Heather Gulian, Lara Kim, Angela Kramer, Beth Smith

•How does this patient make you feel?

•What do you think they need?

•What would you do for them as a nurse?

Nursing diploma ◦ New York Medical College

BS- Public Health Nursing ◦ St. John's University, NY

MA- Mental Health Nursing ◦ Columbia University, NY

Director of Mental Health Psychiatric Nursing Graduate Program◦ Yale SON, CT

NIMH – Research grant◦ Integration of Mental Health Concepts in Basic Nursing

Curriculum Observed patient-nurse interactions

◦ “Good” – effective◦ “Bad” – ineffective

How can you analyze “good” and “bad” nursing without defining nursing, its function, and its desired outcome?

GOAL: “To develop a ‘theory of effective nursing practice’ that would identify a distinctive role for the professional nurses that would provide a systematic foundation for the study of nursing.” (Schmieding, 2006, 433)

1961 – The Dynamic Nurse-Patient Relationship: Function, Process, and Principles of Professional Nursing Practice

1962 – Employed as a Clinical Nurse Consultant at McLean Hospital in MA◦ Grant to develop a nursing

training program based on her theory

1972 – The Discipline and Teaching of Nursing Process: An Evaluative Study

McLean Hospital, nd.

Distress is the experience of a patient whose need has not been met.

Nursing role is to discover and meet the patient’s immediate need for help.◦ Patient’s behavior may not represent the true need.◦ The nurse validates his/her understanding of the need with the

patient.

Nursing actions directly or indirectly provide for the patient’s immediate need.

An outcome is a change in the behavior of the patient indicating either a relief from distress or an unmet need.◦ Observable verbally and nonverbally.

Shifted from care based on medical diagnoses to care based on patients’ immediate needs.

MD’s orders are assigned to patients not to nurses.◦ If nurses focus on orders (versus immediate

patient needs), it keeps the nurse dependent.◦ Immediate needs may include assisting the

patient to comply with the doctor’s orders.

• Automatic actions are carried out for reasons other than meeting the patient’s immediate needs.

• Prevents the responsibility of nursing from being performed.

Pelletier, 1968.

• Stresses the reciprocal relationship between the nurse and patient.

• Nurse seeks verification or correction of his/her thoughts with the patient.

• Patients’ needs and nurses’ reactions to each need are unique.

Pelletier, 1968.

(Potter & Tinker, 2000)

A patient is frequently asking the nurse to do things for him that he could do for himself. The nurse initially feels frustrated and that the patient doesn’t want to help himself. However, the nurse also realizes that something else may be going on. The nurse asks, “I feel like you could be doing many of these things on your own. Is there something else you need?” The patient replied that when he was upset it was reassuring to have a nurse come into the room.

(Schmieding, 1984)

Health Promotion & Protection, Disease Prevention & Treatment◦ Open communication with patient in order to determine their healthcare

needs and develop effective diagnoses and care plans◦ Teenage female requesting birth control (Sylvia Wood)

Nurse-Patient Relationship◦ Promotes effective communication between nurse and patient

Teaching-Coaching◦ Evaluating patient’s needs, promoting behavioral changes, evaluating

outcomes with the patient Professional Role

◦ Allows for autonomy in nursing role◦ Interdisciplinary boundaries: “If I do that, I won’t be able to do my job,

which is to observe the patient and find out and meet the patient’s needs for help.” (Schmieding, 1984, p761)

◦ Nursing accountability◦ Understanding supervisee true needs: A nurse’s request for a weekend off

may represent his/her dissatisfaction with another nurse that is scheduled to work that weekend as well. (Schmieding, 1984, p761)

Managing/Negotiating health care delivery systems◦ Control costs by focusing care on immediate needs, not

unnecessary tasks◦ Patient requests codeine, and the nurse explores the pain

sensation. The patient shows the nurse the afflicted area, and the nurse sees the discomfort may be due to the old tape adhesive. After removing the adhesive, the patient states that the area feels much better and that the codeine she had received the night before had been ineffective. (Orlando, 1961)

Monitoring and ensuring the quality of health care practice◦ Validating that needs are met and that nursing action

provided a positive outcome Cultural competence

◦ Keeps the nurse from labeling patients and staff

Concepts are observable, however these vary from case to case as outcomes are based on both patients and nurses perception of the interaction

Research tools are specific to the outcome being measured (i.e. anxiety, pain)◦ Surveys, questionnaires, and other tools which

measure patient outcome, nursing process, nurse empathy, and patient perceived empathy.

Studies supporting the theory◦ Pilot study (2000) – implemented

Orlando’s theory resulting in: Positive, patient-centered outcomes A staff-patient approach model Decreased patient (immediate) stress

◦ VA study (1987) – implemented theoretical model with bipolar patients. Results indicate: Higher patient retention Reduction of emergency services Decreased hospital stay Increased patient satisfaction

The relative simplicity of the theory lends itself well to internal consistency.

Semantic inconsistency:◦ Theory Title:

Deliberative Nursing Process (1961) Nursing Process Discipline (1972)

◦ Nursing action: Good Effective (Deliberative) Bad Ineffective (Automatic)

Requires education to implement:◦ Orlando’s 1972 book

introduces and evaluates a training program.

Very applicable to real-world nursing situations improve patient outcomes ◦ Every face-to-face

interaction.

Feasibility:◦ Feasible to teach.◦ Unrealistic to expect all

nurses to internalize this model.

Compatible with expectations for nursing practice:◦ May appear more time

consuming initially, but assists the nurse in meeting true needs the first time.

Favorable outcomes:◦ Patient needs are met◦ Research shows deliberative

nursing process is more likely to produce favorable outcomes then automatic nursing process.

Care is patient-focused◦ Patients are treated as individuals

Patients assume active role in their care The theory can be learned Applicable in various settings

◦ clinical/educational/administrative Facilitates cultural understanding and

respect◦ Needs are met regardless of cultural or

language barriers Allows cost and time-saving measures

as actions are based on meeting “immediate needs” and avoiding unnecessary tasks

Conceptual model:◦ Emphasizes the internal reaction of the nurse◦ Needs to expand more on the process of validation

Metaparadigm, concepts, propositions, and philosophical claims:◦ Present and clearly stated, but not explicitly identified in a

systematic manner◦ Implicit and not completely clear on how they were derived

No bibliographic references:◦ Some feel the vast majority of her work was Orlando’s original

thought, not stemming from antecedent knowledge◦ Others feel her theory incorporates the underpinnings of multiple

theories including: Peplau’s Interpersonal Relationships (nursing), Symbolic Interaction (sociology), Dewey’s Theory of Inquiry (philosophy, psychology), and Behavioral Theory (psychology)

Clear and Concise◦ Yes:

Limited in concepts, propositions, and variables.

◦ No: Some concepts are

expanded upon in a second book.

Focus is on short-term care Requires training from a

qualified nurse Does not apply to all patients

◦ Pediatrics◦ Unconscious◦ Mentally-ill/impaired

Does not address the family/caregiver Simplicity of theory masks the intricacy

of the nurse-patient dynamic

Defined nurses’ role focusing on patients’ need rather than MD’s orders

Provide nurse’s with autonomy Enriches nursing’s unique body of

knowledge Strengthens nurse/patient relationship

◦ Positive patient outcomes

Apply to other fields in order to validate the needs of clients◦ Psychology: counseling◦ Customer service

Develop a unique/modifiable tool that applies this theory in various clinical settings to achieve positive outcomes

Focus on long-term care needs

Helene Fuld Health Trust (Producer) (1990). The Nurse Theorists: Portraits of Excellence: Ida J. Orlando Pelletier [Motion picture]. United States: Samuel Merritt College Studio Three.

National Organization of Nurse Practitioner Faculties (2006). Domains and core competencies of nurse practitioner practice. Access October 25, 2009 from https://sakai.plu.edu/access/content/group/NURS523_01_20233_FALL2009/Articles/CoreComps.pdf.

Orlando, I.J. (1972). The Discipline and Teaching of Nursing Process: An Evaluative Study. NY: G.P. Putnam’s Sons.

Orlando, I. J. (1990). The Dynamic Nurse-Patient Relation: Function, Process, and Principle. NY: National League for Nursing.

Potter, M.L. (2009). Deliberative nursing process. In Peterson, S. J. & Bredow, T. S. (Eds.) Middle Range Theories: Application to Nursing Research (2nd ed). (304-325). Philadelphia: Lippincott Williams & Wilkins.

Potter, M. & Bockenhauer, B. (2000). Implementing Orlando's nursing theory: A pilot study. Journal of Psychosocial Nursing & Mental Health Services, March, 38(3), 14-21.

Potter, M. & Tinker, S. (2000). Put power in nurses' hands: Orlando's nursing theory supports nurses simply. Nursing Management, July, 40-41.

Schmieding, N. J. (1984). Putting Orlando’s theory into practice. Journal of Advanced Nursing, 84(6), 759-761.

Schmieding, N. J. (1987). Analysing managerial responses in face-to-face contacts. Journal of Advanced Nursing, 12, 357-365.

Schmieding, N. J. (1989). An integrative nursing theoretical framework. Journal of Advanced Nursing, 15, 463-467.

Schmieding, N. J. (2006). Nursing process theory. In Tomey, A.M. & Alligood, M. R. (Eds.), Nursing Theorists and their Work. (431-451). St. Louis: Mosby Elsevier.