Ida Jean Orlando

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.

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.

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.

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.”

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