| Objectives:1. To establish diabetes transitional care model by using Omaha System as a framework, being conducted by the Holistic nursing care theory, Maslow?s hierarchy of basic needs theory, KAP model.2. To explore the effects on diabetes patients? self-care abilities and quality of life with the application of diabetes transitional care model which is established by using Omaha System as a framework. Methods and Results: 1. To establish the diabetes transitional care model by using Omaha System as a framework 1.1 MethodsThrough literature review, checking out literatures related to Omaha System and diabetes transitional care reasearches, establishing the diabetes transitional care model initially by using Omaha System as a framework and guided by Holistic nursing theory, Maslow?s hierarchy of basic needs theory, KAP model, combined with the characteristics of physiology and disease of diabetes patients. The model consists of diabetes transitional care table which contains nursing assessment program, intervention scheme and effectiveness evaluation, problem rating scale for outcomes and the diabetes transitional care scheme.The diabetes transitional care table which contains nursing assessment program, intervention scheme and effectiveness evaluation parts is constructed by using the time as the abscissa axis and 31 diabetes related nursing problems as the ordinate axis which belongs to the environmental, psychological, physiological and health-related behaviors domain. The first to fourth columns are assessment program which is constructed by using Omaha Problem Classification Scheme as a framework, It contains four domains which thirty-one nursing problems belongs to, thirty-one diabetes related nursing problems which belongs to the four domains, modifiers and signs/symptoms; the fifth to seventh columns are intervention system which is constructed by using Omaha Intervention Scheme as a framework,it contains categories of interventions,targets, and intervention scheme;the eighth to tenth columns are effectiveness evaluation of the intervention scheme at different time, which is using the Likert-type Rating Scale to evaluate the scores of patients with related nursing problems from knowledge, behavior and the status, each time should record the corresponding evaluation time, in order to analysis the effectiveness of the nursing problems.The scoring examples of effectiveness evaluation of transitional care model is constructed to illustrate the scoring methods of thirty-one diabetes related nursing problems from knowledge, behavior, and status.The diabetes transitional care scheme mainly incudes: ① nursing assessment, using the diabetes transitional care table which contains nursing assessment program, intervention scheme and effectiveness evaluation to assess nursing problems; ②nursing intervention scheme,selecting appropriate catogories of interventions,targets, and intervention scheme according to the results of nursing assessment; ③effectiveness evaluation, K-B-S scores of patients with related nursing problems at the time before intervention and the time after intervention. 1.2 ResultsThrough literature review and preliminary experiments, deleting and adding the nursing problems, adjusting the nursing measures and evaluation standards, establishing the diabetes transitonal care model by using Omaha System as a framework. This model designs comprehensive diabetes transitonal care assessment system, provides evidence-based intervention scheme, and uses Omaha Problem Rating Scale for Outcomes to explore the effectiveness of nursing intervention from the knowledge,behavior and status of patients dynamically,the application of this model simplifies the process of nursing procedures, specifies the diabetes transitonal care records of languages and the implementation processes, and quantifies the evaluation of transitional care outcome. 2. To evaluate the effectiveness of the diabetes transitional care model which is established by using Omaha System as a framework 2.1 MethodsUsing convenience sampling method, we recruit 90 diabetes patients according to the inclusion and exclusion criterias who are admitted to the endocrinology department of one Grade A hospital in Guang Zhou from July to November in 2014, they are randomly divided into experimental group(n=45) and control group(n=45) after signed the informed consent of the reasearch.The control group receives normal care and follow up visits by nurse in the endocrinology department. The nurse manages to assess patients? problems during the hospitalization and constructs the care plans according to the results of nursing assessment. Then,the nurse implentments the care plans and assess the problems of patients prior to discharge and give relevant discharge guidance and formulate the discharge plan. Discharge plan includes: plan for diet and physical exercise programs, blood glucose monitoring programs and so on. The nurse in charge of the patient should implement the follow-up visits by telephone or clinic at one week, one month and three months after discharge, which consists of the nursing assessment and the supervision of the implementation of discharge planning.The experimental group receives the transitional care which is framed by the Omaha System, The intervention is mainly divided into two stages: Hospitalization period: the day when patients are admitted in hospital to the day when patient discharges; Discharge period: the day when patient discharge from the hospital to three months after discharge. Using diabetes transitional care table which contains nursing assessment,intervention and evaluation parts to assess nursing problems in each stage, the evaluation time is the first day of admission, the day before discharge, one weeks, one month and three months after discharge. Evaluating the patients ’knowledge, behavior and status of nursing problems, then choosing the corresponding nursing measures to implement according to the assessment results. Through the evaluation results to explore the effectiveness of nursing intervention IX scheme dynamically and adjust nursing measures of the next stage. And the process of effectiveness of evaluation and nursing intervention are implemented circularly.Observing all patients? scores of the Summary of Diabetes Self-Care Activities Questionnaire(SDSCA) at the time before intervention,one week,one month and three months after discharge. Observing all patients? scores of the Diabetes Specific Quality of Life Scale(DAQL) at the time before intervention,one week,one month and three months after discharge. 2.2 ResultsWe actually recruit 100 diabetes patients in this research,5 cases in the control group quitted from the study because of replacing the phone number or changing hospitals, the dropout rate was 10%. 5 cases in the experimental group quitted from the study because of changing hospitals, there is no significant difference between the two groups? rate of default(P>0.05).No significant differences in baseline data between the two groups(P>0.05),the baseline data includes age, gender, marital status, education level, disease diagnosis time, life style, comorbidities, treatment methods.① Using diabetes transitional care table which contsists of nursing assessment program, intervention scheme and effectiveness of evaluation to assess nursing problems. Using Problem rating scale for outcomes to explore the effectiveness of nursing intervention scheme from the knowledge,behavior and status of patients, if any scores of K-B-S of nursing problem are less than four, we can conclude that the patient has this nursing problem. There are 317 nursing problems of patients in experimental group during the hospitalization, they are health-related behaviors nursing problems(42.6%), physiological nursing problems(42.6%), psychological nursing problems(12.0%), environmental nursing problems(2.8%).There are 359 nursing problems of patients in experimental group during the hospitalization, health-related behaviors nursing problems are the most(47.6%), they are the physiological nursing problems(33.1%), psychological nursing problems(11.4%), environmental nursing problems(7.8%).② There are 10 nursing problems which occurred more than thirty percents of total diabetes patients during hospitalization, nutrition(100%), physical activity X(93.3%), circulation(66.7%), skin(51.1%), vision(48.9%), oral health(40%), medication regimen(37.8%),role change(35.6%),mental health(33.3%), neuro-musculo-skeletal function(31.1%).There are 11 nursing problems which occurred more than 30% of diabetes patients during discharge period, nutrition(100%), physical activity(88.9%), health care supervision(77.8%), circulation(73.3%), medication regimen(68.9%), skin(51.1%),vision(48.9%), role change(44.4%), mental health(33.3%), sanitation(33.3%), oral health(31.1%).③ Analyzing the ten nursing problems which occurred more than thirty percents of total diabetes patients during hospitaliazation,we can see that there are significant differences in the knowledge of skin nursing problem(P<0.05), no significant differences in the behaviors and status of the skin nursing problem(P>0.05). There were significant differences in the knowledge and behaviors of the vision and oral health nursing problems(P<0.05),the status scores of them has no significant differences(P>0.05). There were no significant differences in the other nursing problems? K-B-S scores(P<0.05).④ Analyzing the eleven nursing problems which occurred more than thirty percents of diabetes patients during discharge period, we can see that there are significant differences in all nursing problem?s K-B-S scores except the status of vision(P<0.05).there were no significant difference between the behaviors of skin nursing problems at the time of one month after discharge and at the time of one week after discharge(P>0.05).there were no significant difference between the status of oral health problems at the time of one month after discharge compared with the one at the time of one week after discharge.⑤ There were significant differences between the two groups in total scores of SDSCA without consideration of time,The score of experimental group is higher than the control group(F=29.213,P=0.000).There were significant differences between the two groups in the total scores of SDSCA at different time(F=359.678,P=0.000),There were no significant differences between the two groups in the total scores of SDSCA before the intervention(P>0.05),At the time of one week,one month and three months after discharge, there were significant difference in the total scores XI between the two groups(P<0.05).The scores of each dimensions of SDSCA at different time were all significant higher than admission(P<0.05),There were no significant differences between the two groups in the scores of each dimensions of SDSCA before the intervention(P>0.05),At one week,one month and three months after discharge, there were significant difference between the two groups in the scores of diet, exercises, blood glucose monitoring(P<0.05),no significant differences between the two groups in the scores of foot care abilities at one week after discharge(P>0.05).⑥ There were significant differences between the two groups in the scores of DSQL without consideration of time(F=4.187,P=0.044),the scores of experimental group is lower than control group. There were significant differences between the two groups in the scores of DSQL at different time(F=104.344,P=0.000),there was interaction between the intervention scheme and time in the scores of DSQL,the change tendency of scores were different between the two groups(F=11.276,P=0.000). According to the principle of DSQL,the lower the scores is,the better the quality of life of the patients is,the refelects that the quality of life after intervention in experimental group is better than control group. There were no significant difference between the two groups in the scores of DSQL at the day of admission and the day of discharge(P>0.05),At one month and three months after discharge, there were significant difference between the two groups in the scores of DSQL(P<0.05). 3. Conclusions 1.The research confirms that the diabetes transitional care model which is established by using Omaha System as a framework can comprehensively assess nursing problems related to diabetes from environmental, psychological, physiological, health-related behavior domains, the transitional care model of diabetes framed by Omaha System can improve the outcome of patients(Knowledge,Behavior, Status) through the implenmentation of specific nursing intervention finally. 2.The research confirms that the diabetes transitional care model which is established by using Omaha System as a framework can improve patients? diet, exercises, blood glucose monitoring, foot care abilities and self-care abilities. 3.The research confirms that the diabetes transitional care model which is established by using Omaha System as a framework can improve patients? quality of life. |
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