A Close Encounter: Orlando's Dynamic Nurse-Patient Relationship

"I can't move, I can't speak, I need help..."

An origami design is used to express Orlando-Pelletier’s Nursing Theory. The three large folds represents the three steps or processes of patient behavior, nurse reaction, and nurse action.

Subsequent smaller folds would include the assumptions associated with the theory. The finished object might resemble a silhouette of two people connected to one another, alluding to the ongoing nurse and client interaction required for deliberative care to effectively take place.

Understanding Ida Jean Orlando-Pelletier’s
Dynamic Nurse-Patient Relationship

Know the THEORIST

Ida Jean Orlando, a first-generation American of Italian descent was born in 1926. She received her nursing diploma from New York Medical College, Lower Fifth Avenue Hospital, School of Nursing, her BS in public health nursing from St. John's University, Brooklyn, NY, and her MA in mental health nursing from Teachers College, Columbia University, New York. Orlando was an Associate Professor at Yale School of Nursing where she was Director of the Graduate Program in Mental Health Psychiatric Nursing. While at Yale she was project investigator of a National Institute of Mental Health grant entitled: Integration of Mental Health Concepts in a Basic Nursing Curriculum. It was from this research that Orlando developed her theory which was published in her 1961 book, The Dynamic Nurse-Patient Relationship. She furthered the development of her theory when at McLean Hospital in Belmont, MA as Director of a Research Project: Two Systems of Nursing in a Psychiatric Hospital. The results of this research are contained in her 1972 book titled: The Discipline and Teaching of Nursing Processs. Orlando held various positions in the Boston area, was a board member of Harvard Community Health Plan, and served as both a national and international consultant. She is a frequent lecturer and conducted numerous seminars on nursing process. She is married to RobertPelletier and lives in the Boston area. She passed away on November 28 , 2007.

Distinguish the THEORY
Case Scenario

“Nurse, can you give me my morphine,” cried out Mrs. So. “Can you tell how painful it is using the 0 ‐10 pain scale, where 0 being not painful and 10 being severely painful?”replied the nurse. “Ummm... I think it’s about 7. Can I have my morphine now?” “Mrs. So, I think something is bothering you besides your pain. Am I correct?” Mrs. So cried and said, “I can’t help it. I’m so worried about my 3 boys. I’m not sure how they are or who’s been taking care of them. They’re still so young to be left alone. My husband is in Yemen right now and he won’t be back until next month.” “Why don’t we make a phone call to your house so you could check out on your boys?” Mrs. So phoned his sons. “Thank you nurse. I don’t think I still need that morphine. My boys are fine. Our neighbour, Mrs. Yee, she’s watching over my boys right now.”

The focus of Orlando’s paradigm hubs the context of a dynamic nurse-patient phenomenon constructively realized through highlighting the key concepts such as : Patient Behavior, Nurse Reaction , Nurse Action.

1. The nursing process is set in motion by the Patient Behavior. All patient behavior, verbal ( a patient’s use of language ) or non-verbal ( includes physiological symptoms, motor activity, and nonverbal communication) , no matter how insignificant, must be considered an expression of a need for help and needs to be validated . If a patient’s behavior does not effectively assessed by the nurse then a major problem in giving care would rise leading to a nurse-patient relationship failure. Overtime . the more it is difficult to establish rapport to the patient once behavior is not determined. Communicating effectively is vital to achieve patient’s cooperation in achieving health.

Remember : When a patient has a need for help that cannot be resolved without the help of another, helplessness results

2. The Patient behavior stimulates a Nurse Reaction . In this part, the beginning of the nurse-patient relationship takes place. It is important to correctly evaluate the behavior of the patient using the nurse reactions steps to achieve positive feedback response from the patient. The steps are as follows:
The nurse perceives behavior through any of the senses -> The perception leads to automatic thought -> The thought produces an automatic feeling ->The nurse shares reactions with the patient to ascertain whether perceptions are accurate or inaccurate -> The nurse consciously deliberates about personal reactions and patient input in order to produce professional deliberative actions based on mindful assessment rather than automatic reactions.

Remember : Exploration with the patient helps validate the patient’s behavior.

3. Critically considering one or two ways in implementing Nurse Action. When providing care, nursing action can be done either automatic or deliberative.

Automatic reactions stem from nursing behaviors that are performed to satisfy a directive other than the patient’s need for help.
For example, the nurse who gives a sleeping pill to a patient every evening because it is ordered by the physician, without first discussing the need for the medication with the patient, is engaging in automatic, non-deliberative behavior. This is because the reason for giving the pill has more to do with following medical orders (automatically) than with the patient’s immediate expressed need for help.

Deliberative reaction is a “disciplined professional response” It can be argued that all nursing actions are meant to help the client and should be considered deliberative. However, correct identification of actions from the nurse’s assessment should be determined to achieve reciprocal help between nurse and patient’s health. The following criterias should be considered.

• Deliberative actions result from the correct identification of patient needs by validation of the nurses’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 compelling it.
• The nurse is free of stimuli unrelated to the patient’s need (when action is taken).

Remember : for an action to have been truly deliberative, it must undergo reflective evaluation to determine if the action helped the client by addressing the need as determined by the nurse and the client in the immediate situation.

Learn more about the THEORY

METAPARADIGM CONCEPTS

Human/Person An individual in need. Unique individual behaving verbally or nonverbally. Assumption is that individuals are at times able to meet their own needs and at other times unable to do so.
Health Assumption is that being without emotional or physical discomfort and having a sense of well-being contribute to a healthy state. She further assumed that freedom from mental or physical discomfort and feelings of adequacy and well being contribute to health. she also noted that repeated experiences of having been helped undoubtedly culminate over periods of time in greater degrees of improvement
Environment Orlando assumes it as a nursing situation that occurs when there is a nurse-patient contact and that both nurse and patient perceive, think, feel and act in the immediate situation. any aspect of the environment, even though its designed for therapeutic and helpful purposes, can cause the patient to become distressed. She stressed out that when a nurse observes a patient behavior, it should be perceived as a signal of distress.
Nursing A distinct profession "Providing direct assistance to individuals in whatever setting they are found for he purpose of avoiding, relieving, diminishing, or curing the individual's sense of helplessness" (Orlando, 1972, p. 22). Professional nursing is conceptualized as finding out and meeting the client’s immediate need for help.
Cite the Applications of the THEORY

In Nursing Research

1. In a Veterans Administration (VA) ambulatory psychiatric practice in Providence, RI Shea, McBride, Gavin, and Bauer (1987) used Orlando’s theoretical model with patients having a bipolar disorder.Their research results indicate that there were: higher patient retention, reduction of emergency services, decreased hospital stay, and increased satisfaction. They recommended its use throughout the VA system.Currently Orlando’s model is being used in a multi-million dollar research study of patients with a bipolar disorder at 12 sites in the VA system (McBride, Telephone interview, July, 2000). McBride and colleagues continue its use in practice and research at the Veteran Administration Hospital in Providence, RI.
2. In a pilot study, Potter and Bockenhauer (2000) found positive results after implementing Orlando’s theory. These included:positive, patient-centered outcomes, a model for staff to use to approach patients, and a decrease in patient’s immediate distress. The study provides variable measurements that might be used in other research studies.

in Nursing Education

1. Orlando's theory has a continuing influence on nursing education. Through e-mail communication it was found that the Midwestern State University in Wichita Falls, Texas, is using Orlando's theory for teaching entering nursing students. According to Greene (e-mail communication, June, 2000) she became aware, when taking a doctoral course about nursing theories, that it was Orlando theory used by its school.
2. Through networking the author found that for over 10 years South Dakota State University in Brookings, SD has been using Haggerty’s (1985) description of the communication based on Orlando’s theory for entering nursing students as well as re-enforcing it in their junior year (e-mail communication, (J. Fjelland, June, 2000). Joyce Fjelland, MS, RN. After working with Schmieding at Boston City Hospital, Lois Haggerty used Orlando’s theory in her teaching of students and in conducting a research study of students’ responses to distressed patients at BostonCollege in Chestnut Hill, Massachusetts.

in Nursing Practice

From an ICU nurse: “Patients have an initial ability to communicate their need for help”. Consider a case of an immediate post Coronary Artery Bypass Graft (CABG) patient. Once relieved from the effects of anesthetic sedation, though intubated, you would realize his excruciating retort from the sternotomy incisional pain through implicit cues. Morphine Sulfate 1 to 2 mg To be given via slow IV push every 1 to 2 hours or Ketorolac 15 mg IV every 6 hours is the typical pro re nata (PRN) order of a cardiac intensivist to relieve the client from pain. Automatic response of a nurse is to calm the client and encourage relaxation through deep breathing while splinting the chest with a pillow. Being Deliberate in your actions include knowing the pharmacokinetics of an ordered drug in relation to the client’s physiologic standing. If the creatinine level were elevated, would you administer ketorolac? If the client is on respiratory precaution, would you administer Morphine? You would ask yourself, what other alternatives do I have to ease my client from pain? “The client’s behavior is meaningful”. If such “need” would be fittingly dealt with, the intervention is thriving. “When patient’s needs are not met, they become distressed.”

Analyze the THEORY

Case Study
A relative of a patient at the emergency room went to the nurse’s station and began complaining in a loud shouting voice that their patient being a charity case is not being given the same quality of care as that of the other patients who are under private consultants. He claimed that their patient who was hyperventilating and was complanining of difficulty of breathing due to neurocirculatory astheinia was just forced to sit in the cubicle, while the rich-looking patient was a gomey.

Question
How will you handle this kind of situation and avoid conflict? How can Orlando’s dynamic nurse-patient interaction theory be utilized in this type of situation?

This Group Blog is Submitted to Ms. Sheila Bonito, FIC,
in Partial Fulfillment of the Requirements in N207.
Manager: Aux Lizares
Editor: Maria Mae Juanich
Contributors:
Katrina Anne Limos
Ginno Paulo Maglaya
Diana Jasmin Lee

Acknowledgment

We would like to acknowledge the following people: Ma’am Shiela Bonito, for coming up with this group work which really challenged not only our knowledge, understanding and creativity but also our ability to stay connected despite the distance, Ms. Aux Lizares, for diligently sorting out the articles, Ms. Maria Mae Juanich, for organizing the articles into a working blog, and for Ms. Katrina Anne Limos, Mr. Gino Paulo Maglaya, and Ms. Diana Jasmin Lee, for tirelessly contributing their thoughts, ideas, and resources. Without all of you, this blog would have never been possible. Thank you very much!!!

Dear classmates,

Let us learn together. Have we done justice to Ida J. Orlando in presenting her theory this way? We would like to invite you to share with us your thoughts, feelings, comments or reactions on our blog entitled, “Understanding Ida Jean Orlando-Pelletier’sDynamic Nurse-Patient Relationship.” Thank you for your participation!

Regards,

Group G

Reference:

Orlando, I. J. (1972). The discipline and teaching of nursing process: An evaluative study. New York: G. P. Putnam.
http://www.enursescribe.com/orlando.htm
George, J.B. (2002). Nursing Process Discipline: Ida Jean Orlando. In George, J.B. (Ed.). Nursing Theories: the Base for professional nursing practice (5th Ed.). Upper Saddle River, New Jersey: Prentice Hall, pp. 189-208.
Schmieding, N.J. (2002). Ida Jean Orlando (Pelletier): Nursing Process Theory. In Tomey, A.M., & Alligood, M.R.. Nurse theorists and their work (5th Ed.). St. Louis: Mosby, pp. 399-417.
http://www.uri.edu/nursing/schmieding/orlando/
Orlando, I.J. (1961). The dynamic nurse-patient relationship, function, process and principles. New York: G. P. Putnam.]
Haggerty, L.A. (1985). A theoretical model for developing students’ communication skills. Journal of Nursing Education, 24(7), 296-298.
Haggerty, L.A. (1987). An analysis of senior nursing students’ immediate responses to distressed patients.. Journal of Advanced Nursing, 12, 451-461.
Nancy M. Shea, Linda McBride, Christopher Gavin, and Mark Bauer
Bauer, M. S. (2001). The collaborative practice model for bipolar disorder-Design and implementation in a multisite randomized controlled trial. Bipolar Disorders 3(5), 233-244. Bauer, M.S., & McBride, L.(2002). Structured group psychotherapy for bipolar disorder (2nd Ed). New York: Springer Publishing Co. Shea, N. M., McBride, L. Gavin, C., & Bauer, M. (1997). The effects of ambulatory collaboration practice model on process and outcome of care for bipolar disorder. Journal of the American Psychiatric Nurses Association 3(2), 49-57. Mertie. L. Potter, ND, ARNP, CS and Barbara Jo Bockenhauer, MS, RNC
Potter, M.L. & Bockenhauer, B.J. (2000). Implementing Orlando’s nursing process theory: A pilot study. Journa
l of Psychosocial Nursing nd Mental Health Services, 38(3), 14-21