| BACKGROUNDChina’s social-economic development and the health care system are facing great challenges owing to the rapidly aging populations and high incidence of chronic diseases in the elderly. More than 200 million elderly people lived in china in 2014, among whom the morbidity of chronic diseases was over 52.4%. There are some special characteristics for elderly patients, such as long duration of diseases, coexisting with many health problems, atypical symptoms, and difficult cure for many complications, unsuccessful drugs administration, concealed psychological problems, and long convalescence of diseases. Considering the large number and complicated conditions in elderly patients, how to identify the geriatric nursing priorities as well as establish a new transitional care model with high economic and social benefits to take fully care of them in physiological, psychological and social aspects as well as from admission to discharge, and constantly improve their outcomes and quality of life, are what the health care system should be taken into consideration.At present, the heath care system in many countries has been paying equal attention to economic and efficiency. When it comes to the evaluation of its effectiveness, the government and the people put more emphases on health service expenses and patient outcomes. Nurses play significant role in patients’ rehabilitation. However, nurses are usually busy with daily affairs whose professional values are not evident. Nursing behaviors and their influences for patient outcomes are often overlooked. In order to avoid such situation, nursing effectiveness and its contributions for patient outcomes call for supportive data. As the identifying and evaluating data for patients and health care system, the nursing sensitive indicators play a significant role in the contributions for multidisciplinary collaborations. Furthermore, the development of nursing informationization accelerates the application of standardized nursing terminologies in nursing database scientifically and normatively, which lays a solid foundation for the design and promotion of the nursing sensitive indicators. In recent years, six nations (USA, Canada, Australia, England, Norway, Denmark) have nationally standardized assessment and collection of nursing sensitive indicators. The university of Iowa college of Nursing developed a comprehensive classification of nursing-sensitive patient outcomes in 1990s, among which ranked highest in geriatric nursing were pressure ulcers, falls,pain management, sleep conditions, infection control and nutrition conditions. Nursing sensitive indicators in china started late and immaturely, the majority of which are nursing quality management indicators, the specialized researches of which are still on the early stage. Geriatric nursing sensitive indicators are mainly refer to quality evaluation for skilled nursing facilities or geriatric hospitals, most of which focused on structure and process study. There is a phenomenon that china is lack of the nursing sensitive indicators based on patient outcomes in geriatric nursing.Diabetes is currently one of the most important chronic threats to human health worldwide. According to the International Diabetes Federation (IDF) 2013 statistics, there are 98.4 million diabetes in China, the morbidity of which in elderly was 20.4%. It would go a long way toward helping patients and their families proper management of diabetes. Therefore, this study chose elderly diabetic patients as our target subject, to provide nursing data for the future research of other chronic disease.OBJECTIVESTo explore core nursing problems and nursing sensitive indicators in geriatric nursing. To design a geriatric nursing sensitive indicator system. To establish a transitional care model based on geriatric nursing sensitive indicator system. To explore the application of the model in elderly patients with diabetes and provide evidence for promoting the nursing outcomes.METHODS1. Using Delphi technique to design a geriatric nursing sensitive indicator system oriented by Nursing Outcomes Classification. To identify the core nursing problems and nursing sensitive indicators for geriatric nursing, a Delphi technique was used to recognize three rounds of 26 experts’consultations with Omaha System and Nursing Outcomes Classification as the theoretical basis as well as clinical researches and reference literatures as the empirical basis. Geriatric core nursing problems were screened by the critical value method. Indicators whose sensitivity above 90% were selected to geriatric nursing sensitive ones. Combined with experts’ consultations, the research results were confirmed after the research group’s discussion.2. Design and application of the transitional care model based on nursing sensitive indicators in elderly patients. Centering on the geriatric nursing sensitive indicator system and guided by some theories such as Empowerment, Holistic nursing care and Maslow’s hierarchy of needs theory, the geriatric transitional care model was designed framed with the Omaha System. A performing flow chart for the model was designed to standardize nursing actions. A record form for the model contained a comprehensive nursing procedure form hospitalization to discharge. With which patients would be served with comprehensive nursing assessment, sensitive nursing diagnosis, targeted nursing plan, effective nursing intervention, and dynamic nursing evaluation. Then the model was applied to the elderly patients with diabetes. A convenience sample was recruited from a Level Three general hospital at inpatient department of endocrinology in Guangzhou from December 2014 to February 2015. A total of forty-seven patients were recruited. Human subject ethic review was approved by the institutional review board of the hospitals and informed consent to participate was obtained before data collection. The study was implemented by gathering survey data. During hospitalization, nurses performed individualized interventions per 48h. After discharge, a telephone follow-up was made within 48h and once a week subsequently. At last, patients were asked to have a return visit to Diabetes Specialty Clinics within 1 month after discharge. We evaluated the improvement of knowledge, behavior and status by using Omaha System Problem Rating Scale for Outcomes, Diabetes Knowledge Test (DKT), Summary of Diabetes Self-Care Activities Measure (SDSCA) and Diabetes Specific Quality of Life Scale (DSQL) at the time of admission, the day before discharge and 1month after discharge.3. Analyses were performed using Excel2007 and SPSS 13.0. Quantitative variables were described using mean ± SD, and percentage for categorical variables. The experts’ positive coefficient was represented by the effective return rate and propose suggestion rate. Cr stood for the experts’ authority level and Kendall’s W stood for the experts’ coordination level. Core nursing problems was ranked with percentage weight method. The improvements of scores in nursing outcomes, diabetes knowledge, self-care behaviors and quality of life were analyzed with repeated measures ANOVA at the time of admission, the day before discharge and 1month after discharge.RESULTS1. Three rounds of Delphi study were conducted in 7 cities,3 universities and 16 3-A-grade hospitals by 26 experts nationally. The effective return rate for 3rounds consultation were 86.67%,100%,96.15%, the propose suggestion rate for which were 53.85%,26.92%,16%, Cr and Kendall’s W of which were separately 0.832, 0.864,0.865 and 0.197,0.571,0.583. It turned out that the results of this study were reliable.2. There were 11 core nursing problems of the elderly during hospitalization, involved into physical domain, health-related domain and social-psychological domain. They were sleep and rest patterns, bowel function, neuro-musculo-skeletal function, medication regimen, circulation, physical activity, digestion-hydration, personal care, pain, nutrition and spirituality. At the same time, after discharge there were 7 core nursing problems which were medication regimen, bowel function, sleep and rest patterns, neuro-musculo-skeletal function, physical activity, nutrition and personal care. Among them, sleep and rest patterns, bowel function, neuro-musculo-skeletal function and medication regimen were common core nursing problems which ranked 4rd during two phases.3. Classified by Omaha System,54 geriatric nursing sensitive indicators which were linked to the core nursing problems were involved into physical domain, health-related domain and social-psychological domain. There were 25 sensitive indicators in both physical domain and health-related domain, accounting for 46.3% of the total separately. The percentage of 4 sensitive indicators in social psychological domain was 7.4%.The approval rate of Vital signs, as one of the sensitive indicators to reflect patients’condition, was 100%. The approval rate of indicators referring safe such as fall prevention and drugs administration were over 96%. When it comes to keep homeostasis balanced and maintain function healthy such as electrolyte, nutrition, sleep, activity and self-care, the approval rate of indicators were above 92%.4. The 9 core nursing problems in elderly patients with diabetes were as follows: physical domain included neuro-musculo-skeletal function, circulation, bowel function and pain; health-related domain included nutrition, medication regimen, sleep and rest patterns and physical activity; social-psychological domain was spirituality. After nursing interventions, the results were as follows: ①Compared with admission, patients showed significant differences in the Knowledge, Behavior, and Status of the 9 core nursing problems at the day before discharge and 1 month after discharge (P<0.05). However there were no significant differences in the status of neuro-musculo-skeletal function, circulation, spirituality between the day before discharge and 1 month after discharge (P>0.05).②Patients showed significant differences in the promotion of the DKT in three stages (P<0.05).③Compared with admission, patients showed significant differences in total and each factor score of the SDSCA at the day before discharge and 1 month after discharge (P<0.05). However there was no significant difference in the promotion of medication dimension between the day before discharge and 1 month after discharge (P>0.05).④Compared with admission, patients showed significant differences in total and each factor score of the DSQL at the day before discharge and 1 month after discharge (P<0.05) However there was no significant difference in the promotion of physical dimension between the day before discharge and 1 month after discharge (P>0.05)CONCLUSIONS1. The sensitive indicator system based on Omaha System and Nursing Outcomes Classification for geriatric nursing can help nurses find out what is important for patients’safety and comfort rapidly, and clarify what they can do.2. The geriatric transitional care model based on nursing sensitive indicators could promote the core nursing outcomes of elderly patients with diabetes mellitus as well as increase specialized knowledge, establish self-care behaviors and improve quality of life. After discharge, the promotion of neuro-musculo-skeletal function, circulation and spirituality need longer, which should be nursing concerns during follow-up.3. Omaha System and Nursing Outcomes Classification not only are acceptable for nurses but also can be combined successfully in the application of the geriatric transitional care model in China. |
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