Sunday, July 20, 2008

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.

o Deliberative actions result from the correct identification of patient needs by validation
of the nurses’s reaction to patient behavior.

o The nurse explores the meaning of the action with the patient and its relevance to
meeting his need.

o The nurse validates the action’s effectiveness immediately after compelling it.

o 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?