Nurses have a calling to care for and educate their patients. A group of nurses on a medical/surgical unit in central Texas realized that they were seeing diabetic patients frequently readmitted due to poor self-management. While digging deeper into the problem, it was found that the underserved population seemed to be the ones readmitted more frequently. This population lacked insurance and some of the resources needed to manage their health. A review of the outpatient resources available revealed that the current diabetes self-management classes required insurance or for the patient to pay out of pocket. That leaves a significant gap in coverage for a large portion of the community who could benefit from this education.
Diabetes is a medical condition that affects around 9.4% of the population (Centers for Disease Control and Prevention, 2018). It is the seventh leading cause of death in the United States. It is a very serious condition, but it can be managed. Diabetes self-management education and support (DSMES) is a critical piece to reducing diabetes related complications. “Numerous studies have shown the benefits of DSMES, which include improved clinical outcomes and quality of life while reducing hospitalizations and health care costs” (Beck et al., 2017).
The lack of outpatient diabetes self-management education accessible to the underserved portion of the community is an issue that must be addressed. There is simply not enough time for all of this education to be provided to them while they are admitted, and they may not even be in a state to retain the education at that point in time. However, these patients are not equipped to handle their day to day self-management due to not being properly educated. This leads to extra health complications for them and frequent readmissions that affect reimbursement for the hospital.
Practice Change, Quality Improvement, or Innovation
The purpose of this project is to coordinate a community based diabetes self-management course run by the hospital that is free of charge. The aim will be to provide a resource to the underserved community to learn how to manage their disease process day to day. This will be a team approach that includes several nurses on the unit to teach, this author to coordinate, and help from the CNO to secure the resources necessary to conduct the education.
The American Diabetes Association will be contacted to determine what resources they can provide. There will be discussions with the CNO to get the necessary funding to pay the nurses teaching, secure the resources for the class, and ensure that the nurses can be paid for their time outside of their normal duties.
Advertising the course will be instrumental to the success of the project. The marketing department will be contacted for help with developing flyers for the classes. These will be distributed to the inpatient units to give on discharge, and they will be given out to the local clinics as an additional resource for their patients.
Rationale for the Practice Change, Quality Improvement, or Innovation
There are many reasons why this project needs to be implemented. One is the potential financial impact of reducing the 30-day readmission rate which affects reimbursement for the hospital. Hospitals are being challenged to find ways to reduce costs and this is an investment on the front end to potentially save money on the back end. The main reason for this project however is to improve community health. Nurses strive to provide the best possible care for their patients, and they want to see their patient's health improving. It is disheartening to see that some patients simply do not have to access to the education they need to manage their health. Implementing a resource for this underserved portion of the community is the right thing to do. This project has the potential to positively impact the lives of many people by reducing their risks of complications and limiting the frequency of hospitalizations.
Chapter 2: Review of the Literature
A table of credible sources supporting this project has been added to Appendix A. Included in this table are the authors, the database used to find the source, whether the source is peer reviewed, the applicability of source, an evidence grade, a summary of the article, and inclusion status.
A review of the literature related to diabetes self-management education has shown that it is an effective way to educate patients on the proper way to maintain their health. Patients must be armed with the knowledge of how to care for themselves outside of the hospital or their health will continue to decline, and they will continue to be readmitted to the hospital. There are many ways to approach this type of education, but there are key components to include. Some common areas of education that have proven to lead to positive outcomes in diabetic patients include increasing activity, making changes to their diet, the importance of monitoring their blood sugar levels, and general knowledge about diabetes (Fløde, Iversen, Aarflot, & Haltbakk, 2017; Fu, Hu, & Cai, 2015; Harris, Silva, Intini, Smith, & Vorderstrasse, 2014; Islam et al., 2013). These are the topics that will lead to positive lifestyle changes and ultimately improve the health of the participants.
Diabetes is a disease that affects so many people, and it can be detrimental if the proper steps to manage it are not taken. By recent estimates, there are roughly 30 million people in the U.S. living with diabetes (Beck et al., 2017). It is also estimated that 84 million more are at risk for type 2 diabetes. This is a disease that is reaching epidemic proportions globally. However, it is also a disease that can be controlled with lifestyle changes in most cases. The issue is that some patients never get educated on the skills they need to live with diabetes. The lower income, underserved population are particularly at risk due to the lack of resources available to them. This is a gap in the care of the community that is frequently not addressed. The literature suggests that diabetes self-management education (DSME) is an effective tool to help patients better understand and manage their health.
Diabetes self-management education in low-income patients
As mentioned previously, the low-income, medically underserved population is a vulnerable population due to its lack of resources and access to care. This is an important segment of the population to target to make a big difference in the health of the community. There is evidence to show that people who feel they have less support tend to have poorer control of their diabetes (Rotberg, Junqueira, Gosdin, Mejia, & Umpierrez, 2016). Having DSME classes was shown to improve their HbA1c, and it also led to the participants feeling like they had more support. In a study by Towne et al. (2017), they found that people of lower socio-economic status were more likely to forgo medical care. Another study by Fritz (2017) showed that low-income patients experience more disruptions in daily life and are more likely to not have access to care which puts them at a greater risk for not being able to manage their health. For all of these reasons, it would be valuable to find ways to get education to this subgroup of people to ensure they have the knowledge to properly care for themselves and avoid serious complications.
Impact of diabetes self-management education
There is a plethora of studies that have implemented diabetes self-management classes to try to impact patients living with diabetes. It has been a proven way to improve the health of diabetic patients. One outcome measure that is frequently used in studies is HbA1c, a lab test that gives an average of the blood sugar levels over a two to three-month period. Studies have shown that implementing DSME can result in a reduction of the patient's HbA1c (Essien et al., 2017; Haesun, Thompson, Evans Kreider, & Vorderstrasse, 2017; Jayasuriya et al., 2015; Klein, Jackson, Street, Whitacre, & Klein, 2013; Nicoll et al., 2014; Rotberg, Junqueira, Gosdin, Mejia, & Umpierrez, 2016; Shakibazadeh, Bartholomew, Rashidian, & Larijani, 2016). This is evidence that DSME is changing the patient's day to day behavior and is possibly the best indicator that this education is making an impact. The entire goal of DSME is helping people make healthy lifestyle changes, and this is objective evidence of them doing just that.
Some studies did not choose HbA1C as their outcome measure and focused more on improving the patient's knowledge base. Lack of knowledge related to diabetes self-management can lead to serious health complications. The evidence shows that DSME is an effective way to increase the knowledge of diabetes for course participants (Fløde, Iversen, Aarflot, & Haltbakk, 2017; Fu, Hu, & Cai, 2015; Harris, Silva, Intini, Smith, & Vorderstrasse, 2014; Islam et al., 2013). The common areas of focus for education were increasing activity, making changes to their diet, the importance of monitoring their blood sugar levels, and general knowledge about diabetes. Increasing the knowledge of the patients is paramount to their ability to care for themselves. They need to understand how their lifestyle decisions affect their health, and they must also know the ways in which they can make positive changes.
Recommended Practice Change, Quality Improvement, or Innovation
It has been noticed that there is a large amount of readmissions on the unit due to complications from diabetes. While exploring what options patients had for outpatient diabetic self-management classes, it was found that there are no classes available to patients who do not have insurance or cannot afford to pay out of pocket. This leaves out a significant portion of the diabetic patient population. The recommendation is to implement an evidence-based diabetic self-management education course that is free to the community. This will ensure that everyone in the community has the opportunity to learn how to properly care for themselves at home.
The first step to get this started is to reach out to the American Diabetes Association to determine what resources and education material they can provide. A team of nurses on the unit will be formed to teach the classes. Then, this idea will need to be presented to the key stakeholder, the Chief Nursing Officer. He will be the one who can remove road blocks that can prevent this project from being implemented, and he will be the one who can provide the financial resources. A room will be secured on campus to host the courses, and the marketing department will be utilized to get the word out about the class through a variety of methods. One way will be a flyer that can be passed out to patients in the hospital that are discharging as well as passed to local clinics for them to hand out to patients. Another form will be through the hospital's social media platforms. The education will be divided into four classes that will be scheduled every other week. The material that will be presented to the course participants is based on evidence through multiple studies and will include increasing activity, making changes to their diet, the importance of monitoring their blood sugar levels, and general knowledge about diabetes (Fløde, Iversen, Aarflot, & Haltbakk, 2017; Fu, Hu, & Cai, 2015; Harris, Silva, Intini, Smith, & Vorderstrasse, 2014; Islam et al., 2013).
Chapter 3: Implementation
Capstone Project Steps
The community diabetes self-management courses were planned and coordinated over the over the course of several weeks. The first week was spent gathering information about what it would take to implement this plan. The ADA was contacted to determine what resources they could provide. It was found through those conversations that they have lesson plans for these courses available as well as material that could be passed out to class participants that correlate with the theme of each class. In addition, they were able to provide someone to educate the nurses about the best way to approach these classes. The estimated cost to pay the nurses for their time, and the resources that needed to be purchased were calculated to be presented to key stakeholders.
The second week involved speaking with key stakeholders about implementing this project and gaining support from executive leadership. The proposal to implement these classes was presented to the Nurse Director of the unit, the Vice President of Medical/Surgical Nursing, and the Chief Nursing Officer. In this meeting, these leaders were informed of the reasons why this project is important to the community and how it could potentially save money for the organization due to decreasing readmissions. The costs associated with implementation were discussed, and the CNO ultimately agreed to fund this project. They also helped secure a room for the classes to take place.
In the third week, the ADA instructor came to the organization to teach eight nurses the learning material they would be providing. They recommended leading four classes per cohort scheduled every other week to get maximum attendance and participation. The topics to be covered were general diabetes knowledge, the importance of exercise, and proper nutrition.
Week four was about addressing the marketing for the classes. The ADA recommended allowing at least three weeks to market the classes prior to starting the first one. The marketing department made organization approved flyers advertising the course. These flyers were provided to each unit in the hospital to give to patients being discharged. The flyers were also handed out to the local clinics for them to hand out to the patients they feel could benefit from the education. The marketing department also used the organization's Facebook page to create an event for people to register that way. The goal was to provide as much exposure as possible.
Changes to original implementation plan.
While most of the original implementation went as planned, there were a few unexpected changes. One change was due to meeting with the ADA. It was found in those meetings that they were willing to train the nurses that would be educating the community free of charge. This was something that was unexpected but definitely a positive change. This was added into the implementation plan.
Another change was the location of the class. It was anticipated that the classes would be held on campus to save money. However, the CNO offered to rent space at a local community center to hold the classes. He felt this would be more accessible to the participants and they had resources there that would be beneficial to the course. For example, there is a kitchen with a mirror so that the class participants can view the nurses cooking a diabetes friendly meal. There is also a projector in a large room which is used for PowerPoint presentations as well as space for demonstrating exercises.
Barriers associated with implementation.
The support from leadership for this project was overwhelming, so many potential barriers were mitigated before they became a problem. There were concerns about how this project would be funded originally, because it does cost a considerable amount to pay for the nurses to teach and the resources to hold these courses. Organizations are constantly searching for ways to spend money efficiently, so the barrier at the beginning was having money to get this project off the ground.
Another barrier was scheduling the nurses that were involved in the project in a way that does not conflict with the preparation of this project or the safe staffing of the unit. This barrier was exacerbated by the fact that it was coordinated during flu season which led to severe staffing strains due to call-ins on the unit.
As mentioned previously, support from leadership was phenomenal. When this project was submitted to the key stakeholders, they were more than willing to fund everything. They saw the potential benefit, and they wanted to see how this education could impact community health, length of stay, and readmission rates. In addition, they agreed that they wanted the organization to have a bigger presence in the community.
Overcoming the scheduling issues was something that required time and planning. This author took the time to carefully schedule the nurses that would be teaching off for the various planning sessions and education from the ADA. This sometimes required up staffing those shifts to ensure there were enough nurses on the unit during those times to cover call-ins due to illness. This was challenging at times, but it was able to be accomplished.
This project required the help of many people to be coordinated. The people involved included the staff nurses, the Nursing Director, the VP of Medical/Surgical Nursing, the CNO, and the ADA.
How relationships facilitated implementation.
Relationships between everyone involved played a major role in the success of getting this project off the ground. Gaining the approval of the project through the Director, VP, and CNO was the first major step. Their willingness to fund the project and support evidence based-practice in general was the beginning of this project start. It could not have continued on without their help. The nurses on the unit who put in the extra time to learn how to properly educate the community and deliver the information was the other major factor. The relationship with the ADA was one that was not expected to be as influential as it was. Their willingness to come teach the nurses how to deliver information to the participants was huge a huge part of the success of the project. They provided resources that became the core layout of the course. In general, the collaboration between everyone involved showed that the common interest of supporting the community was very important, and it led to the successful coordination of free diabetes self-management education.
Chapter 4: Post Capstone Project Considerations
There was a lot about this project that would be considered successful. One success is that there is now a diabetes self-management course available to the underserved population. They can now receive education free of charge that could ultimately positively impact their health. Another success is the knowledge and confidence the nurses have gained with diabetic teaching. They have been able to apply their knowledge to inpatient teaching, and they are encouraging other nurses on the unit to get involved in the community classes. Lastly, this project has brought awareness to the fact that there may be some gaps in the resources to the low-income, underserved population. This identified one educational gap, but there are surely other areas where this subset of the population gets left behind.
Impact on future projects.
This project can have a profound effect on future projects in the organization. Making this course a reality is an example of what a nurse can do when they want to make a change. The hope is that this will spur on more nurses to examine how they can make a positive change to impact outcomes. The executive leadership team is focused on driving outcomes and are very much engaged in investing changes to improve them. This model of education could also be used for other disease processes. Community outreach is a tool that the organization has not used as often as internal process changes. One example of this could be heart failure education. This is a population that struggles with readmissions. Perhaps teaching self-management courses in the community could help reach this population as well. Lastly, this project could be shared throughout the system as a model for how to address the issue of diabetes self-management.
Aspects that did not go well.
Fortunately, there were not many negative aspects in this project. The one area that was slightly disappointing was how long it took from the time of the idea to the scheduling of the first class. This is to be expected due to the careful planning to ensure that the everyone is prepared and that there is time to market the classes to encourage participation. The proper steps had to be taken to make sure the class was a success.
Impact on future projects.
There were not any negative aspects that would prevent a future project from happening. In fact, this project will hopefully be the impetus for more projects after seeing the success. Future project teams should be aware of the time it takes to carefully coordinate their plans depending on the complexity of the project however. This project took time to take through the proper channels and ultimately be implemented.
Evidence and Current Practice
While performing a literature review, there was a plethora of evidence in support of implementing community-based diabetes self-management classes. The whole concept was brand new to the organization, because there was nothing comparable in place already. The previous state of diabetic education ended at discharge unless the patient had access to health insurance or the money to pay out of pocket for outpatient self-management classes. The entire justification for the implementation of this project is based on the positive outcomes driven by previous research studies
The curriculum for the courses was chosen based on education used in the evidence. The focus of the classes were common self-management topics including diabetes knowledge, the importance of exercise, the importance of monitoring their blood sugar, and proper nutrition. The literature showed that participants had a better grasp of their disease process after learning about these topics, and they ultimately showed improvements in their health because of that knowledge.
The focus of this project was to engage with people of a lower socio-economic status that do not have access to other educational resources. The research shows that this population is particularly at risk for diabetic complications. The implementation of this project was intended to provide these people with a resource to help them gain control of their disease process and ultimately keep them from being readmitted due to poor self-management.
Plans to sustain the project post implementation will be important in both the short and long term. To ensure that there are plenty of nurses able to educate, one long term plan will be training for those want to volunteer to teach. This training will be extended hospital wide in the future to maintain a steady supply of educators. Training more nurses will also lighten the burden of those participating which will prevent staff from burning out. The goal will be to have a rotating schedule of educators with oversight from this author. This plan will be for long term sustainment due to the amount of time it will take for the education to take place and due to the fact that it should remain ongoing. For a short term plan to sustain, there will be an update provided at the monthly nurse leadership council to let the organization know how things are going. This also increases accountability, because it will be presented in front of executive leadership. Another short term measure to support the project post-implementation will be to gather feedback from both the participants and the educators. This will allow for rapid changes to increase the effectiveness of the classes. With all of these measures in place, there should be no problem sustaining the project going forward.
Resources Required for Post-Implementation Support
As mentioned previously, the educators are a resource. There will be a push to train more nurses to be capable of teaching the courses. Another resource is the money to continue funding the project. This money goes towards securing the space for the classes as well as resources for the class. A group will be put together to research submitting for grants to possibly help with the financial aspect of the project. Until that happens, executive leadership will be the resource to approve the finances of the project.
Chapter 5: Reflection
Integration of MSN Program Outcomes
Design innovative nursing practice to impact quality outcomes
Implementing these community-based diabetic self-management courses was a great example of innovative nursing practice meant to positively impact quality outcomes on many different levels. One area this project sought to impact was the diabetic readmission rate in the organization. The idea was to better educate the patient, so that they took better care of themselves at home. The project also targeted a specific patient population that has been often overlooked in the past. It was geared towards patients who had no options for diabetes self-management courses due to not having insurance and not being able to afford the classes. This improvement in the quality of their education gives them the ability to live a better quality of life with potentially less time spent seeking medical care. This project impacted the nurses involved as well by giving them the confidence to teach patients about diabetes. One of the big successes of this project is how many different ways it impacts quality outcomes.
Utilize applied research outcomes
The entire project was based on research outcomes that backed up what was being implemented. An extensive literature review was performed, and the project plan was drafted from that review. The research guided the topics that developed into the teaching plans. The literature review also revealed that the patient population the project was trying to reach was particularly at risk due to their lack of resources. Every aspect of the project was based on the research found in the literature review. It is important that nurses continue to drive outcomes using research outcomes as the basis for the change. The profession thrives on evidence-based practice.
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