How theories can help improve patient teaching

Theories that explain behavior change serve as guidelines for teaching. Theories that can
be applied to patient teaching come from the disciplines of sociology, psychology, adult
education, communication, and organizational development. Some of the most relevant
theories for patient and family teaching are the Health Belief Model, self-efficacy theory,
and locus of control theory. Stress, coping, and social support theories are other theories
that are relevant for patient teaching.

The Health Belief Model helps explain why individual patients may accept or reject
preventive health practices or adopt health behaviors. This theory proposes that people
will respond best to messages about health promotion or disease prevention when an
individual believes that:

• He or she is at risk of developing a specific condition

• The risk is serious and the consequences of developing the condition are
undesirable
• The risk will be reduced by a specific behavior change
• Barriers to the behavior change can be overcome and managed

The first condition in the Health Belief Model is perceived threat. If the person does not
see a health behavior as dangerous, there is no stimulus for change. There are two types
of perceived threat- susceptibility and severity. Susceptibility refers to how much risk a
person believes he is at; severity refers to how serious the consequences might be. To
effectively change health behaviors, the individual must usually sense both susceptibility
and severity. This is one reason why many people become motivated to change behavior
after they have been diagnosed with cancer, heart disease, or diabetes.

Patients must also have the expectation that the new behavior will be beneficial; they
must feel that barriers to change don't outweigh the benefits and that they can realistically
accomplish the needed behavior change. Knowing what aspect of the Health Belief
Model patients accept or reject can help you design appropriate interventions. For
example, if a patient is aware of a risk, but feels the behavior change is overwhelming or
unachievable, you can focus your teaching efforts to helping the patient overcome the
perceived barriers.

Self-efficacy refers to the extent a person has confidence in his or her abilities. Because
self-efficacy is based on feelings of self-confidence and control, it is a good predictor of
motivation and behavior. Research shows that healthcare professionals can have an
impact on self-efficacy by using teaching techniques such as skills mastery and modeling.
Skills mastery is a teaching technique in which skills are broken down into small,
manageable tasks that are likely to be done successfully.

Modeling helps increase self-efficacy by exposing the patient to someone else with a
similar problem who can model positive behavior change. Recognizing and rewarding the
patient for accomplishing tasks is important to help build the esteem that is the basis of
self-efficacy. Recognition is particularly important for patients with a limited education
or who have low literacy skills.

Locus of control theory describes the extent to which people believe they are in control of
their own choices. This theory proposes that people who believe they are in charge of
their own health status( internal locus of control) are more likely to make necessary
changes that those who believe their health is in the hands of others or decided by fate
(external locus of control). You can assist patients with external locus of control by
helping them consider the abilities they have to control health events, by helping them
improve their decision making skills, and encouraging them to use social support
systems.

Helping patients achieve compliance

Health care professionals consider patients “compliant" when they follow treatment
recommendations for health care management. We describe patients as “noncompliant"
when they ignore instructions or don't follow them correctly. The nursing diagnosis on
noncompliance is defined as “behavior of a person and/or caregiver that fails to coincide
with a health-promoting or therapeutic plan agreed upon by the person (and/or family)
and health care professionals."

The extent to which patients comply with health care teaching and instructions is a major
issue in health care today. Most studies show that a large percentage of patients are
noncompliant and that health care professionals significantly underestimate how common
noncompliance is. Concern about compliance with health teaching has a long history -
even Hippocrates is reported to have complained about patients being noncompliant.

Noncompliance negatively affects the patient's health status, the health of a community,
the motivation and job satisfaction of nurses and other health care professionals, and the
country's health care system. Significant financial resources are wasted when medications
are not taken correctly, when medical equipment is misused, when patients are re-
admitted for costly hospital care for preventable problems, and when a large percentage
of the public continue to practice health habits that inevitably lead to serious disease.

The bottom line is that patients control what they do with the health teaching you
provide. Your responsibility is to assist patients in achieving and maintaining health by
sharing knowledge, helping with the practical problems of carrying out instructions, and
supporting patients as they integrate new knowledge and skills. By following some basic
steps, you can help make it easier for patients and families to comply.

The first step is to make sure that health care instructions are understandable and
compatible with patient goals. It is vital to remember that patients cannot carry out
recommendations they don't understand and will not carry out recommendations they do
not agree with.
The next step is to include the patient as a partner in the process rather than as a passive
recipient of health teaching. We should not approach patients as passive learners who are
obligated to change their behaviors based solely on our directions. By using teaching
strategies that are interactive and allow patients equal participation, you can help promote
compliance.

The third step is to view the patient teaching as a process that requires a strong
interpersonal relationship with the patient and his or her family. There is a growing
consensus among researchers that the health care professional's ability to communicate
and explain information while expressing empathy and concern for the patient is
associated with increased patient compliance.

One study showed that nurses and other health care professionals who motivated patients
to comply shared certain characteristics. These effective health care educators discussed
treatment and self-care with patients, worked with patients to develop a teaching plan,
demonstrated interest in how patients fit self-care needs into daily life, helped patients
problem solve, discussed issues with patients in order to plan care, and listened to
patients' opinions. Other strategies you can use to help increase compliance are listed in
Table 2.

The key to effective health teaching is to develop an equal partnership that enables
patients and families to manage health care problems with skill and confidence.
Understanding the goals of patient education, knowing your role and how to work with
other team members, using theories as a base for patient teaching, and employing
strategies that help patients comply will significantly increase your effectiveness as a
patient teacher.

TABLE 2: Strategies for Increasing Compliance

• Ask the patient why he or she is not able to comply. The patient's view of why
compliance is a problem is the one that counts.
• Don't propose an immediate solution when a patient doesn't comply. Instead focus
your efforts on helping the patient learn problem-solving skills.
• Find out whether the patient believes that compliance will help solve the problem.
If the answer is “no", assess the patient's beliefs about the problem.
• Determine whether the patient knows how to follow instructions. When people
aren't sure of what to do, they may do nothing rather than risk making a mistake
or embarrassing themselves.
• Find out whether the patient has the skills to comply. Does the patient have
sensory, mobility, or other limitations that make compliance difficult? If so, help
the patient learn how to compensate for the limitations.
• Is compliance punishing? Some drugs have unpleasant side effects, or an exercise
program may cause pain or stiffness.
• Is the new health behavior too complex? Analyze everything you are asking the
patient to do and simplify tasks if needed.
 Nursing Theorists
This page was last updated on 16-07-2010
Definitions

• Theory- a set of related statements that describes or explains phenomena in a

systematic way
• Concept-a mental idea of a phenomenon
• Construct- a phenomena that cannot be observed and must be inferred
• Proposition- a statement of relationship between concepts
• Conceptual model- made up of concepts and propositions

Nursing Theorists

1. Florence Nightingale,
2. Hildegard Peplau
3. Virginia Henderson
4. Fay Abdella
5. Ida Jean Orlando
6. Dorothy Johnson
7. Martha Rogers
8. Dorothea Orem
9. Imogene King
10. Betty Neuman
11. Sister Calista Roy,
12. Jean Watson
13. Rosemary Rizzo Parse
14. Madeleine Leininger
15. Patricia Benner

Concepts in the nursing

Metaparadigms

1.Person

• Recipient of care, including physical, spiritual, psychological, and sociocultural

components.
• Individual, family, or community

2. Environment
 • All internal and external conditions, circumstances, and influences affecting the
person

3. Health

• Degree of wellness or illness experienced by the person

4. Nursing

• Actions, characteristics and attributes of person giving care

Florence Nightingale- Environmental Theory

• First nursing theorist

• Unsanitary conditions posed health hazard (Notes on Nursing, 1859)
• 5 components of environment
o ventilation, light, warmth, effluvia, noise
• External influences can prevent, suppress or contribute to disease or death

Nightingale’s Concepts

1. Person

• Patient who is acted on by nurse

• Affected by environment
• Has reparative powers

2. Environment

• Foundation of theory. Included everything, physical, psychological, and social

3. Health

• Maintaining well-being by using a person’s powers

• Maintained by control of environment

4. Nursing

• Provided fresh air, warmth, cleanliness, good diet, quiet to facilitate person’s
reparative process

Hildegard Peplau -Interpersonal Relations Model

• Based on psychodynamic nursing

• using an understanding of one’s own behavior to help others identify their
 difficulties
• Applies principles of human relations
• Patient has a felt need

Peplau’s Concepts

1. Person

• An individual; a developing organism who tries to reduce anxiety caused by needs

• Lives in instable equilibrium

2. Environment

• Not defined

3. Health

• Implies forward movement of the personality and human processes toward

creative, constructive, productive, personal, and community living

4. Nursing

• A significant, therapeutic, interpersonal process that functions cooperatively with

others to make health possible
• Involves problem-solving

Virginia Henderson -The Nature of Nursing

"The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery (or to peaceful
death) that he would perform unaided if he had the necessary strength, will, or
knowledge. And to do this in such a way as to help him gain independence as rapidly as
possible. She must in a sense, get inside the skin of each of her patients in order to know
what he needs".

Fay Abdella- Topology of 21 Nursing Problems

• A list of 21 nursing problems

• Condition presented or faced by the patient or family.
• Problems are in 3 categories
o physical, social and emotional
• The nurse must be a good problem solver

Abdella’s Concepts
1. Nursing

• A helping profession
• A comprehensive service to meet patient’s needs
• Increases or restores self-help ability
• Uses 21 problems to guide nursing care

2. Health

• Excludes illness
• No unmet needs and no actual or anticipated impairments

3. Person

• One who has physical, emotional, or social needs

• The recipient of nursing care.

4. Environment

• Did not discuss much

• Includes room, home, and community

Ida Jean Orlando- Deliberative Nursing Process

• The deliberative nursing process is set in motion by the patient’s behavior

• All behavior may represent a cry for help. Patient’s behavior can be verbal or
non-verbal.
• The nurse reacts to patient’s behavior and forms basis for determining nurse’s
acts.
• Perception, thought, feeling
• Nurses’ actions should be deliberative, rather than automatic
• Deliberative actions explore the meaning and relevance of an action.

Dorothy Johnson-Behavioral Systems Model

• The person is a behavioral system comprised of a set of organized, interactive,

interdependent, and integrated subsystems
• Constancy is maintained through biological, psychological, and sociological
factors.
• A steady state is maintained through adjusting and adapting to internal and
external forces.

Johnson’s 7 Subsystems
Affiliative subsystem

• social bonds

Dependency

• helping or nuturing

Ingestive

• food intake

Eliminative

• excretion

Sexual

• procreation and gratification

Aggressive

• self-protection and preservation

Achievement

• efforts to gain mastery and control

Johnson’s Concepts

1. Person

• A behavioral system comprised of subsystems constantly trying to maintain a

steady state

2. Environment

• Not specifically defined but does say there is an internal and external environment

3. Health

• Balance and stability.

4. Nursing
 • External regulatory force that is indicated only when there is instability.

Martha Rogers -Unitary Human Beings

• Energy fields
• Fundamental unity of things that are unique, dynamic, open, and infinite
• Unitary man and environmental field

Universe of open systems

• Energy fields are open, infinite, and interactive

Pattern

• Characteristic of energy field

• A wave that changes, becomes complex and diverse

Pandimensionality

• A nonlinear domain with out time or space

Roger’s Definitions

Integrality

• Continuous and mutual interaction between man and environment

Resonancy

• Continuous change longer to shorter wave patterns in human and environmental

fields

Helicy

• Continuous, probabilistic, increasing diversity of the human and envrionmental

fields.
• Characterized by nonrepeating rhymicities
• Change

Dorothea Orem- Self-Care Model

• Self-care comprises those activities performed independently by an individual to

promote and maintain person well-being
• Self care agency is the individual’s ability to perform self care activities
• Self- care deficit occurs when the person cannot carry out self-care
 • The nurse then meets the self-care needs by acting or doing for; guiding, teaching,
supporting or providing the environment to promote patient’s ability
• Wholly compensatory nursing system-Patient dependent
• Partially compensatory- Patient can meet some needs but needs nursing assistance
• Supportive educative-Patient can meet self care requisites, but needs assistance
with decision making or knowledge

Imogene King-Goal Attainment Theory

• Open systems framework

• Human beings are open systems in constant interaction with the environment
• Personal System
o individual; perception, self, growth, development, time space, body image
o Interpersonal
o Society
• Personal System
o Individual; perception, self, growth, development, time space, body image
• Interpersonal
o Socialization; interaction, communication and transaction
• Society
o Family, religious groups, schools, work, peers
• The nurse and patient mutually communicate, establish goals and take action to
attain goals
• Each individual brings a different set of values, ideas, attitudes, perceptions to
exchange

Betty Neuman - Health Care Systems Model

• The person is a complete system, with interrelated parts

• maintains balance and harmony between internal and external environment by
adjusting to stress and defending against tension-producing stimuli
• Focuses on stress and stress reduction
• Primarily concerned with effects of stress on health
• Stressors are any forces that alter the system’s stability
• Flexible lines of resistance - Surround basic core
• Internal factors that help defend against stressors
• Normal line of resistance - Normal adaptation state
• Flexible line of defense - Protective barrier, changing, affected by variables
• Wellness is equilibrium

Nursing interventions are activates to:

• strengthen flexible lines of defense

• strengthen resistance to stressors
• maintain adaptation
Sister Calista Roy - Adaptation Model

Five Interrelated Essential Elements

1. Patiency- The person receiving care

2. Goal of nursing- Adapting to change
3. Health-Being and becoming a whole person
4. Environment
5. Direction of nursing activities- Facilitating adaptation

• The person is an open adaptive system with input (stimuli), who adapts by
processes or control mechanisms (throughput)
• The output can be either adaptive responses or ineffective responses

Jean Watson - Philosophy and Science of Caring

• Caring can be demonstrated and practiced

• Caring consists of carative factors
• Caring promotes growth
• A caring environment accepts a person as he is and looks to what the person may
become
• A caring environment offers development of potential
• Caring promotes health better than curing
• Caring is central to nursing

Watson’s 10 Carative Factors

• Forming humanistic-altruistic value system

• Instilling faith-hope
• Cultivating sensitivity to self and others
• Developing helping-trust relationship
• Promoting expression of feelings
• Using problem-solving for decision making
• Promoting teaching-learning
• Promoting supportive environment
• Assisting with gratification of human needs
• Allowing for existential-phenomenological forces

Watson’s Concepts

• Person
o Human being to be valued, cared for, respected, nurtured, understood and
assisted
• Environment
o Society
 • Health
o Complete physical, mental and social well-being and functioning
• Nursing
o Concerned with promoting and restoring health, preventing illness

Rosemary Parse - Human Becoming Theory

• Human Becoming Theory includes Totality Paradigm

o Man is a combination of biological, psychological, sociological and
spiritual factors
• Simultaneity Paradigm
o Man is a unitary being in continuous, mutual interaction with environment
• Originally Man-Living-Health Theory

Parse’s Three Principles

• Meaning
o Man’s reality is given meaning through lived experiences
o Man and environment cocreate
• Rhythmicity
o Man and environment cocreate ( imaging, valuing, languaging) in
rhythmical patterns
• Cotranscendence
o Refers to reaching out and beyond the limits that a person sets
o One constantly transforms
• Person
o Open being who is more than and different from the sum of the parts
• Environment
o Everything in the person and his experiences
o Inseparable, complimentary to and evolving with
• Health
o Open process of being and becoming. Involves synthesis of values
• Nursing
o A human science and art that uses an abstract body of knowledge to serve
people

Madeleine Leininger - Culture Care Diversity and Universality

• Based on transcultural nursing, whose goal is to provide care congruent with

cultural values, beliefs, and practices
• Sunrise model consists of 4 levels that provide a base of knowledge for delivering
cultural congruent care
• Modes of nursing action
• Cultural care preservation
o help maintain or preserve health, recover from illness, or face death
• Cultural care accommodation
 o help adapt to or negotiate for a beneficial health status, or face death
• Cultural care re-patterning
o help restructure or change lifestyles that are culturally meaningful

Patricia Benner - From Novice to Expert

• Described 5 levels of nursing experience and developed exemplars and paradigm

cases to illustrate each level

1. Novice
2. Advanced beginner
3. Competent
4. Proficient
5. Expert

• Levels reflect:
o movement from reliance on past abstract principles to the use of past
concrete experience as paradigms
o change in perception of situation as a complete whole in which certain
parts are relevant

Importance of Theoretical Frameworks

• Foundation of any profession is the development of a specialized body of

knowledge. Theories should be developed in nursing, not borrow theories form
other disciplines
• Responsibility of nurses to know and understand theorists
• Critically analyze theoretical frameworks

Reference

1. Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed.
Mosby, Philadelphia, 2002.
2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002.
3. George B. Julia , Nursing Theories- The base for professional Nursing Practice ,
3rd ed. Norwalk, Appleton and Lange.
4. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williamsand wilkins.
5. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and Progress
3rd ed. Philadelphia, Lippincott.
6. Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
7. Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts
Process and Practice 3rd ed. London Mosby Year Book.
Teaching around the cycle: strategies for teaching
theory to undergraduate nursing students.
Publication: Nursing Education Perspectives Format: Online
Publication Date: 01-NOV-07 Delivery: Immediate Online Access

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Article Excerpt
AS IN MANY DISCIPLINES, A COURSE IN THEORY IS A MAINSTAY OF
BACCALAUREATE NURSING CURRICULA. THE THEORY COURSE IS
CONSIDERED ESSENTIAL TO ESTABLISH A CONCEPTUAL FRAMEWORK FOR
NURSING, TO FAMILIARIZE UNDERGRADUATE STUDENTS WITH MAJOR
INTELLECTUAL CONCERNS WITHIN THE PROFESSION, AND TO INTRODUCE
CONCEPTS THAT INFORM NURSING SCHOLARSHIP. However, despite its
centrality in the curriculum, teaching theory to undergraduates can be a challenging
instructional assignment. Many students find the complex concepts and the abstract
nature of theory difficult to comprehend (1,2). * This article describes a balanced
instructional program for teaching nursing theory that uses a pedagogy known as
"teaching around the cycle." Incorporating a variety of teaching techniques, teaching
around the cycle acknowledges the full spectrum of learning styles and narrows the
performance differences that are brought about by reliance on one teaching methodology.
With this pedagogy, students are encouraged to recognize and cope with numerous ways
of acquiring information. * The techniques described in this article were developed for an
undergraduate introductory nursing theory course where students represent a range of
backgrounds. Among the students are nursing majors, first-semester juniors, sophomores
not yet enrolled in clinical nursing courses, registered nurses pursuing the BSN degree,
and students with baccalaureate degrees in other fields enrolled in fast-track programs to
earn a second baccalaureate degree in nursing. The activities have been used for four
years and implemented in groups as small as eight students and as large as 140 with equal
success.
A Multimethod Approach Much has been written about learning and teaching styles (3).
It is acknowledged that to think critically and function effectively in a complex and
dynamic profession such as nursing, many learning skills are necessary for knowledge
acquisition and information processing. Teaching around the cycle encompasses
traditional lectures, active learning strategies, collaborative learning, and problem solving
as a balanced and effective approach to teaching. While the strategies described in this
article form a comprehensive instructional approach for teaching nursing theory, they can
also be used individually to augment traditional lectures.

Understanding nursing theory requires critical thinking and complex thought processes.
Students are required to apply abstract concepts or conceptual relationships to an
extensive array of patient information and laboratory data. For this course, basic
information about nursing theory is introduced through lecture and structured classroom
discussion. The more advanced theoretical knowledge and cognitive skills of application,
analysis, synthesis, and evaluation (4) are facilitated through active, collaborative
strategies featuring faculty and student interaction.

A seminal work for educators, Chickering and Gamson's Seven Principles for Good
Practice in Undergraduate Education, encourages active student involvement and
cooperation in the learning process (5,6). Teaching strategies that encourage student
engagement, self-directed learning (7), and active processing of information promote
understanding of complex concepts and retention of material (7-9). By working on
projects in small groups, students develop cooperative learning strategies that
significantly enhance their problem-solving abilities and interpersonal communication
skills, as well as their content acquisition and retention (8).

Learning Activities BASIC KNOWLEDGE ACQUISITION Lecture and class discussion

are used to introduce theory and provide a foundation for later class activities. The
discussion begins with dissection of broad and familiar theories such as those of Einstein
and Darwin and progresses to contemporary and focused theories developed by Maslow
(10) and Lazarus and Folkman (11). The progression from familiar to unfamiliar, and
from a broad to narrow focus, is designed to increase students' comfort with abstract
concepts and theories. This method provides a balance of concrete information with more
abstract concepts (12).

Following this discussion, concepts of nursing theory are introduced. Specific nursing
theorists and their backgrounds are described so that students can gain an understanding
of the influence of personal and professional experience in theory development. Major
metaparadigm concepts within nursing theory--person, health, nurse, and environment--
are identified to provide foundational knowledge for participation in later class activities.
A nurse theorist outline developed by the instructor serves as a study guide and assists
students with subsequent class activities.

THE THEORY GAME Participation in the Theory Game reinforces student knowledge
about nursing theorists and theoretical concepts. (See the Figure on the following page
for details about how the game is played.) Gaming is a teaching technique that requires
active learning and collaborative and cooperative learning strategies within a group. Used
in a familiar setting, gaming will stimulate students' imagination and learning.

Figure. Directions for the Theory Game * Group representatives draw straws for the
order of play, roll dice to determine number of spaces moved on the playing board, move
the playing piece, and draw color-coded questions indicated by roll of dice. * Group
spokespersons gain consensus and report the group's answer. * Students use the following
references to answer questions: a theorist outline distributed in class, class lecture notes,
computer (if appropriate for the setting), and assigned reading materials. * Group
representatives throw dice or select straws to determine the order of play, While the order
of play is being determined, all groups select a group spokesperson. * All playing pieces
are placed on the section labeled "Start," and play proceeds in a clockwise direction
according to the order of play. * Each group representative rolls dice when it is the
group's turn and moves the playing piece the number of spaces indicated. The group
representative follows the directions indicated on the game board space. If the piece lands
in a blue, green yellow, or red section, a card of the same color is selected. * The
instructor reads the question to the entire class. * The group in play has two minutes to
search through resources, engage in discussion, and determine the correct answer. *
Other groups quietly discuss the question in order to identify the correct answer if the
group in play answers incorrectly ("steal-away"). The order of play for the steal-away is
determined by straw length or dice roll completed by group representatives during the
two-minute time period. * After two minutes, the spokesperson for the group in play
reports the answer. If the group in play answers incorrectly, then the spokesperson for the
first group in the steal-away answers. The steal-away continues until one group reports
the correct answer. The group correctly answering the question receives the points
indicated by the question color. * Earned points are recorded on the board and totaled at
the end of the game. Game length is determined by a prespecified time or number of
rounds. Sudden death playoff is used for tie breaking. * The group with the most points
receives the prize.

A board game that can be played in small groups and in large classroom settings, the
Theory Game uses a question-and-answer format and requires active participation. As
students work together to formulate answers through consensus, they develop
information-seeking strategies and improve their communication skills.

The game is designed to increase student familiarity and confidence with new and
abstract theoretical content. Colored spaces on the game board (shown here in shades of
grey) represent different types of questions, which are weighted as to difficulty, as in the
following examples:

* Blue (1 point): Name of theory or conceptual framework, e.g., What is the name of the
theory that focuses on diversity?

[ILLUSTRATION OMITTED]
* Green (1 point): Name of nurse theorist, e.g., Who developed the adaptation model?

* Yellow (2 points): Description of nursing theory or conceptual framework, e.g., What

conceptual framework incorporates concepts of adaptation, client holism, and Selye's
(13) stress theory?

* Red (5 points): Metaparadigm concepts, e.g., In which theory is nursing defined as a

service that helps both self and others to promote self-care?

Players may use various information-seeking strategies organized for rapid retrieval,
including printed material such as texts, notes, handouts, and computer and online
resources. Some groups soon realize that if certain players are assigned to certain
specialty areas, the group can more quickly retrieve information. Since students work in
groups or teams, this game can be used in small and large classes. In large classes, the
teacher can project the game board on a screen and read the questions to the entire class.
With two minutes to the find the answers, the game generates a great deal of excitement,
and prizes are awarded to the winning team.

THEORY ANALYSIS With this activity, students analyze theory in research and
practice by evaluating current journal articles in small-group discussions. Two lists, each
containing five journal articles, are made available to the class. Students are not told that
the...

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Understanding Ida Jean Orlando-Pelletier’s

Dynamic Nurse-Patient Relationship

Know the THEORIST

Ida Jean Orlando, a first-generation American of Italian descent was

born in 1926. She received her nursing diploma from New York Medical College, Lower Fifth
Avenue Hospital, School of Nursing, her BS in public health nursing from St. John's University,
Brooklyn, NY, and her MA in mental health nursing from Teachers College, Columbia University,
New York. Orlando was an Associate Professor at Yale School of Nursing where she was Director
of the Graduate Program in Mental Health Psychiatric Nursing. While at Yale she was project
investigator of a National Institute of Mental Health grant entitled: Integration of Mental
Health Concepts in a Basic Nursing Curriculum. It was from this research that Orlando
developed her theory which was published in her 1961 book, The Dynamic Nurse-Patient
Relationship. She furthered the development of her theory when at McLean Hospital in
Belmont, MA as Director of a Research Project: Two Systems of Nursing in a Psychiatric
Hospital. The results of this research are contained in her 1972 book titled: The Discipline and
Teaching of Nursing Processs. Orlando held various positions in the Boston area, was a board
member of Harvard Community Health Plan, and served as both a national and international
consultant. She is a frequent lecturer and conducted numerous seminars on nursing process.
She is married to RobertPelletier and lives in the Boston area. She passed away on November
28 , 2007.

Distinguish the THEORY

Case Scenario
“Nurse, can you give me my morphine,” cried out Mrs. So. “Can you tell how painful it is using
the 0 ‐10 pain scale, where 0 being not painful and 10 being severely painful?”replied the nurse.
“Ummm... I think it’s about 7. Can I have my morphine now?” “Mrs. So, I think something is
bothering you besides your pain. Am I correct?” Mrs. So cried and said, “I can’t help it. I’m so
worried about my 3 boys. I’m not sure how they are or who’s been taking care of them. They’re
still so young to be left alone. My husband is in Yemen right now and he won’t be back until next
month.” “Why don’t we make a phone call to your house so you could check out on your boys?”
Mrs. So phoned his sons. “Thank you nurse. I don’t think I still need that morphine. My boys are
fine. Our neighbour, Mrs. Yee, she’s watching over my boys right now.”

The focus of Orlando’s paradigm hubs the context of a dynamic nurse-patient phenomenon
constructively realized through highlighting the key concepts such as : Patient Behavior, Nurse
Reaction , Nurse Action.

1. The nursing process is set in motion by the Patient Behavior. All patient behavior, verbal (
a patient’s use of language ) or non-verbal ( includes physiological symptoms, motor activity,
and nonverbal communication) , no matter how insignificant, must be considered an expression
of a need for help and needs to be validated . If a patient’s behavior does not effectively
assessed by the nurse then a major problem in giving care would rise leading to a nurse-patient
relationship failure. Overtime . the more it is difficult to establish rapport to the patient once
behavior is not determined. Communicating effectively is vital to achieve patient’s cooperation
in achieving health.

Remember : When a patient has a need for help that cannot be resolved without the help of
another, helplessness results
2. The Patient behavior stimulates a Nurse Reaction . In this part, the beginning of the
nurse-patient relationship takes place. It is important to correctly evaluate the behavior of the
patient using the nurse reactions steps to achieve positive feedback response from the patient.
The steps are as follows:
The nurse perceives behavior through any of the senses -> The perception leads to automatic
thought -> The thought produces an automatic feeling ->The nurse shares reactions with the
patient to ascertain whether perceptions are accurate or inaccurate -> The nurse consciously
deliberates about personal reactions and patient input in order to produce professional
deliberative actions based on mindful assessment rather than automatic reactions.

Remember : Exploration with the patient helps validate the patient’s behavior.

3. Critically considering one or two ways in implementing Nurse Action. When providing
care, nursing action can be done either automatic or deliberative.

Automatic reactions stem from nursing behaviors that are performed to satisfy a directive
other than the patient’s need for help.
For example, the nurse who gives a sleeping pill to a patient every evening because it is
ordered by the physician, without first discussing the need for the medication with the patient,
is engaging in automatic, non-deliberative behavior. This is because the reason for giving the
pill has more to do with following medical orders (automatically) than with the patient’s
immediate expressed need for help.

Deliberative reaction is a “disciplined professional response” It can be argued that all nursing
actions are meant to help the client and should be considered deliberative. However, correct
identification of actions from the nurse’s assessment should be determined to achieve
reciprocal help between nurse and patient’s health. The following criterias should be
considered.

o Deliberative actions result from the correct identification of patient needs by

validation of the nurses’s reaction to patient behavior.
o The nurse explores the meaning of the action with the patient and its
relevance to meeting his need.
o The nurse validates the action’s effectiveness immediately after compelling it.
o The nurse is free of stimuli unrelated to the patient’s need (when action is
taken).

Remember : for an action to have been truly deliberative, it must undergo reflective
evaluation to determine if the action helped the client by addressing the need as determined
by the nurse and the client in the immediate situation.

Learn more about the THEORY

METAPARADIGM CONCEPTS

Human/Person An individual in need. Unique individual behaving verbally or nonverbally.

Assumption is that individuals are at times able to meet their own needs and at other times unable to do so.
Health Assumption is that being without emotional or physical discomfort and having a sense of well-
being contribute to a healthy state. She further assumed that freedom from mental or physical discomfort
and feelings of adequacy and well being contribute to health. she also noted that repeated experiences of
having been helped undoubtedly culminate over periods of time in greater degrees of improvement
Environment Orlando assumes it as a nursing situation that occurs when there is a nurse-patient
contact and that both nurse and patient perceive, think, feel and act in the immediate situation. any aspect of
the environment, even though its designed for therapeutic and helpful purposes, can cause the patient to
become distressed. She stressed out that when a nurse observes a patient behavior, it should be perceived as
a signal of distress.
Nursing A distinct profession "Providing direct assistance to individuals in whatever setting they are
found for he purpose of avoiding, relieving, diminishing, or curing the individual's sense of helplessness"
(Orlando, 1972, p. 22). Professional nursing is conceptualized as finding out and meeting the client’s
immediate need for help.

Cite the Applications of the THEORY

In Nursing Research

1. In a Veterans Administration (VA) ambulatory psychiatric pr

actice in Providence, RI
Shea, McBride, Gavin, and Bauer (1987) used Orlando’s theoretical
model with patients having a bipolar disorder.Their research results
indicate that there were: higher patient retention, reduction of
emergency services, decreased hospital stay, and increased satisfaction.
They recommended its use throughout the VA system.Currently
Orlando’s model is being used in a multi-million dollar research study of
patients with a bipolar disorder at 12 sites in the VA system (McBride,
Telephone interview, July, 2000). McBride and colleagues continue its
use in practice and research at the Veteran Administration Hospital in
Providence, RI.
2. In a pilot study, Potter and Bockenhauer (2000) found positive results
after implementing Orlando’s theory. These included:positive, patient-
centered outcomes, a model for staff to use to approach patients, and a
decrease in patient’s immediate distress. The study provides variable
measurements that might be used in other research studies.

in Nursing Education
 1. Orlando's theory has a continuing influence on nursing education.
Through e-mail communication it was found that the Midwestern State
University in Wichita Falls, Texas, is using Orlando's theory for teaching
entering nursing students. According to Greene (e-mail communication,
June, 2000) she became aware, when taking a doctoral course about
nursing theories, that it was Orlando theory used by its school.
2. Through networking the author found

that for over 10 years South

Dakota State University in Brookings, SD has been using Haggerty’s
(1985) description of the communication based on Orlando’s theory for
entering nursing students as well as re-enforcing it in their junior year
(e-mail communication, (J. Fjelland, June, 2000). Joyce Fjelland, MS,
RN. After working with Schmieding at Boston City Hospital, Lois Haggerty
used Orlando’s theory in her teaching of students and in conducting a
research study of students’ responses to distressed patients at
BostonCollege in Chestnut Hill, Massachusetts.

in Nursing Practice

From an ICU nurse: “Patients have an initial

ability to communicate their need for help”. Consider a case of an immediate post Coronary
Artery Bypass Graft (CABG) patient. Once relieved from the effects of anesthetic sedation,
though intubated, you would realize his excruciating retort from the sternotomy incisional pain
through implicit cues. Morphine Sulfate 1 to 2 mg To be given via slow IV push every 1 to 2
hours or Ketorolac 15 mg IV every 6 hours is the typical pro re nata (PRN) order of a cardiac
intensivist to relieve the client from pain. Automatic response of a nurse is to calm the client
and encourage relaxation through deep breathing while splinting the chest with a pillow. Being
Deliberate in your actions include knowing the pharmacokinetics of an ordered drug in relation
to the client’s physiologic standing. If the creatinine level were elevated, would you administer
ketorolac? If the client is on respiratory precaution, would you administer Morphine? You would
ask yourself, what other alternatives do I have to ease my client from pain? “The client’s
behavior is meaningful”. If such “need” would be fittingly dealt with, the intervention is
thriving. “When patient’s needs are not met, they become distressed.”

Analyze the THEORY

Case Study
A relative of a patient at the emergency room went to the nurse’s station and began complaining
in a loud shouting voice that their patient being a charity case is not being given the same quality
of care as that of the other patients who are under private consultants. He claimed that their
patient who was hyperventilating and was complanining of difficulty of breathing due to
neurocirculatory astheinia was just forced to sit in the cubicle, while the rich-looking patient was a
gomey.

Question
How will you handle this kind of situation and avoid conflict? How can Orlando’s dynamic nurse-
patient interaction theory be utilized in this type of situation?
This Group Blog is Submitted to Ms. Sheila Bonito,
FIC,
in Partial Fulfillment of the Requirements in N207.
Manager: Aux Lizares
Editor: Maria Mae Juanich
Contributors:
Katrina Anne Limos
Ginno Paulo Maglaya
Diana Jasmin Lee

Acknowledgment
We would like to acknowledge the following people: Ma’am Shiela Bonito, for coming up with this
group work which really challenged not only our knowledge, understanding and creativity but also
our ability to stay connected despite the distance, Ms. Aux Lizares, for diligently sorting out the
articles, Ms. Maria Mae Juanich, for organizing the articles into a working blog, and for Ms.
Katrina Anne Limos, Mr. Gino Paulo Maglaya, and Ms. Diana Jasmin Lee, for tirelessly
contributing their thoughts, ideas, and resources. Without all of you, this blog would have never
been possible. Thank you very much!!!

Dear classmates,

Let us learn together. Have we done justice to Ida J. Orlando in presenting her theory this way?
We would like to invite you to share with us your thoughts, feelings, comments or reactions on our
blog entitled, “Understanding Ida Jean Orlando-Pelletier’sDynamic Nurse-Patient
Relationship.” Thank you for your participation!

Regards,
Group G

Reference:
Orlando, I. J. (1972). The discipline and teaching of nursing process: An evaluative study. New York:
G. P. Putnam.
http://www.enursescribe.com/orlando.htm
George, J.B. (2002). Nursing Process Discipline: Ida Jean Orlando. In George, J.B. (Ed.). Nursing
Theories: the Base for professional nursing practice (5th Ed.). Upper Saddle River, New Jersey:
Prentice Hall, pp. 189-208.
Schmieding, N.J. (2002). Ida Jean Orlando (Pelletier): Nursing Process Theory. In Tomey, A.M., &
Alligood, M.R.. Nurse theorists and their work (5th Ed.). St. Louis: Mosby, pp. 399-417.
http://www.uri.edu/nursing/schmieding/orlando/
Orlando, I.J. (1961). The dynamic nurse-patient relationship, function, process and principles. New
York: G. P. Putnam.]
Haggerty, L.A. (1985). A theoretical model for developing students’ communication skills. Journal of
Nursing Education, 24(7), 296-298.
Haggerty, L.A. (1987). An analysis of senior nursing students’ immediate responses to distressed
patients.. Journal of Advanced Nursing, 12, 451-461.
Nancy M. Shea, Linda McBride, Christopher Gavin, and Mark Bauer
Bauer, M. S. (2001). The collaborative practice model for bipolar disorder-Design and implementation
in a multisite randomized controlled trial. Bipolar Disorders 3(5), 233-244. Bauer, M.S., & McBride, L.
(2002). Structured group psychotherapy for bipolar disorder (2nd Ed). New York: Springer Publishing
Co. Shea, N. M., McBride, L. Gavin, C., & Bauer, M. (1997). The effects of ambulatory collaboration
practice model on process and outcome of care for bipolar disorder. Journal of the American
Psychiatric Nurses Association 3(2), 49-57. Mertie. L. Potter, ND, ARNP, CS and Barbara Jo
Bockenhauer, MS, RNC
Potter, M.L. & Bockenhauer, B.J. (2000). Implementing Orlando’s nursing process theory: A pilot
study. Journa
l of Psychosocial Nursing nd Mental Health Services, 38(3), 14-21

Posted by Group G: UPOU Orem's Supporters at 1:47 AM

11 comments:

mayang said...

For everybody's information:

ANA - Automatic Nursing Action
DNA - Deliberate Nursing Action

July 20, 2008 3:04 PM

N207 Students said...

Wow a very factual presentation. The applications of the theory are very realistic.
I also like the coordination of the colors. Congratulations to your group the
 explanation of the theory of Orlando is very precise and specific.

July 21, 2008 4:06 AM

mayang said...

thank you!

July 24, 2008 3:08 PM

nursing student said...

That was very informative. I am writing from Canada. I am in my 4th year of

Nursing School and am doing a presentation on Orlando. I enjoyed especially
your clinical cases.

October 15, 2008 11:57 AM

Sheri said...

Thank you! BSN student in Illinois doing a presentatin on Ida and I used alot of
your information.

November 17, 2008 7:33 AM

gavynus said...

This is great.
Can I have permission to utilize and or recreate your charts of your interpretation
of Orlando's theory for my Master's project?

Thanks for your time.

April 8, 2009 6:12 AM

Christina said...

Very creative and informative blog. Enjoyed it immensely. I am a BSN student

from Florida, currently studying nursing theories and models and it helped me
understand the orlando's theory well. I loved the analogy of the oragami.

May 21, 2009 7:33 PM

mayang said...
 hello all!

my name is maria mae juanich (mayang) and i am one of those who put the ideas
together from all the referrences. i appreciate seeing all your comments... i am a
lil sad that it took a while for me to look back and see that you have wonderful
comments. thanks a lot!

@gavynus: i know it is late to say this but yes you may... the referrences were
listed at the bottom of the article.

February 27, 2010 8:43 AM

gary said...

For what its worth I worked with Ida At Metropolitan state hospital in the
1980"s . I recieved weekly supervision from her in regards to my clinical
practice.She was instrumental in my decision to go to nursing school.
I did not here of her passing as I was deployed with a combat support hospital in
Mosul iraq at the time.
Her impact on nursing remains.I believe Her patient focused approach approach is
a forerunner of the psycho social rehab model that is in fashion at the moment.
I think of her often
Gary Grossi
LTC/AN

March 17, 2010 3:12 PM

mayang said...

hi gary...

indeed u are lucky to have experienced nursing with her. i also admire her
works :-)

March 27, 2010 7:49 AM

mayang said...

...ummmm by the way, what i meant was clinical nursing practice hehe not just