After an hour of interactive discussion, the masterand will be able to:
Cite the credentials and background of Ida Jean Orlando Relate a Case Scenario pertaining to the theory Define the metaparadigm of nursing in Orlando¶s theory Describe the historical background of the development of Orlando¶s Nursing Process Discipline Present the theoretical assumptions in relation to her theory Discuss thoroughly the Nursing Process Discipline of Orlando with a conceptual framework presentation Discuss how the community accepted the theory and its application Identify strengths and weaknesses of the Nursing Process Discipline for clinical practice
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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
Staff nurse, varied specialties (OB, MS, ER) Supervisor in a General Hospital Research Associate & Principal Investi ator of a Federal Project entitled ³Inte ration of Mental Health Concepts in a Basic Curriculum´ at Yale University in New Haven, Connecticut (1954-1961) Clinical Nursin 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 Nursin for Education and Research at Metropolitan State Hospital (September1987) Retired in 1992
1961 - ´The Dynamic Nurse-Patient Relationship: Function, Process and Principlesµ 1967 - ´The Patients Predicament and Nursing Function µ an issue of Psychiatric Opinion 1972 - ´The Discipline and Teaching of Nursing Process : An Evaluative Studyµ
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 Nurse¶s Association in 2001
Mrs. So: ³Nurse, can you give me my morphine!´ Nurse: ³Can you tell how painful it is using the 0 10 pain scale, where 0 being not painful and 10 being severely painful? Mrs.So: ³Ummm... I think it¶s about 7. Can I have my morphine now?´ Nurse: ³Mrs. So, I think something is bothering you besides your pain. Am I correct?´ Mrs. So (crying): ³I can¶t help it. I¶m so worried about my 3 boys. I¶m not sure how they are or who¶s been taking care of them. They¶re still so young to be left alone. My husband is in Yemen right now and he won¶t be back until next month.´ Nurse: ³Why don¶t 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: ³Thank you nurse. I don¶t think I still need that morphine. My boys are fine. Our neighbour, Mrs. Yee, she¶s watching over my boys right now.´
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 person¶s sense of helplessness
HEALTH is not well-defined but assumed as ³freedom from mental or physical discomfort and feelings of adequacy and well-being ´
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 ± nurse¶s focus was on the patient¶s immediate verbal and nonverbal behavior from the beginning through the end of the contact *Bad Nursing ± nurse¶s focus was on a prescribed activity or something that had nothing to do with the patient¶s behavior
From these observations, she formulated the ³Deliberative Nursin 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 ³Nursin 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 about Nurses: ³The nurse¶s reaction to each patient is unique´ ³Nurses should not add to the patient¶s distress´ ³The nurse¶s mind is the major tool for helping patients´ ³The nurse¶s use of automatic responses prevents the responsibility of nursing from being fulfilled´ ³Nurse¶s practice is improved through self-reflection´
Assumptions about Patients: ³Patients¶ needs for help are unique´ ³Patients have an initial ability to communicate their needs for help´ ³When patients cannot meet their own needs they become distressed´ ³The patient¶s behaviour is meaningful´ ³Patients are able and willing to communicate verbally (and nonverbally when unable to communicate verbally)´
Assumptions about the nursepatient situation: ³The nurse-patient situation is a dynamic whole´ ³The phenomenon of the nursepatient encounter represents a major source of nursing knowledge´
Assumptions about Nursin : ³Nursing is a distinct profession separate from other disciplines´ ³Professional nursing has a distinct function and product (outcome)´ ³There is a difference between lay and professional nursing´ ³Nursing is aligned with medicine´
Introduction to the Theory
"I can't move, I can't speak, I need help..."
Patient Behavior Nurse Reaction Nurse Action
A) The nursin process is set in motion by the Patient Behavior
- All patient behavior: a) verbal ( a patient¶s 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 patient¶s cooperation in achieving health. Remember: When a patient¶s 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 patient¶s 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 patient¶s behavior.
C) Critically considerin one or two ways in implementin Nurse Action
Automatic Reaction (Non-Deliberative) stem from nursing behaviors that are performed to satisfy a directive other than the patient¶s 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 patient¶s immediate expressed need for help. Deliberative Reaction is a ³disciplined 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 nurses¶s 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 action¶s effectiveness immediately after compelling it. The nurse is free of stimuli unrelated to the patient¶s 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.
Orlando¶s Nursin 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.
MAJOR DIMENSIONS OF THE THEORY
Function of Professional Nursin - Or anizin Principle Presentin Behavior - Problematic Situation Immediate Reaction - Internal Response
Nursin Process Discipline ± Investi ation Improvement - Resolution
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 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
Distin uish the Theory Analyze the Theory
ACCEPTANCE by the Nursing Community:
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:
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ACCEPTANCE by the Nursing Community:
Orlando¶s 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 Nursin process: A-D-P-I-E
ANALYSIS / CRITIQUE:
SIMPLICITY Theory is consi ered sim le yet eleg nt nd has enefited research applications. It was also sed 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 hose focus is on identifying and finding out patient·s i ediate need for help. EMPIRICAL PRECISI N 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 Orlando·s theory benefits the patient, enhances the nurse·s professional identity, and helps to advance the nursing profession.
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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
Her theory struggles with the authority derived from the function of profession and that of the employing institution¶s commitment to the public
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
Mr. So: ³Nurse, can you give me my morphine!´ Nurse: ³Can you tell how painful it is using the 0 10 pain scale, where 0 being not painful and 10 being severely painful? Mr .So: ³Ummm... I think it¶s about 7. Can I have my morphine now?´ Nurse: ³Mrs. So, I think something is bothering you besides your pain. Am I correct?´ Mrs. So (crying): ³I can¶t help it. I¶m so worried about my 3 boys. I¶m not sure how they are or who¶s been taking care of them. They¶re still so young to be left alone. My husband is in Yemen right now and he won¶t be back until next month.´ Nurse: ³Why don¶t 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: ³Thank you nurse. I don¶t think I still need that morphine. My boys are fine. Our neighbour, Mrs. Yee, she¶s watching over my boys right now.´
Assessin a Patient by usin Orlando¶s Theory to uide the Nurse¶s Process
1. Guidin Principle Findin out and meetin the patient¶s immediate need for help 2. Problematic situation and immediate reaction(s) 3. Inquiry-Problem Determination 4. Identifyin specific plans for each problem
The nurse¶s focus is on the patient and free of distracting thoughts -The nurse reco nizes cues that a patient problem may exist before the next step in the process. -The nurse identifies his or her immediate perception, thou hts, feelin s (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. The nurse asks the patient whether the action helped and observes the patient¶s 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 and GOOD NIGHT!
1. Guiding Principle Finding out and meeting the patient s immediate need for help 2. Problematic situation and immediate reaction(s) 3. Inquiry-Problem Determination 4. Identifying specific plans for each problem 5. Implement
The nurse s 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. The nurse asks the patient whether the action helped and observes the patient s 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.