One important thing that nurses do is converse with the patients and let them know what the plan of care for the day is going to be. However, regardless of how well thought out a nursing care plan is for a patient, unexpected problems to the patient’s recovery may arise at any time. With these, the job of the nurse is to know how to deal with those problems so the patient can continue to get back and reclaim his or her well-being. Ida Jean Orlando developed her Deliberative Nursing Process that allows nurses to formulate an effective nursing care plan that can also be easily adapted when and if any complexity come up with the patient.
Orlando’s nursing process discipline is rooted in the interaction between a nurse and a patient at a specific time and place. A sequence of interchanges involving patient behavior and nurse reaction takes place until the patient’s need for help, as he perceives it, is clarified. The nurse then decides on an appropriate action to resolve the need in cooperation with the patient. This action is evaluated after it is carried out. If the patient behavior improves, the action was successful and the process is completed. If there is no change or the behavior gets worse, the process recycles with new efforts to clarify the patient’s behavior or the appropriate nursing action.
Assumptions
Orlando’s model of nursing makes the following assumptions:
- When patients are unable to cope with their needs on their own, they become distressed by feelings of helplessness.
- In its professional character, nursing adds to the distress of the patient.
- Patients are unique and individual in how they respond.
- Nursing offers mothering and nursing analogous to an adult who mothers and nurtures a child.
- The practice of nursing deals with people, environment, and health.
- Patients need help communicating their needs; they are uncomfortable and ambivalent about their dependency needs.
- People 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 the nurse and the patient.
- People attach meanings to situations and actions that aren’t apparent to others.
- Patients enter into nursing care through medicine.
- The patient is unable to state the nature and meaning of his or her distress without the help of the nurse, or without him or her first having established a helpful relationship with the patient.
- Any observation shared and observed with the patient is immediately helpful in ascertaining and meeting his or her need, or finding out that he or she is not in need at that time.
- Nurses are concerned with the needs the patient is unable to meet on his or her own.
Major Concepts
The nursing metaparadigm consists of four concepts: person, environment, health, and nursing. Of the four concepts, Orlando only included three in her theory of Nursing Process Discipline: person, health, and nursing.
Human Being
Orlando uses the concept of human as she emphasizes individuality and the dynamic nature of the nurse-patient relationship. For her, humans in need are the focus of nursing practice.
Health
In Orlando’s theory, health is replaced by a sense of helplessness as the initiator of a necessity for nursing. She stated that nursing deals with individuals who are in need of help.
Environment
Orlando completely disregarded environment in her theory, only focusing on the immediate need of the patient, chiefly the relationship and actions between the nurse and the patient (only an individual in her theory; no families or groups were mentioned). The effect that the environment could have on the patient was never mentioned in Orlando’s theory.
Nursing
Orlando speaks of nursing as unique and independent in its concerns for an individual’s need for help in an immediate situation. The efforts to meet the individual’s need for help are carried out in an interactive situation and in a disciplined manner that requires proper training.
Subconcepts
Patient Behavior
This sets the nursing process discipline in motion.
All patient behavior, no matter how insignificant, must be considered an expression of need for help until its meaning to a particular patient in the immediate situation is understood.
“The presenting behavior of the patient, regardless of the form in which it appears, may represent a plea for help” (Orlando, 1990).
Patient behavior may be verbal or nonverbal. Inconsistency between these two types of behavior may be the factor that alerts the nurse that the patient needs help.
Distress
The patient’s behavior reflects distress when the patient experiences a need that he cannot resolve, a sense of helplessness occurs.
Some categories of patient distress are: “physical limitations,… adverse reactions to the setting and … experiences which prevent the patient from communicating his needs” (Orlando, 1990).
Nurse Reaction
The patient behavior stimulated a nurse reaction, which marks the beginning of the nursing process discipline.
This reaction is comprised of three sequential parts (Orlando, 1972). First, the nurse perceives the behavior through any of her senses. Second, the perception leads to automatic thought. Finally, the thought produces an automatic feeling.
“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” (Orlando, 1990).
The nurse must learn to identify each part of her action so the process becomes logical rather than intuitive and thus, disciplined rather than automatic.
Orlando (1972) also provides three criteria to ensure that the nurse’s exploration of her reaction with the patient is unsuccessful:
1. What the nurse says to the individual in the contact must match any or all of the items contained in the immediate reaction, and what the nurse does nonverbally must be verbally expressed and the expression must match one or all of the items contained in the immediate reaction.
2. The nurse must clearly communicate to the individual that the item being expressed belongs to herself.
3. The nurse must ask the individual about the item expressed in order to obtain correction or verification from that same individual.
Nurse’s Action
Orlando (1990) includes “only what she [the nurse] says or does with or for the benefit of the patient” as professional nursing action. “The nurse initiates a process of exploration to ascertain how the patient is affected by what she says or does.”
The nurse can act in two ways: automatic or deliberative. Only the second manner fulfills her professional function.
Automatic actions are “those decided upon for reasons other than the patient’s immediate need,” whereas deliberative actions ascertain and meet this need.
The following list identifies the criteria for deliberative actions:
1. Deliberative actions result from the correct identification of patient needs by validation of the nurse’s reaction to patient behavior.
2. The nurse explores the meaning of the action with the patient and its relevance to meeting his need.
3. The nurse validates the action’s effectiveness immediately after completing it.
4. The nurse is free of stimuli unrelated to the patient’s need when she acts.
5 Stages of the Deliberative Nursing Process
The Deliberative Nursing Process has five stages: assessment, diagnosis, planning, implementation, and evaluation.
Assessment
In the assessment stage, the nurse completes a holistic assessment of the patient’s needs. This is done without taking the reason for the encounter into consideration. The nurse uses a nursing framework to collect both subjective and objective data about the patient.
Diagnosis
The diagnosis stage uses the nurse’s clinical judgment about health problems. The diagnosis can then be confirmed using links to defining characteristics, related factors, and risk factors found in the patient’s assessment.
Planning
The planning stage addresses each of the problems identified in the diagnosis. Each problem is given a specific goal or outcome, and each goal or outcome is given nursing interventions to help achieve the goal. By the end of this stage, the nurse will have a nursing care plan.
Implementation
In the implementation stage, the nurse begins using the nursing care plan.
Evaluation
Finally, in the evaluation stage, the nurse looks at the progress of the patient toward the goals set in the nursing care plan. Changes can be made to the nursing care plan based on how well (or poorly) the patient is progressing toward the goals. If any new problems are identified in the evaluation stage, they can be addressed, and the process starts over again for those specific problems.
Strengths
The guarantee that patients will be treated as individuals is very much applied in Orlando’s theory of Deliberative Nursing Process. Each patient will have an active and constant input into their own care.
Assertion of nursing’s independence as a profession and her belief that this independence must be based on a sound theoretical framework.
The model also guides the nurse to evaluate her care in terms of objectively observable patient outcomes.
Weaknesses
The lack of the operational definitions of society or environment was evident which limits the development of research hypothesis. Orlando’s work focuses on short term care, particularly aware and conscious individuals and on the virtual absence of reference group or family members.
Conclusion
Orlando’s nursing theory stresses the reciprocal relationship between patient and nurse. What the nurse and the patient say and do affects them both. Orlando views the professional function of nursing as finding out and meeting the patient’s immediate need for help. She was one of the first nursing leaders to identify and emphasize the elements of nursing process and the critical importance of the patient’s participation in the nursing process. Orlando’s theory focuses on how to produce improvement in the patient’s behavior. Evidence of relieving the patient’s distress is seen as positive changes in the patient’s observable behavior. Orlando may have facilitated the development of nurses as logical thinkers.
The Deliberative Nursing Process helps nurses achieve more successful patient outcomes such as fall reduction. Orlando’s theory remains a most effective practice theory that is especially helpful to new nurses as they begin their practice.
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