ORLANDO'S NURSING PROCESS THEORY
INTRODUCTION
Ida Jean Orlando, a first-generation American of
Italian descent was born in 1926.
She received her nursing diploma from New York
Medical College, her BS in public health nursing
from St. John's University, NY, and her MA in
mental health nursing from Columbia University,
New York.
Orlando was an Associate Professor at Yale
School of Nursing where she was Director of the
Graduate Program in Mental Health Psychiatric
Nursing.
While at Yale she was project investigator
of a National Institute of Mental Health grant
entitled: Integration of Mental Health Concepts
in a Basic Nursing Curriculum.
It was from this research that she developed
her theory which was published in her 1961 book, The Dynamic Nurse-Patient Relationship.
She furthered the development of her theory
when at McLean Hospital in Belmont, MA as
Director of a Research Project: Two Systems of
Nursing in a Psychiatric Hospital.
The results of this research are contained in
her 1972 book titled: The Discipline and
Teaching of Nursing Processes
Orlando held various positions in the Boston
area, was a board member of Harvard Community
Health Plan, and served as both a national and
international consultant.
She is a frequent lecturer and conducted
numerous seminars on nursing process.
Orlando's
theory was developed in the late 1950s from
observations she recorded between a nurse and
patient.
Despite her efforts, she was only able to
categorize the records as "good" or "bad" nursing.
It then dawned on her that both the
formulations for "good" and "bad" nursing were
contained in the records.
From these observations she formulated the
deliberative nursing process
Questions
What prompts nursing actions?
What are the properties of dynamic nurse
patient relationships that may lead to effective
care?
Answer
Nurses were prompted in their actions for
reasons other than the patients immediate
experiences and needs
INTRODUCTION TO
THEORY
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.
MAJOR DIMENSIONS
OF THE THEORY
Function of professional nursing -
organizing principle
Presenting behavior - problematic situation
Immediate reaction - internal response
Nursing process discipline – investigation
Improvement - resolution
FUNCTIONS 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
Nursing thought - Does the patient have an
immediate need for help or not?
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
Nursing – is responsive to individuals who
suffer or anticipate a sense of helplessness
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
Goal of nursing – increased sense of well
being, increase in ability, adequacy in better
care of self and improvement in patients behavior
Health – sense of adequacy or well being .
Fulfilled needs. Sense of comfort
Environment – not defined directly but
implicitly in the immediate context for a
patient
Human being – developmental beings with needs,
individuals have their own subjective perceptions
and feelings that may not be observable directly
Nursing client – patients who are under
medical care and who cannot deal with their needs
or who cannot carry out medical treatment alone
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
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
Nurse – patient relations – central in theory
and not differentiated from nursing therapeutics
or nursing process
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.
Indirect function – calling for help of others
, whatever help the patient may require for his
need to be met
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
Automatic activities – perception by five
senses, automatic thoughts, automatic feeling,
action
THEORY ANALYSIS
PARADIGMATIC ORIGINS
Paplau’s focus of interpersonal
relationships in nursing
Paplau acknowledged the influence of Harry
Stack Sullivan on the development of her ideas
Symbolic interactionism – Chicago school
Use of field methodology
John Dewey’s theory of inquiry
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
Theories must be logical in
nature
Theories should be relatively
simple yet generalizable
Theories can be the bases for
hypotheses that can be tested
Theories contribute to and
assist in increasing the general body of knowledge
within the discipline through the research
implemented to validate them
Theories can be utililized by
practitioners to guide and improve their practice
Theories must be consistent
with other validated theories, laws, and
principles but will leave open unanswered
questions that need to be investigated
INTERNAL
DIMENSIONS
-
Analyzed 2000 nurse – patient interactions
to identify the properties, dimensions and goals
of interactions
-
Use of field approach
-
Focus on describing psychosocial aspects of
nurse - patient interaction
-
Used a mixture of operational and
problematic methods of theory development
-
Focus on how to deliver care not on what
care to be given
-
Nursing process theory of low to medium
level abstraction
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
COMPARISON WITH
NURSING PROCESS
Validation of perceptions, thoughts and
feelings is essential for enhancing the
congruence between patient’s needs and the care
given
Results indicate unique nursing process is
more effective than other approaches in dealing
with pain, in reducing stress, in understanding
patient’s needs, in relieving distress to
experienced by patients during the process of
admission to a hospital
Used in describing the responsibilities of
nursing students to distressed patients
A number of studies focused on explicating
the properties and components of nurse – patient
interactions
Perceptions was used as a frame work to
describe needs of grieving spouses
Gillis supported Orlando’s differentiation
between presenting problems as perceived by the
nurse and those as perceived and validated by
patients
Used as a framework to research nursing
administration
USES OF THEORY
Use in Education
Midwestern State University in Wichita
Falls, Texas, is using Orlando's theory for
teaching entering nursing students.
South Dakota State University in Brookings,
SD has been using Haggerty’s (1985) description
of the communication based on Orlando’s theory
for entering nursing students as well as
re-enforcing it in their junior year
Uses in Administration
-
Schmieding successfully used Orlando's
theory in two major hospitals for both
practice and administration (Lincoln General
Hospital, Lincoln, NE and Boston City
Hospital, Boston, MA).. Implementation of
Orlando’s theory produced substantial
benefits. Its use increased effectiveness in
meeting patient needs; improved
decision-making skills among staff nurses,
including determining what constituted nursing
versus non-nursing functions; negotiated more
effectively in resolving conflict among staff
nurses and between staff and physicians; and
influenced a more positive nursing identity
and unity among staff.
Use in Research
-
In an Veterans Administration (VA)
ambulatory psychiatric practice in Providence,
RI Shea, McBride, Gavin, and Bauer
(1987) used Orlando’s theoretical model with
patients (N = 76) having a bipolar disorder.
Their research results indicate that there
were: higher patient retention, reduction of
emergency services, decreased hospital stay,
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