan kepribadian pasien dan terkadang tidak
sengaja terlibat dalam pola berinteraksi produk itu atau meniru
patologi daripada meningkatkan pertumbuhan (Peplau, 1989a).
Peplau (1989b) mengidentifikasi empat konsep bahwa perawat harus
memahami dan gunakan untuk memastikan bahwa mereka terlibat
dalam "interpersonal aman praktik keperawatan": kecemasan,
interaksi pola, mandiri, dan cara mengalami. Interaksi Need-pola
yang dipertimbangkan di sini. integrasi pola Analisis terpisah
kemungkinan terbaik selesai dalam lingkungan di mana
perawatnyaman mendiskusikan reaksi pribadi, dan harapan mereka,
warga. Dengan demikian, hubungan yang mendukung dengan rekan-
rekan, daripada penyediaan perawatan, menjadi sarana bagi staf untuk
meredakan kecemasan yang terkait dengan bekerja sama dengan
penduduk muda. Meningkatkan sumber daya pribadi dan profesional
perawat dapat secara efektif dapat dicapai dengan memberikan
pelatihan khusus dalam komunikasi dan interaksi pola. Namun, biaya
pelatihan semua perawatdapat melebihi sumber daya keuangan dan
fasilitas perawatan jangka panjang. Alternatif akan membuat posisi
pada setiap lingkungan untuk individu terlatih khusus, seperti perawat
psikiatri, untuk menilai interaksi pola dan mempromosikan peluang
untuk pertumbuhan melalui interaksi yang sehat warga dan pengasuh.
 Dengan demikian, pergeseran penekanan dari kualitas pelayanan
terhadap kualitas hidup dan lingkungan kerja, akan tercapai.
Mempromosikan suasana di mana perawatbebas untuk memeriksa
reaksi mereka kepada penduduk, dan didukung dalam membuat
perubahan yang diperlukan dalam perilaku mereka, dapat mengurangi
kemungkinan reaksi pribadi menjadi bahan bakar patologi
memproduksi, kebutuhan-pola integrasi. Sebagai Peplau (1989a)
menegaskan, cara terbaik untuk mencegah menjadi tanpa disadari
terlibat dalam sehat membutuhkan-pola integrasi adalah untuk
perawat menyadari harapan mereka pegang warga.

C. Pembahasan Jurnal
Dari kedua jurnal diatas dapat dilihat perkembangan dari teori Peplau. Dimulai pada
tahun 1940-an Peplau merumuskan ide-ide teoritis nya tentang proses terapi keperawatan
dan pada tahun 1952 Peplau menerbitkannya dalam buku tentang Hubungan
Interpersonal dalam Keperawatan. Menurut Peplau struktur hubungan interpersonal
yang awalnya digambarkan dalam empat fase: orientasi, identifikasi, eksploitasi, dan
resolusi (Peplau, 1952). Pada tahun 1991 dengan dukungan dari Peplau, Forchuk
menjelaskan struktur hubungan interpersonal terdiri dari tiga tahap utama: orientasi,
bekerja (yang dimasukkan identifikasi dan eksploitasi), dan terminasi. Dalam publikasi
tahun 1997, Peplau mendukung ini tampilan tiga fasa dan menjelaskan bahwa fase yang
tumpang tindih, masing-masing memiliki karakteristik yang unik. Pada tahun 1997 juga
Peplau mengatakan bahwa “Hubungan perawat-pasien sangat penting untuk memberikan
asuhan keperawatan dan bersumber dari kebutuhan manusia akan keterhubungan yang
masih penting dalam abad ke-21”. Pada tahun 1998 Sills menyatakan bahwa teori Peplau
telah mempromosikan "paradigma profesionalisasi" dan pemberdayaan untuk mendidik
perawat untuk abad ke-21. Beeber (1998) penelitian dan pengembangan teori telah
diperpanjang Model Peplau dalam cara yang penting, menggunakan estetika untuk
menguraikan konsep pola interpersonal yang diresmikan oleh Peplau pada tahun1997
yang merupakan gagasan transisi dalam teori praktek keperawatan terhadap depresi.
Kebangkitan keperawatan oleh ide-ide Peplau di tahun 1950-an berlanjut hari ini melalui
eksplorasi, studi, dan penggunaan praktek sciencebased teori hubungan interpersonal.
Tulisan metateoretis dari Peden (1998) dan Reed (1996a), terinspirasi oleh strategi
practicebased Peplau pembangunan teori, meramalkan filosofi muncul ilmu keperawatan
bahwa sanksi dokter serta peneliti tradisional pengetahuan-pembangun. Secara
 internasional, perawat mengakui warisan Peplau dan relevansi abadi teorinya untuk
keperawatan di milenium baru (misalnya, Barker 2000). Hal diatas dapat membuktikan
bahwa pengembangan empiris tentang model konseptual dari teori Peplau. Model teoritis
Peplau dapat dikategorikan sebagai middle range theory. Hal ini sempit dalam lingkup
dari model konseptual atau grand theory dan alamat sejumlah jelas konsep terukur
(misalnya, hubungan terapeutik, kecemasan). Peplau mendefinisikan Manusia sebagai
suatu organism yang berjuang dengan caranya sendiri untuk mengurangi ketegangan
yang disebabkan oleh kebutuhan. Lingkungan budaya dan adat istiadat merupakan factor
yang perlu dipertimbangkan dalam menghadapi kehidupan. Kesehatan merupakan
simbol kata yang menyiratkan gerak maju kepribadian dan proses manusia lainnya yang
sedang berlangsung ke arah kreatif, konstruktif, produktif, hidup pribadi dan komunitas.
Keperawatan adalah hubungan manusia antara individu yang sakit atau membutuhkan
pelayanan kesehatan, dan perawat terutama dididik untuk mengenali dan merespon
kebutuhan bantuan.

D. Kekuatan dan kelemahan dalam aplikasi masing-masing peminatan

1. Kelebihan.

a. Dapat meningkatkan kejiwaan pasien untuk lebih baik.

b. Dapat menurunkan kecemasan klien dalam teori keperawatan.
c. Dapat memberikan asuhan keperawatan yang lebih baik.
d. Dapat medorong pasien untuk lebih mandiri.

2. Kelemahan
a. Berfokus pada kejiwaan pasien dalam penyembuhannya.
 BAB III
PENUTUP

A. Kesimpulan

Pada tahun 1940-an Peplau merumuskan ide-ide teoritis nya tentang proses terapi
keperawatan dan pada tahun 1952 Peplau menerbitkannya dalam buku tentang
Hubungan Interpersonal dalam Keperawatan. Menurut Peplau struktur hubungan
interpersonal yang awalnya digambarkan dalam empat fase: orientasi, identifikasi,
eksploitasi, dan resolusi (Peplau, 1952). Pada tahun 1991 dengan dukungan dari Peplau,
Forchuk menjelaskan struktur hubungan interpersonal terdiri dari tiga tahap utama:
orientasi, bekerja (yang dimasukkan identifikasi dan eksploitasi), dan terminasi. Dalam
publikasi tahun 1997, Peplau mendukung ini tampilan tiga fasa dan menjelaskan bahwa
fase yang tumpang tindih, masing-masing memiliki karakteristik yang unik. Model
teoritis Peplau dapat dikategorikan sebagai middle range theory. Hal ini sempit dalam
lingkup dari model konseptual atau grand theory dan alamat sejumlah jelas konsep
terukur (misalnya, hubungan terapeutik, kecemasan).
B. Saran
Seperti yang kita ketahui bahwa manusia dipandang sebagai sistem holistic yang terdiri
dari bio-psiko-sosial-spiritual. Pada teori Peplau ini mempunyai kelemahan yaitu lebih
menitikberatkan pada keperawatan jiwa, hal ini dapat dibuktikan pada gagasan Peplau
yang di kembangkan pada pemantapan perkembangan kepribadian.

DAFTAR PUSTAKA

Reed, Pamela G, Shearer, Nelma B. 2006 . Peplau's Theoretical Model. New York: Springer
Publishing Company. Search.proquest.com. diakses 26 September 2014.
Schafer, Penny; Middleton, Joan. 2011. Examining peplau's pattern integrations in long-term
care. United Kingdom : Blackwell Publishing Ltd. Search.proquest.com. diakses 26
September 2014.
Hidayat, A. Aziz Alimul. 2004. Pengantar Konsep Dasar Keperawatan. Jakarta : Salemba
medika.
Lampiran
Peplau's Theoretical Model
Reed, Pamela G ; Shearer, Nelma B . New York: Springer Publishing Company, 2006.
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Hildegard Peplau (1909-1999) formulated her theoretical ideas about the therapeutic process
of nursing in the 1940s and published them in the now-classic 1952 book, Interpersonal
Relations in Nursing, after a lengthy dispute with publishers about the ability of a nurse to
author a book. At a time when nurses were "doers" for patients and "followers" of physicians'
orders, Peplau's theoretical work and teachings helped catapult nursing from an occupation to
a profession. Peplau's ideas provided a foundation for nurses to understand health from a
nursing theoretical perspective and to establish interpersonal relationships with patients as the
significant context in which nurses facilitate patients' well-being.
Through Peplau's therapeutic relationship, the patient develops inner resources for healthy
behaviors by actively participating with the nurse in a developmental process of change.
Peplau's interpersonal relationship is also a process through which nursing knowledge is
developed and validated (Reed, 1996b). Peplau (1992) purposefully linked her theory to
practice and research, as evidenced in her basic assumption that "what goes on between
people can be noticed, studied, explained, understood, and, if detrimental, changed" (p. 14).
Peplau's theoretical model derives from the perspective of a critical philosophy that integrates
both the science and practice of nursing in theory development. Peplau's theoretical model
was based upon her study, observation, and analyses of nurses and patients and was
influenced by Harry Stack Sullivan and others' psychodynamic perspectives. Peplau's (1952)
classic descriptions of nursing express the nature and goals of the interpersonal process:
"Nursing is a human relationship between an individual who is sick or in need of health
services, and a nurse especially educated to recognize and to respond to the need for help"
(pp. 5-6). Nursing is an "educative instrument, a maturing force, that aims to promote
forward movement of personality in the direction of creative, constructive, productive,
personal, and community living" (p. 16). Peplau (1988) further described nursing as an
"enabling, empowering, or transforming art" (p. 9). Health, according to Peplau (1952), is a
"word symbol that implies forward movement of personality and other ongoing human
processes in the direction of creative, constructive, productive, personal and community
living" (p. 12). Illness forces a "stocktaking by the sick person, which nurses can use to
promote learning, growth and improved competencies for living" (Peplau, 1992, p. 13).
Health and illness are closely linked to successful management of anxiety, which ranges from
pure euphoria to pure anxiety. An optimal level lies between these anxiety extremes, as
determined by nurse and patient.
Through the therapeutic relationship, the nurse uses a complex set of strategies to assist the
patient in using energy provided by the anxiety to identify and grow from a problematic
situation (O'Toole Sc Welt, 1989; Reed, 2005). The nurse-patient relationship is fundamental
to providing nursing care and derives from the human need for connectedness that is still
essential in the 21st century (Peplau, 1997). Through this interpersonal relationship, nurses
assess and assist people to: (a) achieve healthy levels of anxiety intrapersonally and (b)
facilitate healthy pattern integrations interpersonally, with the overall goal of fostering well-
being, health, and development. This relationship also provides the context for the nurse to
develop, apply, and evaluate theory-based knowledge for nursing care. Nurse interpersonal
competencies, investigative skill, and theoretical knowledge as well as patient characteristics
and needs are all important dimensions in the process and outcomes of the relationship
(Peplau).
The structure of the interpersonal relationship was originally described in terms of four
phases: orientation, identification, exploitation, and resolution (Peplau, 1952). Forchuk
(1991), with the support of Peplau, clarified the structure as consisting of three main phases:
orientation, working (which incorporated identification and exploitation), and termination. In
a 1997 publication, Peplau endorsed this three-phase view and explained that the phases were
overlapping, each having unique characteristics. Throughout these phases the nurse functions
cooperatively with the patient in the nursing roles of stranger, resource person, counselor,
leader, surrogate, and teacher. The nurse's range of focus includes the patient in relationship
with the family, other health care providers, and community (Peplau, 1952, 1997).
The orientation phase marks a first step in the personal growth of the patient and is initiated
when the patient has a "felt need" and seeks professional assistance (Peplau, 1952, p. 18). The
nurse focuses on "knowing the patient as a person" and uncovering erroneous preconceptions,
as well as gathering information about the patient's mental health problem (Peplau, 1997).
The nurse and patient collaborate on a plan, with consideration of the patient's educative
needs. Throughout the process, the nurse recognizes that the power to accomplish the tasks at
hand resides within the patient and is facilitated through the workings of therapeutic
relationship.
The focus of the working phase is on: (a) the patient's efforts to acquire and employ
knowledge about the illness, available resources, and personal strengths, and (b) the nurse's
enactment of the roles of resource person, counselor, surrogate, and teacher in facilitating the
patient's development toward well-being (Peplau, 1952, 1997). The relationship is flexible
enough for the patient to function dependently, independently, or interdependently with the
nurse, based on the patient's developmental capacity, level of anxiety, self-awareness, and
needs.
Termination is the final phase in the process of the therapeutic interpersonal relationship.
Patients move beyond the initial identification with the nurse and engage their own strengths
to foster health outside the therapeutic relationship (Peplau, 1952, 1988). In addition to
addressing closure issues, the nurse and patient engage in planning for discharge and
potential needs for transitional care (Peplau, 1997).
Peplau's theoretical model can be categorized as a middle-range theory. It is narrower in
scope than a conceptual model or grand theory and addresses a clearly defined number of
measurable concepts (e.g., therapeutic relationship, anxiety). The theory has a specific focus
on the characteristics and process of the therapeutic relationship as a nursing method to help
manage anxiety and foster healthy development. As such, the model is directly applicable to
research and practice.
Peplau was explicit in promoting researchbased theory. Research based on Peplau's
theoretical model has addressed topics related to both nurse behaviors and patient health
conditions. Nurse-focused topics include: (a) the practices of psychiatric mental-health
nurses, (b) family systems nursing, and (c) the nature of the nurse-patient relationship in
reference to roles and role changes over the trajectory of a mental illness, boundary issues in
pediatric nursing, and concepts such as therapeutic intimacy. Patient-focused research has
addressed health conditions including depression, psychosis, sexual abuse, Alzheimer's
disease, and multiple sclerosis. A particularly notable Peplau-based researcher is Forchuk
(e.g., Forchuk, 1994; Forchuk et al., 1998; Forchuck, Jewell, Tweedell, Sc Steinnagel, 2003)
who, along with colleagues, has conducted a program of research into applications of the
interpersonal relationship process in psychiatric mental-health nursing care.
Peplau's model is historically significant for practice in that it propelled psychiatric nursing
from custodial-based care to interpersonal relationship theory-based care. Peplau is
considered the founder of professional psychiatric mental-health nursing and was the first to
initiate an area of advanced practice nursing. Her theoretical ideas continue to be significant
in contemporary nursing for their relevance in not only psychiatric mentalhealth nursing
practice but practice anywhere a nurse-patient relationship exists. Applications of the model
are found in individual psychotherapy, reminiscence therapy, terminal illness care, and group
and family therapy. Practices based upon Peplau's theory range from hospital to community
and home-based.
Peplau's theory has provided an enduring educational foundation for teaching the nurse-
patient relationship as a pivotal nursing process in all contexts of practice. A common
philosophy underlying all nursing curricula is a belief in the value of a therapeutic nurse-
patient relationship that promotes active participation of patients in their health care. Peplau's
theoretical work has also promoted a "paradigm of professionalization" and empowerment
for educating nurses for the 21st century (Sills, 1998).
Peplau's theoretical model continues to influence nursing research, practice, and education
(O'Toole Sc Welt, 1989), although her original contributions have become knowledge in the
public domain and are not always explicitly acknowledged. Internationally, nurses are
recognizing Peplau's legacy and the enduring relevance of her theory for nursing in the new
millennium (e.g., Barker [2000]). The clinical significance of the therapeutic relationship is
likely to increase as health problems shift to those related to stress-related conditions, chronic
illness, aging processes, and end of life, where medical-surgical approaches alone have little
success in promoting well-being. Peplau's interpersonal relationship theory is expected to
withstand the current health care crisis and provide a cost-effective and satisfying resource
for patient well-being across a variety of nursing contexts.
The reawakening of nursing by Peplau's ideas in the 1950s continues today through
exploration, study, and use of the sciencebased practice of interpersonal relations theory.
Beeber's (1998) research and theory development have extended Peplau's model in important
ways, using aesthetic knowing to elaborate on the concept of interpersonal pattern and
formalizing Peplau's (1997) idea of transitions in a practice theory of depression.
Metatheoretical writings of Peden (1998) and Reed (1996a), inspired by Peplau's
practicebased strategy of theory development, portend an emerging philosophy of nursing
science that sanctions clinicians as well as traditional researchers as knowledge-builders.
Through the creative scholarship of nurses, Peplau's theoretical model can continue to evolve
and inspire development of nurse-patient processes that meet contemporary health needs of
society.
PAMELA G. REED
NELMA B. SHEARER
AuthorAffiliation
Pamela G. Reed, PhD, RN, FAAN
Professor
University of Arizona
College of Nursing
Tucson, AZ
Peplau's Theoretical Model; Spirituality
Nelma B. Shearer, PhD, RN
Assistant Professor
College of Nursing
Arizona State University
Tempe, AZ
Peplau's Theoretical Model
Word count: 1571
Copyright Springer Publishing Company 2006
Examining peplau's pattern integrations in long-term care
Schafer, Penny; Middleton, Joan. Rehabilitation Nursing 26.5 (Sep/Oct 2011):
192-7.

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Contrary to the societal view that only the frail elderly reside in long-term care facilities,
many young adults who require residential care to maintain optimal health, or who are in a
rehabilitation program, also live in these facilities. The relationships between residents and
caregivers in long-term care facilities may develop into relationships that are more typically
familial than professional. With these emerging family-like relationships, the interpersonal
pattern interactions may be healthy or unhealthy and may create opportunities for growth or
pathology-producing patterns. This article illustrates how applying Peplau's concept of need-
pattern integrations in the long-term care setting has the potential to enhance understanding,
and subsequently guide interactions, between younger residents and caregivers. The potential
is greatest when interactions are guided.
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Headnote
Key words
interpersonal theory, therapeutic relationships, power
Headnote

Contrary to the societal view that only the frail elderly reside in long-term care facilities,
many young adults who require residential care to maintain optimal health, or who are in a
rehabilitation program, also live in these facilities. The relationships between residents and
caregivers in long-term care facilities may develop into relationships that are more typically
familial than professional. With these emerging familylike relationships, the interpersonal
pattern interactions may be healthy or unhealthy and may create opportunities for growth or
pathology-producing patterns. This article illustrates how applying Peplau's concept of need-
pattern integrations in the long-term care setting has the potential to enhance understanding,
and subsequently
Headnote

guide interactions, between younger residents and caregivers. The potential is greatest when
interactions are guided.
Headnote

Penny Schafer is a group coordinator for the Aggressive Behavior Control Program at the
Regional Psychiatric Centre (Prairies) in Saskatoon, SK, Canada. Her research has examined
therapeutic relationships and therapeutic boundary maintenance. Joan Middleton is a clinical
nurse specialist at Parkridge Centre in Saskatoon. She has worked in long-term care and
education for 20 years. Her specialty areas are behavior management and mental health
nursing. Her major research is on pain in the communicatively impaired elderly. Address
correspondence to Penny Schafer, 327 Eastman Cove, Saskatoon, SK S7N 4L1, Canada or e-
mail p.schafer@sk.sympatico.ca.
Peplau (1989a) argued that pattern integrations was a useful concept with which to assess
interaction patterns and to then intervene to produce growth-promoting patterns in an
inpatient psychiatric setting. Although mental illness is not typically a factor that precipitates
admission to long-term care, pattern integrations appear to have utility in long-term care.
Using vignettes of younger adults who live in long-term care environments to maintain their
optimal health, or to receive rehabilitation services, we illustrate here how Peplau's (1989a)
need-pattern integrations concept has the potential to enhance understanding between
caregivers and residents and guide their interactions. Once guided, interactions promote
growth, and the residents' physical and psychosocial needs remain central to the emerging
relationship.
Long-term care facilities become the homes of those people who reside in them, and in living
together, as family, they share the available resources. Long-term care residents are generally
dependent to some degree on the assistance of other people. Thus, the care they receive, and
those who provide that care, become their most valuable resources. Understandably, the
interaction between residents and caregivers may develop into relationships that are more
typically familial than professional (Middleton, Stewart, & Richardson, 1999). Additionally,
relationships between residents may also acquire many of the characteristics more typical of
those relationships between family members. Consequently, long-term care facilities become
the areas where both caregivers and residents recreate the patterns of interacting that
characterized previous experiences. Just as it happens in families, the emerging interpersonal
pattern interactions may be either healthy or unhealthy, may create growth promoting
opportunities or result in pathology-producing pat-. terns (Peplau, 1989a).
Peplau's interpersonal theory, typically applied in psychiatric nursing (Forchuk, 1993), also
has applications in long-term care, where caregivers may unknowingly participate in patterns
that do not foster growth for the facility's residents. A complete review of Peplau's (1952)
interpersonal theory is beyond the scope of this paper. Yet, a summary is not likely to provide
the detail necessary for the reader to master the need-pattern concept that is applied
extensively here. The following material is a very brief overview of Peplau's interpersonal
theory, and a synopsis of the concept need-pattern integrations.
Peplau's interpersonal theory of nursing
When the nurse-patient relationship is central to the provision of care, the focus shifts from
doing "for" patients to doing "with" patients (Forchuk, 1993). Peplau's (1952) theory
emphasizes the individual's personal-social growth, rather than the problem necessitating
care. In providing care and attempting to resolve the presenting problem, the nurse
establishes with the patient a relationship that becomes the means through which the patient
can achieve growth in personality development. Peplau identified four phases of the
therapeutic relationship: (a) orientation, (b) identification, (c) exploitation, and (d) resolution.
The primary task of the orientation phase is to identify the problem and the needs that
motivated the patient to seek help. During the identification phase, the nurse and patient
continue to clarify the problem and the patient assesses the nurse's ability to help. Patients
identify with the nurse based on their need for help and the nurse's ability to help. The
exploitation phase occurs when the patient, on the basis of self-interest or need, makes full
use of services available. The resolution phase is characterized by the patient's perceptions of
new needs as the original needs are met.
Although the potential for the nurse to grow professionally is inherent in the nurse-patient
therapeutic relationship, it is the patient's needs that remain central to that relationship. When
the patient's basic needs are met, other more complex needs emerge. Unfortunately, when the
nurse's needs are not recognized, they become his or her top priority and require that the
nurse focus on the ways in which the patient is meeting these needs rather than on the
patient's needs (Peplau, 1952). The nurse, less aware of what is actually occurring, is not
adequately prepared to use interpersonal relations to promote the patient's personality growth
and may unintentionally engage in patterns of interacting that produce or replicate pathology
rather than enhance growth (Peplau, 1989a). Peplau (1989b) identified the four concepts that
nurses must understand and use to ensure that they are engaging in "interpersonally safe
nursing practice": anxiety, pattern interactions, self, and modes of experiencing (Table 1).
Need-pattern interactions are considered here.
Pattern integrations
Peplau (1989a) defined a pattern as a "characteristic mode of behavior" (p. 108), with an aim,
intention, or theme. A pattern may be intrapersonal, interpersonal, or a system phenomena.
Consequently, pattern interactions are the interactions between two or more patterns, and
pattern integration is the merging of patterns. In need-pattern integration, there is a fit
between the patterns of two or more individuals so that needs of all are met. In essence, the
merging of patterns is necessary for the whole to function, because a disruption in the pattern,
such as when a person is admitted to long-term care, provokes panic, anxiety, and attempts to
reinstate the pattern integration. For example, the individual who always carried a wallet, and
had the power to purchase desired items, upon entering long-term care suddenly loses the
independence and power associated with carrying cash. The facility's business office is now
the keeper of the individual's cash, and the agency potentially gains power over the
individual. The loss of independence and power provokes anxiety in the individual, who may
then begin to hoard items and become suspicious of caregivers and other residents. Such
behavior may restore a sense of power and independence, and reduce the individual's anxiety,
but it creates the potential for further problematic pattern integrations.
Peplau (1989a) identified four types of pattern integrations: mutualities, complementaries,
reciprocal or alternating, and antagonistic. Mutualities are patterns such as mutual
withdrawal, dependency, or hostility. Complementaries are pattern integrations that fit
together, such as domination and submission. Reciprocal or alternating patterns of
integrations are those where the pattern reverses, with the resident becoming the helper, and
the caregiver becoming the person receiving help, or having personal needs met. Finally,
antagonistic pattern integrations occur when the patterns of two individuals, groups, or
organizations do not fit, yet a relationship is maintained--consider the interpersonal need-
pattern integrations that emerge in a long-term care setting.
Interpersonal need-pattern integrations: There are different need-pattern integrations apparent
to an observer of the interactions between long-term care residents and caregivers. The most
problematic patterns appear to be between residents and caregivers, rather than between
residents. This is not surprising, given the complexity of the relationships between residents
and caregivers.
Between residents. Mutual dependence frequently emerges as need-pattern integration
between residents. Depending upon one another for support, socialization, and manipulation
of their environment may enhance relationships among residents. Conversely, the pattern of
mutual hostility that sometimes emerges between two residents, or between one resident and
a group of residents, is problematic. Mutual hostility may take the form of verbal or physical
attacks, hurtful gossip, and complaints to caregivers. Most often, the mutual hostility appears
to center on a competition among residents for the caregiver's time or favor, as residents may
organize their behavior to gain the caregiver's approval (Peplau, 1989c). For example, a
resident may ask a caregiver, "Why do you give all the attention to her?"; the response from
the other resident, and not the caregiver, may be "You're just jealous 'cause she [the caregiver]
likes me better."
Caregivers may unwittingly perpetuate patterns of mutual hostility among residents.
Embracing residents' complaints about other residents perpetuates the pattern integration.
Furthermore, residents may selectively complain about, or direct hostility at, residents who
they perceive caregivers are reacting to personally. By doing so, a resident may form an
alliance with a caregiver by being a vehicle for that caregiver to express feelings that cannot
be expressed directly, and thereby ensure the resident's continued satisfaction of personal care
needs. Caregivers who are focused solely on the residents' physical care needs, and are
unaware of the interaction patterns emerging, are unwittingly drawn into these nontherapeutic
interaction patterns.
The patterns between residents are not occurring in isolation. Rather, they are affected by the
caregivers. Therefore, growthpromoting interactions must be context specific and must stem
from a thorough assessment and analysis of the interactions between caregivers and residents,
and between residents. While it may be the aim of the residents to ensure that they receive
adequate and equitable care, caregivers may be struggling to cope with conflicting feelings
toward the residents, especially if the residents are verbally or physically aggressive.
Between residents and caregivers. There is a multitude of need-pattern integrations that may
emerge between residents and caregivers because of the complexity of their relationships.
Caregivers have positions of power over residents, who are particularly vulnerable because of
their dependence on them. Furthermore, when residents are unable to direct their personal
care, having those needs met may conflict with their need for autonomy. Consequently, just
as did the physically disabled in Lillesto's (1997) study, long-term care residents may
experience personal care as a violation, transgression, or infringement upon them by those
who provide their care. Yet, caregivers do not expect that residents will view the care as a
violation. Rather, they may expect that residents will accept, comply with, and appreciate the
care. Caregivers, unaware that they have these expectations, may unwittingly aim to have
them fulfilled (Peplau, 1989a). The potentially conflicting needs of the residents, coupled
with the expectations and the power of caregivers, creates an environment in which the
potential for problematic need-pattern integrations may be greater than the potential for
interactions that promote autonomy and independence.
With the intent of having their personal care needs met while they maintain a sense of
autonomy, long-term care residents may attempt to control their care by asserting power over
the caregivers. Aggression and demanding behavior may be the means used to assert their
power and maintain control. Joking at their own expense, compartmentalizing the personal
care experience by viewing their bodies as public, or daydreaming while specific care is
being provided (Lillesto, 1997) may also be ways that residents cope with the conflict
between maintaining autonomy and feeling violated in receiving personal care. For example,
a resident may enlist the family, or even politicians, to help ensure that their care needs are
met in a manner that is consistent with their wishes.
The resident who is aggressive and demanding is unlikely to meet the caregiver's
expectations. The latter may view the resident as difficult and unappreciative, reflecting a
tendency to label patients as either good or bad, based on whether the patients meet the
caregiver's expectations (Kelly & May, 1982). This may result in a need-pattern integration of
mutual hostility, whereby the resident's intention is to assert autonomy through aggression,
and the caregiver responds by setting limits. While this may temporarily enhance resident
compliance, and fulfill the caregiver's expectations, setting limits may also perpetuate the
pattern by increasing the resident's vulnerability, and threatening his or her sense of
autonomy. Feeling vulnerable, residents become more aggressive in their efforts to assert
autonomy.
Caregivers, in addition to expecting residents to be compliant, and implicit in their need to
help others, is their expectation that residents will respond to the care that they receive. This
may be particularly true when the resident does not fit the stereotypical image of a long-term
care resident. The typically societal view of such residents is that of older adults (Middleton,
1994) who are unable to live independently and may be alone or without family willing to
care for them. This view is likely held by caregivers working in long-term care.
Consequently, few caregivers are prepared to provide care for younger residents. Residents
are admitted to long-term care for different reasons. For young adults, admission may result
from head or spinal cord injuries, or the progression of a terminal disease. For the young
resident recovering from trauma, rehabilitation is the objective of both the resident and
caregivers. With young adults, caregivers may be unable to separate their feelings about the
care they are providing from their feelings about the care they would expect if they, or a
member of their family, were entering long-term care.
Consequently, the care they provide becomes the means used to relieve their anxiety over
interpersonal relationships (Peplau, 1989c) with residents who provoke feelings about the
uncertainty of their own futures. Caregivers may go out of their way to help the resident, not
to promote the resident's independence, but to relieve their own anxiety and despair when
they picture themselves, or a loved one, as a long-term care resident. Young adults in long-
term care may learn that the best way to help relieve a caregiver's anxiety, which is
communicated interpersonally (Peplau, 1989c), is to need them. Consequently, dependence,
rather than independence is encouraged, and this conflicts with caregiver expectations that
the residents will improve as a result of their care. The methods used to relieve the anxiety in
the interpersonal situation has, as Peplau (1952) argued, interfered with the development of a
growth-promoting relationship between the resident and caregiver.
As time passes and the resident's progress does not meet the challenges of community living,
caregivers are left with unmet expectations, and they may view this as both a personal and
professional failure. Facing their own potential to become a longterm care resident,
caregivers are disappointed personally when a resident fails to regain independence.
Additionally, caregivers must question the effectiveness of their care when residents do not
progress as expected. As Peplau (1989a) stressed, the caregiver's unmet expectations, and the
pain of acknowledging the discrepancy between the help they believe they provide, and the
resident's progress, may be expressed as hostility toward, or emotional withdrawal from, the
resident.
Caregivers may complain about the resident who does not progress as they expect. They may
see requests as demands for special attention, or simply whining, and dependence may
become manipulation. What was once a complementary need-pattern integration of
dependence and anxiety relief for the caregiver may become a mutual pattern of hostility or
emotional withdrawal. Caregivers may respond to a resident's perceived demands by setting
limits and providing care that is less personal than that given when expectations were being
met. Caregivers may be reluctant to respond to a call light, hoping for a response from
another caregiver. The resident may respond by monitoring the care provided for others, and
demanding equal care, while complaining about the care they do receive. Ironically, in some
cases, the resident's pattern of dependence that is now perceived by the caregiver as evidence
of failure by both resident and self was, in fact, perpetuated by the caregiver. The potential for
interactions to replicate or produce pathology (Peplau, 1989a) is realized.
Residents who cope with the potentially conflicting needs for personal care and autonomy by
withdrawing may perpetuate mutual withdrawal patterns. Yet, as with aggression and
demanding behavior, withdrawal is not likely to meet caregiver expectations, nor is the
emerging pattern of mutual withdrawal a growth-promoting pattern. Some residents may fear
the withdrawal of care. They may not be satisfied with the care they are receiving, yet they do
not feel safe voicing concerns to their caregivers. Consequently, they accept the care
provided, without expecting additional care. They may stay in their rooms, or leave the unit
to avoid the risk of displeasing or having hostile interactions with caregivers.
Many interactions between residents and caregivers are public. Residents may have seen
hostile interactions between other residents and caregivers, interactions that may have
resulted in limit setting and the temporary withdrawal of care. This withdrawal is threatening
to people who are dependent on caregivers to meet their personal care needs, regardless of
how temporary it may be or the events that precipitated it. However, the temporary
withdrawal of care is a very effective way to demonstrate power and control, and to
temporarily reestablish a need-pattern integration of submission-domination. Although this
may be threatening and demoralizing to residents, it may also be the only way caregivers can
prevent feeling powerless and demoralized. For many, residents and caregivers alike, mutual
withdrawal is a pattern preferable to mutual hostility, or the antagonistic pattern of needs for
independence, autonomy, and control by the residents, with the pattern of needs for
domination, control, and power by the caregivers.
While mutual hostility and withdrawal are often observed in the long-term care setting, the
most frequently observed need-- pattern integration is that of the complementary pattern of
domination-submission (Peplau, 1989a). The residents' dependence on caregivers to have
their personal care needs met makes them particularly vulnerable. Some residents are
apologetic for their dependence, an indication of their submissiveness (Peplau, 1989a) and
willingness to comply with their caregivers' expectations. For as long as the caregiver has
needs to dominate, the pattern that emerges will be complementary. However, in long-term
care the need-pattern of domination-submission may not occur in isolation. A reciprocal
need-pattern integration, whereby the residents meet the caregivers' need to maintain a sense
of control over their work, may be occurring simultaneously. Residents may avoid making
requests while complying with all expectations, and never fail to express gratitude for the
care they receive. In essence, the residents ensure the continued provision of personal care by
fulfilling the needs of caregivers to be needed and to be in control.
Reciprocal need-pattern integrations may develop based on different caregiver needs (Peplau,
19$9a). Perhaps one of the most potentially complex needs is the caregiver's need to validate
his or her sexual attractiveness. Flattery and flirting may be used by residents to meet that
need. However, the residents also have a need to express their sexuality. Caregivers may tell
sexual jokes to residents, or sexualize their relationship with the resident. Given that both
resident and caregiver have these needs, would the resulting need-pattern integrations be
problematic?
A man who had been a long-term care resident believed that female caregivers used him to
express and validate their sexuality because they viewed him as safe. He was not expected to
act on any sexual feelings that he may have experienced toward his female caregivers. After
all, he was wheelchair-bound, and he believed that others viewed him as unable to act on his
sexual feelings. Furthermore, to respond sexually toward caregivers would have been
considered inappropriate. Ironically, he was challenged to achieve a balance between
validating his caregivers' sexual attractiveness, while not being overtly sexual. The need--
pattern integration that emerged was reciprocal rather than mutual, with the resident meeting
the needs of the caregiver.
The highly structured activity and treatment schedules of many long-term care residents
leaves little room for flexibility or sequencing of the daily tasks completed by people who
work as attendants to the residents. For example, this group of caregivers may be required to
prepare patients for physical therapy so that the therapists can make maximum use of their
time. If residents are not prepared for the scheduled therapy or activity, it may be canceled or
postponed, and the attendants are held responsible. This contributes to a discrepancy between
the levels of their responsibility and their authority. In essence, the attendants are powerless,
except that they can assert power over the residents who depend on them for care. Residents
need to maintain a sense of control or autonomy over their care, yet the people providing the
care do not have the authority to be flexible in meeting the residents' personal care needs.
Consequently, the personal care choices that attendants can offer residents are limited.
Without choices, residents have few options with which to meet their needs for autonomy and
control over their personal care. In such a context, patterns of domination-submission are
more likely to be promoted, rather than patterns of interacting in which the care to be
provided is negotiated between resident and caregiver.
In addition to the disparity between the levels of responsibility and authority of attendants,
staff in long-term care facilities is often encouraged to fulfill surrogate family roles for the
residents. Staff members may be asked to go shopping for residents or to spend extra time at
work during holidays to meet the needs of residents who do not have families. Some staff
members may take residents to their own homes for some of the holiday season. When staff
fulfills surrogate family roles, the line between professional and personal relationships may
become blurred, and the potential for a dual relationship is increased. Dual relationships,
whereby attendants maintain both a personal and professional relationship with the residents,
appear to be a sociocultural expectation of caregivers in long-term care. Clearly, the context
of care influences the need-pattern integrations that emerge in long-term care. However, to
examine all possible patterns on a system level is beyond the scope of this article and is likely
of limited utility to the reader, given the diversity of care delivery systems. Instead, we
examined how the concept need-pattern interaction (Peplau, 1989a) can guide interactions
between residents and caregivers so that interactions are not random, but rather are guided
and growth-promoting.
Guided interactions: Need-pattern integrations that emerge in long-term care have been
examined here on the interpersonal level. Intervening on that level may require increasing the
personal and professional resources of caregivers. Peplau (1989a) maintained that the ability
to identifying problematic patterns varied among professionals. Once caregivers have an
understanding of need-pattern interactions, application involves gathering data from multiple
sources, making a detached analysis to identify the pattern, identifying the role of staff in the
pattern, and deciding what needs to change (Peplau, 1989a). The vignette in Table 2
illustrates this process.
Team meetings or case conferences may be the best method for gathering data from multiple
sources. When problem behaviors are identified, caregivers need to be encouraged to describe
the behavior, the staff's response, and subsequent resident and staff responses, if relevant data
is to be collected. Completing a detached analysis can be particularly challenging when
hostility and aggressive behaviors are involved and when caregivers are unaware or
uncomfortable with their reactions to residents. Developing a checklist, or a list of questions
related to the common problematic patterns, may enhance a detached analysis.
For example, a checklist to identify and analyze potential patterns of dominance and
submission might include the following questions: Is the resident apologetic for requiring
assistance? Does the resident offer gifts or excessive gratitude for care received? What are the
resident's needs? What self-image may the resident be attempting to maintain? What is the
role of caregivers? What are the caregivers' expectations of this resident? Is there a healthier
way for the resident to meet this need? What does staff need to change?
A detached analysis is likely best completed in a setting where caregivers are comfortable
discussing personal reactions to, and their expectations of, residents. As such, supportive
relationships with colleagues, rather than the provision of care, become a means for staff to
relieve anxieties associated with working with younger residents.
Increasing the personal and professional resources of caregivers may effectively be achieved
by providing specialized training in communications and pattern interactions. However, the
cost of training all caregivers may exceed the financial resources of many longterm care
facilities. An alternative would be to create a position on each ward for a specially-trained
individual, such as a psychiatric nurse, to assess pattern interactions and promote
opportunities for growth through healthy interactions of residents and caregivers. Thus, a
shift in the emphasis from quality of care to quality of life and work environment, would be
achieved. Promoting an atmosphere where caregivers are free to examine their reactions to
residents, and are supported in making necessary changes in their behavior, can reduce the
likelihood of personal reactions becoming the fuel of pathology-producing, need-pattern
integrations. As Peplau (1989a) asserted, the best way to guard against being unwittingly
involved in unhealthy need-pattern integrations is for the caregiver to be aware of the
expectations they hold of residents.
Sidebar

There is a multitude of need-pattern integrations that may emerge between residents and
caregivers because of the complexity of their relationships.
Sidebar

The highly structured activity and treatment schedules of many long-term care residents
leaves little room for flexibility or sequencing of the daily tasks completed by people who
work as attendants to the residents
References

References
References

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Peplau, H.E. (1989b). Interpersonal relationships: The purpose and characteristics of
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References

This continuing education offering (code number RNC-184) will provide I contact hour to
those who read this article and complete the application form on page 202. This independent
study offering is appropriate for all rehabilitation nurses.
References

By reading this article, the learner will achieve the following objectives:
1. Define Peplau's concept need-pattern integration and list the four types of need-pattern
integrations.
2. Identify the concepts essential for interpersonally safe nursing practice according to
Peplau.
3. Describe the steps used to intervene in non-growthpromoting patterns.
Copyright Association of Rehabilitation Nurses Sep/Oct 2011