Ida Jean Orlando’s Deliberative Nursing Process Theory

Ida Jean Orlando-Pelletier was born in 1926 in New York, was the first generation
American born from Italian immigrant parents. She was an internationally known
psychiatric health nurse, theorist, and researcher who developed the “
Deliberative Nursing Process Theory”. Orlando’s model was developed after
being dissatisfied with the views that nurses were motivated to act as a result of:
orders from physicians, institutional policies, and other reasons, none of which
related to nursing action based on meeting patients’ needs. Orlando`s theory was
formulated in a time when the exact role of a nurse was not written. Her theory
radically shifted the nurse`s focus from the medical diagnosis, automatic
activities and decided upon without patient participation to deliberative nursing
action. Ida Jean Orlando developed her theory from a study conducted at the
Yale University School of Nursing, integrating mental health concepts into a basic
nursing curriculum. She proposed that “patients have their own meanings and
interpretations of situations and therefore nurses must validate their inferences
and analysis with patients before concluding.”

Five Concepts:
The function of (1) 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. And lastly, (5) improvement is the resolution to the patient’s
situation.
The engagement of the nurse-client relationship provides a means by which
management of care and/or employees becomes a process of providing direction
rather than control.

STRENGTHS
-The use of Orlando’s theory assures that every patient will be treated as an
individual and that they will have active and constant input into their own care.
-The model also guides the nurse to evaluate her care in terms of objectively
observable patients outcomes because the nurse has to constantly explore her
reaction with the patient before giving her findings to avoid inaccurate diagnosis.

WEAKNESSES
-The lack of operational definitions of the environment was evident, limiting the
development of the research hypothesis.
-The model is applied to an immediate situation, so its applicability to a long term
care plan is feasible.

APPLICABILITY:
NURSING PRACTICE
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).
Nurses help patients express and understand the meaning of behavior. Nurses
use direct and indirect observations of patient behavior to discover distress and
meaning. The basis for nursing action is the distress experienced and expressed
by the patient. Finding out and meeting the patient's immediate needs for help.
The nurse recognizes the situation as problematic, regardless in the form which it
appears, may represent a plea for help. As a response, the patient stimulates a
perception of thought and feelings about what to act.The nurse initiates a
process of exploration to ascertain how the patient is affected by what she says
or does. The result of the interaction is evaluated whether it is a poor or a good
outcome.Changes can be changed in plan based on how well or poor the patient
is progressing toward the good.

EDUCATION
The Deliberative Nursing Process is applicable in education. It could be used in
learning of the students, such as teaching them to be organized, how to
communicate, sense of humor, have their own thoughts and decisions and
disciplined self. The nurse-client relationship has factors relevant to integrating
psychiatric-mental health principles into the nursing curriculum. In affiliation with
psycho-educational curriculum, Deliberative Nursing Theory can be used to ease
the mental health learning as it is vital in communicating, observation and
diagnosis, and improvement. It could be used as a guide in empowering nurses
to do critical thinking and meet his/clients needs by the concept of the theory in
regulation of the care plan. The three elements (patient’s behavior, nurse’s
reaction, and anything the nurse does to alleviate the distress) can effectively act
as a road map for decreasing fall risk.

RESEARCH
Orlando’s theoretical work reveals and bears witness to the essence of nursing
as a practice discipline. Orlando’s work has been used as a foundation for
master’s theses. Reinforcing Orlando’s theory as a practice and conceptual
framework continues to be relevant and applicable to nursing situations in today’s
healthcare environment. Orlando’s theory as a conceptual framework for the
Influenza Initiative in New York City, addresses the linguistic disparities within
communities. A needs survey identified unmet linguistic needs and gaps existing
within the city; nursing students, many of whom were bilingual, served as
translators for non-English speaking Spanish, Chinese, Russian, and Ukraine
residents. Another research study, Orlando’s concepts were used to guide the
creation of the safety agreement, the effectiveness of implementing a safety
agreement tool among patients who threaten self-harm. Results demonstrated
that registered nurses perceived the safety agreements as promoting a more
positive and effective nurse–patient relationship related to the risk of self-harm
and believed the safety agreements increased their comfort in helping patients at
risk for self-harm.
The Deliberative Nursing Theory enables nurses to create a nursing care plan
that is both efficient and adaptable enough to be changed when and if the patient
encounters difficulties. The main purpose is to serve the patient with delicate
care through nurse-patient relations. It includes identifying the needs of patients,
responses of the nurse, and nursing action. The quality of health care depends
on their ability to explain problems and identify their own needs. Nurses can
hardly guess what patients and their families want to achieve. Communication is
the method of data exchange that has to be properly developed. 

The most important contribution of Orlando’s theoretical work is the primacy of

the nurse– client relationship. Inherent in this theory is a strong statement: What
transpires between the patient and the nurse is of the highest value. The true
worth of her ideas is that it clearly states what nursing is or should be today.
Regardless of the changes in the health-care system, the human transaction
between the nurse and the patient in any setting holds the greatest value —not
only for nursing, but also for society at large. Thereby generating nursing leaders
in roles of authority rather than just nurse managers of care.
 VIRGINIA HENDERSON’S NEED THEORY

Virgina Henderson was born on November 30, 1897 at Kansas City, Missouri.
Henderson was a nurse, theorist, and author. Henderson is also known as “The
First Lady of Nursing”, “The Nightingale of Modern Nursing”,”Modern Day Mother
of Nursing''and “The 20th Century Florence Nightingale”. In 1939, she was the
author of three editions of “Principles and Practices of Nursing ''. Her “Basic
Principles of Nursing”, published in 1966 and revised in 1972 and published in 27
languages. Survey and Assessment written with Leo Simmons and published in
1964 and her four volume “Nursing Studies Index'' completed in 1972. The Basic
Principles of Nursing(ICN, 1960) resulted from this and became one of the
landmark books in nursing and is considered the 20th century equivalent of
Nightingale’s notes. The Nursing Studies Index (ICN, 1963) is one of
Henderson’s famous works. Henderson’s 14 Need as applied to Maslow’s
Hierarchy of Needs.
Virginia Henderson presented her definition of the nature of nursing in an era
when few nurses had ventured into describing the complex phenomena of
modern nursing. Henderson wrote about nursing the way she lived it: focusing on
what nurses do, how nurses function, and nursing’s unique role in health care.

14 Components of the Need Theory

1. Breathe normally
2. Eat and drink adequately
3. Eliminate body wastes
4. Move and maintain desirable postures
5. Sleep and rest
6. Select suitable clothes – dress and undress
7. Maintain body temperature within normal range by adjusting clothing and
modifying environment
8. Keep the body clean and well-groomed and protect the integument
9. Avoid dangers in the environment and avoid injuring others
10. Communicate with others in expressing emotions, needs, fears, or
opinions.
11. Worship according to one’s faith
12. Work in such a way that there is a sense of accomplishment
13. Play or participate in various forms of recreation
14. Learn, discover, or satisfy the curiosity that leads to normal development
and health and use the available health facilities.
The 14 components are categorized as physiological, psychological, spiritual,
and social needs:
Physiological needs cover areas relating to sleep, eating, dress and environment.
Psychological needs highlight communication, emotion, learning and handling
fears.
Spiritual needs relate to faith and worship.
Social needs cover accomplishment and recreational activities
STRENGTHS
-Virginia Henderson’s concept of nursing is widely accepted in nursing practice
today.
-Her Theory and 14 components are relatively simple, logical, and applied to
individuals of all ages.

WEAKNESSES
-There is an absence of a conceptual diagram that interconnects Henderson’s
theory’s 14 concepts and subconcepts.
-On assisting the individual in the dying process, there is little explanation of what
the nurse does to provide “peaceful death”.

APPLICABILITY:
NURSING PRACTICE
Henderson’s Needs Theory can be applied to nursing practice as a way for
nurses to set goals based on Henderson’s 14 components.
Nursing as “The unique function of the nurse is to assist the individuals in the
performance of these activities contributing to health or its recovery that he would
perform unaided if he had the necessary strength, will or knowledge”. It is
likewise the unique contribution of nursing to help people be independent of such
assistance as soon as possible. Nurse is, and should be legally, an independent
practitioner and able to make independent judgments as long as he, or she, is
not diagnosing, prescribing treatment for disease, or making a prognosis, for
these are the physician’s functions. The nurse has the responsibility to assess
the needs of the individual patient, help individuals meet their health needs,
and/or provide an environment in which the individual can perform activities
unaided. It is the nurse’s role, according to Henderson, “to ‘get inside the
patient’s skin” and supplement his strength, will or knowledge according to his
needs''. Meeting the goal of achieving the 14 needs of the client can be a great
basis to further improve one’s performance towards nursing care. The nurse
approach the patient is the way he/she treat himself/herself in meeting the needs
in attaining well-being and makes the patient independent.Patients experience
distress when they cannot cope with unmet needs, so nursing process will be
implemented from assessing what the patient in physical, emotional, mental,
sociological and spiritual needs, from there, nurse can make an outline care plan
to be implement on what’s lacking from the patient that could alleviate the
patient’s distress. The example where this theory could be used is a situation
when a patient is being treated in the therapeutic department, and his sleep has
been disturbed for three days. The nurse should find out the cause of a sleep
disorder and, with the patient, establish activities that would allow a patient to
achieve as much independence as possible and pursue actions that would be the
most appropriate, such as relaxation exercises or airing the room before going to
bed.
EDUCATION
It was formulated to be an instrument for nursing education, so it is most suitable
and useful in that field. The nursing model is intended to guide care in hospital
institutions but can also be applied to community health nursing, as well. The
Need Theory could be a backbone in exploring and learning the world upon us, in
meeting the expectations and essential needs of every individual. Considering
nursing practice in a theory context helps students to develop analytical skills and
critical thinking ability and to clarify their values and assumptions. Integrating
Henderson’s nursing need theory within their curricula, educators can teach
nurses how to create practical therapeutic plans that supplement a patient’s own
strengths, allowing the patient to gradually become more independent and
eventually regain their ability to care for themselves. Utilization of the need theory
is vital in learning so that miscalculation will not happen in assessing the patient's
need.

RESEARCH
Henderson’s Need Theory could be used as a nursing model and assessment
structures to implement the nursing process. The needs of people or patients
vary and not everyone in the said composition of need theory is attained.
Research could use the theory as the foundation in defining and deepening the
study of individuals' needs and nursing process. The theory could be used in the
study of socialization and learning individuals. It will be helpful in research of
psychological, psychological, sociological and spiritual needs of a human person
in improving his life and achieving well-being. The Need Theory could serve as a
theoretical framework in the need to increase research studies focusing on the
effect of nursing practice on a patient's outcome. Also, a useful conceptual theory
in understanding human behavior. This would motivate the patient or people to
live a life where fulfillness is met.

Virginia Henderson developed the Nursing Need Theory to define the unique
focus of nursing practice. The theory focuses on the importance of increasing the
patient’s independence to hasten their progress in the hospital. She goes beyond
stereotypes to treat people as individuals with basic needs. The approach of
caring based on the perspective of the individual being cared for through
observing, communicating, designing, and reporting.

Henderson hoped to encourage others to develop their own working concept of

nursing and nursing’s unique function in society. She believed the definitions of
the day were too general and failed to differentiate nurses from other
members of the health team, which led to the following questions: “What is
nursing that is not also medicine, physical therapy, social work, etc.?” and “What
is the unique function of the nurse?”. Therefore, the individual being nursed is a
person, not an object, and that the relationship of nurse and patient is valuable to
all.
 MADELEINE LEININGER’S THEORY OF CULTURE CARE DIVERSITY AND
UNIVERSALITY

Madeleine Leininger was born on July 13, 1925 in Sutton, Nebraska. In 1998 she
was named a “Living Legend” by the American Academy of Nursing. The founder
and leader of the academic field of transcultural nursing with focus on
comparative human care theory and research. She received her basic nursing
education at St. Anthony’s School of Nursing, Denver, Colorado, graduating in
1948. She worked with patients from diverse cultural backgrounds, which
influenced her perception of the differences that existed among patients based
on their individual and cultural perceptions.Through constant observations and
questioning of human care concepts, Leininger was able to establish the theory
of cultural care, introduced in the early 1960s to provide culturally congruent and
competent care. Leininger held that caring for people of many cultures was a
critical and essential need, yet nurses and other health professionals were not
prepared to meet this global challenge. Instead, nursing and medicine were
focused on using new medical technologies and treatment regimens. They
concentrated on biomedical study of diseases and symptoms. Shifting to a
transcultural perspective was a major but critically needed change. Culture care
is strongly influenced by relevant aspects of an individual’s worldview;
technological, religious, kinship, political -legal, economic, and educational
factors; cultural values and lifeways; environmental context, language, and
ethnohistory; and generic care (emic/folk) and professional care (etic) practices.
These factors critically influence personal patterns that can be used to predict
health, prosperity, sickness, and how someone behaves when confronted with
difficult care concepts, like disability and death.

The culture care theory addresses the care needs of patients of diverse cultures
in hospitals, clinics, and other community settings. To help nurses and nurse
educators develop realistic, new, and comprehensive care practices that
effectively serve the unique cultural demands of the ill.

Three nursing decision and action modes to achieve culturally congruent care:
Culture care preservation or maintenance.
Culture care accommodation or negotiation.
Culture care repatterning or restructuring .

These three modes were very different from traditional nursing practices,
routines, or interventions. They are focused on ways to use theoretical data
creatively to facilitate congruent care to fit clients’ particular cultural needs.
Leininger believed that routine interventions would not always be appropriate and
could lead to cultural imposition, tensions, and conflicts. The clinical use of the
three major care modes by nurses to guide nursing judgments, decisions, and
actions is essential in order to provide culturally congruent care that is beneficial,
satisfying, and meaningful to the people nurses serve.
STRENGTHS
-The recognition of the importance of culture and its influence on everything that
involves the recipients and provides nursing care.
-It helps nurses to become culture sensitive and respond in accordance with the
needs of patients as per their cultural values and beliefs.

WEAKNESSES
-The static culture framework as proposed by Leininger’s theory is limited in its
applicability since there is no attention in regards to the structural context of
health care.

APPLICABILITY:
NURSING PRACTICE
Nurses need to shift from relying on routine interventions and from focusing on
symptoms to employing care practices derived from the clients’ culture and
from the theory. They need to use holistic care knowledge from the theory as
opposed to relying solely on medical data. Most important of all, they need to use
both generic (emic) and professional (etik) care findings. This was a new
challenge but a rewarding one for the nurse and the client if thoughtfully done, as
it fosters nurse–client collaboration. To arrive at culturally appropriate care, the
nurse has to draw on fresh culture care research and discover knowledge from
the people along with theoretical data findings. The care is tailored to client
needs. Generic Care and Professional care, an example of is the consumption of
raw liver, which is rich in iron and is used to treat anemia or iron deficiency.
Another example is treating head lice by pouring gasoline over the scalp and
massaging it into the hair. Folk practices that are beneficial to health included
eating in moderation, exercising, and taking vitamin C when treating a cold. Such
information can be turned into culturally congruent decisions and actions that can
impact clinical practice through the application of Leininger’s culture care modes.
The harmful folk practices of using gasoline to treat head lice and consuming raw
liver to treat anemia can be repatterned and/or restructured through education of
ramifications and discussion of healthier alternatives. The nurse's approach to
the culture, beliefs, and religion of the patient is not to set out but to make one
better and safer plan through the progress of the patient.

EDUCATION
The use of Leininger’s theory has helped uncover significant cultural differences
and similarities. The theory’s overriding purpose is to discover, document,
analyze, and identify the cultural and care factors influencing humans in health,
sickness, and dying and to thereby advance and improve nursing practices. The
theory of culture care diversity and universality will be applied in education, not
only in the nursing process. Nurses must become aware of the social structure,
cultural history, language use, and the environment in which people live to
understand cultural care expressions. Thus, nurses need to understand the
philosophy of transcultural nursing, the culture care theory, and ways to discover
culture knowledge. Transcultural nursing courses and programs are essential to
provide the necessary instruction and mentoring.
It could be a useful framework and literature in teaching and learning different
cultures, ethnicity, religions, beliefs as these are broad in nature. It could ease
the thought of unveiling facts about the factors affecting it. Culture shock will
hinder the professional care if we are ambiguous about the culture and belief
about the patient’s background, and there, by studying the Culture Care Diversity
and Universality we reduce ambiguity, to become knowledgeable about and
sensitive and responsible to people of diverse cultures who need care .
Accordingly, nurses and other health-care providers can preserve and/or
maintain the cultural beliefs, expressions, and practices of traditions by
respecting the need for modesty and segregation and assigning same-sex
health-care providers whenever possible to avoid harmful ramifications.

RESEARCH
Leininger’s Theory of Culture Care Diversity and Universality is applied in
research as culture changes over time, beliefs, religions, ethnicity and
socialization varies. The utilization of this theory is continuous to make
significance in deepening the study of anthropology. The theory is applied to
discover unknown care phenomena in various cultures. For example, the theory
can be used to understand the type of care needed for a certain culture
group.Findings from the theory could provide the knowledge to care for people of
different cultures. Leininger listed the 11 most dominant constructs of care in
priority ranking, with the most universal or frequently discovered first: respect
for/about, concern for/about; attention to (details)/in anticipation of;
helping–assisting or facilitative acts; active helping; presence (being physically
there); understanding (beliefs, values, lifeways, and environmental);
connectedness; protection (gender related); touching; and comfort measures.
These care constructs are the most critical and important universal or common
findings to consider in nursing practice, but care diversities will also be found and
must be considered. The ways in which culture care is applied and used in
specific cultures will reflect both similarities and differences among and within
different cultures. Next, two ethnonursing studies are reviewed with focus on the
findings, which have implications for nursing practice.

The Theory of Culture Care Diversity and Universality is a major change in

nursing practices. The purpose of the Culture Care Diversity and Universality and
the ethnonursing method is to discover culture care knowledge and to combine
generic and professional care. The goal is to provide culturally congruent nursing
care using the three modes of nursing actions and decisions that are meaningful,
safe, and beneficial to people of similar and diverse cultures worldwide.
Care and caring is for everyone who feels the need of medication and seeking
well-being no matter what culture and ethnicity you come from. The use of the
theory helped in caring individuals who are diverse in culture. Discovering
cultural care knowledge requires entering the cultural world to observe, listen,
and validate ideas. Transcultural nursing is an immersion experience, not a “dip
in and dip out” experience. No longer can nurses rely only on fragments of
medical and psychological knowledge.
Using Leininger’s care modes in clinical practice shows respect to clients’ beliefs,
values, and expressions and establishes a partnership between health-care. The
theory serves in creating ripples in the world’s diversity.