The objective of this study is to determine the effect of pre-discharge and post-discharge intervention, on readmission rates for COPD patients using Dorothea Orem’s Self Care Deficit theory (Fawcett, 2001). Dorthea Orem’s Self-Care Deficit Model describes nursing care and explains why and where nurses are needed to help the patient cope and recover from illness (Fawcett, 2001). The PICOT question is, “In adult patients diagnosed with COPD and having chronic dyspnea, how effective would pre-discharge education, post discharge telephone follow- up, and weekly nurse home care nurse visits be in reducing readmissions for chronic dyspnea, as compared to brief discharge instructions (current standard care) over a 30 day period?” The relevant time period is 30 days post discharge.
Individuals living with Chronic Obstructive Pulmonary Disease (COPD) have a diminished quality of life, suffer from psychological stress, constant breathlessness, and may experience extended periods of isolation (Halding, & Heggdal, 2012). Further, patients with COPD also experience diminished body control and a decrease in daily self-care activities (Brandt, 2013). The theoretical framework applicable in the prevention of hospital readmission for COPD patients is the Self-Care Deficit Nursing Theory (Comley, 1994).
According to Orem, the Self-Care Deficit Nursing Theory offers philosophical principles instrumental in the facilitation of quality healthcare (Comley, 1994). Barbara Banfield defines Orem’s theory as moderate realism (Fawcett, 2001 pg. 37). As COPD worsens over time, patients suffering from this disease typically become frequent visitors at emergency rooms (Brandt, 2013). Recognizing an exacerbation of COPD is challenging for patients because they must learn to differentiate between daily COPD symptoms and mild changes leading to an exacerbation (Brandt, 2013).
Problem Introduction and Implementation
Minimizing readmission rates for COPD patients is the goal of this research project. Chronic obstructive pulmonary disease (COPD) will be the third leading cause of death in 2020, and is considered a major contributor to disability (Halding, Heggdal, & Wahl, 2011). Reducing healthcare costs and simultaneously enhancing patient care, requires initiatives to diminish hospital readmission rates. According to research studies approximately 15-25 percent of patients discharged will be readmitted within 30 days (Center for Healthcare Quality & Payment Reform, 2013).
Current readmission reduction programs often have one of three identified deficiencies. Readmission programs must be more data driven to measure intervention effectiveness (Center for Healthcare Quality & Payment Reform, 2013). Also, interventions are often hospital-based or transitional, creating huge gaps in the delivery care process. This is especially true when dealing with patients who have chronic diseases, such as COPD. Finally, readmission programs require payment reform to ensure clinicians, hospitals, and other medical providers have flexibility, and appropriately modify care to prevent readmission (Center for Healthcare Quality & Payment Reform, 2013).
Therefore, Dorthea Orem’s Self-Care Deficit Model and the proposed PICOT question will guide the research and implementation processes. The PICOT question is, “In adult patients diagnosed with COPD and having chronic dyspnea, how effective would pre-discharge education, post discharge telephone follow- up, and weekly nurse home care visits be, in reducing readmissions for chronic dyspnea as compared to brief discharge instructions (current standard care) over a 30 day period?”
Purpose of proposed change in practice
The purpose of the research is to evaluate current treatments and interventions, to prevent Chronic Obstructive Pulmonary Disease (COPD) readmissions and more effectively manage patient discharges. Proposed change is based on compelling empirical data regarding excessive readmission. The HRPP is part of the Centers for Medicare and Medicaid efforts to reduce excessive readmission, by managing patient outcomes (The National Association for Medical Direction of Respiratory Care, 2010).
Currently hospital readmission rates for all causes of COPD are presently within the range of 17-25 percent. The readmissions occurred within 30 days of the original hospital visit (The National Association for Medical Direction of Respiratory Care, 2010). Although there are a number of care models, clinical practice guidelines and formal standards of care are at the infancy stage. Therefore, hospital systems and physicians are reliant on existent NQF COPD related standards (The National Association for Medical Direction of Respiratory Care, 2010).
The four existent standards are NQF 0091 (COPD Spirometry Evaluation), NQF 0102 (COPD Bronchodilator Therapy Preventative Care), NQF 0041 (Preventative Care and Screening Influenza Immunization), and NQF 0043 (Preventative Care and Screening Pneumococcal Vaccination for Patients 65 and older (The National Association for Medical Direction of Respiratory Care, 2010).
CMS has validated the fact that physicians and hospitals have minimal leadership to mitigate all cause readmission post hospital visits for COPD exacerbation. This is due to the absence of clinical practice guidelines or standards (The National Association for Medical Direction of Respiratory Care, 2010). Also there is scarcity of peer reviewed data addressing levels of effectiveness in hospital readmissions. Finally, since 17-25% of COPD patients end up being readmitted within 30 days, the remaining 75-83 percent are left to manage symptoms with minimal healthcare engagement (The National Association for Medical Direction of Respiratory Care, 2010).
The Self-Care concept by Dorothea Orem includes a determination of what needs to be done to regulate the basic functions of an individual. The Self-Care concept encourages the person to self-evaluate and analyze the effectiveness of care and their own functioning, development, and well-being (The National Association for Medical Direction of Respiratory Care, 2010). The PICOT question provides a formula for research, to obtain evidence about effective intervention practices, in the reduction of COPD readmission.
Chronic disease self-management includes the ability to identify daily steps necessary for controlling or reducing chronic medical symptoms (Brandt, 2013). The effective self-management of Chronic Obstructive Pulmonary Disease (COPD) requires knowledge of the condition and the appropriate steps necessary for treatment. Appropriate steps include use of antibiotics and steroids when appropriate, using daily prescribed medications as ordered, and identifying symptoms that may lead to an exacerbation. It is important that patients are able to follow-up with medical care when symptoms worsen (Brandt, 2013).
According to Brant (2013), educating patients on self-management may reduce hospital admission rates. It is important to recognize that pulmonary rehabilitation (PR) programs play an important role in educating patients with COPD on self-management and its disease process. Pulmonary rehabilitation programs use guidelines which emphasize educating patients on COPD self-management including identifying symptoms and treatment of exacerbation as early as possible (Brandt, 2013).
Pulmonary rehabilitation focuses on reducing symptoms and slowing down the disease progress to improve the patients’ quality of life. Further, pulmonary rehabilitation seeks to increase functional abilities, which may also increase participation in social activities (Halding, & Heggdal, 2012).
Dorothea Orem's Theoretical Framework
The theoretical framework by Dorothea Orem will be used and applied with the evidence that is available to prevent COPD readmission. To simply Orem’s concepts and her care model (Appendix A), is a table and an illustration that will be used. Self-Care is defined as the purposeful actions that a person does to maintain his or her health (Halding, & Heggdal, 2012). Appendix A reveals the phases of Orem’s model and the implementation of associated nursing practices (Bieda, Centopanti, & Callaghan, 2012).
Orem’s model for implementation is broken down into four phases. These four phases are needed to treat patients and help them achieve an improved Self-Care state. The four phases illustrated in Appendix A, are essential to pre and post-discharge strategies for reducing COPD readmission rates. They include assessment, planning, implementation, and evaluation (Bieda, Centopanti, & Callaghan, 2012).
In order to continue discussing Orem’s theory and propose a change, some key concepts need to be understood. Orem’s Self-Care deficit Theory is constructed based on three concepts. Those concepts include the Theory of Nursing Systems, Theory of Self-Care, and Theory of Self-Care Deficit (Comley, 1994).
The metaparadigm concepts of Orem
The theoretical concepts of Orem will be the primary source of the theoretical framework. Appendix 2 is a chart analyzing and describing Orem’s theoretical concepts. The concepts outlined in Appendix 2, are critical in the effective implementation of intervention strategies. They include an analysis of the factors affecting COPD readmissions, which are person, health, environment, and nursing (Comley, 1994).
Implementation of Theoretical Framework
As described in Appendix A and B, there are four phases to Orem’s model and nursing process. Those areas are assessment, planning, implementation, and evaluation. Within the pre-discharge and post-discharge process, all four assessment phases will be implemented.
Orem defines assessment as the ability to determine the individual qualities a person possesses, enabling them to collaboratively achieve therapeutic self-care. The individual qualities that Orem references, are known as power components (The University of Tennessee at Chattanooga School of Nursing Faculty & Students, 2014). Power components are understood as the capacity of an individual to meet self-care rudiments. Within the healthcare setting, nurses will apply this understanding by assessing COPD patients’ power components, during hospitalization. Ideally a medical assessment should occur when a nurse is conducting a health history and physical evaluation (The University of Tennessee at Chattanooga School of Nursing Faculty & Students, 2014).
The assessment phase will be applied by collecting data from the patient during the hospital visit. Surveys, face-to-face-interviews, and descriptive narratives will effectively measure a patient’s capacity to meet self-care rudiments. Appendix 3 provides the power components that can be useful in assessing COPD patients. There are nine recommended power components, including management of physical activities, reasoning capacity, and decision-making capabilities (The University of Tennessee at Chattanooga School of Nursing Faculty & Students, 2014).
Orem defines planning as the process for determining who can or should perform the self-care operations of a patient. As such, there are three levels of support within the nursing system. This includes wholly compensatory, partly compensatory, and supportive-educative (The University of Tennessee at Chattanooga School of Nursing Faculty & Students, 2014). By conducting the assessment phase the nurse will have sufficient information to determine whether the patient needs wholly compensatory, partly compensatory, or supportive-educative services. If the displays a complete inability to engage in self-care activities then wholly compensatory services are required (The University of Tennessee at Chattanooga School of Nursing Faculty & Students, 2014).
If the patient is able to perform certain self-care activities then the nurse may recommend partly compensatory services. Finally, if the patient indicates sufficient self-care requisites, then the nursing system will utilize supportive-educative (The University of Tennessee at Chattanooga School of Nursing Faculty & Students, 2014). Implicit within Orem’s theory is the fact that supportive-educative services should be the goal of healthcare organizations. In further analysis of the PICOT question, effective pre-discharge education should eventually transition COPD patients towards greater self-care requisites.
The implementation of the planning phase will include targeted and specific educational resources. For example, the nursing staff will teach the patient how to know, understand, and manage health deviation. For example it would be important for a patient to understand the role of COPD management strategies. COPD management includes avoiding tobacco smoke, eliminating air pollutants from work or home environments (Center for Disease Control and Prevention, 2015). Also the incorporation of breathing strategies, energy conservation techniques, and nutritional advice, are useful in mitigating COPD risks. If a patient has low blood oxygen levels then they need to monitor when supplemental oxygen is required (Center for Disease Control and Prevention, 2015). These are specific strategies that will be implemented in the planning and education of COPD patients prior to discharge.
According to Orem the implementation phase is defined as putting the proposed plan into effect (Bieda, Centopanti, & Callaghan, 2012). Appendix 1 lists 6 possible examples of how implementation could occur within the healthcare setting. In the study the goal will be to provide educational counseling that will help the patient to use appropriate behavior once they are discharged from the hospital. According to the first Appendix, one example of implementation would be actions done on behalf of a patient. This approach would be ideal for patients who require wholly compensatory services (Bieda, Centopanti, & Callaghan, 2012).
Finally, there is an evaluation process that should be done for the COPD patient. Even those patients readmitted within 30 days, should be evaluated throughout their care continuum. One approach can be based on Orem’s concept of Self-Care and Self-Care Deficit by evaluating each COPD patient on whether they are Wholly Compensatory, Partially Compensatory, or Supportive Educative (Bieda, Centopanti, & Callaghan, 2012). Hospitals, clinics and other healthcare organizations may consistently move patients from one phase to the next over the course of their healthcare experience.
Theories are conveyed in order to identify predictive patterns, or challenge traditional assumptions relative to a current phenomenon. The theoretical framework should introduce and describe a relevant theory, leading to further research (University of Southern California, 2015). Since 75-83 percent of COPD patients’ are left to manage symptoms with minimal healthcare engagement, better educative support is required (The National Association for Medical Direction of Respiratory Care, 2010).
This theoretical framework report has sought to provide a description of Dorthea Orem’s Self-Care Deficit Model. Further it has sought to explain how subsequent research and plan implementation will support the PICOT question. By incorporating the Self-Care Deficit Model it is the intention of this report to provide strategies for reducing COPD readmission rates.
Bieda, S., Centopanti, J., & Callaghan, N. (2012). Nursing Grand Theory. Retrieved from http://grandtheoryroyandorem.weebly.com/theory-analysis-orem.html
Brandt, C. L. (2013). Study of older adults' use of self-regulation for COPD self-management informs an evidence-based patient teaching plan. Rehabilitation Nursing: The Official Journal of The Association Of Rehabilitation Nurses, 38(1), 11-23. doi:10.1002/rnj.56
Center for Disease Control and Prevention. (2015, January 26). What is COPD. Retrieved from http://www.cdc.gov/copd/
Center for Healthcare Quality & Payment Reform. (2013). Reducing Hospital Readmissions. Retrieved from http://www.chqpr.org/readmissions.html
Comley, A. L. (1994). Journal of Advanced Nursing. A comparative analysis of Orem’s self-care, 20(1), 755-760.
Fawcett, J. (2001, January). The Nurse Theorists: 21st-Century Updates-Dorothea E. Orem. «Nursing Science Quarterly, 14»(1), 34-38. doi:10.1177/08943180122108021
Halding, A., & Heggdal, K. (2012). Patients' experiences of health transitions in pulmonary rehabilitation. Nursing Inquiry, 19(4), 345-356. doi:10.1111/j.1440-1800.2011.00573.x
The National Association for Medical Direction of Respiratory Care (2010). Hospital Readmissions – Managing COPD Patients Post Discharge. Retrieved from http://www.namdrc.org/pubs/HospitalReadmissions.pdf
The University of Tennessee at Chattanooga School of Nursing Faculty & Students. (2014, Fall). Theory based nursing practice. Retrieved from http://www.utc.edu/nursing/pdfs/classes/orem-handbook.pdf
University of Southern California. (2015, February 6). Organizing your Social Sciences Research Paper. Retrieved from http://libguides.usc.edu/content.php?pid=83009&sid=618409
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