Ida Jean Orlando

“Theory of Deliberative Nursing Process”

 “A deliberate 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.”
 The role of the nurse is to find out and meet the patient’s immediate need for help.
 Nurses need to use their perception, thoughts about the perception, or the feelings
engendered from their thoughts to explore with patients the meaning of their behavior.
This process helps the nurse find out the nature of the distress and what help the
patient needs.
 The patient’s presenting behavior might be a cry for help.

Major Dimensions of Orlando’s Nursing Process Theory

1. Function of professional nursing is the organizing principle.
2. Presenting behavior is the patient’s problematic situation.
3. The immediate reaction is the internal response.
4. The nursing process discipline is the investigation into the patient’s needs.
5. Improvement is the resolution to the patient’s situation.

Professional Nursing Function – Organizing Principle

 The nurse’s unique function is finding out and meeting the patient’s immediate needs
for help.
 Nursing is responsive to individuals who suffer or anticipate a sense of helplessness; it is
focused on the process of care in an immediate experience, it is concerned with
providing direct assistance to individuals in whatever setting they are found for the
purpose of avoiding, relieving, diminishing, or cutting the individual’s sense of
helplessness.
 The patient’s sense of helplessness, stress, or need originates from physical limitations,
adverse reaction to the setting, and experiences that prevent a patient from
communicating his or her needs.
 Need is a situationally defined as a requirement of the patient which, if supplied,
relieves or diminishes his immediate distress or improving his immediate sense of
adequacy or wellbeing.
 Nurse’s thought: Does the patient have an immediate need for help or not?

The Patient’s Presenting Behavior – Problematic Situation

 To find out the immediate need for help, the nurse must first recognize the situation as
problematic.
 The presenting behavior of the patient, regardless of the form in which it appears, may
be a plea for help.
 Both the patient and the nurse participate in the exploratory process to identify the
problem as well as the solution.
  The nurse-patient situation is a dynamic whole; each is affected by the behavior of the
other. The interaction is unique for each situation.
 The patient’s behavior stimulates the nurse’s immediate reaction and becomes the
starting point of the investigation.

Immediate Reaction – Internal Response

 The problematic situation in the form of the patient’s presenting behavior (e.g. requests,
comments, complaints, questions, moaning, crying, wheezing, clenching fist, pallor,
reddened face, difficulty of breathing, increased blood pressure), triggers an automatic
immediate reaction in the nurse that is both cognitive and affective.
 The reaction comprises the nurse’s perceptions, thoughts about the perceptions, and
the feelings evoked from the thoughts; they cannot be controlled. These items occur in
an automatic, almost instantaneous sequence.
 In any person’s process of action, four distinct items occur sequentially:
1. The person perceives with any one of his five sense organs an object or objects.
2. The perceptions stimulate automatic thought.
3. Each thought stimulates an automatic feeling.
4. The person acts.
 The interaction of these items is called the nursing process. The first three items cannot
be observed; only the action can. The action is what the person says verbally or conveys
nonverbally.
 The nurse’s immediate reaction is unique for each situation. What the nurse perceives,
thinks, or feels reflects his or her individuality. The automatic thoughts come from the
nurse’s interpretation or meaning attached to the perception. It may or may not be
correct from the patient’s point of view.
 Regardless of the extent of the nurse’s accuracy, the perception that evoked the
thoughts are communications from the patient and represent the raw data for the nurse
to use in investigating or exploring the patient’s behavior.

Deliberative Nursing Process – Reflective Inquiry

 The deliberative nursing process views the nurse-patient situation as a dynamic whole.
 The nurse’s behavior affects the patient, and the nurse is affected by the patient’s
behavior. Understanding the patient’s behavior is a complex process in which
observations and thoughts are used in a serial responsive way to get the “facts of the
case.”
 To be successful, the nurse’s focus must be on the patient rather than on an assumption
that he/she knows what the patient’s problems are and on arbitrary decisions about
what action to take.
 The use of Orlando’s deliberative process requires that there is a shared communicating
process between the nurse and the patient to determine the following:
1. The meaning of the patient’s behavior
2. The help required by the patient
3. Whether the patient was helped by the nurse’s action
  Any observation shared and explored with the patient is immediately useful in
ascertaining and meeting his or her need, or finding out he or she has no needs at that
time.
 The nurse cannot assume that any aspect of his or her reaction to the patient is correct,
helpful, or appropriate until he or she checks the validity of it by exploring it with the
patient.
 The nurse initiates this exploration to determine how the patient is affected by what he
or she says and does.
 When the nurse doesn’t explore the patient’s reaction with him or her, it is reasonably
certain that effective communication between the nurse and patient stops.

Improvement – Resolution
 When the situation becomes clear, it loses its problematic character and a new
equilibrium is established.
 When the patient’s immediate need for help have been determined and met, there is
improvement.
 If the patient’s behavior has not changed, the function of nursing has not been met and
the nurse continues with the inquiry process until there is improvement.
 This change is observable, both in the patient’s verbal and nonverbal behavior.
 This allows the nurse to conclude that the patient’s sense of helplessness has been
relieved, prevented, or diminished.
 It is not the nurse’s activity that is evaluated but rather its result – whether the nurse’s
action helped the patient communicate his or her needs for help and whether that need
was met.
 In each contract the nurse repeats a process of learning how to help the individual
patient.

Assumptions
 When the patients cannot cope with their needs without help, they become distressed
with feelings of helplessness.
 Nursing, in its professional character, does add to the distress of the patient.
 Patients are unique and individual in their responses.
 Nursing offers mothering and nursing analogous to an adult mothering and nurturing of
a child.
 Nursing deals with people, environment and health.
 Patient needs help in communicating needs, they are uncomfortable and ambivalent
about dependency needs.
 Human beings are able to be secretive or explicit about their needs, perceptions,
thoughts and feelings.
 The nurse-patient situation is dynamic, actions and reactions are influenced by both
nurse and patient.
 Human beings attach meanings to situations and actions that are not apparent to others.
 Patient’s entry into nursing care is through medicine.
  The patient cannot state the nature and meaning of the distress for his need without the
nurse’s help, or without her first having established a helpful relationship with him.
 Any observation shared and observed with the patient is immediately useful in
ascertaining and meeting his need or finding out that he is not in need at that time.
 Nurses are concerned with need that patients cannot meet on their own.

Deliberative Nursing Process

The theory focuses on the interaction between the nurse and patient, perception
validation, and the use of the nursing process to produce positive outcomes or patient
improvement. The model provides a framework for nursing, but the use of her theory does not
exclude nurses from using other nursing theories while caring for patients.
Five stages of the deliberative nursing process include assessment, diagnosis, planning,
implementation, and evaluation.

1. Assessment
 The nurse completes a holistic assessment of the patient’s needs.
 This is done without taking the reason for the encounter into consideration.
 The nurse uses a nursing framework to collect both subjective and objective data
about the patient.

2. Diagnosis
 It uses the nurse’s clinical judgment about health problems.
 The diagnosis can then be confirmed using links to defining characteristics,
related factors, and risk factors found in the patient’s assessment.

3. Planning
 It addresses each of the problems identified in the diagnosis.
 Each problem is given a specific goal or outcome, and each goal or outcome is
given nursing interventions to help achieve the goal.
 By the end of this stage, the nurse will have a nursing care plan.

4. Implementation
 The nurse begins using the nursing care plan.

5. Evaluation
 The nurse looks at the progress of the patient towards the goals set in the
nursing care plan.
 Changes can be made to the nursing care plan based on how well (or poorly) the
patient is progressing towards the goals.
 If any new problems are identified in the evaluation stage, they can be
addressed, and the process starts over again for those specific problems.
 The goal of this model is for the nurse to act deliberatively rather than automatically.
This way, a nurse will have a meaning behind the action which means the patient gets care
geared specifically toward his or her needs at that time.
Nursing care has to be flexible. Not only does a nursing care plan depend on the needs
of the patient at the time or admittance, but it also needs to be able to change when and if any
complications come up during the treatment and recovery process. Ida Jean Orlando’s
Deliberative Nursing process directly addresses this need – flexibility, and helps nurses focus on
the patient rather than simply sticking to a nursing care plan no matter what.

Theoretical Assertions
Person
 A developmental being with needs.
 Nursing clients are patients who are under medical care and who cannot deal with their
needs who cannot carry out medical treatment alone.

Environment
 Not defined directly in Orlando’s Theory but implicitly in the immediate context for a
patient.

Health
 A sense of adequacy or well-being
 Fulfilled needs.
 Sense of comfort

Nursing
 Is a dynamic nurse-patient relationship.
 Is responsive to individuals who suffer or anticipate a sense of helplessness