Ida Jean Orlando – The Nursing Process Theory

• Born in 1962
• Wrote about THE NURSING PROCESS.
• Nursing diploma – New York Medical
College
• BS in public health nursing – St.
John’s University, NY
• MA in mental health nursing –
Columbia University, New York
• Associate Professor at Yale School of
Nursing and Director of the Graduate
Program in Mental Health Psychiatric
Nursing
• Project investigator of a National Institute of Mental Health
grant entitled: Integration of Mental Health Concepts in a
Basic Nursing Curriculum.
• Published in her 1961 book, The Dynamic Nurse-Patient
Relationship and revised 1972 book: The Discipline and
Teaching of Nursing Processes
• A board member of Harvard Community Health Plan.
Theoretical Sources
• Orlando acknowledges no theoretical sources for the
development of her theory. None of her publications
includes a bibliography.
Use of Empirical Evidence
• Orlando synthesized facts from observations to develop her
theory. She asserted that her theory is valid and applied it in
her work with patients and nurses and the teaching of
students.

• She gathered a considerable amount of data before

constructing her theory.
Major Concepts/ Definitions
Definitions
• 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.
• Patients behavior may not present the true need.
• The nurse validates his or 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.
Concepts
1. Function of professional nursing – organizing principle
2. Presenting behavior – problematic situation
3. Immediate reaction – internal response
4. Nursing discipline – investigation
5. Improvement - resolution
Funtion of professional nursing
– organizing principle
• Finding out and meeting the patients immediate need for
help.

• “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
Presenting Behavior
- problematic situation
• To find out the immediate need for help the nurse must first
recognize the situation as “problematic”.

• The presenting behavior of the patient, regardless of the

form in which it appears, may represent a plea for help.

• The presenting behavior of the patient, the “stimulus”,

causes an automatic internal response in the nurse, and the
nurses behavior causes a response in the patient.
Immediate Reaction
- internal response
• Person perceives with any one of his five sense organs an object or
objects.

• The perceptions stimulate automatic thoughts.

• Each thought stimulates an automatic feelings.

• Then the person acts.

• The first three items taken together are defined as the person’s
immediate reaction.
Nursing Process Discipline
- investigation
• Any observation shared and explored with the patient is immediately
useful in ascertaining and meeting his need or finding out that he is
not in need at that time.
• The nurse does not assume that any aspect of her reaction to the
patient is correct, helpful or appropriate until she checks the validity
of it in exploration with the patient.
• The nurse initiates a process of exploration to ascertain how the
patient is affected by what she says or does.
• When the nurse does not explore with the patient her reaction it
seems reasonably certain that clear communication between them
stops.
Improvement
- resolution
• It is not the nurses activity that is evaluated but rather its
result: whether the activity serves to help the patient,
whether it communicates his or her need for help and how
the need was met.

• With each contact the nurse repeats a process of learning

how to help the individual patient.
Major Dimensions
• 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.

• Therefore, nurses need to use their perception, thoughts about

the perception, or the feeling engendered from their thoughts to
explore with patients the meaning of their behavior.

• This process helps nurse find out the nature of the distress and
what help the patient needs.
• Nursing client – patients who are under medical care and who cannot
deal with their needs or who cannot carry out medical treatment
alone
• Nursing problem – distress due to unmet needs due to physical
limitations, adverse reactions to the setting or experiences which
prevent the patient from communicating his needs
• Nursing process – the interaction of 1) the behavior of the patient, 2)
the reaction of the nurse and 3) the nursing actions which are
assigned for the patients benefit
• Nurse – patient relations – central in theory and not differentiated
from nursing therapeutics or nursing process
• Nursing therapeutics – Direct function : initiates a process of helping the
patient express the specific meaning of his behavior in order to ascertain
his distress and helps the patient explore the distress in order to ascertain
the help he requires so that his distress may be relieved.
• Indirect function – calling for help of others, whatever help the patient
may require for his need to be met.
• Nursing therapeutics - Disciplined and professional activities – automatic
activities plus matching of verbal and nonverbal responses, validation of
perceptions, matching of thoughts and feelings with action
• Automatic activities – perception by five senses, automatic thoughts,
automatic feeling, action
Major Assumptions
• When patients cannot cope with their needs without help,
they become distressed with feelings of helplessness.
• Patients are unique and individual in their responses.
• Nursing offers mothering and nursing analogous to an adult
mothering and nurturing of a child
• Nursing deals with people, environment and health
Major Assumptions
• Patient need help in communicating needs, they are
uncomfortable and ambivalent about dependency needs.
• Human beings are able to be secretive or explicit about their
needs, perceptions, thoughts and feelings.
• The nurse – patient situation is dynamic, actions and reactions
are influenced by both nurse and patient.
• Human beings attach meanings to situations and actions that are
not apparent to others .
• Nurses are concerned with needs that patients cannot meet on
their own.
Nursing
• Is responsive to individuals who
suffer or anticipate a sense of
helplessness
• Process of care in an immediate
experience….. for avoiding,
relieving, diminishing or curing the
individuals sense of helplessness.
Finding out meeting the patients
immediate need for help
• Goal of nursing – increased sense
of well being, increase in ability,
adequacy in better care of self and
improvement in patients behavior
Person
• developmental beings with
needs.
• Are individuals who have their
own subjective perceptions and
feelings that may not be
observable directly.
Health
• sense of adequacy or well being.
• fulfilled needs.
• sense of comfort.
Environment
• not defined directly but
implicitly in the immediate
context for a patient.
Acceptance by the Nursing Community
PRACTICE
• Clearly applicable to nursing practice.
• Basis of practice in hospitals.
• Used at the patient care level, managerial level, and nursing
division level.

EDUCATION
• Orlando’s process recording has made a significant contribution
to nursing education.
• Process recording – a tool to facilitate self evaluation of whether
or not the process discipline was used.
Acceptance by the Nursing Community
RESEARCH
• Enjoyed considerable acceptance by the nursing profession
in the area of research and has been applied to a variety of
research settings.
Josephine Paterson and Loretta Zderad
“Humanistic Nursing Theory”
Background of the Theorists
• Dr. Paterson Mastered in Public Health Nursing; Completed
Doctor of Nursing in Science degree at Boston University;
Dissertation on “Comfort”.
• Dr. Zderad Mastered in Psychiatry; Doctorate at Georgetown
University in Philosophy with Dissertation on “Empathy”.
• Met in the 1950’s while working at Catholic University, where
their task was to create a new program that would include
Psychiatric and Community Health components as part of the
graduate program.
• Friendship that has lasted over 35years.
• Shared experiences, ideas and insight to form a concept that
evolved into the Formal Theory of Humanistic Nursing.
• Josephine G. Paterson and Loretta T. Zderad first published
their book Humanistic Nursingin1976.
• Their initial commitment to creativity conceptualize nursing
constructs developed into “Nursology”, a phenomenological
approach to studying nursing as an existential experience.
• “Human Experience”
Major Concepts
• Humanistic nursing theory is ‘Multidimensional ’ and it is an
‘Interactive Theory’.
• In Humanistic nursing theory the components identified as
humans are the patient (can refer to the person, family,
community ) and the nurse.

The Person who calls for help

is the Patient

The Person who recognizes and responds to the call

is the Nurse
Major Concepts
• ”Dialogue’’ which provides methadological bridge between
theory and practice
• Dialogue – Nurturing of ‘wellbeing’ and ‘morebeing’
• What happens during this dialogue, the “and” in the “call-
and-response”, the between, is nursing
• Although the call and response is between the nurse and the
patient, it is important to understand all else that makes
the individual person to interact.
• The nurse interweaves her professional identity and
professional education, with all her other life experiences to
create her own tapestry, which she projects through her
nursing responses.
Mataparadigms
Person
• Person is viewed as an “Incarnate being” always becoming in
relation with man and things in a world of time and space’’
• Person has the capability of self reflection.
Nursing
• Nursing is conceptualized as a lived human act , a response
to a human act ,a response to human situation.
• The dialogical quality of nursing is emphasized; nursing is
viewed as a transaction between persons.
Metaparadigms
Humanistic Nursing
• Transactional relationship whose meaningfulness demands
conceptualization founded on a nurse’s existential awareness
of self and the other.
• Humanistic nursing aims at the development of human
potential, at wellbeing and more being
Metaparadigms
Health
• Nursing’s concern is said to be ‘not merely with a person’s
wellbeing but within his morebeing; with helping him become
more as humanly possible in his particular life situation.
• Wellbeing and Morebeing, that health is conceptualized as
somewhat more than the freedom from disease.
Environment – the time and space where nursing occurs
View person as actually living in two worlds.
• An angular, inner world, also described as a biased or shaded
reality.
• The objective world , of persons and things. Openness to and
acceptance of the other’s inner world is essential for true
interaction between persons.
Existentialism
• “Man is nothing else but what he makes of himself”
• Existential philosophy
• Thinking starts with the feeling, acting and living individual.
• Human beings are unique.
• Focus: human’s wholeness and unique attributes, value,
freedom of choice (autonomy).
Phases of Phenomenological Description
Preparation of the nurse knower for coming to know

Nursing knowing the other intuitively

Nurse knowing the other scientifically

Nurse complementarily synthesizing know others

Succession within the nurse from the many to the paradoxical one
1. Preparation of the nurse knower
for coming to know
• Understanding own viewpoint/ angle helps to make sense
and aid in acquiring meaning of experience.
• “Angular view involves the gestalt of the human.
• She struggles with understanding and identifying her own
“angular view”
• Being open to new and different ideas/understandings is a
necessary position in being able to get to know the other
intuitively
2. Knowing
the other
intuitively
3. Nurse knowing the other scientifically
4. Nurse complementarily synthesizing
known others
• The ability of the nurse to develop or see themselves as a
source of knowledge, to continually develop the nursing
community through education, and increased understanding
of their learned experiences.
5. Succession within the nurse from the many
to the paradoxical one
• Allows for reflection, correction and expansion of own
angular interpretation.
• Implies universal understanding from the simplest to most
complex dialogue and interactions between the nurse and
assimilates patient experience.
Use of Theory in Research
• The Phenomenological method is proposed as a descriptive
approach for participants in the nursing situation to study,
interpret, and attest the nature and meaning of the lived
events .
• A group research project that was conducted in the clinical
setting of a psychiatric hospital by Paterson and
Zderad(1988).
• In an effort to better understand why some patients stayed
in the day hospital and others left, the nursing staff
conducted a phenomenological study that investigated the
experiences of patients as they enter and become engaged
in treatment in a day hospital system.
• The initial step in the process, in Dr. Paterson’s and Dr.
Zderad’s terms, is to prepare the nurse knower for coming to
know.
• Literature was handed out on this and meetings were held to
discuss the articles and any questions about them. They also
shared their feelings about this method, their concerns, and
other experiences related to this study.
• As they did this, they began to establish an atmosphere of
openness and trust.
• Once the descriptions were obtained, they interpreted with
the phenomenological method of reflecting, intuiting,
analyzing, and synthesizing.
• They interviewed 15 patients over a period of 8 months, on
their day of admission and every 4 weeks thereafter until
discharge.
• They found from interviews that there were many anxiety
producing experiences on the first day in the day hospital,
but very few anxiety-reducing experiences that offered the
patient comfort and support.
• After reviewing the interviews of a patient who had a
particularly difficult course of treatment, one of the nurses
who was on her treatment team remarked, “We weren’t
listening to what she was telling us—we just didn’t hear the
pain. ”Another nurse had a similar insight into a patient’s
experiences. In future interactions with this patient the
nurse was empathic and supportive rather than judgmental
and angry.
Application to Nursing Practice
• The bounded concern for attention to physical status gives
support for application of the theory.
• The difficulty of continuous “active presence “ with the
whole of the nurse’s being is addressed by the theorists.
• Have limited applicability in situations in which the nurse as
helper interacts with a child or comatose patient
Evidenced Based Practice
Humanistic nursing theory : application to hospice and palliative
care.
Wu HL, Volker DL
The philosophical perspectives of Humanistic Nursing Theory are
relevant to the practice of hospice and palliative care nursing . By
being with and doing with hospice and palliative nurses can work
with patients to achieve their final goal in the last phase.
Use of core concepts from Humanistic Nursing Theory can provide
a unifying language for planning care and description of
investigations. Future research efforts in hospice and palliative
nursing should define and evaluate these concepts for efficacy in
practice settings.
References
• Fitzpatrick J, Whall A. Conceptual models of nursing: analysis
and application.
• Bowie (ML): Robert J Brady co; p. 181-200. 2. Marilyn EP.
Nursing theories and nursing practice. Philadelphia (AS): FA
Davis Company; p. 152-67 3.
• Josephine Paterson and Loretta Zderad . The Project
Gutenberg eBook: Humanistic Nursing. 2008; p. 3-112 4.
• Ellis R. Annual review of nursing research: philosophic
inquiry. New York: Springer Publishing Company; p. 211-228
 DOROTHY JOHNSON
“Behavioral System Model”

Born August 21, 1919, in Savannah, Georgia, USA

Introduction

Dorothy E. Johnson was born August 21,

1919, in Savannah, Georgia.

B. S. N. from Vanderbilt University in

Nashville, Tennessee, in 1942; and her
M.P.H. from Harvard University in Boston in
1948.

From 1949 until her retirement in 1978 she

was an assistant professor of pediatric
nursing, an associate professor of nursing,
and a professor of nursing at the University
of California in Los Angeles
Introduction

Dorothy Johnson has had an influence

on nursing through her publications since
the 1950s. Throughout her career, Johnson
has stressed the importance of
research-based knowledge about the effect
of nursing care on clients.
 Died at the age of 80 in the year 1999.
 OVERVIEW OF THE THEORY

Johnson's theory of nursing

believes that humans are
behavioral systems made up of
seven subsystems.

“ Each individual has a

predisposition to act with
reference to the goal, in
certain ways rather than in
other ways.”
BEHAVIOR

 Output of intraorganismic
structures and processes as
they are coordinated and
articulated by and responsive to
changes in sensory stimulation.
SYSTEM
 Is a whole that functions as a
whole by virtue of the
interdependence of its parts

 There is “ organization, interaction,

interdependency, and integration
of the parts and elements” --- Chinn

 adjustments + adaptations
= balance
BEHAVIORAL SYSTEM
 Encompasses the patterned,
repetitive, and purposeful ways of
behaving = organized and
integrated functional unit

 A person is a behavioral system

tries to achieve stability and
balance

 System is usually flexible enough

rac/2008
 4 METAPARADIGM IN NURSING

 PERSON

Johnson views “human being” as having

two major systems:

Biological System – It is the role of

medicine to focus on biological system

Behavioral System – Focus of nursing

 4 METAPARADIGM IN NURSING

 HEALTH

Health is a state that is affected by social,

psychological, biological & physiological.

Individual is striving to retain some balance or

equilibrium.

Individual’s goal is to sustain the entire

behavioral system efficiently & effectively to
return to an acceptable balance if malfunction
disrupts the original balance.
 4 METAPARADIGM IN NURSING

 ENVIRONMENT

Individual’s behavior is influenced by

all the events in the environment.

Cultural influences on the

individual’s behavior are viewed as
profound.
 4 METAPARADIGM IN NURSING

 NURSING

Nursing implementations may focus

on correction of a behavior that is
not concerned to maintaining
equilibrium for the individual.
 SEVEN BEHAVIORAL SYSTEM

“The seven subsystems are

considered to be interrelated,
thus changes in one changes in
one subsystem affect all
subsystem”
ATTACHMENT / AFFILIATIVE
 Most critical = basis for all social
organization
 Provides survival and security
 Consequences:
 social inclusion
 intimacy
 formation and maintenance of
strong social bond
DEPENDENCY
 Promotes helping behavior that
calls for a nurturing response

 Consequences:
 approval/consent
 attention or recognition
 physical assistance
INGESTIVE
 Relates to the behaviors surrounding
the ingestion of food.
 “Has to do with when, how, what,
how much, and under what
conditions we eat”
 It serves the broad function of
appetitive satisfaction
 Associated with social, psychological
and biological considerations
ELIMINATIVE

 Relates to the behaviors surrounding

the excretion of waste products from
the body

Human cultures have defined

different socially acceptable behaviors
for excretion of waste.
SEXUAL
 Has the dual functions of
procreation and gratification

 Begins with the development of

gender role identity and includes
broad range of sex-role behaviors
ACHIEVEMENT

 Contains behaviors that attempt

to control he environment.

 Areas of achievement:
 intellectual
 physical
 creative
 mechanical
 social
AGGRESSIVE
 Relates to behaviors concerned
with defense & self preservation

 It does not include those

behaviors with primary purpose
of injuring other individual, but
rather those whose purpose is to
PROTECT & CONSERVE SELF &
SOCIETY
Johnson’s Model
The are four assumptions about structure and function that are common to
each of the seven subsystems:

(1) “From the form the behavior takes and the consequences it achieves
can be inferred what ‘drive’ has been stimulated or what ‘goal’ is being
sought.”

(2) Each individual person has a “predisposition to act with reference to the
goal, in certain ways rather than the other ways.” This predisposition is
called a “set.”

(3) Each subsystem has a repertoire of choices called a “scope of action.”

(4) The individual patient’s behavior produces an outcome that can be

observed.
• Each of the subsystem has three functional
requirements which include:
1. protection from noxious influences,
2. provision for a nurturing environment, and
3. stimulation for growth.
• An imbalance in each system results in disequilibrium.
The nurse’s role is to help the patient maintain his or
her equilibrium.
SISTER CALLISTA ROY
“Adaptation Model”
INTRODUCTION

Born at Los Angeles on October 14,

1939 as the 2nd child of Mr. and Mrs.
Fabien Roy

At age 14 she began working at a large

general hospital, first as a pantry girl,
then as a maid, and finally as a nurse's
aid.

She entered the Sisters of Saint Joseph

of Carondelet.
She earned a Bachelor of Arts with a
major in nursing from Mount St.
Mary's College, Los Angeles in 1963.

A master's degree program in

pediatric nursing at the University of
California ,Los Angeles in 1966.

She also earned a master’s & PhD in

Sociology in 1973 & 1977, respectively
Sr. Callista had the significant
opportunity of working with Dorothy
E. Johnson
Johnson's work with focusing
knowledge for the discipline of nursing
convinced Sr. Callista of the
importance of describing the nature of
nursing as a service to society and
prompted her to begin developing her
model with the goal of nursing being
to promote adaptation.
http://currentnursing.com/nursing_theory/application_Roy's_adaptatio
n_model.html
 “Roy's theory sees the person
as "a bio-psycho-social being in
constant interaction with a
changing environment"
(Rambo, 1984). The person is
an open, adaptive system who
uses coping skills to deal with
stressors”
 Terms used in the
Roy Adaptation Model (RAM)
System-a set of parts connected to
function as a whole for some purpose.

Stimulus-something that provokes a

response, point of interaction for the
human system and the environment

Three types of STIMULI:

- Focal Stimuli
- Contextual Stimuli
- Residual Stimuli
Focal Stimuli-internal or external
stimulus immediately affecting the
system. Ex: Immobility

Contextual Stimulus-all other stimulus

present in the situation.
Ex: Amputation of the Limb

Residual Stimulus-environmental factor,

that can affect the focal stimulus but
the effects are unclear.
The adaptation level is modulated by
persons coping mechanism & control
process. Thus person does not respond
passively to environmental stimuli.

Two categories of COPING MECHANISMS:

a. Regulator subsystem
b. Cognator subsystem
Regulator Subsystem- automatic
response to stimulus transpires through
neural, chemical, and endocrine.
Ex: (increase vital signs)

Cognator Subsystem - responds through

four cognitive-emotional channels:
perceptual and information processing,
learning, judgment and emotion.
 “The Four Adaptive Modes are
interrelated through perception. An
adaptive response in one mode can
influence adaptation in the other
modes” ….Sister Callista Roy
1. Physiological-Physical Adaptive Mode
Goal: Physiological Integrity

-The way the person responds as a

physical well-being to stimuli from the
environment
-Nurse must be knowledgeable about
normal processes
-Five Physiologic Needs (Oxygenation,
Nutrition, Elimination, Activity & Rest,
and Protection)
2. Self Concept-Group Identity Adaptive Mode

Goal: Psychological Integrity

Psychological & spiritual characteristics of the

person consist of all beliefs & feelings that
one has formed about oneself.

two components:
Physical Self = body sensation & body image
Personal Self = self consistency, self ideal &
moral ethical spiritual self
3. Role Function Adaptive Mode
-Different roles that a person performs in
the society

A role is a set of expectations about how a

person occupying ones position behaves
towards a person occupying another
position.

Goal: Social Integrity

4. Interdependence Adaptive Mode
Coping mechanism from close relationship
which results to giving & receiving of love,
respect and value.

Occurs between the person & the most

significant other or support system.

Goal: Affectional adequacy

Ex: giving & receiving love, respect &
value through effective communication
Nursing Process:

Step 1: Assessment of the behavior

- gather data about the behavior of the person
as an adaptive system in each of the adaptive
mode
Observable behavior (Overt/Objective)
Non-observable (Covert/Subjective)

Step 2. Assessment of Stimuli

Focal
Contextual
Residual
Nursing Process:

Step 3: Nursing Diagnosis

- formulation of statements that interpret data
about the adaptation status of the person,
including the behavior and most relevant
stimuli.

Step 4: Goal Setting

- Establishment of statements of the
behavioral outcomes for nursing care which is
realistic and attainable. This is done together
with the client.
Nursing Process:

Step 5: Intervention
- determination of how best to assist the
person in attaining the established goals

Step 6: Evaluation
- Judging the effectiveness of the nursing
intervention in relation to the behavior after
it was performed in comparison with the goal
established.
 Application of Roy’s
Adaptation Theory utilizing
the Nursing Process
Mang Goryo, a 50-year-old driver has
diabetes for 5 years and has not followed
the prescribed treatment regimen.

He has a non-healing would on his right

foot which prompted the surgeon to
perform above-knee amputation to
prevent further complication.

His past health history revealed that Mang

Goryo seldom visit his doctor for his check
up. He smokes approximately two packs
of cigarretes per day for the past 10 years
and also drinks alcohol
In addition Mang Goryo is the bread-winner
In the family. He has 6 children & described his
wife as verbally abusive (bungangera) at times
because of financial instability.

A day after the surgery Mang Goryo said.

“Namatay ang tatay at nanay ko dahil s
diabetes. Bakit pa ako magbabago kun
mamamatay rin lang ako”.

When the nurse explored his feelings, Mang

Goryo become extremely tearful and
expressed his concern about about him being
worthless, the future of his family. He believes
that the Illness is a punishment for his past life.
 Physiologic Adaptive Mode

Step 1. Assessment of the behavior

- Mang Goryo had undergone amputation of
the leg, his mobility is impaired.
Step 2. Assessment of the stimuli
- Bacause of amputation the patient has
impaired mobility
Focal Stimulus is immobility
Contextual Stimulus is amputation of the limb

Step 3. Nursing Diagnosis

Impaired mobility related to amputation of the
right leg
 Physiologic Adaptive Mode

Step 4. Goal Setting

“ Mang Goryo should be able to verbalize
understanding of the situation & rehabilitation
treatment regimen & safety measures.

Step 5. Intervention
a. Encourage to participate in self-care
activities & rehabilitation
b. Demonstrate proper use of crutches
c. Allow Mang Goryo to do return
demonstration of proper use of crutches
d. Emphasize safety measures in using the
assistive device
 Physiologic Adaptive Mode

Step 6. Evaluation
a. Mang Goryo was able to verbalize
understanding of the importance of
rehabilitation

b. Mang Goryo is able to properly

demonstrate crutch walking
 CONTROL EFFECTOR
INPUT OUTPUT
PROCESS

Physiological Adaptive
or
Coping Mechanism: Self-Concept
Stimuli ineffective
Adaptation Role Function responses
a. Regulator
level
b.Cognator Interdependence

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