Peplau’s Interpersonal Relation Nursing Model
Explain the Effect of Using Peplau’s Interpersonal Relation Nursing Model in the care of a juvenile delinquent
Effect of Using Peplau’s Interpersonal Relation Nursing Model in the care of a juvenile delinquent Crime is defined as the entire range of unlawful behaviors that have existed throughout the history of humanity. Criminal behavior can be observed in every stage of human development. However, given that individuals under 18 years of age are generally recognized as children, the exhibition of unlawful behaviors by individuals 18-years-old and younger is termed “delinquent” behavior.[1,2] Data from the literature indicate that the majority of delinquent children are boys and that in 79% of cases, the history of delinquency behavior starts between the ages of 10 and 15. Delinquent juveniles are found to be guilty of crimes are not only judged within the legal system, but they also frequently come under the care of psychiatry clinics due to a number of mental disorders. Research shows that the prevalence of the type of delinquency and the observed mental disorder related to each type differ in these children. In a study conducted by Moore, Gaskin and Indig involving delinquent juvenile-adolescents, it was reported that 78% of the juveniles had received at least one mental diagnosis, while 44.7% had received at least two mental diagnoses. Şenses et al., in their study, examined delinquent juvenile-adolescents who had committed property crimes and found that 63% of the adolescents had at least one mental diagnosis. The most common mental disorders observed in delinquent children and adolescents include post-traumatic stress disorder,[6,8] behavioral disorders,[9,10] attention deficit hyperactivity disorder (ADHD),[7,11,12] and depressive disorders.[7,13,14] In the clinics, both general psychiatric nurses and adolescent psychiatric nurses The shaping of nursing care within a specific theoretical framework is important in terms of contributing to the improvement of the quality of care. The aim of this case study is to determine the role of therapeutic interaction and communication in the case of a child delinquent by applying Peplau’s Interpersonal Relations Theory. The case under question involves a 15-year- old juvenile delinquent who had a preliminary diagnosis of depression and was receiving care at a child-adolescent psychiatry clinic. A total of eight semi-structured interviews were conducted with the patient between February and March 2018. The data were collected using semi-structured interview forms prepared by the researcher after conducting a review of the literature. The data were evaluated within the framework of Peplau’s Interpersonal Relations Theory. After undergoing a long period of treatment and care, the patient was discharged with a commitment to take responsibility for his life. Keywords: Case reports; nursing care; juvenile delinquency. Leyla Baysan Arabacı, Gülsenay Taş Division of Nursing, Department of Mental Health and Psychiatry Nursing, İzmir Katip Çelebi Unıversty Faculty of Health Sciences, İzmir, Turkey Abstract What is known on this subject? • The shaping of nursing care within a theoretical framework is important insofar as it contributes to increasing the quality of care. What is the contribution of this paper? • Peplau’s theory provides a convenient approach to performing nursing care directed at developing a therapeutic patient-nurse relationship with delinquent juveniles. What is its contribution to the practice? • Peplau’s Theory of Interpersonal Relations, as an approach to analyze the relationship established with patients and to solve communicationbased problems, is suggested for nursing care. Leyla Baysan Arabacı, Effect of using model in care / dx.doi.org/10.14744/phd.2019.54366 219 are involved in the treatment and care of delinquent juveniles who have a psychiatric diagnosis. In general, nursing applies a humanistic approach of help that is based on a holistic understanding of health care. Yet, nursing is not only based on helping and providing care, it also has a theoretical foundation based on science and art. Hildegard E. Peplau, who provided major contributions to the formation of the theoretical basis of psychiatric nursing, defined the significance of the patient-nurse relationship in her Theory of Interpersonal Relations, which she developed in 1952, where she proposed that the therapeutic relationship established between the nurse and the patient forms the basis of nursing care. According to Peplau, the most significant factor in this relationship is that the communication between the patient and the nurse be based on trust. The understanding that the problems identified and resolved based on the patient/nurse relationship serve as the basis for psychiatric nursing and that holding to this understanding is effective when providing patient care was applied in practice after Peplau introduced the theory, and since then, many researchers have contributed to the body of knowledge on nursing care based on her theory. In Turkey, the theory is used in the care of mentally disabled individuals. A study performed on the care and consultancy process applied based on Peplau’s nursing approach that involved the participation of individuals diagnosed with post-traumatic stress disorder evaluated the coping skills of individuals. Çunkuş and Taşdemir-Yiğitoğlu provided nursing care based on Peplau’s theory to a patient with attention deficit hyperactivity disorder and determined that there was a significant increase in the patient’s trust and belief in and motivation for the treatment process. The same study emphasized that the transformation of the theory into practice was helpful and effective for the psychiatric nurses in fulfilling the patient’s requirements. The purpose of case studies is to describe a case as accurately as possible. Case studies are significant in that they contribute to improving the care quality of nursing. Providing nursing care within a theoretical/model framework could contribute to the development of the nursing profession as a science and the practical use of the theory. In the light of this information, considering that providing care to a delinquent child and establishing therapeutic communication with them may involve many difficulties and ethical problems for a psychiatric nurse, in some cases, the building of a relationship on trust between the patient and nurse could be jeopardized. In these situations, equipping psychiatric nurses with scientific-based and/ or evidence-based care (for instance; providing care based on a model) could allow them to overcome these difficulties and ethical problems in a simple way. Providing this type of care within the framework of scientific theories can contribute to the development of the therapeutic relationship between the patient-nurse. Thus, this case study aims to determine the role of therapeutic interaction and communication in the care of delinquent children. Peplau’s theory of “Interpersonal Relations” was used to determine this relationship. Hildegar Peplau’s Theory of Interpersonal Relations Peplau stressed that many nursing problems can be overcome through strong interpersonal relations. In the Theory of Interpersonal Relations she developed, she identified four distinct stages in the patient-nurse relationship, namely, orientation, identification, exploitation, and resolution (Fig. 1). In addition, continuous evaluations should be performed in each stage. Orientation: This is the stage where the patient seeks help, and the nurse identifies the problem and supports the patient in recognizing their problem. It is particularly important at this stage that a relationship of trust be established between the nurse and the patient, as this helps to reduce the anxiety of the patient. Identification: This stage involves the processes of planning and determining goals. With the start of a good relationship, the nurse gives the patient the opportunity to open their emotions and channels their emotions in a positive direction. This is important to meet the needs of the patient. Exploitation: At this stage, assuming that a good relationship has been established between the patient and nurse, the patient needs to be informed to such a degree whereby they can now cope with their problem(s). Furthermore, at this stage, professional cooperation takes place, and the patient-nurse relationship matures. The “Therapeutic relation” develops once the patient takes responsibility and is active in communication. Resolution: At this phase, the patient is expected to be successful in all of the activities discussed. Here it is important to ensure that the patient does not develop any dependency on the nurse. As the patient now has the capacity to make individual decisions, the patient-nurse relationship ends at this stage. Model-Based Nursing Care in a Delinquent Child Case In this case, the effect of the care provided was evaluated using Peplau’s theory of “Interpersonal Relations”. Two nurses On admission During intensive treatment period Convalescence and rehabilitation Discharge ORIENTATION IDENTIFICATION EXPLOITATION RESOLUTION Fig. 1. The stages of the nurse-patient relationship. 220 Psikiyatri Hemşireliği Dergisi – Journal of Psychiatric Nursing with different educational backgrounds and clinical experiences provided care to an adolescent patient with a history of delinquency and a medical disorder diagnosis at a child and adolescent psychiatry clinic. During this period of care, three days of the week, Peplau’s theory of interpersonal relations was applied by a nurse who was in the process of undergoing specialist training and therapy training, while on the other days routine care was provided by the service nurse. The nurse applying Peplau’s theory conducted 30-40-minute interviews with the patient when he was at the clinic. Outside of the time of the interviews, the patient participated in service activities and was followed up. Interventions were performed within the context of the nursing diagnosis defined. Socio-demographic Data and Medical History: S.Ö. (pseudonym used for the patient) is a 15-year-old male patient who was admitted to the child-adolescent psychiatry clinic with a depression pre-diagnosis and suicidal ideations. The environment he resides in is of a low socio-economic status and has higher substance use rates compared to that of other living areas. He has a history of delinquency that includes multiple offenses, including bodily harm, theft, and robbery. He committed bodily harm with a knife twice. The judicial trial of the patient, who has a criminal record, is still in process. In addition, he has a history of substance use. He stated that he does not go to school, that he works in a bakery, and that his father has alcohol issues and commits violence against his mother. He has two brothers. Orientation: From the model/theory-based clinical interview conducted between the adolescent/patient and the nurse, who is currently still in the process of undergoing specialist training, the following information was obtained: According to the patient’s own statement, he has committed acts of delinquency 13–14 times (bodily harm, theft, and robbery). He further stated that he and his friends did not stay at home, and that he committed theft out of a desire to steal. He expressed that he did not enjoy life, was not happy and did not laugh, and that there was nothing that he enjoyed doing. It was observed through the patient’s discourse that he had a blunted sense of emotion and that when he spoke he did not make any eye contact. He indicated that he had a hot temper and difficulty controlling his anger. Regarding his feelings, he expressed generally negative ones, like hopelessness, disappointment, and anger. He believed that since he had a criminal record he would not be able to succeed in life anymore nor even continue his education. Therefore, he felt that after being discharged from the clinic, he would not be able to change in his life and that he would continue to use substances. Identification: A trust-based relationship was established between the specialist nursing student and the adolescent patient, and the patient’s history and his existing problems were defined. Within the context of these identified problems, the nursing diagnosis, which was based on the NANDA taxonomy system, the Nursing Diagnosis Handbook, and Nursing Diagnoses, Interventions, and Outcomes, was defined as follows.[23,24] • Suicide Risk • Lack of Impulse Control • Ineffective Coping • Impaired Social Interaction • Low Self-Respect • Ineffective Health Management • Hopelessness Exploitation: The nursing interventions planned for the problems determined in the identification phase were applied and evaluated (Table 1). Now that a good relationship had been established based on trust, the patient was allowed to participate in the care process in accordance with the information received from the healthcare team. However, in the ongoing care process, when the patient exhibited maladaptive behavior, the service nurse responsible for providing care to the patient reminded him of the clinic norms. In those times that the patient exhibited these behaviors, it was observed that he felt that he was not being understood, and his bursts of anger were associated with the feeling of obstructiveness. It was further observed that these bursts of anger would occur when the patient felt that he was being prevented from doing something, and after several incidences of this, it started to form a vicious cycle. As a result of insufficient communication with the patient, there were two incidences when the relationship built on trust between the nurses and the patient broke down. Following these episodes, it was observed that the patient had difficulty communicating and had conflicts inside the clinic, and there was a decline in his relationship of trust with the healthcare team. Resolution: In addition to the treatment processes of the patient inside the clinic, the semi-structured one-to-one interviews and interventions conducted by the nurse in training to define the emotions experienced by the patient helped to increase the patient’s motivation for and belief in life, and he participated in his care by determining two major life objectives (go on to school, desist from substance use) and made decisions related to his treatment processes. After 23 days of hospitalization, the patient was discharged by request of the doctor. During the discharge process, the nurse in training interviewed him to determine his life objectives, while the service nurse performed the routine discharge preparations. During the discharge process, a verbal agreement was made with the patient that he would come to routine checks after his discharge from the clinic. Ethical Considerations The patient was informed that the interviews would be used for scientific purposes, and verbal and written approvals were obtained from the patient and his family prior to conducting the case study. The required permissions were obtained from the institution where the research was performed (approval no. 76379986-604.01.02).