Deliberative Nursing Practice Ida Jean Orlando Deliberative Nursing Practice Evidence Based Practice Angela Common, David Feiertag, Stacie Koelewyn and John Richardson Ferris State University NUR 324

Theory Overview Orlando's theory was developed in the late 1950s from observations she recorded between a nurse and patient. The role of the nurse is to find out and meet the patient's immediate need for help. The patient's presenting behavior may be a plea for help, however, the help needed may not be what it appears to be.

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

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

Orlando’s evidence based research is full circle (Mercy Medical Center, 2009)

Rationale for Use of Nursing Theory Nursing educators use Orlando’s theory because it allows students to focus on the many aspects of communication between the student and patient. Administrators have adopted Orlando’s theory throughout nursing departments as it has shown to increase effectiveness in meeting patients needs and increase decision making skills among staff nurses.

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

Rationale for Use of Nursing Theory Cont.

Research Studies Research studies selected were chosen based off of the four metaparadigms of nursing which include person, environment, health, and nursing. Orlando’s theory is primarily focused toward the mental well being of the patient as it relates to communication.

Person Based on her observations, Orlando believes that people behave both verbally and nonverbally. People are able to meet their own needs for help in some situations. People become distressed if they are unable to meet their own needs. Nurses should check in with their patients often to determine if they have new needs for help.

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

Positive Patient Centered Outcomes Cont. Results Scales showed a decrease in the patient’s distress levels in the study group. Additionally nurses reported greater satisfaction with having a “road map” to patient interactions.

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

Environment The nurse-patient interactions occur in a healing and therapeutic environment ideally. If a nurse ignores the patient’s needs, then the area of care can become a non-therapeutic environment which is harmful to the patient both physically and mentally. When a nurse responds to a patient’s verbal and non-verbal behavior positively, there is an emotionally healthy environment. 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 must continually reevaluate the patient’s condition and behavior.

Environment ICU Psychosis A study supported by the Agency for Healthcare Research and Quality used Orlando’s theory to understand the needs of critically ill patients (Agency for Healthcare Research and Quality, 2001) . The study interviewed stable Intensive Care Unit (ICU) patients as well as floor status patients who had recently been in the ICU who had spent at least 3 days in an ICU (Agency for Healthcare Research and Quality, 2001) .

Stressed?

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

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

Health Orlando viewed health as the absence of physical and emotional distress and a sense of well-being. She also believed that a person’s degree of well-being improved as a person’s needs were continually met (in this case by the nurse caring for a patient).

Research Study by Shea, McBride, Gavin, and Bauer (1987) At a Veterans Administration ambulatory psychiatric care clinic in Providence, Rhode Island; a study was performed using Orlando’s Nursing Process Theory. 76 patients being treated for bipolar disorder through the outpatient clinic were placed into a six month program described as being a “high-intensity collaborative practice program”.

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

Health continued… Results After applying Orlando’s Nursing Process Theory to patient care, the following results were discovered: Increased patient satisfaction Decreased hospital length of stay Less emergency services required Higher patient retention Increased intensity of medication treatment Decreased use of costly mental health services

Suggestions on findings After conducting this research study, Bauer, McBride, Shea, and Gavin suggested that the VA should use Orlando’s theory across the entire organization. In July of 2000, Orlando’s theory was being used in a multi-million dollar study of patients with bi-polar disorder at 12 different VA sites.

Successful results This research study has helped to show the real health benefits of Orlando’s Nursing Process Theory when applied to patient care. This research study is a great example of benefits to patients in mental health care, but the principles of Orlando’s theory are basic enough to be applied to any area of patient care.

Nursing Communication Nursing is an autonomous profession that must work closely together with medical teams Nurses should pay attention to other nurses verbal and non-verbal body language to increase communication

Communication Study Specifics This study on communication focused on supportive communication during shift report Study was in a medical/surgical intensive care unit Consisted of 4 charge nurses, and 13 staff nurses during midnight shift Some were BSN prepared RN’s some were ADN’s The 4 charge nurses were all women The 13 staff nurses consisted of eight women, five men in total Average time spent in report was 15 minutes 51 seconds

Supportive Behaviors Study looked for verbal and non-verbal behaviors between shifts during report Nurses were filmed during report with no one else in the room, face to face Supportive behaviors were classified as, head nods, praise, support, reassurance, concern (Hays, page 6).

Results In 162 charge nurse reports there were no supportive behaviors observed Of the oncoming staff getting report from the charge nurse there were only 11 supportive behaviors observed All non-verbal head nods

Results Supportive behaviors between staff RN’s were identified 50% of the time (6 out of 12 interactions) Seven of the RN’s in these interactions were female, four male. All the behaviors were non-verbal head nods

Limitations Nurse’s schedules The study did not address patient acuity RN to patient ratio was not factored into the report analysis Personal issues (external/internal stresses of the RN’s) Cultural differences were not factored into communication styles RN’s may have reported differently off camera

Conclusion There was no positive communication outcomes from the leadership (Charge nurses) Women are more likely to give a supportive non-verbal then men Support came from the bedside nurse to the next bedside nurse Overall report communication was not supportive and all non-verbal

Suggestions to change Managers need to evaluate the leaders on the floor from supervisor, to charge, to nurses and techs In-service for nursing leadership and communication road blocks Allow the nurse’s to view their report Encourage to learn from other’s mistakes After one receives report to give an appraisal or validation of the off going RN’s work

References Agency for Healthcare Research and Quality, (May 2001).Quality of care ICU patients. Agency for Healthcare Research and Quality. 249, 11-12. Hays, Mary M. (2002).An exploratory study of supportice communication during shift report. Sourther Online Journal of Nursing Research. 3, 1-14. Limos, K., Maglaya, G., Lee, D., (2008). A Close Encounter: Orlando's Dynamic Nurse-Patient Relationship. Retrieved April 11, 2009, from http://nursingtheories.blogspot.com/2008/07/close- encounter-orlandos-dynamic-nurse.html Potter, M.L., & Bockenhauer, B.J. (2000). Implementing Orlando's Nursing Theory: a pilot study. Journal of Psychosocial Nursing and Mental Health Services. 38(3), 14-21. Shea, N., McBride, L., & Bauer, C., Gavin, M. (1997). The Effects of an Ambulatory Collaborative Practice Model on Process and Outcome of Care for Bipolar Disorder. Journal of the American Psychiatric Nurses Association, 3, Retrieved April 11, 2009, from http://jap.sagepub.com/cgi/content/abstract/3/2/49.