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Ida Jean Orlando (Pelletier) is a significant contributor to the development of theoretical nursing knowledge. According to Fitzpatrick and Whall (1989) and Marriner -Tomey (1989), Orlando was born August 12, 1926. In 1947, she received a diploma in nursing from New York Medical College, Flower Fifth Avenue Hospital School of Nursing. She received a B.S. degree in Public Health Nursing from St. Johns University in Brooklyn, New York, in 1951, and an M.A. in Mental Health Consultation from Columbia University Teacher's College in New York to 1954. While pursuing her education, Orlando was employed as a staff nurse in obstetrical, medical, surgical and emergency nursing.
After receiving her master's degree in 1954, Orlando went to the Yale University School of Nursing in New Haven, Connecticut, for eight years. As an associate professor of mental health and psychiatric nursing at Yale, she was awarded a federal grant and became a research associate and the principal project investigator of a National Institute of Mental health Institute of the United States Public Health
Service's grant entitled "Integration of Mental Health Concepts in a Basic Curriculum." The project sought to identify those factors relevant to the integration of psychiatric-mental health principles into the nursing curriculum.
During 1958-1961, Orlando, as an associate professor and the director of the graduate program in mental health and psychiatric nursing at Yale University, used her proposed conceptual nursing model as the foundation for the curriculum of the program. From 1962-1972, Orlando served as a clinical nurse consultant at McClean Hospital in Belmont. Massachusetts. In this position, she studied the interactions of nurses with clients, other nurses and other staff members and how these interactions affected the process of the nurse's help to clients. Orlando convinced the administration that an educational program for nurses was needed, whereupon McClean Hospital initiated an educational program based on her nursing model (Marriner-Torrey, 1989).
Orlando's Nursing Process Theory
As indicated previously, based on her psychiatric-mental health nursing education and practice, Orlando inductively proposed her conceptual nursing model in her first book, The Dynamic Nurse-Patient relationship, published in 1961 and it focuses on the task of the professional nurse and provides a foundational understanding of Orlando s conceptualization of nursing. It also discusses Orlando's deliberative nursing process and examines problems encountered in nursing situations and presents client case studies to illustrate how Orlando's model can be applied directly with clients in nursing practice.
Intent of Theory
The central focus of Orlando's proposed conceptual nursing model is nurse-client interaction. Orlando identifies that "since the nurse and patient are both people, they interact, and a process goes on between them" (p. 8). Orlando further states, "learning how to understand what is happening between herself and the patient is the central core of the nurse's practice and comprises the basic framework for the help she lives to patients" (p. 4).
Concepts and propositions of the theory
The first of the four metaparadigm concepts, person or patient (client) is explicated in Orlando's model. Conceptualizing person as a behaving, human organism who has needs, Orlando asserts that nurses should be concerned only with those individuals who are unable to meet their needs. Focusing on the individual person, Orlando defines the client of nursing as "a person who becomes distressed, when without help, he cannot meet his needs" (p. 11). The distress experienced by the client may result from physical limitations, adverse reactions to the setting or experiences that prevent clients from communicating their needs. Implying that nursing is dependent on medicine, Orlando states, "the doctor places the patient under the can of the nurse for either or both of the following reasons: (1) the patient cannot deal with what he needs, or (2) he cannot carry out the prescribed treatment or diagnostic plan alone" (p. 5). Consequently, the physician identifies the client for nursing. Thus, the clients of nursing, according to Orlando, are individuals, who are distressed from the inability to meet their needs, who are undergoing some form of medical treatment or supervision and who have been identified by the physician as necessitating nursing.
Orlando perceives the second metaparadigm concept, nursing, as a dynamic, deliberative, situationally unique process, in which the nurse ascertains the client's needs and initiates a process to meet these needs. She differentiates nursing in the general sense from professional nursing.
Nursing in the general sense occurs when any individual carries, in whole or part, the burden of responsibility for what the person cannot yet or can no longer do alone. In contrast, the professional nurse, aligned with the practice of medicine, offers whatever help the patient may require to meet his needs while he is undergoing some form of medical treatment or supervision (Orlando, 1961, p. 5).
The goal of nursing "is to supply the help a patient requires in order for his needs to be met" (p. 8). Thus, "the desired outcome of nursing is an improvement in the patient's sense of well-being or a change for the better in his condition, which contributes simultaneously to the patient's physical and mental health" (p. 9).
Orlando contends that the nun: achieves the goal and desired outcome of nursing by "initiating a process which ascertains the patient's immediate need and helps to meet the immediate need directly or indirectly"(p. 8). The nurse meets the need directly when patients are unable to meet their own needs. Needs are met indirectly when the nurse helps patients obtain the services of a person, agency or resource by which their needs can be met.
Using the four basic nursing practices of observation, reporting, recording and actions carried out with and for the client, Orlando proposes that the nurse "initiates a process of helping the patient express the specific meaning of his behavior in order to ascertain his distress and helps the patient explore the distress in order to ascertain the help he requires so that his distress may be relieved" (p. 20). This process is unique for each nursing situation.
Orlando (p. 36) postulates that three basic elements comprise a nursing situation: (1) the behavior of the patient; (2) the reaction of the nurse; and (3) the nursing actions that are designed for the patient's benefit. The interaction of these three elements comprises Orlando's deliberative nursing process. The first element of the process, the patient's behavior, is what is observed by the nurse in an immediate nurse-patient situation and is determined by the nurse's perceptions. The patient's behavior may be nonverbal, such as motor activity or physiological manifestations, or may be verbal. The presenting behavior of the patient, regardless of the form in which it appears, represents a plea for help in meeting unmet needs.
According to Orlando (p. 40), the second clement of the deliberative nursing process, the nurse's reaction, consists of three aspects: (1) perceptions of the patient's behavior; (2) the thoughts stimulated by the perceptions; and (3) feelings in response to these perceptions and thoughts. In essence, the nurse, based on her/his perceptions, attaches a meaning or interpretation to the patient's behavior. Orlando cautions, however, that the "nurse does not assume that any aspect of her reaction to the patient is correct, helpful or appropriate until the nurse validates her interpretation of the patient's Behavior with the patient" (p. 56).
The third element, the nurse's activity, is any action the nurse carries out. It includes only what the nurse says or does with or for the benefit of the patient. Orlando (p. 60) proposes two kinds of nursing activities: (1) deliberative actions, which consist of those actions that ascertain or meet the patient's immediate need for help and (2) automatic actions or those activities decided on for reasons other than the patient's immediate need. Although both types of nursing activities have purpose, Orlando (p. 65) concludes that only activities carried out deliberatively by the nurse are effective since only these nursing activities meet the patient's immediate need and accomplish the goal of nursing.
Usefulness of the theory in nursing practice
Several propositions that are evident in the nursing model include the following:
When the patient is able to meet his own needs and is able to carry out prescribed measures unaided, he is not dependent on the nurse for help (pp. 5-6).
In order for the nurse to develop and maintain the professional character of her work, she must know and be able to validate how her actions and reactions help or do not help the patient or know and be able to validate that the patient does not require her help at a given time (p. 9).
In order to meet the patient's needs, the nurse (1) initiates a process of helping the patient express the specific meaning of his behavior in order to ascertain his distress and (2) helps the patient explore the distress in order to ascertain the help he requires so that his distress may be relieved (p. 29).
The deliberative nursing process is clearly related to the nurse's professional function of helping the patient because she is in the position of knowing what is happening and whether or not she is being helpful. The nurse recognizes if she has met the patient's need for help by noting the presence or absence of improvement in his presenting behavior. In the absence of improvement, the nurse knows the patient's need has not yet been met, and, if she remains available, she starts the process all over again with whatever presenting behavior is then observed (p. 68).
Although Orlando identifies that the success of implementing the deliberative nursing process is dependent on the communication ability of the nurse, she does not define or describe communication.
In analyzing how the concepts of Orlando's deliberative nursing process model are related. Orlando primarily identifies and describes the major concepts, rather than depicting relationships among the concepts. The concepts in Orlando's conceptual Model are related sequentially. A time dimension is incorporated in the relationships among the concepts. One example is Orlando's deliberative nursing process. The client's action initiates the process. Based on the action of the client, the nurse reacts. The combination of perception, thought and feeling results in the nurse's immediate reaction. The nurse's immediate reaction then precipitates the client to act and an interactive process occurs between the nurse and client, with each redefining the actions and reactions of the other.
Another sequential relationship that can be identified in the model is
Orlando's contention that the inability of persons to meet their own needs or carry out prescribed medical measures must precede the requirement for nursing. The major disciplines that Orlando seems to use in the development of her model are sociology, psychology and medicine.
Orlando uses an interactional process orientation to develop and structure her model. Her view of nursing as an interaction process, with the focus on understanding the interaction between nurse and client, is consistent with an interactional process orientation.