Orlando’s Nursing Process Theory in Nursing Practice
Barbara A. May∗
Ida Jean Orlando Pelletier, a nursing leader and theorist, passed away on November 28, 2007. She discovered, as she preferred to say, her middle-range, research-based theory, Deliberative Nursing Process, in the 1950’s and described it in her first book.
History and Background
In the 1950s, governmental grants became available for studies integrating mental health concepts into nursing curricula. Yale University received such a National Institute of Mental Health grant and Ida Orlando became project investigator. Whereas nursing theories were most often developed deductively in the 1950s, Orlando was the first to develop theory inductively in an empirical study of nursing practice. For 3 years she observed and recorded what she saw and heard in interactions between patients and nurses (Orlando, 1989; Pelletier, 1976).
After examining 2000 records, Orlando was able to categorize them as “good” and “bad” nursing. Orlando asked nurses with dissimilar views, experience, and education to place each record into one of the categories she had initially identified. All the nurses agreed with Orlando’s categorization. Orlando believed that if they all agreed, then the record’s anecdotal content contained “what made good and bad nursing happen” (Pelletier, 1976, p. 22).
According to Orlando, “In the records judged as good the nurse’s focus was on the patient’s immediate verbal and nonverbal behavior from the beginning through the end of the contact; whereas in those judged bad, the nurse’s focus was on a prescribed activity or something that had nothing to do with the patient’s behavior”(Pelletier, 1976, p. 23). When good nursing occurred, the nurse listened to what was happening and identified the patient’s distress. The nurse understood why the patient was distressed and recognized that without the nurse’s help, the patient’s distress was not relieved. Orlando concluded, “that the function of professional nursing is to find out and meet the patient’s immediate needs for HELP” (Pelletier, 1976, p. 24). This original work published in 1961 became the basis for Orlando’s deliberative nursing theory (republished in 1990 by the National League for Nursing).
Orlando conducted research at McLean Hospital in Belmont, Massachusetts, and was funded with a Mental Health Public Service grant. In the second study, she assessed the relevance of earlier formulations, educated and evaluated nurses in the use of her formulations, and tested the validity of the theory formulations. Based on this research, her original formulations were validated and showed significant research results. She also extended her theory to include the entire nursing practice system (Orlando, 1972).
Orlando’s theory is appealing because it clearly describes what nurses consider good nursing and she proposed its value for the twenty-first century (Orlando, 1987). Many theory scholars have published descriptions and analyses of her work (Alligood & Tomey, 2010; Fawcett, 2005; George, 2011; Meleis, 2007; Parker, 2006). The theory has been discussed in articles related to its use in research (Haggerty, 1987; Olson & Hanchett, 1997; Reid-Ponte, 1992). In addition, Orlando’s theory has been used for and by both clinical and administrative practice in two acute-care hospitals (Schmieding, 1984), in operating rooms (Rosenthal, 1996), in a psychiatric hospital (Potter & Bockenhauer, 2000), in nursing management (Laurent, 2000), and in a long-term care facility (Faust, 2002). Orlando’s work has been translated into six languages. A Web page on Orlando’s theory, developed by Schmieding, is updated periodically and contains extensive references (www.uri.edu/nursing/schmieding/orlando).
Overview of Orlando’s Nursing Process Theory
Various theorists have categorized Orlando’s theory differently. Woolridge, Skipper, and Leonard (1968) classified it as a prescriptive theory. Others including Barnum (1998) and Crane (1980) described it as an interaction theory, and Fawcett (1993) classified it as a middle-range predictive theory. Orlando’s theory is a reflective practice theory that is based on discovering and resolving problematic situations. If the problem is not discovered, it cannot be solved. The centrality of the patient is ever-present when using Orlando’s theory (Schmieding, 1983). Orlando described her theory as a nursing process theory rather than effective nursing care theory (Orlando-Pelletier, 1990).
Framework of the Theory
As a reflective practice theory, Orlando’s theory contains concepts that are interrelated but are described separately. These five interrelated concepts are addressed within the problematic framework derived from Schmieding’s (1983, 1987) analysis of Orlando’s theory using the writings of John Dewey (1933, 1938) and Thomas Kuhn (1970). The five concepts are the following:
1. Professional nursing function—organizing principle
2. Patient’s presenting behavior—problematic situation
3. Immediate reaction—internal response
4. Deliberative nursing process—reflective inquiry
Professional Nursing Function: Organizing Principle
Orlando believed that without the authority derived from a distinct function of nursing, nurses’ practice could not be autonomous. From her research, she conceptualized the nurse’s unique function as “finding out and meeting the patient’s immediate needs for help” (Orlando, 1972, p. 20), which constitutes the theory’s organizing principle. Thus the patient is the focal point of the nurse’s function. Orlando states, “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 curing the individual’s sense of helplessness” (Orlando, 1972, p. 12).
According to Orlando (1961), “Need is situationally defined as a requirement of the patient which, if supplied, relieves or diminishes his immediate distress or improves his immediate sense of adequacy or well-being” (p. 5). It is the nurse’s responsibility to meet the patient’s immediate needs for help either by supplying it directly or by calling in the services of others. The central core of the nurse’s practice is to understand what is happening between the patient and the nurse, which provides the framework for the help the nurse gives the patient (Orlando, 1961).
At the first nurse-patient contact, the nurse does not know whether the patient is in need of help. However, information is available though assessment to achieve an accurate understanding of the patient’s presenting behavior and to determine if the patient is in need of help. This is not as easy as it appears. Orlando (1961) asserts, “First, the nurse must take the initiative in helping the patient express the specific meaning of his behavior in order to ascertain his distress. Second, she must help the patient explore the distress in order to ascertain the help he requires for his [immediate] need [for help] to be met” (p. 26).
If the patient is in need and the need is fulfilled, the nursing function has been fulfilled. Orlando (1972) states, “The product of meeting the patient’s immediate need for help is…‘improvement’ in the immediate verbal and nonverbal behavior of the patient. This observable change allows the nurse to believe or disbelieve that her activity relieved, prevented, or diminished the patient’s sense of helplessness” (p. 21).
The distinct function clarifies the nurse’s role and guides the assessment by directing it to the patient’s immediate needs for help in the immediate situation. The function remains the same regardless of the patient’s diagnosis, treatment, or age or whether the patient is hospitalized or at home (Orlando, 1972).
The Patient’s Presenting Behavior: Problematic Situation
Orlando focuses almost exclusively on understanding the complexities of problematic situations. Nursing practice comprises frequent patient-nurse contacts in which the patient manifests verbal and nonverbal behavior. Behaviors can be manifested in verbal forms (e.g., requests, comments, complaints, questions, moaning, crying, wheezing), in nonverbal forms (e.g., skin color, silence,clenching fist, reddened face), or in physical forms (e.g., respirations, blood pressure). These situations disrupt the equilibrium and are cues that get the nurse’s attention. It is unclear, however, whether the patient is experiencing a need for help. From her research, Orlando formulated the following statement to guide the nurse’s observation: “The presenting behavior of the patient, regardless of the form in which it appears, may be a plea for help” (Orlando, 1961, p. 40). However, the need for help may not be what it appears to be. Therefore, the initial behavior is not reliable for determining the meaning of the behavior or the help, if any, that the patient requires. Nonetheless, a nurse often makes assumptions or inferences about what help the patient needs and acts on the basis of these assumptions without first exploring the observation with the patient.
Orlando specifies that both the patient and the nurse participate in the exploratory process to identify the problem as well as the solution. Therefore, the nurse-patient situation is a dynamic process; 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 assessment.
Immediate Reaction: Internal Response
The problematic situation, in the form of the patient’s presenting behavior, triggers an automatic immediate reaction in the nurse that is both cognitive and affective. The reaction comprises the nurse’s perceptions, the thoughts about the perceptions, and the feelings evoked from the thoughts; they cannot be controlled. The reaction occurs in an automatic, almost instantaneous sequence (Orlando, 1972). The nurse’s past experiences and knowledge combine with the nurse’s understanding of the immediate situation to produce the nurse’s unique reaction.
In any person’s process of action, four distinct items occur sequentially. Orlando (1972) notes:
These separate items reside within an individual and at any given moment occur in the following automatic, sometimes instantaneous, sequence: (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; and (4) then the person acts (p. 25).
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 (Orlando, 1961). Regardless of the extent of the nurse’s accuracy, the perceptions that evoked the thoughts are communications from the patient and represent the raw data for the nurse to use in assessing the patient’s behavior (Orlando, 1961). In 1972, Orlando renamed the deliberative nursing process the disciplined nursing process; however, for consistency, the deliberative nursing process term will continue to be used throughout this chapter.
Deliberative Nursing Process: Reflective Inquiry
Orlando’s (1961) 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. To be successful, the nurse’s focus must be on the patient rather than on an assumption about the nature of the patient’s problem and on arbitrary decisions about actions to be undertaken.
To understand this process, Orlando (1972) describes the components of a person’s action process. In a person-to-person encounter, each person experiences an immediate reaction that contains the person’s perception of the other person’s behavior, the thought about this perception, and the feelings associated with the thought. Unless the content of a person’s reaction is openly disclosed, it remains a secret from the other person. For example, if a nurse makes a statement to the patient and does not disclose what perceptions, thoughts, or feelings led to his or her action, the patient remains unaware of it because it was not expressed. Orlando (1972) notes this action process often functions in secret.
Although it is at first difficult to separate perceptions, thoughts, and feelings from one another, this separation will help a nurse visualize how one aspect of the reaction affects other aspects (Orlando, 1961). In 1972, Orlando developed specific guidelines that specify a person’s use of the content or his or her reaction in a deliberative way. They include the following: “(a) in a situation a person verbally states to the other person any or all of the items of his or her immediate reaction; (b) the stated item must be expressed as self-designated; and (c) the person asks the other person to verify or correct the item verbally expressed” (Schmieding, 1993, p. 24). The deliberative nursing process is described as follows: “Whatever the nurse perceives about the patient with any one of the five sense organs and thinks and feels about the perception must, at least in part, be verbally expressed as self-designated to the patient and then asked about” (Schmieding, 1993, p. 25).
According to Orlando (1961), “The nurse does not assume that any aspect of her reaction to the patient is correct, helpful or appropriate until she checks the validity of it in exploration with the patient” (p. 56). The nurse will find it more efficient to learn the nature of the patient’s immediate need for help by first exploring and understanding the meaning of the patient’s perception. The patient is more likely to agree with the correctness of the perception and often explains its meaning to the nurse. Efficiency is important because the longer it takes to determine the patient’s immediate need for help, the more distressed the patient becomes (Orlando, 1961).
The nurse’s automatic thoughts can also be used, but this approach is less efficient. However, if exploring perceptions is not successful, the nurse uses his or her thoughts to try to understand the nature of the patient’s distress. Orlando (1961) cautions that the nurse’s thoughts may not be valid. When using thoughts, the nurse must describe the perception from which the thought was derived and ask the patient whether it is valid. Orlando (1961) cautions that nurses are likely to assume that their thoughts are correct, unless they tentatively formulate them as a question. When the nurse states his or her thoughts as a tentative possibility, the patient ismore likely to respond with his or her own negative reaction—for example: “I saw you close your eyes when I started to change your colostomy bag. I thought you might be frightened about having to learn how to do this yourself. Could that be so or not?” (Schmieding, 1993, p. 26). When nurses express their reactions, it minimizes the opportunity for nurses to make private interpretations about patients.
Feelings, either positive or negative, originate from the thought about the perception. Feelings can also be used, but the nurse must state the perception that evoked the thought from which the feeling was derived. An example of this approach is the following question: “I get annoyed when you keep asking for the urinal because I don’t think you really need it. Am I right or not?” The patient might respond, “Yes, but I’m afraid I might get short of breath and then I wouldn’t be able to call for the nurse.” If nurses do not resolve their feelings with the patient, these same feelings occur each time they are in contact with the patient. In addition, these unexpressed feelings may be apparent in the nurse’s verbal or nonverbal behavior.
Regardless of what aspect of his or her reaction the nurse uses, the patient is affected by the action; therefore, “the nurse initiates a process of exploration to ascertain how the patient is affected by what she says or does. Only in this way can she be clearly aware of how and whether her actions are helping the patient” (Orlando, 1961, p. 67).
When nurses express their immediate actions to patients in a deliberative way, they are more likely to meet patients’ immediate needs for help because when nurses use the deliberative nursing process patients are more likely to use it also. Therefore, both nurses and patients have a better understanding of how each is experiencing the immediate situation (Orlando, 1972). If this is not done, patients remain distressed because the communication between them was unclear and the nurse’s response to the patient was automatic (Orlando, 1961).
Orlando (1961) noted that automatic personal responses contribute to situational conflicts. Thus it is important to understand them so that problems associated with their use can be avoided. Actions based on the nurse’s conclusion, without the patient’s participation, are often not helpful. Therefore, the nurse’s decisions are based on reasons other than the meaning of the patient’s behavior. Thus if actions are carried out automatically, even though they could be correct, they are ineffective in helping the patient because the patient was not involved (Orlando, 1961). A nurse’s past experiences are not sufficient as the basis for understanding the patient’s immediate behavior. Therefore, in each nurse-patient experience, a deliberative process of inquiry is required to prevent the use of automatic responses and arbitrary actions. When this occurs, the patient’s immediate behavior improves.
Improvement: Resolution
When a situation becomes clear, it loses its problematic character and a new equilibrium is established. When the patient’s immediate needs for help have been determined and met, there is improvement (Orlando, 1961). This change is observable in both 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 (Orlando, 1972). If the patient’s behavior has not changed, the function of nursing has not been met and the nurse continues with the process until there is improvement.
According to Orlando (1961), it is not the nurse’s activity that is evaluated. Rather, it is the results—namely, whether the nurse’s action helped the patient communicate his or her need for help and whether that need was met. Schmieding (1993) explains:
Orlando’s deliberative nursing process is not a linear process….Rather the deliberative process is a “muddy,” serial, back-and-forth process because it has elements of continuous reflection as the nurse attempts to understand the patient’s meaning of the behavior and what help the patient needs from the nurse in order to be helped (p. 27).
Orlando’s deliberative nursing process is an important and integral part of her theory. The theory’s simplicity disguises the complexity of its use. Learning to use it requires its deliberate use, followed by a self-reflective analysis of one’s action process. Practicing to separate one’s perceptions, thoughts, and feelings allows nurses to analyze their practice to see whether they have incorporated all or part of their immediate reaction into the action they have taken with the patient. If this is done, the nurse will include the patient as a reciprocal partner in determining both the immediate need for help and the action that will best meet the patient’s need, thus relieving the patient’s distress.
Critical Thinking in Nursing Practice with Orlando’s Theory
Each component of the nursing process depends on the previous component before the next step is taken (Barnum, 1998). Although it systematizes and standardizes an approach to nursing practice, it is linear in design and patients have minimal involvement in any element of the process. Nurses assess, determine a nursing diagnosis for each problem, establish goals and interventions, implement them, and evaluate the results. With the exception of assessment and implementation, other aspects of the nursing process are formulated without the patient’s participation. Because patients have minimal involvement in the process, there is little opportunity for patients to agree or disagree with any aspect of the nursing process.
From an Orlando perspective, the espoused linear nursing process is fertile ground for basing assumptions. The diagnostic classifications attached to patients generally lack patient participation and can readily lead to patient labeling and stereotyping. The nursing process offers little, if any, encouragement for nurses to use, in their actions, their thoughts about the situation. Rather, nurses tend to withhold their thoughts without verifying or correcting them, thus operating as if the thoughts, assumptions, and inferences, conceived in their minds, are factual and justifiable as the basis for nursing action. Consequently, patients cannot confirm or refute these assumptions. However, these thoughts, if stated, might be useful—even critical—in patient assessment, plans, goals, and interventions. Subsequently, many nurses have not fully developed the critical thinking processes that would enhance their effectiveness.
Leaders in nursing recognized the need to incorporate a nonlinear process—critical thinking—into the nurse’s practice. As with theories, nurses select the description of critical thinking that best matches their conception of what will help them most in using a nonlinear thinking approach in all aspects of their patient care.
How to think is more important than what to think, because there is no one right answer (Jones & Brown, 1993). Regardless of the thoughts, they can be used in understanding any aspect of the patient’s behavior (Orlando, 1961). Consequently, critical thinking requires a reflective process that is patient-centered (Daly, 1998) and also enhances nurses’ functioning in the complex health environment. In contrast to the nursing process, critical thinking is characterized as a “unique, cognitive thought process that is grounded in reflection” (Jones & Brown, 1993, p. 73). Kataoka-Yahiro and Saylor (1994) stress that attitudes toward critical thinking, knowledge fundamental to nursing practice, experience that leads to understanding complex situations, and cognitive competencies are needed for nursing judgment. Miller and Malcolm (1990) include similar criteria.
According to Dewey (1933), reflective thinking “involves (1) a state of doubt, hesitation, perplexity, mental difficulty, in which thinking originates; and (2) an act of searching, hunting, inquiring to find material that will resolve the doubt, settle and dispose of the perplexity” (p. 12). Dewey continues, “Any attempt to decide the matter by thinking will involve inquiring into other facts, whether brought to mind by memory, or by further observation, or by both” (pp. 13, 14). The facts to which Dewey refers are not in one’s mind but are available only in observable data. Therefore, Dewey emphasizes that conclusions must be based on existing evidence. In other words, both the problem and its solution require observable evidence. Thus critical thinking counteracts the tendency to base conclusions on assumptions.
In Orlando’s theory, ascertaining the patient’s immediate need for help emphasizes the importance Orlando gives to the first step of the critical thinking process. If the problem is inaccurately identified, the development of goals, strategies, and other components of the nursing process will not be effective because they are based on a faulty foundation. In all aspects of the nursing process, Orlando’s theory places high priority on patient involvement. In essence, the nurse and patient are partners in the process. Orlando’s theory also emphasizes that patient improvement is determined by positive changes in both the verbal and the nonverbal behavior of the patient, which from Dewey’s perspective is the basis of evidence (Dewey, 1938).
Thus critical thinking is an integral part of Orlando’s theory. Her work, a derivative of Dewey’s (1938) Theory of Inquiry, contains the basic elements of reflective inquiry (Schmieding, 1986). Orlando’s work reflects her assumption that the nurse’s mind is the most important tool and that the reflective process is recognized as critical in all phases of the deliberative nursing process used with patients. Our thoughts propel our actions, and therefore understanding the process by which we think is critical in any nursing situation. Each situation evokes in the nurse an immediate reaction that comprises the present situation, previous knowledge and theories, past nursing, and other work experiences. These elements combine to make the nurse’s reaction unique for each situation. Within the nurse’s reactions are tentative assumptions and inferences that the nurse will use to seek further evidence to refute or confirm them. This can be determined only by returning to the original source, namely, the patient.
In understanding and using the elements of the nurse’s immediate reaction in a deliberative exploratory process, the nurse discovers, from the patient, information about the present situation. The nurse involves the patient in exploring alternativepossibilities about the help the patient needs and exercises judgment while ascertaining with the patient whether the patient is capable of doing each intervention alone. If not, the nurse helps the patient as needed or performs the intervention on the patient’s behalf. Nurses using Orlando’s deliberative nursing process incorporate reflective elements of critical thinking into all phases of their practice.
National and International Use of Orlando’s Theory
The use of Orlando’s Deliberative Nursing Process Theory has been permeated nationally and internationally. Nurses, both in nursing schools and in practice, are increasingly using Orlando’s theory. Hospitals, long-term care facilities, and community health agencies are also using Orlando’s theory. More recently, nurse administrators, leaders in practice, and individual practice nurses use Orlando’s theory.
New Hampshire Hospital nurses have used Orlando’s theory for many years. Bockenhauer (Potter & Bockenhauer, 2000) has worked with staff in developing their deliberative nursing process skills. Potter and Dawson (2001) used contracts and safety agreements to help psychiatric patients. Potter (2004) applied Orlando’s theory in groups and nursing students, and in developing research based on her theory.
Previously and increasingly, nurses in administration and leadership roles are using Orlando’s theory. Schmieding used Orlando’s theory simultaneously in both practice and administration within several hospitals in the early 1970s. In 1984, Schmieding reported the advantages of adopting Orlando’s theory throughout a nursing department. Its use increases effectiveness in meeting patient needs, improves staff nurses’ decision making, and more easily determines nursing versus nonnursing functions. Schmieding (1987) discusses “how specific types of actions facilitate or thwart problem identification” (pp. 431-440).
With few exceptions, most nursing theorists focus on management of patients. Astute nurses recognize that managers and leaders are not the same. Orlando’s “dynamic leadership-follower relationship model” (Laurent, 2000, p. 85) is based on the dynamic nurse-patient relationship theory. According to Laurent, Orlando advocates exploration to identify patients’ immediate needs for help. Laurent proposed a leadership theory using Orlando’s theory.
Orlando’s theory was used in an extended care facility in which one older adult woman was constantly calling for staff and another was constantly removing her oxygen (Faust, 2002). Using Orlando’s theory, Faust’s staff was able to determine what the women were thinking as well as the reasons for their actions. Faust noted that the use of research-based evidence to guide interventions with patients experiencing stressful behaviors leads to positive outcomes.
Valentine (2005) used Laurent’s (2000) nursing leadership theory that was based on Orlando’s work for development of nursing leadership ideas for the new nurse. She identifies patients’ distress and their immediate needs for help. Interaction between managers and new nurses can develop basic leadership principles by interactions with established nurse leaders. Finally, Bauer and McBride (2002) have used Orlando’s theory to treat people with bipolar disorders. They report the use of various evidenced-based data for interventions.
Orlando’s work has resonated with nurses in many countries. The purpose of the work of Johansson, Blomquist, Nilsson, and colleagues (1996-1998) was to support reflective thinking. Orlando’s nursing theory was used because it was inductively developed. In England, Price (2003) examined the understanding and origin of practice problems and the concern for reflective practice. Price used Schmieding’s (1999) inquiry process for decision making based on a back-and-forth gathering of information as well as collaboration with others to make decisions. And in Australia, instructors at the University of Southern Queensland developed a management course using Schmieding’s (1999) reflective framework for administration. Primomo (2000) provides an overview of the work in Japan and references published information about Japan’s preparation for care of growing numbers of elderly people. The purpose was to identify universal theories and practice in two different cultures. Primomo reported on the research work of Schmieding and Kokuyama (1995) that was cross-cultural and comparative. Also, other authors noted research and practice in Japan using Orlando’s theory (Kawamura, Shijiki, & Mastsuo, 2004; Kobayshi, 1998; Kumata & Goto, 1984). In Germany, Mischo-Kelling and Wittneben, (1995) included a section on Orlando’s theory that highlighted Orlando’s focus on problematic situations. The situations and the investigation of the patient’s immediate need for help were found to be essential in determining patient needs. Finally, a descriptive exploratory study was conducted through the Brazilian online databases that identified five elements. Orlando’s theory was used for practicing the response to customers whose face surgery was canceled.
In a national conference with three nursing theories, one of which was Orlando’s theory, nurses shared how to integrate theory and practice. Orlando’s reflective tools were developed in two separate steps. Also, teachers were trained in reflective thinking (Selanders, Schmieding, & Hartweg, 1995). Toniolli and Pagliuca (2002) reviewed published articles containing Orlando’s theory. The applicability of the theory was verified.
