ORLANDOS THEORY

G MOUNIKA
MSC NURSING
GCON
 INTRODUCTION:

• IDA JEAN ORLANDO, A FIRST-GENERATION AMERICAN OF ITALIAN DESCENT, WAS BORN IN 1926.
• IDA J. ORLANDO WAS ONE OF THE FIRST NURSING THEORISTS TO WRITE ABOUT THE NURSING PROCESS BASED ON HER OWN RESEARCH. (FAUST
C, 2002).
• NURSING DIPLOMA FROM NEW YORK MEDICAL COLLEGE.
• BS IN PUBLIC HEALTH NURSING FROM ST. JOHN'S UNIVERSITY, NEW YORK.
• MA IN MENTAL HEALTH NURSING FROM COLUMBIA UNIVERSITY, NEW YORK.
• ASSOCIATE PROFESSOR AT YALE SCHOOL OF NURSING AND DIRECTOR OF THE GRADUATE PROGRAM IN MENTAL HEALTH PSYCHIATRIC NURSING.
• 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'S THEORY WAS DEVELOPED IN THE LATE 1950S FROM OBSERVATIONS SHE RECORDED BETWEEN A NURSE AND PATIENT.
• SHE WAS MARRIED TO ROBERT PELLETIER AND LIVED IN THE BOSTON AREA.
• SHE PASSED AWAY ON NOVEMBER 28, 2007.
 THE FOCUS OF ORLANDO’S PARADIGM HUBS THE
CONTEXT OF A DYNAMIC NURSE-PATIENT PHENOMENON
CONSTRUCTIVELY REALIZED THROUGH HIGHLIGHTING
THE KEY CONCEPTS SUCH AS: PATIENT BEHAVIOR,
NURSE REACTION, AND NURSE ACTION

• THE NURSING PROCESS IS SET IN MOTION BY THE PATIENT BEHAVIOR.

 ALL PATIENT BEHAVIOR, VERBAL (A PATIENT’S USE OF LANGUAGE) OR NON-
VERBAL (INCLUDES PHYSIOLOGICAL SYMPTOMS, MOTOR ACTIVITY, AND
NONVERBAL COMMUNICATION), NO MATTER HOW INSIGNIFICANT, MUST BE
CONSIDERED AN EXPRESSION OF A NEED FOR HELP AND NEEDS TO BE
VALIDATED. IF A PATIENT’S BEHAVIOR IS NOT EFFECTIVELY ASSESSED BY THE
NURSE THEN A MAJOR PROBLEM IN GIVING CARE WOULD RISE, LEADING TO A
NURSE-PATIENT RELATIONSHIP FAILURE. OVERTIME, THE MORE IT IS
DIFFICULT TO ESTABLISH RAPPORT TO THE PATIENT ONCE BEHAVIOR IS NOT
DETERMINED. COMMUNICATING EFFECTIVELY IS VITAL TO ACHIEVE
PATIENT’S COOPERATION IN ACHIEVING HEALTH.
• THE PATIENT BEHAVIOR STIMULATES A NURSE REACTION. 
 IN THIS PART, THE BEGINNING OF THE NURSE-PATIENT RELATIONSHIP TAKES PLACE. IT IS
IMPORTANT TO CORRECTLY EVALUATE THE BEHAVIOR OF THE PATIENT USING THE NURSE
REACTIONS STEPS TO ACHIEVE POSITIVE FEEDBACK RESPONSE FROM THE PATIENT. THE
STEPS ARE AS FOLLOWS:

THE NURSE PERCEIVES BEHAVIOR THROUGH ANY OF THE SENSES -> THE PERCEPTION LEADS
TO AUTOMATIC THOUGHT -> THE THOUGHT PRODUCES AN AUTOMATIC FEELING ->THE
NURSE SHARES REACTIONS WITH THE PATIENT TO ASCERTAIN WHETHER PERCEPTIONS ARE
ACCURATE OR INACCURATE -> 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.
• CRITICALLY CONSIDERING ONE OR TWO WAYS IN IMPLEMENTING NURSE ACTION .
 WHEN PROVIDING CARE, NURSING ACTION CAN BE DONE EITHER AUTOMATIC OR DELIBERATIVE.
AUTOMATIC REACTIONS STEM FROM NURSING BEHAVIORS THAT ARE PERFORMED TO SATISFY A DIRECTIVE
OTHER THAN THE PATIENT’S NEED FOR HELP.

FOR 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, IS
ENGAGING IN AUTOMATIC, NON-DELIBERATIVE BEHAVIOR. THIS IS BECAUSE THE REASON FOR GIVING 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 “DISCIPLINED PROFESSIONAL RESPONSE”. IT CAN BE ARGUED THAT ALL NURSING
ACTIONS ARE MEANT TO HELP THE CLIENT AND SHOULD BE CONSIDERED DELIBERATIVE. HOWEVER, CORRECT
IDENTIFICATION OF ACTIONS FROM THE NURSE’S ASSESSMENT SHOULD BE DETERMINED TO ACHIEVE
RECIPROCAL HELP BETWEEN NURSE AND PATIENT’S HEALTH. THE FOLLOWING CRITERIA SHOULD BE
CONSIDERED.
• DELIBERATIVE ACTIONS RESULT FROM THE CORRECT IDENTIFICATION OF PATIENT NEEDS BY VALIDATION OF
THE NURSES’ REACTION TO PATIENT BEHAVIOUR.
• 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).
 CASE SCENARIO:

• “NURSE, CAN YOU GIVE ME MY MORPHINE,” CRIED OUT MRS. SO. “CAN YOU TELL
HOW PAINFUL IT IS USING THE 0 ‐10 PAIN SCALE, WHERE 0 BEING NOT PAINFUL AND
10 BEING SEVERELY PAINFUL?”REPLIED THE NURSE. “UMMM... I THINK IT’S ABOUT
7. CAN I HAVE MY MORPHINE NOW?” “MRS. SO, I THINK SOMETHING IS BOTHERING
YOU BESIDES YOUR PAIN. AM I CORRECT?” MRS. SO CRIED AND SAID, “I 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.”
“WHY DON’T WE MAKE A PHONE CALL TO YOUR HOUSE SO YOU COULD CHECK OUT
ON YOUR BOYS?” MRS. SO PHONED HIS SONS. “THANK 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.”
DIAGRAM
 THE NURSING PROCESS

• ASSESSMENT:
• THIS IS THE DATA COLLECTION STEP. FOR RNS IT ALSO ENTAILS ANALYZING THE DATA AND POSSIBLY MAKING A
MORE COMPLEX AND IN-DEPTH ASSESSMENT BASED ON THE FINDINGS. ASSESSMENT INVOLVES TAKING VITAL
SIGNS, PERFORMING A HEAD TO TOE ASSESSMENT, LISTENING TO THE PATIENT'S COMMENTS AND QUESTIONS ABOUT
HIS HEALTH STATUS, OBSERVING HIS REACTIONS AND INTERACTIONS WITH OTHERS. IT INVOLVES ASKING
PERTINENT QUESTIONS ABOUT HIS SIGNS AND SYMPTOMS, AND LISTENING CAREFULLY TO THE ANSWERS.

• DIAGNOSIS:
• ONCE YOU HAVE IDENTIFIED THE PATIENT'S PROBLEMS RELATED TO HIS HEALTH STATUS, YOU FORMULATE A
NURSING DIAGNOSIS FOR EACH OF THEM. YOU WILL ALSO PRIORITIZE THE PROBLEMS IN FORMULATING YOUR
PLAN AND GOALS.

• PLANNING:
• SETTING GOALS TO IMPROVE THE OUTCOMES FOR THE PATIENT IS A PRIMARY FOCUS OF THE NURSING PROCESS.
BASED ON THE NURSING DIAGNOSES, WHAT ARE THE EXPECTATIONS FOR THIS PATIENT?  THIS SHOULD BE
PATIENT-CENTERED GOALS. THIS IS ABOUT IMPROVING THE HEALTH STATUS AND QUALITY OF LIFE FOR YOUR
PATIENT. THIS IS ABOUT WHAT YOUR PATIENT NEEDS TO DO TO IMPROVE HIS HEALTH STATUS AND/OR BETTER
COPE WITH HIS ILLNESS.
• IMPLEMENTATION:
• IMPLEMENTATION IS SETTING YOUR PLANS IN MOTION AND DELEGATING
RESPONSIBILITIES FOR EACH STEP. COMMUNICATION IS ESSENTIAL TO THE
NURSING PROCESS. ALL MEMBERS OF THE HEALTH CARE TEAM SHOULD BE
INFORMED OF THE PATIENT'S STATUS AND NURSING DIAGNOSIS, THE GOALS
AND THE PLANS. THEY ARE ALSO RESPONSIBLE TO REPORT BACK TO THE RN
ALL SIGNIFICANT FINDINGS AND TO DOCUMENT THEIR OBSERVATIONS AND
INTERVENTIONS AS WELL AS THE PATIENT'S RESPONSE AND OUTCOMES

• EVALUATION:
• THE NURSING PROCESS IS AN ON-GOING PROCESS. EVALUATION INVOLVES NOT
ONLY ANALYZING THE SUCCESS (OR FAILURE) OF THE CURRENT GOALS AND
INTERVENTIONS, BUT EXAMINING THE NEED FOR ADJUSTMENTS AND CHANGES
AS WELL.  THE EVALUATION PROCESS INCORPORATES ALL INPUT FROM THE
ENTIRE HEALTH CARE TEAM, INCLUDING THE PATIENT. EVALUATION LEADS
BACK TO ASSESSMENT AND THE WHOLE PROCESS BEGINS AGAIN.
 METAPARADIGM CONCEPTS:

• HUMAN/PERSON.  AN INDIVIDUAL IN NEED. UNIQUE INDIVIDUAL BEHAVING VERBALLY OR NONVERBALLY. ASSUMPTION IS THAT
INDIVIDUALS ARE AT TIMES ABLE TO MEET THEIR OWN NEEDS AND AT OTHER TIMES UNABLE TO DO SO.
•
HEALTH.  ASSUMPTION IS THAT BEING WITHOUT EMOTIONAL OR PHYSICAL DISCOMFORT AND HAVING A SENSE OF WELL-BEING
CONTRIBUTE TO A HEALTHY STATE. SHE FURTHER ASSUMED THAT FREEDOM FROM MENTAL OR PHYSICAL DISCOMFORT AND
FEELINGS OF ADEQUACY AND WELL-BEING CONTRIBUTE TO HEALTH. SHE ALSO NOTED THAT REPEATED EXPERIENCES OF HAVING
BEEN HELPED UNDOUBTEDLY CULMINATE OVER PERIODS OF TIME IN GREATER DEGREES OF IMPROVEMENT
•
ENVIRONMENT.  ORLANDO ASSUMES IT AS A NURSING SITUATION THAT OCCURS WHEN THERE IS A NURSE-PATIENT CONTACT AND
THAT BOTH NURSE AND PATIENT PERCEIVE, THINK, FEEL AND ACT IN THE IMMEDIATE SITUATION. ANY ASPECT OF THE
ENVIRONMENT, EVEN THOUGH IT’S DESIGNED FOR THERAPEUTIC AND HELPFUL PURPOSES, CAN CAUSE THE PATIENT TO BECOME
DISTRESSED. SHE STRESSED OUT THAT WHEN A NURSE OBSERVES A PATIENT BEHAVIOR, IT SHOULD BE PERCEIVED AS A SIGNAL OF
DISTRESS.
•
NURSING.  A DISTINCT PROFESSION. “PROVIDING DIRECT ASSISTANCE TO INDIVIDUALS IN WHATEVER SETTING THEY ARE FOUND
FOR THE PURPOSE OF AVOIDING, RELIEVING, DIMINISHING, OR CURING THE INDIVIDUAL'S SENSE OF HELPLESSNESS" (ORLANDO,
1972, P. 22). PROFESSIONAL NURSING IS CONCEPTUALIZED AS FINDING OUT AND MEETING THE CLIENT’S IMMEDIATE NEED FOR
HELP.
 ASSUMPTIONS:

• WHEN PATIENTS CANNOT COPE WITH THEIR NEEDS WITHOUT HELP, THEY BECOME DISTRESSED
WITH FEELINGS OF HELPLESSNESS.
• PATIENTS ARE UNIQUE AND INDIVIDUAL IN THEIR RESPONSES.
• NURSING DEALS WITH PEOPLE, ENVIRONMENT AND HEALTH.
• THE NURSE – PATIENT SITUATION IS DYNAMIC. ACTIONS AND REACTIONS ARE INFLUENCED BY
BOTH NURSE AND PATIENT.
• 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.
 APPLICATION OF THE THEORY:

• FROM AN ICU NURSE: “PATIENTS HAVE AN INITIAL ABILITY TO COMMUNICATE THEIR NEED FOR HELP”.
CONSIDER A CASE OF AN IMMEDIATE POST CORONARY ARTERY BYPASS GRAFT (CABG) PATIENT. ONCE
RELIEVED FROM THE EFFECTS OF ANESTHETIC SEDATION, THOUGH INTUBATED, YOU WOULD REALIZE
HIS EXCRUCIATING RETORT FROM THE STERNOTOMY INCISIONAL PAIN THROUGH IMPLICIT CUES.
MORPHINE SULFATE 1 TO 2 MG TO BE GIVEN VIA SLOW IV PUSH EVERY 1 TO 2 HOURS OR KETOROLAC 15
MG IV EVERY 6 HOURS IS THE TYPICAL PRO RE NATA (PRN) ORDER OF A CARDIAC INTENSIVIST TO
RELIEVE THE CLIENT FROM PAIN. AUTOMATIC RESPONSE OF A NURSE IS TO CALM THE CLIENT AND
ENCOURAGE RELAXATION THROUGH DEEP BREATHING WHILE SPLINTING THE CHEST WITH A PILLOW.
BEING DELIBERATE IN YOUR ACTIONS INCLUDE KNOWING THE PHARMACOKINETICS OF AN ORDERED
DRUG IN RELATION TO THE CLIENT’S PHYSIOLOGIC STANDING. IF THE CREATININE LEVEL WERE
ELEVATED, WOULD YOU ADMINISTER KETOROLAC? IF THE CLIENT IS ON RESPIRATORY PRECAUTION,
WOULD YOU ADMINISTER MORPHINE? YOU WOULD ASK YOURSELF, WHAT OTHER ALTERNATIVES DO I
HAVE TO EASE MY CLIENT FROM PAIN? “THE CLIENT’S BEHAVIOR IS MEANINGFUL”. IF SUCH “NEED”
WOULD BE FITTINGLY DEALT WITH, THE INTERVENTION IS THRIVING. “WHEN PATIENT’S NEEDS ARE
NOT MET, THEY BECOME DISTRESSED.”
 CONCLUSIONS:

• 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.
• CASE STUDY
A RELATIVE OF A PATIENT AT THE EMERGENCY ROOM WENT TO THE
NURSE’S STATION AND BEGAN COMPLAINING IN A LOUD SHOUTING
VOICE THAT THEIR PATIENT BEING A CHARITY CASE IS NOT BEING
GIVEN THE SAME QUALITY OF CARE AS THAT OF THE OTHER PATIENTS
WHO ARE UNDER PRIVATE CONSULTANTS. HE CLAIMED THAT THEIR
PATIENT WHO WAS HYPERVENTILATING AND WAS COMPLAINING OF
DIFFICULTY OF BREATHING DUE TO NEUROCIRCULATORY ASTHEINIA
WAS JUST FORCED TO SIT IN THE CUBICLE, WHILE THE RICH-LOOKING
PATIENT WAS A GOMEY.

QUESTION
HOW WILL YOU HANDLE THIS KIND OF SITUATION AND AVOID
CONFLICT? HOW CAN ORLANDO’S DYNAMIC NURSE-PATIENT
INTERACTION THEORY BE UTILIZED IN THIS TYPE OF SITUATION?
THANK YOU!