Orems Theory Integration into the Study

In nursing, an extensive and wide body of knowledge exists and extends from grand to mid-range theories. Consequently, research in nursing is based on theories that guide or drive the practice. Grand theories in nursing are broad in nature and do not necessarily present some variables subject to empirical testing. However, nursing research and practice should be based on those theories that provide strong basis for elements of any study. This study has based its process on Orems theory of Self Care. The central concept of Orems theory attempts to address the deficits in self-care practice as well as the role of nurse professionals in helping their clients (patients) to take care of themselves during and after recovery. In developing the concept, this theory considers a number of factors, both external and internal. For instance, it considers the environment of the patients home, communal resources and social support systems that provide support to the patients and affects their ability to take care of themselves. The theory places a great emphasis on self-care paradigm, which incorporates aspects of self-care and its relationship with the self-care agency. Noteworthy, the self-care paradigm involves caring for oneself with an aim of promoting individual wellbeing and health. An individuals ability to perform self-care behaviours needed for health maintenance is the optimal aspect of self-care, which involves both the self-care agency and the self-care behaviours. According to Kearny-Nunnery, 2008), this concept of self-care is subjected to the influence of a number of factors. For instance, patient factors such as age and gender, family and family system factors, the environment, cultural influence, health care system and the current state of health are likely to have a significant effect on the individuals ability to . According to Sodserhamn (2000), a phenomenon known as self-care deficit is a major problem affecting self-care paradigm in practice. By definition, self-care deficit is a situation that results when an individuals abilities to meet self-care agency needs are fewer than the demands for self-care. According to Soderhamn (2000), as a need for personal interaction with the current environment and health situation. It encourages the individual patients to prevail over an array of obstacles and allow them to engage actively in self-care, which is likely to help an individual develop self-care practice. As such, Solderhamn (2000) asserts that self-care agency is spontaneously learnt.

Orems theory emphasizes on the importance of understanding patients needs. Accordingly, it takes these needs as the starting point in the patients conditions. Noteworthy, care needs for an individual is parallel to the concept of asking the individual perceptions of goals and barriers for discharge. This should be done as early as possible within the period a patient is staying at the healthcare facility. The self-care theory is importance in encouraging the patients to be part of their care by engaging them in the discharge process as well as encouraging them to partner with healthcare professional team. In this way, it ensures that the patients are part of the team that makes crucial decisions relating to the process of care as well as planning on how to tackle barriers in the discharge process. In addition, it allows the interdisciplinary team to ensure that they assist the patients in making decisions to determine an individuals discharge plan. It also provides space for inclusion of family and community support systems, awareness to overcome barriers and allow for identification of cultural, social and ethnic values, beliefs and practices that may have an impact on the process of developing self-care behaviours after discharge.

According to Moore and Pichler (2000), Orems theory has become an important pillar in developing appropriate and effective practices in a number of healthcare areas. For instance, it has been used extensively in symptom management, acute care, chronic illness, health maintenance and other fields.

Conceptual Framework
According to Mitchell, Ferketich and Jennings (1998), there has been a shift in the emphasis on evaluation and management of healthcare from structure to processes and outcomes. Therefore, within this conceptual framework, three elements are emphasized- structures, processes and outcomes. Each of the three elements has its meaning, roles and functions within any healthcare setting. In simple terms, the term structures are used in reference to the practice of having the right things. The term processes is used to refer to the practice of doing the right things while the term outcomes stands for the process of getting the right things to happen. The model developed by Donabedian is the best example of a conceptual framework that adopts an intensive use of the three elements (Donabedian, 2005). According to Donabedian (2005), the model conceptualizes these three elements. This aspect has shaped the study of quality attributes of every healthcare setting. To expand the model on system and patient factors, researchers carried out a number of studies.

In particular, the work of Mitchell, Ferketich and Jennings (1998) and McBryde-Foster & Allen (2005) used the Donabedian Model to expand its focus on systems and patient factors. In this case, the researchers emphasized on care as a collective entity in which the patient passes through transitional points over time and between environments of care (Mitchell, Ferketich &Jennings, 1998; McBryde-Foster & Allen, 2005). The work of other researchers such as Holland and Harris (2007) has expanded the McBryde and Allen Model to include an emphasis on organization of concepts of discharge planning, continuity and transitional of care into a conceptual framework characterized with temporal dynamism at all levels. According to these authors, a number of sub-elements are as important as the main elements of the concept. For instance, discharge planning process, transitional and coordination of care, continuity of care process and the achievement of the desired outcomes are critical sub-elements of the entire process.

Discharge planning process
This interdisciplinary process takes place in a healthcare setting with an aim of providing a desired method of assessment, planning and intervention management for the needs of continuity. According to Bull, Hansen and Gross (2000), assessment and planning for continuity needs require an intensive follow-up process after hospitalization through arranging for community or health professional or both.

Coordination of care
According to Hagerty, Reid and McKendry (2002), coordination of care focuses on the process of integrating and sequencing all the activities involved in patient care. It places a lot of emphasis on linking the activities of planning and management across different care providers working within the same healthcare setting.

Transitional care process
This stands for the transmission of an array of information and services across the community and healthcare locations as well as providers (Haggerty, Reid, Freeman, Starfield, et al., 2003). It is designed to support and promote a safe process of timely transferring patients between levels of care (Coleman & Bout, 2003).

Continuity of care
This term refers to the mechanisms that hospital systems or agencies use to decrease asymmetry of information and increase goal alignment between the care providers and their patients. According to Holland and Harris (2007), continuity of care is of three kinds- informational, managerial and regional. Informational continuity care occurs when there is an availability of information about the patients past, which can be used to provide current care for the patient (Van Servellen, Fongwa & Mockus DErrico, 2006). A technological tool known as EHR was developed to create a chronological library to store and manage information related to healthcare of a patient over a given time. It also provides information needed to bridge the gaps between different healthcare providers.

Relational continuity is the relationship between the patient and care team within the context of therapeutic interventions. There is a mutual trust between the two parties (Haggerty et al., 2003). On the other hand, managerial continuity of care refers to the use of guidelines and protocols to provide assurance in treatment provided by the providers in a system that has a well-connected, complimentary, timely and orderly manner of doing things.

This study used the Holland and Harris Model to focus on hospital setting. In particular, the data used was obtained from nursing records taken during the patients process and history of admission in HER nursing used to support discharge planning in NCM referral. The study was interested in the first 24 to 72 hours from the initial admission of the patient in the facility.

Analysis of Donabedian model
The Donabedian Model is conceptual in nature and seeks to provide a good framework through which healthcare settings can examine their services and evaluate quality of care. The model requires information about quality of care to come from three areas- structure, process and outcomes. Accordingly, each category has its meaning within the framework.

First, structures refer to the context in which the healthcare is provided, including the staff, equipment, buildings and financial sources. Secondly, processes are the relationships between providers and clients. The outcomes refer to the impact of healthcare delivery on patients and the general population.

A number of other frameworks are in existence. For instance, Bamako Initiative and the WHO-Recommended Quality of Care Framework are effective. However, the Donabedian Model is the dominant method for assessing healthcare quality.

A chain of three boxes is used to represent the model in theory. Each box represents each of the three elements of healthcare- structure, process and outcomes. Unidirectional arrows connecting the boxes are used to describe how the assessment process moves within the system. In addition, the boxes represent the type of information collectable from each of the three areas of quality healthcare system.

Structures
The structure box shows the factors that have an influence on the context of healthcare delivery. These factors control the process and manner of providing healthcare, including the actions and behaviours of the personnel involved. They are the measures of the average quality of care given in the healthcare system of a given facility.