NURSING PROCESS
INTRODUCTION TO THEORIST
Ida jean Orlando was born in 1926 in New
York.
She has varied carrier as a practitioner,
educator, researcher and consultant in nursing.
Her nursing education began at New York
Medical College School of nursing where she
received a diploma in nursing.
In 1951 she received a Bachelor of Science
degree in public health nursing from St.
John’s University New York.
In1954 she completed master’s degree in
nursing from Columbia University.
Her first book “The Dynamic Nurse-Patient
relationship: Function, Process and Principles”
were published when she was director of the
graduate program in mental health and
psychiatric nursing.
In 1962, she became a clinical nursing
consultant to a psychiatric hospital.
She carried out a research that led to the
publication in 1972 of her second book “The
Discipline and Teaching of Nursing Process.”
Throughout her carrier she has been active in
a variety of organizations.
She has also lectured and offered workshops
and consultant to a wide variety of agencies.
INTRODUCTION TO THEORY
Orlando’s theory was developed in the late 1950
from observations she recorded between a nurse
and patient. She was only able to categorize the
records as “good” or “bad” nursing. From these
observations she formulated the deliberative
nursing process. The role of the nurse is to find
out and meet the patient’s immediate need for
help. This process helps the nurse find out the
nature of the distress and what help the patient
needs. The use of her theory keeps the nurse’s
focus on the patient.
ORLANDO’S KEY CONCEPTS
Certain major concepts are evident in
Orlando’s theory of nursing. She believes that
nursing is unique and independent because it
concerns itself with an individual’s need for
help, real or potential, in an immediate
situation. The process by which nursing
resolves this helplessness is interactive and
is pursued in a disciplined manner that
requires training.
Throughout her career, Orlando has been
concerned with identifying that which is
uniquely nursing. She believes that the use of
general principles from other fields is not
sufficient to help the nurse in her interaction
with patients. She identifies nursing’s role as
“it is the nurse’s direct responsibility to see to
it that the patient’s needs for help are met
either by her own activity or by calling in the
help of others.
It is the unique function that gives nurses the
authority to work independently. Nurse must
resolve conflicts between the patient’s need
for help and institutional policies. Nursing’s
unique function allows nurses to work in any
setting where persons experience a need for
help that they cannot resolve themselves.
Nurses may practice with well or ill persons in
an independent practice or in an institutional
setting.
Orlando’s theory focus on the patient as
an individual. Nurses cannot act based
only on principles, past experience, or
physicians’ orders. They must first
ascertain that their actions will meet the
specific patient’s need for help. Nursing is
concerned with “individuals who suffer or
anticipate a sense of helplessness.” The
nurse’s function is to correctly identify and
relieve this need for help.
Orlando’s nursing process is totally
interactive. The process involves the nurse’s
reaction to this behavior and the nurse’s
consequent action. Orlando’s principles are
meant to guide the nurse at various stages
of the interaction. The actual process of a
nurse-patient interaction is the same as that
of any interaction between two persons.
When nurses use this process in caring for
patients, Orlando calls it the “nursing
process.” It is the tool that nurses use to
fulfill their function to patients. Orlando
broadens the use of the process beyond the
individual nurse-patient relationship in her
book “The Discipline and Teaching of
Nursing Process.”
If the nursing process is the same as the
interactive process between any two
individuals, how can nursing call itself a
profession? The key is discipline in use of the
process. Learning to employ the process
discipline requires training. This justifies the
need for specific education in nursing.
ORLANDO’S NURSING PROCESS
Orlando’s nursing process is based on the
“process by which any individual acts.” The
purpose of the process when used between a
nurse and a patient is meeting the patient’s
need for help. The process is also used with
other persons working in job setting. This
allows each nurse to effectively fulfill her
professional function for the patient with in
the organizational setting.
PATIENT BEHAVIOR
The nursing process is set in motion by
patient behavior. Orlando stresses this in her
first principle: “The presenting behavior of the
patient, regardless of the form in which it
appears, may represent a need for help.
When the patient experiences a need that he
cannot resolve, a sense of helplessness
occurs. The patient’s behavior reflects
distress.
Physical Limitations: Feelings of helplessness
due to physical limitations may result from
incomplete development, temporary or
permanent disability, or restrictions of the
environment, real or imagined.
Adverse reactions to the settings: These are
usually results from incorrect or inadequate
understanding of an experience there. Patient
may become distressed from a negative
reaction to any aspect of the setting.
Frequently a need for help for help may also
arise from the patient’s inability to
communicate effectively. Patient’s behavior
may be verbal or nonverbal. Inconsistency
between these two types of behavior may be
the factor that alters the nurse that the patient
needs help.
Verbal behavior encompasses the entire
patient’s use of language i.e. complaints,
requests, questions, refusals or demands.
Nonverbal behavior includes physiological
manifestations such as heart rate,
perspiration, edema and motor activity as
smiling, walking, avoiding eye contact. It may
also be vocal such as laughing, shouting etc.
Although all patients’ behavior may indicate a
need for help, the behavior may not effectively
communicate that need. When the behavior
dose not communicates the need, problems in
the nurse-patient relationship can arise.
Ineffective patient behavior may also indicate
difficulties in the initial establishment of the
nurse-patient relationship, inaccurate
identification of the patient’s need by the nurse
or negative patient reaction to nursing action.
NURSE REACTION
The patient behavior stimulates a nurse
reaction, which marks the beginning of the
nursing process. This reaction is
comprised of three sequential parts.
The nurse perceives the behavior through
any of her senses.
The perception leads to thought.
The thought produces an automatic feeling.
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 dose nonverbally must be
verbally expressed and the expression
must match one or all of the items
contained in the immediate reaction.
The nurse must clearly communicate to the
individual that the item being expressed
belongs to her.
The nurse must ask the individual about the
item expressed in order to obtain correction
or verification from that same individual.
Adequate identification of the three aspects
of the nurse’s reaction helps to resolve
extraneous feelings that may interfere with
the patient’s care. Orlando used her three
criteria in the study described in The
Discipline and Teaching of Nursing Process
and found that use of the process discipline
is positively related to improvement in patient
behavior.
NURSE’S ACTION
Once the nurse has validated or corrected
her reaction to the patient’s behavior through
exploration with him, she can complete the
nursing process with the nurse’s action.
Orlando’s principle guiding nursing action
states, “The nurse initiates a process of
exploration to ascertain how the patient is
affected by what she says or dose.”
The nurse can act in two ways: automatic or
deliberative. Only the deliberative manner
fulfills her professional function. Automatic
actions are those decided upon for reasons
other than the patient’s immediate need,
where as deliberative actions ascertain and
meet this need.
Criteria for Deliberative Actions
1. Deliberative actions results 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
to 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.
Automatic actions fail to meet one or more
of these criteria. Automatic actions are most
likely to be done by nurses primarily
concerned with carrying out physicians’
orders, routines of patient care, or general
principles for protecting health or by nurses
who do not validate their reactions to
patient behaviors.
PROFESSIONAL FUNCTION
Nurses often work within organizations with
other professionals, and are subject to the
authority of the organization that employs
them. Nonprofessional actions can prevent
the nurse from carrying out her professional
function, and this can lead to inadequate
patient care. A well-defined function of the
profession can help to prevent and resolve
this conflict.
Orlando believes that an employer is unlikely
to continue to require job activities that
interfere with a well-defined function of a
profession. Nurses must be constantly aware
that their “activity is professional only when it
deliberately achieves the purpose of helping
the patient.” Nursing care delivery systems are
being evaluated and revised to enable the
nurse to practice in those situations or areas
where she is most needed.
Some of these situations have been specifically
identified by the Professional Nursing
Accreditation Committee and through their input,
reflected in the accreditation standards of the
Joint Commission on Accreditation for Health
Care Organizations. These are:
1. When the patient is admitted, a professional
nursing assessment is needed to identify the
patient’s need for help.
2. When the patient has a need for education
commonly called patient education.
3. When the patient is being prepared for
discharge.
In each of these situations, the use of
Orlando’s theory would guide the nurse in
expeditiously meeting the patient’s need. At
this time, nurses in acute care facilities are
being looked to use their professional skills
and knowledge to recognize and resolve the
patient’s need for help. Under this system,
emphasis is placed on the patient being
treated and discharge within a predetermined
number of days.
Nursing can capitalize on this situation and
use it to the patient’s and professions best
interest. Orlando’s theory is simple in
nature, provides directions and focus for
identifying and understanding the patient’s
need.
ORLANDO’S THEORY AND THE FOUR
MAJOR CONCEPTS
Orlando includes material specific to three of
the four major concepts: the human, health,
and nursing. The fourth concept, society, is
not included in her theory.
Human: She uses the concept of human as
she emphasizes individuality and the
dynamic nature of the nurse-patient relation.
Health
Health is not specified, it is implied. In her
initial work, Orlando focused on illness. Later
she indicated that nursing deals with the
individual whenever there is a need for help.
Thus a sense of helplessness replaces the
concept of health as the initiator of a need for
nursing.
Society
Orlando largely ignores society. She deals only
with the interaction between a nurse and a
patient in an immediate situation and speaks to
the importance of individuality. She dose make
some attempt to discuss the overall nursing
system in an institutional setting. However, she
dose not discuss how the patient is affected by
the society in which he lives nor dose she use
society as a focus of nursing action.
Nursing
Nursing is the focus of Orlando’s work. She
speaks of nursing as unique and independent
in its concern 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
COMPARISON OF ORLANDO’S PROCESS
AND THE NURSING PROCESS
Orlando’s nursing process may be compared
with the nursing process. Certain overall
characteristics are similar in both processes
such as both are interpersonal in nature and
require interaction between patient and
nurse. Both processes also view the patient
as a total person. Both processes are also
used as a method to provide nursing care
and as a means to evaluate that care.
The assessment phase of the nursing
process corresponds to the sharing of the
nurse reaction to the patient behavior in
Orlando’s process. The collection of data
includes only information relevant to identifying
patient’s need for help. Orlando discusses data
collection in her first book, The Dynamic
Nurse-Patient Relationship. She defines
observation as “any information pertaining to a
patient whom the nurse acquires while she is
on duty.”
Direct data are comprised of “any perception,
thought, or feeling the nurse has from her own
experience of the patient’s behavior.
Indirect data come from sources other than the
patient, such as records, health team members,
or the patient’s significant.
Both types of data require exploration with the
patient to determine their relevance to the
specific situation. This corresponds somewhat
with subjective and objective data in the
nursing process.
The sharing of nurse’s reaction in the Orlando’s
process has components similar to the analysis
in the nursing process. Orlando’s sharing of the
reaction, is a process of exploration with the
patient. The nursing process, on the other
hand, makes use of nursing’s theoretical base
and principles from the physical and behavioral
sciences. The product of the analysis in the
nursing process is the nursing diagnosis.
Exploration of the nurse’s reaction with the
patient in Orlando’s process leads to
identification of his need for help.
The planning phase of the nursing process
involves writing goals and objectives and
deciding upon appropriate nursing action.
The goal of Orlando’s process is always
relief of the patient’s need for help; the
objective relates to improvement in the
patient’s behavior. The nursing process
mandates a more formal action of writing
and giving priority to goals and objectives.
Both processes require patient participation
in determining the appropriate action.
Orlando’s process sees the patient as an
active participation in determining the actual
nurse action. The nursing process, on the
other hand, relies more heavily on scientific
principles and nursing theories in deciding
how the nurse will act.
Implementation involves the final selection
and carrying out of the planned action. This is
also part of the nurse’s action phase of
Orlando’s process. Both processes mandate
that the action be appropriate for the patient
as a unique individual. The nursing process
expects the nurse to consider all possible
effects of the action upon the patient.
Orlando’s process is concerned with the
effectiveness of the action in resolving the
immediate need for help.
Evaluation is inherent in Orlando’s action
phase of her process. Evaluation in both
processes is based on objective criteria. In
the nursing process, evaluation asks whether
the behaviorally stated objectives were met.
In Orlando’s process, the nurse observes
patient behavior to see whether the patient
has been helped. Thus both processes
evaluate in terms of outcomes of care.
ORLANDO’S WORK AND THE
CHARACTERISTICS OF A THEORY
Theories can interrelate concepts in such a
way as to create a different way of looking at
a particular phenomenon. Nursing is the
focus of Orlando’s work. Her theory views
nursing as interacting with an individual in an
immediate situation to relieve a sense of
helplessness.
Theories must be logical in nature. Orlando’s
work dose provides a reasonable and
sequential process for nursing. Patient
behavior initiates the nurse reaction.
Exploration of this reaction with the patient
leads to identification of a need and of an
action to resolve that need. She must
evaluate her action to be certain of its
effectiveness.
Theories should be relatively simple yet
generalizable. Orlando’s theory is simple in
nature, it dose generalize well to all of
nursing practice. The theory remains simple
by revolving around the nurse-patient
interaction, the basic unit of nursing. This
also makes the theory generalizable.
Theories can be the bases for hypotheses
that can be tested. Orlando did derive
hypotheses from her theory and tested them.
Her initial study was observational; she
tested her ideas in a variety of nursing
situations. In her second study, she
developed criteria for the nurse’s reaction
that were specific enough for the
development of hypotheses and statistical
testing.
Theories contribute to and assist in increasing
the general body of knowledge within the
discipline through the research implemented to
validate them. In testing her theory, Orlando
added to the general body of nursing
knowledge. She was able to test the
effectiveness of her process discipline in a
nurse’s contacts with the patients, staff and
workers she supervisors. Her findings showed
a positive relationship between use of the
process discipline and helpful outcomes of
contacts.
Theories can be utilized by the practitioners
to guide and improve their practice. Orlando
has been quite successful in developing a
theory useful to practice. Nurses can easily
use her principles and process discipline in
their interactions with patients and fellow
workers.
SUMMARY
Orlando’s nursing process 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.
Orlando summarizes her process as: A
deliberative nursing process has elements of
continuous reflection as the nurse tries to
understand the meaning to the patient of the
behavior she observes and what he needs
from her in order to be helped. Responses
comprising this process are stimulated by the
nurse’s unfolding awareness of the
particulars of the individual situation.
