Orlando's Nursing Process Theory

INTRODUCTION

About the Theorist

• Theorist, Ida Jean Orlando was born in 1926.
• Ida J. Orlando was one of the first nursing theorists to write about the nursing process.
• Nursing diploma - New York Medical College
• BS in public health nursing - St. John's University, NY,
• MA in mental health nursing - Columbia University, New York.
• Associate Professor at Yale School of Nursing and Director of the Graduate Program in Mental Health Psychiatric Nursing.
• Project investigator of a National Institute of Mental Health grant entitled: Integration of Mental Health Concepts in a Basic Nursing Curriculum.
• Her theory was published in her 1961 book, The Dynamic Nurse-Patient Relationship.
• Further development of her theory at McLean Hospital in Belmont, MA as Director of a Research Project: Two Systems of Nursing in a Psychiatric Hospital. The results were conceptualized in her 1972 book titled: The Discipline and Teaching of Nursing Processes
• A board member of Harvard Community Health Plan, and served as both a national and international consultant.

Major Dimensions

• The role of the nurse is to find out and meet the patient's immediate need for help.
• The patient's presenting behavior may be a plea for help, however, the help needed may not be what it appears to be.
• Therefore, nurses need to use their perception, thoughts about the perception, or the feeling engendered from their thoughts to explore with patients the meaning of their behavior.
• This process helps nurse find out the nature of the distress and what help the patient needs.

Terms

• Distress is the experience of a patient whose need has not been met.
• Nursing role is to discover and meet the patient’s immediate need for help.
  • Patient’s behavior may not represent the true need.
  • The nurse validates his/her understanding of the need with the patient.
• Nursing actions directly or indirectly provide for the patient’s immediate need.
• An outcome is a change in the behavior of the patient indicating either a relief from distress or an unmet need.
• Observable verbally and nonverbally.

CONCEPTS

• Function of professional nursing - organizing principle
• Presenting behavior - problematic situation
• Immediate reaction - internal response
• Nursing process discipline – investigation
• Improvement - resolution

Function of professional nursing - organizing principle

• Finding out and meeting the patients immediate needs for help

Nursing….is responsive to individuals who suffer or anticipate a sense of helplessness, it is focused on the process of care in an immediate experience, it is concerned with providing direct assistance to individuals in whatever setting they are found for the purpose of avoiding, relieving, diminishing or curing the individuals sense of helplessness

• The purpose of nursing is to supply the help a patient requires for his needs to be met.
• If the patient has an immediate need for help and the nurse finds out and meets that need ,the function of professional nursing is achieved

Presenting behavior - problematic situation

• To find out the immediate need for help the nurse must first recognize the situation as problematic
• The presenting behavior of the patient, regardless of the form in which it appears, may represent a plea for help
• The presenting behavior of the patient, the stimulus, causes an automatic internal response in the nurse, and the nurses behavior causes a response in the patient

Immediate reaction - internal response

• Person perceives with any one of his five sense organs an object or objects
• The perceptions stimulate automatic thought
• Each thought stimulates an automatic feeling
• Then the person acts
• The first three items taken together are defined as the person’s immediate reaction
• Reflects how the nurse experiences her or his participation in the nurse patient situation

Nursing process discipline – investigation

• Any observation shared and explored with the patient is immediately useful in ascertaining and meeting his need or finding out that he is not in need at that time
• The nurse does not assume that any aspect of her reaction to the patient is correct, helpful or appropriate until she checks the validity of it in exploration with the patient
• The nurse initiates a process of exploration to ascertain how the patient is affected by what she says or does
• Automatic reactions are not effective because the nurses action is decided upon for reasons other than the meaning of the patients behavior or the patients immediate need for help
• When the nurse does not explore with the patient her reaction it seems reasonably certain that clear communication between them stops

Improvement - resolution

• It is not the nurses activity that is evaluated but rather its result : whether the activity serves to help the patient communicate her or his need for help and how it is met
• In each contact the nurse repeats a process of learning how to help the individual patient.
• Her own individuality and that of the patient requires that she go through this each time she is called upon to render service to those who need her.

ASSUMPTIONS

• When patients cannot cope with their needs without help, they become distressed with feelings of helplessness
• Nursing , in its professional character , does add to the distress of the patient
• Patients are unique and individual in their responses
• Nursing offers mothering and nursing analogous to an adult mothering and nurturing of a child
• Nursing deals with people, environment and health
• Patient need help in communicating needs, they are uncomfortable and ambivalent about dependency needs
• Human beings are able to be secretive or explicit about their needs, perceptions, thoughts and feelings
• The nurse – patient situation is dynamic, actions and reactions are influenced by both nurse and patient
• Human beings attach meanings to situations and actions that are not apparent to others
• Patients entry into nursing care is through medicine
• The patient cannot state the nature and meaning of his distress for his need without the nurses help or without her first having established a helpful relationship with him
• Any observation shared and observed with the patient is immediately useful in ascertaining and meeting his need or finding out that he is not in need at that time
• Nurses are concerned with needs that patients cannot meet on their own

DOMAIN CONCEPTS

1. Nursing – is responsive to individuals who suffer or anticipate a sense of helplessness
2. Process of care in an immediate experience….. for avoiding, relieving, diminishing or curing the individuals sense of helplessness. Finding out meeting the patients immediate need for help
3. Goal of nursing – increased sense of well being, increase in ability, adequacy in better care of self and improvement in patients behavior
4. Health – sense of adequacy or well being . Fulfilled needs. Sense of comfort
5. Environment – not defined directly but implicitly in the immediate context for a patient
6. Human being – developmental beings with needs, individuals have their own subjective perceptions and feelings that may not be observable directly
7. Nursing client – patients who are under medical care and who cannot deal with their needs or who cannot carry out medical treatment alone
8. Nursing problem – distress due to unmet needs due to physical limitations, adverse reactions to the setting or experiences which prevent the patient from communicating his needs
9. Nursing process – the interaction of 1)the behavior of the patient, 2) the reaction of the nurse and 3)the nursing actions which are assigned for the patients benefit
10. Nurse – patient relations – central in theory and not differentiated from nursing therapeutics or nursing process
11. Nursing therapeutics – Direct function : initiates a process of helping the patient express the specific meaning of his behavior in order to ascertain his distress and helps the patient explore the distress in order to ascertain the help he requires so that his distress may be relieved.
12. Indirect function – calling for help of others , whatever help the patient may require for his need to be met
13. Nursing therapeutics - Disciplined and professional activities – automatic activities plus matching of verbal and nonverbal responses, validation of perceptions, matching of thoughts and feelings with action
14. Automatic activities – perception by five senses, automatic thoughts, automatic feeling, action

ORLANDO'S WORK AND CHARACTERISTICS OF A THEORY

• Theories can interrelate concepts in such a way in such a way as to create a different way of looking at a particular phenomenon - Orlando's theory interrrelate concepts
• Theories must be logical in nature - Orlando's theory has a logical nature
• Theories should be relatively simple yet generalizable - Orlando's theory is simple and applicable in the daily practice.
• Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them - Orlando's theory contribute to the professional knowledge.
• Theories can be utililized by practitioners to guide and improve their practice - Orlando's theory is applicable in clinical practice

STRENGTHS

• Use of her theory assures that patient will be treated as individuals and that they will have active and constant input into their own care
• Prevents inaccurate diagnosis or ineffective plans because the nurse has to constantly explore her reactions with the patient
• Assertion of nursing’s independence as a profession and her belief that this independence must be based on a sound theoretical frame work
• Guides the nurse to evaluate her care in terms of objectively observable patient outcomes
• Make evaluation a less time consuming and more deliberate function, the results of which would be documented in patients charts
• Nursing can pursue Orlando's work for retesting and further developing her work

THEORY CRITIQUE

• Lack of operational definitions for concepts – limits development of research hypothesis
• Theory is more congruent in guiding nurse – patient interactions for assessing needs and in providing nursing therapeutics deemed necessary to patient care
• Focus on short term care, particularly aware and conscious individuals and on the virtual absence of reference group or family members

LIMITATIONS

• Highly interactive nature Orlando's theory makes it hard to include the highly technical and physical care that nurses give in certain settings
• Her theory struggles with the authority derived from the function of profession and that of the employing institution’s commitment to the public

EXTERNAL COMPONENTS

• Value of nursing shifted from task oriented to patient oriented nursing process
• Theory is culturally bound
• Misinterpretation of continuous validation as lack of knowledge and expertise
• The uniqueness of individuals assumed by the theory could counteract automatic responses of nurses

Use in Clinical Practice

• Nursing care plan
• Case studies
• Progressive patient care settings

Nursing process

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

CONCLUSION TO THEORY

• Orlando's Deliberative Nursing Process Theory focuses on the interaction between the nurse and patient, perception validation, and the use of the nursing process to produce positive outcomes or patient improvement. Orlando's key focus was to define the function of nursing. (Faust C., 2002)
• Orlando's theory remains one the of the most effective practice theories available.
• The use of her theory keeps the nurse's focus on the patient.
• The strength of the theory is that it is clear, concise, and easy to use.
• While providing the overall framework for nursing, the use of her theory does not exclude nurses from using other theories while caring for the patient.

REFERENCES

1. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.
2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.
3. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia,  Lippincott.
4. Taylor Carol,Lillis Carol (2001)The Art & Science  Of Nursing Care 4th ed. Philadelphia,  Lippincott.
5. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.
6. Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15
7. Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225.
8. Faust C. .Orlando's deliberative nursing process theory: a practice application in an extended care facility. J Gerontol Nurs. 2002 Jul;28(7):14-8