Heather Gulian, Lara Kim,

Angela Kramer, Beth Smith

• How does this patient
make you feel?

• What do you think

they need?

• What would you do

for them as a nurse?
 Nursing diploma
◦ New York Medical College
 BS- Public Health Nursing
◦ St. John's University, NY
 MA- Mental Health Nursing
◦ Columbia University, NY

 Director of Mental Health Psychiatric Nursing

Graduate Program
◦ Yale SON, CT
 NIMH – Research grant
◦ Integration of Mental Health Concepts in Basic Nursing
Curriculum
 Observed patient-nurse interactions
◦ “Good” – effective
◦ “Bad” – ineffective
 How can you analyze “good” and “bad” nursing without
defining nursing, its function, and its desired outcome?
 GOAL: “To develop a ‘theory of effective nursing
practice’ that would identify a distinctive role for the
professional nurses that would provide a systematic
foundation for the study of nursing.”
(Schmieding, 2006, 433)
  1961 – The Dynamic Nurse-
Patient Relationship: Function,
Process, and Principles of
Professional Nursing Practice
 1962 – Employed as a Clinical
Nurse Consultant at McLean
Hospital in MA
◦ Grant to develop a nursing training
program based on her theory
 1972 – The Discipline and
McLean Hospital, nd. Teaching of Nursing Process:
An Evaluative Study
 Distress is the experience of a patient whose need has not
been met.

 Nursing role is to discover and meet the patient’s

immediate need for help.
◦ Patient’s behavior may not represent the true need.
◦ The nurse validates his/her understanding of the need with the
patient.

 Nursing actions directly or indirectly provide for the

patient’s immediate need.

 An outcome is a change in the behavior of the patient

indicating either a relief from distress or an unmet need.
◦ Observable verbally and nonverbally.
 Shifted from care based on medical
diagnoses to care based on patients’
immediate needs.

 MD’s orders are assigned to patients not to

nurses.
◦ If nurses focus on orders (versus immediate patient
needs), it keeps the nurse dependent.
◦ Immediate needs may include assisting the patient
to comply with the doctor’s orders.
 Pelletier, 1968. Pelletier, 1968.

• Stresses the reciprocal relationship • Automatic actions are

between the nurse and patient.
• Nurse seeks verification or
correction of his/her thoughts with
the patient.
• Patients’ needs and nurses’
reactions to each need are unique.
carried out for reasons other
than meeting the patient’s
immediate needs.
• Prevents the responsibility of
nursing from being
performed.
(Potter & Tinker, 2000)
 A patient is frequently asking the nurse to do
things for him that he could do for himself.
The nurse initially feels frustrated and that
the patient doesn’t want to help himself.
However, the nurse also realizes that
something else may be going on. The nurse
asks, “I feel like you could be doing many of
these things on your own. Is there something
else you need?” The patient replied that
when he was upset it was reassuring to have
a nurse come into the room.

(Schmieding, 1984)
 Health Promotion & Protection, Disease Prevention & Treatment
◦ Open communication with patient in order to determine their healthcare
needs and develop effective diagnoses and care plans
◦ Teenage female requesting birth control (Sylvia Wood)
 Nurse-Patient Relationship
◦ Promotes effective communication between nurse and patient
 Teaching-Coaching
◦ Evaluating patient’s needs, promoting behavioral changes, evaluating
outcomes with the patient
 Professional Role
◦ Allows for autonomy in nursing role
◦ Interdisciplinary boundaries: “If I do that, I won’t be able to do my job, which
is to observe the patient and find out and meet the patient’s needs for help.”
(Schmieding, 1984, p761)
◦ Nursing accountability
◦ Understanding supervisee true needs: A nurse’s request for a weekend off
may represent his/her dissatisfaction with another nurse that is scheduled to
work that weekend as well. (Schmieding, 1984, p761)
 Managing/Negotiating health care delivery systems
◦ Control costs by focusing care on immediate needs, not
unnecessary tasks
◦ Patient requests codeine, and the nurse explores the pain
sensation. The patient shows the nurse the afflicted area,
and the nurse sees the discomfort may be due to the old
tape adhesive. After removing the adhesive, the patient
states that the area feels much better and that the codeine
she had received the night before had been ineffective.
(Orlando, 1961)
 Monitoring and ensuring the quality of health care
practice
◦ Validating that needs are met and that nursing action
provided a positive outcome
 Cultural competence
◦ Keeps the nurse from labeling patients and staff
 Concepts are observable, however these vary
from case to case as outcomes are based on
both patients and nurses perception of the
interaction
 Research tools are specific to the outcome

being measured (i.e. anxiety, pain)

◦ Surveys, questionnaires, and other tools which
measure patient outcome, nursing process, nurse
empathy, and patient perceived empathy.
 Studies supporting the theory
◦ Pilot study (2000) – implemented
Orlando’s theory resulting in:
 Positive, patient-centered outcomes
 A staff-patient approach model
 Decreased patient (immediate) stress
◦ VA study (1987) – implemented
theoretical model with bipolar patients.
Results indicate:
 Higher patient retention
 Reduction of emergency services
 Decreased hospital stay
 Increased patient satisfaction
 The relative simplicity of the theory lends
itself well to internal consistency.
 Semantic inconsistency:

◦ Theory Title:
 Deliberative Nursing Process (1961)
 Nursing Process Discipline (1972)
◦ Nursing action:
 Good  Effective (Deliberative)
 Bad  Ineffective (Automatic)
 Requires education to
implement:
◦ Orlando’s 1972 book
introduces and evaluates a
training program.
 Very applicable to real-
world nursing situations
improve patient outcomes
 Favorable outcomes:
◦ Every face-to-face
interaction.
 Feasibility:
◦ Feasible to teach.
◦ Unrealistic to expect all nurses
to internalize this model.
 Compatible with
expectations for nursing
practice:
◦ May appear more time
consuming initially, but
assists the nurse in meeting
true needs the first time.
◦ Patient needs are met
◦ Research shows deliberative
nursing process is more likely
to produce favorable
outcomes then automatic
nursing process.
 Care is patient-focused
◦ Patients are treated as individuals
 Patients assume active role in their care
 The theory can be learned
 Applicable in various settings
◦ clinical/educational/administrative
 Facilitates cultural understanding and
respect
◦ Needs are met regardless of cultural or
language barriers
 Allows cost and time-saving measures as
actions are based on meeting “immediate
needs” and avoiding unnecessary tasks
 Conceptual model:
◦ Emphasizes the internal reaction of the nurse
◦ Needs to expand more on the process of validation
 Metaparadigm, concepts, propositions, and philosophical
claims:
◦ Present and clearly stated, but not explicitly identified in a systematic
manner
◦ Implicit and not completely clear on how they were derived
 No bibliographic references:
◦ Some feel the vast majority of her work was Orlando’s original
thought, not stemming from antecedent knowledge
◦ Others feel her theory incorporates the underpinnings of multiple
theories including: Peplau’s Interpersonal Relationships (nursing),
Symbolic Interaction (sociology), Dewey’s Theory of Inquiry
(philosophy, psychology), and Behavioral Theory (psychology)
 Clear and Concise
◦ Yes:
 Limited in concepts,
propositions, and
variables.
◦ No:
 Some concepts are
expanded upon in a
second book.
 Focus is on short-term care
 Requires training from a

qualified nurse
 Does not apply to all patients

◦ Pediatrics
◦ Unconscious
◦ Mentally-ill/impaired
 Does not address the family/caregiver
 Simplicity of theory masks the intricacy

of the nurse-patient dynamic

 Defined nurses’ role focusing on patients’
need rather than MD’s orders
 Provide nurse’s with autonomy
 Enriches nursing’s unique body of knowledge
 Strengthens nurse/patient relationship

◦ Positive patient outcomes

 Apply to other fields in order to validate the
needs of clients
◦ Psychology: counseling
◦ Customer service
 Develop a unique/modifiable tool that applies
this theory in various clinical settings to
achieve positive outcomes
 Focus on long-term care needs
 Helene Fuld Health Trust (Producer) (1990). The Nurse Theorists: Portraits of Excellence: Ida J.
Orlando Pelletier [Motion picture]. United States: Samuel Merritt College Studio Three.
 National Organization of Nurse Practitioner Faculties (2006). Domains and core competencies of
nurse practitioner practice. Access October 25, 2009 from
https://sakai.plu.edu/access/content/group/NURS523_01_20233_FALL2009/Articles/CoreCom
ps.pdf.
 Orlando, I.J. (1972). The Discipline and Teaching of Nursing Process: An Evaluative Study. NY:
G.P. Putnam’s Sons.
 Orlando, I. J. (1990). The Dynamic Nurse-Patient Relation: Function, Process, and Principle. NY:
National League for Nursing.
 Potter, M.L. (2009). Deliberative nursing process. In Peterson, S. J. & Bredow, T. S. (Eds.) Middle
Range Theories: Application to Nursing Research (2nd ed). (304-325). Philadelphia: Lippincott
Williams & Wilkins.
 Potter, M. & Bockenhauer, B. (2000). Implementing Orlando's nursing theory: A pilot study.
Journal of Psychosocial Nursing & Mental Health Services, March, 38(3), 14-21.
 Potter, M. & Tinker, S. (2000). Put power in nurses' hands: Orlando's nursing theory supports
nurses simply. Nursing Management, July, 40-41.
 Schmieding, N. J. (1984). Putting Orlando’s theory into practice. Journal of Advanced Nursing,
84(6), 759-761.
 Schmieding, N. J. (1987). Analysing managerial responses in face-to-face contacts. Journal of
Advanced Nursing, 12, 357-365.
 Schmieding, N. J. (1989). An integrative nursing theoretical framework. Journal of Advanced
Nursing, 15, 463-467.
 Schmieding, N. J. (2006). Nursing process theory. In Tomey, A.M. & Alligood, M. R. (Eds.),
Nursing Theorists and their Work. (431-451). St. Louis: Mosby Elsevier.