Nurses prove key to improving quality in healthcare through the identification of quality improvement areas and creative solutions. For several decades, nurses have been involved in discovering hidden insights, learning new techniques for patient care, and promoting medication management to address the aspect of quality care. However, recent approaches have focused on the use of evidence-based practices to inform clinical decision-making (Penney et al., 2018). One of the areas that prove to be challenging in today’s complex healthcare system is reducing hospital readmissions. Unplanned readmissions are a top challenge that can be prevented through the use of evidence-based strategies while utilizing concepts from nursing theory.
Nursing Practice Outcome
Early hospital readmissions have long been used as a measure of quality in healthcare. Hospital readmissions represent any admissions that occur within a specific time frame after discharge of the patient. Although the causes of readmissions can result from factors outside hospitalization, most readmissions are related to inappropriate patient preparation and planning of discharge (Rasmussen et al., 2021). For instance, about 20% of Medicare patients leave the hospital only to be readmitted after 30 days with an estimated cost of $20 billion for medicare patients alone (Seegert, 2021). These readmissions have a huge financial impact on healthcare organizations and eventually reduce the quality of life of patients. Hospitals with many readmissions face penalties from Medicare with recent adjustments increasing the financial penalties to 3% depending on the type of healthcare facility (Upadhyay et al., 2019). Nurses can play a crucial role in addressing this problem to improve the quality of care and other aspects like patient satisfaction.
The degree to which hospital readmissions can be prevented is still debatable because of the various factors involved. However, there is growing consensus regarding the need for improving care transition from the hospital to home to address this challenge (Pugh et al., 2021). Nurses can play a huge role in improving the transition of care by changing several aspects of discharge. Evidence suggests that discharge planning and coordinating communication among providers, patients, and caregivers can aid in addressing the challenge of readmissions (Seegert, 2021). The discharge process can sometimes be complex due to the number of patients handled and health literacy levels among patients. Emphasis on comprehensive patient assessment, health education, and provision of necessary resources has seen hospitals reduce readmissions significantly (Rasmussen et al., 2021). During the care transition process, nurses should educate patients about medications, when to seek healthcare and other necessary components like hygiene. Additionally, improving care transition will require nurses to spend more time with patients and families to assess readiness for discharge and any assistance that may be required after discharge.
One of the ways to ensure caring is central to patients is to endorse Watson’s caring theory in contemporary nursing practice. Nurses should understand that nursing is defined by caring and that caring helps providers to embrace positive energy that flows from the body, mind, and spirit. Jean Watson developed the caring theory to guide nursing practice, management, education, and research. Watson’s belief that ideal caring can affect human development is the key factor behind the development of the theory. The theory explains that humans cannot be treated as objects and that humans cannot be separated from self, other, nature, and the larger workforce (Pajnkihar et al., 2017). Practicing caring is more than the performance of the organization because it can translate to improved quality of care and patient satisfaction.
The practice of caring in nursing is not just a task, but a combination of different aspects defined through the Caritas processes. The Caritas processes are tangible manifestations of caring that occur within the interaction between the patient and the nurse (Pajnkihar et al., 2017). The structure for the science of caring is built upon ten carative factors that can be integrated to improve patient experiences. One of the carative factors that correlate with addressing the challenge of increased readmissions in the facility is the use of scientific problem-solving methods for caring decision-making. Nurses are required to demonstrate systematic use of a creative problem-solving caring process to address challenges during care delivery (Gonzalo, 2021). Improving care transition is an evidence-based intervention that is based on nursing science and research to address the challenge of hospital readmissions.
Explanation and Measuring of Concepts
The healthcare challenge identified is hospital readmissions that can be solved using an improved nursing care transition approach. Unplanned readmission is observed to originate from insufficient discharge planning and unintended events during discharge. For instance, inadequate communication between healthcare providers and patients/families can contribute to poor outcomes upon discharge (Upadhyay et al., 2019). Well-planned care transition should include aspects like patient education, assessment of the patient’s medication, and linkage of the patient to their primary care provider. Nurses can improve in these aspects by having a well-planned discharge that addresses all the crucial aspects of care at home.
The second concept comes from Watson’s caring theory and involves the use of science to solve problems concerning patient care. Scientific methods are based on research and experimentation to provide healthcare providers with sufficient evidence on why certain practices should be utilized. Watson’s theory emphasizes providing care beyond the bedside and this encompasses practices after discharge. The nurse is obliged to ensure creative use of self and all ways of knowing as part of the caring process (Gonzalo, 2021). The nurse should be aware that lack of adequate patent preparation during discharge can lead to rehospitalization alongside other consequences like increased financial costs to the organization.
The use of evidence-based practices to inform nursing decisions is the recommended practice today because it improves quality patient outcomes. Improving care transition to address the challenge of readmission is an evidence-based approach supported by research. The intervention is scientific because it has been studied by numerous researchers and proved effective in improving patient outcomes. For instance, implementing a patient communication framework is among the care transition approaches to ensure patients stay in touch with their primary care providers upon leaving the facility. The nurses and other providers can also improve care transition by providing clearly defined recommendations and backup plans upon discharge. These interventions relate to Watson’s theory because they incorporate science in caring decision-making. The theory requires nurses to deepen their understanding of scientific approaches to solving healthcare problems (Pajnkihar et al., 2017). The connection between these concepts indicates that Watson’s theory can be used to address the issue of patient readmission by extending care to patients after discharge.
Measurement is the process used to describe and ascribe meaning to key facts, concepts, or other phenomenal requiring investigation. The concepts described above can be measured using various mechanisms that rough direct or indirect observation. The intervention of improved care transition can be measured through a reduced number of hospital readmissions in the organization. It is anticipated that improving care transition processes like communication will lead to more patients understanding their care upon leaving the facility. Proper communication will ensure that patients stay in touch with their primary care providers and seek help immediately when required (Penney et al., 2018). The result is improved outcomes upon discharge translating to reduced hospital readmissions. To effectively measure this concept, the baseline hospital readmission rates will be compared to the readmissions after implementation of the new changes. Reduced readmission rates will indicate that improving care transition is an important step for nurses towards addressing care delivery issues in the facility.
The concept of scientific problem-solving methods for caring decision-making highlights how the utilization of nursing science can improve patient care approaches. Although this concept cannot be measured using observation, the confluence of things that are made up from the concept can be measured. For instance, demonstrating caring using this approach can translate to improved patient satisfaction with the quality of care administered in the facility. Demonstrating caring will eventually address the aspect of quality that is key in attracting new patients to the organization. Applying this concept will demonstrate increased knowledge on solving complex healthcare problems and this will put nurses in a better position to influence quality outcomes (Pugh et al., 2021). Long-term measurement of the two concepts can be done using patient satisfaction scores and improved reimbursements from the CMS following reduced readmission rates.
Nursing theories provide a framework for nursing interventions and can be used to measure practice outcomes. Jean Watson’s theory of human caring is one of the theories that help nurses to demonstrate emotional sensitivity and caring attitudes in contemporary nursing practice. Caring is what makes nursing different from other professions and it is a form of affirming our humanity. This discussion demonstrates how addressing hospital readmissions can be done using Watson’s carative factors. The concept of scientific problem-solving methods for caring decision-making can be incorporated to solve hospital readmission through evidence-based practice use. The process selected to improve readmissions involves the coordination of care transitions during discharge through interventions focusing on communication and patient education. This evidence-based intervention incorporates Watson’s theory and significantly reduces hospital readmissions.
Gonzalo, A. (2021). Jean Watson: Theory of human caring. https://nurseslabs.com/jean-watsons-philosophy-theory-transpersonal-caring/
Pajnkihar, M., Štiglic, G., & Vrbnjak, D. (2017). The concept of Watson’s carative factors in nursing and their (dis)harmony with patient satisfaction. PeerJ, 5, e2940. https://doi.org/10.7717/peerj.2940
Penney, L. S., Nahid, M., Leykum, L. K., Lanham, H. J., Noël, P. H., Finley, E. P., & Pugh, J. (2018). Interventions to reduce readmissions: can complex adaptive system theory explain the heterogeneity in effectiveness? A systematic review. BMC Health Services Research, 18(1), 894. https://doi.org/10.1186/s12913-018-3712-7
Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., … & Leykum, L. (2021). Evidence based processes to prevent readmissions: More is better, a ten-site observational study. BMC Health Services Research, 21(1), 1-11. https://doi.org/10.1186/s12913-021-06193-x
Rasmussen, L. F., Grode, L. B., Lange, J., Barat, I., & Gregersen, M. (2021). Impact of transitional care interventions on hospital readmissions in older medical patients: A systematic review. BMJ Open, 11(1), e040057. https://bmjopen.bmj.com/content/11/1/e040057
Seegert, L. (2021). Improving discharge procedures to reduce hospital readmissions. American journal of Nursing, 121, 12. https://doi.org/10.1097/01.NAJ.0000803148.45426.39
Upadhyay, S., Stephenson, A. L., & Smith, D. G. (2019). Readmission rates and their impact on hospital financial performance: A study of Washington hospitals. Inquiry : A Journal Of Medical Care Organization, Provision and Financing, 56, 46958019860386. https://doi.org/10.1177/0046958019860386
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