Improving Subject Recruitment, Retention, and Participation in Research through Peplau’s Theory of Interpersonal Relations
Sue Penckofer, RN;PhD,1Mary Byrn, RN, BSN,2Patricia Mumby, RN;PhD,3 and Carol Estwing Ferrans, RN; PhD; FAAN4
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Recruitment and retention of persons participating in research is one of the most significant challenges faced by investigators. Although incentives are often used to improve recruitment and retention, evidence suggests that the relationship of the patient to study personnel may be the single, most important factor in subject accrual and continued participation. Peplau’s theory of interpersonal relations provides a framework to study the nurse-patient relationship during the research process. In this paper the authors provide a brief summary of research strategies that have been used for the recruitment and retention of subjects and an overview of Peplau’s theory of interpersonal relations including its use in research studies. In addition, a discussion of how this theory was used for the successful recruitment and retention of women with type 2 diabetes who participated in a clinical trial using a nurse-delivered psychoeducational intervention for depression is addressed.
Keywords: Peplau, research recruitment, research retention
Participant recruitment and retention is essential for successful research, and this process begins with a trusting relationship. Peplau’s theory of interpersonal relations (1952, 1991, 1992, 1997) is a framework that can be used successfully during the various phases of the nurse-patient relationship or as described in this paper, the nurse-participant relationship. The purpose of this paper is to illustrate how Peplau’s theory of interpersonal relations was used for the recruitment, retention, and participation of women with type 2 diabetes who enrolled in a clinical trial using a nurse-delivered psychoeducational intervention for depression (Penckofer, Ferrans, Byrn, Mumby, & Lustman, 2009). First, however, an overview of recruitment and retention strategies cited in the literature and a discussion of Peplau’s theory is provided.
Recruitment and Retention Strategies
Successful retention begins at recruitment (McFarlane, 2007). One innovative retention strategy includes project identity so that participants recognize the project and the materials associated with the project from beginning to end (Goldberg & Kiernan, 2005). Froelicher and colleagues (2003) stated that the commitment of study participants can be enhanced by personal trust with the study staff. They delineated a number of retention strategies grouped according to enrollment, phone contact, and follow-up visits, but stated that there is no magic bullet. Mapstone, Elbourne, and Roberts (2007) identified 15 research trials that examined effective methods of recruitment, and reported that trials with monetary incentives were beneficial. In addition to money, incentives for retention may include certificates, t-shirts, motivational phone calls, and a party at the end of the program (Voyer, Lauzon, Collin, & O’Brien, 2008). One study reported that the demographic characteristics of age and race were predictors of retention (Ariail, Watts, & Bowen, 2006). Others have reported that treating participants as individuals (Good & Schuler, 1997), knowing participants’ characteristics (personal, health, and available resources) (Keller, Gonzales, & Fleuriet, 2005), and treating participants with respect (Kerllenevich, Noller, & Bibace, 2005) were important for successful retention. Andresen (2007) stated that researchers need to examine their own values and beliefs to ensure that that they do not conflict with those of the study participants. She discussed the concept of relational engagement, and how this engenders study bias if the investigator is not cautious. Others have stated that knowing what participants want and need, and making them feel important is fundamental to successful recruitment and retention (Improve your site’s subject retention, 2008).
Perhaps one of the most potent motivators for participation is the altruistic desire to help others (Andresen, 1997). In addition to altruism, African Americans identified getting better care, newer treatments, free medications, and stipends as possible advantages for participation. They also identified missing work, changing their usual routine, not having child-care, treatment side effects, and being treated like a guinea pig as reasons for not participating (Kennedy & Burnett, 2007). Partnering with community-based agencies, using multimedia approaches, and ensuring cultural sensitivity have been reported to optimize recruitment (Taylor-Pilae & Froelicher, 2007). Staffileno and Coke (2006) reported that advertisements and flyers are successful for recruitment, but the importance of the community cannot be underestimated. They stated that establishing trust, cultural sensitivity, and demonstrating a strong sense of caring are essential.
Peplau’s Theory of Interpersonal Relations
According to Peplau, trust between the nurse and the person is essential in the nurse-patient relationship. The environment must be conducive for this trusting relationship to develop. In a research context, one of the key roles of the nurse is to provide the facts about the research study so that there is a clear understanding of the person’s participation and to ensure that there is not undue anxiety.
Peplau believed that nurses have an important role in helping people to reduce their anxiety (Forchuk, 1991; Kuhns, 2007). She also believed that the relationship of the person and the nurse significantly influences the outcomes of care (Peplau, 1952, 1991). She described participant observation in which the nurse, the patient, and their relationship are all part of the experience necessary to promote the patient’s health (Peplau, 1997). She believed that both the nurse and the patient have beliefs and experiences that they bring to the interpersonal relationship. If nurses fail to recognize the individual needs of persons, they have their own needs met, but not those of the persons (Gastmans, 1998). In addition, by knowing the individual needs of the person, the nurse helps to establish caring interactions that are necessary for the nurse-patient relationship.
Peplau’s theory of interpersonal relations was developed from her clinical work with psychiatric patients (Peplau, 1992). She credited Harry Stack Sullivan (1953), a psychoanalyst who created the psychiatry of interpersonal relations. He believed that mental disorders often resulted from inadequate communication. Sullivan thought that when persons interact, they share an interpersonal field rather than act as sole entities and that anxiety could be a disruptive force in this relationship. He stated that the environment needed to be considered in the treatment of patients. Thus, the manner in which treatment was delivered changed from that of observer to that of participant-observer. From his work, the term therapeutic environment or therapeutic milieu evolved (Kuhns, 2007).
Peplau believed that nurses were key to fostering the therapeutic milieu. In fact, she believed that nurses needed to interact with the person as a “human being, with respect, empathy, and acceptance” (Kuhns, 2007, p.308). Peplau described the structure of the nurse-patient relationship as one of building trust and helping persons to begin to identify problems (orientation phase), assisting patients to work on their problems, which may include providing physical care, health teaching, and counseling (working phase), and finally providing closure of their work together (termination phase) (Peplau,1997).
Previous researchers have used Peplau’s theory of interpersonal relations to guide their research. Significant work has been done by Forchuk and colleagues in understanding the orientation phase of the nurse-patient relationship (Stockmann, 2005). Forchuk and Brown (1989) developed and tested the Relationship Form, an instrument to measure the phases of the nurse-client relationship, in a community mental-health promotion program. Forchuk (1992) also examined the length of time needed to progress patients with mental illness through the nurse-patient relationship. She reported that those patients who remained in the orientation phase longer also had longer hospitalizations. Forchuk (1994) has also studied interpersonal relations in persons with persistent mental illness using nurse-patient dyads. She determined that preconceptions held by the nurse and the patient influenced relationship development. More recently, she examined factors that influence the movement of the nurse-patient relationship from the orientation phase to the working phase (Forchuk et al., 1998, 2000).
Researchers have also used Peplau’s theory as a guide in examining persons with depression. Peden (1993) reported that the use of Peplau’s theory to study depression is appropriate because depression may be the result of existing in an environment that lacks factors necessary for human development. She conducted a descriptive, exploratory study of seven women who were once hospitalized for depression. Using a qualitative method, women were asked to “talk about the days they began to recover.” She reported that the women experienced growth and improved self-esteem as they reflected on their experience with their depression, and that support from others (professionals and family members) was important for their recovery. Using their previous work with young depressed women, Beeber and Caldwell (1996) developed and tested an intervention to treat depressed women using the Interpersonal Theory of Peplau (Beeber & Charlie, 1998). Following an average duration of 11 weeks, there was an improvement in depressive symptoms that was correlated with their self-efficacy and self-esteem. However, because of the small sample (N = 33) and lack of a control group, other factors could have contributed to their improvement. The researchers could not find any published studies using Peplau’s theory as a strategy to recruit and retain participants in a research study for depressed women.
Peplau’s Interpersonal Theory for Successful Participant Recruitment and Retention
The Study of Women’s Emotions and Psychoeducational Program (SWEEP) was a clinical trial for the treatment of depression in women with diabetes (Penckofer, 2008). Women who had depressive symptoms were randomized to either an eight week nurse-delivered group intervention for the education and treatment of dysphoric moods (depression, anxiety, and anger) or usual care. Traditional cognitive behavioral theory, not Peplau’s theory, was used to develop the treatment intervention. However, Peplau’s theory was used to guide recruitment, participation, and retention in this longitudinal clinical trial. For the SWEEP study, women were seen at baseline, and then at 3 and 6 months following enrollment. Overall retention rate was 86% for participants. Strategies for the recruitment, participation, and retention of our study subjects will be described relative to the three phases of Peplau’s framework. Throughout each of these phases, it should be clear that the elements of successful recruitment and retention include: gaining and maintaining the participant’s trust, demonstrating a sense of caring, and respecting and valuing the contribution of the individual to the interpersonal relationship.
Three Phases in Peplau’s Relationship Theory
This is the time that the nurse and participant will have their first encounter. According to Peplau (1997), the nurse should identify herself and her professional status, as well as the purpose of the interaction, in this case the research project. The orientation phase for the study included phone recruitment, a baseline enrollment visit, and the first few weeks of the SWEEP program. In the study reported here, phone recruitment was the first step to building trust. When participants called about the study, the nurses asked how they found out about the study. Participants were asked to describe why they called to participate. Through this interaction, the nurses were able to understand their needs. Sometimes as reported by Kennedy and Burnett (2007), potential participants were seeking medical care, but were informed that the study was not a replacement for their medical care. If they were in need of healthcare (mental or physical), they were directed to their healthcare provider. And, if they did not have a healthcare provider, a contact list was provided.
Next, the SWEEP program was described and participants were informed that they would be randomly assigned to either the group that gets the nursing intervention or the group that does not. It is during this time that participants must understand that they may not get the nursing intervention. On one occasion, a potential participant stated that she would only participate if she was given the treatment. In this situation the person was advised to decline participation. If patients were interested in the study, they were informed that a health screening would be conducted to determine their eligibility for participation. It was important to let the persons know that because of exclusionary criteria, they might not be eligible for participation. Upon conclusion of the phone screening, all participants were told how valuable their contribution had been, and were thanked for their interest and their time. If they were eligible, they were informed that a letter would be mailed providing detailed information regarding their first study visit.
As identified by Goldberg and Kiernan (2005), branding is important for recruitment so that participants remember the study. The brand for the SWEEP study was a decorative broom that indicated that the program was for “cleaning the mind of negative thoughts.” During the baseline visit, participants were directed to the study site by bright signs that stated “SWEEP” study, and the logo was placed on all study materials. Upon their visit, the nurses reiterated the purpose of the study and explained the informed consent document. They were given adequate time to review, process, and ask questions regarding the consent and their participation in the study. A caring environment was provided by skilled nurses who did the laboratory and physical measurements. Subsequently, participants were directed to a private room where breakfast was provided and they completed the self-administered questionnaires. The booklets were checked for missing data to determine if it was accidental or intentional (prefers not to answer); the desire not to answer questions was always respected. Upon completion of the data collection, every participant (treatment and control) was given a stipend. We provided a personal thank you card that included monetary compensation for their time as well as a parking token. Women were paid for their data collection points using a stepped compensation method (each return visit payment was higher than the previous one) to demonstrate that we valued their time and continued participation. During the visits, trust was building between nurses and participants.
Once randomization was complete, all participants were called and their assignment was discussed. At this time, some persons who did not receive the treatment expressed disappointment. It was important for them to voice their concerns; however, the nurses reiterated the random assignment process and reminded them that they were extremely valuable to the study. All participants were sent a personal letter regarding their study group assignment and a depression resource list. Keeping contact was important to trust-building.
For participants who began treatment in the SWEEP program, further trust-building occurred, particularly in the first week of class. In order to ensure familiarity among the group participants, name tags were used and self-introductions were performed. Participants were informed about ground rules for the SWEEP program: (a) Everyone will have a turn to talk if they want; (b) try to listen without interrupting; (c) share your experiences but don’t give advice; (d) everyone is different and entitled to their own opinions; and (e) personal issues that are discussed in the class should stay in the class, unless it involves safety and then we are required to take steps to try and insure safety for the individual. They were also asked if any additions or changes were needed for these rules. This was done to provide a respectful, caring, and secure environment so that persons could be successful in the program. During the first class, an overview of the program was provided. All participants were given a blue bag with SWEEP program materials (dates of the meetings, the phone numbers for the group leaders, and space for the weekly class handouts and homework). At the completion of the first class, a rose ceremony was performed. This included giving each participant a live rose decorated with ribbons to thank them for attending. The rose was also symbolic of the growth they would experience on their journey through the program.
All group sessions were taped so that the researchers could review the verbal participation in the nurse-participant relationship. By doing so, it provided an opportunity to gain better understanding of her role in the group. Peplau (1997) emphasized that it is imperative that the nurse be cognizant of the needs of the person, and not utilize the relationship to have their own personal needs met. “The main focus of the nurse’s attention is on the patient, listening, hearing what is said, and asking, who-, what-, where-, and when-type questions to stimulate the patient’s descriptions and stories” (Peplau, 1997, p. 164).
The working phase of the relationship begins as the nurse allows the patients to learn about their current health condition, understand their condition, and identify what is required for them to care for themselves (Peplau, 1997). During this time in the research program, it was important that the views of the participants be respected and heard. It was also important that differing views were voiced and discussed. Thus, continued reference to the group rules was important. Peplau viewed nursing interventions as those that “assist patients in gaining interpersonal and intellectual competencies beyond those that they had at the onset of illness, and such competencies evolve through the nurse-patient relationship” (Peden, 1998, p. 174). The nursing role during the working phase includes that of health teaching which builds upon and augments what the patient already knows. In addition, it is during this phase that counseling skills of investigative inquiry and attentive listening are implemented by the nurse (Peplau, 1997).
During the SWEEP program, participants were educated about the signs and symptoms of dysphoric moods (depression, anxiety, anger), how to identify these emotions, and how to manage these emotions using traditional cognitive behavioral therapy (Beck, 1995). Management skills included stress relaxation, changing negative thinking, communicating effectively with others, and examining the impact that relationships have on emotions. Homework is an important component of cognitive behavioral therapy (Cowan et al., 2008). Participants were encouraged to complete homework assignments that reinforced the skills they learned each week (Figure 1). The homework was an excellent tool for participants to practice new skills and for the nurse to focus discussion for the following session. Voluntary sharing of the homework was encouraged so women could learn from each other. This was important as it also provided an opportunity for women to support each other. The homework was turned in after each session, reviewed by the nurse, and returned at the next class session. Positive handwritten comments were provided by the nurse on the homework which served as another strategy for encouraging and retaining participants in the study.
Homework: Understanding our social circle.
Finally, each group session concluded with a summary of what had been accomplished and the expected goals for the next session. In addition, a weekly grab bag (personal items like soap or lotion) was conducted. The name tags for each session were placed in a gift bag, and one name was selected by a member of the group. Participants unanimously voted that if a person had won a grab bag, that their name would not be placed in the bag for the following weeks. Members looked forward to the grab bag each week. This activity truly generated enthusiasm and facilitated group camaraderie.
Throughout the working phase of the relationship, trust continued to build between the nurses and the participants, but also among the participants. Peplau believed that “nursing should aim at reducing as much as possible people’s dependence” (Gastmans, 1998, p.1316). Thus, during the SWEEP program, the nurse educated participants about their emotions, but facilitated their ability to gain insight into their own thinking patterns and subsequent behaviors.
Peplau (1997) emphasized that because the nurse-patient relationship is not a social relationship, it is time limited. However, it is important to provide sufficient time to allow individuals to express their feelings about termination. Thus, preparation for the termination of the relationship actually began during the 7th week of the SWEEP program. A plan for terminating the group was discussed. Because the nurse and group assisted with each individual’s progress, potential support systems outside the group were identified. The termination phase of the relationship is a time where the work that has been accomplished is summarized. It requires reflection by the patient as well as the nurse (Peplau, 1997). In this research project this was usually completed during the eighth session where the participants shared what they had accomplished, and what work still needed to be done. The termination phase also included booster sessions, where participants returned every 6 weeks over a period of 3 months. It was during this time that they discussed the challenges and successes with the implementation of their skills. At the end of the SWEEP program, each participant was given a handmade beaded bracelet. This was given as a token of appreciation for their participation, and also as a reminder of their experience in the SWEEP program.
The recruitment and retention of participants for research studies is often a challenge. Nurse researchers have the ability, by the nature of their role, to be successful in this endeavor. Nurses are caring, provide comfort, and often are the persons whom persons trust most in the healthcare experience. Using the interpersonal relations theory by Peplau, the researchers were able to share strategies used to recruit, encourage participation, and retain women for the study and to illustrate how these strategies were used during the various phases (orientation, working, termination) of the nurse-participant relationship. Patients with chronic illness often have co-morbid depression and anxiety. Peplau’s theory is a framework that can easily be used in caring for these patients, but can also provide a sound basis for conducting successful research.
This work was supported by Loyola University Chicago School of Nursing and the National Institute of Nursing Research (K23NR00092400)
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
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Nursing Paper on Peplau's Theory of Interpersonal Relations
1734 WordsApr 7th, 20147 Pages
Peplau’s Theory of Interpersonal Relations Jennifer Holzer Chamberlain College of Nursing Nursing 501 Theoretical Basis for Advanced Nursing Practice Spring 2014
Nursing theory is important because it is the foundation and structure for the profession of nursing. There are many different types of theories and they all serve a specific purpose. Theories are important and valuable because they allow the nurse to understand and comprehend their role as a nursing professional. Theories also play a part in helping the nurse deal with patients and other disciplines in nursing and most important the role of a nurse in this profession. Theories explain and help to grasp the…show more content…
Peplau’s major concepts discuss how the nurse and the patient work together to achieve the same result. Her theory would be categorized as a middle range theory. Through this process the nurse and the patient both gain more information, knowledge. They will grow during the process. In Peplau’s Theory there are phases, roles of the nurse and components which make up the entire theory. The orientation phase is when the nurse and patient first meet. The role of the nurse would be that similar to a stranger. It is important to develop trust and a good rapport with the patient. Her identification of this relation is extremely valid and meaningful. I understand how a patient would feel apprehensive and nervous about the Orientation Phase .I think her terminology is spot on because in essence the patients are all strangers to us as we are to them. The interpersonal process involves the person, environment and health. The person is defined as the patient. The environment is defined as the setting to where the interaction will take place such as a hospital or doctor’s office. The goal in the environment is to make the patient feel safe and ease they anxiety often felt between the nurse and patient. The health is defined as the overall wellbeing of the patient and the progress being made to achieve wellness. The Identification phase is when the nurse selects the most appropriate assistance. The role of the nurse in this phase is that of a surrogate. The exploitation