Development of nursing care model for chronic obstructive pulmonary disease patients with telenursing in Thungsaliam Hospital, Sukhothai Province.

Abstract

     This study was action research aimed to develop an integrated nursing model combined with telenursing for chronic obstructive pulmonary disease (COPD) patients at Thung Saliam Hospital, Sukhothai Province, conducted from January 2025 to September 2025. The study participants comprised 18 interprofessional healthcare team members and 116 COPD patients divided into two groups of 58 patients each. Research instruments included focus group discussion guidelines, general information questionnaires, COPD knowledge assessment forms, self-care behavior assessment forms, quality of life assessment forms, satisfaction assessment forms, and clinical outcome data collection forms. Data were analyzed using descriptive statistics, content analysis, and pre-post intervention testing with paired t-test and independent t-test statistics.

     The study findings revealed that the development of an integrated nursing model combined with telenursing for COPD patients utilized holistic care concepts, patient-centered care, interprofessional collaboration, and continuous care follow-up as the conceptual framework. The model comprised 14 main components: principles and concepts, model components, screening and admission procedures, care planning procedures, hospital-based care, telenursing, home visits, medication management and inhaler use, exacerbation management, exercise promotion and rehabilitation, nutritional care, coordination and communication systems, monitoring and evaluation with improvement, and implementation requirements and sustainability. The effectiveness of the nursing model demonstrated that COPD knowledge increased from moderate to good level, self-care behavior improved from moderate to high level, and overall quality of life enhanced from moderate to good level, with statistical significance at .001 level (t = 12.45, 15.28, 18.92, respectively). Clinical outcomes improved across all indicators: emergency room re-visit rates decreased from 254 to 178 per 100 patients, 28-day re-admission rates reduced from 40 to 28 per 100 patients, correct inhaler use increased from 61.58% to 87.25%, and average hospitalization days decreased from 5.80 to 4.20 days per patient. Patients demonstrated high satisfaction levels with the nursing model.