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 comes up with the patient.
Orlando’s theory stresses the reciprocal relationship between patient and nurse. It emphasizes the critical importance of the patient’s participation in the nursing process. Orlando also considered nursing as a distinct profession and separated it from medicine where nurses as determining nursing action rather than being prompted by physician’s orders, organizational needs and past personal experiences. She believed that the physician’s orders are for patients and not for nurses.
She proposed that “patients have their own meanings and interpretations of situations and therefore nurses must validate their inferences and analyses with patients before drawing conclusions.”
Orlando’s goal is to develop a theory of effective nursing practice. The theory explains that the role of the nurse is to find out and meet the patient’s immediate needs for help. According to the theory, all patient behavior can be a cry for help. Through these, the nurse’s job is to find out the nature of the patient’s distress and provide the help he or she needs.
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.
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.
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.
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.
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.
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.
Orlando described her model as revolving around the following five major interrelated concepts: the function of professional nursing, presenting behavior, immediate reaction, nursing process discipline, and improvement.
Function of Professional Nursing
The function of professional nursing is the organizing principle. This means finding out and meeting the patient’s immediate needs for help. According to Orlando, nursing is responsive to individuals who suffer, or who anticipate a sense of helplessness. It is focused on the process of care in an immediate experience, and is concerned with providing direct assistance to a patient in whatever setting they are found in for the purpose of avoiding, relieving, diminishing, or curing the sense of helplessness in the patient. The Nursing Process Discipline Theory labels the purpose of nursing to supply the help a patient needs for his or her needs to be met. That is, if the patient has an immediate need for help, and the nurse discovers and meets that need, the purpose of nursing has been achieved.
Presenting behavior is the patient’s problematic situation. Through the presenting behavior, the nurse finds the patient’s immediate need for help. To do this, the nurse must first recognize the situation as problematic. Regardless of how the presenting behavior appears, it may represent a cry for help from the patient. The presenting behavior of the patient, which is considered the stimulus, causes an automatic internal response in the nurse, which in turn causes a response in the patient.
The patient’s behavior reflects distress when the patient experiences a need that he cannot resolve, a sense of helplessness occurs.
The immediate reaction is the internal response. The patient perceives objects with his or her five senses. These perceptions stimulate automatic thought, and each thought stimulates an automatic feeling, causing the patient to act. These three items are the patient’s immediate response. The immediate response reflects how the nurse experiences his or her participation in the nurse-patient relationship.
The patient behavior stimulated a nurse reaction, which marks the beginning of the nursing process discipline.
When the nurse acts, an action process transpires. This action process by the nurse in a nurse-patient contact is called nursing process. The nurse’s action may be automatic or deliberative.
Automatic Nursing Actions are nursing actions decided upon for reasons other than the patient’s immediate need.
Deliberative Nursing Actions are actions decided upon after ascertaining a need and then meeting this need
The following list identifies the criteria for deliberative actions:
- Deliberative actions result from the correct identification of patient needs by validation of the nurse’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 completing it.
- The nurse is free of stimuli unrelated to the patient’s need when she acts.
Nursing Process Discipline
The nursing process discipline is the investigation into the patient’s needs. Any observation shared and explored with the patient is immediately useful in ascertaining and meeting his or her need, or finding out he or she has no needs at that time. The nurse cannot assume that any aspect of his or her reaction to the patient is correct, helpful, or appropriate until he or she checks the validity of it by exploring it with the patient. The nurse initiates this exploration to determine how the patient is affected by what he or she says and does. Automatic reactions are ineffective because the nurse’s action is determined for reasons other than the meaning of the patient’s behavior or the patient’s immediate need for help. When the nurse doesn’t explore the patient’s reaction with him or her, it is reasonably certain that effective communication between nurse and patient stops.
The nurse 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.
The action process in a person-to-person contact functioning in secret. The perceptions, thoughts, and feelings of each individual are not directly available to the perception of the other individual through the observable action.
The action process in a person-to-person contact functioning by open disclosure. The perceptions, thoughts, and feelings of each individual are directly available to the perception of the other individual through the observable action.
Improvement is the resolution to the patient’s situation. In the resolution, the nurse’s actions are not evaluated. Instead, the result of his or her actions are evaluated to determine whether his or her actions served to help the patient communicate his or her need for help and how it was met. In each contact, the nurse repeats a process of learning how he or she can help the patient. The nurse’s own individuality, as well as that of the patient, requires going through this each time the nurse is called upon to render service to those who need him or her.
5 Stages of the Deliberative Nursing Process
The Deliberative Nursing Process has five stages: assessment, diagnosis, planning, implementation, and evaluation.
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.
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.
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.
In the implementation stage, the nurse begins using the nursing care plan.
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.
The dynamic concept of the nurse-patient interaction was justified since the participation of the patient in the relationship was sought. The whole process is in constant revision through continuous validation of findings of the nurse’s findings with that of the patient.
Because the nurse has to constantly explore her reactions with the patient, it prevents inaccurate diagnosis or ineffective plans.
Since the model is applied to an immediate situation, its applicability to a long term care plan is not feasible.
The concept of interaction also limits it to individuals capable of conversing, a shared limitation with other nurse-client dynamic theories – unconscious patients are not covered by this theory.
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.
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.
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 the 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.
- Ida Jean Orlando: A Nursing Process Theory (Notes on Nursing Theories)
- Nursing Theorists and Their Work, 8th Edition
- George, J.B. (2011). Nursing theories: The base for professional nursing practice (6th ed.). Philadelphia: Pearson.com/nursing_theory/Orlando_nursing_process.html
- Orlando, I. J. (1972). The discipline and teaching of nursing process. In George, J. (Ed.). Nursing theories: the base for professional nursing practice. Norwalk, Connecticut: Appleton & Lange.
- Orlando, I. J. (1990). The dynamic nurse-patient relationship: Function, process and principles. In George, J. (Ed.). Nursing theories: the base for professional nursing practice. Norwalk, Connecticut: Appleton & Lange.
- Potter, P.A., & Perry, A.G. (2012). Fundamentals of nursing (8th ed.). St. Louis, MO: Mosby Elsevier.
- Schmieding, N. (1990). An integrative nursing theoretical framework. Journal of Advanced. Nursing, 15(4), 463-467.
With contributions by Wayne, G., Ramirez, Q.Last updated on