Effects of a self-care deficit nursing theory-designed nursing system on sympton control in children with asthma

Asthma is the most frequent reason for preventable hospital admissions among children regardless of race or socio-economic status. Since asthma hospitalizations are preventable, an implicit assumption is that parents are not optimally managing the illness condition. Using Orem's Self-Care Deficit Nursing Theory, 14 antecedent conditions necessary for competent action by dependent-care agents (usually parents) were uncovered in the pediatric asthma literature. All but two of the 14 antecedent conditions are influenced by factors partly or completely controlled by the health care system. Given this new understanding, a unique partnership between a health care system and a Medicaid managed care health plan was forged to remove health care system barriers that interfere with dependent-care agent competency for the management of asthma. A nursing system was designed and implemented to improve health care system factors associated with optimal symptom control: accurate diagnosis, appropriate treatment, continuity, access, and parent/child teaching. The multi-faceted nursing system was implemented across three professional groups (physicians, nurses, and respiratory therapists) within one ER, three hospital units, and six outpatient clinic sites. One component of the nursing system involved formal annual training of participants on appropriate diagnosis and optimal treatment. Other nursing system components focused attention on children who had failed outpatient management. Specifically, between October l, 1998, and March 31, 2001, 753 children were brought to one emergency room or three hospital units for treatment of an asthma exacerbation. The nursing system was successfully implemented on behalf of 75% of these children. Using Medicaid managed care enrollment files and claims data for asthma care, the effects of the nursing system on symptom control were compared before: and after the nursing system intervention, and between two groups of health care providers who had either been maximally or minimally impacted by the nursing system. Rates for asthma claims used to proxy symptom control included ER, hospital, and clinic visits for asthma. Children who had providers in the maximally involved group were one-half as likely to be hospitalized for an asthma exacerbation as children with providers in the minimally involved group. The results of this study confirm that when nursing theory guides practice, patient outcomes improve