IDA JEAN ORLANDO

A Close Encounter

NURSING PROCESS DISCIPLINE

The Theorist: IDA JEAN ORLANDO - PELLETIER

Nursing theorist in focus

A first-generation American of Italian descent Birth date : August 12, 1926 Birthplace : New York Husband : Robert Pelletier (lived in Boston) Death date : November 28, 2007

EDUCATIONAL BACKGROUND:
1947 - Diploma in Nursing, New York Medical College 1951 - B.S. in Public Health Nursing, St. John's University, Brooklyn, New York 1954 - M.A. in mental health consultation, Columbia University, New York

NURSING CAREE R : Staff nurse, varied specialties (OB, MS, ER)

Supervisor in a General Hospital Research Associate & Principal Investigator of a Federal Project entitled Integration of Mental Health Concepts in a Basic Curriculum at Yale University in New Haven, Connecticut (19541961) Clinical Nursing Consultant in Mental Health, McLean Hospital in Belmont, Massachusetts (1962-1972) Served on various committees at Harvard Community Health Plan in Boston, Massachusetts since 1972 Nurse Educator for Metropolitan State Hospital in Waltham, Massachusetts in 1981 Assistant Director of Nursing for Education and Research at Metropolitan State Hospital (September1987) Retired in 1992

ATTAINMENTS & HONOR:

Books Published:

1961 - The Dynamic Nurse-Patient Relationship: Function, Process and Principles 1967 - The Patients Predicament and Nursing Function an issue of Psychiatric Opinion 1972 - The Discipline and Teaching of Nursing Process : An Evaluative Study

Conducted Training Programs at McLean Hospital Managed 60 workshops about her theory in USA and Canada (1972-1981) Outstanding Nurse in the Hall of Fame of Massachusetts Nurses Association in 2001

METAPARADIGM OF NURSING
PERSON unique and developmental beings with needs, individuals have their own subjective perceptions and feelings that may not be observable directly NURSING providing direct assistance to individuals in whatever setting for the purpose of avoiding, relieving, diminishing, or curing the persons sense of helplessness HEALTH is not well-defined but assumed as freedom from mental or physical discomfort and feelings of adequacy and wellbeing
ORLANDO

ENVIRONMENT is not clearly defined as well but assumed as a nursing situation when there is a nurse-patient contact and that both nurse and patient perceive, think, feel, and act in the immediate situation

Development of Theory
In the late 1950s, Orlando developed her theory inductively through an empirical study of nursing practice. For 3 years, she recorded 2000 observations between a nurse and patient interactions. She was only able to categorize the records as "good" or "bad" nursing.

According to records: *Good Nursing nurses focus was on the patients immediate verbal and nonverbal behavior from the beginning through the end of the contact *Bad Nursing nurses focus was on a prescribed activity or something that had nothing to do with the patients behavior

From these observations, she formulated the Deliberative Nursing Process which was published in 1961. Conducted research at McLean Hospital through continuous tape recording of nurses with patients and other health care members Based on this research, her formulations were validated, thus she extended her theory to include the entire nursing practice system which then evolved as Nursing Process Discipline Orlando's theory remains one the of the most effective practice theories available. Many theory scholars utilized her concept as basis for their further studies. Her work has been translated into six languages and was contained in the international section. A web page about her theory, developed by Schmieding in 1999, is updated periodically and contains extensive references.

ASSUMPTIONS:

Assumptions about Nurses: The nurses reaction to each patient is unique Nurses should not add to the patients distress The nurses mind is the major tool for helping patients The nurses use of automatic responses prevents the responsibility of nursing from being fulfilled Nurses practice is improved through self-reflection

Assumptions about Patients: Patients needs for help are unique Patients have an initial ability to communicate their needs for help When patients cannot meet their own needs they become distressed The patients behaviour is meaningful Patients are able and willing to communicate verbally (and nonverbally when unable to communicate verbally)

ASSUMPTIONS:

Assumptions about the nursepatient situation: The nurse-patient situation is a dynamic whole The phenomenon of the nursepatient encounter represents a major source of nursing knowledge

Assumptions about Nursing: Nursing is a distinct profession separate from other disciplines Professional nursing has a distinct function and product (outcome) There is a difference between lay and professional nursing Nursing is aligned with medicine

Introduction to the Theory

"I can't move, I can't speak, I need help..."

A) The nursing process is set in motion by the Patient Behavior

- All patient behavior: a) verbal ( a patients use of language ) b) non-verbal ( includes physiological symptoms, motor activity, and nonverbal communication) c) physical forms (vital signs) - Must be considered an expression of a need for help and has to be validated . - Ineffective assessment by the nurse leads nurse-patient relationship failure. - Communication process is vital to acquire patients cooperation in achieving health. Remember: When a patients need for help is not resolved even with the help of another, will result to sense of helplessness.

B) The Patient Behavior stimulates a Nurse Reaction

- Nurse-patient relationship takes place. - Correct evaluation of patients behavior by using the nurse reactions steps yields positive feedback response from the patient. The steps are as follows: 1) The nurse perceives behavior through any of the senses 2) The perception leads to automatic thought 3) The thought produces an automatic feeling 4) The nurse shares reactions with the patient to ascertain whether perceptions are accurate or inaccurate 5) The nurse consciously deliberates about personal reactions and patient input in order to produce professional deliberative actions based on mindful assessment rather than automatic reactions. Remember : Exploration with the patient helps validate the patients behavior.

C) Critically considering one or two ways in implementing Nurse Action

Automatic Reaction (Non-Deliberative) stem from nursing behaviors that are performed to satisfy a directive other than the patients need for help. Example: The nurse who gives a sleeping pill to a patient every evening because it is ordered by the physician, without first discussing the need for the medication with the patient. Rationale : Giving of the pill has more to do with following medical orders (automatically) than with the patients immediate expressed need for help. Deliberative Reaction is a disciplined professional response, that all nursing actions are meant to help the client and should be considered deliberative. The following criteria should be considered. Deliberative actions result from the correct identification of patient needs by validation of the nursess reaction to patient behavior. The nurse explores the meaning of the action with the patient and its relevance to meeting his need. The nurse validates the actions effectiveness immediately after compelling it. The nurse is free of stimuli unrelated to the patients need (when action is taken). Remember : For an action to have been truly deliberative, it must undergo reflective evaluation to determine if the action helped the client by addressing the need as determined by the nurse and the client in the immediate situation.

Orlandos Nursing Process Discipline

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.

FunctionProcess Presenting Immediate Nursing of Reaction Professional Discipline - Internal Nursing Investigation Response - Organizing Principle

MAJOR DIMENSIONS OF THE THEORY 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 persons 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

CONCEPTUAL FRAMEWORK
Distinguish the Theory Analyze the Theory

ACCEPTANCE by the Nursing Community:

RESEARCH
The diversity of the research using the theory attests to its breadth of application. It also indicates its utility for application of the findings in: Perioperative Nursing Studying Nurse-Patient Relationships Advanced-Nursing Practice and Administrations Responses to distressed patients Mental Illnesses Positive Patient-Centered Outcomes

ACCEPTANCE by the Nursing Community:

EDUCATION
Orlandos nursing process theory was recommended for teaching BSN students and conceptualize BSN curriculums which has an emphasis on the interaction process and its goal on communication and psychosocial foundations which may translate into more effective exploratory skills in the students.

ACCEPTANCE by the Nursing Community:

PRACTICE
Orlandos nursing process discipline reflects the elements of the therapeutic relationships which include expression of empathy, warmth, and genuineness that would increase the therapeutic effectiveness of nursing having applied throughout various nursing departments: Operating Rooms, Mental Health Units, Administrations and Public Health departments Use in Clinical Practice: Nursing care plan, Case studies, Progressive patient care settings Nursing process: A-D-P-I-E

ANALYSIS / CRITIQUE:
CLARITY Presents concepts clearly and consistently uses the same words for her major components and processes.The writing style involves defining concepts minimally at first and then developing them throughout the book. SIMPLICITY Theory is considered simple yet elegant and has benefited research applications. It was also used as an example of grand nursing theory and described as a practice theory. GENERALITY Conceivably, the theory could be adapted to other nursing situation and other professional fields whose focus is on identifying and finding out patients immediate need for help. EMPIRICAL PRECISION Orlando used a qualitative method to obtain data from which she developed her theory. She also utilized field methodology before it became a world view in research. DERIVABLE CONSEQUENCES The nursing process discipline allows the nurses to view the patient from a medical disease orientation. The use of Orlandos theory benefits the patient, enhances the nurses professional identity, and helps to advance the nursing profession.

STRENGTHS

Limitations

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 .

Nursing can pursue Orlando's work for retesting and further developing her work

Highly interactive nature Orlando's theory makes it hard to include the highly technical and physical care that nurses give in certain settings

Prevents inaccurate diagnosis or ineffective plans because the nurse has to constantly explore her reactions with the patient

Make evaluation a less time consuming and more deliberate function, the results of which would be documented in patients charts

Assertion of nursings independence as a profession and her belief that this independence must be based on a sound theoretical frame work

Her theory struggles with the authority derived from the function of profession and that of the employing institutions commitment to the public

Guides the nurse to evaluate her care in terms of objectively observable patient outcomes

CASE SCENARIO
Mr. So: Nurse, can you give me my morphine! Nurse: Can you tell how painful it is using the 0 10 pain scale, where 0 being not painful and 10 being severely painful? Mr .So: Ummm... I think its about 7. Can I have my morphine now? Nurse: Mrs. So, I think something is bothering you besides your pain. Am I correct? Mrs. So (crying): I cant help it. Im so worried about my 3 boys. Im not sure how they are or whos been taking care of them. Theyre still so young to be left alone. My husband is in Yemen right now and he wont be back until next month. Nurse: Why dont we make a phone call to your house so you could check out on your boys? Mrs. So called up his sons. After the phone call. Mrs. So: Thank you nurse. I dont think I still need that morphine. My boys are fine. Our neighbour, Mrs. Yee, shes watching over my boys right now.

Assessing a Patient by using Orlandos Theory to guide the Nurses Process

1. Guiding Principle Finding out and meeting the patients immediate need for help 2. Problematic situation and immediate reaction(s) 3. Inquiry-Problem Determination 4. Identifying specific plans for each problem
The nurses focus is on the patient and free of distracting thoughts The nurse recognizes cues that a patient problem may exist before the next step in the process. The nurse identifies his or her immediate perception, thoughts, feelings (Immediate reaction) The nurse uses terms the patient can understand and explores immediate reactions with the patient to discover physical/nonphysical problems. As the problem is identified, the nurse asks the patient to confirm or refute its accuracy. The nurse explores the disagreement to determine its basis With the patient, the nurse determines action(s) needed and develops plans for each problem. The nurse explores whether the patient agrees with or refutes the plan. The nurse explores and resolves the basis of disagreement. The patient verbally or nonverbally agrees. If not, the nurse continues the inquiry for the basis. If the patient is unable, the nurse implements the plan and asks the patient whether the action is helpful. If it is not, the nurse explores the basis . The nurse helps the patient if he or she is unable to do it alone and explores whether the patient was helped. The nurse inquires about his or her results.

5. Implement

6. Improvement

The nurse asks the patient whether the action helped and observes the patients verbal and nonverbal behavior. If he or she has improved, the need for help was mer. If not, the nurse continues to use the content of immediate reaction to explore with the patient until a positive change is evident.

THANK YOU !!! Marie Joyce D. Sablan