Ida Jean OrlandoIda Jean OrlandoDeliberative Nursing PracticeDeliberative Nursing Practice

Angela Common, David Feiertag, Stacie Koelewyn and John Richardson

Ferris State University NUR 324

Evidence Based Practice

Theory OverviewTheory OverviewOOrlando's theory was rlando's theory was developed in the late developed in the late 1950s from observations 1950s from observations she recorded between a she recorded between a nurse and patient. nurse and patient.

The role of the nurse is to The role of the nurse is to find out and meet the find out and meet the patient's immediate need patient's immediate need for help. The patient's for help. The patient's presenting behavior may presenting behavior may be a plea for help, be a plea for help, however, the help needed however, the help needed may not be what it may not be what it appears to be. appears to be.

Theory Overview Cont.Theory Overview Cont.

Nurses need to explore with patients the Nurses need to explore with patients the meanings of their behavior. meanings of their behavior. This process helps the nurse find out the This process helps the nurse find out the nature of the distress and what help the nature of the distress and what help the patient needs. patient needs. The use of her theory keeps the nurse's The use of her theory keeps the nurse's focus on the patient. The strength of the focus on the patient. The strength of the theory is that it is clear, concise, and easy theory is that it is clear, concise, and easy to use. to use.

Theory Overview Cont.Theory Overview Cont.

While providing the overall framework for While providing the overall framework for nursing, the use of her theory does not nursing, the use of her theory does not exclude nurses from using other theories exclude nurses from using other theories while caring for the patient. while caring for the patient. Orlando's theory is evident in nursing Orlando's theory is evident in nursing education, practice, and research.  Users education, practice, and research.  Users of the theory in practice and education are of the theory in practice and education are often not aware of their use of Orlando's often not aware of their use of Orlando's theory.  theory. 

Orlando’s evidence based research is full circle

(Mercy Medical Center, 2009)

Rationale for Use of Nursing Rationale for Use of Nursing TheoryTheory

Nursing educators use Orlando’s Nursing educators use Orlando’s theory because it allows students to theory because it allows students to focus on the many aspects of focus on the many aspects of communication between the student communication between the student and patient.and patient.

Administrators have adopted Orlando’s Administrators have adopted Orlando’s theory throughout nursing departments theory throughout nursing departments as it has shown to increase as it has shown to increase effectiveness in meeting patients needs effectiveness in meeting patients needs and increase decision making skills and increase decision making skills among staff nurses.among staff nurses.

Rationale for Use of Nursing Rationale for Use of Nursing TheoryTheory

Nurses, physicians, and families benefit Nurses, physicians, and families benefit from the use of Orlando’s theory because from the use of Orlando’s theory because of the overall increase in patient of the overall increase in patient satisfaction. When patients are satisfied, satisfaction. When patients are satisfied, they make things easier for those who they make things easier for those who care for them.care for them.

Rationale for Use of Nursing Rationale for Use of Nursing Theory Cont.Theory Cont.

Orlando’s Theory

Educators

Administrators

Nurses

Physicians

Families

Research StudiesResearch StudiesResearch studies Research studies selected were chosen selected were chosen based off of the four based off of the four metaparadigms of metaparadigms of nursing which include nursing which include person, environment, person, environment, health, and nursing.health, and nursing.

Orlando’s theory is Orlando’s theory is primarily focused toward primarily focused toward the mental well being of the mental well being of the patient as it relates to the patient as it relates to communication. communication.

PersonPerson

Based on her observations, Orlando believes that people Based on her observations, Orlando believes that people behave both verbally and nonverbally. behave both verbally and nonverbally.

People are able to meet their own needs for help in some People are able to meet their own needs for help in some situations.situations.

People become distressed if they are unable to meet their People become distressed if they are unable to meet their own needs. own needs.

Nurses should check in with their patients often to determine Nurses should check in with their patients often to determine if they have new needs for help. if they have new needs for help.

PersonPerson

Study was based in a State Psychiatric Hospital using Study was based in a State Psychiatric Hospital using two similar type units. Thirty patients were involved with two similar type units. Thirty patients were involved with similar diagnosis. Nineteen in the test group and eleven similar diagnosis. Nineteen in the test group and eleven in the control.in the control.It was a twelve week study.It was a twelve week study.Ten nurses participated six were trained in Orlando’s Ten nurses participated six were trained in Orlando’s Deliberate theory and its clinical application. All ten RN’s Deliberate theory and its clinical application. All ten RN’s were trained to use a the Bockenhauser-Potter Scale of were trained to use a the Bockenhauser-Potter Scale of Immediate Distress (BPSID).Immediate Distress (BPSID).The BPSID was developed as a five point scale to The BPSID was developed as a five point scale to subjectively measure the patient’s immediate level of subjectively measure the patient’s immediate level of distress.distress.Stress levels were measured before and after each Stress levels were measured before and after each interaction.interaction.

Positive Patient Centered Outcomes

Positive Patient Centered Outcomes Cont.

Scales showed a decrease in Scales showed a decrease in the patient’s distress levels in the patient’s distress levels in the study group.the study group.

Additionally nurses reported Additionally nurses reported greater satisfaction with having greater satisfaction with having a “road map” to patient a “road map” to patient interactions.interactions.

Results

Positive Patient Centered OutcomesLimitations

Very small study limited in patient numbers and nurse Very small study limited in patient numbers and nurse numbers.numbers.Short study.Short study.Limited patient type. Limited patient type. Considering the limited time of use and small amount of Considering the limited time of use and small amount of training received, the nurses demonstrated a good training received, the nurses demonstrated a good success rate using the theory.success rate using the theory.The success of the study implies that the use of The success of the study implies that the use of Orlando’s Deliberate Nursing Process in nurse patient Orlando’s Deliberate Nursing Process in nurse patient interactions immediately reduces the amount of stress interactions immediately reduces the amount of stress demonstrated by a patient. Reducing stress may lead to demonstrated by a patient. Reducing stress may lead to improved outcomes for patients across the spectrum of improved outcomes for patients across the spectrum of nursing practice.nursing practice.

EnvironmentEnvironment

The nurse-patient interactions occur in a healing and therapeutic The nurse-patient interactions occur in a healing and therapeutic environment ideally.environment ideally.

If a nurse ignores the patient’s needs, then the area of care can If a nurse ignores the patient’s needs, then the area of care can become a non-therapeutic environment which is harmful to the become a non-therapeutic environment which is harmful to the patient both physically and mentally. patient both physically and mentally.

When a nurse responds to a patient’s verbal and non-verbal When a nurse responds to a patient’s verbal and non-verbal behavior positively, there is an emotionally healthy environment.behavior positively, there is an emotionally healthy environment.

It is possible for a patient to react negatively to a situation that is It is possible for a patient to react negatively to a situation that is intended to be therapeutic and helpful, and that is why a nurse intended to be therapeutic and helpful, and that is why a nurse must continually reevaluate the patient’s condition and behavior. must continually reevaluate the patient’s condition and behavior.

EnvironmentEnvironment

A study supported by the Agency for Healthcare A study supported by the Agency for Healthcare Research and Quality used Orlando’s theory to Research and Quality used Orlando’s theory to understand the needs of critically ill patients understand the needs of critically ill patients (Agency for Healthcare Research and Quality, (Agency for Healthcare Research and Quality, 2001) .2001) .

The study interviewed stable Intensive Care Unit The study interviewed stable Intensive Care Unit (ICU) patients as well as floor status patients (ICU) patients as well as floor status patients who had recently been in the ICU who had spent who had recently been in the ICU who had spent at least 3 days in an ICU (Agency for Healthcare at least 3 days in an ICU (Agency for Healthcare Research and Quality, 2001) .Research and Quality, 2001) .

ICU Psychosis

Stressed?

ICU Psychosis Cont.ICU Psychosis Cont.

Orlando’s theory helped this study to focus on the Orlando’s theory helped this study to focus on the patient’s perception of feeling safe. The patient’s patient’s perception of feeling safe. The patient’s perception of feeling safe is influenced by their friends perception of feeling safe is influenced by their friends and family, ICU staff, religious beliefs, and what they and family, ICU staff, religious beliefs, and what they understood about their care. understood about their care. The study showed that poor communication between the The study showed that poor communication between the medical team and the patient caused the patients to medical team and the patient caused the patients to become fearful and paranoid in relation to the staff.become fearful and paranoid in relation to the staff.According to Orlando, the role of the nurse is to find out According to Orlando, the role of the nurse is to find out and meet the patient’s immediate need for help: the and meet the patient’s immediate need for help: the study showed that nurses can work with families and study showed that nurses can work with families and patients to build a trusting relationship and decrease patients to build a trusting relationship and decrease internal stress.internal stress.

ICU Psychosis Cont.ICU Psychosis Cont.

This study fails to focus on the ICU patients that are This study fails to focus on the ICU patients that are unable to verbalize their discomforts. In this study, tape unable to verbalize their discomforts. In this study, tape recorded interviews were analyzed to model the recorded interviews were analyzed to model the psychosocial needs of the patient, the study did not look psychosocial needs of the patient, the study did not look at the physical needs.at the physical needs.This study further supports Orlando’s theory in that it This study further supports Orlando’s theory in that it reinforces the need for the nurse to improve reinforces the need for the nurse to improve communication and understand the emotional needs of communication and understand the emotional needs of the patient.the patient.Reflecting on this study, it can be said that nursing is too Reflecting on this study, it can be said that nursing is too often a task oriented profession. The bedside nurse often a task oriented profession. The bedside nurse needs to further develop interpersonal skills for the well-needs to further develop interpersonal skills for the well-being of their patients.being of their patients.

HealthHealth

Orlando viewed health as the Orlando viewed health as the absence of physical and absence of physical and emotional distress and a sense emotional distress and a sense of well-being.of well-being.

She also believed that a person’s She also believed that a person’s degree of well-being improved as degree of well-being improved as a person’s needs were a person’s needs were continually met (in this case by continually met (in this case by the nurse caring for a patient).the nurse caring for a patient).

Research Study by Shea, McBride, Research Study by Shea, McBride, Gavin, and Bauer (1987)Gavin, and Bauer (1987)

At a Veterans Administration ambulatory At a Veterans Administration ambulatory psychiatric care clinic in Providence, Rhode psychiatric care clinic in Providence, Rhode Island; a study was performed using Orlando’s Island; a study was performed using Orlando’s Nursing Process Theory.Nursing Process Theory.

76 patients being treated for bipolar disorder 76 patients being treated for bipolar disorder through the outpatient clinic were placed into a through the outpatient clinic were placed into a six month program described as being a “high-six month program described as being a “high-intensity collaborative practice program”.intensity collaborative practice program”.

Health continued…Health continued…

The goal of the research study was to establish The goal of the research study was to establish the effect of this “high intensity program” on the effect of this “high intensity program” on patient satisfaction, intensity of medication patient satisfaction, intensity of medication treatment, and frequency and pattern of patient treatment, and frequency and pattern of patient use of the clinic’s services.use of the clinic’s services.The patients were assigned to clinical nurse The patients were assigned to clinical nurse specialists who served as primary care givers. specialists who served as primary care givers. The patients were additionally supported by a The patients were additionally supported by a psychiatrist as needed.psychiatrist as needed.

Health continued…Health continued…

After applying Orlando’s Nursing Process Theory to After applying Orlando’s Nursing Process Theory to patient care, the following results were discovered:patient care, the following results were discovered:Increased patient satisfactionIncreased patient satisfactionDecreased hospital length of stayDecreased hospital length of stayLess emergency services requiredLess emergency services requiredHigher patient retentionHigher patient retentionIncreased intensity of medication treatmentIncreased intensity of medication treatmentDecreased use of costly mental health servicesDecreased use of costly mental health services

Results

Suggestions on findingsSuggestions on findingsAfter conducting this research study, Bauer, McBride, Shea, and Gavin suggested that the VA should use Orlando’s theory across the After conducting this research study, Bauer, McBride, Shea, and Gavin suggested that the VA should use Orlando’s theory across the entire organization.entire organization.

In July of 2000, Orlando’s In July of 2000, Orlando’s theory was being used in atheory was being used in amulti-million dollar study of multi-million dollar study of patients with bi-polar disorder patients with bi-polar disorder at 12 different VA sites.at 12 different VA sites.

Successful resultsSuccessful results

This research study has helped to show the real This research study has helped to show the real health benefits of Orlando’s Nursing Process health benefits of Orlando’s Nursing Process Theory when applied to patient care.Theory when applied to patient care.

This research study is a great example of This research study is a great example of benefits to patients in mental health care, but the benefits to patients in mental health care, but the principles of Orlando’s theory are basic enough principles of Orlando’s theory are basic enough to be applied to any area of patient care.to be applied to any area of patient care.

NursingNursingCommunicationCommunication

Nursing is an autonomous profession that must Nursing is an autonomous profession that must work closely together with medical teams work closely together with medical teams

Nurses should pay attention to other nurses Nurses should pay attention to other nurses verbal and non-verbal body language to verbal and non-verbal body language to increase communicationincrease communication

Communication Study SpecificsCommunication Study Specifics

This study on communication focused on supportive This study on communication focused on supportive communication during shift reportcommunication during shift report

Study was in a medical/surgical intensive care unitStudy was in a medical/surgical intensive care unit

Consisted of 4 charge nurses, and 13 staff nurses during Consisted of 4 charge nurses, and 13 staff nurses during midnight shiftmidnight shift

Some were BSN prepared RN’s some were ADN’s Some were BSN prepared RN’s some were ADN’s

The 4 charge nurses were all womenThe 4 charge nurses were all women

The 13 staff nurses consisted of eight women, five men The 13 staff nurses consisted of eight women, five men in total in total

Average time spent in report was 15 minutes 51 secondsAverage time spent in report was 15 minutes 51 seconds

Supportive BehaviorsSupportive Behaviors

Study looked for verbal and non-verbal Study looked for verbal and non-verbal behaviors between shifts during reportbehaviors between shifts during report

Nurses were filmed during report with no Nurses were filmed during report with no one else in the room, face to faceone else in the room, face to face

Supportive behaviors were classified as, Supportive behaviors were classified as, head nods, praise, support, reassurance, head nods, praise, support, reassurance, concern (Hays, page 6). concern (Hays, page 6).

ResultsResults

In 162 charge nurse reports there were no In 162 charge nurse reports there were no supportive behaviors observedsupportive behaviors observed

Of the oncoming staff getting report from Of the oncoming staff getting report from the charge nurse there were only 11 the charge nurse there were only 11 supportive behaviors observedsupportive behaviors observed– All non-verbal head nodsAll non-verbal head nods

ResultsResults

Supportive behaviors Supportive behaviors between staff RN’s between staff RN’s were identified 50% of were identified 50% of the time (6 out of 12 the time (6 out of 12 interactions)interactions)

Seven of the RN’s in Seven of the RN’s in these interactions these interactions were female, four were female, four male.male.

All the behaviors were All the behaviors were non-verbal head nodsnon-verbal head nods

LimitationsLimitations

Nurse’s schedules Nurse’s schedules

The study did not address patient acuityThe study did not address patient acuity

RN to patient ratio was not factored into the RN to patient ratio was not factored into the report analysisreport analysis

Personal issues (external/internal stresses of the Personal issues (external/internal stresses of the RN’s)RN’s)

Cultural differences were not factored into Cultural differences were not factored into communication stylescommunication styles

RN’s may have reported differently off cameraRN’s may have reported differently off camera

ConclusionConclusion

There was no positive communication There was no positive communication outcomes from the leadership (Charge outcomes from the leadership (Charge nurses)nurses)

Women are more likely to give a Women are more likely to give a supportive non-verbal then mensupportive non-verbal then men

Support came from the bedside nurse to Support came from the bedside nurse to the next bedside nursethe next bedside nurse

Overall report communication was not Overall report communication was not supportive and all non-verbalsupportive and all non-verbal

Suggestions to changeSuggestions to changeManagers need to evaluate the Managers need to evaluate the leaders on the floor from supervisor, leaders on the floor from supervisor, to charge, to nurses and techsto charge, to nurses and techs

In-service for nursing leadership and In-service for nursing leadership and communication road blockscommunication road blocks

Allow the nurse’s to view their reportAllow the nurse’s to view their report

Encourage to learn from other’s Encourage to learn from other’s mistakesmistakes

After one receives report to give an After one receives report to give an appraisal or validation of the off appraisal or validation of the off going RN’s workgoing RN’s work

ReferencesReferences

Agency for Healthcare Research and Quality, (May 2001).Quality of Agency for Healthcare Research and Quality, (May 2001).Quality of care ICU patients. care ICU patients. Agency for Healthcare Research and Agency for Healthcare Research and

QualityQuality. . 249249, 11-12. , 11-12. Hays, Mary M. (2002).An exploratory study of supportice Hays, Mary M. (2002).An exploratory study of supportice communication during shift report. communication during shift report. Sourther Online Journal of Sourther Online Journal of Nursing ResearchNursing Research. . 33, 1-14. , 1-14. Limos, K., Maglaya, G., Lee, D., (2008). A Close Encounter: Orlando's Limos, K., Maglaya, G., Lee, D., (2008). A Close Encounter: Orlando's

Dynamic Nurse-Patient Relationship. Retrieved April 11, Dynamic Nurse-Patient Relationship. Retrieved April 11, 2009, 2009, from from http://nursingtheories.blogspot.com/2008/07/close-http://nursingtheories.blogspot.com/2008/07/close-encounter-orlandos-dynamic-nurse.htmlencounter-orlandos-dynamic-nurse.htmlPotter, M.L., & Bockenhauer, B.J. (2000). Implementing Orlando's Potter, M.L., & Bockenhauer, B.J. (2000). Implementing Orlando's

Nursing Theory: a pilot study. Nursing Theory: a pilot study. Journal of Psychosocial Nursing Journal of Psychosocial Nursing and Mental Health Servicesand Mental Health Services. . 38(3)38(3), 14-21., 14-21.

Shea, N., McBride, L., & Bauer, C., Gavin, M. (1997). The Effects of Shea, N., McBride, L., & Bauer, C., Gavin, M. (1997). The Effects of an Ambulatory Collaborative Practice Model on Process and an Ambulatory Collaborative Practice Model on Process and Outcome of Care for Bipolar Disorder. Outcome of Care for Bipolar Disorder. Journal of the Journal of the

American American Psychiatric Nurses AssociationPsychiatric Nurses Association, , 33, Retrieved April 11, , Retrieved April 11, 2009, from 2009, from http://jap.sagepub.com/cgi/content/abstract/3/2/49.http://jap.sagepub.com/cgi/content/abstract/3/2/49.