Hildegard Peplau was a nursing theorist who published the theory of interpersonal relations in 1952. During her early years of nursing, she had a passion for integrating psychology into (what seemed at the time) a very task-oriented state of nursing. She furthered her education through her master's degree and became a faculty member at Rutgers University for 20 years. There she created the first graduate program for ‘clinical nurse specialists’ in psychiatric nursing, and in 1968 her interpersonal techniques became the core of psychiatric nursing (Spray, 1999).
Peplau's interpersonal theory is applicable to all types of nursing practice; however, it is particularly relevant in psychiatric nursing due to the fact that most psychiatric patients have difficulty communicating and trusting their providers (Peplau, 1992). Interpersonal techniques encompass skilled verbal interventions aimed at accomplishing a deepened nurse-patient relationship, problem resolution, and confidence building in patients through joint efforts of understanding and treating their perceptions of problems (Delaney et al, 2017; Peplau, 1992).
Although aesthetic nursing does not currently fall into the psychiatric field of medicine, there are several reasons why it could potentially be sub-categorised as so. Because these procedures are not medically necessary, the impact of these procedures fall within the psychological domain (Sarwer, 2012). Secondly, aesthetic procedures are not covered by insurance, thus the typical patient needs to have the means, or their desire must be so profound that the means becomes secondary (Sobanko et al., 2015). Lastly, studies show that cosmetic medicine profoundly affects the psyche. For instance, Sommer and colleagues (2003) found that 80 percent of patients reported that cosmetic injectable treatments had been ‘beneficial’ to them; 50 percent reported greater confidence; 30 percent reported that their emotional wellbeing had improved; and 20 percent expected improvements at work following their treatment.
Taking an interpersonal point of view, almost one-third of aesthetic patients had a ‘major life event’ such as divorce or death of a spouse the preceding year, and almost 50 percent were receiving counselling from a mental health specialist during the time of their treatment, with 25 percent of the patients taking some sort of psychiatric medication during such periods. When compared to same age, non-aesthetically motivated patients, these numbers were considered approximately four times higher (Sobanko et al, 2015). This suggests the possibility that a higher percentage of patients seeking cosmetic treatments may struggle from a personality disorder, an increase in insecurities and anxieties, or some form of dysmorphia; at the very least, they could be searching for fulfilment from an external source (Sobanko et al, 2015).
Peplau's views of interpersonal relations synchronises with the field of cosmetic medicine for many reasons. Peplau is a proponent of spending time with a patient to deduce their clinical as well as emotional needs (Peplau, 1992). When the success of cosmetic treatments was studied, patients reported higher satisfaction with their treatments if the treating provider spent quality time interacting with them (Sobanko et al., 2015). For Peplau's theories to be implemented successfully, especially with the fragile psyche of a patient, it takes time and deduction from clinical data as well as the patient's psychological needs to take place (Peplau, 1992). For example, very relevant psychological diagnosis such as body dysmorphia disorder, trypanophobia, trichotillomania, social appearance anxiety, or generalised anxiety are more likely to be disclosed when the patient has spent time with a clinician and trusts them. From the author's personal experience, aesthetic nurses generally spend anywhere from 15 to 30 minutes per appointment, rarely spending over an hour with their patients. This is simply not enough time to address all the necessary teaching and credentialing.
Aesthetic medicine should encompass more time with the patient than general medicine wherever the billing of insurance is involved. During this orientation, there are several courses of action that need to take place. Based on the patient's response to those actions, the clinician can proceed with the physical or psychosocial path they see most fit for treatment (or non-treatment if the patient is not suitable) (see adaptation of Peplau's conceptual theory map for aesthetics).
Nursing theory addresses the psychological health of aesthetic patients
Using Peplau's Interpersonal Theory, the psychological aspect of the patients can be addressed. Peplau is an advocate of allocating quality time with a patient so that practitioners can surmise their patient's emotional needs (Peplau, 1992). In the 2021 Journal of Cosmetic Dermatology, an article entitled ‘Development of a multiphasic, cryptic screening protocol for body dysmorphic disorder (BDD) in cosmetic dermatology’ aimed to examine the use of a screening protocol on mitigating unsatisfactory outcomes among high-risk patients. In this study, the screening protocol for body dysmorphic disorder was provided to eight aesthetic clinics in the U.S. This anonymous, cryptic pre-screening form was given to all incoming patients. Anyone who had suspected or subclinical body dysmorphic disorder was denied treatment if deemed unsuitable. This screening tool was found helpful to identify individuals who may have BDD, thus encouraging communication between patient and healthcare provider. 100% of the sites stated they would continue to take the time to screen for psychological disorders after this study concluded (Fletcher, 2021).
» … a higher percentage of patients seeking cosmetic treatments may struggle from a personality disorder, an increase in insecurities and anxieties, or some form of dysmorphia; at the very least, they could be searching for fulfillment from an external source «
If practitioners are encouraged to screen for BDD, the potential diminishes for an unsatisfactory outcome and possible litigation against the practitioner; as well as having an impact on an earlier diagnosis with possible intervention for the patient.
The theoretical concept of nursing
Nursing is defined by Peplau as ‘a human relationship between an individual who is sick or in need of health services’ (Peplau, 1991: 56). The fact that her definition of nursing included the additional need for health services implies her value of health promotion (Peplau, 1992).
Her value of interpersonal communicative relationships and its ability to teach, grow, and reduce anxiety relate to past experiences. Using energy for healing, Peplau believes that interpersonal behaviour is purposeful and can offer patients their universal need for security (Peterson, 2017).
Noteworthy is that although Peplau's theories are predominantly applied to psychiatric nursing, Peplau's intent was for them to be a refreshing assistance to nurses of all ‘specialties’. As she stated in her book, ‘the purpose of this text is to aid graduate nurses and nursing students to improve their relations with patients….in order that their work will be more effective and socially useful’ (Peplau, 1991: ix).
Phases of the nurse-patient relationship
The nursing process is described by Peplau as ‘an investigative sequence of stages in problem solving utilized in nursing care’ (Peplau, 1992:16), and it is ‘an interpersonal interaction process’ (Peplau, 1992:16). There are three phases of the nurse-patient relationship, which may overlap or work in conjunction at times. The objective of these is to secure the interpersonal relationship (Fernandes and Miranda, 2016):
The orientation phase
Peplau stated that the ‘orientation phase is especially important as it sets the stage for the serious workload is to follow’ (Peplau, 1992: 14). The nurse is to use the orientation phase to determine the patient's psychological needs as they pertain to their treatment needs (Delaney et al, 2017). In aesthetic nursing, it is during this stage that the treating clinician should be observing for signs of BDD and other relevant psychological disorders before treatment commences. In the author's experience, patients are generally anxious during their initial consultation for aesthetic treatments; occasionally, they may have had previous negative experiences and may be dealing with something similar to post traumatic stress syndrome with regard to injections. In these cases, the time the nurse spends as a counsellor, resource expert, teacher, leader, and surrogate may need to be extended to ease them past their anxiety (Peterson, 2017). Studies have shown that the more time a provider takes in listening and exploring the patient's needs, the more involved the patient will be in the decision-making process and they may have an increase in satisfaction with the interaction (Wills, 2010). It is during this extended phase that the clinician decides, via observation or screening, if the patient may or may not have BDD. When the clinician spends ample time observing and screening during orientation phase, the chances are higher that BDD or other psychological disorders such as anxiety could be successfully identified.
In a study, Peplau's Interpersonal Relations Model (IRM) was randomly applied to 60 patients and not applied to the other 60 patients going in for surgery. The level of anxiety of patients both pre and post operation using the IRM was statistically lower than the control (non IRM) group (Erci et al, 2008). Peplau herself stated that ‘anxiety is also transmitted interpersonally, by way of empathic observation, the ability to feel in oneself the tensions and emotions which another person in the same situation is experiencing’ (Peplau, 1992: 17).
The working phase
The better the stage is set in the orientation phase, the more likely the working phase will be successful (Peplau, 1992). The working phase is where all major therapeutic treatments are implemented (Nelson, 2017). This is done through problem-solving, such as utilising known resources and innovating some unknown therapeutic resources offered in a controlled environment (Nelson, 2017). The aim of the working phase is to ‘promote favourable changes in patients’ (Peplau, 1992). In the case of aesthetic nursing, this phase is when the procedures are performed. If ample time is spent preparing the patient, such as using baseline, standardised photography and setting reasonable expectations for a successful treatment, the treatment will be perceived as more successful.
The resolution phase
The freeing resolution phase is where the nurse and patient mutually agree that services are no longer needed and/or the patient is left with a maintenance plan for continued health (Nelson, 2017). This echoes with Peplau's (1992) words: ‘the relationship is an interpersonal process. It has a starting point, proceeds through definable phases, and being time-limited, has an end point’ (Peplau, 1992: 14). In the case of aesthetic treatments, occasionally it is a challenge for patients to see the changes for the better in their aesthetic treatments. Their perception is the only reality they can see. If the practitioner takes the time to show the patient their before and after images with objective tools (such as using a wound-measuring ruler to show the height of a brow), the patient may have an easier time visualising changes or improvements. Once these improvements are made and perceived, resolution may take place. From the author's personal experience in aesthetic nursing, however, the goal is to have an ongoing healthy nurse-patient relationship as opposed to ending it since treatments need to be maintained at regularly scheduled intervals.
Separate nursing roles
As described by Peplau (and as slightly mentioned earlier), there are multiple roles of nursing:
- The stranger role: the nurse approaches the prospective patient the way a stranger would, offering them respect and interest.
- The resource role: the nurse supplies answers to necessary questions, interprets data for use in the professional context.
- The teaching role: the nurse offers additional information and provides training according to the patients' learning level.
- The counselling role: the nurse actively listens and observes, offering guidance and encouragement so that psychological change can occur.
- The surrogate role: the nurse recognises the countertransference of past experiences and teaches new ways of reacting to those
- The technical expert role: the nurse understands the medical functions and can provide direction and advocacy for physical care for the patient (Peterson, 2017).
With a goal of interpersonal relationships for patients in mind, nurses have many hats to wear from role models, to advocates, to the director of treatment plans (Kuzub and Kuzub, 2004). It is also important to offer a non-judgemental acceptance of our patients, show understanding and a willingness to listen, and put personal points of view aside (Kuzub and Kuzub, 2004). Making our visits with our patients as purposeful and therapeutic as possible follows Peplau's theories (Kuzub and Kuzub, 2004).
So, how are these roles best implemented when the patient loads are high and time is scarce? Nurses have expressed that they wish they could spend more time with patients, however their tasks and patient load seem to take over in importance (Delaney et al, 2017). Perhaps the time needs to be reallocated to more time spent uninterrupted, leaving the patient feeling like they are the only patient on the schedule that day.
In the author's personal experience, hiring a medical assistant can really help in terms of making more time for patients. Tasks for such an assistant could include: to help clean the rooms in between patient visits, to prepare the patient and apply ice or sunscreen afterwards, or to scribe the notes from the visit so that the nurse could devote full attention to nourishing interpersonal relationships with the patient.
Having an interpersonal connection is more than basic question and answering. There is also an element of nonverbal communication skills, sense of touch, personal involvement and simply making a patient feel special (Marshall, 2003). Patients often disclose that they felt there was a disconnection between themselves and the staff, stating that they felt their nurses were too busy, too focused on tasks, or not taking the time to delve into meaningful conversations. Some go on to note that they simply wish that their nurses would offer an authentic response (Delaney et al, 2017).
Conclusion
The theory of interpersonal relationships provides a relevant viewpoint, which encompasses the psychological factors that affect patients who chose to undergo any sort of elective, cosmetic procedure. Peplau's theory emphasises the relevance of implementing a therapeutic relationship before the elective choice can truly be considered an ‘informed consent’. In a therapeutic relationship, the nurse and the patient synchronise to determine a problem and develop the best strategy to overcome that problem (Peplau, 1991). In aesthetic nursing, this exact interaction happens during the lengthy consultation phase. The patient attempts to articulate their most bothersome trait, and the nurse helps determine how to effectively minimise this trait. If not all tasks are accomplished during this orientation phase, it is challenging to successfully move to the working or resolution phase.
The tremendous association that interpersonal relationships have in aesthetic nursing can be summarised in a quote: ‘in nursing the aesthetic is not primarily that experienced by the practitioner, the aesthetic is found in the beauty and meaning associated with the patient's experiences of health and healing—the phenomena of concern to nursing. The aesthetic is what is desired, meaningful, beautiful—whether it is an experienced through the art of a painter, a musician, or a nurse’ (Reed, 1995: 80).